Weight Regain after Metabolic Surgery: Beyond the Surgical Failure

Patients undergoing metabolic surgery have factors ranging from anatomo-surgical, endocrine metabolic, eating patterns and physical activity, mental health and psychological factors. Some of the latter can explain the possible pathophysiological neuroendocrine, metabolic, and adaptive mechanisms that cause the high prevalence of weight regain in postbariatric patients. Even metabolic surgery has proven to be effective in reducing excess weight in patients with obesity; some of them regain weight after this intervention. In this vein, several studies have been conducted to search factors and mechanisms involved in weight regain, to stablish strategies to manage this complication by combining metabolic surgery with either lifestyle changes, behavioral therapies, pharmacotherapy, endoscopic interventions, or finally, surgical revision. The aim of this revision is to describe certain aspects and mechanisms behind weight regain after metabolic surgery, along with preventive and therapeutic strategies for this complication.

The Role of Specialized Pro-Resolving Lipid Mediators in Inflammation-Induced Carcinogenesis

Cancer is a process involving cell mutation, increased proliferation, invasion, and metastasis. Over the years, this condition has represented one of the most concerning health problems worldwide due to its significant morbidity and mortality. At present, the incidence of cancer continues to grow exponentially. Thus, it is imperative to open new avenues in cancer research to understand the molecular changes driving DNA transformation, cell-to-cell interaction derangements, and immune system surveillance decay. In this regard, evidence supports the relationship between chronic inflammation and cancer. In light of this, a group of bioactive lipids derived from polyunsaturated fatty acids (PUFAs) may have a position as novel anti-inflammatory molecules known as the specialized pro-resolving mediators (SPMs), a group of pro-resolutive inflammation agents that could improve the anti-tumor immunity. These molecules have the potential role of chemopreventive and therapeutic agents for various cancer types, and their effects have been documented in the scientific literature. Thus, this review objective centers around understanding the effect of SPMs on carcinogenesis and their potential therapeutic effect.

AB1023 CHARACTERISTICS OF PATIENTS REFERRED FOR FIRST BONE DENSITOMETRY TO A RHEUMATOLOGY FLS, WITH NORMAL RESULTS IN THE LUMBAR SPINE

Objectives

To analyze the characteristics of postmenopausal women referred for the first bone densitometry (BMD), with normal results in the lumbar spine.

Methods

Retrospective study of postmenopausal women, for a first BMD, at a rheumatology FLS, during February/2010-December/2021.

General patient data (age, gender), osteoporosis (OP) risk factors were collected: age at menopause, parental hip fracture, body mass index (BMI), smoking and alcohol habit, drugs and potentially osteopenizing diseases, low-impact fractures in adulthood (fractures of osteoporotic origin included: vertebral, hip, humeral head and distal radius and pelvis), current treatment for OP and FRAX index.

Results

2.930 postmenopausal women with normal lumbar BMD are included: 505 (17%) had suffered an OP fracture: mean age (SD): 63.2 years (8.5) and of menopause 48 years (10). Among the OP risk factors: early menopause: 818 (28%) women, active smoking: 521 (18%), alcohol > 3 units: 84 (2%), parents hip fracture: 310 (11%). Among osteopenizing diseases: rheumatoid arthritis/chronic arthritis: 112 (4%) patients, inflammatory bowel disease: 44 (2%), arteritis/polymyalgia rheumatica: 35 (1%) and the rest <1%. Among the osteopenizing drugs: omeprazole: 967 (33%) patients, thyroxine: 354 (12%), oral or inhaled corticosteroids: 261 (9%) and aromatase inhibitors: 168 (6%).

427 (15%) patients had had a previous OP fracture: distal radius: 188 (6%), vertebral: 146 (5%), humeral head: 46 (2%) and hip: 47 (2%). 808 (28%) patients were receiving treatment for OP: oral bisphosphonates: 518 (18%), SERM: 136 (5%), strontium ranelate: 75 (3%), denosumab: 51 (2%), teriparatide: 16 (0.7%) and zoledronate: 12 (0.5%) (Table 1).

Table 1.

Characteristics of patients with normal lumbar spine BMD.

TOTAL BMD LS NormalN: 2.930Normal BMD LS WITH fractureN: 505 (17%)Normal BMD LS WITHOUT fractureN: 2.425 (83%)pAge in BMD, years, mean (SD)63,270.5 (7.78)60.6 (26)0.0001Menopausal age, years, mean (SD)48 (8.4)45 (5.46)48 (8.48)0.0001Early menopause, n (%)814 (28)171 (34)643 (27)0.07BMI, kg/m2, media (SD)29,1 (10.3)29.5 (17.03)28,9 (10.3)0.44Active tobacco, n (%)521 (18)40 (8)481 (20)0.06Alcohol ≥ 3 units, n (%)84 (2)10 (2)74 (3)0.85Parent hip fracture, n (%)310 (11)60 (12)250 (10)0.65Ostepenizing drug, n (%):1.750289 (57)1.461 (60)0.34  Omeprazole967 (33)178 (35)789 (33)0.60  Thyroxine354 (12)53 (10)301 (12)0.67  Corticosteroids261 (9)42 (8)219 (9)0.83  Aromatasa Inhibitor168 (6)16 (3)152 (6)0.62Treatment, n (%):808 (34)226 (48)582 (24)0.0001  Oral bisphosphonate518 (18)127 (25)391 (16)  SERM136 (5)24 (5)112 (5)0.02  Strontium ranelate75 (3)20 (4)55 (2)1  Denosumab51 (2)31 (6)20 (0.8)0.35  Zoledronate12 (0.5)10 (2)2 (<0.1)0.84  Teriparatide16 (0.7)14 (3)2 (<0.1)0.84BMD, mean Tscore (SD):  Lumbar spine0.890.04 (1.49)0.05 (1.49)0.89  Femoral neck0.70-1.3 (1.06)-0.54 (1.06)0.0001   Osteoporosis, n (%)108 (4)51 (10)57 (2)0.07    Osteopenia, n (%)981 (33)247 (49)734 (30)0.0001  Total hip-0.31-0.8 (1.12)-0.17 (1.12)0,0001FRAX with BMD, mean (SD):  Mean fracture5.2310.6 (5.79)3.99 (5.78)0.0001  Hip fracture1.543.7 (3.58)1.09 (3.58)0.0001

The group with OP fractures, are significantly (Table 1): older (p<0.0001), with lower mean age of menopause (p<0.0001), receive more treatment (p<0.0001), especially oral bisphosphonates (p=0.02), have worse results in hip BMD (p<0.0001), with a higher percentage of osteopenia (50% vs 30%, p<0.0001) and worse result in FRAX of major fracture (p<0.0001) and of hip (p<0.001).

