Transthyretin amyloid polyneuropathy in France: A cross-sectional study with 413 patients and real-world tafamidis meglumine use (2009-2019)

OBJECTIVE

We aimed to describe characteristics of patients with ATTR variant polyneuropathy (ATTRv-PN) and ATTRv-mixed and assess the real-world use and safety profile of tafamidis meglumine 20mg.

METHODS

Thirty-eight French hospitals were invited. Patient files were reviewed to identify clinical manifestations, diagnostic methods, and treatment compliance.

RESULTS

Four hundred and thirteen patients (296 ATTRv-PN, 117 ATTRv-mixed) were analyzed. Patients were predominantly male (68.0%) with a mean age of 57.2±17.2 years. Interval between first symptom(s) and diagnosis was 3.4±4.3 years. First symptoms included sensory complaints (85.9%), dysautonomia (38.5%), motor deficits (26.4%), carpal tunnel syndrome (31.5%), shortness of breath (13.3%), and unexplained weight loss (16.0%). Mini-invasive accessory salivary gland or punch skin and nerve biopsies were most common, with a performance of 78.8-100%. TTR genetic sequencing, performed in all patients, revealed 31 TTR variants. Tafamidis meglumine was initiated in 156/214 (72.9%) ATTRv-PN patients at an early disease stage. Median treatment duration was 6.00 years in ATTRv-PN and 3.42 years in ATTRv-mixed patients. Tafamidis was well tolerated, with 20 adverse events likely related to study drug among the 336 patients.

CONCLUSION

In France, ATTRv patients are usually identified early thanks to the national network and the help of diagnosis combining genetic testing and mini-invasive biopsies.

[Peripheral neuropathies during systemic diseases: Part I (connective tissue diseases and granulomatosis)]

Systemic diseases (connective disease, granulomatosis) may be associated with peripheral neuropathies. The diagnosis can be complex when the neuropathy is the presenting manifestation of the disease, requiring close collaboration between neurologists and internists. Conversely, when the systemic disease is already known, the main question remaining is its imputability in the neuropathy. Regardless of the situation, the positive diagnosis of neuropathy is based on a systematic and rigorous electro-clinical investigation, specifying the topography, the evolution and the mechanism of the nerve damage. Certain imaging examinations, such as nerve and/or plexus MRI, or other more invasive examinations (skin biopsy, neuromuscular biopsy) enable to specify the topography and the mechanism of the injury. The imputability of the neuropathy in the course of a known systemic disease is based mainly on its electro-clinical pattern, on which the alternatives diagnoses depend. In the case of an inaugural neuropathy, a set of arguments orients the diagnosis, including the underlying terrain (young subject), possible associated systemic manifestations (inflammatory arthralgias, polyadenopathy), results of first-line laboratory tests (lymphopenia, hyper-gammaglobulinemia, hypocomplementemia), autoantibodies (antinuclear, anti-native DNA, anti-SSA/B) and sometimes invasive examinations (neuromuscular biopsy).

Treating hereditary transthyretin amyloidosis: Present & future challenges

Hereditary transthyretin amyloidosis (ATTRv) is a rare, lethal, autosomal dominant adult-onset genetic gain-of function (GOF) disorder provoked by mutations in the TTR gene. Until recently, therapeutic options were limited and consisted mainly in liver transplantation and TTR-stabilizers. In the last few years, ATTRv has been at the center of major therapeutic breakthroughs, including development of effective small interfering RNA (siRNA) and antisense oligonucleotide (ASO) treatments targeting liver TTR mRNA. Both siRNA (patisiran) and ASO (inotersen) treatments are now commercially available and have dramatically improved ATTRv neurological outcome. Ongoing clinical trials currently evaluate another siRNA, vutrisiran and a novel ASO formulation, eplontersen. A CRISPR-Cas9-based TTR gene editing treatment is also currently evaluated, with encouraging preliminary results. These recent therapeutic developments demonstrate the shifting paradigm of ATTRv, a previously untreatable and lethal disorder and provide a proof-of-concept for developing siRNA, ASO and CRISPR-Cas9 treatments for other GOF genetic disorders.

Subclinical Doses of Combined Fumonisins and Deoxynivalenol Predispose Clostridium perfringens–Inoculated Broilers to Necrotic Enteritis

Fumonisins (FB) and deoxynivalenol (DON) are mycotoxins which may predispose broiler chickens to necrotic enteritis (NE). The objective of this study was to identify the effects of subclinical doses of combined FB and DON on NE. A total of 480 day-old male broiler chicks were divided into four treatment groups; 1) control group (basal diet + Clostridium perfringens); 2) necrotic enteritis group (basal diet + Eimeria maxima + C. perfringens); 3) FB + DON group (basal diet + 3 mg/kg FB + 4 mg/kg DON + C. perfringens); and 4) FB + DON + NE group (basal diet + 3 mg/kg FB + 4 mg/kg DON + E. maxima + C. perfringens). Birds in NE and FB + DON + NE groups received 2.5 × 10³E. maxima on day 14. All birds were inoculated with C. perfringens on days 19, 20, and 21. On day 35, birds in the NE, FB + DON, and FB + DON + NE groups had 242, 84, and 339 g lower BWG and a 19-, 2-, and 22-point increase in FCR respectively, than in the control group. Subclinical doses of FB + DON increased (p < 0.05) the NE lesion scores compared to the control group on day 21. On day 21, birds in the NE, FB + DON, and FB + DON + NE groups had increased (p < 0.05) serum FITC-D, lower (p < 0.05) jejunal tight junction protein mRNA, and increased (p < 0.05) cecal tonsil IL-1 mRNA compared to control group. On day 21, birds in the NE group had decreased (p < 0.05) villi height to crypt depth ratio compared to the control group and the presence of FB + DON in NE-induced birds further decreased the villi height to crypt depth ratio. Birds in the NE, FB + DON, and FB + DON + NE groups had increased (p < 0.05) C. perfringens, lower (p < 0.05) Lactobacillus loads in the cecal content, and a lower (p < 0.05) CD8⁺: CD4⁺ cell ratio in the cecal tonsils compared to the control group. It can be concluded that subclinical doses of combined FB and DON predispose C. perfringens-inoculated birds to NE, and the presence of FB + DON in NE-induced birds exacerbated the severity of NE.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Neuropathies périphériques associées aux syndromes lymphoprolifératifs : spectre clinique et démarche diagnostique

