[Effect of multimodal rheumatologic complex treatment in patients with axial spondylarthritis : A systematic evaluation with standardized outcome parameters, such as the ASAS Health Index]

BACKGROUND

Multimodal rheumatologic complex treatment (MRCT) is based on an acute inpatient treatment concept for patients with clinically relevant functional impairments and exacerbation of pain, which are caused by rheumatic and musculoskeletal diseases. Patients with axial spondylarthritis (axSpA) including ankylosing spondylarthritis (AS) often suffer from such health problems. Regular movement exercises and physical therapy measures are an important pillar of treatment management. The ASAS Health Index (ASAS-HI) can be used to document the global functional ability and health of axSpA patients. The selectivity of the ASAS HI for nonpharmacological treatment changes has so far not yet been proven.

OBJECTIVE

Evaluation of the MRCT and ASAS HI for nonpharmacological treatment measures of patients with axSpA carried out in the Ruhr Area Rheumatism Center. The primary endpoint was an improvement of the ASDAS≥ 1.1. It was assumed that > 25% of the patients would achieve this threshold.

METHODS

Consecutively included patients with active axSpA and relevant functional impairments received inpatient treatment for 14 days during MRCT. On days 1 (V1) and 14 (V2) all patients completed questionnaires on pain (NRS), disease activity (BASDAI, ASDAS) and function (BASFI, ASAS HI). The clinical examination was carried out using BASMI and measurement of C‑reactive protein (CRP) at both times.

RESULTS

The 66 prospectively included patients had an average age of 47.2 years (SD 14.2 years), a duration of symptoms of ca. 20 years, 65.3% were male, 75% were positive for HLA B27 and CRP was elevated in 41.3%. The disease activity at V1 was elevated: BASDAI 5.6 (1.8), ASDAS 3.1 (0.9), whereas functional ability and mobility were reduced: BASFI 3.5 (1.8), BASMI 5.6 (2.1), ASAS-HI 8.4 (3.4). During the course the global patient verdict improved (NRS 0-10) from 6.9 (1.7) at V1 to 4.8 (1.8) at V2 and the pain from 6.9 (1.9) to 4.7 (2.0) (all p < 0.001). The disease activity also decreased at V2: BASDAI 4.1 (1.9), ASDAS 2.4 (1.0), function and mobility were also improved: BASFI 4.3 (2.4), BASMI 2.7 (1.6), ASAS HI 6.5 (3.8) (all p < 0.001).

CONCLUSION

In this study the effectiveness of a 2‑week MRCT according to OPS 8-983.1 with respect to important patient-centered outcomes (PCO) could be proven and the results of previous studies could be confirmed. In this context ASAS-HI was also sensitive to change.

[Frequency and severity of sarcopenia in patients with inflammatory and noninflammatory musculoskeletal diseases : Results of a monocentric study in a tertiary care center]

INTRODUCTION

Sarcopenia (SP) is defined as the pathological loss of muscle mass and function. This is a clinically relevant problem, especially in geriatric patients, because SP is associated with falls, frailty, loss of function, and increased mortality. People with inflammatory and degenerative rheumatic musculoskeletal disorders (RMD) are also at risk for developing SP; however, there is little research on the prevalence of this health disorder in this patient group using currently available SP criteria.

OBJECTIVE

To investigate the prevalence and severity of SP in patients with RMD.

METHODS

A total of 141 consecutive patients over 65 years of age with rheumatoid arthritis (RA), spondylarthritis (SpA), vasculitis, and noninflammatory musculoskeletal diseases were recruited in a cross-sectional study at a tertiary care center. The European Working Group on Sarcopenia in Older People (EWGSOP 1 and 2) definitions of presarcopenia, SP, and severe SP were used to determine the prevalence. Lean mass as a parameter of muscle mass and bone density were measured by dual X‑ray absorptiometry (DXA). Handgrip strength and the short physical performance battery (SPPB) were performed in a standardized manner. Furthermore, the frequency of falls and the presence of frailty were determined. Student's T-test and the χ2-test were used for statistics.

RESULTS

Of the patients included 73% were female, the mean age was 73 years and 80% had an inflammatory RMD. According to EWGSOP 2, 58.9% of participants probable had SP due to low muscle function. When muscle mass was added for confirmation, the prevalence of SP was 10.6%, 5.6% of whom had severe SP. The prevalence was numerically but not statistically different between inflammatory (11.5%) and noninflammatory RMD (7.1%). The prevalence of SP was highest in patients with RA (9.5%) and vasculitis (24%), and lowest in SpA (4%). Both osteoporosis (40% vs. 18.5%) and falls (15% vs. 8.6%) occurred more frequently in patients with SP than those without SP.

DISCUSSION

This study showed a relatively high prevalence of SP, especially in patients with RA and vasculitis. In patients at risk, measures to detect SP should routinely be performed in a standardized manner in the clinical practice. The high frequency of muscle function deficits in this study population supports the importance of measuring muscle mass in addition to bone density with DXA to confirm SP.

[Lay version of the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis : Translation into German and linguistic validation in German-speaking countries with people affected]

BACKGROUND

Physical activity and exercise are beneficial for people with rheumatic diseases; however, recommendations for the management of rheumatoid arthritis (RA), spondyloarthritis (SpA) and hip- and knee osteoarthritis (HOA/KOA) are usually unspecific with respect to mode and dose of exercise. This is why the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis were formulated. The recommendations consist of 4 overarching principles and 10 recommendations. These were also published as a lay version in the English language.

AIM

Translation of the lay version into German and its linguistic validation in Austria, Germany and Switzerland.

METHODS

A professional translation was reviewed by the authors, including people with, RA, SpA, HOA/KOA from the three German-speaking countries, which provided a prefinal lay version. Subsequently, eight interviews with people with RA, SpA, HOA/KOA were conducted in each country to evaluate understandability, wording, completeness and feasibility of the prefinal lay version. Finally, the authors, i.e. those with RA, SpA, and osteoarthritis, anonymously rated their agreement to the final lay version on a 0-10 scale.

RESULTS

The professional translation was substantially revised by the authors and based on the interviews. Formulations were adapted to increase readability and understandability and specify statements. Comments that would have changed content or structure were not considered. Average agreement with the particular recommendations was between 10 (SD 0) and 7.6 (SD 1.67).

DISCUSSION

For people with RA/SpA/HOA/KOA the EULAR physical activity recommendations should be available in their mother language. The final German lay version is valid and accepted across all three German-speaking countries. Thus, the physical activity recommendations can be provided to people with rheumatic diseases in an understandable and feasible way.

AB1068 HIGH FREQUENCY OF STRUCTURAL DAMAGE IN THE LOWER SPINE OF PATIENTS WITH CHONDROCALCINOSIS

Background

Calcium pyrophosphate dihydrate crystal deposition disease (CPPD, chondrocalcinosis) is known to affect fibrocartilaginous tissue in the large and smaller peripheral joints. The affection of similar structures in the axial skeleton is unclear.

Objectives

To assess the frequency and severity of structural changes in the lower spine in patients with established CPPD in comparison to degenerative disc disease (DDD).

Methods

In a retrospective study, patients with CPPD or DDD as a main diagnosis with available spinal conventional radiographs (CR) performed during 2014 – 2020 were included. Definite other inflammatory conditions affecting the spine were excluded. The CR segments T7/8-L5/S1 were evaluated for the occurrence of disc calcification, intradiscal vacuum phenomenon, disc height (normal, narrowing, complete loss), endplate erosion, osteophytes and spondylolisthesis. When lumbar spine MRIs of the same time point were available, discovertebral units were evaluated for the occurrence of vacuum phenomena, endplate erosion, Modic changes and disc dehydration (Pfirrmann). Follow up CR were assessed if available. All available images were evaluated by 2 independent readers and discrepancies were solved by consensus.