Conclusion

Among the patients referred to BMD, although the result of lumbar spine is normal, 17% have suffered an OP fracture, presenting this group: 1) Older age, 2) Osteopenia in hip BMD 50%, with high risk of fracture due to FRAX and they followed treatment for OP, especially oral bisphosphonates. 3) It is advisable to simultaneously perform BMD at the lumbar and hip levels, especially in older subjects

Acknowledgements

The study was supported by a research grant from the Marina Baixa Association for Research in Rheumatology (AIRE-MB).

Disclosure of Interests

None declared

Obesity as a neurobiologic disorder: a heavyweight contender

Abstract:

Obesity is a multifactorial metabolic condition characterized by an abnormal or excessive accumulation of fat in the adipose tissue, capable of decreasing life expectancy. Chronically, the exacerbated inflammatory response interferes with the proper functioning of organs and tissues external to adipose tissue, becoming the cornerstone of various major metabolic imbalances in places such as the central nervous system. In this matter, obesity’s meta-inflammation indirectly affects brain regions related to psychiatric illnesses and cognitive function. Also, it has been established that several neurobiological mechanisms related to appetite regulation and impulse control disorders could explain the onset of obesity. Thus, because of the high prevalence of mental illnesses linked to obese patients and the fact that a bidirectional relation between these two entities has been observed, many efforts have been made to establish an effective and secure pharmacological approach for obesity. In this context, several psychotropics and appetite-suppressant drugs, along with lifestyle changes, have been highlighted as promising therapeutic tools against obesity.

The Role of the α Cell in the Pathogenesis of Diabetes: A World beyond the Mirror

Type 2 Diabetes Mellitus (T2DM) is one of the most prevalent chronic metabolic disorders, and insulin has been placed at the epicentre of its pathophysiological basis. However, the involvement of impaired alpha (α) cell function has been recognized as playing an essential role in several diseases, since hyperglucagonemia has been evidenced in both Type 1 and T2DM. This phenomenon has been attributed to intra-islet defects, like modifications in pancreatic α cell mass or dysfunction in glucagon's secretion. Emerging evidence has shown that chronic hyperglycaemia provokes changes in the Langerhans' islets cytoarchitecture, including α cell hyperplasia, pancreatic beta (β) cell dedifferentiation into glucagon-positive producing cells, and loss of paracrine and endocrine regulation due to β cell mass loss. Other abnormalities like α cell insulin resistance, sensor machinery dysfunction, or paradoxical ATP-sensitive potassium channels (KATP) opening have also been linked to glucagon hypersecretion. Recent clinical trials in phases 1 or 2 have shown new molecules with glucagon-antagonist properties with considerable effectiveness and acceptable safety profiles. Glucagon-like peptide-1 (GLP-1) agonists and Dipeptidyl Peptidase-4 inhibitors (DPP-4 inhibitors) have been shown to decrease glucagon secretion in T2DM, and their possible therapeutic role in T1DM means they are attractive as an insulin-adjuvant therapy.

Lipid Accumulation Product Is More Related to Insulin Resistance than the Visceral Adiposity Index in the Maracaibo City Population, Venezuela

BACKGROUND

Visceral adiposity is related to insulin resistance (IR), a metabolic state considered as a risk factor for other cardiometabolic diseases. In that matter, mathematical indexes such as the visceral adiposity index (VAI) and the lipid accumulation product (LAP) could indirectly assess IR based on visceral adiposity.

OBJECTIVE

To evaluate the association and diagnostic accuracy of VAI and LAP to diagnose IR in the adult population of Maracaibo city.

METHODS

This is a cross-sectional descriptive study with multistage sampling. Receiver operating characteristic (ROC) curves were built to determine VAI and LAP cutoff points to predict IR. A set of logistic regression models was constructed according to sociodemographic, psychobiologic, and metabolic variables.

RESULTS

1818 subjects were evaluated (51.4% women). The area under the curve (AUC) values for LAP and VAI were 0.689 (0.665-0.714) and 0.645 (0.619-0.670), respectively. Both indexes showed a higher IR risk in the upper tertile in bivariate analysis. However, in the logistic regression analysis for the IR risk, only the 2nd (OR: 1.91; 95% CI: 1.37-2.65; p < 0.01) and 3rd (OR: 5.40; 95% CI: 3.48-8.39; p < 0.01) LAP tertiles showed a significant increase. This behaviour was also observed after adjusting for hs-C-reactive protein (hs-CPR).

CONCLUSION

Although both indexes show a low predictive capacity in individuals with IR in the Maracaibo city population, the LAP index was more strongly associated with IR.

Potential role of bioactive lipids in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease, which involves a pathological inflammatory response against articular cartilage in multiple joints throughout the body. It is a complex disorder associated with comorbidities such as depression, lymphoma, osteoporosis and cardiovascular disease (CVD), which significantly deteriorate patients' quality of life and prognosis. This has ignited a large initiative to elucidate the physiopathology of RA, aiming to identify new therapeutic targets and approaches in its multidisciplinary management. Recently, various lipid bioactive products have been proposed to have an essential role in this process; including eicosanoids, specialized pro-resolving mediators, phospholipids/sphingolipids, and endocannabinoids. Dietary interventions using omega-3 polyunsaturated fatty acids or treatment with synthetic endocannabinoids agonists have been shown to significantly ameliorate RA symptoms. Indeed, the modulation of lipid metabolism may be crucial in the pathophysiology and treatment of autoimmune diseases.