Lymphoproliferative syndromes (multiple myeloma, Waldenström's disease, chronic lymphocytic leukemia, lymphomas) may be associated with peripheral neuropathies. The mechanism can be dysimmune, associated or not with monoclonal gammopathies; paraneoplastic; infiltrative; or more commonly, iatrogenic or due to vitamin deficiency. The diagnosis can be complex, especially when the neuropathy is the presenting manifestation, requiring a close cooperation between internists and neurologists. The positive diagnosis of the neuropathy is based on a systematic electro-clinical investigation, which specifies the topography and the mechanism of the nerve damage, sometimes reinforced by imaging examinations, in particular, nerve and/or plexus MRI. The imputability of the neuropathy to a lymphoproliferative syndrome is based on a set of arguments including the clinical context (B signs, tumour syndrome), first-line laboratory tests (hemogram, protein electrophoresis, viral serologies, complement), auto-antibodies discussed according to the neuropathy (anti-MAG, anti-gangliosides) and sometimes more invasive examinations (bone marrow or neuro-muscular biopsies).

POS0912 LONG-TERM TREATMENT WITH IXEKIZUMAB IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: TWO-YEAR RESULTS FROM COAST-Y

Background:

The efficacy and safety of the interleukin-17 inhibitor ixekizumab (IXE) for the treatment of radiographic (r-) and non-radiographic (nr-) axial spondyloarthritis (axSpA) has been shown for up to 52 weeks.1-2

Objectives:

To study the efficacy and safety of ixekizumab in the treatment of patients with r- and nr-axSpA for up to 116 weeks.

Methods:

COAST-Y (NCT03129100) is the 2-year extension of the COAST-V, -W, and -X trials. Patients continued with the dose received at the end of the originating trial at Week 52, either with 80 mg IXE every 4 weeks (Q4W) or every 2 weeks (Q2W). Patients who had been assigned to adalimumab or placebo were re-randomized to IXE Q4W or Q2W at Week 16 in COAST-V and -W. Patients who had received placebo for 52 weeks in COAST-X were switched to IXE Q4W in COAST-Y. Patients who switched from placebo or adalimumab treatment to IXE (COAST-V, -W, or -X) or from IXE Q4W to open-label IXE Q2W (COAST-X) during the originating studies were analyzed separately from patients continuously treated with IXE. Standardized efficacy measures were used (Table 1). Missing data were handled by non-responder imputation for categorical data and modified baseline observation carried forward for continuous data. Safety data were analyzed for all patients who received ≥1 dose of IXE.

Table 1.

Demographic and efficacy results for patients continuously treated with IXE for 116 weeks

IXE Q4W N=157IXE Q2W N=195Demographics Age42.7 (13.0)41.8 (11.2) Male (n, [%])124 (79.0)132 (67.7) Baseline ASDAS3.92 (0.80)3.95 (0.76) Baseline BASDAI7.07 (1.26)7.18 (1.35) Baseline BASFI6.57 (1.76)6.74 (1.86) Baseline BASMI4.08 (1.46)3.97 (1.52) Baseline SF-36 PCS33.90 (7.27)33.26 (6.88)Outcome measureResponse (n, [%])Week 52Week 116Week 52Week 116 ASDAS <2.175 (47.8)69 (43.9)88 (45.1)96 (49.2) ASAS partial remission34 (21.7)31 (19.7)35 (17.9)39 (20.0) ASAS4082 (52.2)89 (56.7)99 (50.8)108 (55.4) BASDAI5078 (49.7)75 (47.8)83 (42.6)99 (50.8)Change from baseline ASDAS-1.64 (1.05)-1.60 (1.15)-1.63 (1.03)-1.78 (1.04) BASFI-2.88 (2.31)-2.76 (2.39)-2.83 (2.38)-3.15 (2.34) BASMI-0.57 (0.95)-0.57 (0.93)-0.53 (0.92)-0.60 (1.00) SF-36 PCS9.03 (8.62)8.43 (8.70)8.87 (7.57)9.86 (8.45)

Data are mean (SD) unless otherwise noted. Non-responder imputation was used for categorical variables, and modified baseline observation carried forward for continuous variables.

Results:

Of the 773 patients enrolled in COAST-Y, 86.0% completed Week 116 of treatment (52 weeks of one of the originating trials and 64 weeks of COAST-Y). Among the patients continuously treated with IXE for 116 weeks (IXE Q4W: N=157; IXE Q2W: N=195), 46.9% achieved low disease activity (ASDAS <2.1), and 19.9% achieved ASAS partial remission at 116 weeks (Table 1; Figure 1). In comparison to baseline, 56.0% achieved ASAS40 (Table 1). The mean change from baseline at Week 116 was –1.70 for ASDAS, –2.98 for BASFI, and 9.22 for SF-36 Physical Component Summary (Table 1). Similar observed responses were achieved between the patients continuously treated with IXE and patients initially treated with placebo or adalimumab. For the 932 patients in the safety population, no new safety signals were identified.

Conclusion:

Ixekizumab treatment led to consistent and sustained long-term improvements in disease activity and quality of life in patients with r- and nr-axSpA, with no new safety signals after up to 2 years of treatment.

References:

[1]Dougados, et al. Ann Rheum Dis 2020;79:176-185.

[2]Deodhar, et al. Lancet 2020; 395:53-64.

