Clinical significance of the anti-Nucleolar Organizer Region 90 antibodies (NOR90) in systemic sclerosis: Analysis of the European Scleroderma Trials and Research (EUSTAR) cohort and a systematic literature review

BACKGROUND

The anti-Nucleolar Organizer Region 90 antibodies (NOR90) are rare antinuclear antibodies (ANA) reported in systemic sclerosis (SSc). Especially due to low prevalence, the clinical relevance of NOR90 in SSc remains uncertain.

OBJECTIVES

To analyze the clinical associations of NOR90 in patients with SSc in a multicentric cohort.

METHODS

Post-hoc, cross-sectional study of prospectively collected data from the European Scleroderma Trials and Research (EUSTAR) database, with additional information on NOR90. Further, we performed a systematic literature search, using the terms "systemic sclerosis" and "NOR90" across three databases: Medline via PubMed, Scopus, and Thomson Reuters' Web of Science Core Collection, from inception to November 1st, 2023.

RESULTS

Overall, 1318 patients with SSc were included (mean age 58.3 ± 13.7 years, 81.3 % female), of whom 44 (3.3 %) were positive for NOR90. Of these, 32 were also positive for one of the SSc-criteria antibodies: 9/44 (20.5 %) for anti-topoisomerase I, 18/42 (42.9 %) for anti-centromere, and 5/40 (12.5 %) for anti-RNA polymerase III. NOR90-positive patients were more frequently female, had lower modified Rodnan skin score (mRSS), and lower prevalence of upper and lower gastrointestinal (GI) symptoms compared to NOR90-negative patients. In multivariable analysis, NOR90 remained significantly associated with lower mRSS and less frequent GI symptoms. The literature search identified 17 articles, including a total number of 87 NOR90-positive out of 3357 SSc patients, corresponding to an overall prevalence of 2.6 %.

CONCLUSION

To our best knowledge, this is the largest SSc cohort tested for NOR90 to date, confirming the NOR90 prevalence in SSc patients is around 3 %.

CMR-driven immunosuppressive therapy in systemic sclerosis patients with suspected myocarditis: a single-center experience

Background

Systemic sclerosis (SSc) myocarditis is common, but often underrecognized due to absence of symptoms at early stages. Cardiac Magnetic Resonance (CMR) is the imaging modality of choice for detection of SSc myocarditis. Current guidelines recommend CMR in case of alterations in first level cardiologic diagnostic tests. Immunosuppressive therapy is only indicated for patients with organ involvement, i.e. most frequently heart and lung, or with diffuse cutaneous systemic sclerosis.

Purpose

To explore the impact of CMR in the diagnostic and therapeutic pathway of SSc patients.

Methods

Of 286 SSc patients referred to our hospital, we retrospectively enrolled patients who received CMR during an observational period of 6 years (2016–2022). Exclusion criteria were previous immunosuppressive therapy and cardiopathy from other cause. Clinical data including Holter-ECG performed within 90 days from CMR were available.

Results

39 patients (67 [58–72] years; females 87%) were identified. 15 patients were excluded due to previous immunosuppressive therapy (9), lack of information on therapy (3), cardiopathy from other causes (3). 24 patients were finally included in the study.

14 patients (58%) did not show myocardial inflammation at CMR (LVEF 65.5 [61–69]%, LVEDV 114.5 [92–141] ml, T2 ratio 1.6 [1.4–1.9]). 1 patient presented with mid-wall inferior late gadolinium enhancement (LGE) indicative of previous myocarditis. 1 patient received immunosuppressive therapy due to SSc lung involvement in follow-up. In this group premature ventricular contractions (PVCs) during 24-hours Holter-ECG were rare (29 [3–48]). When measured, high-sensitivity Troponin I (hsTnI) was 2.4 [0.8–5] ng/L.

10 patients (42%) showed myocardial inflammation at CMR: LVEF 60 [56–65] %, LVEDV 137,5 [122–166] ml, T2 ratio 2.1 [1.7–2.3], T1 mapping 1022.5 [1010–1036] msec and T2 mapping 50.5 [50–52] msec. Myocardial LGE with non-ischemic pattern was seen in 6 patients. The number of PVCs at 24-hours Holter-ECG was collectively higher in these patients (354 [1–4245]). When measured, hsTnI was 8 [6–18] ng/L. With detection of myocardial inflammation at CMR all 10 patients eventually received immunosuppressive therapy (mycophenolate mofetil (MMF) or azathioprine in case of MMF intolerance).

At follow-up CMR performed 4 [3–6] months later on therapy various parameter differences were observed: LVEF (+2 [−2; 4] %), T1 mapping (−23 [−27; −12] msec), T2 mapping (−2 [−4; −1] msec), T2 ratio (−0.5 [−0.6; −0,2]). Of 6 patients with LGE, 4 displayed LGE persistence at follow-up.

Conclusions

In our experience, CMR was the tool of choice for diagnosis and therapeutic management in SSc patients with suspected cardiac involvement. SSc myocarditis patients tended to display more arrhythmic burden at Holter-ECG and higher cardiac biomarkers. Our data suggest to intensify first level cardiological screening, in order to identify suitable candidates to CMR.

Funding Acknowledgement

Type of funding sources: None.

Multidisciplinary team directed analysis of whole genome sequencing reveals pathogenic non-coding variants in molecularly undiagnosed inherited retinal dystrophies

The purpose of this paper is to identify likely pathogenic non-coding variants in inherited retinal dystrophy (IRD) genes, using genome sequencing (GS). Patients with IRD were recruited to the study and underwent comprehensive ophthalmological evaluation and GS. The results of GS were investigated through virtual gene panel analysis, and plausible pathogenic variants and clinical phenotype evaluated by the multidisciplinary team (MDT) discussion. For unsolved patients in whom a specific gene was suspected to harbor a missed pathogenic variant, targeted re-analysis of non-coding regions was performed on GS data. Candidate variants were functionally tested by messenger RNA analysis, minigene or luciferase reporter assays. Previously unreported, likely pathogenic, non-coding variants in 7 genes (PRPF31, NDP, IFT140, CRB1, USH2A, BBS10 and GUCY2D), were identified in 11 patients. These were shown to lead to mis-splicing (PRPF31, IFT140, CRB1 and USH2A) or altered transcription levels (BBS10 and GUCY2D). MDT-led, phenotype-driven, non-coding variant re-analysis of GS is effective in identifying the missing causative alleles.

AB0050 ALTERED NAMPT, ADIPOKINE AND CYTOKINE LEVELS CHARACTERIZE MONOCYTE ACTIVITY AND CORRELATE WITH DISEASE SEVERITY IN OSTEOARTHRITIS

Background

Osteoarthritis (OA) is a chronic, debilitating, aging-associated disease (1), characterized by chronic low-grade inflammation, the underlying mechanisms of which are poorly understood (2). Intracellular nicotinamide phosphoribosyltransferase (iNAMPT) is the rate-limiting enzyme in the NAD+ salvage pathway, in charge of maintaining cellular homeostasis through redox reactions. NAD+ promotes the expression of sirtuin-1 (SIRT1), which regulates the mobilization of myeloid-derived suppressor cells from the bone marrow. Extracellular eNAMPT, the secreted form of NAMPT also known as visfatin, is an adipokine involved in OA pathogenesis (3,4).

Objectives

We aim to analyse the cytokine and adipokine profile and the role of i- and eNAMPT in OA-related inflammation.

