[Systematic investigation of surgical site infections (SSI) in plastic reconstructive and aesthetic surgery (ERCS): Feedback]

Surgical site infection (SSI) in plastic, reconstructive and aesthetic surgery (ERCP) is quite uncommon compared to other surgical specialities but remains one of the main complications. The aim of our study was to provide feedback on the systematic investigation of SSI in ERCP. This is a monocentric retrospective study, including all paediatric and adult patients who have undergone ERCP surgery between 01/01/2014 and 31/12/2021. During this period, the department systematically investigated all SSI cases. Eight thousand eight hundred and seventy-eight surgical procedures were performed. The SSI rate was 0.34%. Thirty SSIs (19W,11M), with a mean age of 56 years (none paediatric), were investigated. Twenty-seven patients suffered from comorbidities. The surgical indications included 17 cases of skin cancer, 7 cases of weight loss, 4 cases of breast reconstruction, 1 lipoma, 1 pectus excavatum. Eleven surgeries consisted in lymphnode procedures (8 sentinel lymphnodes, 3 curage). The average operating time was 116minutes. Nineteen patients received antibiotic prophylaxis. The average time to onset of SSI after surgery was 10 days. The most prevalent bacteria were commensals of the skin flora and the digestive tract. Apart from surgical management, 100% of patients were treated with antibiotics. High age, multiple comorbidities, long, combined procedures, placement of equipment, lymph node surgery, post-operative punctures on implanted equipment, are all risks factors for SSI. The implementation of a systematic monitoring of SSI within our department has provided us with the opportunity to analyse our data in real time and allow us to adjust our practices if necessary. This process can be used in other plastic reconstructive and aesthetic surgery departments. The collection and analysis of SSIs is both easily done and the procedure is well standardized. The assistance of the operational hygiene team is a key asset for the success of this project. The development of this type of procedure on a national level could be an asset to improve the management of SSI by taking advantage of the experience of a larger number of centres.

Rates and correlates of alcohol and substance use among women Veterans during the COVID-19 pandemic: The moderating role of COVID-specific anxiety

Introduction

Mental health symptoms and substance use increased during the COVID-19 pandemic and women may be disproportionately impacted. Women report substantial mental health consequences, and women veterans may experience additional risks associated with military service. However, rates and correlates of substance use and consequences among women veterans are largely unknown. This study aims to 1) report rates of substance use and consequences among women veterans; 2) identify correlates of substance use and consequences; and 3) test COVID-specific anxiety as a moderator.

Method

Women veterans (n = 209) enrolled in Veteran’s Health Administration (VHA) primary care completed measures of demographics, psychiatric and substance use disorder (SUD) diagnoses, current mental health symptoms, alcohol consumption, drug-related problems, and COVID-specific anxiety. Bivariate correlations evaluated demographics (age, race, employment, relationship status), psychiatric (depression/anxiety/PTSD) and SUD diagnoses, and current mental health (depression/anxiety) symptoms as correlates of substance use outcomes. For any relationships between correlates and outcomes that were statistically significant, COVID-specific anxiety was tested as a moderator using the PROCESS macro in SPSS version 27. Any statistically significant moderation effects were further investigated using the PROCESS macro to estimate conditional effects. COVID-specific anxiety was mean-centered prior to analyses. Alpha was set to .05 for all statistical tests.

Results

36% screened positive for hazardous (AUDIT-C ≥ 3) alcohol consumption and 26% reported drug-related problems (18% low-level, 7% moderate-level, and 2% substantial per DAST-10 scores). Drug-related problems were positively associated with: COVID-specific anxiety, psychiatric diagnosis, SUD diagnosis, and depression symptoms. Alcohol consumption was significantly associated with SUD diagnosis. COVID-specific anxiety significantly moderated relationships between SUD diagnosis and both outcomes.

Discussion

Results help identify women veterans with SUD diagnoses and high COVID-specific anxiety as at risk for increased substance use during COVID-19 and suggest a potential intervention target (COVID-specific anxiety).

O-218 Single-cell RNA sequencing reveals that Ashermańs syndrome is caused by chronic inflammation that induces differential molecular and cellular cartography in the human endometrium

Study question

What is the differential cellular, transcriptomic and immunological differences of the human endometrium in AS versus healthy patients at single cell resolution?

Summary answer

The epithelial fraction is decreased, the myeloid and lymphoid cell lineages increased with an altered inflammation, inhibition of angiogenesis and EM abnormal remodeling.

What is known already

Asherman’s Syndrome (AS) is an acquired pathological condition, defined by the presence of intrauterine adhesions (IUAs) causing the uterine walls to adhere to one another resulting in menstrual abnormalities, pelvic pain, infertility, recurrent miscarriage, and abnormal placentation. However, the underlaying cellular, transcriptomic and immunological mechanisms at the single-cell level that occur in AS have not been investigated. 

Study design, size, duration

Single cell RNA-seq (scRNA-seq) was performed on 41,854 cells corresponding to endometrial biopsies from a total of 7 individuals with severe AS (AFS classification 1998). These patients were involved in a phase I/II, prospective, non-randomized, uncontrolled, multicenter, interventional clinical trial authorized by the Spanish Medicines Agency (AEMPS)(2016-003973-23). Control healthy endometrium was represented by 68,026 cell transcriptomes from our previous work (Wang et al. 2020). 

Participants/materials, setting, methods

Seven patients were included. Ultrasound and hysteroscopies were performed in mid secretory phase. Endometrial specimens were digested with collagenase and filtered. Epithelial cells were digested with trypsin and red blood cells removed. After MACS live enrichment, cells were loaded onto ChromiumNext GEM (10xGenomics). Libraries were sequenced in a Novaseq, and reads processed with CellRanger. Quality filtering, normalization, clustering and differential expression analysis were applied from ‘Seurat’ package. Functional enrichment analysis was computed using ‘escape’ package.

Main results and the role of chance

In total 109,880 cell transcriptomes were compared and found changes in cell population ratios in two specific cell types. First, the epithelial fraction was decreased in AS compared to healthy condition (26.53% vs 45.7%, respectively) specifically the epithelium representing the opening of the window of implantation (WOI) (0.25% vs 2.01%respectively), and the ciliated epithelium (0.84% vs 6.12%, respectively). Second, the myeloid and lymphoid cell lineages, which are much more abundant in AS samples. Macrophages (1.97% vs 0.24%, respectively), CD8+ T cells (3.71% vs 1.34%, respectively), and CD8- T cells (2.28% vs 0.55%, respectively).

In addition, there was a different transcriptomic composition represented by three differential linked clusters related to AS condition. First, a unique stromal cluster labelled as stromal_ACTA2 that express genes related to contractile functions (ACTA2, MYH11, DES). Second, a specific AS epithelium cluster closely related to antigen processing and presentation of HLA class II family genes. Third, a KRT8 ACTA2 cluster composed by genes related to collagen (COL3A1 and COL1A1) and IGFBP5.

Enrichment analysis performed with ssGSEA revealed the functional impact of the AS condition identifying an increase in different GO terms related to tissue damage, pro-inflammatory processes, inhibition of angiogenesis.

Limitations, reasons for caution

Despite these promising results, this is an study in progress to be completed with 10 patients 

Wider implications of the findings

These findings describe for the first time the pathophysiology of AS at single cell level with the functional involvement of inflammation, fibrosis, and defective angiogenesis in this pathological condition. 

Trial registration number

Eudra CT 2016-003975-23

POS0494 ARTERIAL WALL DENDRITIC CELLS IN GIANT CELL ARTERITIS (GCA) AND POLYMYALGIA RHEUMATICA (PMR)

Background

Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease (1) associated in 16 to 21% of cases with giant cell arteritis (GCA). The association of these two conditions raises the question of a pathophysiological continuum between PMR and GCA. An early study reported mature arterial wall dendritic cells (DC) in patients with GCA or PMR leading, during GCA, to CD4+ T cell recruitment and the development of vasculitis (2). However, these data have never been confirmed in other studies. There are 3 main types of DC: plasmacytoid DC (expressing CD123), conventional DC (cDC) expressing CD141 (cDC1) or CD1c (cDC2) and monocyte-derived DC (mo-DC) expressing CD14.

Objectives

The aim of this study was to describe the arterial wall infiltrating DCs, their phenotype and maturation state, during PMR and GCA.

Methods

Using temporal artery biopsies (TAB) from patients with PMR, GCA and healthy controls, the level of expression of CD11c, CD83, CCR7, CCR6, CD1c, CCL18, CCL19, CCL20, CCL21, GM-CSF, CD3, CD68 genes was assessed by RT-PCR. Expression of markers of DC lineage (CD209), DC maturation state (CD83 and CCR7) and DC origin (CD14, CD68, CD1c, CD141) were studied by confocal microscopy.