Disclosure of Interests:

Juergen Braun Speakers bureau: Abbvie, Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD, Mundipharma, Novartis, Pfizer, Roche, Sanofi-Aventis, and UCB, Consultant of: Abbvie, Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD, Mundipharma, Novartis, Pfizer, Roche, Sanofi-Aventis, and UCB, Grant/research support from: Abbvie, Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD, Mundipharma, Novartis, Pfizer, Roche, Sanofi-Aventis, and UCB, Uta Kiltz Speakers bureau: AbbVie, Hexal, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Hexal, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Biogen, Hexal, Novartis, and Pfizer, Atul Deodhar Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly and Company, Giliad, GlaxoSmith & Kline, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, GlaxoSmith & Kline, Novartis, Pfizer, and UCB, Tetsuya Tomita Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Eisai, Eli Lilly and Company, Janssen, Mitsubishi Tanabe, Novartis, Takeda, Pfizer, Consultant of: AbbVie, Astellas, Bristol-Myers Squibb, Eisai, Eli Lilly and Company, Janssen, Mitsubishi Tanabe, Novartis, Takeda, Pfizer, Maxime Dougados Consultant of: AbbVie, BMS, Eli Lilly and Company, Merck, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, BMS, Eli Lilly and Company, Merck, Novartis, Pfizer, Roche, and UCB, Rebecca Bolce Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, David Sandoval Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, David Adams Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Chen-Yen Lin Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Jessica A. Walsh Consultant of: AbbVie, Amgen, Eli Lilly and Company, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Merck, and Pfizer

POS0918 EVALUATION OF SPINAL RADIOGRAPHIC PROGRESSION IN PATIENTS WITH RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS RECEIVING IXEKIZUMAB THERAPY OVER 2 YEARS

Background:

It is important to understand the potential effect long-term therapy with biologics can have on structural changes in the spine among patients with active radiographic axial spondyloarthritis (r-axSpA, ankylosing spondylitis).

Objectives:

We examined radiographic progression in the spine among patients with active r-axSpA treated with ixekizumab, an IL-17A antagonist, for 2 years, and potential predictors of spinal radiographic progression.

Methods:

Patients with active r-axSpA, biologic-naive (COAST-V, NCT02696785) or with prior experience with a maximum of 2 TNF inhibitors (COAST-W, NCT02696798), received 80 mg ixekizumab every 2 or 4 weeks for 2 years (108 weeks, of which 56 weeks were the COAST-Y extension study, NCT03129100). Mean change from baseline of modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) (average score from 2 selected readers, blinded for time order) for patients treated with ixekizumab for 2 years with data at both baseline and year 2 is presented (N=230; 54% of total randomized patients). Non-progression is presented for all patients and subgroups based on TNFi-experience. Predictors were identified in multivariate logistic regression models with stepwise selection criteria of p-value <0.1. All data are observed.

Results:

At baseline, patients (N=230) were predominately male (82%) with an average age of 43 years, mean symptom duration of 16 years, 52% were TNFi-experienced, mean (SD) ASDAS score was 4.0 (0.7), most were HLA-B27 positive (87%) and 40% had syndesmophytes (identified by both selected readers at the same location). Baseline mSASSS (SD) was 11.0 (16.3) and change from baseline at year 2 of treatment was 0.3 (1.8) (Table 1). The proportion of non-progressors (mSASSS change from baseline <2) over 2 years was 89.6% (total IXE [all patients]), 90.9% (biologic-naive) and 88.3% (TNFi-experienced), and, if defined as mSASSS change from baseline ≤0, 75.7% (total IXE [all patients]), 78.2% (biologic-naive) and 73.3% (TNFi-experienced) (Table 1). Predictors of structural progression at year 2 (mSASSS change >0) were age, baseline syndesmophytes, HLA-B27 status and gender (Table 1). Week 52 inflammation in MRI SPARCC spine was also identified as a predictor for structural progression at year 2 in a separate model for patients from COAST-V where MRI measures were available at baseline and Week 52 (N=109).

Conclusion:

The majority of patients treated with ixekizumab for 2 years did not show radiographic progression, and the overall mean progression was low. Similar levels of non-progression were observed in biologic-naive patients and patients previously exposed to TNFis. Predictors were generally consistent with previous studies.

Table 1.

Spinal radiographic changes for patients with active r-axSpA treated with ixekizumab for 2 years

Change in mSASSS at year 2All patientsaN=230Biologic-naiveN=110TNFi-experiencedN=120 Baseline mSASSS, mean (SD)11.0 (16.3)10.1 (15.5)11.7 (17.0) Change at year 2, mean (SD)0.3 (1.8)0.3 (2.0)0.4 (1.6) Change in total mSASSS <2, n (%)206 (89.6)100 (90.9)106 (88.3) Change in total mSASSS ≤0, n (%)174 (75.7)86 (78.2)88 (73.3)Multivariable logistic regression modelPrediction for change in total mSASSS >0, OR (95% CI), p-valueAll patientsa,bN=228 Age (≥40 years vs. <40 years)2.97 (1.41, 6.28)p=0.004c Baseline syndesmophytesb (yes vs. no)2.31 (1.18, 4.54)p=0.015c Baseline HLA-B27 (positive vs. negative)3.78 (1.04, 13.75)p=0.044c Gender (male vs. female)3.16 (1.01, 9.86)p=0.047c Baseline ASDAS state (>3.5 vs. [2.1, 3.5])2.26 (0.96, 5.34)p=0.063

aCombined ixekizumab group of Q2W and Q4W patients with baseline and year-2 mSASSS data

bIdentified by both selected readers at the same location (2 patients were not evaluable by both readers)

cp<0.05

Abbreviations: ASDAS=Assessment of Disease Activity, CI=confidence interval, IXE=ixekizumab, mSASSS=modified Stoke Ankylosing Spondylitis Spinal Score, OR=odds ratio, Q2W=every 2 weeks, Q4W=every 4 weeks, SD=standard deviation, TNFi=tumor necrosis factor inhibitor

