THE EFFECT OF NUTRITIONAL GENOMICS ON CARDIOVASCULAR SYSTEM

The idea that obesity and cardiovascular diseases together are considered for a sizable share of adult global morbidity and mortality is supported by epidemiological data. They have intricate systems in which environmental and genetic variables interact, including nutrition. As an environmental component, nutrition has a major and well-known role in managing health and preventing obesity and disorders connected to obesity, such as cardiovascular disease (CVD). Nonetheless, people with the same food pattern but obese exhibit a notable difference in CVD. This variance might be explained by the various genetic polymorphisms which gave rise to the field of nutrigenetics. The discipline known as nutritional genomics, or nutrigenetics, examines and describes gene variants linked to varying reactions to particular nutrients and links these variations to various disorders, including obesity-related cardiovascular disease (CVD). Therefore, tailored nutrition advice depending on a person's genetic background could enhance the results of a particular dietary intervention and offer a novel dietary technique to enhance health by lowering obesity and cardiovascular disease. With these suppositions, it seems reasonable to assume that understanding food and gene interactions will provide more targeted and efficacious dietary treatments in preventing obesity and CVD by nutrigenetics-based personalized nutrition. In addition to elucidating the connection between diet and gene expression and the major nutrition-related genes involved in obesity and CVD, this research seeks to provide a concise summary of the greater significant genes linked to obesity and CVD.

Opportunities and challenges of lupus care in Latin America, the Middle East, and Asia-Pacific: A call to action

Lupus remains a disease with a low prioritisation in the national agendas of many countries in Latin America, the Middle East, and Asia-Pacific, where there is a dearth of rheumatologists and limited access to new or even standard lupus treatments. There is thus an important need for education, advocacy, and outreach to prioritise lupus in these regions to ensure that patients receive the care they need. This article reviews some of the specific challenges facing the care and management of people with lupus in these regions and suggests strategies for improving patient outcomes. Specifically, we review and discuss (with a focus on the aforementioned regions) the epidemiology of lupus; economic costs, disease burden, and effects on quality of life; barriers to care related to disease assessment; barriers to effective treatment, including limitations of standard treatments, high glucocorticoid use, inadequate access to new treatments, and low adherence to medications; and strategies to improve lupus management and patient outcomes. We hope that this represents a call to action to come together and act now for the lupus community, policymakers, health authorities, and healthcare professionals to improve lupus management and patient outcomes in Latin America, the Middle East, and Asia-Pacific.

Infant feeding practice and gastrointestinal tolerance: a real-world, multi-country, cross-sectional observational study

BACKGROUND

Signs of feeding intolerance, such as gastrointestinal (GI) symptoms, are frequently observed in otherwise healthy formula-fed infants in the first months of life. The primary objective of this observational study was to examine GI tolerance in formula-fed infants (FFI) vs. breastfed infants (BFI) in a real-world setting with a secondary objective being the comparison of infants fed formula with pre- and/or probiotics (FFI_PP) and those fed formula without any pre- and/or probiotics (FFI_noPP) as well as BFI.

METHODS

A six-country, cross-sectional study in full-term exclusively/predominantly FFI (n = 2036) and BFI (n = 760) aged 6-16 weeks was conducted using the validated Infant Gastrointestinal Symptom Questionnaire (IGSQ) and a Feeding Practice and Gut Comfort Questionnaire.

RESULTS

The IGSQ composite score in FFI was non-inferior compared to BFI (mean difference [95%CI]: 0.17 [-0.34, 0.67]; non-inferiority p-value < 0.0001) and scores for BFI and FFI were below the threshold of 23, indicating no GI discomfort. Adjusted mean IGSQ scores ± SE were similar in FFI_PP (22.1 ± 0.2) and BFI (22.3 ± 0.3) while FFI_noPP (23.4 ± 0.3) was significantly higher and above 23 indicating some GI discomfort (mean differences [95%CI] FFI_noPP minus FFI_PP and FFI_noPP minus BFI were 1.28 [0.57, 1.98] and 1.09 [0.38, 1.80], respectively; both p < 0.01). Hard stools and difficulty in passing stool were more common in FFI compared to BFI (p < 0.01) but were less common in FFI_PP compared to FFI_noPP (p < 0.01). FFI_PP showed significantly less crying than FFI_noPP and was similar to BFI. Significantly fewer physician-confirmed colic episodes (Rome IV criteria) were reported in FFI_PP compared with FFI_noPP or BFI.

CONCLUSIONS

In this real-world observational study, FFI had non-inferior overall GI tolerance compared to BFI. Within FFI, infants receiving formulas with pre- and/or probiotics had a better GI tolerance, improved stooling and less infantile colic compared to those receiving formula without any pre- and/or probiotics and were more similar to BFI.

TRIAL REGISTRATION

NCT03703583, 12/10/2018 ( https://clinicaltrials.gov/ct2/show/NCT03703583 ).