Results

CR of 140 patients (1.171 discovertebral units) with CPPD and 99 DDD (803 discovertebral units) were evaluated (mean age 74.4±9.9 and 71±6.2, 20% vs. 20.2% males, respectively). MRIs of the spine were available from 48 CPPD and 44 DDD patients. Vacuum phenomena, disc calcification, osteophytes and erosion were significantly more frequently seen in patients with CPPD compared to DDD (Table 1) with no differences between the thoracic and the lumbar spine. Follow-up CR were available for 29 patients with CPPD and 46 DDD. Both groups presented statistically significant progression of endplate erosions and osteophytes (p 0.001 - 0.02 for both groups). Notably, even though CR follow-up times in the CPPD group were, compared to DDD (median (IQR) 1.9 (2.4) vs 3.0 (3.1) years, p=0.033, respectively), shorter, radiographic progression was noted more frequently in CPPD vs. DDD for erosive changes (6.8% vs. 0.6%, p=0.018) and disc calcification (5.8% vs. 0.6%, p=0.007), respectively. When comparing MRIs, a higher number of discovertebral units was affected by vacuum phenomena (34 vs 13, p=0.04) and endplate erosions (L4/5 (45.5% vs 24.4%, p=0.04), L5/S1(40.4% vs 19.5%, p=0.03) in patients with CPPD vs. DDD, respectively.

Table 1.

Frequency of affected discovertebral units on conventional radiographs

CPPDDDDpVacuum phenomenon156 (13.3%)44 (5.5%)<0.001Disc calcification193 (16.5%)42 (5.2%)<0.001Endplate erosion159 (13.6%)26 (3.2%)<0.001Osteophytes861 (73.5%)480 (59.8%)<0.001Spondylolisthesis126 (10.8%)69 (8.6%)0.264

CPPD: calcium pyrophosphate dihydrate crystal deposition disease DDD: degenerative disc disease

Conclusion

Patients with chondrocalcinosis showed more severe and progressive degenerative findings in the lower spine as assessed by both, CR and MRI, even more in comparison to established DDD. This data shows that disease manifestations of CPPD in the axial skeleton are clinically relevant.

Disclosure of Interests

None declared

AB0184 IDENTIFYING TRAJECTORIES OF REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED IN A TERTIARY CARE CENTRE

Background

The main goal of treatment for patients (pts) with rheumatoid arthritis (RA) is remission to preserve physical function and prevent radiographic damage. However, less than 50% of pts with early RA have achieved remission in clinical studies and inception cohorts 1. Little is known about the course of disease and the clinical patterns when remission is tried to be achieved in pts with RA.

Objectives

To identify subgroups with distinct trajectories of DAS28-CRP in pts with RA.

Methods

Longitudinal data from adult RA pts presenting to a tertiary centre were used. Socio-demographic data, disease characteristics and standard assessments including established outcome parameters for disease activity (DAS28-CRP) and physical function (FFbH) were retrospectively analysed. Group-based trajectory modelling (GBTM) was used to identify homogeneous classes of DAS28-CRP trajectories, where the number of classes was selected using Nagin’s Bayesian information criterion (BIC). Differences between the identified classes and clinical variables were studied.

Results

Data of 134 pts with 849 DAS28-CRP values were analysed. Retrospective chart data were available for a follow-up of 33.7 (SD 18.0) months. One third of pts already had erosions and severe limitations in physical functioning. About half of the pts were on bDMARDS and <20% on steroids. Five distinct classes of DAS28-CRP trajectories were identified (Figure 1). These groups were subsequently categorized as 1) high-increasing, 2) high-stable, 3) low-increasing, 4) low-decreasing disease activity, and 5) remission. Pts.’ characteristics at baseline in each trajectory group are shown in Table 1. Group 4 had a shorter disease duration but more erosions, a better function and a higher educational level than seen in other groups. The increase of disease activity in group 3 was modest.

Table 1.

Patients demographics and disease characteristics at baseline in trajectory groups

Class 1(N=10)Class 2(N=36)Class 3(N=56)Class 4(N=23)Class 5(N=9)Age, years65.8 (12.7)60.6 (10.6)56.7 (16.0)50.5 (15.4)56.8 (12.0)Gender, female80.0% (N=8)77.8% (N=28)82.1% (N=46)52.2% (N=12)66.7% (N=6)Education level university0.0% (N=0)11.1% (N=4)16.1% (N=9)21.7% (N=5)0.0% (N=0)Employment10.0% (N=1)33.3% (N=12)53.6% (N=30)69.6% (N=16)33.3% (N=3)Body mass index30.6 (5.4)27.8 (4.3)27.1 (4.7)25.2 (4.2)29.0 (6.4)Symptom duration, years12.8 (7.3)10.4 (8.3)9.5 (9.6)6.7 (3.6)12.4 (13.2)Anti-CCP49.2 (63.9)101.3 (89.7)98.6 (95.6)94.9 (78.2)114.5 (84.6)CRP1.0 (1.1)0.7 (0.9)0.4 (0.4)0.4 (0.5)1.2 (1.1)Erosions20.0% (N=2)36.1% (N=13)28.6% (N=14)45.5% (N=10)44.4% (N=4)At least one Comorbidity100.0% (N=10)94.4% (N=34)78.6% (N=44)65.2% (N=15)88.9% (N=8)Charlson Comorbidity Index (0-29)1.1 (1.4)1.1 (1.3)0.6 (0.9)0.4 (0.7)1.2 (1.3)No. of patients on steroids0.0% (N=0)0.0% (N=0)2.9% (N=1)15.4% (N=2)0.0% (N=0)No. of patients on bDMARD77.8% (N=7)45.8% (N=11)41.2% (N=14)30.8% (N=4)71.4% (N=5)No. of patients on tsDMARD0.0% (N=0)0.0% (N=0)5.9% (N=2)7.7% (N=1)0.0% (N=0)Pain (NRS 0-10)6.1 (1.8)5.8 (1.8)4.2 (2.0)2.3 (2.6)4.2 (2.0)Patient Global (NRS 0-10)5.8 (2.8)5.3 (1.7)3.7 (2.1)2.8 (3.0)6.3 (2.2)DAS28-CRP5.3 (1.2)3.9 (0.7)2.5 (0.7)2.1 (1.0)4.6 (0.9)FFbH38.5 (29.0)48.8 (21.8)74.2 (18.9)90.4 (8.8)61.1 (19.4)RAID (0-10)6.5 (2.0)5.3 (2.1)3.8 (1.9)1.8 (1.8)4.6 (1.8)Figure 1.

Longitudinal DAS-28-CRP in trajectory groups

Conclusion

Using GBTM five distinct trajectories in pts with RA were identified. Only a small proportion of pts showed a reduction in disease activity over time, whereas the largest proportion of pts showed rather constant high or constant low disease activity. The cohort size may have impacted the modelling and further analyses in larger cohorts are needed. Importantly, even though well established in our hospital it is unclear how consequent the T2T strategy was followed and which intervention was successful to reach remission. The impact of pts global assessment on DAS28 values also needs further study.