Methods

Peripheral blood and, whenever possible, synovial fluid from knee joint were collected from patients with OA older than 50 years. Samples from subjects without OA older than 50 (non-OA>50y) and younger than 30 (non-OA<30y) were used as controls. Serum, plasmatic, and synovial fluid adipokines and cytokines were measured by ELISA. Peripheral blood mononuclear cells were purified with Ficoll gradient and monocytes were selected with anti-human CD14 microbeads; RNA was extracted for polymerase chain reaction for NAMPT, SIRT1 and pro/anti-inflammatory cytokines. Monocyte intracellular NAD+ was measured at baseline and 1 hour after nicotinamide (a NAMPT substrate and precursor of NAD+) supplementation. Results were correlated with clinical data.

Results

Peripheral blood was obtained from 51 patients with OA (19 with synovial fluid also), 44 from non-OA>50y, and 35 from non-OA<30y controls. Plasmatic chemerin and leptin were higher in OA patients, visfatin was higher in OA and in non-OA>50y group (p<0.01 for all analyses). Plasmatic and synovial levels of leptin and resistin were correlated (p<0.001, r=0.6 for both comparisons); synovial leptin and resistin correlated with synovial IL-6, VEGF, and TNFα and these were higher in polyarticular OA (vs monoarticular, p=0.01 and p=0.03, respectively) and in OA with more severe Kellgren-Lawrence score (p=0.003 and p=0.03, respectively). Monocyte expression of NAMPT and anti-inflammatory cytokines IL-10 and Arginase-1 was increased in non-OA<30y controls compared to OA patients and non-OA>50y subjects (p<0.05 for all analyses). At baseline, monocyte intracellular NAD+ content was higher in the non-OA>50y cohort; after niacin supplementation, non-OA>50y subjects had the highest content, whereas OA patients had higher NAD levels than at baseline, but significantly lower than non-OA>50y controls (Figure 1).

Figure 1.

Monocyte NAD+ content at baseline and 1 hour after nicotinamide supplementation. *p<0.05 **p<0.01 ****p<0.0001.

Conclusion

A specific plasmatic and synovial adipokine signature characterizes OA and patients with more severe disease. In monocytes there is a age-related reduction of iNAMPT and anti-inflammatory cytokine expression, whereas eNAMPT is higher in elderly compared with younger subjects. In non-OA>50y subjects there might be an increase of iNAMPT activity which leads to NAD+ production, while in OA patients this mechanism seems to be impaired and can be only partially enhanced by nicotinamide supplementation, leading to reduced intracellular redox efficiency. These results suggest that NAMPT activity might be a key component of the mechanisms underlying inflammation in OA patients.

References

[1]Hunter DJ, et al. Lancet. 2019 Apr 27;393(10182):1745-1759.

[2]Motta F, et al. Front Immunol. 2020 Oct 29;11:576134.

[3]Travelli C, et al. Cancer Res. 2019 Apr 15;79(8):1938-1951.

[4]Liao L, et al. J Bone Miner Metab. 2016 Sep;34(5):485-90.

Disclosure of Interests

Francesca Motta Consultant of: Thermo Fisher, Barbara Durante: None declared, Chiara Pandolfo: None declared, Carlo Selmi Speakers bureau: AbbVie, Amgen, Alfa-Wassermann, Biogen, Celgene, Eli-Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme, Consultant of: AbbVie, Amgen, Alfa-Wassermann, Biogen, Celgene, Eli-Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme, Grant/research support from: AbbVie, Amgen, Janssen, Pfizer, Antonio Sica: None declared

AB0627 Evaluation of internal consistency, feasibility, and reliability of the Italian version of ANCA-associated vasculitis patient-reported outcome (AAV-PRO_ita) questionnaire: preliminary results from a multicenter study on a large cohort of Italian patients

Background

The ANCA-associated vasculitis patient-reported outcome (AAV-PRO) questionnaire is a 29-item disease-specific PRO measure for AAV[1]. The Italian version of the AAV-PRO questionnaire (AAV-PRO_ita) was translated in collaboration with Oxford and Bristol University (UK) and was preliminarily tested on a single-center Italian cohort[2].

Objectives

The main objective of this multicentric study was to assess the internal consistency, feasibility, and reliability of the AAV-PRO_ita in a large cohort of Italian AAV patients. The secondary objective was to investigate the clinical characteristics of AAV patients associated with AAV-PRO_ita domains.

Methods

The AAV-PRO_ita is describes the following disease domains: (1) organ-specific and systemic symptoms and signs (SSS); (2) physical function (PF); (3) social and emotional impact (SEI). In this study, Italian-speaking AAV patients were recruited from Italian Centres (N=13) with a large experience in the diagnosis and treatment of systemic vasculitis, belonging to the Vasculitis Study Group of the Italian Society of Rheumatology. Inclusion criteria were: a confirmed diagnosis of GPA, MPA, or EGPA; ANCA positivity in at least once occasion or biopsy-proven AAV; and age ≥18 years old. Participants completed the AAV-PRO_ita at three different time-points: baseline, after 5-7 days, and at month 3.

Results

229 AAV-patients (56.3% women) with a median age of 61 (IQR 51-72) were recruited and completed the questionnaires. The subtype of AAV was mainly GPA (131, 57.2%), followed by EGPA (58, 25.3%), and MPA (40, 17.5%). Median BVASv3 at baseline was 0 (IQR 0-3), whereas the median BVASv3 at the onset of disease was 14 (IQR 9-20). Participants had a median duration of disease of 67 (IQR 24-126) months. Patients who experienced at least one relapse, one hospitalization, and one severe infection were 40.2%, 53.3%, and 24%, respectively. 83% of the patients were on immunosuppressant therapy and 71.6% were still receiving glucocorticoids (GC).

AAV-PRO_ita questionnaire had good internal consistency (Cronbach’s Alpha range 0.81-0.93) and good test-retest reliability (ICCs range 0.93-0.96). Item response rates were high overall (maximum 0.87% missing data), supporting the feasibility of the questionnaire.

Concerning the domains of the questionnaire, female AAV patients scored higher (i.e. worse) in all three domains, especially in the SEI domain (p-value<0.001). Older participants (≥65 years) scored higher in the PF domain (p-value<0.05) in all three times of self-completions of the questionnaire. The ongoing treatment also influenced the results. In fact, patients on GC showed higher scores in the PF domain (p-value=0.003) and SEI domain (p-value=0.021). The VDI value seemed to be related to AAV-PRO_ita scores more than disease duration or disease activity, especially in the SSS domain (ρ>0.3, p-value<0.001). Conversely, subtype of AAV did not influence the item scores.

Conclusion

The AAV-PRO_ita questionnaire is a new 29-item, disease-specific PRO measure for use in AAV in the Italian language. It is a self-administered Italian questionnaire with good internal consistency, feasibility, and reliability. AAV-PRO_ita proved to be a useful tool to explore the AAV patient’s perception of quality of life, and it could become an important way of measuring the unmet needs of AAV patients.

References

[1]Robson, J.C. et al. Validation of the ANCA-Associated Vasculitis Patient-Reported Outcomes (AAV-PRO) Questionnaire. Ann. Rheum. Dis.2018, 77, 1157–1164, doi:10.1136/annrheumdis-2017-212713.

[2]Treppo, E.; Palese, A.; Vita, S.D.; Quartuccio, L. AB0392 PRELIMINARY VALIDATION OF THE ITALIAN VERSION OF ANCA-ASSOCIATED VASCULITIS PATIENT-REPORTED OUTCOME (AAV-PRO_ita) QUESTIONNAIRE: FATIGUE AND CHRONIC PAIN AS UNMET NEEDS BY CURRENT TREATMENTS. Ann. Rheum. Dis.2021, 80, 1224–1224, doi:10.1136/annrheumdis-2021-eular.2123.

Acknowledgements

We thank the Italian Study Group on Systemic Vasculitis.