Anti-Aging Effect of Metformin: A Molecular and Therapeutical Perspective

Aging is a time-dependent inevitable process, in which cellular homeostasis is affected, which has an impact on tissue function. This represents a risk factor for the development of numerous non-transmissible diseases. In consequence, the scientific community continues to search for therapeutic measures capable of improving quality of life and delaying cellular aging. At the center of this research is metformin, a widely used drug in Type 2 Diabetes Mellitus treatment that has a reduced adverse effects profile. Furthermore, there is evidence that this drug has beneficial health effects that go beyond its anti-hyperglycemic properties. Among these effects, its geronto-protection capability stands out. There is growing evidence that points out to an increased life expectancy as well as the quality of life in model organisms treated with metformin. Therefore, there is an abundance of research centered on elucidating the mechanism through which metformin has its anti-aging effects. Among these, the AMPK, mTORC1, SIRT1, FOXO, NF.kB, and DICER1 pathways can be mentioned. Furthermore, studies have highlighted the possibility of a role for the gut microbiome in these processes. The next step is the design of clinical essays that have as a goal evaluating the efficacy and safety of metformin as an anti-aging drug in humans to create a paradigm in the medical horizon. The question being if metformin is, in fact, the new antiaging therapy in humans?

Exploring Phytotherapeutic Alternatives for Obesity, Insulin Resistance and Diabetes Mellitus

At present, the pathologic spectrum of obesity-insulin resistance (IR)-diabetes mellitus (DM) represents not only a pressing matter in public health but also a paramount object of study in biomedical research, as they constitute major risk factors for cardiovascular disease (CVD), and other chronic non-communicable diseases (NCD). Phytotherapy, the use of medicinal herbs (MH) with treatment purposes, offers a wide array of opportunities for innovation in the management of these disorders; mainly as pharmacological research on small molecules accumulates. Several MH has displayed varied mechanisms of action relevant to the pathogenesis of obesity, IR and DM, including immunological and endocrine modulation, reduction of inflammation and oxidative stress (OS), regulation of appetite, thermogenesis and energy homeostasis, sensitisation to insulin function and potentiation of insulin release, among many others. However, the clinical correlates of these molecular phenomena remain relatively uncertain, with only a handful of MH boasting convincing clinical evidence in this regard. This review comprises an exploration of currently available preclinical and clinical research on the role of MH in the management of obesity, IR, and DM.

Role of Dietary Polyphenols in Adipose Tissue Browning: A Narrative Review

Lifestyle modifications such as energy restriction and increased physical activity are highly effective in the management of obesity. However, adherence to these therapeutic approaches is poor. On the other hand, synthetic drugs used for obesity control are plagued by adverse effects. Despite these failures, adipose tissue is still an attractive therapeutic target for novel molecules, and thus, the characterisation of new and safer anti-obesity drugs is of significant interest. For this reason, in recent years, phenolic constituents of diverse plants have drawn much attention due to their health-promoting properties, opening new research lines related to brown adipose tissue activation and white adipose tissue (WAT) browning. The goal is to increase energy expenditure levels through thermogenic activity activation by multiple factors, like polyphenols. The suggested mechanisms by which polyphenols can modulate thermogenesis include Nor-epinephrine/Catechol-O-Methyl-Transferase (NE/COMT) inhibition, PPARγ co-activator alpha (PGC-1α)-dependent pathways activation, and mitochondrial biogenesis, among others. Although polyphenols such as quercetin, catechins, chrysin, luteolin, curcumin, resveratrol, gallic acid, and lignans have shown a positive effect on Non-Shivering Thermogenesis and WAT browning, most of them have only been active in murine models or in vitro systems, and their reproducibility in humans has to be proved. Probably in the future, an approach that includes these compounds as part of the nutritional regimen in conjunction with physical exercise, pharmacological and surgical therapy, would allow modulating a pathophysiological mechanism that is still elusive.

Age-specific waist circumference cutoff-points for abdominal obesity diagnosis: a personalized strategy for a large Venezuelan population

Background

Evidence shows that the ageing process is a determining factor in fat distribution, composition, and functionality. The goal of this research was to determine cut-off points for waist circumference according to age in the adult population from Maracaibo city, Venezuela.

Methodology

The Metabolic Syndrome Prevalence Study is a descriptive, cross-sectional study with multi-stage randomized sampling. In this post-hoc analysis 1902 individuals ≥18 years and from both sexes were evaluated. Waist circumference ROC curves were built for each age group and sex, using metabolic phenotypes for classification.

Results

52.2% (n = 992) were women, and the mean age was 38.7 ± 2. Cut-off points obtained for the <30 years age group were: 91 cm for women (Sensitivity: 96,8%, Specificity: 97,7%) and 94 cm for men (Sensitivity:100%, Specificity: 99,2%); for 30-49 years: women 94 cm (Sensitivity: 93.7%, Specificity: 97.1%) and men 95 cm (Sensitivity: 97.3%, Specificity: 100%); for ≥50 years: women 94 cm (Sensitivity: 91.8%, Specificity: 86.7%) and men 101 cm (Sensitivity: 100%, Specificity: 100%).

Conclusion

The use of specific cut-off points according to age groups is proposed to determine abdominal obesity in Maracaibo city due to the underestimation seen in young people and the overestimation observed in older people when using a unique cut-off point.

Chronobiology and Chronotherapy in Depression: Current Knowledge and Chronotherapeutic Promises

Background:

Depression is a heavily prevalent mental disorder. Symptoms of depression extend beyond mood, cognition, and behavior to include a spectrum of somatic manifestations in all organic systems. Changes in sleep and neuroendocrine rhythms are especially prominent, and disruptions of circadian rhythms have been closely related to the neurobiology of depression. With the advent of increased research in chronobiology, various pathophysiologic mechanisms have been proposed, including anomalies of sleep architecture, the effects of clock gene polymorphisms in monoamine metabolism, and the deleterious impact of social zeitgebers. The identification of these chronodisruptions has propelled the emergence of several chronotherapeutic strategies, both pharmacological and non-pharmacological, with varying degrees of clinical evidence.

Methods:

The fundamental objective of this review is to integrate current knowledge about the role of chronobiology and depression and to summarize the interventions developed to resynchronize biorhythms both within an individual and with geophysical time.

Results:

We have found that among the non-pharmacological alternatives, triple chronotherapywhich encompasses bright light therapy, sleep deprivation therapy, and consecutive sleep phase advance therapy-has garnered the most considerable scientific interest. On the other hand, agomelatine appears to be the most promising pharmacological option, given its unique melatonergic pharmacodynamics.