Results

Fourty-one patients were included (14 GCA, 16 PMR, 11 controls). Within the arterial wall, DCs were identified in GCA patients, with a mature DC phenotype (CD209+CD83+CCR7+). DC were present in all three layers of the arterial wall and also expressed CD14 and often CD68 but neither CD1c nor CD141, which could be explained by a monocytic/macrophage origin. TAB from GCA patients were characterized by a high level of expression of CD83, CCR7, CCR6, CCL18, CCL19, CCL20, CD11c, GM-CSF, CD3 and CD68 gene. This expression was significantly higher (p<0.05) compared to the control and PMR groups.

Confocal microscopy analyses of arteries from the PMR and controls did not detect the presence of DCs into the arterial wall. In addition, level of expression of CD83, CCR7, CCL18, CCL19, CCL21 and CD68 genes in temporal arteries was comparable between PMR and healthy controls.

Conclusion

This work confirms the presence of mature CD209+CD83+CCR7+ DCs within the arterial wall in GCA. The phenotype of these DCs mainly fits with DC of monocytic origin (mo-DCs). However, both by RT-PCR and confocal microscopy, we did not identify DCs in the arterial wall of PMR patients. This discrepancy with previous work (3) could be explained by a better diagnosis of GCA in PMR patients since the development of imaging techniques.

References

[1]Weyand CM, Goronzy JJ. Giant-Cell Arteritis and Polymyalgia Rheumatica. N Engl J Med. 2014;371:50-7.

[2]Samson M, Corbera-Bellalta M, Audia S, Planas-Rigol E, Martin L, Cid MC, et al. Recent advances in our understanding of giant cell arteritis pathogenesis. Autoimmun Rev. 2017;16:833-44.

[3]Ma-Krupa W, Jeon M-S, Spoerl S, Tedder TF, Goronzy JJ, Weyand CM. Activation of Arterial Wall Dendritic Cells and Breakdown of Self-tolerance in Giant Cell Arteritis. J Exp Med. 2004;199:173-83.

Disclosure of Interests

None declared.

AB1348 COMPARISON OF SACROILIAC CT FINDINGS IN PATIENTS WITH AND WITHOUT PSORIATIC ARTHRITIS: RESULTS OF THE CASIPSA STUDY

Background

Psoriatic arthritis (PsA) is an inflammatory arthritis associated with various rheumatological manifestations, such as arthritis or enthesitis, predominantly in the peripheral skeleton. However, the axial skeleton may be affected, as shown clinically or by conventional radiographs in up to 70% of patients with peripheral involvement. While there are studies comparing joint damage on standard radiography between patients with PsA and patients with ankylosing spondylitis [1], to our knowledge, no study has specifically evaluated the extent of structural lesions of the sacroiliac joints (SIJs) on computed tomography (CT) in patients with PsA compared with healthy controls.

Objectives

To describe SIJ CT characteristics in patients with PsA and compare them with those of age- and sex-matched controls.

Methods

An observational, retrospective study was performed using medical records from Besançon and Dijon University Hospital’s rheumatology departments, which were screened to identify patients with PsA, according to the CASPAR criteria. A search was then carried out for patients in the hospitals’ imaging archiving system to identify those who had undergone a CT which included the SIJs in their entirety. Non-inclusion criteria were the existence of pelvic bone lesions and a history of pelvic radiotherapy. Each patient was then matched with a control of the same age and sex, recruited through the hospital’s imaging archiving system.

For each individual, CT was interpreted by two independent readers using a score previously used by Diekhoff et al. [2], dividing each SIJ into 12 regions, for each of which joint space narrowing (JSN), erosions, and sclerosis are assessed. For this study, we also observed the existence of intra-articular gas and diffuse idiopathic skeletal hyperostosis (DISH) lesions for each region. Quantitative variables were compared using Student’s t-test. Qualitative variables were compared using the Chi-2 test.

Results

48 patients and 48 controls were included. Mean (SD) age was 54.76 ± 12.91 in the PsA group and 54.74 + 12.87 in the control group. 26 (54.18%) were male in both groups. In PsA patients, mean (SD) disease duration was 22.87 ± 14.95 years, 10 (43.48 %) were HLA-B27 positive, and 1 (2.86%) had a bamboo spine. CT findings are described in Table 1. The only lesion found significantly more frequently in PsA patients was erosion, which appeared to be preferentially located on the anterior and middle regions of the SIJs (Figure 1). A positive CT scan (significant joint space narrowing, erosion and/or sclerosis) was found in 15 (32.61%) of the patients with peripheral involvement and 6 (30.00%) of the patients with axial involvement.

Table 1.

Sacro-iliac CT findings using a score modified from Diekhoff et al.

FindingPsA PatientsControlsp-valueMean (SD) total score (range 0-264)26.37 ± 29.1214.47 ± 10.850.01Global positivity, n (%)16 (33.33 %)10 (20.83 %)0.17Bilateral ankylosis, n (%)5 (10.42 %)0 (0.00 %)0.02Positive joint space score, n (%)15 (31.25 %)10 (20.83 %)0.25Positive erosion score, n (%)9 (18.75 %)1 (2.08 %)0.008Significant sclerosis, n (%)11 (22.92 %)12 (25.00 %)0.81Intra-articular gas, n (%)29 (60.42 %)35 (72.92 %)0.19DISH, n (%)9 (18.75%)11 (22.92 %)0.62Figure 1.

Mean scores by region on anterior, middle, and posterior slices (JS: joint space, Ero: erosions, Scl: sclerosis) in PsA patients (A) and controls (B).

Conclusion

The CT characteristics of SIJs from patients with PsA were similar to those of age- and sex-matched controls, but with a higher prevalence of erosions. Structural lesions of the SIJs were found in nearly one PsA patient out of three.

References

[1]Jadon DR, Sengupta R, Nightingale A, et al. Axial Disease in Psoriatic Arthritis study: defining the clinical and radiographic phenotype of psoriatic spondyloarthritis. Ann Rheum Dis. 2017;76:701–7.

[2]Diekhoff T, Hermann K-GA, Greese J, et al. Comparison of MRI with radiography for detecting structural lesions of the sacroiliac joint using CT as standard of reference: results from the SIMACT study. Ann Rheum Dis. 2017;76(9):1502-1508.

Disclosure of Interests

None declared

POS0252 MYOFIBROBLASTS MAINTAIN Th1 and Tc1 POLARIZATIONS IN GIANT CELL ARTERITIS

Background

Giant cell arteritis (GCA) is a large-vessel vasculitis mainly involving the aorta and cranial arteries. It is the most frequent vasculitis in adults over 50 years. When they are stimulated by interferon-gamma (IFN-γ), vascular smooth muscle cells (VSMC) contribute to GCA pathogenesis by producing chemokines triggering the recruitment of pro-inflammatory T cells and monocytes (1).

Objectives

Current knowledge about the interaction between resident cells of the vascular wall (VSMC, myofibroblasts [MF]) and immune cells is limited. The aim of our research was to better characterize the interactions between VSMC, MF and T cells in GCA.

Methods

Fresh fragments of temporal artery biopsies (TAB) performed at Dijon university hospital (France) were prospectively sent to our research unit. Fresh sections of positive and negative TAB were fixed and embedded in optimal cutting temperature OCT and stored at -80°C. Then, cryostat sections were fixed, permeabilized, blocked and incubated with primary antibodies (anti-alpha smooth muscle actin [α-SMA], anti-myosin heavy chain 11 [MHC11], anti-Desmin, anti CD90, anti-CD45, anti-HLA-DR, anti-phospho STAT1 [pSTAT1] and anti-pSTAT3) and secondary antibodies for confocal microscopy analyses. Fresh sections of healthy TAB were embedded in MATRIGEL and covered by DMEM to obtain vascular cells in culture. Cells were treated with trypsina-EDTA between each passage. Vascular cells were used after 4-7 doubling passages. Cells were analyzed by immunofluorescence, flow cytometry and RT-PCR and their proliferation was evaluated by impedancemetry (iCELLigence system). Peripheral blood mononuclear cells (PBMC) and vascular cells thus obtained were co-cultured for 7 days in different conditions. Vascular cells were cultured in the presence or absence of IFN-γ and tumor necrosis factor alpha (TNF-α) or interleukin-6 (IL-6) and soluble receptor of IL-6 for 72 hours. When cells reached confluence, they were cultured alone or with allogenic PBMC activated with anti-CD3/CD28 microbeads. After 7 days of culture, cells were separated with a treatment with EDTA and studied by flow cytometry.