Response of Canola productivity to integration between mineral nitrogen with yeast extract under poor fertility sandy soil condition

Canola is one of the important oil crops and is considered the most promising oil source and adapts to reclaimed soil conditions. The current study aimed to evaluate the influence of yeast extract (YE) integrated with nitrogen (N) rates and treatments were arranged as follows: Control (without F0), 95 kg N ha^-1 (F1), 120 kg N ha^-1 (F2), 142 kg N ha^-1 (F3), 95 kg N ha^-1 + YE (F4), 120 kg N ha^-1 + YE (F5) and 142 kg N ha^-1 + YE (F6) on physico-chemical properties, yield and its components for three Canola genotypes i.e. AD201 (G1), Topaz and SemuDNK 234/84 under the sandy soil. In this work, Results reveal that increasing rates of Nitrogen fertilization from 95 kg N ha^-1 to 142 kg N ha^-1 have a great effect on physicochemical properties yield and its components. The result proved that 142 kg N ha^-1 with yeast treatment was the best treatment for three Canola genotypes. Also, the result showed that seed yield was positively correlated with Chl. a/b ratio, plant height, number of branches/plant, number of pods/plant, and number of seeds/pod, and a strong negative correlation was detected between seed oil percentage when the amount of nitrogen fertilization applied without or with yeast extract is increased.

Local immune response as novel disease mechanism underlying abdominal pain in patients with irritable bowel syndrome

OBJECTIVES

Irritable bowel syndrome (IBS) is the most frequently diagnosed functional gastrointestinal disorder, with a prevalence of up to 25% of the global population. IBS patients suffer from abnormal abdominal pain, or visceral hypersensitivity (VHS), associated with altered bowel habits in the absence of an organic detectable cause. The pathophysiology of the disease is incompletely understood, but the dysregulation of the brain-gut axis is well established in IBS.

METHODS

IBS onset is mainly triggered by infectious gastroenteritis, psychological factors, and dietary factors, but genetic predispositions and intestinal dysbiosis might also play a role. Additionally, immune activation, and particularly chronic mast cell activation, have been shown to underlie the development of abdominal pain in IBS.

RESULTS

By releasing increased levels of mediators, including histamine, mast cells sensitize enteric nociceptors and lead to VHS development. The mechanisms underlying aberrant mast cell activation in IBS are still under investigation, but we recently showed that a local break in oral tolerance to food antigens led to IgE-mediated mast cell activation and food-induced abdominal pain in preclinical models and in IBS patients.

CONCLUSION

The concept of food-mediated VHS highlights the potential of therapies targeting upstream mechanisms of mast cell sensitization to treat IBS.

Real world radiation exposure in left atrial appendage occlusion device implantation performed in a high volume center

 

Left atrial appendage occlusion (LAAO) is an established and effective treatment to reduce the risk of thromboembolic stroke derived from the LAA in patient with non valvular atrial fibrillation. Per-cutaneous closure of the LAA is typically guided by fluoroscopic and echocardiographic guidance.

The purpose of our study is to ascertain real world radiation exposure during the LAAO performed in our institution and the interplay of different variables and patient characteristics.

Our study retrospectively analyzed all consecutive LAAO procedures performed at our Tertiary level Teaching Hospital. Data was collected using Hospital electronic records and cardiac catherization laboratory records.

A total of 261 patients who underwent LAAO were identified, 28% were female. Average age at the time of procedure was 77 years (range 54–93 years). Mean fluoroscopy time was 10.2 minutes (±7.0), average Radiation dose was 67 gy/cm2 (±73). Interestingly, gy/cm2 per minute of fluoroscopy averaged at 6.69 (±5.0).

Subgroup analysis focused on the effect of Body mass index (BMI) on radiation dose. Since the recent introduction of a partial electronic health record system, BMI data was only available on 161 patients. The cohort with BMI &lt;30 had a mean radiation dose of 57±62 gy/cm2, whereas for BMI &gt;30 mean dose was 96.8±68, p=0.0025 (95% CI (65 to 14)).

Analysis by the four different device types (Watchman, Watchman Flx, Wavecrest and ACP) were used for LAAO, with highest number been watchman (n=189). Upon comparing the radiation exposure in our study cohort watchman device had the least Dose adjusted Product (DAP) at 62gy/cm2 but the newer watchman flx (n=25) had slightly lower gy/cm2 per minute of fluoroscopy time 6.58±3.41 versus 6.83±5.56.

In addition, operator volume between our two implanters was assessed. Our highest volume operator implanted the majority of devices (n=235) whilst the Watchman Flx was predominantly implanted by our newer implanter (n=26). Despite the relatively modest numbers of the Watchman Flx, there was minimal difference in exposure time in favor of the more senior interventionist.

In conclusion, LAAO in our center has encouraging radiation safety data, which is comparable to previously published data in internationally recognized high volume centers. Normal BMI patients had the least radiation exposure, with the dose increasing with rising BMI.