Disclosure of Interests

None declared

AB0098 TOFACITINIB IS SUPERIOR TO DEXAMETHASONE IN MODULATING MAIT CELLS, INNATE LYMPHOID CELLS, AND Th9 CELLS IN PSORIATIC ARTHRITIS

Background

Tofacitinib is a potent and selective oral inhibitor prevalently of JAK1 and JAK3and is currently included in the international recommendations for the management of psoriatic arthritis (PsA). Nonetheless, the mechanisms of the immune response to the treatment remain unclear, particularly regarding the effects on overlooked immune cell subpopulations specifically involved in the pathogenesis of PsA, i.e. mucosal-associated invariant T cells (MAIT), innate lymphoid cells (ILCs), both relevant sources of IL-17, and T lymphocytes producing interleukin 9 (Th9). We thus investigated the effect of tofacitinib on these cell population function and compared with glucocorticoids.

Objectives

To investigate the effect of tofacitinib and dexamethasone on MAIT cells, ILCs, and Th9 cells in PsA.

Methods

We investigated synovial fluid and peripheral blood mononuclear cells from patients with PsA that were cultured with phorbol myristate acetate (PMA)/ionomycin in the presence or absence of 100 or 300nM Tofacitinib or 1000uM Dexamethasone for 24 hours and the addition of brefeldin in the last 2 hours. FACS analysis allowed to identify MAIT cells by CD3+CD161+Valpha7.2TCR; ILCs by CD3+CD45+CD127+, from this population ILC1 were arrayed as cKit- CRTH2-; ILC2 as cKit +/- and CRTH2+, and ILC3 as cKit+ and CRTH2-; Th9: CD3+CD4+IL-9+.

Results

A significant decrease in IL-17 production was observed in CD8+ MAIT cells treated with tofacitinib 300 nM compared to untreated conditions, with a magnitude similar to what observed with dexamethasone [mean fluorescence intensity-MFI median 1920 (interquartile range-IQR 1597-2761), 18.6% (3.9-31.4) in untreated cultures; 1481 (1325-3163), 13.4% (4.5-9.3) in tofacitinib-treated cultures; 1511 (1147-2882); 11.5% (2.5-49) in Dexamethasone-treated cultures; Figure 1]. A reduction of IL-17 production was observed also in ILC3 [52.1% (4.2-59.4) in untreated cultures; 25.8% (5.3-40.3) in Tofacitinib-treated cultures; 35.4% (6.3-47.9) in dexamethasone-treated cultures]. A reduction of IL-9 production was observed in peripheral blood T cells [2.19% (1.3-2.3) in untreated cultures; 0.6% (0.0-1.8) in Tofacitinib-treated cultures; 0.97% (0.07-1.13) in Dexamethasone-treated cultures].

Figure 1.

Conclusion

In PsA, tofacitinib is superior to dexamethasone in reducing the production of IL-17 by synovial fluid MAIT cells and ILC3 cells and of IL-9 by peripheral blood T cells.

Disclosure of Interests

Maria De Santis Grant/research support from: AbbVie, Amgen, Alfa-Wassermann, Biogen, Celgene, Eli-Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme, Actelion, Boehringer, Italfarmaco, Grunenthal, Roche, Natasa Isailovic: None declared, Angela Ceribelli Speakers bureau: Amgen, Paid instructor for: SPA Farmaceutici, Grant/research support from: Eli-Lilly, Grunenthal, GSK, Novartis, Pfizer, Francesca Motta Consultant of: Thermo-Fisher, Matteo Vecellio: None declared, Marta Caprioli: None declared, Giacomo Maria Guidelli Speakers bureau: Amgen, UCB, Galapagos, Eli-Lilly, Consultant of: Amgen, UCB, Galapagos, Eli-Lilly, Nicoletta Luciano Speakers bureau: Eli-Lilly, Galapagos, Consultant of: Eli-Lilly, Galapagos, Carlo Selmi Speakers bureau: AbbVie, Amgen, Alfa-Wassermann, Biogen, Celgene, Eli-Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme), Paid instructor for: AbbVie, Amgen, Alfa-Wassermann, Biogen, Celgene, Eli-Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme), Consultant of: AbbVie, Amgen, Alfa-Wassermann, Biogen, Celgene, Eli-Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme), Grant/research support from: AbbVie, Amgen, Janssen, Pfizer

POS0294 ARTIFICIAL INTELLIGENCE TO CONNECT THE USE OF BIOLOGICS AND SMALL MOLECULES IN RHEUMATOID AND PSORIATIC ARTHRITIS WITH A MULTIDISCIPLINARY EVALUATION: A REAL WORLD EVIDENCE APPROACH THROUGH NATURAL-LANGUAGE PROCESSING

Background

The management of rheumatoid arthritis (RA) and psoriatic arthritis (PsA) is often relying on a multidisciplinary approach with different specialists evaluating the patient for treatment choices. The ultimate impact of such management on the use of systemic glucocorticoids and more innovative drugs such as biologics and small molecules, however, is unclear. Artificial intelligence tools, particularly natural language processing and machine learning, allow to manage large datasets and investigate associations between variables.

Objectives

To use a natural language processing approach to demonstrate whether a multidisciplinary approach to RA or PsA changes treatment choices.

Methods

We analysed the clinical notes of hospital encounters between 2017 and 2020 of patients with a terminated or ongoing care process at outpatient clinics included in the Humanitas Center for immune-mediated disease. To extract structured information from text data we used regular expressions (RegEx), a technique that allows to define elastic search patterns. RegEx were also used to detect negations to consider only affirmative citation of diseases or prescribed therapy. Care processes were described by binary flags which express the presence of RA or PsA and the prescription of glucocorticoids and biologics /small molecules for each patient. Working with only categorical data, we relied on the chi squared test to detect possible correlations between prescribed treatments and the characteristics of the care process, including whether a multidisciplinary evaluation had occurred.

Results

Our analysis included 1839 patients with RA (77% women, mean+standard deviation age 58±16 years) and 1652 patients with PsA (46% women, age 57±15 years), accounting for 5517 and 3992 outpatient visits with different specialists over the study period, respectively. Among patients with RA and PsA, 378 (22%) and 371 (25%) were prescribed biologics or small molecules, respectively, while 830 (47%) RA and 431 (29%) PsA cases received a prescription for systemic glucocorticoids during one of the visits and patients seen three of more times by the rheumatologists received significantly more biologics / small molecules. Importantly, 4.5% of patients with RA and 9.4% of patients with PsA were evaluated also by dermatology, gastroenterology, allergy and pulmonary disease specialists and these patients were treated more frequently with glucocorticoids (70% vs.47% for RA, P<0.001; 60% vs. 29% for PsA, P<0.001) as well as with biologics / small molecules (42% vs. 22% for RA, P<0.001; 58% vs. 25% in PsA, P<0.001).

Conclusion

Natural language processing and machine learning were applied to unstructured electronic clinical charts in a large Center dedicated to immune-mediated diseases and allowed to demonstrate that patients with RA or PsA undergoing multiple evaluations are more likely to receive biologics or small molecules.

Disclosure of Interests

Pierandrea Moranding: None declared, Fiore Maffia: None declared, Francesca Puggioni Consultant of: Sanofi, GSK, Novartis, Teva, Francesca Motta: None declared, Matteo Vecellio: None declared, Antonio Costanzo Speakers bureau: bbvie, Almirall, Amgen, Lilly, Novartis, Galderma, Boehringer, Janssen, Leo Pfarma, Pfizer Sanofi, Celgene, Paid instructor for: Abbvie, Almirall, Amgen, Lilly, Novartis, Galderma, Boehringer, Janssen Leo Pfarma Pfizer, Sanofi, Celgene, Grant/research support from: bbvie, Janssen, Novartis, Victor Savevski: None declared, Carlo Selmi Speakers bureau: AbbVie, Amgen, Alfa-Wassermann, Biogen, Celgene, Eli-Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme, Paid instructor for: AbbVie, Amgen, Alfa-Wassermann, Biogen, Celgene, Eli-Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme, Consultant of: AbbVie, Amgen, Alfa-Wassermann, Biogen, Celgene, Eli-Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme, Grant/research support from: AbbVie, Amgen, Janssen, Pfizer

Synthesis and evaluation of photocatalytic and photoluminescent properties of Zn2+-doped Bi2WO6

This study consists of the synthesis of zinc-doped Bi2WO6 obtained by the sonochemical method. The XRD results indicated that the samples showed an orthorhombic phase with the P21ab space group...