References

[1]Nikiphorou Rheumatol 2020

Disclosure of Interests

None declared

[Axial spondyloarthritis : Update on management based on the interdisciplinary S3 guidelines on axial spondyloarthritis including early forms and ankylosing spondylitis]

This review article presents the innovations in the update of the S3 guidelines on axial spondylarthritis. The total of eight new recommendations address the areas of the consideration of differential diagnoses, coordination of comorbidity management, including a vaccination strategy, treatment targets, safety of nonsteroidal anti-inflammatory drugs (NSAID), treatment response to biological disease-modifying antirheumatic drugs (bDMARD) and discontinuation strategies when remission has been achieved. In this article the authors deal particularly with the areas of early diagnosis and referral as well as exercise therapy and drug treatment.

POS0973 CONTEXTUAL FACTORS SHOULD COMPLETE THE ASSESSMENT OF FUNCTIONING IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS (axSpA)

Background:

Functioning of patients (pts.) with axial spondyloarthritis (axSpA) is influenced by a variety of factors. In contrast to clinical factors, the influence of contextual factors on functioning has not been well studied. According to the According to the International Classification of Functioning, Disability and Health (ICF), functioning is a complex interaction between health status and contextual factors such as social support, relationships and attitudes.

Objectives:

The aim of this study is to understand limitations in participation and to investigate barriers and facilitators of contextual factors in pts. with axSpA.

Methods:

Consecutive axSpA pts. underwent a standardized assessment with collection of patient and disease characteristics, patient-reported outcomes (ASDAS, BASFI, BASMI, PHQ-9, ICF Measure of Participation and ACTivities questionnaire (IMPACT-S (0-100%)), ASAS Health Index (ASAS HI and environment factor item set (EFIS) (1). The EFIS contains 9 dichotomous questions addressing ICF categories of products and technologies (e1), support and relationship (e3), attitudes (e4) and health services (e5). Validated cut-offs of ASAS HI were used to categorize global functioning.

Results:

A total of 200 axSpA pts. were included: 69% males, 44.3±12.5 years, symptom duration 17.9±12.6 years, ASDAS 2.5±1.1, BASFI 4.0±2.7, BASMI 3.5±1.8, ASAS HI 7.0±4.1. Pts. reported limitations in the IMPACT-S activity and participation domain (82.3% (15.2) and 83.5% (16.8), respectively. The majority of pts. reported as barrier that treatment of axSpA requires time (e4, 58.5%). A minority of pts. but quite a few reported as barrier the need for support by family members (e3, 43.5%), the need to modify home and work environment (e1, 39.5%) and that they cannot rely on family members for help (e3, 22%). Some pts. (< 20%) reported that they have problems to be understood by health care professionals when experiencing a flare (e5, 18.5%), that pts. at home are not adequately taken care of (e4, 18.5%), disliking friends’ behavior toward them (e4, 13.5%), and that friends are too demanding (e4, 13%). The majority of pts. (e4, 75.9%) identified attitudes of friends as the only and major facilitator. All pts. reporting at least one barrier had significantly worse global functioning (ASAS HI, IMPACT-S), and depression (PHQ-9) compared to patients who reported no barriers in the respective ICF categories (p< 0.01). Similarly, pts. with poor functioning are more likely to report barriers in contextual factors compared to pts. with good functioning (Table 1). Pts. having to ask for more support from their families expressed the feeling that they cannot rely on that.

Conclusion:

Barriers more than facilitators of contextual factors are present in pts. with axSpA. This study shows that barriers in contextual factors are more common in pts. with impairments in self-reported and performed functioning as in those without impairments. This underlines the importance of contextual factors in the management of axSpA pts.

References:

[1]Kiltz et al. Ann Rheum Dis 2013;72(s3):572

Table 1.

Presence of contextual factors, stratified for global functioning categories

ICF categoryEFIS ItemGlobal Functioning (ASAS HI 0-17)Good ≤ 5(n= 69)Moderate <5 to <12(n= 106Poor ≥ 12(n= 25)e3EFIS 1: As a result of my rheumatic disease, the children take more responsibility for household tasks.11 (15.9)55 (51.9)21 (84)e3EFIS 2: I don’t like the way my friends acts around me.0 (0)15 (14,2)12 (48,0)e3EFIS 3: I can’t count on my relatives to help me with my problems11 (15,9)24 (22,6)9 (36)e1EFIS 4: I modify my home and work environments.16 (23,2)47 (44,3)9 (36)e5EFIS 5: I have difficulties getting worsening of my disease acknowledged by a health care professional3 (4,3)21 (19,8)16 (64)e5EFIS 6: Treatment of my rheumatic disease is taking up time22 (31,9)73 (68,9)22 (88)e4,EFIS 7: My friends expect too much of1 (1,4)18 (17,0)7 (28)e4EFIS 8: No one pays much attention to me at home10 (14,5)20 (18,9)7 (28)e4EFIS 9: My friends understand me56 (17,4)83 (78,3)12 (48)

values given as number (%)

Disclosure of Interests:

None declared.

AB0684 LESS THAN 20% OF PATIENTS WITH A CHRONIC INFLAMMATORY RHEUMATIC DISEASE CHANGED THEIR IMMUNOSUPPRESSIVE MEDICATION BECAUSE OF THE COVID 19 PANDEMIC

Background:

The best treatment options of patients with chronic inflammatory rheumatic diseases (CIRD) in the pandemic have not been completely clear, especially in the beginning of the lockdown. Whether and to which degree pandemic-related therapy changes have occurred, has not been studied in detail.

Objectives:

To study the behaviour of patients with CIRD initially facing the COVID 19 pandemic related to their disease status and medication.

Methods:

Patients with CIRD were contacted by telephone to assess their health status and ask for changes in medication. Standardized assessment tools were used to assess disease activity, depression and anxiety. High disease activity was assumed if RADAI-5 ≥ 3.2 and BASDAI ≥ 4. Anxiety (HADS-A) and depression (HADS-D) of patients were assessed using HADS. A score < 8 was taken as indication of no major problem in this regard.

Results:

A total of 886 patients was interviewed between April 15 and June 15 of 2020. Here we report on 550 patients with complete information on standard assessments (62%). About 60% were female, mean age 54.4±13.7, mean disease duration 12.2±10.5 years. Most had spondyloarthritis (SpA, n=287) including axial SpA (axSpA, n=172) and psoriatic arthritis (PsA, n=116), in total 52.2%, while 40.2% had rheumatoid arthritis (RA, n=221), and 7.6% connective tissue diseases (CTD, n=42). Most RA patients were on methotrexate (48.8%), while 43.8% took glucocorticoids. In addition, 61.0% of patients were on bDMARDs, mostly on TNF inhibitors (59.6%). More SpA than RA patients were on bDMARDs: 71.0% vs 49.7% respectively. A recent change in medication was reported by 182 patients (33.1%): 89 with RA (40.2%), 88 with SpA (30.6%) and 5 with CTD (11.9%). Half of those who changed (n=92; 50.5%) admitted that the change was mainly made due to fear of the pandemic (16.7% of all patients). Altogether, significantly more patients changed bDMARDs (68.5%) than csDMARDs (57.3%). The data of patients who changed vs patients who didn’t change is shown in the Table 1, including subgroup analyses. The median HADS scores were < 8.

Table 1.