Funding Acknowledgement

Type of funding sources: None. Bar Graph, radiation dose vs BMIScatter Plot, radiation dose vs BMI

772 Surgery for Bullous Lung Disease

Aim

The aim of this study to assess the surgical presentation and outcome for bullous lung disease in Sudanese patients.

Method

A cross sectional hospital based descriptive retrospective study. Procedures were conducted at Al-Shaab Teaching Hospital Sudan during the period from November 2009 to September 2012.

Results

11 patients had lung bullae in the given period. Smoking does not play an important role in the development of bullae in healthy young adults in our patients. Vanishing Lung syndrome (VLS) was seen in 18% of patients without history of smoking. The patients presenting in the fifth decade of life constituted (36.3%) of total number. symptoms of presentation were chest pain and SOB and half of them (45.5%) had exertional dyspnoea. The duration of symptoms before presentation was more than 2 months. Asthma was the only respiratory disease associated seen in 45%. HBV and HTN were the most associated diseases seen in 27% and 18% respectively without significant findings in the history. The diagnosis was made by highresolution CT. Chest in all patients. Bullectomy was done to majority of patients. Muscle sparing thoracotomy is the standard approach (Posterolateral Thoracotomy). improved regarding symptoms and signs (90.9%) and) and no death reported.

Conclusions

Bullous lung disease with bilateral lung involvement is common in our patients. However, there was no association between lung bullae and smoking in our population. lt's associated with other respiratory disease. The outcome was excellent, and no death was reported. To prevent the miss diagnosis we need sensitive and noninvasive investigation tools.

OP0096 EXPOSURE TO DENGUE INFECTION DO NOT RAISE RISK OF RHEUMATOID ARTHRITIS: FINDINGS FROM THE MALAYSIAN EPIDEMIOLOGICAL INVESTIGATION OF RHEUMATOID ARTHRITIS (MYEIRA) CASE-CONTROL STUDY

Background:

Dengue infection is associated with joints pain mimicking disease onset symptom of rheumatoid arthritis (RA). However, there is lack of epidemiological studies on exposure to dengue infection and risk of future RA.

Objectives:

We investigated the relationship between exposure to dengue infection and risk of developing different subsets of RA, defined by the presence of anti-citrullinated peptide antibody (ACPA) in the multi-ethnic Malaysian population.

Methods:

Serum samples from 1,235 RA cases (i.e. 516 Malay, 254 Chinese, 405 Indians and 60 others/mixed-ethnicity) and 1,624 epidemiological matched population-based controls (i.e. 1,023 Malay, 208 Chinese, 297 Indians and 96 others/mixed-ethnicity) were assayed for presence of dengue IgG antibody using World Health Organization recommended ELISA kits. Positive results of dengue IgG antibodies indicates previous exposure to dengue infection(s). We performed chi-square and Mann-Whitney U analysis to determine the association of ever-exposed dengue infection with ACPA-positive/ACPA-negative RA and to investigate the antibody frequency and levels among the studied populations.

Results:

We observed high occurrence of dengue IgG antibody in the overall RA cases (79.7%) and matched controls (77.3%), with no significant differences detected between the ACPA subsets of RA. Ethnicity stratification analysis revealed a decrease risk of developing ACPA-positive RA in the Indian patients with positive dengue IgG antibody (OR=0.59, 95% CI=0.37-0.94, p=0.03), and in particular patients with elevated level of dengue IgG antibody (OR=0.44, 95% CI=0.25-0.78, p<0.05). On the other hand, the significant decrease mean levels of dengue IgG antibody were observed in the ACPA-positive RA subset for all three major ethnic groups (i.e. Malay, p<0.0001, Chinese, p<0.01 and Indian<0.05) (Figure 1). No association was observed between presence of dengue IgG antibody and ACPA-negative RA subset.

Figure 1.

Comparison of mean dengue IgG antibody level between ever-exposed dengue infection RA cases, stratified by ACPA status. Comparison of median dengue IgG antibody level between the ever-exposed dengue infection ACPA-positive RA and normal controls in the four ethnic groups. The red line indicates the mean level of dengue IgG antibody level

Conclusion:

Our findings demonstrated that exposure to dengue infection do not increase the risk of developing future RA in the multi-ethnic Malaysian population. The inverse associations observed in the Indian ethnic group are in line with the other studies investigating exposure to viral infection and risk of RA.

References:

[1]Sherina et al (2017) Low levels of antibodies against common viruses associate with anti-citrullinated protein antibody-positive rheumatoid arthritis; implications for disease aetiology. Arthritis Research & Therapy 2017, 19:2169

[2]Gissel García et. al. (2011) Long-term persistence of clinical symptoms in dengue-infected persons and its association with immunological disorders. International Journal of Infectious Diseases 15 (2011) e38–e43

Acknowledgements:

The authors would like to thank the Director General of Health, Ministry of Health Malaysia for supporting this study. The authors are also indebted to participants for their kind participation. This study was financially supported by the Ministry of Health, Malaysia (JPP-IMR 17-025) and the short-term research grant by UniKL RCMP (str16037).