POS0361 DNA METHYLATION SIGNATURES CHARACTERIZE PSORIASIS AND PSORIATIC ARTHRITIS IN MONOZYGOTIC TWINS DISCORDANT FOR THE DISEASE

Background:

Psoriatic disease is a chronic inflammatory disorder spanning from skin disease (psoriasis) to psoriatic arthritis (PsA). The genetic background is insufficient to explain disease onset as illustrated by not very informative Genome Wide Association Studies and monozygotic (MZ) twin studies recently performed. It is strongly assumed that epigenetics may contribute to disease susceptibility modulating gene expression. DNA methylation has been found involved in several autoimmune inflammatory rheumatic diseases. Here we have analysed the DNA methylation profile of a selected cohort of MZ twins discordant for psoriasis/PsA.

Objectives:

To identify the methylome associated with psoriasis and PsA in the peripheral blood of MZ twins discordant for these conditions.

Methods:

Peripheral blood from 7 couples of MZ twins discordant for psoriatic disease was collected and DNA extracted for a genome-wide evaluation of the DNA methylation profile, with the Infinium MethylationEPIC BeadChip. Minfi and the packages of the Bioconductor were used to analyse the data obtained. Quality control and exclusion criteria were applied to the raw data having a final number of 762.451 probes, which accounts for 88% of the total.

Results:

The approach first identified 2564 differentially methylated positions (DMPs; *p<0.005) with 19 genes potentially affected (with at least two DMPs within 1 kb of distance), including SMAD3 and SMARCA4/BRG1 involved in the Interferon and TGFβ pathways. Gene Ontology (GO) analysis of DMP-associated genes showed a significative enrichment (*p<0.005) in transcription factor binding, transcription corepressor and transcription coactivator activity, SMAD binding and histone -lysine-N-methyltransferase activity. To further validate the results, 5’-methylcytosine immunoprecipitation (MedIP) followed by Real Time PCR was performed to assess the methylation level of SMAD3 and SMARCA4/BRG1 promoters in the same cohort of MZ twins. We found significantly DNA methylation enrichment in SMARCA4/BRG1 promoter in psoriatic disease twins (p<0.05). SMAD3 and SMARCA4/BRG1 mRNA expression was also assessed to evaluate any inverse correlation with promoter methylation level, on the MZ cohort used for the EPIC array (n=4) and on a cohort of PsA/Ps patients (n=8) and appropriate healthy controls (n=3). Reduced mRNA expression (p<0.05) was demonstrated for SMARCA4/BRG1 (n=4). Conversely, no changes were found for SMAD3.

Conclusion:

We report the first DNA methylation approach in MZ twins discordant for psoriatic disease. We believe that the observed changes in SMAD3 and SMARCA/BRG1 genes may suggest an epigenetic imbalance of chromatin remodelling factors involved in inflammation pathways with a potential role in PsA/psoriasis immunopathogenesis.

Disclosure of Interests:

None declared

OP0249 SERUM PROTEOMIC BIOMARKERS DEFINE PATIENTS WITH SYSTEMIC SCLEROSIS WITH INTERSTITIAL LUNG DISEASE

Background:

Systemic sclerosis (SSc) is a systemic condition affecting multiple organs and thus being burdened by high morbidity and mortality; disease management is based largely on the early detection of organ involvement, particularly in the case of interstitial lung disease (ILD), ideally through noninvasive biomarkers. Beside serum autoantibodies associated with diffuse SSc, there is currently no reliable serum marker to predict the onset of SSc organ involvement, monitor its progression, and foresee the response to treatments. Proteomic analysis based on aptamer technology is a powerful method with the potential to address this unmet need in SSc.

Objectives:

To identify serum biomarkers associated with ILD in SSc.

Methods:

Serum samples from 6 women with SSc (3 with ILD at high-resolution pulmonary CT scan) and 7 age-matched female healthy controls (HC) were analyzed using the SOMAscan platform (SomaLogic, Inc., Boulder, CO, USA) to test more than 1300 proteins even at femtomolar concentration. Subsequent validation of candidate proteins was performed using ELISA in an independent cohort of 88 patients with SSc and 48 HC. Statistical analysis included Student’s t-test and was assessed using the SomaSuite software (SomaLogic, Boulder, CO, USA).

Results:

The proteomic analysis identified 33 proteins with significantly different serum levels in SSc cases compared to HC and 9 proteins differentiating SSc patients according to ILD (Table 1). Compared to HC, SSc sera manifested an altered expression of proteins involved in extracellular matrix formation and cell-cell adhesion (with higher Calpain, EphA5, IDS, MATN2, MMP-12, TNR4, and lower desmoglein-1, SNP25), angiogenesis (with higher anti-angiogenetic factors as angiopoietin-2 and kininogen high molecular weight) lymphocyte recruitment, activation, and signaling (with higher CXCL-1, LAG3 and lower SH21A) with an overall inhibition of neutrophil function (with lower G-CSF-R, CD177, calgranulin B).

Table 1.

Significantly altered proteins at serum proteomic analysis of systemic sclerosis (SSc) with or without interstitial lung disease (ILD) and healthy controls (HC)

SSc versus healthy controlsSSc with ILD versus SSc without ILD and healthy controlsIncreasedReducedIncreasedReducedAldolase AAngiopoietin-2*C1QR1CalpainCOLEC12 EotaxinEphA5Fractalkine/CXCL-1GranulinsIDS Kininogen, HMVLAG-3Lamin-B1LRP1bMATN2MMP-12STAT1 TMR4AdrenomedullinASGR1C1sC5Calgranulin BCD177Desmoglein-1Flt-3 ligandG-CFS-RIL-1RaLeptinLypd3SH21ASNP25TPBS2FCRL3IL-22BP**MCP-3PDE11PGP9.5sICAM-5StratifinBAFFDERM

*significantly increased also at ELISA

** significantly increased at ELISA only in SSc with ILD versus HC

The majority of proteins with higher levels in SSc with ILD compared to SSc without ILD were involved in intracellular signaling and cell cycle (FCRL3, PDE11, Stratifin), along with higher MCP-3, a monocyte chemoattractant, and sICAM-5, ligand for the leukocyte adhesion protein LFA-1. Of note, we found that increased IL-22BP, antagonist of IL-22, and decreased BAFF levels characterized SSc with ILD.

Conclusion:

Aptamer proteomic analysis allowed to define serum profiles differentiating SSc patients from healthy controls and SSc with ILD from SSc without ILD; the proteins identified are involved in SSc pathogenic pathways and after further investigation on larger cohorts they can be used as reliable biomarkers.

Characters from table content including title and footnotes: 631

Disclosure of Interests:

None declared

Denosumab for the treatment of HIV-associated osteoporosis with fractures in a premenopausal woman

The prevalence of osteoporosis is about three times greater in people living with HIV than in the general population. Bisphosphonates are the only class of antiresorptive drugs which have proved to be safe and effective in HIV patients. However, bisphosphonates are not recommended in women of childbearing age due to an increased rate of associated neonatal complications. To the best of our knowledge no reports on the use of denosumab in HIV-infected individuals have been published so far. We describe a 38 year-old woman with HIV, osteoporosis and vertebral fractures treated with denosumab, a monoclonal antibody targeting RANKL. After four years of treatment, bone mineral density improved, no new fractures occurred, and neither HIV reactivation nor opportunistic infections were observed. We show that denosumab could be a safe and effective approach for osteoporosis in patients with HIV and could be considered in women of childbearing age.