Results

Confocal microscopy analyses of GCA arteries showed that neointima was mainly composed of myofibroblasts (MF) (α-SMA+Desmin+MHC11lowCD90+) in contact with CD45+ cells and that MF expressed HLA-DR, the phosphorylated form of STAT1 (pSTAT1) and in a lesser extent pSTAT3, strongly suggesting the activation of the IFN-γ signaling pathway rather than the IL-6 pathway. The phenotype of cultured vascular cells isolated from fresh TAB was consistent with MF. When MF were exposed to IFN-γ and TNF-α in vitro, their proliferation capacity decreased and their levels of expression of HLA-DR and CD86 increased (median fluorescence intensity [MFI] from 0 to 57 [p=0.03] and from 34 to 103 [p=0.03], respectively). In addition, co-cultures of MF and activated PBMC revealed that MF maintained the polarization of T cells into Th1 and Tc1 cells (p≤0.001) and to a lesser extent into Th17 and Tc17 cells (p=0.03). This effect was even more significant when MF were previously exposed to IFN-γ and TNF-α but not when they were exposed to IL-6.

Conclusion

Our results show that myofibroblasts are present in the neointima of GCA patients and that these MF activate signaling pathways indicative of IFN-γ exposure. Moreover, these MF, especially when exposed to IFN-γ, maintain the polarization of T cells into Th1 and Tc1 cells, which contributes to amplify the production of IFN-γ and thus initiate a pro-inflammatory amplification loop that likely participates in vascular inflammation and remodelling.

References

[1]Corbera-Bellalta M, Planas-Rigol E, Lozano E, Terrades-Garcia N, Alba MA, Prieto-Gonzalez S, et al. Blocking interferon gamma reduces expression of chemokines CXCL9, CXCL10 and CXCL11 and decreases macrophage infiltration in ex vivo cultured arteries from patients with giant cell arteritis. Ann Rheum Dis 2016;75:1177-86.

Disclosure of Interests

None declared

AB1558-HPR TELERHEUMATOLOGY WITH PRIMARY CARE CENTERS: FEEDBACK FROM AN EXPERIMENTAL TELEMEDICINE PROJECT IN BURGUNDY (2019-2021)

Background

Telemedicine could be an innovative and sustainable response for rheumatologic advice in areas with low medical density. Improving coordination of investigations, access to allied health members and dedicated telehealth platform may improve the management of many rheumatologic patients.

Methods

This French TeleRheumatology project with multidisciplinary primary care centres was set up in 2019, specifically targeting the Burgundy region in Eastern France and was financed by the Regional Health Agency. Four rheumatologists from the Dijon University Hospital took turns to respond to the various requests for telemedicine (teleconsultation, teleexpertises) on a dedicated digital platform integrating a medical imaging viewer. In addition to the activity (number and type of procedures performed) and the distances avoided for the patient for rheumatology consultation, feasibility of this colaborative digital project was assessed on the basis of a participant satisfaction questionnaire (rheumatologists, general practitioners and patients).

Results

From October 2019 to january 2022, this TeleRheumatology project allowed the progressive integration of 23 primary care centres despite the concomitant COVID-19 crisis which slowed down the deployment. 212 procedures were performed (96% teleexpertises): 76% for mechanical disorders (spine 31%, osteoporosis 19%, osteoarthritis 15%), 18% for inflammatory rheumatism, 53% advice for diagnosis, 41% for management and/or therapy, 89% with imaging (X-Rays, CT- Scan, MRI) to be reviewed. The average response time was 16 hours and the average number of round-trip kilometers avoided was 216. Only 15% of the rheumatologic advices led to a face-to-face consultation or hospitalization at the University Rheumatology Department and 6% to other specialists. 97% of the patients would like to use this Telerheumatology program again (Satisfaction score: 9.1/10). 100% of the expert rheumatologists (satisfaction score 9.25/10) and the general practitioners (satisfaction score: 9.0/10) wanted to continue this digital health partnership in their daily practice.

Conclusion

Despite the inherent limitations of telemedicine (absence of clinical examination, technical barriers of interoperability, etc.), this french innovative TeleRheumatology project with primary care centres has shown encouraging results in terms of acceptability and satisfaction thanks to the coordination of the Regional Health agency and physicians’ motivations. Telerexpertise seems to be the preferred modality given its better practical feasibility. Approval and acceptance are increasing in the Rheumatology community because telemedicine appears to be an effective tool for improving health care access as demonstrated by its rapid expansion, especially during the COVID-19 pandemic.

References

[1]Opportunities and Barriers of Telemedicine in Rheumatology: A Participatory, Mixed-Methods Study.Muehlensiepen F, Knitza J, Marquardt W, May S, Krusche M, Hueber A, Schwarz J, Vuillerme N, Heinze M, Welcker M. Int J Environ Res Public Health. 2021 Dec 13;18(24):13127.

Disclosure of Interests

None declared

OP0066 IMPACT OF DIAGNOSIS AND TREATMENT OF TROPHERYMA WHIPPLEI INFECTION IN PATIENTS WITH PRE-EXISTING CHRONIC INFLAMMATORY RHEUMATIC DISEASES: DATA FROM THE NATIONAL Tw-IRD REGISTRY

Background

Tropheryma whipplei (Tw) infection is a rare condition, characterized by inflammatory joint symptoms in more than 75% of the cases, which can lead the physician to diagnose chronic inflammatory rheumatic diseases (IRD) and to initiate DMARDs. DMARDs are often ineffective and may reveal digestive signs, systemic manifestations or involvement of other organs. We hypothesized that treatment of Tw infection has a favorable impact on rheumatologic and extra-rheumatologic manifestations attributed to IRD.

Objectives

To validate this hypothesis, we initiated a registry with the objectives to describe the characteristics of IRD and their treatments, the diagnostic and therapeutic modalities of Tw infections and the impact of the treatment of Tw infection on the evolution of IRD and associated DMARDs.

Methods

We initiated a French National register including adult patients with pre-existing IRD, treated with DMARDs, later diagnosed with Tw infection. Cases were identified through a call for observation via the “Club Rhumatismes et inflammations” website. We collected clinical and biological data about the characteristics of IRD and their treatments, the diagnostic and therapeutic modalities of Tw infections, and the impact of the treatment of Tw infection on the evolution of IRD and associated DMARDs.

Results

Seventy-three IRD patients were included. Mean age at diagnosis was 49 years (SD +/- 10.9), with 78% of men, median IRD duration was 79 months (IQR 36; 140), including rheumatoid arthritis (31 cases), spondyloarthritis (14 cases), psoriatic arthritis (6 cases) and other IRDs (22 cases). All IRD patients were treated with DMARDs, with no therapeutic response in 51% of the cases, worsening of rheumatologic symptoms in 34% of the cases, and occurrence of extra-articular manifestations in 27% of the cases. Screening for Tw infection mainly involved saliva and stool PCR, while diagnostic modalities involved organ specific PCR and biopsies, in particular duodenal biopsies (PCR positive in 87% of cases and histology in only 38% of cases). At the time of Tw infection diagnosis, mean age was 58 years (SD +/- 10.1), all patients had joint involvement, 33% axial involvement, 11% entheseal involvement, 84% extra-articular manifestations, 93% elevated CRP, 86% hypoalbuminemia and 67% anemia. Tw infection treatment modalities (median follow-up of 22 months) mainly involved a combination of doxycycline (95%) and hydroxychloroquine (96%), with complete recovery in 79% of the cases and Tw-related deaths in 2 cases. At the same time, Tw infection treatment was associated with IRD remission in 93% of cases, with a median time to remission of 2 months (IQR 1; 4.25), leading to DMARD withdrawal in 94% of cases and corticosteroid therapy withdrawal in 65% of cases.

Conclusion

A Tw infection should be considered in IRD patients with peripheral joint involvement and inadequate response to DMARDs, particularly in the presence of extra-articular manifestations, elevated CRP and hypoalbuminemia. In such patients, positive results of screening and diagnostic tests for Tw infection may lead to the initiation of Tw infection treatment which is associated with complete recovery of Tw infection and rapid remission of the IRD, allowing DMARD and corticosteroid therapy withdrawal in most the cases.

References

[1]Marth T. Tropheryma whipplei infection and Whipple’s disease. The Lancet Infectious Diseases 2016;16(3):e13–22.

[2]Puéchal X. Whipple’s arthritis. Joint Bone Spine 2016;83(6):631–5.

Acknowledgements

Club Rhumatismes et Inflammations.

