Belimumab in the treatment of Portuguese Systemic Lupus Erythematosus patients: a real-life multicenter study

OBJECTIVES

To evaluate belimumab effectiveness and safety in real-life Portuguese patients with Systemic Lupus Erythematosus (SLE).

MATERIALS AND METHODS

Multicenter cohort study including all SLE patients treated with belimumab in seven Portuguese rheumatology centers. Demographic, clinical and serological data were collected at baseline, 6, 12 and 24 months of treatment with belimumab. To evaluate effectiveness we used SLE Responder Index (SRI) rates and changes in SELENA-SLEDAI. Safety was evaluated by the number of adverse events.

RESULTS

Thirty-eight patients were included: 37 (97.4%) female, with a mean age of 46.2±13.9 years. Mean SELENA-SLEDAI was 8.2±3.9, 78.8% had elevated anti-double-stranded DNA (anti-dsDNA) antibodies and 72.7% had complement consumption at baseline. Multiorgan involvement was the leading cause for the use of belimumab. SRI response was achieved in 51.9%, 60% and 91.7% at 6, 12 and 24 months of belimumab treatment, respectively. LUNDEX adjusted SRI response rates were 45.4%, 45.0% and 45.8% at 6, 12 and 24 months of belimumab, respectively. Mean SELENA-SLEDAI, anti-dsDNA antibodies and daily prednisolone dosage decreased significantly from baseline to 6, 12 and 24 months and C3 levels increased significantly at 12 months of belimumab treatment. Five patients presented adverse events (infections in three cases) and eleven patients discontinued belimumab (four due to inefficacy, three due to adverse events and four were lost to follow-up).

CONCLUSIONS

Our study confirmed, in real-life Portuguese patients with active SLE, the effectiveness of belimumab in reduction of disease activity, immunological response and steroid-sparing, with a good safety profile.

Are we overlooking osteoarthritis? - A comparative study of pain, function and quality of life in patiens with hand osteoarthritis and rheumatoid arthritis

Osteoarthritis (OA) is frequently regarded by patients and health care providers as a normal consequence of ageing and a minor condition. In contrast, rheumatoid arthritis (RA) is a pathological condition that usually requires prolonged treatment and regular Rheumatology follow-up. Pain and physical limitations are hallmarks of both conditions and some previous studies suggest that OA and RA may have a similar burden for both groups of patients although those works usually do not take into account the inflammatory activity of RA. With this work, the authors compare levels of pain, physical disability and health-related quality of life in patients with primary hand osteoarthritis (hOA) and with RA - active disease (aRA) or in remission (rRA). The results show that hOA may have similar or even higher burden of pain than RA even with clinically relevant inflammatory activity in hand joints. Rather than suggesting that OA could be as severe as RA (or more or less severe), this brief study highlights OA as a cause of severe pain, which should lead us to try to achieve better symptom control for these patients and encourage rheumatologists to endeavor efforts to perform more studies in the field of OA.

FRI0388 ARE WE OVERLOOKING OSTEOARTHRITIS? – A COMPARATIVE STUDY OF PAIN, FUNCTION AND QUALIFY OF LIFE IN PATIENTS WITH HAND OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS

Background:

Osteoarthritis (OA) is frequently regarded by patients and health care providers as a normal consequence of ageing (1). On the other hand, it is well established that rheumatoid arthritis (RA) is a pathological condition requiring prompt and efficacious treatment and in which remarkable progresses have been achieved in the last decades. Pain and physical limitations are hallmarks of both conditions. Some previous studies suggest that OA and RA may have a similar burden (2,3).

Objectives:

To compare levels of pain, physical disability and health-related quality of life in patients with primary hand osteoarthritis (hOA) and with RA: active disease (aRA) or in remission (rRA).

Methods:

Observational cross-sectional study including patients of two clinical centres with hOA and RA, either in remission or with active disease (at least two swollen and/or tender hand joints). Matching for sex and age was performed. Patients were asked to complete a survey consisting of visual analogic scale (VAS) for pain, Health Assessment Questionnaire (HAQ) and Short Form 36 (SF36). Mean values for each domain were compared between the three groups using one-way ANOVA test with significance accepted for p<.05.

Results:

Thirty patients with hOA and 93 with RA (33 with aRA and 60 with rRA) were included. All patients were caucasian females with no significant differences in age between groups. Patients with hOA reported higher levels of pain in comparison with aRA patients (mean VAS 57.3vs49.3mm, respectively, p=.265) and with rRA patients (57.3vs28.6mm, respectively, p<.001) [F(2.120)=25.907, p<.001]. Regarding physical function, patients with hOA reported levels of disability similar to rRA patients, but significantly lower disability than patients with aRA [F(2.120)=6.962, p=.001]. Patients with hOA evaluated their quality of life significantly better than patients with aRA and in similar levels to patients with rRA, as measured by mental health and general health status domains of SF36.

Conclusion:

Our results show that hOA may have similar or even higher burden of pain than RA; this is in line with previous studies, although most of them did not consider the level of inflammatory activity of RA. On the other hand, patients with hOA seem to preserve function and have better health-related quality of life despite the higher levels of pain. These results highlight OA as a cause of severe pain, which should lead us to try an optimal symptom control for these patients. These findings should also encourage rheumatologists to endeavor efforts to perform more studies in the field of OA, to better understand its pathogenesis and to eventually find disease modifying drugs.