Zirconia/hydroxyapatite (80/20) scaffold repair in critical size calvarial defect increased FGF-2, osteocalcin and OPG immunostaining and IL-10 levels

The aim of this study was to characterize and evaluate zirconia/hydroxyapatite in a critical size calvarial defect model in rats. Zirconia/hydroxyapatite (80/20) scaffold was characterized by X-ray diffraction (XRD) and Scanning Electron Microscopy (SEM). Critical size (8 mm) calvarial defects were created in wistar rats (n=48) and divided into four groups (90 days): G0 Group: positive control; G1 Group: hydroxyapatite; G2 Group: Zirconia; G3 Group: Zirconia/hydroxyapatite (80/20). Calvaria were subjected to Micro CT, histological and immunohistochemical analyses (RANK, RANKL, OPG, osteocalcin and FGF-2). IL-1 beta, IL-10 and TNF-alpha levels were analyzed by Elisa Immunoassay. The XRD analysis confirmed the formation of a crystalline structure and SEM showed the presence of regions corresponding to Zirconia and Hydroxyapatite. The Micro CT showed increased bone volume (BV/TV) and bone mineral density (BMD) in the G3 group (P<0.05). In addition, discrete periosteal bone formation was found at the interface of the defect edge and the external surface of the scaffold in the G3 group, showing osteocytes inside and osteoblasts (P<0.05) with scarce mononuclear inflammatory cells (P<0.01) in the central region of the defect. The immunostaining was moderate for RANKL, Osteocalcin and FGF-2 in the G3 group (P<0.5), while it was intense for OPG (P<0.001). IL-1 beta levels were decreased and IL-10 levels increased (P<0.05). Zirconia/hydroxyapatite (80/20) scaffold repair in critical size calvarial defects increased bone density, osteoblast and osteoclast cell numbers, FGF-2, osteocalcin and OPG immunostaining and IL-10 levels.

SAT0280 IMPACT OF PLACENTAL FACTORS ON PREGNANCY AND FETAL OUTCOME IN SYSTEMIC SCLEROSIS

Background:

Systemic Sclerosis (SSc) is one of the rheumatic diseases burdened with obstetrical complications. An Italian multicenter study showed that women with SSc have a higher-than-normal risk of intrauterine growth restriction, preterm delivery, very-low birth weight babies and pregnancy should be discouraged in patients with severe organ damage. However, with a multidisciplinary management, patients with SSc can have successful outcomes1. Little is known about the pathogenesis of obstetrical complications, as studies on placenta are case reports or description of a few cases2,3.

Objectives:

The aim of this study was to analyze the placental alterations with a focus on the role of inflammation in the pathogenesis of obstetrical complications in SSc, including the study of the atypical chemokine receptor 2 (ACKR2), involved in immune modulation and known to be highly expressed in circulating leucocytes in SSc patients4-6.

Methods:

Eight SSc pregnant patients were compared with 16 patients with other rheumatic diseases (ORD) and 16 healthy controls (HC), matched for gestational age. Clinical data were collected. Placentas biopsies were obtained for histopathological analysis and immunohistochemistry for CD3, CD20, CD11c, CD68 and ACKR2. Frozen placenta samples from 4 SSc, 8 ORD and 8 HC were analyzed by qPCR for ACKR2 gene expression and proteins were extracted for multiplex assay for cytokines, chemokines and growth factors involved in angiogenesis and inflammation. Statistical analysis was performed with parametric or non-parametric tests depending on samples distribution.

Results:

The number of placental CD3 (p<0.05), CD68 (p<0.001) and CD11c+ (p<0.001) cells was significantly higher considering the group of patients affected by rheumatic diseases (SSc+ORD) compared to HC. The SSc group alone did not show significance due to the lower sample size. No differences were observed between groups in terms of vascular alterations or fibrosis. The percentage of stained area for ACKR2 and the ACKR2 transcripts levels were comparable between groups. Hepatocyte growth factor (HGF), involved in angiogenesis, was significantly increased in the group of rheumatic diseases patients (SSc+ORD) compared to HC (p<0.05), while the chemokine CCL5 was significantly higher in SSc patients compared to patients affected by ORD (p<0.05) and to HC (p<0.01). CCL5 levels directly correlated with the number of all inflammatory cells considered and higher levels were associated to histological villitis (p<0.01).

Conclusion:

The higher number of placental inflammatory cells and the alterations in the levels of HGF and especially CCL5 could play a role in the pathogenesis of the obstetrical complications in SSc. ACKR2 does not seem involved in the obstetrical complications of SSc.

References:

[1]Taraborelli M, et al. Arthritis Rheum. 2012

[2]Ibba-Manneschi L, et al. Ann Rheum Dis. 2010

[3]Doss BJ, et al. Hum Pathol. 1998

[4]Graham GJ. Eur J Immunol. 2009

[5]Martinez de la Torre Y, et al. Proc Natl Acad Sci U S A. 2007

[6]Codullo V, et al. Ann Rheum Dis. 2011

Disclosure of Interests:

None declared

OP0040 ANTI-CITRULLINATED PROTEIN AUTOANTIBODIES ARE ASSOCIATED WITH ONGOING SYSTEMIC BONE LOSS IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS TREATED ACCORDING TO THE PRINCIPLES OF TREAT-TO-TARGET AND TIGHT-CONTROL

Background:

Anti-citrullinated protein antibodies (ACPA) are a major risk factor for local and systemic bone loss in patients with rheumatoid arthritis (RA). We previously demonstrated that early RA patients at disease presentation already show reduced systemic bone mineral density (BMD) in association with ACPA-positivity (1). Whether the negative impact of ACPA on bone continues over time despite treatment institution is however unknown.

Objectives:

To investigate longitudinally the course of systemic bone loss in patients with early RA after institution of treatment with disease modifying anti-rheumatic drugs (DMARDs) according to the principles of treat-to-target and tight-control.

Methods:

The study population included 100 consecutive early RA patients (<12 months of symptoms) recruited at our Early Arthritis inception cohort and already evaluated for systemic BMD at disease presentation before treatment start (1). After diagnosis, patients were prospectively followed-up at three-months intervals upon initiation of therapy with conventional synthetic DMARDs (methotrexate in 85% of the cases) aimed at the achievement of low disease activity (LDA, 28-joints disease activity score [DAS28] <3.2). BMD was re-assessed after 24 months at the lumbar spine (L1-L4) and hip by the same dual X-ray absorptiometry (DXA) equipment used at baseline. Differences in BMD from baseline were evaluated in relation to demographic and clinical variables (listed in Table 1).

Table.

Predictors of bone mineral density changes over 24 months

% change in BMDlumbar spinetotal hipfemoral neckrprprpAge0.2690.0080.0690.500.2580.01female gender0.0850.42-0.0230.54-0.1210.23menopause0.1370.200.0670.530.0870.41disease duration0.0740.470.0440.670.0160.87cumulative DAS280.0180.860.0020.870.0110.91time to LDA0.1420.16-0.0230.76-0.0440.66time to remission0.0350.74-0.0020.97-0.0110.91ACPA-0.2510.010.1260.22-0.1300.04RF-0.1130.270.1110.280.0010.99months of bisphosphonates0.3680.0030.1710.090.2910.04cumulative steroids-0.1430.16-0.0070.78-0.0090.93months of bDMARDs-0.1630.11-0.0540.48-0.0630.54

Results:

The study population was mainly composed of females (84%), of whom 64.3% were in post-menopause; the mean (SD) age was 57.4 (13.5) years. Median (IQR) symptoms duration before treatment start was 14 (9-24) weeks. Fourty-three percent of the patients was ACPA positive. After 24 months of treatment, LDA was achieved in 79% of the cases, and remission in 46%; 17.7% of the patients had initiated a biological DMARD. At DXA re-scanning, the BMD at the lumbar spine and total hip remained largely unchanged, whilst at the femoral neck decreased from 0.726 g/cm2 to 0.713 g/cm2 (mean difference [SD] -0.013 [0.056], p=0.02). Predictors of BMD changes at different sites are shown in Table 1. The cumulative dose of prednisone was borderline significant for more BMD loss at the lumbar spine. Cumulative disease activity did not significantly affect BMD changes. Rather, ACPA-positive patients had higher percent changes at both the lumbar spine and the femoral neck. In multivariable analyses, ACPA remained associated with more BMD loss even when adjusting for confounders (age, gender, cumulative steroids, bisphosphonate treatment) (r -0.126, p=0.04 at the lumbar spine; r -0.126, p=0.04 at the femoral neck).