Disclosure of Interests

None declared.

POS1129 OPTIMIZATION OF DUAL ENERGY COMPUTED TOMOGRAPHY POST-PROCESSING TO REDUCE LOWER LIMB ARTIFACTS IN GOUT

Background:

Dual energy computed tomography (DECT) is highly accurate for the diagnosis of gout. However, many artifacts have been described (1,2) such as nail bed, skin, beam hardening, sub-millimeter and vascular artifacts). Their presence can lead to a risk of over-diagnosis (false positives).

Objectives:

Main objective of this case-control study was to determine the optimal DECT settings post-treatment parameters (ratio and attenuation coefficient (HU)) in order to reduce the frequency of lower limb artifacts in patients with suspected gout of the lower limbs.

Methods:

Seventy-seven patients hospitalized for suspected gout arthritis (feet/ankles and/or knees) who received a DECT imaging were consecutively included (final diagnosis of 43 gout and 34 other rheumatic disorders). Different post-treatment settings were evaluated from the Syngovia software: an R1 (standard) setting with a ratio at 1.36 and minimum attenuation at 150 HU; an R2 setting with a ratio at 1.28 and minimum attenuation at 170 HU and an R3 setting with a ratio at 1.28 and minimum attenuation at 120 HU. The frequency of each artifact according to the 3 settings was determined. Diagnostic accuracy of R1 and R2 settings has been calculated. Correlations between artefacts and patient’s clinical characteristics were obtained by performing a Spearman test.

Results:

The R2 setting (170 HU, ratio=1.28) significantly reduced the presence of knee and foot/ankle artifacts compared to the standard R1 setting (85% and 94% decrease in beam hardening and clumpy artifacts in the ankle and foot, respectively (p < 0.001); a decrease of 71%, 60% and 88% respectively of meniscal beam hardening, beam hardening and submillimeter artifacts in the knee (p < 0.001). The use of R3 setting lead to a significant increase of some artifacts (clumpy artifacts, skin artifacts, beam hardening and nail beds.). In addition, our results found a positive correlation between the presence of deposits of knee menisci beam hardening chondrocalcinosis. Body mass index was also positively correlated with the presence of knee beam hardening artifact. Compared to standard setting, the use of R2 settings decreased sensitivity (0.79 [95CI: 0.65;0.88] versus 0.90 [95CI: 0.78;0.96] and increased specificity (0.86 [95CI: 0.71;0.93) versus 0.63 [95CI: 0.47;0.77] (p<0.001).

Conclusion:

Applying a ratio of 1.28 and a minimum attenuation of 170 HU (R2 settings) in DECT post-processing eliminates the majority of the artifacts located on the lower limbs, particularly the clumpy artifact and the beam hardening artifact.

References:

[1]Neogi T, Jansen TLTA, Dalbeth N, Fransen J, Schumacher HR, Berendsen D, et al. 2015 Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis. 2015;74:1789-98.

[2]Mallinson PI, Coupal T, Reisinger C, Chou H, Munk PL, Nicolaou S, et al. Artifacts in dual-energy CT gout protocol: a review of 50 suspected cases with an artifact identification guide. AJR 2014;203:W103-109.

Disclosure of Interests:

None declared.

Effectiveness, safety, and cost-utility of a knee brace in medial knee osteoarthritis: the ERGONOMIE randomized controlled trial

OBJECTIVE

This pragmatic, multicenter, open-label, randomized controlled trial (RCT) aimed to compare the effectiveness, safety, and cost-utility of a custom-made knee brace versus usual care over 1 year in medial knee osteoarthritis (OA).

DESIGN

120 patients with medial knee OA (VAS pain at rest >40/100), classified as Kellgren-Lawrence grade II-IV, were randomized into two groups: ODRA plus usual care (ODRA group) and usual care alone (UCA group). The primary effectiveness outcome was the change in VAS pain between M0 and M12. Secondary outcomes included changes over 1 year in KOOS (function) and OAKHQOL (quality of life) scores. Drug consumption, compliance, safety of the knee brace, and cost-utility over 1 year were also assessed.

RESULTS

The ODRA group was associated with a higher improvement in: VAS pain (adjusted mean difference of -11.8; 95% CI: -21.1 to -2.5); all KOOS subscales (pain: +8.8; 95% CI: 1.4-16.2); other symptoms (+10.4; 95% CI: 2.7-18); function in activities of daily living (+9.2; 95% CI: 1.1-17.2); function in sports and leisure (+12.3; 95% CI: 4.3-20.3); quality of life (+9.9; 95% CI: 0.9-15.9), OAKHQOL subscales (pain: +14.8; 95% CI: 5.0-24.6); and physical activities (+8.2; 95% CI: 0.6-15.8), and with a significant decrease in analgesics consumption at M12 compared with the UCA group. Despite localized side-effects, observance was good at M12 (median: 5.3 h/day). The ODRA group had a more than 85% chance of being cost-effective for a willingness-to-pay threshold of €45 000 per QALY.

CONCLUSIONS

The ERGONOMIE RCT demonstrated significant clinical benefits of an unloader custom-made knee brace in terms of improvements in pain, function, and some aspects of quality of life over 1 year in medial knee OA, as well as its potential cost-utility from a societal perspective.

THU0441 DIAGNOSTIC ACCURACY OF THE NIJMENGEN SCORE FOR GOUTY ARTHRITIS IN PATIENTS HOSPITALIZED FOR ACUTE MONOARTHRITIS

Background:

The gold-standard for diagnosis of gout is the identification of monosodium urate (MSU) crystal in joint fluid. However, the sensitivity, specificity, and reproducibility of such analysis are not excellent, and joint aspiration is sometimes difficult, or impossible. The Nijmengen score is an easy-to-use rule without joint fluid analysis with excellent validity, in primary as well as in secondary care (1, 2). However, it’s validity as not been evaluated in the particular situation of patients whose acute arthritis necessitates hospitalization.

Objectives:

The objective of the present study was to assess diagnosis performances of the score in patients hospitalized for acute monoarthritis.

Methods:

Inclusion: all patients hospitalized for acute monoarthritis in the rheumatology department of the Dijon University Hospital between 2016 and 2019.Assessment: 1- clinical examination by an experimented rheumatologist; 2- joint aspiration and synovial fluid analysis following aspiration; 3- ultrasound (US) examination of the knees, first metatarso-phalangeal joints, and arthritic joint by a trained rheumatologist; 4- dual-energy computed tomography (DECT) of the arthritic joint; 5- Nijmengen score (cutoff scores of ≥ 8 needed for diagnosis of gout, and ≤ 4 to rule out gout) and ACR/EULAR 2015 classification criteria (3) (cut-off score of ≥ 8 needed for diagnosis of gout).Analysis: positive and negative predictive values, and ROC curve analysis of the Nijmengen score, using as gold-standard on one hand the results of the MSU crystal research, on the other hand those of the ACR/EULAR criteria.

Results:

A total of 39 patients were included (mean age = 69.8 ± 15 years, 74.4 % males, mean BMI = 27.5 ± 4.6 Kg/m2, mean serum uric acid = 354.6 ± 117.5 µmol/l). The affected joints were the knee (n = 31), ankle (n = 3), hip (n = 2), wrist (n = 2), shoulder (n = 1). Joint fluid analysis revealed MSU crystal in 11 patients. The ACR/EULAR was ≥ 8 in 15 patients. The Nijmengen score was ≥ 8 in 11 patients, including 5 with MSU crystal on joint fluid analysis and 9 with an ACR/EULAR score ≥ 8. The Nijmengen score was ≤ 4 in 15 patients, including 14 with no MSU crystal on joint fluid analysis and 14 with an ACR/EULAR score < 8. The positive predictive values of a Nijmengen score ≥ 8 were 45 % (joint fluid analysis as gold standard) and 81.8 % (ACR/EULAR). The negative predictive values of a Nijmengen score ≤ 4 were 93.3 % (joint fluid analysis and ACR/EULAR as gold standard). On ROC curve analyses, the areas under the curve were 0.763 (95% CI = 0.612 – 0.914) using joint fluid analysis as gold standard (figure 1) and 0.908 (95% CI = 0.814 – 1.0) using the ACR/EULAR score as gold standard (figure 2).

Fig. 1

ROC curve (fluid analysis as gold standard)

Fig. 2

Roc curve (ACR/EULAR as gold standard)

Conclusion:

Although having been developed for use in primary-care, the Nijmengen score appears to be useful in patients hospitalized for acute monoarthritis in a rheumatology unit.

References:

[1]Janssens et al. A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Arch Intern Med 2010; 170:1120-6.