References:

[1]Gignac MAM, Davis AM, Hawker G, Wright JG, Mahomed N, Fortin PR, et al. “What do you expect? You’re just getting older”: A comparison of perceived osteoarthritis-related and aging-related health experiences in middle- and older-age adults. Arthritis Rheum. 2006 Dec 15;55(6):905–12.

[2]El-Haddad C, Castrejon I, Gibson KA, Yazici Y, Bergman MJ, Pincus T. MDHAQ/RAPID3 scores in patients with osteoarthritis are similar to or higher than in patients with rheumatoid arthritis: a cross-sectional study from current routine rheumatology care at four sites. RMD Open. 2017 Jul;3(1):e000391.

[3]Slatkowsky-Christensen B, Mowinckel P, Kvien T. Health status and perception of pain: a comparative study between female patients with hand osteoarthritis and rheumatoid arthritis. Scand J Rheumatol. 2009 Jan;38(5):342–8.

Disclosure of Interests:

None declared

AB0192 RHEUMATOID ARTHRITIS: IS IT WORTH IT TO ADD LEFLUNOMIDE TO METHOTREXATE IN REFRACTORY DISEASE?

Background:

In refractory rheumatoid arthritis (RA), adding other classic synthetic disease-modifying antirheumatic drug (csDMARD) such as leflunomide (LFN) to methotrexate (MTX) is one suitable option [1,2]. Yet, there are safety issues to consider which may limit this strategy, but also regarding its true effectiveness in avoiding exposure to biological DMARDs (bDMARD) or target synthetic DMARDs (tsDMARD).

Objectives:

To assess the effectiveness and safety of adding LFN to MTX and to evaluate the predictors of drug retention, toxicity and inefficacy.

Methods:

A retrospective clinical record review of adult RA patients followed on our rheumatology department in whom LFN was added to MTX was done. Sociodemographic information, comorbidities, disease related information, adverse reactions and disease activity according to Disease Activity Score 28 – C reactive protein (DAS28) were recorded at baseline and after 3, 6 and 12 months of combination therapy (3_DAS28; 6_DAS28; 12_DAS28, respectively). Information regarding toxicity (need to dose adjustment/suspension) and inefficacy (add/switch to bDMARD/tsDMARD) were recorded. Follow-up was considered until last medical record available. SPSS was used for statistical analysis. Kaplan Meier and Cox-regression were used for univariate and multivariate analysis, respectively, significant level was 2-sidedp<.05.

Results:

In total, 77 patients were included, 66.20% females, with a mean age of 56±11 years old. There was a significant reduction of DAS28 only after 3 months of therapy (4.01±1.01 to 2.57±1.52,p=.003; ΔDAS28 = 1.58±1.17). However, during a median follow up time of 64 (IQR 39-83) months, 58.44% of patients needed to change treatment strategy, 66.67% due to toxicity (median time to toxicity 13 months, IQR 2-16) and 33.33% due to inefficacy (median time to inefficacy of 10 months, IQR 5.84-17.64). Gastrointestinal intolerance was the main reported toxicity (46.15%). In univariate analysis, anti-citrullinated protein antibodies (ACPA) positivity, alcohol consumption, lack of comorbidities, hepatic toxicity, higher 6_DAS28, swollen joint count and tender joint count on the 6thmonth were associated to lower retention rates.

In multivariate analysis, lack of comorbidities (HR=3.3, CI 95% 1.4-7.8,p=.006) and higher 6_DAS28 (HR=0.32, CI 95% 0.14-0.72,p=.006) were independent predictors of suspension of combination therapy. Moreover, both male gender (HR=2.87, 95%CI 1.2-6.56,p=.016) and positivity to ACPA (HR=0.1, 95%CI 0.01-0.73,p=.024) were independent predictors of toxicity. There was also higher tendency to toxicity, but without statistical significance, in alcohol consumers (p=.08). Regarding inefficacy, smoking habits (HR=0.15, 95%CI 0.04-0.52) and 3_DAS28 (HR=0.15, 95%CI 0.04-0.53) were independent predictors.

Conclusion:

Addition of LFN to MTX showed an early positive response. However, it was frequently associated to toxicity, and less than half of the patients continued with this therapeutic strategy after 5 years of follow up. Male gender, smoking habits and positivity to ACPA were predictors of worse outcome, as already reported in literature [1]. Lack of comorbidities was an independent predictor of suspension. This can be explained by the fact that physicians tend to adopt a more aggressive strategy on patients without comorbidities, switching earlier to bDMARDs/tsDMARDs.

This study also showed that early response to combination therapy is an independent predictor on drug retention, suggesting that decisions on treatment strategy should be made early after the beginning of MTX/LFN.

References:

[1]Smolen JS, et al. Ann Rheum Dis 2020;0:1–15. doi:10.1136/annrheumdis-2019-216655

[2]Kremer J, et al. J Rheumatol. 2004 Aug;31(8):1521-31. PMID: 15290730

Disclosure of Interests:

None declared

AB0236 DIFFERENCES AND DETERMINANTS OF PHYSICIAN’S AND PATIENT’S PERCEPTION IN GLOBAL ASSESSMENT OF RHEUMATOID ARTHRITIS

Background:

Patient’s Global Assessment of Disease Activity (PtGA) and Physician’s Global Assessment of Disease Activity (PhGA) are assessed as part of commonly used measures of disease activity in RA.1Both are important measures in treat-to-target strategies in Rheumatoid Arthritis (RA), but often provide discordant results.2,3This can provide an erroneous assessment of disease activity in patients under Biologic treatment and mislead treatment decisions, namely switches.