RA and SpA patients who changed and who did not change their medication

Group (N) / ReasonNActive disease (%)HADS-D≥ 8 (%)HADS-A≥ 8 (%)bDMARD therapy (%)Rheumatoid arthritis221134 (60.6)76 (35.0) [4]94 (43.3) [4]110 (50.9) [5]Spondyloarthritis287130 (45.4)83 (29.5) [6]109 (38.8) [6]204 (72.6) [6]  Pa (RA vs SpA)<0.0010.2280.354<0.001Patients did not change their medication Rheumatoid arthritis (%)132 (59.7)84 (63.6)46 (35.9) [4]58 (45.3) [4]62 (48.4) [4] Spondyloarthritis (%)199 (69.3)88 (44.2)58 (30.1) [6]69 (35.8) [6]137 (71.0) [6]  P (RA vs SpA)0.031<0.0010.3580.101<0.001Patients changed their medication Rheumatoid arthritis89 (40.3)50 (56.2)30 (33.7)36 (40.4)48 (54.5) [1]  P (vs no change)0.3310.8460.5670.457  Reason[9] Pandemic41 (51.3)15 (36.6)11 (26.8)14 (34.1)24 (60.0) [1] Inactive disease23 (28.8)12 (52.2)6 (26.1)10 (43.5)12 (52.2) Active disease b16 (20.0)14 (87.5)6 (37.5)7 (43.8)7 (43.8)  P (reasons)0.0030.6870.6870.526 Spondyloarthritis88 (30.7)42 (47.7)25 (28.4)40 (45.5)67 (76.1)  P (vs no change)0.6730.8890.1570.451  Reason[6] Pandemic50 (61.0)22 (44.0)13 (26.0)22 (44.0)42 (84.0) Inactive disease15 (18.3) 7 (46.7)4 (26.7)7 (46.7)10 (66.7) Active disease b17 (20.7)11 (64.7)6 (35.3)6 (35.3)11 (64.7)  P (reasons)0.3310.7560.7740.156  P (RA vs SpA)0.0310.2940.9500.6030.004

Data are presented as numbers (percentage proportions; across rows except for column N) or medians (interquartile ranges). Missing values are in square brackets.

a P values calculated using χ2 test or Mann-Whitney rank sum test.

b Self-reported claim of disease activity.

Conclusion:

Two thirds of patients did not change medication but one third changed. A relatively high number of patients did so due to fear of the pandemic, mostly those on biologics. There were no major differences between RA and SpA. Anxiety and depression do not seem to play an important role for the decision to change medication (Table 1 below).

Disclosure of Interests:

None declared

Laser spectroscopy of the [Formula: see text], [Formula: see text] transitions in stored and cooled relativistic C[Formula: see text] ions

The [Formula: see text] and [Formula: see text] transitions in Li-like carbon ions stored and cooled at a velocity of [Formula: see text] in the experimental storage ring (ESR) at the GSI Helmholtz Centre in Darmstadt have been investigated in a laser spectroscopy experiment. Resonance wavelengths were obtained using a new continuous-wave UV laser system and a novel extreme UV (XUV) detection system to detect forward emitted fluorescence photons. The results obtained for the two transitions are compared to existing experimental and theoretical data. A discrepancy found in an earlier laser spectroscopy measurement at the ESR with results from plasma spectroscopy and interferometry has been resolved and agreement between experiment and theory is confirmed.

[How well are patients with inflammatory rheumatic diseases protected against measles?]

Hintergrund

Patienten mit entzündlich rheumatischen Erkrankungen haben aufgrund ihrer Autoimmunerkrankung, aber auch bedingt durch die immunsuppressive Medikation ein erhöhtes Infektrisiko. Obwohl Impfungen in der Primärprophylaxe von Infektionen bekanntermaßen effektiv sind, ist die Impfrate in Deutschland generell zu niedrig. Wegen des zuletzt zunehmenden, teils epidemieartigen Auftretens von Masern ist die Lebendimpfung gegen Masern in Deutschland seit Kurzem gesetzlich vorgeschrieben.

Fragestellung

Wie viele Patienten mit entzündlich rheumatischen Erkrankungen sind aktuell ausreichend gegen Masern geschützt?

Methode

Patienten mit entzündlich rheumatischen Erkrankungen des Rheumazentrums Ruhrgebiet wurden zwischen Dezember 2017 und Oktober 2018 prospektiv und konsekutiv eingeschlossen. Dabei wurden Daten zu Erkrankung und Therapie auf Ebene von Substanzklassen sowie die Impf- und Infektanamnese erhoben. Alle Angaben zu Impfungen wurden im Impfpass kontrolliert. Antikörpertiter gegen Masern wurden mit ELISA bestimmt. Als Schwellenwert für einen ausreichenden Schutz gegen Masern wurden 150 mIU/ml festgelegt.

Ergebnis

Von 975 Patienten konnten 540 (55,4 %) einen Impfausweis vorlegen. Bei 201 Patienten mit Ausweis (37,2 %) lagen dokumentierte Impfungen seit Geburt vor. Insgesamt hatten 45 von 267 nach 1970 geborene Patienten (16,9 %) einen suffizienten Impfschutz gegen Masern. Die anamnestischen Angaben zu einer Masernerkrankung in der Kindheit differenzierten nicht zwischen Patienten mit und ohne protektiven Masern-IgG-Antikörpern. Protektive Masern-IgG-Antikörper wurden bei 901 Patienten von 928 Patienten mit Messung der Masern-IgG-Antikörperspiegel (97,1 %) nachgewiesen. Die unterschiedlichen Wirkprinzipien der aktuellen immunsuppressiven Therapie hatten darauf keinen Einfluss.

Diskussion

Diese Daten zeigen, dass mindestens 2,9 % der Patienten keinen ausreichenden Schutz gegen Masern haben. Interessanterweise hatte die Mehrheit der nach 1970 geborenen Patienten protektive Antikörper trotz fehlenden Impfschutzes gegen Masern. Die Anstrengungen sowohl im primär- als auch im fachärztlichen Bereich sollten dringend verstärkt werden, um eine adäquate Infektionsprophylaxe bei besonders gefährdeten Patienten gewährleisten zu können.

SAT0579 SYSTEMATIC GERIATRIC ASSESSMENT IN OLDER PATIENTS WITH RHEUMATIC DISEASES - THE RheuMAGIC PILOT STUDY

Background:

Current demographic data predict that the number of older adults with rheumatic diseases will considerably increase in the coming years. Geriatric patients differ from younger adults in many ways including their clinical presentation, co-morbidities and response to medication. The management of such patients is often challenging due to the presence of multi-morbidity, polypharmacy and geriatric syndromes (i.e. conditions in which symptoms result from impairments in multiple systems rather than a discrete disease). To systematically assess geriatric patients, specific tools have been developed; however, they are not routinely utilized by rheumatologists. Using these tools could improve patient management and satisfaction in rheumatologic care.

Objectives:

To examine the prevalence of 17 common geriatric health problems using validated geriatric assessment tools in older patients with rheumatic and musculoskeletal diseases.

Methods:

Adults 65 years and older who presented to a tertiary rheumatologic hospital were included after informed consent. All patients recruited were assessed using theMAngableGeriatrICAssessment (MAGIC) which addresses 14 common geriatric health problems. In addition, polypharmacy (≥ 5 medication), muscle function using the Short Physical Performance Battery and frailty applying the Fried definition were assessed. Disability was quantified with the “Funktionsfragebogen Hannover” (FFbH), a validated tool for patients with rheumatologic diseases that can be easily converted to Health Assessment Questionnaire (HAQ) scores. Primary outcome was the frequency of the selected 17 geriatric health problems; the correlation of the total number of problems with HAQ scores was a secondary outcome.