Disclosure of Interests:

Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma, Employee of: Director of Imaging Rheumatology bv., Mikkel Østergaard Consultant of: AbbVie, BMS, Boehringer-Ingelheim, Eli Lilly and Company, Janssen, Merck, Pfizer, Roche, UCB, Celgene, Sanofi, Regeneron, Novartis, Grant/research support from: AbbVie, BMS, Merck, UCB, Celgene, Novartis, John D Reveille Paid instructor for: UCB, Eli Lilly and Company, Consultant of: UCB, Eli Lilly and Company, Pfizer, Novartis, Grant/research support from: Janssen, Eli Lilly and Company, Xenofon Baraliakos Speakers bureau: Abbvie, BMS, Lilly, Janssen, Novartis, MSD, Pfizer, Galapagos, Gilead, UCB, Paid instructor for: Abbvie, BMS, Lilly, Janssen, Novartis, MSD, Pfizer, Galapagos, Gilead, UCB, Consultant of: Abbvie, BMS, Lilly, Janssen, Novartis, MSD, Pfizer, Galapagos, Gilead, UCB, Andris Kronbergs Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, David Sandoval Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Xiaoqi Li Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Hilde Carlier Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, David Adams Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, Boehringer, BMS, Eli Lilly and Company, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

FLT3 inhibitors in acute myeloid leukaemia: assessment of clinical effectiveness, adverse events and future research-a systematic review and meta-analysis

BACKGROUND

FMS-like tyrosine kinase 3 (FLT3) is the most frequent mutation in AML. With two FLT3 inhibitors recently approved by the FDA (midostaurin and gilteritinib), there is a need to evaluate these targeted agents.

PURPOSE

To assess the clinical effectiveness of FLT3 inhibitors in AML patients.

METHODS

Standard systematic review methods were utilised. Searches were conducted to July 2020 for completed and in-progress randomised controlled trials of FLT3 inhibitors in AML. A fixed-effect meta-analysis was undertaken.

RESULTS

Eight completed trials involving 2656 patients and assessing five different FLT3 inhibitors (sorafenib, lestaurtinib, midostaurin, gilteritinib and quizartinib) were included. The pooled results were as follows (FLT3 inhibitor/control): overall survival hazard ratio (HR) = 0.83 (95% confidence interval [CI] 0.75 to 0.92, p = 0.0005), event-free survival HR = 0.85 (95% CI 0.77 to 0.94, p = 0.002), relapse-free survival HR = 0.76 (95% CI 0.64 to 0.90, p = 0.001), complete remission relative risk (RR) = 1.11 (95% CI 1.00 to 1.22. p = 0.05) and 60-day mortality RR = 1.04 (95% CI 0.77 to 1.40, p = 0.79). Relative risk of grade 3 and above vascular, dermatological, respiratory and hepatobiliary adverse events were found to be statistically significantly higher in the FLT3 inhibitor group compared to control, but the actual numbers of events were relatively small. Nineteen ongoing trials are still in progress, only one of which specifically targets older patients with AML.

CONCLUSIONS

There is evidence to support the use of FLT3 inhibitors in patients with AML, but more data is needed to verify the optimum use of the drugs regarding type of inhibitor, disease stage and patient characteristics, not only in relation to disease control, but adverse events and quality of life. There are a large number of ongoing trials; therefore, the results of this review are not a fait accompli; thus, is it recommended that the review be updated in a couple of years' time. Given the challenges in extracting the complete data set required to assess clinical effectiveness, it is highly recommended that ongoing and future trials improve transparency and consistency of reporting of all trial outcomes, particularly disease control and adverse events, to enable a global clinical effectiveness assessment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017055581.

Early detection of skin and cardiac amyloid deposits among asymptomatic carriers of hereditary pathogenic transthyretin mutation with normal electroneuromyography

Introduction

During the last decade, disease modifying therapies have been proposed for hereditary amyloidogenic transthyretin (ATTRv) amyloidosis. It is essential to screen for disease onset among asymptomatic mutation carriers in order to trigger effective therapy as early as possible. We describe clinical and paraclinical data from ATTRv asymptomatic carriers, as a baseline assessment to detect disease onset and progression.

Methods

We retrospectively collected data of asymptomatic ATTRv carriers with normal electroneuromyography (ENMG), between March 1st 2015 and January 31st 2019, including: demographics, symptoms, physical exam, ENMG (initial and follow-up obtained in 73 patients, 56.2%), neurovegetative tests, skin biopsy (amyloid deposition, denervation), and cardiac evaluation (multimodal imaging, cardiac denervation and arrhythmias).

Results

We included 130 patients, aged 43.6 years (± 13.5), selected in family of a proband with an age of onset of 52.7 years (±15.7), 40.8% male, carrying 20 different variants of the TTR gene, including 63.8% Val30Met. Amyloid deposits on skin biopsy and/or cardiac fixation on bone scintigraphy, characteristic of amyloid infiltration, were found in 22/130 patients (16%). Skin biopsy was positive in 11 patients, and cardiac fixation on bone scintigraphy was positive in 15 patients. Amyloid infiltration was statistically associated with age (p=0.024), age difference from index case (p&lt;0.001), electrophysiological carpal tunnel syndrome (p=0.022), interventricular septum thickness &gt;12 mm (p&lt;0.001), contrast enhancement in cardiac MRI (p=0.002), cardiac denervation using MIBG scintigraphy C/M ratio &lt;1.85 (p=0.044). Multivariate analysis showed that age difference with index case and interventricular septum thickness were predictors for amyloid infiltration (OR=1.11, IC [1,04–1,19] and OR=1,76, IC [1,19–2,60]). Subgroup analysis showed electroneuromyography alteration during follow up in 11 patients (delay 26.9 months, range 10–49) with statistic association with amyloid deposits (55.6 versus 7.1% when ENMG was unchanged, p&lt;0.001) and interventricular septum thickness (p&lt;0.010).