Conclusion:

Treatment of patients with early RA according to treat-to-target strategies prevents systemic bone loss. However, despite optimal disease control, ACPA positivity continues to be associated with progressive decline in systemic BMD.

References:

[1]Bugatti S et al. Arthritis Res Ther 2016;18:226.

Disclosure of Interests:

Laura Bogliolo: None declared, Francesca Motta: None declared, Paolo Del Vino: None declared, Carlomaurizio Montecucco: None declared, Serena Bugatti Speakers bureau: Bristol-Myers Squibb, Sanofi, Lilly, Novartis, Pfizer, Abbvie

Calcifying aponeurotic fibroma: a core biopsy-based diagnosis

Calcifying aponeurotic fibroma (CAF) is a very rare tumor of the extremities, which can be difficult to diagnose due to its wide cyto-architectural pattern. We herein report the clinicopathologic features of a case of CAF localized on the dorsal face of the foot in a 5-year-old male child, diagnosed by needle core biopsy. Differential diagnostic problems are discussed. The present case emphasizes that the diagnosis of CAF can be confidentially rendered on core needle biopsy if the main morphological components of this tumor are concurrently present; however, before making the diagnosis of CAF, the clinical and radiological context should be considered.

Perineurioma of the colon: an uncommon tumor with an unusual location. Report of a case and review of the literature

Perineurioma is a relatively rare benign peripheral nerve sheath tumor composed of cells resembling to normal perineurium. Although this tumor may arise in the context of a nerve (intraneural perineurioma), extraneural perineurioma does occur, frequently involving the soft tissues of the lower and upper extremities, trunk and head and neck. Rarely it has also been reported in visceral organs, including gastrointestinal tract. We herein describe the clinicopathologic features of a rare case of a perineurioma presenting as a polypoid lesion of the sigmoid colon, emphasizing the pathologic diagnostic clues.

Metastatic malignant melanoma to the gallbladder. Case report and review of the literature

Solitary metastasis of malignant melanoma (MM) to the gallbladder (GB) is rare and generally originates from skin melanoma. MM is a neoplasm with an often unpredictable course and metastases can potentially affecting all organs. The occurrence of metastasis in the GB is unusual and has only been exceptionally reported in the literature. We describe a case of an 86-year-old man with an isolated MM metastasis located within the GB presenting with symptoms mimicking acute cholecystitis. Anamnestically, he presented a history of malignant melanoma (Clark level III) resected from his left leg 17 years ago. Furthermore we provide a review of the literature with a focus on diagnostic clues to distinguish between primary versus secondary GB MMs and on the best surgical management that should be used.

Can HLA-DRB4 Help to Identify Asthmatic Patients at Risk of Churg-Strauss Syndrome?

HLA-DRB4 gene is associated with Churg-Strauss syndrome (CSS), a systemic eosinophilic vasculitis with a prodromal phase characterized by severe asthma, eosinophilia, nasal polyposis, and sinusitis. Aim of this study was to evaluate if the presence of HLA-DRB4 in asthmatic patients is associated with a clinical picture resembling that of the prodromal phase of CSS. HLA-DRB1 was determined in a cohort of 159 asthmatic patients and its frequency was compared with that of 1808 blood donors. HLA-DRB4 presence/absence was correlated with clinical features, including sinusitis, nasal polyposis, eosinophils, antiasthmatic drugs, asthma severity, and pulmonary function tests. HLA-DRB4 gene was associated with severe persistent asthma before treatment (P < 0.02), near fatal or severe hypoxemic asthma (P < 0.01), sinusitis (P < 0.01), nasal polyposis (P < 0.01), number of patients with eosinophils >1000/ μ l: (P < 0.05), need of beclomethasone >1000-2000  μ g/daily (P < 0.001), use of a third controller (P < 0.05), and oral prednisone (P < 0.02). HLA-DRB4 gene is associated in asthmatic patients with a clinical picture characterized by asthma severity, sinusitis, nasal polyposis, and eosinophilia closely resembling that of the prodromal phase of CSS and might be useful to suspect corticosteroids-masked cases of CSS.

Comparison of peptide nucleic acid fluorescence in situ hybridization assays with culture-based matrix-assisted laser desorption/ionization-time of flight mass spectrometry for the identification of bacteria and yeasts from blood cultures and cerebrospinal fluid cultures

Peptide nucleic acid fluorescence in situ hybridization (PNA FISH) is a molecular diagnostic tool for the rapid detection of pathogens directly from liquid media. The aim of this study was to prospectively evaluate PNA FISH assays in comparison with culture-based matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS) identification, as a reference method, for both blood and cerebrospinal fluid (CSF) cultures, during a 1-year investigation. On the basis of the Gram stain microscopy results, four different PNA FISH commercially available assays were used ('Staphylococcus aureus/CNS', 'Enterococcus faecalis/OE', 'GNR Traffic Light' and 'Yeasts Traffic Light' PNA FISH assays, AdvanDx). The four PNA FISH assays were applied to 956 positive blood cultures (921 for bacteria and 35 for yeasts) and 11 CSF cultures. Among the 921 blood samples positive for bacteria, PNA FISH gave concordant results with MALDI-TOF MS in 908/921 (98.64%) samples, showing an agreement of 99.4% in the case of monomicrobial infections. As regards yeasts, the PNA FISH assay showed a 100% agreement with the result obtained by MALDI-TOF MS. When PNA FISH assays were tested on the 11 CSF cultures, the results agreed with the reference method in all cases (100%). PNA FISH assays provided species identification at least one work-day before the MALDI-TOF MS culture-based identification. PNA FISH assays showed an excellent efficacy in the prompt identification of main pathogens, yielding a significant reduction in reporting time and leading to more appropriate patient management and therapy in cases of sepsis and severe infections.

Double uterus with obstructed hemivagina and ipsilateral renal agenesis: pelvic anatomic variants in 87 cases

STUDY QUESTION

What are the anatomic variants (and their frequencies) of double uterus, obstructed hemivagina and ipsilateral renal agenesis?

SUMMARY ANSWER

Most cases examined (72.4%) were of the classic anatomic variant of the Herlyn-Werner-Wunderlich syndrome (with didelphys uterus, obstructed hemivagina and ipsilateral renal agenesis) but the 27.6% of cases are of a rare variant of the syndrome (with uterus septum or cervical agenesis), showing relevant clinical and surgical implications.

WHAT IS KNOWN ALREADY

The extreme variability of anatomic structures involved in this syndrome (both uterus, cervico-vaginal and renal anomalies) is well known, even if a complete and uniform analysis of all its heterogeneous presentations in a large series is lacking.

STUDY DESIGN, SIZE, DURATION

This is a retrospective study with 87 patients referred to our third level referral center between 1981 and 2011.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We analyzed the laparoscopic and chart records of 87 women, who referred to our institute with double uterus, unilateral cervico-vaginal obstruction and ipsilateral renal anomalies.