Results:

Of the 300 individuals included 67% were female with a mean age of 73±6.6 years; 85% (> 50% with rheumatoid arthritis) had a rheumatologic diagnosis. The remaining participants had either a chronic pain syndrome or degenerative joint/spine disease. On average participants had 7 out of 17 assessed geriatric problems. Females had more such problems than males (8 vs. 6, p<0.0001). Chronic pain and polypharmacy were most common but several others were also seen in more than 50% of patients (see Table). The mean HAQ Score was 1.67±0.79. There was a positive correlation (see Graph) between the number of problems and the HAQ Score (R2= 0.44, p<0.0001).

Conclusion:

A systematic geriatric assessment can be successfully used to discover and quantify geriatric health problems in older patients with rheumatic and musculoskeletal diseases. These problems appear to be very common and importantly, patients with more problems had poorer functional status. Frailty, depression, incomplete vaccination status, cognitive impairment or polypharmacy are all known to negatively impact patient care. Recognizing and addressing geriatric problems has the potential to lead to health care improvements including adherence and medication side effects and might increase patient satisfaction and functional status independent of disease activity.

References:

[1]Buehring, B. and S. Barczi, Assessing the Aging Patient, in Spine Surgery in an Aging Population, N. Brooks and A. Strayer, Editors. 2019, Thieme: New York. p. 208.

[2]Cleutjens F, Boonen A, van Onna MGB. Geriatric syndromes in patients with rheumatoid arthritis: a literature overview. Clin Exp Rheumatol 2019;37(3):496-501

Geriatric Problem% presentProblems with Daily Activities67Problems with Vision28Problems with Hearing38Problems with Falls11Problems with Urinary Incontinence38Problems with Depression57Lack of Social Support10Incomplete Vaccinations53Problems with Cognition31Problems with Chronic Pain90Problems with Dizziness44Problems with Mobility41Problems with Unintentional Weight Loss30Inappropriate Medications present17Polypharmacy present81Frailty present46Short Physical Performance Battery low57

Acknowledgments:

None

Disclosure of Interests:

Anna Berrisch: None declared, Ioana Andreica: None declared, Styliani Tsiami: None declared, David Kiefer Grant/research support from: Novartis, Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Bjoern Buehring Grant/research support from: GE/Lunar, Kinemed, Consultant of: Gilead, Abbvie, Lilly, GE/Lunar, Janssen, Amgen, Speakers bureau: UCB

AB1245 DAILY MANAGEMENT OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS: SELF-MONITORING OF DISEASE ACTIVITY WITH A SMARTPHONE APP IS FEASIBLE – A PROOF OF CONCEPT STUDY

Background:

Assessment and monitoring of disease activity and functioning is of major importance for the course of axial spondyloarthritis (axSpA). This is equally important for patient monitoring in daily routine as also for tight control strategies. Even though there is evidence that a closer monitoring of patients is better than routine care, more intensive treatment schedules are often not realized in daily practice for several reasons including shortage of time and personal resources. Using application software devices (apps) in clinical routine for the recording of disease-specific patient reported outcomes (PRO) may facilitate monitoring and improve clinical decision processes but there is a lack of data on the use of apps.

Objectives:

To investigate the use of such App technology in respect to usability, feasibility and equivalence of data in daily care of patients with axSpA. In more detail, it will be first determined how many patients are capable and ready to use the technology in a routine setting. Furthermore, the usage and behavior of patients using the app will be studied, the usability of the app and the equivalence of the collected parameters as well as the adherence to the documentation of disease activity over time.

Methods:

Patients diagnosed with axSpA were consecutively included in this ongoing monocentric prospective cohort study. In addition to patient and disease characteristics, information on previous experience with digital health apps was collected. Patients were asked to submit BASDAI and BASFI scores regularly every 2 weeks. The free to use AxSpA Live App is available for Android and iOS as a Class I certified medical device.

Results:

Out of 103 axSpA patients asked, 69 patients with axSpA (mean age 41.5 ± 11.3, 58% male, 76.8% use of bDMARDs, BASDAI 4.3 ± 2.0, BASFI 3.8 ± 2.5) out of 103 patients (67%) agreed to use participate, while 5 did not have a smartphone, 1 was unable to download the app for technical reasons, 28 reported other personal reasons). Of the 69, 62 patients (89.9%) reported using electronic media frequently and had used digital health apps (mean apps used 1.0 ± 1.3) in everyday life before. There were no systematic differences between pain levels documented on paper or by app at baseline (ICC 0.9 (95%CI 0.82 – 0.93). Out of 55 patients who completed week 2, only 33 patients (60%) used the App regularly to transmit their BASDAI/BASFI responses within the first two weeks (60%). Patients who started a new drug treatment because of high disease activity, reported BASDAI values more often than patients without a treatment change within a follow-up period of 5.5± 2.4 weeks (Table).

Conclusion:

The majority of patients with axSpA were able to use the AxSpA Live App. Most patients report scores regularly. The current disease activity seems to influence the adherence to reporting.

Patients without change in their medication (n=53)Patients with change in their medication (n=16)Age, years42.0 (11.9)39.8 (9.3)Sex, male (%)62.343.8BASDAI, baseline4.1 (2.1)4.9 (1.7)BASFI, baseline3.8 (2.6)3.8 (2.3)Time of follow-up, in weeks5.4 (2.4)5.6 (2.5)Number of transmitted BASDAI values at week 222 (41%)11 (69%)Median number of transmitted BASDAI values during follow up1.0(3.6)1.5 (1.4)

This work was supported by an unrestricted Grant by Novartis Pharma GmbH, Germany

Acknowledgments:

n/a

Disclosure of Interests:

Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB, Robin Kempin: None declared, Anna Schlegel: None declared, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Styliani Tsiami: None declared, Bjoern Buehring Grant/research support from: GE/Lunar, Kinemed, Consultant of: Gilead, Abbvie, Lilly, GE/Lunar, Janssen, Amgen, Speakers bureau: UCB, David Kiefer Grant/research support from: Novartis, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

[Clinical significance of determination of DFS70 antibodies to rule out connective tissue diseases]

BACKGROUND

Connective tissue diseases (CTD) are autoimmune diseases highly associated with the presence of antinuclear antibodies (ANA). Since ANA and musculoskeletal symptoms are not uncommon in the general population, differential diagnostic challenges frequently occur for the treating physician. Dense fine speckled antibodies (DFS70) were recently discovered but their presence appeared to be rare in CTD.

METHODS

In this cross-sectional study a total of 270 patients treated in the Rheumatism Center of the Ruhr Area (Rheumazentrum Ruhrgebiet) were preferentially included, when they were ANA+ (≥1:80). Other autoantibodies and DFS70 antibodies were also investigated. The diagnosis of CTD was confirmed by rheumatologists. The sensitivity, specificity and the positive predictive value of DFS70 antibodies were differentially evaluated for various ANA titers.

RESULTS

In 91 (33.7%) of the ANA+ patients (33.7%) the diagnosis of CTD was confirmed and in 84 (92.3%) the ANA titer was ≥1:160. The DFS70 antibodies were detected in 17 out of 130 ANA+ patients without CTD (13.1%) versus 2 ANA+ patients (2.2%) with CTD (p = 0.027). None of the patients with ANA 1:80 had DFS70 antibodies. The specificity of DFS70 antibodies to detect the absence of CTD was 97.6%, the sensitivity was 13.1% and the positive predictive value was 89.5%. There was almost no effect of the strength of the different ANA titers.