Conclusions:

Research in chronotherapy as a treatment for depression is currently booming. Novel interventions could play a significant role in adopting new options for the treatment of depression, with Tripe Cronotherapy standing out as the most promising treatment.

Oxidative stress and its role in cancer: a molecular perspective

Cancer development is a product of cellular growth and proliferation caused by DNA mutations, nevertheless, other processes are able to favor tumoral progression, such as the activity of reactive oxygen species (ROS) produced within cells as a result of different metabolic reactions. Oxidative stress is defined as an imbalance between free radicals and highly reactive metabolites synthesis and the antioxidant system capacity to eliminate these molecules. In this sense, the overproduction of free radicals is a typical feature of neoplastic cells that allows the promotion of cellular processes related to survival, proliferation, invasion, and metastasis. Furthermore, underlying mechanisms involved in malignant transformation can modify the antioxidant systems in charge of ROS elimination. However, cancer has the particularity of presenting a dual behavior in which both antioxidant or prooxidant activity within tumoral cells can predominate depending on the stage of the disease. As a consequence, many therapeutic efforts have been directed into the stimulation or inhibition of oxidant and antioxidant components in the tumor microenvironment. The aim of this review is to describe the role of oxidative stress in cancer biology and its therapeutic potential.

Vínculo entre el estrés oxidativo y las anemias hemolíticas: una visión molecular

Las anemias hemolíticas son un conjunto de enfermedades que producen la reducción de la concentración de la hemoglobina en sangre, como resultado del aumento en la destrucción de los glóbulos rojos. Dependiendo de la causa etiológica, estas pueden dividirse en hereditarias o adquiridas. Durante los últimos años, ha ido en aumento la evidencia que indica la participación del estrés oxidativo en diferentes anemias hemolíticas, dentro de las que se encuentran: la deficiencia de la enzima glucosa 6 fosfato deshidrogenasa, anemia falciforme, talasemias, anemia hemolítica autoinmune, hemoglobinuria paroxística nocturna y anemia hemolítica inducida por fármacos. A su vez, se ha sugerido que terapias antioxidantes pueden servir como posibles coadyuvantes en el tratamiento de algunos de estos trastornos hematológicos. Es por esto que el objetivo de esta revisión narrativa es describir concisamente los mecanismos mediante el cual se produce estrés oxidativo en los eritrocitos, su papel en las anemias hemolíticas y los efectos de la terapia antioxidante en el tratamiento de estas. 

FRI0295 ADALIMUMAB LEVELS ARE ASSOCIATED WITH DRUG RETENTION RATES IN AXIAL SPONDYLOARTHRITIS PATIENTS

Background:

Production of anti-drug antibodies (ADA) could cause low serum anti-TNF levels and low drug retention rates.

Objectives:

To assess the relationship between serum adalimumab (ADL) levels and drug retention rates in patients with axial SpA.

Methods:

Single-center prospective study in patients with axial SpA, according to ASAS criteria, being treated with ADL. In the first part of the study, from December 2010 to June 2016, data was collected and serum samples were taken. In a second part of the study, clinical records were reviewed to find out the dates and reasons of treatment discontinuation. Information was collected on age gender, body mass index (BMI), date of diagnosis of SpA, laboratory data, including HLAB27, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), prior biological treatment for SpA, concomitant conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs). SpA disease activity was assessed by BASDAI, ASDAS and PGA scores. A serum sample was taken from all patients just before the next adalimumab dose. ADL and ADA levels were analysed with ELISA Promonitor®, (Proteomika, Progénica, Griffols) and correlated with SpA activity using BASDAI and ASDAS scores. Cox proportional hazards model was performed in order to assess the relation of variables with drug interruption.

Results:

Up to January 2016, 51 consecutive patients were included. The mean (range) age was 46,9 (18–68) and 47.1% were women. HLAB27 was positive in 82,4% of patients. Mean disease duration was 122,9 months (2-408) and mean duration of treatment with adalimumab was 17,8 months (1-69). ADL was the first biological agent received in 36 patients (70.6%). Eleven patients (21.6%) were on concomitant treatment with receiving concomitant csDMARDs, mainly methotrexate (MTX) (15.7%) and sulfasalazine (5.9%). The mean (SD) activity scores were BASDAI 4,0 ± 2,3; ASDAS-PCR 2,1 ± 1,1 and ASDAS-VSG 2,1 ± 1,0.

ADA prevalence was 27.5%, with none detected in the 21.6% taking csDMARDs (p = 0.021). ADL level was normal (> 3 mg/l) in 36 patients (70.6%), all without ADA. Fifteen patients (29.4%) had subtherapeutic ADL levels (< 3 mg/l), with ADA in 14 (93%).

Total ADL treatment time was 241,16 patient/years, and mean ADL treatment time was 4,73 years. Cox model results were resumed in table 1. Multivariate study show that ADL level > 3 mg/L was a protective factor for ADL interruption (HR 0.01 (0.00-0.59, p=0.026), while previous etanercept treatment was a risk factor for ADL interruption 9.54 (1.23-74.08, p=0.031).

Table 1.

Cox model.

ContinueDiscon=tinueUnivariateHRMultivariateHRADL level<3 mg/L13 (86,7%)2 (13,3%)0.05 (0.00-0.65, p=0.022)0.01 (0.00-0.59, p=0.026)≥3 mg/L28 (77,8%)8 (22,2%)Concomitant DMARDYes8 (72,7%)3 (27,3%)0.56 (0.14-2.26, p=0.419)0.28 (0.05-1.65, p=0.159)No33 (82,5%)7 (17,5%)BMINormal13 (86,7%)2 (13,3%)2.56 (0.54-12.23, p=0.239)0.48 (0.02-9.75, p=0.634)Overweight/obese27 (77,1%)8 (22,9%)AgeMean (SD)46,4 (12,2)48,7 (11,6)0.93 (0.24-3.60, p=0.912)0.60 (0.10-3.84, p=0.594)GenderMen19 (70,4%)8 (29,6%)0.43 (0.09-2.03, p=0.283)0.58 (0.03-10.06, p=0.705)Women22 (91,7%)2 (8,3%)InfliximabpreviousYes4 (40,0%)6 (60,0%)3.31 (0.92-11.87, p=0.066)1.37 (0.23-8.24, p=0.731)No37(90,2%)4 (9,8%)EtanerceptpreviousYes2 (22,2%)7 (77,7%)8.17 (2.09-31.90, p=0.003)9.54 (1.23-74.08, p=0.031)No39 (92,9%)3 (7,1%)

ADL: adalimumab; BMI: body mass index; DMARD: disease modifying antirheumatic drug; SD: standard deviation.