Objectives:

To assess differences and determinants of PtGA and PhGA in RA patients under biologic treatment.

Methods:

Cross-sectional study, including 46 patients with RA diagnosed according to the ACR/EULAR criteria, under biologic treatment, consecutively evaluated in day-care unit. Participants completed patient-reported outcomes (PROs), including PtGA, and sociodemographic characteristics. Physicians collected comorbidities and parameters of inflammatory activity (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) and completed PhGA and disease activity score 28 with ESR (DAS28). SPSS was used for statistical analysis and significance level was defined as 2-sided p<0.05.

Results:

Clinical and laboratory characteristics of patients are shown in table 1. PtGA and PhGA were significantly different (36.1±27.6 mmvs8.7±14.2 mm, p< 0.001) and a positive discordance (PtGA>PhGA, more than 25mm in visual analogue scale [VAS]) was found in 54.3% of cases.

PtGA had a correlation with PROs (Pain VAS, 36-Item Short Form Health Survey [SF-36], Health Assessment Questionnaire [HAQ], Functional Assessment of Chronic Illness Therapy [FACIT], EuroQol [EQ5D] and Hospital Anxiety and Depression Scale [HADS]), CRP, tender and swollen joint counts and an association with comorbidities like fibromyalgia or osteoarthritis (OA). No association was found between PtGA and age, sex, education level, profession, employment status, extra-articular manifestations, positivity of rheumatoid factor, ESR, years of disease evolution or number of biologic treatments. In multivariable analyse including SF-36, CRP, tender joints count and OA (R2adjusted= 0.672), the main predictors of PtGA were lower SF36, concomitant OA and higher CRP level.

PhGA had a correlation with PtGA, pain VAS, CRP, tender and swollen joints. No association was found between PhGA and patient or physician age, patient or physician sex, extra-articular manifestations, positivity of rheumatoid factor, ESR level, years of disease evolution or number of biologic treatments. In multivariable analysis including ESR, tender and swollen joints count and CRP (R2adjusted= .800), the main predictors of PhGA were swollen joint count and higher CRP level.

Conclusion:

This study showed the variability implied on global assessment of RA activity. Overall PtGA is based on function and also in subjective and emotional experience of pain, whereas the PhGA is based on more objective measures, more related to disease activity.

References:

[1]Kanekoa Y. et al, Determinants of Patient’s Global Assessment of Disease Activity and Physician’s Global Assessment of Disease Activity in patients with rheumatoid arthritis: A post hoc analysis of overall and Japanese results from phase 3 clinical trials.Modern Rheumatology2018; 28(6):960–967

[2]Furu M. et al. Discordance and accordance between patient’s and physician’s assessments in rheumatoid arthritis.Scand J Rheumatol.2014; 43(4):291-5.

Ann Rheum Dis. 2016 Sep;75(9):1661-6. doi: 10.1136/annrheumdis-2015-208251. Epub 2015 Oct 22.

[3]Portier A. et al, Patient-perceived flares in rheumatoid arthritis: A sub-analysis of the STRASS treatment tapering strategy trial.Joint Bone Spine. 2017; 84(5):577-581

Disclosure of Interests:

None declared

FRI0165 RISK OF CKD IN MEMBRANOUS AND PROLIFERATIVE LUPUS NEPHRITIS - ANALYSIS OF A NATIONWIDE MULTICENTRE COHORT

Background:

Lupus nephritis (LN) is one of the most severe manifestations of Systemic Lupus Erythematosus.

Objectives:

1) To compare proliferative (PLN), membranous (MLN) and mixed LN regarding clinical and laboratory presentation. 2) To investigate predictors of progression to chronic kidney disease (CKD).

Methods:

Multicentre observational study, with retrospective analysis of a prospective cohort, using data from the Portuguese registry of rheumatic diseases – Reuma.pt. Patients with biopsy-proven PLN, MLN and mixed LN were included. Groups were compared using Pearson’s Chi-Square for categorical variables and One-Way ANOVA or Kruskal-Wallis for numerical variables. COX regression analysis was used to investigate predictors of CKD (defined as estimated glomerular filtration rate [eGFR] lower than 60 mL/min/1.73m2for at least 3 months) and Kaplan-Meier curves were drawn.

Results:

236 patients were included. Median follow-up was 8 years (IQR 11; maximum 35 years). As seen in table 1, the level of proteinuria did not differ between groups; however, MLN patients presented with significantly lower serum creatinine. Levels of complement C3 and C4 were reduced in PLN but normal in MLN patients, and there were fewer patients with positive anti-dsDNA antibodies in the MLN group (p<0.001). On univariable COX regression, mixed histology was associated with progression to CKD (HR 26 [95% CI 3 - 255], p 0.005) (figure 1), however, it lost significance after adjusting for eGFR. In fact, eGFR≤75 at one year after the renal biopsy (HR 21 [95% CI 7 - 65], p<0.001) was the strongest predictor of CKD, even after adjusting for hypertension or histology.

Table 1.