[2]Kienhorst L et al. The validation of a diagnostic rule for gout without joint fluid analysis: a prospective study. Rheumatology 2015; 54:609-14.

[3]Neogi T et al. 2015 Gout Classification Criteria: An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative: ACR/EULAR CLASSIFICATION CRITERIA FOR GOUT. Arthritis and Rheumatology. oct 2015;67(10):2557-68.

Disclosure of Interests: :

marie Schmitt: None declared, André Ramon: None declared, Paul Ornetti: None declared, jean Francis Maillefert Grant/research support from: Abbot, shugai, Roche, pfiser, BMS,, Speakers bureau: Abbot, Shugai, Roche, Pfiser, BMS

AB0718 DIAGNOSTIC PERFORMANCE OF VARIOUS CLASSIFICATION CRITERIA IN LOW BACK PAIN PATIENTS WITH SUSPECTED AXIAL SPONDYLOARTHRITIS: A PRAGMATIC STUDY

Background:

In routine practice, axial spondyloarthritis (SpA) can be a diagnostic challenge because there is potential overlap with osteoarthritic low back pain or diffuse polyalgic syndrome with axial pain as fibromyalgia. Internationally recognized classification criteria (AMOR, ASAS (1), ESSG (2)) are often used as diagnostic tools in clinical practice (3), but few studies have sought to establish their “real life” diagnostic performances.

Objectives:

This monocentric study aimed to evaluate the diagnostic performance of different sets of classification criteria for SpA in patients with chronic back pain hospitalized for suspected axial SpA. The second objective was to evaluate the impact of the sacroiliac MRI reading according to the ASAS MRI reading or expert musculoskeletal reading.

Methods:

Patients presenting with inflammatory low back pain who underwent standardized sacroiliac MRI protocol were consecutively included. The diagnoses obtained with the classification criteria (AMOR, ESSG, Modified AMOR and Modified ESSG (with sacroiliac MRI)) were compared to the gold standard diagnoses (made by a college of three experienced rheumatologists). Two readings of the sacroiliac MRI were performed (ASAS MRI reading and Expert MRI reading (including all inflammatory or structural T1 or T2 STIR abnormalities)). Diagnostic performance was measured for each set of classification criteria: sensitivity, specificity, predictive positive and negative values (PPV, NPV) and positive and negative likelihood ratios (PLR, PLN). The clinical, biological and MRI factors associated with axial SpA diagnosis were identified in a multivariate logistic regression model.

Results:

83 patients were included of which 27 had axial SpA according to the opinion of the college of rheumatologists. The AMOR modified criteria (with ASAS MRI reading) had the highest diagnostic performance values, with sensitivity = 96%, specificity = 71%, NPV = 97%, PPV = 54%, PLR = 3.3, and NLR = 0.06. Sacroiliac MRI reading demonstrated poor sensitivity (< 60%) for SpA (ASAS or expert reading), while expert reading of MRI had high specificity (98%), NPV = 90%, PPV = 78%, and PLR = 18. In multivariate logistic regression, the presence of enthesitis (OR = 3.51, IC95% [1.10;11.21]; p = 0.024), positive HLA B27 (OR = 4.22, IC95% [1.25;14.18]; p = 0.02)) or sacroiliitis on MRI (ASAS reading) (OR = 3.34, IC95% [1.04; 10.76]; p = 0.043) were independently associated with the final diagnosis of SpA.

Conclusion:

The results of this pragmatic study suggest that the Modified AMOR criteria with ASAS MRI reading can be used to rule out axial spondyloarthritis (NPV = 97%). However, the use of an MRI ASAS reading alone creates a risk of false positives because of the greater impact on ASAS criteria compared to AMOR or ESSG criteria. Further international studies are needed to decrease the rate of false positives in suspected cases of axial spondyloarthritis in routine practice.

References:

[1]Dougados M, van der Linden S, Juhlin R et al. The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum 1991;34:1218-27.

[2]Rudwaleit M, van der Heijde D, Landewé R et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis. 2009;68:777-83.

[3]Gazeau P, Cornec D, Timsit MA et al. Classification criteria versus physician’s opinion for considering a patient with inflammatory back pain as suffering from spondyloarthritis. Joint Bone Spine 2018;85:85-91.

Disclosure of Interests:

None declared

Application of Dried Human Amnion Graft to Improve Post-Prostatectomy Incontinence and Potency: A Randomized Exploration Study Protocol

Introduction

Incontinence (up to 20%) and erectile dysfunction (up to 70%) occur frequently after radical prostatectomy (RP) in patients with localized prostate cancer. Human amniotic membrane (HAM) can improve tissue regeneration and functional outcome after RP owing to the growth factors and unique immune tolerance. Preliminary studies showed the potential value of HAM in the reconstruction of the urinary tract and nerve protection during RP.

Methods

A protocol is developed for a prospective, randomized, single-blind, single-surgeon, placebo-controlled exploration study of the efficacy and safety of dehydrated human amnion membrane placed around the neurovascular bundle (NVB) and vesicourethral anastomosis (VUA) during RP for the treatment of localized prostate cancer. Eligible for inclusion are patients with localized prostate cancer, requiring a surgical procedure and exclusion of preoperative incontinence and erectile dysfunction. The patients are randomized 1:1 to HAM vs. placebo and blinded during the study period. According to the T test with an alpha of 0.05 and a power of 80% and expecting a dropout of 20% of the patients, an adjusted sample size per arm of 164 patients is required.

Planned Outcomes

The primary outcome is a postoperative continence measured as 24-h pad test up to 12 months postoperatively. Secondary outcomes are potency, time of postoperative catheter removal, postoperative complications, and biochemical recurrence. The protocol for this randomized exploration study defines the conditions to assess the efficacy and safety of HAM application during RP in order to improve the postoperative functional outcome. This trial should pave the way for future studies of tissue engineering in an effort to reduce the morbidity of RP.

Trial Registration

Clinicaltrials.gov, identifier NCT03864939.

[Proposal of guidelines for antibiotic prophylaxis in plastic, reconstructive, and aesthetic surgery]

BACKGROUND

In plastic surgery, guidelines about antibiotic prophylaxis are inaccurate and incomplete, due to result the absence of high-level studies on this subject. The main aim is to establish national common recommendations for plastic surgery antibiotic prophylaxis.

MATERIALS AND METHODS

A working group will discuss and validate a multi-center analysis of practices in three University Hospital Centers compared to an interdisciplinary analysis of recommendations to the French Society of Anaesthesia and Intensive Care Medicine and scientific literature. This working group is composed of plastic surgeon members of the French Society of Aesthetic Reconstructive Plastic Surgery, infectious disease physicians, and anaesthesiologists to define clear and precise antibiotic prophylaxis recommendations.

RESULTS

Antibiotic prophylaxis with cefazoline (or clindamycine±gentamicine in case of allergy), has been recommended for general surgery with flap or implants, for breast surgery, lipofilling, and rhinoplasty. In other plastic surgery, no antibiotic prophylaxis has been recommended.

CONCLUSION

We established common recommendations for plastic surgery antibiotic prophylaxis that is the first step to update these recommendations. Now, they can be evaluated in clinical situation to validate them.

Protocol for a Randomized Phase II Trial for Mesh Optimization by Autologous Plasma Coating in Prolapse Repair: IDEAL Stage 3

INTRODUCTION

Mesh-related complications especially after vaginal implantation have raised awareness lately because of severe adverse reactions and legal aspects. About 20% of patients suffer from complications after mesh insertion in the anterior vaginal wall. Autologous plasma coating of meshes prior to implantation has shown potential to improve the biocompatibility of meshes in vivo and in vitro. This innovative approach has been developed according to the IDEAL recommendations for surgical innovations. The method has still to be assessed at stage 3 accordingly.

METHODS

A protocol is developed for a prospective single-blinded randomized controlled phase II trial for biocompatibility optimization of anterior vaginal meshes for prolapse repair by autologous plasma coating versus non-coated meshes.

RESULTS

The protocol aims at fulfilling the requirements for stage 3 (assessment) according to IDEAL. Eligible for inclusion are women with primary cystocele, requiring a surgical procedure, suitable for randomization, and willing to be randomized. Participants will be followed up by postal questionnaires (6 months post surgery and 12 months post randomization) and will also be reviewed in clinic 12 and 24 months post surgery. Primary endpoint is the assessment of mesh-related complications following the Clavien-Dindo classifications. QoL, sexual function assessment, efficacy, and validation of an already developed long-term register are considered secondary endpoints. To afford a calculated 10% reduction of postoperative complications through plasma-coated meshes vs. non-coated meshes at 1-year follow-up, a total 214 women in each arm will be necessary to achieve 80% power at a significance level of 5%.