Conclusion:

Adalimumab drug levels > 3 mg/L is a protective factor against treatment interruption.

Etanercept previous treatment was a risk factor for treatment interruption.

Acknowledgments:

The study was supported by a grant from “Asociación para la Investigación en Reumatología de la Marina Baixa” (AIRE-MB).

Disclosure of Interests:

None declared

FRI0614-HPR RECOMMENDATIONS FOR PATIENTS WITH RHEUMATIC DISEASES IN TREATMENT WITH METHOTREXATE

Background:

Methotrexate (MTX) is the first choice disease-modifying anti-rheumatic drug (FAME) in the treatment of rheumatoid arthritis among other rheumatic diseases. It is therefore very important that patients are aware of this treatment and have an adequate management of it.

Objectives:

The development of a recommendation leaflet for patients with rheumatic diseases in treatment with MTX.

Methods:

A systematic review of the literature was conducted, defining the criteria for inclusion and exclusion of content. The coordinators of the work generated preliminary recommendations that were evaluated and discussed in GESVR meetings and 10 recommendations on the use of MTX were accepted, which were later ratified by the Valencian Society of Rheumatology.

Results:

The final document with a brief introduction indicates that MTX can be administered orally or subcutaneously, depending on the prescribed dose and its tolerance. In the case of subcutaneous administration, pre-filled syringes or pens are used which do not require any preparation, so there is no risk of handling and/or inhalation toxicity. The proposed recommendations are described below:

[1] MTX should be taken or administered ONLY once a week, and always on the same day of the week. It is important to follow these recommendations to ensure adequate effectiveness and avoid side effects.

[2] It is common to add a folic acid supplement the day after MTX is taken to avoid certain side effects of the drug. In some cases it may be necessary to increase the dose to other days of the week.

[3] Alcohol consumption should be avoided, as it increases the likelihood of adverse effects from the treatment.

[4] Common side effects include nausea or gastrointestinal distress, loss of appetite, headache and fatigue after taking each weekly dose of the drug.

If this happens, you can take the daily dose in two doses, avoid taking large amounts and drink plenty of water on the day of administration. If in spite of everything, they do not disappear, you should consult the Rheumatology Unit.

[5] It is recommended to use sun protection.

[6] Pregnancy and breastfeeding should be avoided while taking MTX. In case of pregnancy desire, you should consult the Rheumatology service in order to schedule a withdrawal of the treatment. In case of unplanned pregnancy, stop treatment and contact the Rheumatology Unit immediately.

[7] The annual flu vaccine is recommended. Consultation with the Rheumatology Unit is recommended for additional vaccines.

[8] The benefits of MTX take several weeks to appear, so you should not modify or interrupt the treatment on your own.

[9] Throughout the treatment, regular tests will be performed to monitor the safety and effectiveness of the drug.

[10] In case of doubts, and in case of infection, surgical intervention, oncological pathology or pregnancy, contact the Rheumatology Unit.

Conclusion:

This leaflet is intended to resolve common doubts of patients receiving treatment with MTX, and thus contribute to improve the therapeutic adherence and avoid errors in the drug taking.

Disclosure of Interests:

None declared

AB0318 CHARACTERISTICS OF PATIENTS WITH RHEUMATOID ARTHRITIS WHO HAVE WITHDRAWN THE LAST BIOLOGICAL DRUG: REAL-LIFE RESULTS FROM A LOCAL REGISTRY

Objectives:

To assess the characteristics of patients with rheumatoid arthritis (RA), who have withdrawn the last biological drug (bDMARD), and to know the reasons for withdrawal of treatment.

Methods:

Retrospective and cross-sectional study on December 31, 2019, of patients with RA, treated with any of the bDMARDs, including JAK (JAKi) inhibitor drugs, commonly used, from 1/1/2000 to 12/31/2019. General data were collected from patients, and RA: time of evolution, presence of rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA), type of bDMARD, time in bDMARD, and cause of withdrawal.

Results:

Of 252 patients, who have received some bDMARD, 81 (32%) patients had withdrawn on 12/31/2019. 62 (77%) patients were women, with a mean age at diagnosis of RA of 48 years (SD: 16.5 years) and 59.5 (15) years at the beginning of the first bDMARD (F1), with an average evolution of RA 10.2 (2.5) years. 68% and 74% of patients were positive for RF and ACPA, respectively.

In 64 (79%) patients, bDMARD was withdrawn as second to fifth bDMARD received (F2 to F5): as F2: 37/81 (46%) patients, F3: 14 (18%), F4: 8 (10%) and as F5: (6%) patients.

When comparing the last bDMARD received, before the suspension as F1 vs F2-F5, 95% vs. 61% of patients (p <0.0001), the drug was an anti-TNF (TNFi); Abatacept: 1 (1%) vs 9 (14%); Tocilizumab: 0% vs 8 (12%); Rituximab: 1 (1%) vs 5 (8%) and JAKi: 4 (5%) vs 3 (5%). The mean time in treatment with some bDMARD was 2.6 (SD: 3) years in the F1 group vs 1.7 (2) years in the F2-F5 group (p = 0.034). Among the F3-F5 patients, 9 (14%) patients had failed at 2 different previous therapeutic targets and 6 (9%) at 3 targets.

No differences were detected between the F1 group vs F2-F5, regarding the causes of withdrawal of bDMARD: whether it had occurred due to 1) loss of efficacy (25/31% patients vs 19/30%); 2) adverse events (31/38% vs. 29/45%): infection: 18/81 (22%) patients, malignancy: 5 (6%), malaise/pain: 11 (14%), laboratory parameters alteration: 7 (9%), death: 5 (6%), others: 14 (17%); 3) change of address/loss of follow-up (20/25% vs. 7/11%) or by 4) voluntary abandonment of treatment by the patient (5/6% vs. 9/14%).