Conclusion

Clinical and paraclinical assessment of asymptomatic carriers of ATTRv mutations shows that skin or cardiac amyloid infiltration may precede ENMG abnormalities in 16% of patients. This may trigger specific therapies in borderline cases. Age close to age of onset among index case and septum interventricular thickness appear as risk factors for developing electroneuromyogram alteration.

Funding Acknowledgement

Type of funding source: None

FRI0286 IXEKIZUMAB TREATMENT IMPROVES FATIGUE, SPINAL PAIN, STIFFNESS, AND SLEEP IN PATIENTS WITH NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS

Background:

Common symptoms of axial spondyloarthritis (axSpA) include fatigue, spinal pain, stiffness, and sleep problems, which can impair health-related quality of life. Ixekizumab (IXE) treatment shows efficacy in active non-radiographic axSpA (nr-axSpA).1

Objectives:

To assess fatigue, spinal pain, stiffness, and sleep with IXE treatment versus (vs) placebo (PBO) in patients (pts) with active nr-axSpA up to 16 and 52 weeks (wks).

Methods:

In COAST-X, pts with active nr-axSpA were randomized to 52 wks of double-blind IXE 80 mg once every 4 wks (Q4W) or 2 wks (Q2W), or PBO. Data were collected from baseline to Wk 52.

Results:

At Wk 16, IXE Q4W significantly improved fatigue, spinal pain, and stiffness, and IXE Q2W improved spinal pain, spinal pain at night, and stiffness vs PBO (Table). At Wk 52, IXE Q4W significantly improved stiffness, and IXE Q2W improved spinal pain, spinal pain at night, and stiffness vs PBO. Numeric improvements in sleep were not significant vs PBO. Wk 1, and up to Wk 16, IXE Q4W and Q2W significantly reduced spinal pain and stiffness vs PBO; stiffness was significantly reduced vs PBO up to Wk 52 (Figure).

Least squares mean (standard error) change from BL-ITT population (mixed-effect model of repeated measures)

MeasureTimepointPBO N=105IXE Q4W N=96IXE Q2W N=102Spinal painaWk 16-1.45 (0.244)-2.35 (0.248)*-2.59 (0.244)†Wk 52-2.29 (0.350)-2.92 (0.305)-3.32 (0.304)*Spinal pain at nightaWk 16-1.71 (0.262)-2.43 (0.267)-2.79 (0.263)*Wk 52-2.25 (0.358)-3.04 (0.312)-3.58 (0.311)*BASDAI-stiffnessb,cWk 16-1.44 (0.242)-2.44 (0.246)*-2.89 (0.242)†Wk 52-1.94 (0.332)-3.15 (0.290)*-3.48 (0.289)†Fatigue severity NRSdWk 16-1.4 (0.24)-2.1 (0.24)*-1.9 (0.24)Wk 52-2.1 (0.38)-2.6 (0.32)-2.7 (0.32)Sleep disturbanceeWk 16-2.3 (0.45)-2.0 (0.45)-2.5 (0.45)Wk 52-2.9 (0.63)-3.6 (0.52)-3.6 (0.53)Pt Global Assessment of Disease ActivityfWk 16-1.30 (0.246)-2.32 (0.251)*-2.64 (0.247)†Wk 52-1.81 (0.378)-2.77 (0.320)-3.30 (0.321)*

*P<.05 vs PBO;†P≤.001 vs PBO. ITT population: all randomized pts. Pts needing rescue treatment after Wk 16 per investigator could switch to open-label IXE Q2W; observations at visits thereafter not included in analyses. BL values similar across treatments. Numerical improvements in BASDAI-fatigue not significant vs PBO.

aScored 0 (no pain) to 10 (most severe pain) on NRS

bMean score BASDAI questions 5 (intensity) and 6 (duration)

cScored 1–10 on NRS

dScored 0 (no fatigue) to 10 (as bad as you can imagine)

eJenkins Sleep Evaluation Questionnaire scored 0 to 20: each of 4 items scored 0 (0 days) to 5 (22–30 days)

fScored 0 (not active) to 10 (very active) on NRS

BASDAI=Bath Ankylosing Spondylitis Disease Activity IndexBL=baselineITT=intent-to-treatIXE=ixekizumabN=number of pts in ITT populationNRS= numeric rating scalePBO=placebopt=patientQ2W=every 2 wksQ4W=every 4 wksvs=versuswk=week

Conclusion:

IXE Q4W and/or Q2W significantly improved spinal pain, spinal pain at night, and stiffness vs PBO at 16 and 52 wks in pts with nr-axSpA. IXE Q4W also improved fatigue at 16 wks in these pts. Numerical improvements in sleep were not significant vs PBO.

References:

[1]Deodhar A, et al. Lancet. 2019

Disclosure of Interests:

Philip J Mease Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Janssen, Eli Lilly, Novartis, Pfizer, Sun Pharma, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Eli Lilly, Galapagos, Gilead, Novartis, Pfizer, Sun Pharma, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Genentech, Janssen, Novartis, Pfizer, UCB Pharma, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Proton Rahman Grant/research support from: Janssen and Novartis, Consultant of: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, and Pfizer., Speakers bureau: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, Pfizer, Helena Marzo-Ortega Grant/research support from: Janssen, Novartis, Consultant of: Abbvie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Speakers bureau: Abbvie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Takeda, UCB, Vibeke Strand Consultant of: AbbVie, Amgen, Biogen, Celltrion, Consortium of Rheumatology Researchers of North America, Crescendo Bioscience, Eli Lilly, Genentech/Roche, GlaxoSmithKline, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi, UCB, Theresa Hunter Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, David Adams Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, David Sandoval Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Andris Kronbergs Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Baojin Zhu Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Ann Leung: None declared, Soyi Liu Leage Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB

THU0395 EFFICACY OF IXEKIZUMAB ON DISEASE ACTIVITY AND QUALITY OF LIFE IN PATIENTS WITH ACTIVE NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS AND OBJECTIVE SIGNS OF INFLAMMATION, STRATIFIED BY BASELINE CRP/SACROILIAC JOINT MRI STATUS

Background:

Ixekizumab (IXE), a high-affinity anti-interleukin-17A monoclonal antibody, is effective in patients (pts) with active non-radiographic axial spondyloarthritis (nr-axSpA), who had elevated C-reactive protein (CRP) and/or active sacroiliitis on magnetic resonance imaging (MRI).1

Objectives:

To determine if disease activity and patient-reported outcomes at Week 16 were similar between groups after stratifying pts by CRP/sacroiliac joint (SIJ) MRI status at baseline.

Methods:

COAST-X (NCT02757352) included pts with active nr-axSpA and objective signs of inflammation, i.e. presence of sacroiliitis on MRI (Assessment of Spondyloarthritis International Society [ASAS]/ Outcome Measures in Rheumatology criteria) or elevation of serum CRP (>5.0 mg/L). Pts were randomized 1:1:1 to receive subcutaneous 80 mg IXE every 4 weeks (Q4W) or Q2W, or placebo (PBO). Depending on the baseline values of CRP and MRI SIJ (Spondyloarthritis Research Consortium of Canada [SPARCC] score), pts in the intent-to-treat population (N=239) were divided into 3 subgroups (CRP >5 and MRI ≥2; CRP ≤5 and MRI ≥2; CRP >5 and MRI <2). Logistic regression analysis with treatment, subgroup, and treatment-by-subgroup interaction was used to detect treatment group differences in ASAS40, Ankylosing Spondylitis Disease Activity Score (ASDAS) <2.1 (low disease activity), and Bath Ankylosing Spondylitis Disease Activity Index 50 (BASDAI50) responses at Week 16. Analysis of covariance model with baseline value, treatment, subgroup, and treatment-by-subgroup interaction was used to detect the treatment group difference in change from baseline in Short Form-36 physical component score (SF-36 PCS).

Results:

The proportion of pts achieving ASAS40 (primary endpoint), ASDAS <2.1, and BASDAI50 (secondary endpoints) was higher in IXE treatment groups compared to PBO at Week 16 (Figure 1). The response rates in IXE-treated subjects were higher in all subgroups (CRP >5 and MRI ≥2; CRP ≤5 and MRI ≥2; CRP >5 and MRI <2) without consistent differences in efficacy between the subgroups. Similarly, pts in the IXE groups showed improvement in SF-36 PCS scores (secondary endpoint) versus pts on PBO at Week 16 (Figure 2).

Conclusion:

Pts with active nr-axSpA and objective signs of inflammation at baseline who were treated with IXE showed an overall improvement in the signs and symptoms of the disease. The efficacy was not different between pts with both elevated CRP and active sacroiliitis on MRI and pts with either elevated CRP or active sacroiliitis on MRI.

References:

[1]Deodhar A, et al.Lancet.2020.

Disclosure of Interests:

Walter P Maksymowych Grant/research support from: Received research and/or educational grants from Abbvie, Novartis, Pfizer, UCB, Consultant of: WPM is Chief Medical Officer of CARE Arthritis Limited, has received consultant/participated in advisory boards for Abbvie, Boehringer, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, UCB, Speakers bureau: Received speaker fees from Abbvie, Janssen, Novartis, Pfizer, UCB., Helena Marzo-Ortega Grant/research support from: Janssen, Novartis, Consultant of: Abbvie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Speakers bureau: Abbvie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Takeda, UCB, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Lianne S. Gensler Grant/research support from: Pfizer, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, GSK, Novartis, UCB, Joerg Ermann Grant/research support from: Boehringer-Ingelheim, Pfizer, Consultant of: Abbvie, Eli Lilly, Janssen, Novartis,

Pfizer, Takeda, UCB, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, David Sandoval Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Rebecca Bolce Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Andris Kronbergs Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Soyi Liu Leage Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Gabriel Doridot Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Vladimir Geneus Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Ann Leung: None declared, David Adams Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma

Guidance for the care of neuromuscular patients during the COVID-19 pandemic outbreak from the French Rare Health Care for Neuromuscular Diseases Network

In France, the epidemic phase of COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began in February 2020 and resulted in the implementation of emergency measures and a degradation in the organization of neuromuscular reference centers. In this special context, the French Rare Health Care for Neuromuscular Diseases Network (FILNEMUS) has established guidance in an attempt to homogenize the management of neuromuscular (NM) patients within the French territory. Hospitalization should be reserved for emergencies, the conduct of treatments that cannot be postponed, check-ups for which the diagnostic delay may result in a loss of survival chance, and cardiorespiratory assessments for which the delay could be detrimental to the patient. A national strategy was adopted during a period of 1 to 2 months concerning treatments usually administered in hospitalization. NM patients treated with steroid/immunosuppressants for a dysimmune pathology should continue all of their treatments in the absence of any manifestations suggestive of COVID-19. A frequently asked questions (FAQ) sheet has been compiled and updated on the FILNEMUS website. Various support systems for self-rehabilitation and guided exercises have been also provided on the website. In the context of NM diseases, particular attention must be paid to two experimental COVID-19 treatments, hydroxycholoroquine and azithromycin: risk of exacerbation of myasthenia gravis and QT prolongation in patients with pre-existing cardiac involvement. The unfavorable emergency context related to COVID-19 may specially affect the potential for intensive care admission (ICU) for people with NMD. In order to preserve the fairest medical decision, a multidisciplinary working group has listed the neuromuscular diseases with a good prognosis, usually eligible for resuscitation admission in ICU and, for other NM conditions, the positive criteria suggesting a good prognosis. Adaptation of the use of noninvasive ventilation (NIV) make it possible to limit nebulization and continue using NIV in ventilator-dependent patients.