CONCLUSION

The protocol for this randomized clinical trial represents the conditions to assess the surgical innovation of plasma coating of meshes in order to improve the meshes' biocompatibility at stage 3 according to the IDEAL recommendations.

Epidemiology and treatment of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic inflammatory disease of the liver that occurs worldwide with a low and probably underestimated prevalence. Although it typically affects young and middle-aged women, it can occur in both sexes and across all age groups. AIH runs a fluctuating course, but can present as severe and even fulminant hepatic failure or at a stage of advanced fibrosis or cirrhosis. Prognosis of severe AIH is poor if untreated. The pathogenesis is complex, combining environmental factors (external chemical or infectious triggers) and host genetic susceptibility. The diagnosis is based, after exclusion of other etiologies of chronic liver disease, on a combination of different elements, including the presence of elevated transaminases, elevated immunoglobulin G (IgG) levels, the presence and pattern of typical autoantibodies, and a liver biopsy showing interface hepatitis and other characteristic features. No single test can be used to make the diagnosis. Response to treatment can also help to establish the diagnosis. Simplified criteria can be used to make a bedside diagnosis with relatively high accuracy. Treatment consists of corticosteroids or other immunosuppressive regimens according to the severity of the disease, the response to the treatment, and the tolerance to therapy, with liver transplantation as an ultimate remedy in treatment-resistant cases with liver decompensation.

Non-alcoholic steatohepatitis induces non-fibrosis-related portal hypertension associated with splanchnic vasodilation and signs of a hyperdynamic circulation in vitro and in vivo in a rat model

INTRODUCTION

Steatosis, without fibrosis, may lead to changes in liver blood flow, which are poorly understood, and to date have not been correlated to portal pressure and related haemodynamics.

AIMS

To study the temporal relation between progressive steatosis, portal pressure, systemic haemodynamics, vascular responsiveness, mesenteric and portal blood flow in methionine-choline-deficient diet (MCDD)-fed rats.

METHODS

Male Wistar rats fed the MCDD were examined at week (w) 0-1-2-3-4-5-6-7-8, respectively, including systemic haemodynamics and portal pressure. At w0-4-8, in vivo blood flow was measured in the portal vein and the superior mesenteric artery. Dose-response curves to phenylephrine (PE) were established in abdominal aortic rings.

RESULTS

Histology showed 100% steatosis from w3 on. Fibrosis was absent. Significant inflammation was nearly absent upon w4. Portal pressure slightly increased at w2, reached a maximum at w4 [9.4 +/- 0.3 vs 2.9 +/- 0.6 mmHg at w0 (P=0.003)] and remained stable upon w8. Mean arterial blood pressure (MABP) decreased from w2 on [98.7 +/- 5.7 mmHg on w4 compared with 123.8 +/- 1.8 on w0 (P=0.002)]. Portal flow increased from 1.85 +/- 0.11 to 3.07 +/- 0.44 ml/min/100 g on w0 and w8 respectively (P=0.039). Mesenteric artery flow increased from 3.40 +/- 0.26 to 4.56 +/- 0.30 ml/min/100 g on w0 and w8 respectively (P=0.043). Vascular responsiveness to PE gradually decreased from 138 +/- 3% on w0 to 110 +/- 5% on w4 (P=0.013).

CONCLUSION

Steatohepatitis induces significant portal hypertension (PHT) in the absence of fibrosis, associated with an increase in mesenteric arterial and portal venous flow, arterial hyporesponsiveness to vasoconstrictors and a decrease in MABP, indicating the presence of splanchnic vasodilation and hyperdynamic circulation. These alterations resemble those seen in cirrhotic PHT.

Spontaneous second-site suppressors of the filamentation defect of prr1Delta mutants define a critical domain of Rim101p in Candida albicans

In response to changes in ambient pH the opportunistic pathogen Candida albicans differentially expresses a number of genes. The response to pH affects morphological differentiation and virulence. The pathway controlling the pH response terminates in the zinc-finger containing transcription factor encoded by RIM101/PRR2. By analogy to the pH response pathway of Aspergillus nidulans, PRR1 of C. albicans encodes a protein that is presumably required to convert Rim101p from an inactive to an active form by proteolytic removal of a C-terminal peptide. A prr1Delta mutant is compromised in its ability to differentiate into the filamentous form. Spontaneous phenotypic revertants of a prr1Delta mutant were selected by their ability to form filamentous colonies. These mutants were also found to be defective in pH-dependent gene expression. Each of the eight mutants examined contained a heterozygous dominant mutation at the RIM101 locus. This was demonstrated genetically in all of the mutants, and directly by sequence determination of both alleles in two of the mutants. The mutant alleles conferred the ability to filament to a prr1Delta mutant, thus demonstrating that they were directly responsible for suppressing the filamentation defect. Seven of the mutant alleles contained a 1-bp substitution and one contained two substitutions at adjacent positions. The mutations were clustered within a 90-bp region near the 3'-end of the gene. In all cases the mutation generated a nonsense codon that resulted in premature termination of Rim101p; the mutant proteins were truncated by 75-104 amino acids. The results define a critical region in the C-terminal region of Rim101p and are consistent with the proposed proteolytic activation of Rim101p.

Dynamics of active progressive infection with HIV1: data acquisition for computer modeling

Nineteen adult patients with progressive HIV1 infection, which progressed within 5 years from acute HIV syndrome to final AIDS were studied. Changes in HIV antibody titer, viral RNA load, peripheral T lymphocytes and subpopulations as well as CD4/CD8 cell ratio and cell death (apoptosis) were monitored. The data were collected for comparison with HHV-6 infection, which involves the same cell populations yet patients usually recover, and to serve as a further basis for future computer simulation studies. The results showed progressive increases of viral RNA copies in the patients' plasma even during clinical latency, which correlates with lymphocyte apoptosis and CD4 cell loss. Besides apparent direct CD4 cell destruction, there was indication of a disturbed intrathymic T cell differentiation. Pathologic cell changes in HIV infection continue until final death of the patient and do not return to normal after variable times as in HHV-6 infection. While HHV-6 infection can serve as models for immunostimulation, with or without immune dysregulation in computer simulation studies, HIV infection is a model for immunostimulation with final immune deficiency and cellular aplasia.

In vitro selection of resistance to clindamycin related to alterations in the attenuator of the erm(TR) gene of Streptococcus pyogenes UCN1 inducibly resistant to erythromycin

A clinical isolate of Streptococcus pyogenes UCN1 intermediate to erythromycin (MIC 1 mg/L) and susceptible to clindamycin (MIC 0.03 mg/L) harboured an inducible erm(TR) gene encoding a ribosomal methylase. We have selected in vitro, in the presence of concentrations of clindamycin ranging from 0.12 to 1 mg/L, one-step mutants that are highly resistant to this antibiotic (MIC 64 mg/L) at a frequency of 10(-7). By contrast, in an erythromycin-susceptible strain of S. pyogenes UCN5, mutants could be selected only by a low concentration of clindamycin (0.12 mg/L) at a frequency of 10(-9). Clindamycin resistance in four of six S. pyogenes UCN1 mutants was associated with deletions of 163 and 6 bp, as well as a tandem duplication of 101 bp in the regulatory sequence of the erm(TR) gene. The role of these structural alterations in clindamycin resistance was demonstrated by cloning the erm(TR) gene from the wild-type and mutant strains in Escherichia coli DB10, a mutant susceptible to macrolides. Clindamycin resistance was expressed only when the erm(TR) gene was preceded by an altered attenuator. Mutations could lead to the formation of mRNA secondary structures accounting for the accessibility of the ribosome-binding site and the initiation codon of the ErmTR methylase to the ribosomes, and subsequently for the translation of the erm(TR) transcripts. The easy selection in one step of mutants resistant to high levels of clindamycin by concentrations of this antibiotic ranging from four to 40 times the MIC leads us to recommend caution in the use of clindamycin therapy in group A Streptococcus infections.