CONCLUSION

It was found that DFS70 antibodies are rarely present in ANA+ patients with CTD but the diagnosis of CTD cannot be reliably ruled out solely by the presence of DFS70 antibodies; however, the high specificity of DFS70 antibodies can be of clinical importance in unclear situations and in cases of anxious patients.

[Epionics SPINE-use of an objective method to examine spinal mobility in patients with axial spondyloarthritis]

Axial spondylarthritis (axSpA) is a chronic inflammatory disease of the spine that can be associated with loss of physical function, mobility and upright postural impairment. Established tools for the assessment of function that are largely based on subjective perception are semiquantitatively recorded by standardized questionnaires (Bath ankylosing spondylitis functional index, BASFI), while measurement of spinal mobility of patients with axSpA is based on physical examination of various movement regions particularly the axial skeleton (Bath ankylosing spondylitis metrology index, BASMI). Recently, a performance test has been added to assess the range of motion and speed of certain tasks (AS performance-based improved test, ASPI); however, since these tests have limited reliability and reproducibility, more objective tests would be desirable. In this study the spinal mobility of patients with axSpA was quantified using the Epionics SPINE device (ES) and data were evaluated using the outcome measures in rheumatology (OMERACT) criteria. The ES automatically measures various patterns of spinal movements using electronic sensors, which also assess the range and speed of carrying out movements. Patients with back pain from other causes and persons without back pain served as controls. The measurement results obtained with ES differed between the groups and correlated with BASMI values (r = 0.53-0.82, all p = <0.03). Patients with radiographically detectable axSpA had more limited and slower mobility than those with non-radiographically detectable axSpA. Overall, the results presented here suggest that ES measurements represent a valid and objective measurement procedure of spinal mobility for axSpA patients.

A transportable Paul-trap for levitation and accurate positioning of micron-scale particles in vacuum for laser-plasma experiments

We report on a Paul-trap system with large access angles that allows positioning of fully isolated micrometer-scale particles with micrometer precision as targets in high-intensity laser-plasma interactions. This paper summarizes theoretical and experimental concepts of the apparatus as well as supporting measurements that were performed for the trapping process of single particles.

Proton acceleration by irradiation of isolated spheres with an intense laser pulse

We report on experiments irradiating isolated plastic spheres with a peak laser intensity of 2-3×10^{20}Wcm^{-2}. With a laser focal spot size of 10 μm full width half maximum (FWHM) the sphere diameter was varied between 520 nm and 19.3 μm. Maximum proton energies of ∼25 MeV are achieved for targets matching the focal spot size of 10 μm in diameter or being slightly smaller. For smaller spheres the kinetic energy distributions of protons become nonmonotonic, indicating a change in the accelerating mechanism from ambipolar expansion towards a regime dominated by effects caused by Coulomb repulsion of ions. The energy conversion efficiency from laser energy to proton kinetic energy is optimized when the target diameter matches the laser focal spot size with efficiencies reaching the percent level. The change of proton acceleration efficiency with target size can be attributed to the reduced cross-sectional overlap of subfocus targets with the laser. Reported experimental observations are in line with 3D3V particle in cell simulations. They make use of well-defined targets and point out pathways for future applications and experiments.

Ion Acceleration Using Relativistic Pulse Shaping in Near-Critical-Density Plasmas

Ultraintense laser pulses with a few-cycle rising edge are ideally suited to accelerating ions from ultrathin foils, and achieving such pulses in practice represents a formidable challenge. We show that such pulses can be obtained using sufficiently strong and well-controlled relativistic nonlinearities in spatially well-defined near-critical-density plasmas. The resulting ultraintense pulses with an extremely steep rising edge give rise to significantly enhanced carbon ion energies consistent with a transition to radiation pressure acceleration.

Bright subcycle extreme ultraviolet bursts from a single dense relativistic electron sheet

Double-foil targets separated by a low density plasma and irradiated by a petawatt-class laser are shown to be a copious source of coherent broadband radiation. Simulations show that a dense sheet of relativistic electrons is formed during the interaction of the laser with the tenuous plasma between the two foils. The coherent motion of the electron sheet as it transits the second foil results in strong broadband emission in the extreme ultraviolet, consistent with our experimental observations.

Dependence of laser-driven coherent synchrotron emission efficiency on pulse ellipticity and implications for polarization gating

The polarization dependence of laser-driven coherent synchrotron emission transmitted through thin foils is investigated experimentally. The harmonic generation process is seen to be almost completely suppressed for circular polarization opening up the possibility of producing isolated attosecond pulses via polarization gating. Particle-in-cell simulations suggest that current laser pulses are capable of generating isolated attosecond pulses with high pulse energies.

Monoenergetic ion beam generation by driving ion solitary waves with circularly polarized laser light

Experimental data from the Trident Laser facility is presented showing quasimonoenergetic carbon ions from nm-scaled foil targets with an energy spread of as low as ±15% at 35 MeV. These results and high-resolution kinetic simulations show laser acceleration of quasimonoenergetic ion beams by the generation of ion solitons with circularly polarized laser pulses (500 fs, λ=1054  nm). The conversion efficiency into monoenergetic ions is increased by an order of magnitude compared with previous experimental results, representing an important step towards applications such as ion fast ignition.

Collective hypersonic excitations in strongly multiple scattering colloids

Unprecedented low-dispersion high-frequency acoustic excitations are observed in dense suspensions of elastically hard colloids. The experimental phononic band structure for SiO(2) particles with different sizes and volume fractions is well represented by rigorous full-elastodynamic multiple-scattering calculations. The slow phonons, which do not relate to particle resonances, are localized in the surrounding liquid medium and stem from coherent multiple scattering that becomes strong in the close-packing regime. Such rich phonon-matter interactions in nanostructures, being still unexplored, can open new opportunities in phononics.

A novel high resolution ion wide angle spectrometer

A novel ion wide angle spectrometer (iWASP) has been developed, which is capable of measuring angularly resolved energy distributions of protons and a second ion species, such as carbon C(6 +), simultaneously. The energy resolution for protons and carbon ions is better than 10% at ∼50 MeV/nucleon and thus suitable for the study of novel laser-ion acceleration schemes aiming for ultrahigh particle energies. A wedged magnet design enables an acceptance angle of 30°(∼524 mrad) and high angular accuracy in the μrad range. First, results obtained at the LANL Trident laser facility are presented demonstrating high energy and angular resolution of this novel iWASP.

Development of a high resolution and high dispersion Thomson parabola

Here, we report on the development of a novel high resolution and high dispersion Thomson parabola for simultaneously resolving protons and low-Z ions of more than 100 MeV/nucleon necessary to explore novel laser ion acceleration schemes. High electric and magnetic fields enable energy resolutions of ΔE∕E < 5% at 100 MeV/nucleon and impede premature merging of different ion species at low energies on the detector plane. First results from laser driven ion acceleration experiments performed at the Trident Laser Facility demonstrate high resolution and superior species and charge state separation of this novel Thomson parabola for ion energies of more than 30 MeV/nucleon.

Radiation-pressure acceleration of ion beams driven by circularly polarized laser pulses

We present experimental studies on ion acceleration from ultrathin diamondlike carbon foils irradiated by ultrahigh contrast laser pulses of energy 0.7 J focused to peak intensities of 5x10(19) W/cm2. A reduction in electron heating is observed when the laser polarization is changed from linear to circular, leading to a pronounced peak in the fully ionized carbon spectrum at the optimum foil thickness of 5.3 nm. Two-dimensional particle-in-cell simulations reveal that those C6+ ions are for the first time dominantly accelerated in a phase-stable way by the laser radiation pressure.