Profiles of atypical sensory processing in Angelman, Cornelia de Lange and Fragile X syndromes

BACKGROUND

There is growing evidence to suggest that children with neurodevelopmental disorders may evidence differences in their sensory processing. The aim of this study was to compare sensory processing patterns in three genetic syndromes associated with sensory difference.

METHODS

Sensory processing in Angelman syndrome (n = 91), Cornelia de Lange syndrome (n = 28) and Fragile X syndrome (n = 40) was examined using the informant report measure the Sensory Experiences Questionnaire (SEQ).

RESULTS

All three groups were associated with a heightened prevalence of unusual sensory processing in comparison with normative data, evidenced in over 80% of all participants. Cross-syndrome comparisons highlighted syndrome-specific sensory processing profiles, with heightened hypo responsivity in Cornelia de Lange syndrome and sensory seeking in Angelman syndrome.

CONCLUSIONS

The results have important implications for the understanding of sensory processing in genetic syndromes and the development of tailored behavioural interventions.

[Cervical spinal sarcoidosis mimicking compressive cervical myelopathy: Poor prognosis after surgery]

INTRODUCTION

Cervical spinal sarcoidosis can mimic compressive cervical myelopathy leading to potentially harmful surgical procedures before the diagnosis can be made.

METHODS

Retrospective description of 3 patients and review of the literature.

RESULTS

Twenty-seven patients (16 men/11 women), median age 58 years [range 29-74] were described. Neurosurgical procedures consisted of laminectomy (n=10), laminoplasty (n=15) and anterior discectomy (n=2). Immediately after surgery, 17 patients (63%) worsened or remained disabled. Among the 10 patients who improved, 9 worsened secondarily. The analysis of preoperative MRI showed T2 hypersignal lesions and contrast enhancement in all patients. Neurological symptoms were inaugural in 25/27 patients, and systemic involvement of the sarcoidosis was found after surgery in 15/27 patients. After surgery, all patients received corticosteroids, along with immunosuppressive therapy in 8 cases/27. After a follow-up of 24 [16-72] months; 13 patients were stabilized or worsened, 7 were partially improved. Three died of other cause. Only 5 recovered without sequelae.

CONCLUSION

In patients with compressive cervical myelopathy, leptomeningeal contrast enhancement, a T2-weighted hypersignal exceeding the compression level on MRI, and the presence of extraneurological symptoms should point to inflammatory disease. These rare manifestations may be the first symptoms of sarcoidosis and should be recognized to avoid harmful surgical procedures and to provide appropriate medical treatment.

Comparison of Lewis-Sumner syndrome with chronic inflammatory demyelinating polyradiculoneuropathy patients in a tertiary care centre

BACKGROUND AND PURPOSE

Whether the Lewis-Sumner syndrome (L-SS) is a distinct entity from other types of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP-ot) remains controversial.

METHOD

The clinical/electrophysiological characteristics and long-term outcomes of 45 L-SS and 35 CIDP-ot patients were retrospectively compared.

RESULTS

The CIDP-ot group was composed of 11 patients with a typical CIDP, 17 with a pure sensory form, four with a distal form and three with a pure motor form. In the L-SS group, asymmetric (P < 0.001) and monomelic involvement (P = 0.04) of the upper limbs (P < 0.001) was significantly more frequent; paucisymptomatic forms (Overall Neuropathy Limitations Scale ≤ 1) were less frequent (P < 0.001); electroneuromyography showed that conduction block in intermediate nerve segments was the main demyelinating feature, with frequent F-wave abnormalities on nerves without conduction block (44%). Long-term prognosis was globally poorer in the L-SS group with more frequent aggravation during treatment (P = 0.02), less frequent treatment withdrawal (P = 0.03) and longer time to achieve successful withdrawal (39 vs. 15 months).

CONCLUSIONS

Our study suggests that L-SS patients have a less favourable therapeutic response rate and long-term outcomes. Rapid differentiation of L-SS from other forms of CIDP is important in order to anticipate a more complicated disease course management, with from one side the inefficacy or even harmfulness of corticosteroids and from the other side a difficult weaning procedure. A prospective study is necessary to confirm these results.

Brief Report: Repetitive Behaviour Profiles in Williams syndrome: Cross Syndrome Comparisons with Prader-Willi and Down syndromes

This study describes the profile of repetitive behaviour in individuals with Williams syndrome, utilising cross-syndrome comparisons with people with Prader-Willi and Down syndromes. The Repetitive Behaviour Questionnaire was administered to caregivers of adults with Williams (n = 96), Prader-Willi (n = 103) and Down (n = 78) syndromes. There were few group differences, although participants with Williams syndrome were more likely to show body stereotypies. Individuals with Williams syndrome also showed more hoarding and less tidying behaviours than those with Down syndrome. IQ and adaptive ability were negatively associated with repetitive questioning in people with Williams syndrome. The profile of repetitive behaviour amongst individuals with Williams syndrome was similar to the comparison syndromes. The cognitive mechanisms underlying these behaviours in genetic syndromes warrant further investigation.

Ptychographic amplitude and phase reconstruction of bichromatic vortex beams

We experimentally demonstrate that ptychographic coherent diffractive imaging can be used to simultaneously characterize the amplitude and phase of bichromatic orbital angular momenta-shaped vortex beams, which consist of a fundamental field, together with its copropagating second-harmonic field. In contrast to most other orbital angular momentum characterization methods, this approach solves for the complex field of a hyperspectral beam. This technique can also be used to characterize other phase-structured illumination beams, and, in the future, will be able to be extended to other complex fields in the extreme ultraviolet or X-ray spectral regions, as well as to matter waves.