Dynamics of infection with human herpesvirus-6 in EBV-negative infectious mononucleosis: data acquisition for computer modeling

Ten adult patients with active HHV-6 variant A infections and clinical infectious mononucleosis-like disease (IM) were studied over a period of 32 weeks after onset of disease for their viral DNA load, changes in peripheral blood T-lymphocytes and subpopulations and frequency of cell death in peripheral blood cells. The data were collected as the basis for an advanced computer simulation study for which available data in the literature were too varied. Since the exact time of primary infection of the patients was not known and thus no time relationship of viral effects at cellular level were determined, we supplemented such data from separate tissue culture studies using HHV-6 alpha infection of HSB2 cells. Patients with IM demonstrate an increase in-HHV-6 DNA copies from 0 to 8.2 log 10/5 microL blood within 4 weeks return to normal by 16 weeks. Total T-lymphocytes follow infection with a 20-fold increase above normal peaking at 8-10 weeks and then return to normal by 24-28 weeks. Coincidently, less mature lymphoid cells carrying markers for stem cells, thymic cortical and medullary cells increase 8-10-fold indicating an enhanced mobilization of such cells from premature cell compartments. Cell death in peripheral mononuclear cells peaked with 30% at 8 weeks after onset of clinical disease and normalized by 24 weeks. HHV-6 replication in cell culture as determined by antigen expression, electron microscopy and harvest of infectious virus indicated a complete cycle of virus infection and replication of at least 6 days. The presented data compare well with others from the literature and will serve for testing in a computer simulation model, which is the subject of a forthcoming paper.

Dominant active alleles of RIM101 (PRR2) bypass the pH restriction on filamentation of Candida albicans

Morphological development of the fungal pathogen Candida albicans is profoundly affected by ambient pH. Acidic pH restricts growth to the yeast form, whereas neutral pH permits development of the filamentous form. Superimposed on the pH restriction is a temperature requirement of approximately 37 degrees C for filamentation. The role of pH in development was investigated by selecting revertants of phr2Delta mutants that had gained the ability to grow at acid pH. The extragenic suppressors in two independent revertants were identified as nonsense mutations in the pH response regulator RIM101 (PRR2) that resulted in a carboxy-terminal truncation of the open reading frame. These dominant active alleles conferred the ability to filament at acidic pH, to express PHR1, an alkaline-expressed gene, at acidic pH, and to repress the acid-expressed gene PHR2. It was also observed that both the wild-type and mutant alleles could act as multicopy suppressors of the temperature restriction on filamentation, allowing extensive filamentation at 29 degrees C. The ability of the activated alleles to promote filamentation was dependent upon the developmental regulator EFG1. The results suggest that RIM101 is responsible for the pH dependence of hyphal development.

HBV-specific lymphoproliferative and cytokine responses in patients with chronic hepatitis B

BACKGROUND/AIMS

Hepatitis B virus specific T cell responses are crucial for viral elimination but their nature is not fully understood.

METHODS

We studied the regulation of proliferation and cytokine production after antigenic stimulation in peripheral blood mononuclear cells from chronically HBV-infected patients and subjects with natural immunity after recovery from an acute infection. Proliferation and production of interferon-gamma, IL-10 and tumor necrosis factor-alpha were determined after stimulation with HBcAg, HBeAg or HBsAg in the absence or presence of IL-12 or neutralizing antibodies to IL-12, interferon-gamma, IL-4, IL-10 or tumor necrosis factor-alpha.

RESULTS

Upon stimulation with HBcAg or HBeAg, peripheral blood mononuclear cells from chronic hepatitis B virus patients displayed a clear class-II restricted proliferative response (SI greater than 2.5). Both interferon-gamma (less than 50 IU/ml) and IL-10 levels up to 600 pg/ml were detected. Proliferative or cytokine responses to HBsAg were very weak or absent. Addition of IL-12 to HBeAg-stimulated cultures increased the production of interferon-gamma to more than 200 IU/ml in all patients and slightly increased the production of IL-10. Neutralization of IL-10 increased the HBeAg-induced interferon-gamma production but had no effect on tumor necrosis factor-alpha production. Addition of anti-IL-4 or anti-tumor necrosis factor-alpha had no significant influence on proliferation or cytokine release. Importantly, in both chronic hepatitis B virus patients and naturally immune subjects, IL-12 induced proliferative and interferon-gamma responses in peripheral blood mononuclear cells stimulated with HBsAg.

CONCLUSIONS

Our data indicate that peripheral blood mononuclear cells from chronic hepatitis B virus patients proliferate and produce interferon-gamma and IL-10 upon HBeAg but not upon HBsAg stimulation. IL-12 augments the HBeAg-induced responses and, additionally, provokes proliferation and interferon-gamma production in HBsAg-stimulated cultures.

[Seroprevalence of HCV in the general population of Niger and in patients with chronic liver diseases: comparison of different second generation tests and PCR]

The aim of our study in Niger was to compare the seroprevalence of hepatitis C in a rural "normal" population and in a group of patients presenting at the hospital with signs of chronic liver disease: to estimate this seroprevalence, we used 4 second generation ELISA screening and 3 confirmatory tests (LIA, RIBA and PCR); genotyping was performed on PCR positive sera, using Inno-LIPA HCV. We could not find a statistically significant difference (Fisher's exact test) between the two groups of healthy and sick people (2.5 versus 5.4% for seroprevalence and 2.5 versus 3.2% for viremia). Our study didn't find any relationship between hepatitis C infection, blood transfusion or surgery; other major ways of transmission of hepatitis C have to be considered. The predominant genotype detected was 2a.

Demonstration of active and latent Epstein-Barr virus and human herpevirus-6 infections in bone marrow cells of patients with myelodysplasia and chronic myeloproliferative diseases

After previous serological screening for Epstein-Barr virus (EBV), human herpesvirus-6 (HHV-6) and human cytomegalovirus (HCMV) showed elevated antibody titers against EBV and HHV-6 in more than 50% of patients with myelodysplasia and chronic myeloproliferative diseases, the present study was carried out in order to investigate viral antigen expression and distribution in bone marrow cells of these patients. Trephine biopsies were studied from 60 patients with myelodysplasia (MDS), 36 patients with chronic myelogenous leukemia (CML) and 18 patients with osteomyelofibrosis (PMF). Elevated anti-EBV EA titers were found in 62% of the MDS cases, in 33% of the CMLs and in 62% of the OMF patients. HHV-6 titers were elevated in 18% of the MDS cases, but in only one case each of CML and OMF. Antigen expression in bone marrow cells was even more frequent: EBV-EA was 76% in MDS cases, 77% in CML and 40% in OMF. HHV-6 p41 was observed in 47% of the MDS cases, in 54% of the CML cases and in 20% of the OMFs. In comparing these data with those from the literature and with our own studies in Hodgkin's disease, it is hypothesized that the reactivated herpesviruses may contribute to the pathogenesis of these hematopoietic disorders by interfering with the cytokine regulation of cell proliferation and differentiation.

Lyme disease in Belgium

A sero-epidemiological clinical and risk-group study was performed in Belgian Military men with a home-made Elisa kit, with the N34 Bb strain kindly provided by Prof. Ackermann Cologne. In the sero-epidemiological group the seroprevalence (age 18-28 years) was 3.2% In the clinical group the results were correlating to the serological and clinical data. In the risk group 44% were IgG positive. In conclusion the exposure of a standard Belgian young male population is low. (Overall IgG seropositivity 3.2%) (Total N = 1,916).

Rapid, sensitive micro blood lead analysis: a mass screening technique for lead poisoning

A rapid micro blood lead method is described. Analyses were performed on 20-microL blood samples spotted on filter paper, collected in graduated heparinized capillary glass tubes following finger pricks. The samples were air dried on filter paper and mailed to the laboratory in glassine envelopes. These samples stored on filter paper are stable for at least six months. The blood spots were punched out with a 1/4-in. diameter hole punch and placed in Delves cups for insertion into the flame atomic absorption spectrometer. The innovation of this method is that an ashing step precedes sample introduction into the flame. In phase 1, the Delves cup with the blood sample is pushed 1 cm from the flame. The heat is sufficient for the filter paper to ignite and burn to completion in seconds. After the smoke dissipates, the samples are introduced into the flame for lead analysis, reading the signal at 283.3 nm. The entire analysis time is 15 s per sample. The limit of quantitation is 4 micrograms/dL of lead. Standard curves were linear from 4-42 micrograms/dL. The average CV for this range is 8.2%. The comparative study between the MIBK extraction method and this method yielded a correlation coefficient r = .99 (n = 55). The method is fast, practical, economical, and easily adaptable to screen large numbers of micro lead samples.