Comparative description of the Reuma.pt cohort of patients with proliferative, membranous and mixed LN

PLNMLNMixedPTotal, N186428Females, N (%)157 (85)39 (95)4 (50)0.004EthnicityWhite European, N (%)163 (90)31 (78)7 (88)0.115Other, N (%)19 (10)9 (23)1 (13)Age LN diagnosis(y), median (IQR)30 (20)34 (16)42 (25)0.409SLEDAI at LN diagnosis, median (IQR)16 (9)10 (10)21 (17)0.006*uPCR at LN diagnosis, median (IQR)1675 (2598)1698 (2153)2160 (3320)0.629Creatinine at LN diagnosis, median (IQR)0.80 (0.32)0.70 (0.20)1.00 (0.95)0.006*eGFR at LN diagnosis, mean ± SD98 ± 33112 ± 1782 ± 450.019*Albumin at LN diagnosis, mean ± SD34 ± 734 ± 730 ± 60.390C3 at LN diagnosis, mean ± SD0.65 ± 0.260.90 ± 0.350.53 ± 0.30<0.001*Positive anti-dsDNA LN diagnosis, N (%)115 (91)11 (48)6 (86)<0.001*Use of antimalarials, N (%)166 (94)36 (92)8 (100)0.688Use of immunosuppressants, N (%)163 (94)33 (87)8 (100)0.245Use of corticosteroids, N (%)145 (84)33 (85)7 (100)0.511CKD after LN diagnosis, N (%)27 (15)1 (3)3 (38)0.018*ESRD, N (%)7 (4)1 (3)2 (25)0.016Deaths, N (%)14 (8)2 (5)00.610

uPCR: urinary protein-creatinine ratio, mg/g; y: years; Creatinine presented in mg/dL, eGFR in mL/min/1.73m2,albumin in g/L and C3 in g/L

Note: Baseline data (LN diagnosis) in grey; other data refer to the course of disease

*Significant difference between the proliferative and membranous groups

Figure 1.

Kaplan-Meir curves showing cumulative survival free of CKD in patients with PLN, MLN and mixed LN

Conclusion:

Our results support previous findings from single-centre studies suggesting that MLN has a different serological profile than PLN, possibly reflecting different pathogenesis. Renal function at one year predicts long-term outcome in LN.

Disclosure of Interests:

Filipa Farinha: None declared, Sofia C Barreira: None declared, Maura Couto: None declared, Margarida Cunha: None declared, Diogo Fonseca: None declared, Raquel Freitas: None declared, Luís Inês: None declared, Mariana Luis: None declared, Carla Macieira: None declared, Ana Rita Prata: None declared, Joana Rodrigues: None declared, Bernardo Santos: None declared, Rita Pinheiro Torres: None declared, Ruth J. Pepper: None declared, Anisur Rahman: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer

AB1350-HPR SOCIOECONOMIC BURDEN OF NON-ATTENDANCE IN RHEUMATOLOGY CONSULTATION

Background:

Outpatient non-attendance refers to the phenomenon of patients who have a medical appointment but do not show up at the specified date, time, and location without giving previous notice.1In addition to affecting the efficiency and thereby increasing the healthcare total costs, nonattendance might also delay access to care for users on waiting lists.1Nonattendance at health appointments is costly to services, and can risk patient health.2There is very little data on the nonattendance prevalence and impact in Portugal. This knowledge might be fundamental to improve effectiveness of outpatient care in Portugal.

Objectives:

1) describe patient’s non-attendance rate; 2) assess and characterize the sociodemographic and clinical characteristics among non-attending patients; 3) estimate the economic burden of non-attendance.

Methods:

Retrospective, cross-sectional and analytical study. We reviewed a one-month Rheumatology consultation period regarding performed medical consultations and non-attended consultations without previous notification from patients. Direct economic costs of non-attended appointments were calculated based on the “Amending Agreement to the ULSAM, EPE Program Agreement”.

Results:

982 consultations within January 2018 were included. Appointments episodes for therapeutic prescription, medical reports or programmed admissions were excluded. Fifty-seven (5.8%) of scheduled outpatient appointments were non-attended. Subsequent consultations represented 85.2% of attended appointments and 80.7% of non-attended appointments. Female gender was the most prevalent in both groups – 620 (67.0%) among attended consultations and 37 (65.0%) among non-attended consultations. Mean age was 57±15 years in the first group and 54±16 years in the second one. Among attended appointments, mean education level was 8±5 years versus 9±6 years among non-attended appointments. There were no differences between both groups in gender, age, education level, diagnosis, disease duration and activity or appointment type (first or subsequent consultation). A cost of 2,438 euros was estimated regarding non-attended appointments for this period, what could represent a burden of more than 29,000 euros yearly, in direct costs, only.

Conclusion:

Non-attendance at scheduled appointments in public hospitals seems to be influenced by other factors besides gender, age and education level. The burden of non-attended appointments is undeniable. In addition to the costs estimated in this study, further indirect costs such as poorer patients outcomes, impaired access to medical care and hospital penalties should be taken into account. Implementation of awareness strategies aiming the optimization and effectiveness of healthcare system are required.

References:

[1]Blæhr EE, Kristensen T, Væggemose U, Søgaard R. The effect of fines on nonattendance in public hospital outpatient clinics: study protocol for a randomized controlled trial.Trials. 2016;17(1):288. doi:10.1186/s13063-016-1420-3

[2]Akter S. A qualitative study of staff perspectives of patient non-attendance in a regional primary healthcare setting.Australas Med J. 2014;7(5):218-226. doi:10.4066/AMJ.2014.2056

Disclosure of Interests:

None declared

ZnAl2O4 decorated Al-doped ZnO tetrapodal 3D networks: microstructure, Raman and detailed temperature dependent photoluminescence analysis