MAIN RESULTS

Sixty-three of 87 patients had the more classic variant of didelphys uterus with obstructed hemivagina; 10/87 patients had septate bicollis uterus with obstructed hemivagina; 9/87 patients had bicornuate bicollis uterus with obstructed hemivagina; 4/87 patients had didelphys uterus with unilateral cervical atresia; 1/87 patients had bicornuate uterus with one septate cervix and unilateral obstructed hemivagina.

LIMITATIONS

This is a retrospective study with a long enrolling period (30 years).

WIDER IMPLICATIONS OF THE FINDINGS

New insights in the anatomic variants of this rare syndrome with their relevant surgical implications.

Abdominal volume contribution to tidal volume as an early indicator of respiratory impairment in Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is characterised by progressive loss of muscular strength that leads to an increasingly restrictive pulmonary syndrome. However, it is still not clear whether this determines alterations in the breathing pattern. We studied: 66 DMD patients at different stages of the disease (mean+/- sem age 12.6+/-0.6 yrs, range 5-22 yrs of age), subdivided into four groups according to age; and 21 age-matched healthy male controls. Spirometry, lung volumes and nocturnal oxygen saturation were measured in all DMD patients. Ventilatory pattern and chest wall volume variations were assessed by optoelectronic plethysmography during spontaneous breathing both in seated and supine positions. Whilst in a seated position, no significant differences were found between patients and controls or between different age groups. In the supine position, the average contribution of abdominal volume change (DeltaV(AB)) to tidal volume progressively decreased with age (p<0.001). The patients who showed nocturnal hypoxaemia showed significantly lower Delta V(AB). In conclusion, chest wall motion during spontaneous breathing in awake conditions and in supine position is an important indicator of the degree of respiratory muscle impairment in DMD. DeltaV(AB) is not only an important marker of the progression of the disease but is also an early indicator of nocturnal hypoxaemia.

Cost-effectiveness modeling of intrathecal baclofen therapy versus other interventions for disabling spasticity

OBJECTIVE

To assess by simulation the cost-effectiveness of intrathecal baclofen (ITB) therapy compared with conventional medical treatments for patients with disabling spasticity and functional dependence caused by any neurological disease.

METHODS

Two models were created to simulate therapeutic strategies for managing severe spasticity, one with and one without the use of ITB, to assess various treatment sequences over 2 years based on current medical practices in France. Successful treatment at each evaluation was defined as a combination of: (1) the increased patient and caregiver satisfaction as assessed by goal attainment scaling (GAS), and (2) a decrease of at least 1 point on the Ashworth score. Probabilistic sensitivity analyses were performed using 5000 Monte-Carlo simulations taking into account specific distribution curves for direct costs and effectiveness parameters in each treatment option.

RESULTS

The model simulations suggest that including ITB as a first option strategy in the management of function of severely impaired patients with disabling spasticity results in a higher success rate (78.7% vs 59.3%; P < .001). In addition, the ITB therapy model revealed a lower cost (pound 59,391 vs pound 88,272; P < .001) and an overall more favorable cost-effectiveness ratio (pound 75,204/success vs pound 148,822/success; P < .001), compared with conventional medical management without ITB.

CONCLUSION

Within the assumptions of our modeling, ITB therapy evaluated by a combination of treatment success criteria at 6-month intervals over a 2-year period may be a cost-effective strategy compared to conventional medical management alone.

Ultrasound-guided laser thermal ablation for parathyroid adenomas: analysis of three cases with a three-year follow-up

BACKGROUND

In patients with primary hyperparathyroidism (pHPT) the therapeutical choice is surgery. In patients with high surgical and anesthetic risks, ultrasound-guided laser ablation (LTA) of parathyroid adenoma has been reported to reduce parathyroid hormone (PTH) hypersecretion without relevant side effects. No data are available from patients followed for >6 months. We report our 3-year follow-up experience with LTA in 3 patients affected by pHPT due to a parathyroid tumor.

METHODS

LTA was performed under color-Doppler ultrasound guidance with a continuous pulse at 2 W (total treatment duration: 300 s in each session; total energy: 1,200 J in two sessions).

RESULTS

In the first patient who refused to undergo the second LTA session, calcium, PTH levels and parathyroid lesion volume showed a slight reduction, returning to baseline values in a month. In the second patient, no modification of parathyroid lesion was obtained even if calcium levels temporarily normalized. In the third patient, LTA led to normalization of calcium and PTH levels and to a 99% reduction of parathyroid volume.

CONCLUSION

After LTA procedures the long-term disease remission of pHPT is achievable in a minority of patients. Data from larger samples are needed to verify the usefulness of this procedure.

[A vaccination campaign for gypsy children in Rome]

Several studies conducted in Rome have shown low levels of vaccination coverage in gypsy communities. Thus a vaccination campaign targeting to 2400 gypsy children aged 0-13 years, present in 32 settlements in Rome, was conducted in 2002. The campaign was related to vaccinations required and recommended in Italy: diphtheria, tetanus, hepatitis B, pertussis (whooping cough), haemophilus influenzae and measles. In the majority of cases it was decided to carry out the vaccinations directly in the gypsy settlements, in accordance with the methods of pulse immunisation. In the case of small settlements a strategy for reorienting the population to vaccination centres was adopted. Around 2000 children were vaccinated, equivalent to 80% of the paediatric population present during the period. The number of children who have never been vaccinated has decreased from 40% prior to the campaign to 9% after the third week. Vaccination coverage in medium- and small-sized settlements (<200 inhabitants) after the campaign shows values of over 70%; in the large settlements, more modest increases have been recorded and coverage has rarely exceeded 50%. This experience has highlighted the importance of networking between public healthcare institutions and non-profit organisations. The mobilisation of a wide range of competences has thus enabled the attainment of a high level of effectiveness.

Use of the normalcy index for the evaluation of gait pathology

The normalcy index (NI) has been proposed as a method for quantifying the amount of deviation in a subject's gait, compared to the gait of the average unimpaired person. The NI was computed for a sample of 144 children affected by cerebral palsy, five idiopathic toe-walkers and 12 able-bodied subjects. It was sensitive enough to distinguish unimpaired subjects from idiopathic toe-walkers and to distinguish between the plegic and uninvolved limbs of hemiplegic patients. The NI was robust enough to categorize pathology, ranging from mild disorders to quadriplegia. The NI was found to be clinically applicable, reliable and easy to use, making it a valuable element in the quantitative evaluation of gait pathology.

Human cytomegalovirus proteins PP65 and IEP72 are targeted to distinct compartments in nuclei and nuclear matrices of infected human embryo fibroblasts

The cellular distribution of the human cytomegalovirus (HCMV)-specific UL83 phosphoprotein (pp65) and UL123 immediate-early protein (IEp72) in lytically infected human embryo fibroblasts was studied by means of indirect immunofluorescence and confocal microscopy. Both proteins were found to have a nuclear localization, but they were concentrated in different compartments within the nuclei. The pp65 was located predominantly in the nucleoli; this was already evident with the parental viral protein, which was targeted to the above nuclear compartment very soon after infection. The nucleolar localization of pp65 was also observed at later stages of the HCMV infectious cycle. After chromatin extraction (in the so-called in situ nuclear matrices), a significant portion of the pp65 remained associated with nucleoli within the first hour after infection, then gradually redistributed in a perinucleolar area, as well as throughout the nucleus, with a granular pattern. A quite different distribution was observed for IEp72 at very early stages after infection of human embryo fibroblasts with HCMV; indeed, this viral protein was found in bright foci, clearly observable in both non-extracted nuclei and in nuclear matrices. At later stages of infection, IEp72 became almost homogeneously distributed within the whole nucleus, while the foci increased in size and were more evenly spread; in several infected cells some of them lay within nucleoli. This peculiar nuclear distribution of IEp72 was preserved in nuclear matrices as well. The entire set of data is discussed in terms of the necessity of integration for HCMV-specific products into the pre-existing nuclear architecture, with the possibility of subsequent adaptation of nuclear compartments to fit the needs of the HCMV replicative cycle.