Conclusion:

1. 32% of patients with RA withdraw the bDMARD. 2. The group treated with TNFi withdraws it significantly higher among the F1 group. 3. Survival of bDMARD is significantly higher in group F1 compared to F2-F5. 4. No differences were detected between the groups regarding the cause of withdrawal of bDMARD. 25% -30% of patients withdraw it due to loss of follow-up or voluntary abandonment of bDMARD.

Acknowledgments:

The study was supported by a research grant from the Association for Research in Rheumatology of the Marina Baixa (AIRE-MB).

Disclosure of Interests:

None declared

OP0299 CLINICAL FEATURES ASSOCIATED WITH FRAGILITY FRACTURE AFTER DISCONTINUATION OF TREATMENT WITH DENOSUMAB: A CASE-CONTROL STUDY

Background:

Discontinuation of denosumab treatment causes an increase in bone resorption that has been linked to the emergence of vertebral fractures.

Objectives:

To evaluate the association of clinical features and demographic characteristics with the emergence of new fragility fractures in patients with osteoporosis who interrupt treatment with denosumab.

Methods:

Retrospective case-control study. Medical records of all patients with osteoporosis, from our local densitometry database, who received treatment with denosumab (at least one dose) and discontinue the treatment, have been studied.

Information was collected on demographic variables (age, sex), risk factors for osteoporosis (alcohol and tobacco consumption, personal history of fragility fracture and history of maternal hip fracture), secondary osteoporosis (due to early menopause, disease or osteopenizing treatment), previous treatment for osteoporosis, start and end date of denosumab treatment and subsequent treatments.

All patients who suffered a fragility fracture from 6 months after the last dose of denosumab up to 20 months later were defined as a case. Prior treatment with bisphosphonate was considered to those who had received it for at least 1 year, and subsequent treatment with bisphosphonate was considered to those who received it immediately or up to 8 months after the last dose of denosumab.

Results:

In total, 63 patients who discontinued treatment with denosumab were included. Ten of them presented fragility fractures (6 vertebral, 3 forearm and 1 hip). Two patients had a fracture after 24 months of the last dose of denosumab, so don’t were considered cases. 61 patients were women (96.83%) and the mean age (SD) was 70.22 (8.95) years. The mean time (SD) of treatment with denosumab was 42.25 (17.32) months, with a mean (SD) doses of 7.85 (2.78). The reasons for interruption of denosumab were: improvement 39 (65%), dental procedure 9 (15%), patient decision 6 (10%), adverse event 4 (6.66%) and inefficacy 2 (3.33%). Demographic and clinical features by fragility fracture are shown in Table 1. We found that subsequent treatment with bisphosphonates after denosumab was initiated in less patients in the fracture group than in the control group (10% vs 42,9%; p=0,05), and we found no fractures in patients diagnosed with secondary osteoporosis. No statistically significant differences were found in the rest of the variables.

Table 1.

Demographic and clinical features by fragility fracture.

No fractureFractureTotalpAge, mean (SD)70.2 (9.5)70.5 (5.5)70.2 (8.9)0.956BMI, mean (SD)25.0 (4.8)25.3 (3.2)25.1 (4.6)0.844Secondary OP (%)26 (49.1)0 (0)26 (41.3)0.004Tobacco (%)17 (32.1)2 (25.0)19 (31.1)0.687Alcohol (%)3 (5.7)0 (0.0)3 (4.9)0.490Previous fracture (%)20 (37.7)6 (66.7)26 (41.9)0.104Mother hip (%)6 (11.3)0 (0.0)6 (9.8)0.316Previous BP (%)29 (67.4)2 (50.0)31 (66.0)0.481Denosumab dose, mean (SD)7.9 (2.8)7.5 (3.0)7.9 (2.8)0.676Subsequent BP (%)21 (42.9)1 (10.0)22 (37.3)0.050

BMI: body mass index; BP: bisphosphonate; OP: osteoporosis; SD: standard deviation.

Conclusion:

Sequential treatment with bisphosphonates and diagnosis of secondary osteoporosis are related to the absence of fractures after discontinuation of denosumab treatment.

Acknowledgments:

This study was supported by a research grant from Asociación para la Investigación en Reumatología de la Marina Baixa (AIRE-MB).

Disclosure of Interests:

None declared

AB0912 CLINICAL UTILITY OF THE WARD TRIANGLE OF HIP BONE DENSITOMETRY: DATA FROM AN FLS UNIT

Objectives:

To evaluate the clinical utility of Ward’s triangle (W) of bone densitometry (BMD) of the hip in a population of postmenopausal women referred to BMD from a FLS Unit coordinated by Rheumatology (FLS-REU).

Methods:

Retrospective study, which includes, after informed consent, postmenopausal women referred by any department of specialized medicine or primary care medicine, of the health department, to the FLS-REU Unit of our center, during the period of February 2010 to October 2019.

General patient data were collected (age, gender), and risk factors for OP. BMD of the lumbar spine (CL) and hip (femoral neck, total hip and W) was performed, except if there was lumbar surgery, severe scoliosis, or a bilateral hip prosthesis. The BMD outcome was distributed in normal (T index [Ts] to -1 SD), osteopenia (Ts: -1.1 to -2.5 SD) and OP (Ts: <-2.5 SD), separated into two groups: mild OP- moderate (Ts: from <-2.5 DE to -3 DE) or severe OP (Ts: <-3 DE).

Results:

5,740 postmenopausal women referred for BMD are included, with the W result available (Table 1). The result of the mean Ts (SD) was: in CL: -1.49 (1.48) SD, femoral neck: -1.33 (1.11) SD and in W: -2.05 (1.12) SD. In 947 (16%) women, the W was normal, with a mean Ts: -0.28 (1.12) SD; osteopenia in 2,606 (45%): -1.83 (1,12) SD and OP in 2,197 (39%) SD, of which 1,010 (61%) had mild-moderate OP and 967 (49%), severe OP.