3D networks of Al-doped ZnO tetrapods decorated with ZnAl2O4 particles synthesised by the flame transport method were investigated in detail using optical techniques combined with morphological/structural characterisation. Low temperature photoluminescence (PL) measurements revealed spectra dominated by near band edge (NBE) recombination in the UV region, together with broad visible bands whose peak positions shift depending on the ZnO : Al mixing ratios. A close inspection of the NBE region evidences the effective doping of the ZnO structures with Al, as corroborated by the broadening and shift of its peak position towards the expected energy associated with the exciton bound to Al. Both temperature and excitation density-dependent PL results pointed to an overlap of multiple optical centres contributing to the broad visible band, with the peak position dependent on the Al content. While in the reference sample the wavelength of the green band remained unchanged with temperature, in the case of the composites, the deep level emission showed a blue shift with increasing temperature, likely due to distinct thermal quenching of the overlapping emitting centres. This assumption was further validated by the time-resolved PL data, which clearly exposed the presence of more than one optical centre in this spectral region. PL excitation analysis demonstrated that the luminescence features of the Al-doped ZnO/ZnAl2O4 composites revealed noticeable changes not only in deep level recombination, but also in the material's bandgap when compared with the ZnO reference sample. At room temperature, the ZnO reference sample exhibited free exciton resonance at ∼3.29 eV, whereas the peak position for the Al-doped ZnO/ZnAl2O4 samples occurred at ∼3.38 eV due to the Burstein-Moss shift, commonly observed in heavily doped semiconductors. Considering the energy shift observed and assuming a parabolic conduction band, a carrier concentration of ∼1.82 ×1019 cm-3 was estimated for the Al-doped ZnO/ZnAl2O4 samples.

Optical properties of hydrothermally synthesised and thermally annealed ZnO/ZnO2 composites

ZnO/ZnO2 composites grown by hydrothermal synthesis at low temperature (180 °C) and thermally annealed at 300 °C were fully analysed by morphological, structural and optical techniques. X-ray diffraction patterns (XRD) and Raman spectroscopy clearly evidence the presence of both crystalline phases in the ZnO/ZnO2 sample. The differential scanning calorimetry analysis and thermogravimetric profiles indicate an exothermic event with a peak temperature ca. 225 °C, which is accompanied by a 8.5% weight loss, being attributed to the crystallization of ZnO from ZnO2. Upon a thermal annealing treatment at 300 °C the ZnO2 phase was completely converted into ZnO, as measured by XRD and Raman spectroscopy. Photoluminescence investigations reveal that the emission is dominated by a broad band recombination in both samples, due to the overlapping of different emitting centres, and that the peak position of the PL emission is dependent on the excitation density. The ZnO/ZnO2 sample exhibits a widening of the bandgap when compared to the one only containing ZnO, likely related to the presence of the additional ZnO2 phase and suggesting a bandgap energy of ~3.42 eV for this compound. Surface analysis revealed that the sample exhibits a surface area of 90 m2 g-1, which decreases to 30 m2 g-1 after the thermal annealing and the full conversion into ZnO. This difference in the surface area showed particular relevance in the stability of the measured optical properties. Particularly, the intensity of the photoluminescence signal was seen to be higher in the ZnO/ZnO2 sample and strongly dependent on the measurement atmosphere, highlighting its potential to be employed in the fabrication of optical-based sensing systems for environmental applications, namely in gas sensors.

Long-Term Response after 94 Cycles of Trabectedin in a Patient with Metastatic Leiomyosarcoma of the Lower Extremity

Leiomyosarcomas of the lower extremity are extremely rare disorders and account for 10-15% of limb soft tissue sarcomas. These tumours have poor prognosis and even in early stages, patients persist at high risk for local and distant relapse; consequently, the treatment of advanced leiomyosarcoma of the lower extremity embodies a substantial defy. We present the case of a 73-year-old man diagnosed with metastatic lower extremity leiomyosarcoma of the hallux soft tissue, and with bone, lung and lymph node metastasis. After core needle biopsy confirmation of high-grade fusocellular sarcoma, the patient underwent surgery of the primary tumour and received anthracycline-based chemotherapy. However, after a 7-month progression-free survival period, a CT revealed lung disease progression. Sequentially, the patient was treated with trabectedin (Yondelis®) at a dose of 1.5 mg/m² resulting in complete remission of the lung metastasis and stable disease of the remaining lesions after 26 months of treatment. Afterwards, the patient started on maintenance therapy with trabectedin, resulting in long-lasting stable disease, as he was able to receive 94 cycles with very acceptable quality of life. Finally, in March 2019, the patient died of community-acquired pneumonia without objective progression disease. This clinical case reports the first patient ever treated with 94 cycles of trabectedin. Our results additionally confirm that trabectedin wields relevant oncostatic benefits with a manageable safety profile and without cumulative toxicities. Trabectedin properties enable a maintenance long-term therapy (until disease progression or unbearable toxicity), with a high impact on survival and with a preserved quality of life.

Fatigue Evaluation through Machine Learning and a Global Fatigue Descriptor

Research in physiology and sports science has shown that fatigue, a complex psychophysiological phenomenon, has a relevant impact in performance and in the correct functioning of our motricity system, potentially being a cause of damage to the human organism. Fatigue can be seen as a subjective or objective phenomenon. Subjective fatigue corresponds to a mental and cognitive event, while fatigue referred as objective is a physical phenomenon. Despite the fact that subjective fatigue is often undervalued, only a physically and mentally healthy athlete is able to achieve top performance in a discipline. Therefore, we argue that physical training programs should address the preventive assessment of both subjective and objective fatigue mechanisms in order to minimize the risk of injuries. In this context, our paper presents a machine-learning system capable of extracting individual fatigue descriptors (IFDs) from electromyographic (EMG) and heart rate variability (HRV) measurements. Our novel approach, using two types of biosignals so that a global (mental and physical) fatigue assessment is taken into account, reflects the onset of fatigue by implementing a combination of a dimensionless (0-1) global fatigue descriptor (GFD) and a support vector machine (SVM) classifier. The system, based on 9 main combined features, achieves fatigue regime classification performances of 0.82 ± 0.24, ensuring a successful preventive assessment when dangerous fatigue levels are reached. Training data were acquired in a constant work rate test (executed by 14 subjects using a cycloergometry device), where the variable under study (fatigue) gradually increased until the volunteer reached an objective exhaustion state.