Enhanced laser-driven ion acceleration in the relativistic transparency regime

We report on the acceleration of ion beams from ultrathin diamondlike carbon foils of thickness 50, 30, and 10 nm irradiated by ultrahigh contrast laser pulses at intensities of approximately 7 x 10;{19} W/cm;{2}. An unprecedented maximum energy of 185 MeV (15 MeV/u) for fully ionized carbon atoms is observed at the optimum thickness of 30 nm. The enhanced acceleration is attributed to self-induced transparency, leading to strong volumetric heating of the classically overdense electron population in the bulk of the target. Our experimental results are supported by both particle-in-cell (PIC) simulations and an analytical model.

Laser-driven shock acceleration of ion beams from spherical mass-limited targets

We report on experimental studies of ion acceleration from spherical targets of diameter 15 microm irradiated by ultraintense (1x10(20) W/cm2) pulses from a 20-TW Ti:sapphire laser system. A highly directed proton beam with plateau-shaped spectrum extending to energies up to 8 MeV is observed in the laser propagation direction. This beam arises from acceleration in a converging shock launched by the laser, which is confirmed by 3-dimensional particle-in-cell simulations. The temporal evolution of the shock-front curvature shows excellent agreement with a two-dimensional radiation pressure model.

Effect of antagonists vs agonists on in vitro fertilization outcome

PURPOSE

To compare outcome following in vitro fertilization-embryo transfer (IVF-ET) using controlled ovarian hyperstimulation (COH) regimens using either the gonadotropin-releasing hormone (GnRH) agonist leuprolide acetate vs the GnRH antagonist ganirelix.

METHODS

Women needing IVF for conception were randomly assigned to 300 IU of gonadotropins with ganirelix used in the follicular phase when a follicle with a 14 mm average diameter was attained vs a regimen using leuprolide acetate from the mid-luteal phase of the previous cycle.

RESULTS

There were no differences found in clinical, ongoing, delivered pregnancy rates or implantation rates between groups.

CONCLUSIONS

The use of GnRH antagonists do not seem to reduce IVF outcome compared to using GnRH agonists in COH regimens.

The importance of number of blastomeres when embryos are transferred in the absence of controlled ovarian hyperstimulation

PURPOSE

To determine if the previous findings that transferring embryos with a higher number of blastomeres results in higher pregnancy rates following fresh but not frozen embryo transfer (ET) was related to the use of controlled ovarian hyperstimulation (COH) in the former but not in the latter.

METHODS

Retrospective review of pregnancy and implantation rates following fresh embryo transfer of donor egg recipient cycles (where no COH is used) vs frozen ETs during the same time period according to whether there was at least one embryo with eight blastomeres transferred or not.

RESULTS

Significantly higher pregnancy rates with an 8-cell ET in donor oocyte recipient cycles but not frozen ETs.

CONCLUSIONS

A less favorable uterine environment caused by the use of high dose gonadotropin is not responsible for the once again observed difference in higher pregnancy rates with higher blastomere number in fresh vs frozen ET. However, an effect of the gonadotropin releasing hormone analogue was not ruled out by this study.

Evidence that exclusive use of Follistim may produce better pregnancy results than the use of Gonal-F following in vitro fertilization (IVF) - embryo transfer (ET)

PURPOSE

To evaluate whether the equal mixture of human menopausal gonadotropin (hMG) to recombinant (r) follicle stimulating hormone (FSH) for controlled ovarian hyperstimulation (COH) adversely affects outcome following in vitro fertilization (IVF). Furthermore, to determine if the specific rFSH preparation used has any differing effects on outcome.

METHODS

Retrospective study of women using the luteal phase leuprolide acetate-gonadotropin COH regimen. Outcome measures included clinical and viable pregnancy rates (PRs) and implantation rates.

RESULTS

The clinical and viable PRs and implantation rates were significantly lower in the group receiving exclusively Gonal-F. Addition of hMG to the treatment protocol not only did not lower the PRs further, but in fact seemed to obviate the adverse effect of Gonal-F.

CONCLUSION

Since exclusive use of Gonal-F did not adversely affect fertilization rates or quality of embryos we suspect its exclusive use in some way makes the uterine environment less receptive.

Sperm toxicity evaluated by the overnight sperm survival test

A subnormal sperm stress test has also been associated with implantation failure despite apparently normal fertilization; however, this test is cumbersome and time-consuming. The overnight sperm survival test has been considered to possibly demonstrate lipid peroxidation abnormalities similar to the sperm stress test. The present study evaluated whether lower overnight survival scores were associated with lower pregnancy and implantation rates following in vitro fertilization-embryo transfer. The results showed no adverse effect of poor overnight survival test scores. Possibly, the overnight survival test, though similar in some respects to the sperm stress test, is not similar for properties of predicting embryo implantation defects. Corroboration that subnormal stress tests predicts implantation disorders is needed.

A study to determine if embryo cryopreservation influences the potential of rapidly growing embryos to successfully implant in uterine environments not influenced by controlled ovarian hyperstimulation

PURPOSE

To determine if transferring at least one embryo with eight blastomeres at 72 hours improves prognosis of donor oocyte recipients. The study aim was to verify if cryopreservation increases or decreases the advantage of rapidly growing embryos. The study could exclude the influence of controlled ovarian hyperstimulation (COH) on the uterine environment.

METHODS

All transfers, fresh or frozen, using exclusively embryos that resulted from fertilization of donor oocytes over a three-year period were evaluated.

RESULTS

Significantly higher pregnancy rates (PRs) and delivery rates were found in donor oocyte recipients receiving at least one eight-cell embryo compared to transfers without any eight-cell embryos. These differences were not found when comparing frozen embryo transfers (ETs). The data could not be explained by confounding variables.

CONCLUSIONS

The inclusion of at least one 8-cell embryo on day 3 fresh ET resulted in higher PRs even without the influence of COH. However, higher blastomere number did not influence frozen ET outcome.

Grey zone score for hypo-osmotic swelling test (HOST) is not associated with embryo implantation defects

PURPOSE

To evaluate the clinical significance of the grey zone range (50-59%) of the hypo-osmotic swelling test (HOST) on sperm samples.

METHODS

Clinical and viable pregnancy rates and implantantion rates following in vitro fertilization-embryo transfer (IVF-ET) were determined in couples where the male partner scored between 50-59% on the HOST. The data were further evaluated according to the discrepancy between viability and HOST. Finally, the study assigned whether treating sperm with the protein digestive enzyme chymotrypsin had any effect on pregnancy outcome.

RESULTS

Pregnancy and implantation rates were comparable for couples with grey zone HOST scores with the normal IVF rate for the center. Having a large discrepancy between viability and HOST scores had no clinical significance nor did treatment with chymotrypsin.

CONCLUSION

In contrast to HOST scores < 50% where extremely poor implantation rates are noted, grey zone scores have no clinical significance.

Treatment of sperm with subnormal host scores with chymotrypsin/viable pregnancy after IUI

Men with low hypoosmotic swelling test (HOST) scores (<50%) rarely achieve a pregnancy with intercourse or conventional intrauterine insemination (IUI) or even IVF. The defect seems to be related to a toxic factor attached to the sperm that can be transferred to the zona pellucida, which ultimately interferes with implantation. A small case series showed optimistic pregnancy outcome with treatment of the sperm with low HOST scores with chymotrypsin. However, the live pregnancy rate in 90 subsequent IUI cycles in men whose low HOST scores were improved by chymotrypsin was only 3.3%. IVF with ICSI remains the only highly effective treatment of this disorder.