Disclosure of Interests:

None declared

PADI4 (rs2240340), PDCD1 (rs10204525), and CTLA4 (231775) gene polymorphisms and polyarticular juvenile idiopathic arthritis

BACKGROUND

Certain single nucleotide polymorphisms (SNPs) in genes such as PADI4 (coding for peptidyl arginine deiminase 4), PDCD1 (coding for programmed cell death 1), and CTLA4 (coding for cytotoxic T-lymphocyte-associated protein 4) are linked to rheumatoid arthritis (RA). However, links between SNPs rs2240340, rs10204525 and rs231775 in PADI4, PDCD1 and CTLA4 respectively, and juvenile idiopathic arthritis (JIA), the commonest type of childhood arthritis, are unclear. We aimed to determine whether any of these SNPs are associated with JIA, and to clinical indices disease activity score (JADAS 71) and functional disability score (CHAQ).

METHODS

We genotyped the three SNPs in 150 children with polyarticular JIA and 160 healthy children, recording standard health questionnaires, clinical features and laboratory markers.

RESULTS

The TT genotype of PADI4 rs2240340 (aOR/95%CI 2.64: 1.31-5.30, P = 0.006) and CT genotype of PDCD1 rs10204525 (aOR/95%CI 4.99: 2.98-8.36, P < 0.0001) were associated with JIA. The AG+GG genotype of CTLA4 rs231175 was modestly linked to disease activity (aOR/95%CI 2.44 (1.19-5.04), p = 0.015). PADI4 rs2240340 was linked to CHAQ score (genotypes p = 0.013, alleles p = 0.006), whilst PDCD1 rs10204525 was linked to anti-CCP antibodies (genotypes p = 0.004), RF (genotypes p = 0.01), and the CHAQ score (genotypes p = 0.005, alleles p = 0.013).

CONCLUSIONS

There are various roles for these SNPs in PADI4, CTLA4 and PDCD1 in the diagnosis and, potentially, in the management of JIA.

A260 THE LACK OF CHROMOGRANIN-A MODIFIES THE GUT MICROBIOTA COMPOSITION AND REGULATES EXPERIMENTAL COLONIC INFLAMMATION

Background

Ulcerative colitis (UC)is characterized by distinct changes in the gut microbiome and elevated chromogranin-A (CHGA) level, which seem to be a relevant pathogenetic mechanism.CHGA, a prohormone produced by enterochromaffin (EC) cells and cleaved into several bioactive peptides, regulates experimental colonic inflammation. In the rodent, intra-rectal infusion of catestatin, a Chga-derived peptide, alters the distal colonic microbial composition. However, the interplay between CHGA, as a pro-hormone, and the gut microbiome remains elusive.

Aims

in homoeostatic and pathophysiologic conditions, we investigated the functional consequences of the lack of Chgaon the distal colonic microbiota.

Methods

Acute colitis (5 % dextran sulfate sodium [DSS], 5 days) was induced in Chga-C57BL/6-deficient (Chga-/-) and wild-type (Chga+/+)mice. Feces and mucosa-associated microbiota (MAM) samples were collected and the V4 region of 16s rRNA was subjected to Miseq Illumina sequencing. Alpha diversity was calculated using Shannon’s diversity index. OTU abundances were summarized using the Bray-Curtis index and non-metric multidimensional scaling (NMDS) analysis to visualize microbiome similarities and a permutational analysis of variance (PERMANOVA) to test the significance of groups were performed respectively.

Results

In non-colitic homoeostatic condition, the absence of Chga (Chga-/) significantly increased the bacterial richness and modified the bacterial community composition at the genera level between the groups, represented by increased abundance of Lactobacillus species and reduced abundance of Helicobacter& Oscillospira species compared to Chga+/+mice in fecal and colonic MAM. Moreover, the absence of Chga (Chga-/-) resulted in a significant change in the alpha-diversity of fecal and colonic MAM compared to Chga+/+mice. DSS induced-colitis resulted in a significant microbial dysbiosis in Chga+/+mice, however, deletion of Chgaprotected against DSS-induced colitis and reduced the microbial dysbiosis, reduced the family of Rikenellaceaeand maintained the abundance of Bacteroides species, compared to wild-type (Chga+/+).

Conclusions

The lack of CHGA regulates the biodiversity and the composition of the colonic gut microbiota suggesting a cross-talk between the EC cell and the microbiome. Therefore, targeting CHGA could provide a novel therapeutic strategy by regulating the gut microbiome in physiological and pathophysiological conditions.