P1466 Pacman heart documented by multimodality echocardiographic techniques

We report a case of a 78-year old female with hypertension, dyslipidemia, atrial fibrillation under warfarin therapy and previously diagnosed HFpEF. She also had a history of recurrent episodes of bilateral inferior limb acute ischemia requiring urgent embolectomy and one previous cardioembolic stroke. She had no history of ischemic heart disease.

She was admitted to our center due to acute decompensated heart failure (NYHA class III). On physical examination there was evidence of pulmonary congestion with bilateral crackles, without heart murmurs. ECG showed AF rhythm, without any other significant changes.

The transthoracic echocardiogram (TTE) showed moderate biventricular hypertrophy with apical predominance and good systolic function. A partial loss of myocardial tissue in the mid segment of the interventricular septum was noticed, with no left-to-right shunt on color Doppler, apparently without interventricular communication (figure A).

For further elucidation of this finding a contrast-enhanced TTE was performed, revealing a serpiginous route through the septum to a small contained cavity within it (figure B). 3D TTE en face views additionally clarified the semilunar shape of this septal defect and its movement during the cardiac cycle, closing during systole and opening during diastole (figure C).

At this point, clinical history and previous diagnostic exams were reviewed. A thoracic CT conducted 3 years before in another clinical context showed that the ventricular septal defect was already present, with similar characteristics (figure D).

As doubts persisted about the existence of interventricular communication, cardiac catheterization with oximetry and ventriculography was performed and interventricular shunt was excluded. There was no evidence of coronary artery disease. Cardiac MRI was not possible due to lack of patient collaboration.

Final diagnosis was a partial ventricular septal defect (PVSD), probably congenital. The patient was discharged under optimized medical therapy.

PVSDs, which are rarely reported in the literature, are thought to be congenital (sporadic or familial) or a consequence of myocardial infarction. They have been described as "Pacman" heart due to the shape changes during the cardiac cycle, becoming slit-like or even absent during systole, like an opening/closing mouth, resembling the Pacman video game. Related complications include conduction disturbances, rupture and disturbed systolic function.

We describe a rare case of a partial ventricular septal defect, documented by multimodality echocardiographic techniques: 2D TTE first showed an incomplete defect of the mid interventricular septum; contrast-enhanced TTE revealed its serpiginous route to a small cavity; 3D TTE en face views further illustrated its semilunar shape and characteristic movement during the cardiac cycle.

Abstract P1466 Figure.

P1718 Multi-modal imaging characterization of contained aortic subannular rupture after transcatheter aortic valve implantation

INTRODUCTION

Aortic annular rupture is a potentially catastrophic complication after transcatheter aortic valve implantation (TAVI), with an estimated incidence of 1%. Rupture occurs in the anatomical device landing zone, that extends from the aortic root to the distal left ventricular outflow tract (LVOT). It usually occurs in the context of highly calcified aortic valve and LVOT, implantation of balloon-expandable valves, valve oversizing and overdilation to treat paravalvular leakage.

CASE REPORT

An 80-year old woman with no past relevant medical history was admitted to our Cardiology Department with decompensated heart failure because of symptomatic severe aortic stenosis, moderate aortic regurgitation and mild left ventricular (LV) dysfunction. She was already in waiting list for TAVI procedure, after being refused for conventional aortic valve replacement due to a "porcelain" aorta. Her pre-operative angiography showed no significant coronary heart disease, and the cardiac computed tomography (cardiac-CT) revealed a severely calcified aortic valve (Agatston score = 4940). An Acurate neo L (27mm) valve was implanted after clinical stabilization with no immediate complications. Because of paravalvular regurgitation, sequential post-dilation was performed with 25mm and 26mm balloons. Post-procedural angiography showed no contrast extravasation (Panel A). In the first hours after the procedure, she was hypotensive with non-specific mild chest discomfort. The EKG showed sinus rhythm with left anterior fascicular block. A transthoracic echocardiogram revealed a moderate pericardial effusion, with no signs of tamponade, and a moderate "paravalvular leak "at the level of the non-coronary cusp to a pulsatile cavity, between the aortic root and the left atrium (Panel B and C). The patient evolved with haemodynamic and electrical stability with no recurrence of chest discomfort. A retrospective cardiac-CT was performed that confirmed the presence of a multilobular cavity below the left coronary artery in continuous with the LVOT, compatible with a contained subannular aortic rupture (Panel E and F), at the level of previous gross calcification in the pre-operative cardiac-CT (Panel D). The case was discussed in Heart Team and a conservative strategy was adopted due to clinical stability and inoperable condition. The patient was discharged at day 28, after CT reavaluation,, that demonstrate similar findings.