Ovarian cancer in a woman previously diagnosed with endometriosis and an extremely high serum CA-125 level

PURPOSE

Follow-up of a woman with a serum CA-125 level > 1000 U/mL where laparoscopy only found endometriosis.

METHODS

Case report-- re-evaluation several years later.

RESULTS

Extensive clear-cell carcinoma of ovary with metastases leading to death.

CONCLUSION

This case suggests that bilateral oophorectomy should be performed in women not desiring any more children if the serum CA- 125 level is very high even if only endometriosis is found initially.

Finding information on herbal therapy: a guide to useful sources for clinicians

Many resources are available to patients and healthcare practitioners interested in learning about complementary and alternative medicine (CAM) therapies such as herbal medicine. This article provides a comprehensive review of herbal medicine sources that are general in scope, clinically oriented, evidence based, and focused on Western phytomedicinals. Tables list 15 books and 8 Internet sites that fulfill these criteria. Information also is provided on 4 monographs, literature databases, and many related sources that may be of interest to clinicians incorporating herbal medicines into their practice or counseling patients on the topic.

Indecisive M13 procoat protein mutants bind to SecA but do not activate the translocation ATPase

The M13 procoat protein serves as the paradigm for the Sec-independent membrane insertion pathway. This protein is inserted into the inner membrane of Escherichia coli with two hydrophobic regions and a central periplasmic loop region of 20 amino acid residues. Extension of the periplasmic loop region renders M13 procoat membrane insertion Sec-dependent. Loop regions with 118 or more residues required SecA and SecYEG and were efficiently translocated in vivo. Two mutants having loop regions of 80 and 100 residues, respectively, interacted with SecA but failed to activate the membrane translocation ATPase of SecA in vitro. Similarly, a procoat mutant with two additional glutamyl residues in the loop region showed binding to SecA but did not stimulate the ATPase. The three mutants were also defective for precursor-stimulated binding of SecA to the membrane surface. Remarkably, the mutant proteins act as competitive inhibitors of the Sec translocase. This suggests that the region to be translocated is sensed by SecA but the activation of the SecA translocation ATPase is only successful for substrates with a minimum length of the translocated region.

Hydrophobic forces drive spontaneous membrane insertion of the bacteriophage Pf3 coat protein without topological control

Bacterial integral inner membrane proteins are either translocated across the lipid bilayer using an energy-driven enzyme, such as the Sec translocase, or they might interact directly with the membrane due to hydrophobic forces. We report that the single-spanning Pf3 coat protein is spontaneously inserted into the membrane of Escherichia coli and requires the electrical component of the membrane potential (DeltaPsi) to translocate its N-terminal region. This results in a final N(out)C(in) orientation of the protein in the cytoplasmic membrane, due the potential-driven translocation of the aspartyl residue at position 18 in the hydrophilic N-terminal tail. Uncharged protein tails are only translocated when the hydrophobic transmembrane region of the protein has been extended. An extended transmembrane anchor allows membrane insertion in the absence of an electrochemical membrane potential, but also causes the loss of a strict determination of the topology.

Oligoasthenozoospermia is not associated with spontaneous abortions following in vivo pregnancies contrasting with in vitro fertilization data

Previous data showed an association between low motile density (< 10 million motile/mL) and spontaneous abortion (SAB) following in vitro fertilization-embryo transfer (IVF-ET). The purpose of this study was to determine if the same association existed following intrauterine insemination (IUI). A retrospective review of IUI pregnancies was conducted. Patients with antisperm antibodies, a low hypo-osmotic swelling (HOS) test score (< 50%), or those using donor sperm were excluded. A total of 52 couples were enrolled in the study: 34 in the normal motile density (MD) group and 18 in the low MD group. The SAB rate in the normal group was 29.4% and in the low group was 27.8%. Thus, these data fail to corroborate the conclusions reached after evaluation of IVF pregnancies that low MD is a cause of SAB. However, since there is a large difference in the number of sperm that come in contact with the oocyte following IVF versus IUI, it may be that the implantation defect is not evident until the oocyte is exposed to a certain number of abnormal sperm.

Assessing the risks and benefits of herbal medicine: an overview of scientific evidence

The use of herbal medicine is widespread and growing, with as many as 3 in 10 Americans using botanical remedies in a given year. Because many herbal medicines have significant pharmacological activity, and thus potential adverse effects and drug interactions, healthcare professionals must be familiar with this therapeutic modality. This article summarizes the history and current use of plant-based medicine and highlights the evidence of the risks and benefits associated with 6 plants: echinacea, garlic, ginger, ginkgo, St John's wort, and valerian. Therapies outside the medical mainstream tend to suffer from a dearth of research and critical evaluation. Critics and supporters alike note the conceptual and practical difficulties in studying many complementary and alternative therapies such as acupuncture, homeopathy, and meditation. Herbal medicine, however, lends itself well to standard evaluation methods. This article summarizes and evaluates evidence from randomized controlled trials and meta-analyses. We present the results of meta-analyses and subsequent randomized controlled trials for garlic and St John's wort; a comprehensive critical review and subsequent randomized controlled trials for ginkgo; and summaries of all identified randomized controlled trials for echinacea, ginger, and valerian.

A review of 12 commonly used medicinal herbs

A large and increasing number of patients use medicinal herbs or seek the advice of their physician regarding their use. More than one third of Americans use herbs for health purposes, yet patients (and physicians) often lack accurate information about the safety and efficacy of herbal remedies. Burgeoning interest in medicinal herbs has increased scientific scrutiny of their therapeutic potential and safety, thereby providing physicians with data to help patients make wise decisions about their use. This article provides a review of the data on 12 of the most commonly used herbs in the United States. In addition, we provide practical information and guidelines for the judicious use of medicinal herbs.

Evidence that oligoasthenozoospermia may be an etiologic factor for spontaneous abortion after in vitro fertilization-embryo transfer

OBJECTIVE

To evaluate whether oligoasthenozoospermia may lead to a higher spontaneous abortion (SAB) rate once a pregnancy is established by IVF-ET.

DESIGN

Retrospective clinical observational study.

SETTING

University-based IVF program.

PATIENT(S)

Three hundred sixty-four couples with normal semen parameters who underwent IVF-ET with conventional sperm incubation; 70 couples with oligoasthenozoospermia but without marked abnormal sperm morphology (< 4% normal forms using strict criteria) who underwent ET after IVF with conventional sperm incubation; and 20 couples with oligoasthenozoospermia but without abnormal sperm morphology who underwent ET after IVF with intracytoplasmic sperm injection (ICSI).

MAIN OUTCOME MEASURE(S)

Implantation rate, clinical pregnancy rate, SAB rate, and delivery rate after IVF-ET.

RESULT(S)

Despite similar pregnancy and implantation rates per ET, as a result of a higher SAB rate (40.0% versus 11.7%), the delivery rates were lower in the female partners of men with oligoasthenozoospermia. Similar patients who used ICSI had a 0% SAB rate.

CONCLUSION(S)

Oligoasthenozoospermia should be considered a possible risk factor for SAB in IVF achieved pregnancies. Further studies are needed to determine whether ICSI reduces the risk of SAB associated with oligoasthenozoospermia.