An immunogenetic map of Lombardy (Northern Italy)

For this study we consulted the Bone Marrow Donors' Registry of Lombardy (Italy) and analyzed 43937 HLA-A,B phenotypes and 13922 HLA-A,B,DR phenotypes. We estimated the HLA-A,B and HLA-A,B,DR haplotype frequencies via the maximum-likelihood method. We analyzed the genetic structure of the 11 provinces of Lombardy by means of Principal Component Analysis and Correspondence Analysis, and estimated the variety of the different haplotypes at provincial level and the percentage of unique phenotypes at village level. We found 11189 different HLA-A,B phenotypes, 661 different HLA-A,B haplotypes and more than 4000 different HLA-A,B,DR haplotypes. We identified 20 villages, in Western Lombardy, very rich in unique/rare phenotypes. Here we report a formula which allows the identification of a putative donor matched for two haplotypes with a recipient. This result may be of great importance for the genetic study of the population of Lombardy and, even more, for bone marrow transplantation programs.

Short-term effects of "botulinum toxin a" as treatment for children with cerebral palsy: kinematic and kinetic aspects at the ankle joint

Botulinum toxin A (BTA) therapy plays several roles in the management of paediatric cerebral palsy (CP). However, few studies contain objective documentation of gait changes. The main aim of this study was to provide objective information on the outcome of the treatment. Gait analysis data from 20 normal subjects and 23 CP children were collected before and after BTA injections into the gastrocnemius-soleus complex. The follow up was performed 1 month after the first injection. The kinematic and kinetic data revealed significant improvements in dynamic ankle dorsiflexion, both in stance and in the swing phase, an improvement of equinus foot upon initial contact and better support in stance. The results of this study are promising, but studies of other joints involved in gait, such as the knee, are also needed.

Energy consumption and gait analysis in children with myelomeningocele

The aim of this study was to determine, in children with different levels of myelomeningocele (MMC), the gait pattern and energy cost of walking with and without ankle-foot orthoses (AFOs). We found that each MMC level was characterised by recognisable gait patterns and that the abnormalities closely reflected the muscle deficits present. Furthermore, the study also introduces new indices for evaluating the energy cost of locomotion and demonstrates that the energy required for walking is increased in children with MMC compared with non disabled children. With respect to barefoot conditions, the use of AFOs leads to an improvement in gait and reduced energy consumption.

Recommendations for the use of botulinum toxin type A in the management of cerebral palsy

Botulinum toxin type A (BTX-A) is increasingly being used for the treatment of childhood spasticity, particularly cerebral palsy. However, until very recently, all such use in this indication has been unapproved with no generally accepted treatment protocols, resulting in considerable uncertainty and variation in its use as a therapeutic agent. In view of the increasing awareness of, and interest in, this approach to the treatment of spasticity, and also the recent licensing in a number of countries of a BTX-A preparation for treating equinus deformity in children, it would seem timely to establish a framework of guidelines for the safe and efficacious use of BTX-A for treating spasticity in children. This paper represents an attempt, by a group of 15 experienced clinicians and scientists from a variety of disciplines, to arrive at a consensus and produce detailed recommendations as to appropriate patient selection and assessment, dosage, injection technique and outcome measurement. The importance of adjunctive physiotherapy, orthoses and casting is also stressed.

Kinematic and dynamic analysis of the ankle joint in children with cerebral palsy

The assessment of walking in children affected by cerebral palsy (CP) is currently based principally on qualitative assessment criteria. Gait analysis, meanwhile, evaluates quantitatively kinematic and dynamic aspects of locomotion. The main aim of this study was to examine (using an optoelectronic system and a force platform) kinematic and dynamic aspects of the ankle joint in hemiplegic and in diplegic children (9 and 11 subjects respectively) and in 10 normal control subjects. Our results reveal, in spastic subjects, "equinus" placement of the foot in the initial contact phase, a lack of dorsiflexion (negative DF peak) in the stance phase and a reduction in push-off capacity (capacity to move the leg forward) in the swing phase. The results furnished by this study represent a useful contribution to the assessment of the walking ability of children affected by CP and to the evaluation of the indications and advantages of the rehabilitative intervention chosen.

[Radiologic assessment in lung volume reduction surgery in emphysema]

Aim of this work is to present and discuss the radiologic protocol we have developed for the preoperative assessment of patients with severe pulmonary emphysema candidate to lung volume reduction surgery (LVRS). The operation aims at improving respiratory mechanics and reducing small airway obstruction by removing variable amounts of emphysematous parenchyma. January to September, 1996, twelve patients were submitted to LVRS. Before surgery all patients were examined with standard chest radiographs during maximal inspiration and expiration, chest Computed Tomography (CT), High Resolution Computed Tomography (HRCT) and air trapping quantitation on HRCT scans. Diaphragm and chest wall excursions, patterns, site and distribution of emphysema, as well as heterogeneity (i.e., the uneven distribution of emphysematous and normal parenchyma) were investigated. Air trapping was quantitated with a dedicated software. Postoperative studies were carried out 2 months later in six patients and included: maximal inspiratory and expiratory chest radiographs and air trapping assessment on 3 standardized HRCT scans. All parameters considered improved in every patient. Radiologic studies proved to be of crucial importance for patient selection and LVRS planning. Despite our limited number of patients, the diagnostic protocol adopted in our Hospital appears a valuable tool for both pre- and post-operative assessment of the patients candidate to LVRS.

Venous aneurysm of extremities: a case report and literature review

A case of venous aneurysm of the short saphenous vein is described in a young woman. The aetiology, diagnosis and treatment of this rare anomaly is reviewed.

[Preoperative role of computerized tomography in videothoracoscopic lung surgery]

Video-assisted thoracic surgery (VATS) is used in a growing range of pulmonary and mediastinal conditions. By avoiding thoracotomy, VATS is minimally invasive and allows shorter postoperative hospitalization. The advantages of video-assisted thoracoscopic techniques are obvious in the patients with severe cardiorespiratory failure. We investigated the role of CT before VATS. From September, 1991, to January, 1994, two hundred and eight patients were submitted to VATS: 80 pleurectomies, 63 lobectomies, 42 wedge resections, 11 bullectomies, 8 biopsies and 4 pneumonectomies were performed in patients with diffuse lung disease. All patients underwent conventional CT and an additional HRCT was performed in 164 patients. Bullae site, number, characteristics and size must be assessed. The possible relationship of bullae to impaired respiratory function must be studied. When nodules are present, their site, depth and relationship to fissures must be defined. With small and deep-seated nodules a thin snap-open mandrel device should be used for intraoperative detection. When lobectomies are contemplated, fissures must be accurately studied to assess their integrity and whether they completely separate the lobes. Fibrous adhesions can prevent pulmonary collapse; unfortunately, some of them cannot be detected by CT. Another limitation is the difficulty in assessing whether fissures are incomplete. To conclude, CT integrated with HRCT provides useful information for correct video-assisted thoracic surgical management.

Diagnosi e trattamento della patologia ascessuale dello psoas: Diagnosis and treatment of the psoas abscess

Abscessual pathology of the psoas muscle is very infrequent: however it must be considered in the differential diagnosis during ultrasound examination involving the retroperitoneum. This work describes 2 cases of abscessual pathology of the psoas muscle, clinically unsuspected but diagnosed by ultrasound. In both cases drainage of the abscess was executed by means of ultrasound and computerized tomography guide.