CONCLUSION

We report a rare and potentially fatal complication of TAVI with a self-expandable valve. This clinical case illustrates how balloon post-dilation to treat moderate post-procedural paravalvular regurgitation lead to tearing of a highly calcified aortic annulus. A multi-modality imaging approach, with echocardiography and computer tomography, was essential for full anatomical definition of the subannular rupture, clinical decision-making and for follow-up surveillance.

Abstract P1718 Figure. Panel A,B,C,D,E,F.

P326 Changes in left atrial dimensions during stress echocardiography: linear vs planimetric methods

OnBehalf

On behalf of the Stress Echo 2020 study group of the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI)

Background The measurement of left atrium (LA) can be obtained with simple linear or more complex biplane disk summation Simpson (S) method at rest and during stress echocardiography (SE). Although planimetric methods are mandatory to accurately assess resting LA volume, we sought to study if linear (L) methods can be equally valuable in assessing dynamic changes during SE.

Purpose

To assess accuracy of LA- SE with S compared to L method.

Methods

SE was performed in 34 patients (age 59 ± 16 years, 18 females) with known or suspected coronary artery disease. All had acceptable acoustic window at rest and were referred for clinically-driven SE (dobutamine in 21, dipyridamole in 13). LA was measured at rest and peak stress with both methods: 1- S biplane method from 4- and 2-chamber views; 2- L method with measurement of anteroposterior diameter from 2-D targeted M-mode in parasternal long-axis view. Two independent observers measured a set of 20 clips and repeated the measurements after 1 month on the same images. Stress-rest differences of L and S were compared with Spearman non-parametric correlation.

Results

LA measurement was obtained in all patients with L, 34/42 with S (feasibility 100%, and 80%, respectively). The off-line analysis time at each step (rest and stress) measured by stop-clock was 22.3 sec for L and 93 sec for S method (p &lt; 0.001). The intra-rater intra-class correlation coefficient for L was 0.965 for single measures and 0.982 for average measures. For S, it was 0.830 in single measures and 0.907 for average measures. The inter-rater correlation coefficient for L was 0.920 for single measures and 0.958 for average measures. For S, it was 0.901 for single measures and 0.948 for average measures. Absolute LA dimensions were moderately correlated between S and L at rest (r = 0.61, p &lt; 0.01), and during stress (r = 0.476, p &lt; 0.01). Rest-stress variations were not correlated (r = 0.004, p = NS).

Conclusion LA measurement is highly feasible during SE with L and S methods. Absolute values with both are only moderately correlated at rest, less at peak stress, and not correlated when only rest-to-stress variations are considered. Although L is more feasible, less time-consuming, and more reproducible, S should be the first choice for more accurate assessment of rest-stress LA dimensions in pharmacologic SE.

Abstract P326 Figure. Correlation of LA rest-stress

Biologic therapy use and pregnancy outcomes in women with immune-mediated inflammatory rheumatic diseases

INTRODUCTION

Concerns about the side effects and interactions of biologic drugs with reproduction and pregnancy have been always an issue between experts. The safety of these therapies during conception and/or pregnancy is not fully understood. The aim of this study was to assess the exposure to biologic drugs before and/or during conception/pregnancy and the risk of adverse pregnancy outcomes in women with rheumatic diseases.

METHODS

We conducted a cohort study of pregnancies reported in women with immune-mediated rheumatic diseases registered at the Rheumatic Diseases Portuguese Registry (Reuma.pt) and exposed to biologic drugs. Data concerning fetal and maternal outcomes (live birth, spontaneous abortion, neonatal and intrauterine death, intrauterine growth restriction, premature delivery, congenital malformations, neonatal lupus, voluntary or medical interruption of pregnancy, disease flares and need for treatment with other drugs) was extracted.

RESULTS

In total, 69 pregnancies from 56 females were analysed, the majority with the diagnosis of spondyloarthritis or rheumatoid arthritis. In almost half of the cases (n=32, 46.4%) the biologic was stopped for pregnancy planning, in 31 cases (44.9%) it was stopped when pregnancy was diagnosed and in 6 pregnancies (8.7%) biologic therapy was maintained, at least until the 2nd trimester. There were 76.8% of live births and 22% of spontaneous abortions. Congenital anomalies were reported in 2 newborns.

CONCLUSIONS

In half cases, it was decided to stop biologic therapy in the family planning period. Using biologic disease-modifying anti-rheumatic drugs before and/or during pregnancy doesn't seem to affect the overall maternal and fetal outcomes. Pregnancy planning and treatment options should be discussed and a shared decision should be established between physician and patient.

Hand function and adaptive equipment use in patients with rheumatoid arthritis

OBJECTIVES

Evaluation and characterization of hand function in patients with rheumatoid (RA) arthritis and, secondarily, identification of the use of adaptive equipments.

MATERIAL AND METHODS

Firstly, a written informed consent was obtained and then an anonymous questionnaire was filled by RA outpatients after observation at the rheumatology consultation with no other musculoskeletal or neuromuscular disorders that would determine major functional impairment of hand function. Sociodemographic and clinical variables were collected and the Cochin Hand Functional Scale (CHFS) was applied. Classical deformities of hand and/or wrist were observed and recorded by the attending physician.

RESULTS

A total of 79 patients were enrolled. In the overall sample, most patients were female A sample of 79 patients, mostly female (69.60%), with a mean age of 59.72 ± 11.77 years and with a mean diagnosis duration of 11.72 ± 8.29 years. The majority (73.40%) had at least one hand or wrist deformity, the most frequent being atrophy of the interosseous muscles followed by ulnar deviation of the metacarpophalangeal joints and piano key deformity of the wrist. The mean CHFS score was 17.94 ± 18.26 points with a minimum and maximum value recorded of 0 and 80 points, respectively. The presence of hand deformities, Health Assessment Questionnaire score (HAQ), hand pain and diagnosis duration were correlated with the CHFS score. Six patients had assistive devices and only in one case it was used to overcome hand's functional impairment.