Funding Agencies

CIHR

The use of equine chondrogenic-induced mesenchymal stem cells as a treatment for osteoarthritis: A randomised, double-blinded, placebo-controlled proof-of-concept study

BACKGROUND

There is a need to improve therapies for osteoarthritis in horses.

OBJECTIVES

To assess the efficacy of equine allogeneic chondrogenic-induced mesenchymal stem cells combined with equine allogeneic plasma as a novel therapy for osteoarthritis in horses.

STUDY DESIGN

Randomised, double-blinded, placebo-controlled experiment.

METHODS

In 12 healthy horses, osteoarthritis was induced in the metacarpophalangeal joint using an osteochondral fragment-groove model. Five weeks after surgery, horses were randomly assigned to either an intra-articular injection with chondrogenic-induced mesenchymal stem cells + equine allogeneic plasma (= intervention) or with 0.9% saline solution (= control). From surgery until the study end, horses underwent a weekly joint and lameness assessment. Synovial fluid was collected for cytology and biomarker analysis before surgery and at Weeks 5, 5 + 1d, 7, 9 and 11. At Week 11, horses were subjected to euthanasia, and the metacarpophalangeal joints were evaluated macroscopically and histologically.

RESULTS

No serious adverse events or suspected adverse drug reactions occurred during the study. A significant improvement in visual and objective lameness was seen with the intervention compared with the control. Synovial fluid displayed a significantly higher viscosity and a significantly lower glycosaminoglycan concentration in the intervention group. Other biomarkers or cytology parameters were not significantly different between the treatment groups. Significantly less wear lines and synovial hyperaemia were present in the intervention group. The amount of cartilage oligomeric matrix protein, collagen type II and glycosaminoglycans were significantly higher in the articular cartilage of the intervention group.

MAIN LIMITATIONS

This study assessed the short-term effect of the intervention on a limited number of horses, using an osteoarthritis model. This study also included multiple statistical tests, increasing the risk of type 1 error.

CONCLUSIONS

Equine allogeneic chondrogenic-induced mesenchymal stem cells combined with equine allogeneic plasma may be a promising treatment for osteoarthritis in horses. The Summary is available in Spanish - see Supporting Information.

Cardiovascular efficacy and safety of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists: a systematic review and network meta-analysis

AIMS

To compare the cardiovascular efficacy and safety of sodium-glucose co-transporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RAs) in adults with Type 2 diabetes.

METHODS

Electronic databases were searched from inception to 22 October 2018 for randomized controlled trials designed to assess the cardiovascular efficacy of SGLT2 inhibitors or GLP-1RAs with regard to a three-point composite measure of major adverse cardiovascular events (non-fatal stroke, non-fatal myocardial infarction and cardiovascular mortality). Cardiovascular and safety data were synthesized using Bayesian network meta-analyses.

RESULTS

Eight trials, including 60 082 participants, were deemed eligible for the network meta-analysis. Both SGLT2 inhibitors [hazard ratio 0.86 (95% credible interval 0.74, 1.01]) and GLP-1RAs [hazard ratio 0.88 (95% credible interval 0.78, 0.98)] reduced the three-point composite measure compared to placebo, with no evidence of differences between them [GLP-1RAs vs SGLT2 inhibitors: hazard ratio 1.02 (95% credible interval 0.83, 1.23)]. SGLT2 inhibitors reduced risk of hospital admission for heart failure compared to placebo [hazard ratio 0.67 (95% credible interval 0.53, 0.85)] and GLP-1RAs [hazard ratio 0.71 (95% credible interval 0.53, 0.93)]. No differences were found between the two drug classes in non-fatal stroke, non-fatal myocardial infarction, cardiovascular mortality, all-cause mortality or safety outcomes.

CONCLUSIONS

SGLT2 inhibitors and GLP-1RAs reduced the three-point major adverse cardiovascular event risk compared to placebo, with no differences between them. Compared with GLP-1RAs and placebo, SGLT2 inhibitors led to a larger reduction in hospital admission for heart failure risk.

Sera of patients with systemic lupus erythematosus cross-neutralizes dengue viruses

Dengue is the most prevalent mosquito-borne disease in Southeast Asia, where the incidence of systemic lupus erythematosus (SLE) is approximately 30 to 53 per 100,000. Severe dengue, however, is rarely reported among individuals with SLE. Here, whether sera of patients with SLE cross-neutralize dengue virus (DENV) was investigated. Serum samples were obtained from individuals with SLE who were dengue IgG and IgM serology negative. Neutralization assays were performed against the three major DENV serotypes. Of the dengue serology negative sera of individuals with SLE, 60%, 61% and 52% of the sera at 1/320 dilution showed more than 50% inhibition against dengue type-1 virus (DENV-1), DENV-2 and DENV-3, respectively. The neutralizing capacity of the sera was significantly greater against DENV-1 (P < 0.001) and DENV-3 (P < 0.01) than against DENV-2 (P < 0.05). Neutralization against the DENV correlated with dengue-specific IgG serum titers below the cut-off point for dengue positivity. Depletion of total IgG from the sera of patients with SLE resulted in significant decreases of up to 80% in DENV inhibition, suggesting that IgG plays an important role. However, some of the SLE sera was still able to neutralize DENV, even with IgG titers <0.1 OD absorbance. Our findings suggest that sera of patients with SLE contain IgG, and possibly other type of antibodies, that can cross-neutralize DENV, which may explain the rarity of severe dengue in individuals with SLE. Further studies, are needed to further substantiate this finding and to elucidate the specific neutralizing epitopes recognized by the sera of individuals with SLE.