The table shows the BMD results of W and CL, the correlation coefficient between them being 0.52 (0.5-0. P <0.001), although with a Kappa coefficient of 0.26 (0.24-0.28. P = 0). The probability that a result in W of normal BMD is normal also in CL is 73% (70% -76%), in osteopenia in both: 47% (45% -49%) and OP: 46% (44 % -48%). In the analysis by ROC curve, the cut-off point of Ts in W for osteopenia in CL is -1.85 SD (sensitivity: 0.648, specificity: 0.649, with AUC: 00.702. [0.687-0.716]) and for OP in CL -2.35 DE (sensitivity: 0.69, specificity: 0.70, with AUC: 0.757 [0.744-0.770]).

LUMBAR SPINE (LS)NormalOsteopeniaOsteoporosis(OP)OP<-2.5 a -3 SDOP<-3.0 SDWard normalN (%): 947 (16)Tscore: -0.28 ± 1.12 SD6810.41±1.78211-1.61±1.7839-2.95±1.7826-2.7±1.7813-3.46±1.78Ward osteopeniaN (%): 2.606 (45)Tscore: -1.83±1.12 SD899-0.07±1.481.192-1.73±1.48463-2.96±1.48310-2.72±1.48153-3.43±1.48Ward OsteoporosisN (%): 2.187 (39)Tscore: -3.07±1.13 SD346-0.19±1.48800-1.83±1.48975-3.23±1.48--Ward Osteoporosis <-2.5 a-3 SDN: 1.010 (51)Tscore: -2.78±1.12 SD188-0.16±1.48416-1.83±1.48-173-2.77±1.48378-3.08±1.48Ward Osteoporosis <-3 SDN: 967 (49)Tscore: -3.51±1.13 SD114-0.24±1.48304-1.84±1,48-193-2.78±1.48327-3.73±1.48

Conclusion:

1.For clinical practice, the usefulness of the W result is low, although if the BMD result is normal, there is a 73% probability that in CL it will also be. 2. The correlation between the result of W and CL, although significant, is slight. 3. The cut-off points of Ts, with better sensitivity and specificity, that correlate a W osteopenia or osteoporosis with the result in CL is -1.85 and -2.35 SD, respectively.

Acknowledgments:

The study was supported by a research grant from the Association for Research in Rheumatology of the Marina Baixa (AIRE-MB).

Disclosure of Interests:

None declared

Neprilysin: A Potential Therapeutic Target of Arterial Hypertension?

Arterial hypertension is the most prevalent chronic disease in the adult population of developed countries and it constitutes a significant risk factor in the development of cardiovascular disease, contributing to the emergence of many comorbidities, among which heart failure excels, a clinical syndrome that nowadays represents a major health problem with uncountable hospitalizations and the indolent course of which progressively worsens until quality of life decreases and lastly death occurs prematurely. In the light of this growing menace, each day more efforts are invested in the field of cardiovascular pharmacology, searching for new therapeutic options that allow us to modulate the physiological systems that appear among these pathologies. Therefore, in the later years, the study of natriuretic peptides has become so relevant, which mediate beneficial effects at the cardiovascular level such as diuresis, natriuresis, and decreasing cardiac remodeling; their metabolism is mediated by neprilysin, a metalloproteinase, widely expressed in the human and capable of catalyzing many substrates. The modulation of these functions has been studied by decades, giving room to Sacubitril, the first neprilysin inhibitor, which in conjunction with an angiotensin receptor blocker has provided a high efficacy and tolerability among patients with heart failure, for whom it has already been approved and recommended. Nonetheless, in the matter of arterial hypertension, significant findings have arisen that demonstrate the potential role that it will play among the pharmacological alternatives in the upcoming years.

HIV infection and care pathway: From guidelines to clinical practice

OBJECTIVES

To quantify within a cohort of HIV-infected individuals the number of medical visits and procedures to be carried out according to comorbidities and risk factors to implement a personalized care pathway.

PATIENTS AND METHODS

Retrospective study of 915 patients consulting from January 1 to December 31, 2016 at an outpatient unit of multidisciplinary consultations, using an electronic patient record. We built an algorithm using parameters required for the application of the national guidelines for the management of HIV-infected individuals. The frequency of comorbidities was measured according to gender, transmission risk group, and nadir CD4 (<or>200/mm³).

RESULTS

Patients were mostly men (median age: 52 years), of whom 16% were aged≥60 years. Viral load was<40 copies/mL in 93.5% of treated patients and CD4 cell count≥500/mm³ for 73%. Overall, 74.5% of patients had at least one comorbidity. The number of comorbidities was similar in men and women but was significantly higher in patients with a nadir CD4 <200/mm3 and increased with age (irrespective of gender). The minimum number of consultations to be scheduled per year was 8123: 70% for the management of comorbidities with an average of six consultations/year/patient. Overall, 53% of patients should attend a proctology consultation. The minimum number of paramedical procedures to be performed was 5115.

CONCLUSION

The implementation of a personalized multidisciplinary management within a single facility seems to be a suitable care model to address the needs of HIV-infected individuals.

Dyslipidemia: Genetics, lipoprotein lipase and HindIII polymorphism

The direct link between lipid metabolism alterations and the increase of cardiovascular risk are well documented. Dyslipidemias, including isolated high LDL-c or mixed dyslipidemia, such as those seen in diabetes (hypertriglyceridemia, high LDL-c or low HDL-c), correlate with a significant risk of cardiovascular and cerebrovascular disease worldwide.  This review analyzes the current knowledge concerning the genetic basis of lipid metabolism alterations, emphasizing lipoprotein lipase gene mutations and the HindIII polymorphism, which are associated with decreased levels of triglycerides and LDL-c, as well as higher levels of HDL-c. These patterns would be associated with decreased global morbidity and mortality, providing protection against cardiovascular and cerebrovascular diseases.

Dyslipidemia: Genetics, lipoprotein lipase and HindIII polymorphism

The direct link between lipid metabolism alterations and the increase of cardiovascular risk are well documented. Dyslipidemias, including isolated high LDL-c or mixed dyslipidemia, such as those seen in diabetes (hypertriglyceridemia, high LDL-c or low HDL-c), correlate with a significant risk of cardiovascular and cerebrovascular disease worldwide.  This review analyzes the current knowledge concerning the genetic basis of lipid metabolism alterations, emphasizing lipoprotein lipase gene mutations and the HindIII polymorphism, which are associated with decreased levels of triglycerides and LDL-c, as well as higher levels of HDL-c. These patterns would be associated with decreased global morbidity and mortality, providing protection against cardiovascular and cerebrovascular diseases.