CONCLUSIONS

Most patients presented at least one classic RA deformity after a mean diagnosis duration of approximately 12 years and under pharmacological treatment. Despite this, most patients scored significantly below CHFS maximum score, but only 18 reported no difficulty in any of the tasks mentioned in the scale. The fact that only a minority of these patients had assistive devices should alerts us to the need for a more thorough functional assessment and identification of needs among RA patients.

Psoriatic arthritis and ankylosing spondylitis impact on health-related quality of life and working life: a comparative population-based study

INTRODUCTION

Psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are chronic disorders that significantly impact patients' quality of life (QoL), health care systems and society. There is very little data on the epidemiology and the impact of PsA and AS in Portugal, so in this study we aim to: 1) estimate the prevalence of PsA and AS in the adult Portuguese population; 2) compare health-related quality of life (QoL) of PsA and AS with the one of other rheumatic and musculoskeletal diseases (RMD) and with subjects with no rheumatic diseases; 3) compare early retirement and productivity loss among PsA and AS with other RMD.

METHODS

We used data from EpiReumaPt, a population-based survey, conducted from 2011 to 2013, in which 10661 subjects over 18 years old were screened for RMD. Spondyloarthritis (SpA) was defined by a positive expert opinion combined with the fulfillment of the assessment of spondyloarthritis international society (ASAS) criteria for axial and peripheral SpA. Estimates were computed as weighted proportions considering the study design. Logistic regressions were used to compare AS/PsA subjects with other RMD and the adult Portuguese population without rheumatic diseases.

RESULTS

Prevalence rate of SpA was 1.6% (95% CI 1.2% to 2.1%). Subjects with AS or PsA had worse QoL, reflected by EQ5D score when compared with the adult Portuguese population without rheumatic diseases (β=- 0.08; p=0.031). AS and PsA also had worst QoL when compared with participants with other RMD (β=-0.22; p>0.001). AS and in comparison to patients with other RMD, PsA subjects retired early due to their illness (OR=4.95; 95% CI 1.54% to 15.93%). A significant proportion of patients with SpA (13.6%) referred absenteeism in the previous 12 months to the interview.

CONCLUSIONS

AS and PsA were found to be associated with poor QoL and a high rate of disease-related early retirement, emphasizing the burden of such rheumatic conditions in Portugal.

ZnO decorated laser-induced graphene produced by direct laser scribing

A scalable laser scribing approach to produce zinc oxide (ZnO) decorated laser-induced graphene (LIG) in a unique laser-processing step was developed by irradiating a polyimide sheet covered with a Zn/ZnO precursor with a CO₂ laser (10.6 μm) under ambient conditions. The laser scribing parameters revealed a strong impact on the surface morphology of the formed LIG, on ZnO microparticles' formation and distribution, as well as on the physical properties of the fashioned composites. The ZnO microparticles were seen to be randomly distributed along the LIG surface, with the amount and dimensions depending on the used laser processing conditions. Besides the synthesis conditions, the use of different precursors also resulted in distinct ZnO growth's yields and morphologies. Raman spectroscopy revealed the existence of both wurtzite-ZnO and sp² carbon in the majority of the produced samples. Broad emission bands in the visible range and the typical ZnO near band edge (NBE) emission were detected by photoluminescence studies. The spectral shape of the luminescence signal was seen to be extremely sensitive to the employed processing parameters and precursors, highlighting their influence on the composites' optical defect distribution. The sample produced from the ZnO-based precursor evidenced the highest luminescence signal, with a dominant NBE recombination. Electrochemical measurements pointed to the existence of charge transfer processes between LIG and the ZnO particles.

First steps to understand productivity loss in Portuguese patients with rheumatoid arthritis

Rheumatoid Arthritis (RA), in consequence of joint inflammation and damage, is known to lead to productivity loss. Developments during the 21st century, such as biologic treatments, allowed remission/low disease activity to be achieved in more RA patients. Despite this, evidence is equivocal concerning work outcomes improvement. Our goal was to evaluate work status and productivity in a Portuguese population with RA from 3 Rheumatology Departments through the questionnaire Work Productivity and Activity Impairment General Health (WPAI).

Source-Sink Regulation in Crops under Water Deficit

To meet the food demands of an increasing world population, it is necessary to improve crop production; a task that is made more challenging by the changing climate. Several recent reports show that increasing the capacity of plants to assimilate carbon (source strength), or to tap into the internal carbon reservoir (sink strength), has the potential to improve plant productivity in the field under water-deficit conditions. Here, we review the effects of water deficit on the source-sink communication, as well as the respective regulatory mechanisms underpinning plant productivity. We also highlight stress-tolerant traits that can contribute to harness source and sink strengths towards producing high-yielding and drought-tolerant crops, depending on the drought scenario.

Sonoanatomy of anterior forearm muscles

The anterior or volar compartment of the forearm contains eight muscles: five belong to the superficial group (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis and flexor carpi ulnaris), and three to the deep group (flexor digitorum profundus, flexor pollicis longus and pronator quadratus). Knowledge of the topographic anatomy is essential for correct performance of ultrasound (US) examinations and correct interpretation of the images provided.