Clinical and economic implications of upper gastrointestinal adverse events in Asian rheumatological patients on long-term non-steroidal anti-inflammatory drugs

AIM

To determine the incidence and direct costs of NSAID-induced upper GI adverse events in Malaysian rheumatology patients.

METHODS

A retrospective, multi-centre, cohort study of rheumatology patients on long-term NSAIDs was conducted. Clinical data of patients treated between 2010 and 2013 were collected for a 24-month follow-up period. The costs of managing upper GI adverse events were based on patient level resource use data.

RESULTS

Six hundred and thirty-four patients met the inclusion criteria: mean age 53.4 years, 89.9% female, diagnosis of rheumatoid arthritis (RA; 59.3%), osteoarthritis (OA; 10.3%) and both RA and OA (30.3%). Three hundred and seventy-one (58.5%) patients were prescribed non-selective NSAIDs and 263 (41.5%) had cyclo-oxygenase-2 inhibitors. Eighty-four upper GI adverse events occurred, translating into a risk of 13.2% and an incidence rate of 66.2 per 1000 person-years. GI adverse events comprised: dyspepsia n = 78 (12.3%), peptic ulcer disease (PUD) n = 5 (0.79%) and upper GI bleeding (UGIB) n = 1 (0.16%). The total direct healthcare cost of managing adverse events was Malaysian Ringgit (MR) 37 352 (US dollars [USD] 11 419) with a mean cost of MR 446.81 ± 534.56 (USD 136.60 ± 163.42) per patient, consisting mainly of GI pharmacotherapy (33.8%), oesophagoduodenoscopies (23.1%) and outpatient clinic visits (18.2%). Mean cost per patient by GI events were: dyspepsia, MR 408.98 ± 513.29 (USD125.03 ± 156.92); PUD, MR 805.93 ± 578.80 (USD 246.39 ± 176.95); UGIB, MR 1601.94 (USD 489.74, n = 1).

CONCLUSION

The economic burden of GI adverse events due to long-term NSAIDs use in Malaysian patients with chronic rheumatic diseases is modest.

A Measurement Protocol for the Marginal and Internal Fit of All-Ceramic Crowns

AIMS

To evaluate in vitro the influence of firing on marginal and internal fit of all-ceramic milled and pressed lithium-disilicate crowns.

MATERIALS AND METHODS

One Standardized model with 1.6mm occlusal and 1.4mm axial reduction was used to fabricate 64 crowns. Using a factorial design, eight groups of lithium disilicate ceramics (n=8) using P=press, C=CAD/CAM, M=monolithic, O=coping, V=veneered, R=as produced: PMR, PMG, POR, PVG, CMR, CMG, COR, CVG. Crowns were produced and cemented on stone dies, then embedded in clear epoxy resin and sectioned into two plains. With a digital microscope, the distance between die and crowns was measured at the occlusal and axial walls. The horizontal/vertical fit at the finishing line of each section were measured as well.

RESULTS

For the marginal fit, the analysis shows that the influence of material and design was significant on horizontal and vertical margins, and the influence of finish was significant with horizontal but not vertical margins (p=0.09). For the internal fit, the analysis showed that the axial gap was significantly influenced by material and finish but not by design (p=0.44).

CONCLUSIONS

With a few exceptions, horizontal and vertical marginal discrepancies were below 100 μm. Additional firing increased the discrepancies.

Budget impact analysis of a breast rapid diagnostic unit

BACKGROUND

The Odette Cancer Centre's recent implementation of a rapid diagnostic unit (rdu) for breast lesions has significantly decreased wait times to diagnosis. However, the economic impact of the unit remains unknown. This project defined the development and implementation costs and the operational costs of a breast rdu in a tertiary care facility.

METHODS

From an institutional perspective, a budget impact analysis identified the direct costs associated with the breast rdu. A base-case model was also used to calculate the cost per patient to achieve a diagnosis. Sensitivity analyses computed costs based on variations in key components. Costs are adjusted to 2015 valuations using health care-specific consumer price indices and are reported in Canadian dollars.