Upper limb onset of hereditary transthyretin amyloidosis is common in non-endemic areas

BACKGROUND AND PURPOSE

The aim is to describe an uncommon phenotype of hereditary ATTR neuropathy with upper limb onset.

METHODS

The French TTR Familial Amyloid Polyneuropathy database was used for a retrospective evaluation of 32 consecutive patients with upper limb onset of the neuropathy (study group) and they were compared to 31 Portuguese early-onset patients and 99 late-onset patients without upper limb onset.

RESULTS

Initial upper limb symptoms were mostly sensory. Lower limb symptoms began 2.3 ± 3 years after upper limb symptoms. Twenty-four (75%) patients were initially misdiagnosed, with 15 different diagnoses. More patients in the study group had a Neuropathy Impairment Score upper limb/lower limb ratio > 1 compared to the late-onset patient group. The study group had significantly more pronounced axonal loss in the median and ulnar motor nerves and the ulnar sensory and sural nerves. On radial nerve biopsies (n = 11), epineurial vessels were abnormal in six cases, including amyloid deposits in vessel walls (3/11), with vessel occlusion in two cases.

CONCLUSION

Upper limb onset of hereditary ATTR neuropathy is not rare in non-endemic areas. It is important to propose early TTR sequencing of patients with idiopathic upper limb neuropathies, as specific management and treatment are required.

Diagnostic usefulness of plexus magnetic resonance imaging in chronic inflammatory demyelinating polyradiculopathy without electrodiagnostic criteria of demyelination

BACKGROUND AND PURPOSE

The usefulness of plexus magnetic resonance imaging (MRI) in the diagnosis of chronic inflammatory demyelinating polyradiculopathy (CIDP) without definite European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) electrodiagnostic criteria is currently unclear.

METHODS

Data from consecutive patients with clinical manifestations suggesting CIDP, with or without (CIDP-D and CIDP-ND, respectively) definite EFNS/PNS electrodiagnostic criteria, and referred for plexus MRI in our imaging centre were retrospectively analysed. An expert committee of neurologists compared the level of suspicion of CIDP in CIDP-ND patients to the blinded/unblinded MRI findings. Plexus MRI was reviewed by a neuroradiologist blinded to the final diagnosis.

RESULTS

In all, 38 patients were assessed with suspected CIDP-ND [7/38 (18%) probable; 13/38 (34%) possible; 18/38 (47%), no EFNS/PNS electrodiagnostic criteria], plus 10 with CIDP-D. Thirty-six of the 38 (95%) fulfilled clinical criteria of CIDP variants, including pure sensory neuropathy in 22/36 (61%). Plexus MRI showed abnormalities in 22/38 (58%) patients including increased nerve signal intensity on T2-weighted images in 22/22 (100%), nerve enlargement in 20/22 (91%) and contrast enhancement in 8/22 (36%). Plexus MRI enabled the expert committee's final diagnosis to be adjusted in 7/38 (18%) patients, and in conjunction with nerve conduction studies was a supportive criterion to classify 7/24 (29%) patients as definite CIDP. MRI abnormalities were more asymmetrical (P = 0.03) and less diffuse (P = 0.1) in CIDP-ND than in CIDP-D.

CONCLUSIONS

Our observations suggest that plexus MRI makes a valuable contribution to the diagnosis of CIDP-ND patients. Further studies are needed to investigate inter-rater reliability of clinical and imaging criteria of CIDP in these patients, and the impact on outcomes.

Causal somatic mutations in urine DNA from persons with the CLOVES subgroup of the PIK3CA-related overgrowth spectrum

Congenital lipomatous overgrowth with vascular, epidermal, and skeletal (CLOVES) anomalies and Klippel-Trenaunay (KTS) syndromes are caused by somatic gain-of-function mutations in PIK3CA, encoding a catalytic subunit of phosphoinositide 3-kinase. Affected tissue is needed to find mutations, as mutant alleles are not detectable in blood. Because some patients with CLOVES develop Wilms tumor, we tested urine as a source of DNA for mutation detection. We extracted DNA from the urine of 17 and 24 individuals with CLOVES and KTS, respectively, and screened 5 common PIK3CA mutation hotspots using droplet digital polymerase chain reaction. Six of 17 CLOVES participants (35%) had mutant PIK3CA alleles in urine. Among 8 individuals in whom a mutation had been previously identified in affected tissue, 4 had the same mutant allele in the urine. One study participant with CLOVES had been treated for Wilms tumor. We detected the same PIK3CA mutation in her affected tissue, urine, and tumor, indicating Wilms tumors probably arise from PIK3CA mutant cells in patients with CLOVES. No urine sample from a participant with KTS had detectable PIK3CA mutations. We suggest that urine, which has the advantage of being collected non-invasively, is useful when searching for mutations in individuals with CLOVES syndrome.

Participation of children on the autism spectrum in home, school, and community

BACKGROUND

Children on the autism spectrum participate less frequently, and in a narrower range of activities, than their nonautistic peers, but little is known about exact participation patterns across contexts or how this is perceived by caregivers. This study aimed to document patterns of participation and caregiver views with regard to frequency and intensity of activities.

METHOD

Caregivers of children on the spectrum aged 5 (n = 90) and 9-10 years (n = 128) completed the Participation and Environment Measure for Children and Youth for home, school, and community. Caregivers reported on frequency of child's participation, level of involvement, and caregivers' desire for change in participation patterns.

RESULTS

Item-level analyses revealed similar patterns of participation across home, school, and community for both cohorts with some small age-appropriate differences. Caregivers generally desired increased diversity, frequency, and involvement in activities but a decreased use of electronics (computers, games, TV, and DVDs).

CONCLUSION

The possibility of autism-specific participation patterns could inform future interventions aimed at enhancing social inclusion. This warrants further investigation through multiinformant designs that seek the perspectives of the child and caregivers.