Postinfectious chronic fatigue syndrome: case history of thirty-five patients in Germany

Thirty-five patients with chronic fatigue syndrome according to the criteria of Holmes were followed for periods of up to eight years. The most frequent symptoms were severe fatigue, arthralgias and myalgias, recurrent oropharyngitis and various psychiatric disorders. More than half of the patients suffered from neuropathy, lymphadenopathy, gastrointestinal complaints and recurrent low-grade fever. Recurrent or persistent activity of human herpesvirus -6 infection was seen in 73% of the patients and of Epstein-Barr virus in 34.4%. In addition, various other infections were diagnosed at lower frequency. Initial routine immunologic screening revealed various types of deficiencies, these were yet inconsistent and variable when different patients were compared with each other. Tentative treatments included in immunoglobulins, nonspecific immunostimulation and virostatic drugs. No consistently positive results were obtained with any treatment schedule although immunoglobulins appeared the most efficient measure. In addition, psychologic care of the patients is indicated, since disturbances in the psycho-neuroimmunologic regulation may play a significant role in the pathogenesis of the disease.

Frequent double infection with Epstein-Barr virus and human herpesvirus-6 in patients with acute infectious mononucleosis

Clinical infectious mononucleosis (IM) represents a benign self-limited form of lymphoproliferative disease which is usually caused by infection with Epstein-Barr virus (EBV). Microscopic characteristics of this lymphoproliferative disorder, however, are not ultimately specific for EBV infection, but can also be seen in infections with other lymphotropic viruses, especially of the herpesvirus family. Human herpesvirus-6 (HHV-6) infection can apparently be associated with a number of diseases also seen in EBV infection. Also, postinfectious chronic fatigue syndrome (PICFS) which may follow IM is in more than 60% of the cases accompanied by persistent active HHV-6 infection. We thus screened serologically 215 cases of acute IM for evidence for infection with EBV, HHV-6 and CMN. Patients were tentatively grouped into those having primary infection or reactivated (probably non-primary) infections. Cases were followed for two years to monitor changes in titers. Of all 215 cases, 211 (98.1%) were positive for EBV, 137 (63.7%) for primary infections, 21 (9.8%) for reactivated infection, and 53 (24.6%) for latent EBV. Thirty-three (15.3%) cases had primary HHV-6 infection, 63 (29.3%) active or reactivated HHV-6 infection, and 71 (33.9%) latent HHV-6. Double active EBV and HHV-6 infection, including primary and reactivated infections, amounted to 89 (39.5%) cases. Cytomegalovirus (CMV) antibody titers were found in 81 (37%) cases, 48 (22.3%) of which indicated latent infection and 33 (15.3%) active infection. Only two cases had evidence of active CMV infection alone, 1 cases of active CMV and HHV-6 infection. Serologic titers in 12 (5.6%) cases indicated combined active infection with CMV, EBV and HHV-6.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical indications and diagnostic techniques of human herpesvirus-6 (HHV-6) infection

The sixth member of the human herpesvirus family, HHV-6, causes early childhood infection with subsequent latency and antibody prevalence of about 60-80%. Active infection is related to a number of acute and chronic diseases such as exanthem subitum, certain cases of infectious mononucleosis and other immunoproliferative syndromes, autoimmune disorders and so-called postinfectious chronic fatigue syndrome. The clinical diagnosis of HHV-6 associated diseases requires detailed clinical differential diagnostic procedures and meticulous serological testing with exclusion of other herpesvirus infections or cross-reactivity between such infections. Diagnostic efforts, however, are warranted by certain indications for therapeutic intervention. The current review summarizes indications, techniques and limitations for the serological diagnosis of HHV-6 infection.

Alpha-1-proteinase inhibitor gene frequencies in Belgium

The alpha-1-antitrypsin phenotype was determined in cord blood of 1345 Belgian newborns by isoelectric focusing in polyacrylamide gels. Proteinase inhibitor (PI) gene frequencies were calculated. The relative gene frequency of the M allele was 0.9245, and those of S and Z alleles were 0.0543 and 0.0167 respectively. I and F alleles were less represented. These results are in agreement with population studies of neighbouring countries.

High-dose intravenous immunoglobulins in HIV-1-infected adults with AIDS-related complex and Walter-Reed 5

The influence of high-dose intravenous immunoglobulins (HD-IVIG) on the clinical status and T4 cell count of adults with AIDS-related complex (ARC) and Walter-Reed 5 (WR5) was evaluated in a randomized double-blind longitudinal study. Inclusion criteria were: (1) T4 cells less than 400/microliters and (2a) oral thrush or cutaneous anergy or (2b) two clinical ARC criteria (fever, diarrhea, weight loss, fatigue, night sweats). Thirty patients [28 males, 2 females, median age 41 (24-64) years] with ARC (n = 8), WR5 (n = 12) and both (n = 10) were stratified according to their T4 cell count (greater than or equal to vs. less than 300/microliters). Fifteen patients received 0.4 g/kg body weight IVIG and 15 placebo (albumin 0.03%) every other week for 26 weeks with follow-up for another 26 weeks. The clinical status was defined as a score consisting of fever, diarrhea, night sweats, fatigue, weight loss, oral candidiasis and mucosal or cutaneous herpes simplex. Clinical examination and routine laboratory assessments were performed before initiation of the study and before each administration, lymphocyte phenotyping every 4 weeks and cutaneous reaction, serology and lymphocyte stimulation every 12 weeks. Both groups were comparable in initial clinical symptoms and laboratory values. Seven patients developed AIDS (treatment group: 3, placebo group: 4), 1 patient died by homicide. After 26 weeks, the clinical score (particularly fatigue and fever) was significantly improved in the treatment group, while the T4 cell count and other clinical and immunological parameters remained unaltered. This limited effect was still evident at termination of the study after 52 weeks. In conclusion, HD-IVIG can improve the clinical status of patients with advanced HIV-1 infection without obviously correcting the underlying impaired cellular immunity. The substitution of intact antibodies in the state of functional hypogammaglobulinemia is suggested as possible therapeutic mechanism.

Virological examinations of patients with AIDS-related complex/Walter-Reed 5 enrolled in a double-blind placebo-controlled study with intravenous gammaglobulin administration. Prognostic value of anti-p24 determination. The ARC-IVIG Study Group

Thirty patients with AIDS-related complex/Walter-Reed 5 enrolled in a placebo-controlled double-blind study with high-dose intravenous gammaglobulin administration were tested by quantitating HIV Western blot and other serological tests for viral antibodies. Furthermore, conventional virus isolation attempts were performed. Absence or loss of p24 antibodies during the study period was associated with progression to AIDS (p = 0.01) and thereby was an earlier prognostic parameter of a poor prognosis than T4 cell count. Neither changes in antibody patterns against other HIV polypeptides, HIV titers in the immunofluorescence test nor demonstration of HIV antigen were significantly associated with progression to AIDS. Cytomegalovirus (CMV) could be isolated from two duodenal biopsies of a patient who developed AIDS at the same time, but a concomitant serological diagnosis of CMV infection was not successful. Though signs in the serology of human herpesviruses (herpes simplex virus, CMV, Epstein-Barr virus), possibly indicating a reactivation of latent infections, could be observed in some instances, a correlation with clinical symptoms or the clinical outcome was not feasible, perhaps also because of a poor standardization of some of the test kits used. All patients were positive for IgG antibodies against the three herpesviruses when entering the study. High prevalence of hepatitis B virus (HBV) markers was found (83% anti-HBc positive), only 1 patient being chronically infected and highly infectious, as shown by HBV-DNA hybridization. No significant difference between treatment and placebo group was observed with the parameters tested in this study.

Cellular immunologic parameters in HIV-positive patients with AIDS-related complex and intravenous immunoglobulin therapy

In a randomized double-blind longitudinal study with 30 HIV-1-positive patients with AIDS-related complex or stage Walter-Reed 5 disease, the effectiveness of intravenous immunoglobulin (IVIG) was tested for correcting eventual immune dysregulation. Although the IVIG-treated patients showed an improvement of their clinical score, no significant changes were observed in lymphocyte phenotypes, activation markers, immunoglobulins and subclasses, lymphocyte turnover or in indicators of acute inflammation. Since severe bacterial infections or autoimmune processes usually leading to IVIG therapy were not prevalent in the patients of the study, such therapy should probably be reserved for later stages of the disease. HIV-1 antigen expression in blood lymphocytes remained uninfluenced by IVIG treatment.

Overview of immunopathology of chronic active herpesvirus infection

Chronic latent infection with human herpesvirus is common; antibody prevalence in the general population varies from 40 to above 95%, for herpesvirus-6 at about 20%. Reactivation occurs in 5-20% of healthy persons. If reactivation coincides with impaired host response, chronic active infection may ensue. Chronic active infection by certain members of the Herpesviridae such as EBV, CMV and HHV-6 is prone to being complicated by autoimmune diseases and atypical lymphoproliferation. Its diagnosis is occasionally rendered difficult by a variety of immunologic interference factors, thus final evaluation must result from clinical, immunopathological and virological cooperation.