RESULTS

Initiation cost for the rdu was $366,243. The annual operational cost for support staff was $111,803. The average per-patient clinical cost for achieving a diagnosis was $770. Sensitivity analyses revealed that, if running at maximal institutional capacity, the total annual clinical cost for achieving a diagnosis could range between $136,080 and $702,675.

CONCLUSIONS

Establishment and maintenance of a breast rdu requires significant investment to achieve reductions in time to diagnosis. Expenditures ought to be interpreted in the context of institutional patient volumes and trade-offs in patient-centred outcomes, including lessened patient anxiety and possibly shorter times to definitive treatment. Our study can be used as a resource-planning tool for future rdus in health care systems wishing to improve diagnostic efficiency.

Antinuclear Antibodies predict a higher number of Pregnancy Loss in Unexplained Recurrent Pregnancy Loss

OBJECTIVE

The etiology of recurrent pregnancy loss (RPL) is unknown in a significant proportion of patients. Autoimmune processes have been implicated in the pathogenesis. The role of antinuclear antibody (ANA) in this context is largely undetermined. In an attempt to address the lack of evidence in this area, we explored the clinical significance of antinuclear antibody (ANA) in unexplained RPL.

MATERIALS AND METHODS

We studied 68 patients with RPL and 60 healthy controls from September 2005 to May 2012. All subjects were tested for ANA by immunofluorescence testing, and a titer of 1: 80 and above was considered positive. We compared the pregnancy outcome between the ANA positive and ANA negative RPL cases.

RESULTS

The incidence of ANA positivity among the cases (35.3%) was significantly higher than the controls (13.3%) (p=0.005). ANA positive cases showed significantly higher number of RPL (p=0.006) and lower number of successful pregnancies (p=0.013) compared to the ANA negative cases . The ANA titre had a significant association with the number of RPL (p<0.05, r=0.724) but not with the number of successful pregnancies (p=0.054).

CONCLUSIONS

ANA positivity predicts a less favorable pregnancy outcome in RPL. Our findings suggest that the ANA titre is a useful positive predictor of the number of RPL. Hence, ANA test is a potential prognostic tool for this condition which merits further research.

Damage in the Multiethnic Malaysian Systemic Lupus Erythematosus (SLE) Cohort: Comparison with Other Cohorts Worldwide

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease and despite the improvement in the survival in the past few decades, the morbidity due to disease damage remains significant. The objectives of this study were to investigate the disease damagepattern and determine the associated factors of damage in the multi-ethnic Malaysian SLE patients. We consecutively 424SLE patients who attended a consistent follow-up at the National University of Malaysia Medical Centre and Putrajaya Hospital were recruited. Disease damage was assessed using the SLICC/ACR (Systemic Lupus International Collaborating Clinics/American College of Rheumatology) Damage Index (SDI) scores. Information on their demographics and disease characteristics were obtained from the clinical record. Univariate analysis was performed and the best model of independent predictors of disease damage was determined by multivariate logistic regression analysis. A total of 182 patients (42.9%) had disease damage (SDI ≥1). A significantly higher number of Indian patients had disease/organ damage and they predominantly developed steroid-induced diabetes mellitus (SDM). Patients with corticosteroid-induced osteoporosis (CIOP) were more likely to be Malayswhile majority of patients who developed malignancy were Chinese (p<0.05). In the univariate and multivariate analyses, disease damage was significantly associated with age, Indian ethnicity, lower mean cumulative C3 level, neuropsychiatry lupus (NPSLE), and antiphospholipid syndrome (APLS). Patients who had ever and early treatment with hydroxychloroquine(HCQ)were less likely to develop disease damage while more patients who had received oral prednisolone ≥1mg/kg daily over 2 weeks had disease damage (p<0.05). In conclusion, there were inter-ethnic differences in the damage pattern and risks among SLE patients.

A Study of Intima Media Thickness and Their Cardiovascular Risk Factors in Patients with Psoriatic Arthritis