Experimental Infection of Domestic Pigs with African Swine Fever Virus Lithuania 2014 Genotype II Field Isolate

An experimental infection was conducted to evaluate horizontal transmission, clinical, virological and humoral response induced in domestic pigs infected with African swine fever (ASF) genotype II virus circulating in 2014 into the European Union (EU). Ten naive pigs were placed in contact with eight pigs experimentally inoculated with the Lithuanian LT14/1490 ASF virus (ASFV) responsible for the first ASF case detected in wild boar in Lithuania in January 2014. Clinical examination and rectal temperature were recorded each day. Blood sampling from every animal was carried out twice weekly. Blood samples were examined for presence of ASF virus-specific antibodies and for determining the ASFV viral load. From the obtained results, it was concluded that the Lithuanian ASFV induced an acute disease which resulted in 94, 5% mortality. The disease was easily detected by real-time PCR prior to the onset of clinical signs and 33% of the animals seroconverted. All findings were in accordance with observations previously made in domestic pigs and wild boar when infected with ASF genotype II viruses characterized by a high virulence. One in-contact pig remained asymptomatic and survived the infection. The role of such animals in virus transmission would need further investigation.

Sensitivity and Specificity Improvement in Abdominal Obesity Diagnosis Using Cluster Analysis during Waist Circumference Cut-Off Point Selection

INTRODUCTION

The purpose of this study was to analyze the influence of metabolic phenotypes during the construction of ROC curves for waist circumference (WC) cutpoint selection.

MATERIALS AND METHODS

A total of 1,902 subjects of both genders were selected from the Maracaibo City Metabolic Syndrome Prevalence Study database. Two-Step Cluster Analysis (TSCA) was applied to select metabolically healthy and sick men and women. ROC curves were constructed to determine WC cutoff points by gender.

RESULTS

Through TSCA, metabolic phenotype predictive variables were selected: HOMA2-IR and HOMA2-βcell for women and HOMA2-IR, HOMA2-βcell, and TAG for men. Subjects were classified as healthy normal weight, metabolically obese normal weight, healthy and metabolically disturbed overweight, and healthy and metabolically disturbed obese. Final WC cutpoints were 91.50 cm for women (93.4% sensitivity, 93.7% specificity) and 98.15 cm for men (96% sensitivity, 99.5% specificity).

CONCLUSIONS

TSCA in the selection of the groups used in ROC curves construction proved to be an important tool, aiding in the detection of MOWN and MHO which cannot be identified with WC alone. The resulting WC cutpoints were <91.00 cm for women and <98.00 cm for men. Furthermore, anthropometry is insufficient to determine healthiness, and, biochemical analysis is needed to properly filter subjects during classification.

Genetic inactivation of the pancreatitis-inducible gene Nupr1 impairs PanIN formation by modulating Kras(G12D)-induced senescence

Nuclear protein 1 (Nupr1), a small chromatin protein, has a critical role in cancer development, progression and resistance to therapy. Previously, we had demonstrated that Nupr1 cooperates with Kras^G12D to induce pancreas intraepithelial neoplasias (PanIN) formation and pancreatic ductal adenocarcinoma development in mice. However, the molecular mechanisms by which Nupr1 influences Kras-mediated preneoplastic growth remain to be fully characterized. In the current study, we report evidence supporting a role for Nupr1 as a gene modifier of Kras^G12D-induced senescence, which must be overcome to promote PanIN formation. We found that genetic inactivation of Nupr1 in mice impairs Kras-induced PanIN, leading to an increase in β-galactosidase-positive cells and an upregulation of surrogate marker genes for senescence. More importantly, both of these cellular and molecular changes are recapitulated by the results of mechanistic experiments using RNAi-based inactivation of Nupr1 in human pancreatic cancer cell models. In addition, the senescent phenotype, which results from Nupr1 inactivation, is accompanied by activation of the FoxO3a-Skp2-p27^Kip1-pRb-E2F pathway in vivo and in vitro. Thus, combined, these results show, for the first time, that Nupr1 aids oncogenic Kras to bypass senescence in a manner that cooperatively promotes PanIN formation. Besides its mechanistic importance, this new knowledge bears medical relevance as it delineates early pathobiological events that may be targeted in the future as a means to interfere with the formation of preneoplastic lesions early during pancreatic carcinogenesis.

An elevated level of physical activity is associated with normal lipoprotein(a) levels in individuals from Maracaibo, Venezuela

Coronary artery disease is the main cause of death worldwide. Lipoprotein(a) [Lp(a)], is an independent risk factor for coronary artery disease in which concentrations are genetically regulated. Contradictory results have been published about physical activity influence on Lp(a) concentration. This research aimed to determine associations between different physical activity levels and Lp(a) concentration. A descriptive and cross-sectional study was made in 1340 randomly selected subjects (males = 598; females = 712) to whom a complete clinical history, the International Physical Activity Questionnaire, and Lp(a) level determination were made. Statistical analysis was carried out to assess qualitative variables relationship by chi2 and differences between means by one-way analysis of variance considering a P value <0.05 as statistically significant. Results are shown as absolute frequencies, percentages, and mean +/- standard deviation according to case. Physical activity levels were ordinal classified as follows: low activity with 24.3% (n = 318), moderate activity with 35.0% (n = 458), and high physical activity with 40.8% (n = 534). Lp(a) concentration in the studied sample was 26.28 +/- 12.64 (IC: 25.59-26.96) mg/dL. Lp(a) concentration according to low, moderate, and high physical activity levels were 29.22 +/- 13.74, 26.27 +/- 12.91, and 24.53 +/- 11.35 mg/dL, respectively, observing statistically significant differences between low and moderate level (P = 0.004) and low and high level (P < 0.001). A strong association (chi2 = 9.771; P = 0.002) was observed among a high physical activity level and a normal concentration of Lp(a) (less than 30 mg/dL). A lifestyle characterized by high physical activity is associated with normal Lp(a) levels.