Introduction: Psoriatic Arthritis (PsA) is an inflammatory arthritis associated with Psoriasis. Its recognition as an inflammatory disease distinct from Rheumatoid Arthritis has put forward for consideration several questions regarding its specific CVS mortality and morbidity (9, 11, 16, 26). Carotid intima media thickness is a useful surrogate and sensitive marker to determine atherosclerosis even in its subclinical stages (6, 14, 22, 27, 32). Objective: Prevalence of carotid intima media thickness in patients with Psoriatic arthritis is unknown in Asian population. We aim to identify the presence of subclinical atherosclerosis in patients with psoriatic arthritis and disease activity association and its predictors in a series of patients with PsA attended to the rheumatology clinic, tertiary hospitals. Methods: A total of 63 patients with PsA who fulfilled the CASPAR criteria were recruited from UKM Medical Centre and Hospital Putrajaya. Common carotid intima media thickness (IMT) was measured in both right and left carotid artery by using high resolution B-mode ultrasound. This was a cross sectional study first done in Malaysia for PsA patients. Results: The positive IMT (IMT >1.00 mm) among PsA was observed in 10 out of 63 patients (15.9 %) regardless of background cardiovascular risk. The mean±SD of IMT was 0.725 ±0.260 mm for this study. Variables significantly associated with positive IMT (p<0.05) included age at the time of study (p=0.005), waist circumference (p=0.001), Hypertension (p=0.007), Diabetes (p=0.002) and Metabolic syndrome (p=0.001) and not associated with gender, ethnicity, duration of PsA disease, pattern of PsA, disease activity and severity. Above all, only age had positive IMT independent predictor (p=0.032), with OR 1.116; 95 % CI (1.010–1.234). Conclusions: There was a significant association between CVS risk and positive Intima Media Thickness in Psoriatic Arthritis patients. Otherwise, there was no association in disease activity, disease severity and DMARDS therapy with positive Intima Media Thickness in Psoriatic Arthritis patients. The study was approved by Research and Ethics Committee of the faculty of medicine, Universiti Kebangsaan Malaysia with project code FF-114-2008 and by Community Research Center (CRC) of National Institutes of Health (NIH) for the case study in Hospital Putrajaya with the project code NMRR-08- 970-2125.

ID: 122: THE LINK BETWEEN OBSTRUCTIVE SLEEP APNEA AND LUNG CANCER: A RETROSPECTIVE CASE CONTROL STUDY

Introduction

Lung cancer accounts for 30% of all cancer deaths in the United States each year. Chronic inflammation has been linked to various steps involved in tumorigenesis. Several pro-inflammatory gene products have been identified that mediate a critical role in suppression of apoptosis, proliferation, angiogenesis, invasion, and metastasis. Among these gene products are Tumor Necrosis Factor (TNF), Interleukin (IL)-1a, IL-1b, IL-6, IL-8, and IL-18. The expression of all these genes is mainly regulated by the transcription factor nuclear factor kappa B (NF-kB), which is constitutively active in most tumors. Apnea-induced hypoxia and reoxygenation generates reactive oxygen species, which activate NF-kB and increase the systemic inflammation. Significant higher levels of pro-inflammatory cytokines TNF-α and IL-6, as well as a decrease in anti-inflammatory cytokines such as IL-10 has been found in obstructive sleep apnea (OSA). Previous studies showed that overnight oxygen desaturation seen in patients with OSA is associated with increased cancer incidence and cancer related mortality; The purpose of this study was to determine if OSA is an independent risk for the development and dissemination of malignancy, including lung cancer.

Methods

This is a retrospective case control chart review study conducted at the Oklahoma City Veterans Affairs Medical Center (VAMC). All adult patients who had a sleep study done between January 1st, 2000 and December 31st, 2007 were included. Patients were divided into 2 groups, based on whether they have OSA or not. The primary outcome was the rate of lung cancer occurring between 1998 and 2012. The secondary outcome was the rate of all cancers occurring during the same period. Fisher exact test was used to compare these rates.

Results

Nine hundred two patients with a sleep study done between 2000 and 2007 were reviewed. Fifty seven patients were excluded since complete sleep study data were not available. Seven hundred and seventy five patients had sleep apnea (91.7%). Lung cancer occurred in 26/775 (3.4%) patients with OSA, vs. 3/70 (4.3%) patients without OSA (p=0.7). The rate of all malignancies was 19% (148/775) in patients with OSA compared to 15.7% (11/70) in patients without OSA (p=0.6).

Conclusion

Sleep apnea does not appear to increase the risk of malignancy in general, and that of lung cancer in particular. Further studies to account for confounding risk factors are needed to definitively answer this question.

Recognizing rheumatoid arthritis: oncoprotein survivin opens new possibilities: a population-based case-control study

Survivin is a biomarker of cancer known for its anti-apoptotic and cell-cycle regulating properties. In the context of non-cancer pathology, high levels of survivin may be measured in blood and synovial fluid of patients with rheumatoid arthritis (RA) and associate with early joint damage and poor therapy response. The aim of the study was to investigate the value of survivin measurements in blood for diagnosis of RA in the frame of the Malaysian epidemiological investigation of rheumatoid arthritis (MyEIRA) study. The study enrolled RA patients from eight rheumatology centres in Peninsular Malaysia. The healthy controls matched by age, gender and ethnicity were recruited on the community basis from the residential area of the patients. Levels of survivin were measured in blood of RA patients (n = 1233) and controls (n = 1566) by an enzyme-linked immuno-sorbent assay (ELISA). The risk for RA was calculated as odds ratio (OR) and 95% confidence intervals in the individuals with high levels of survivin. The risk was calculated in relation to antibodies against cyclic citrullinated peptides (ACPA), detected by ELISA and HLA-DRB1 shared epitope (SE) alleles, identified by the polymerase chain reaction using sequence specific oligonucleotide method. High levels of survivin were detected in 625 of 1233 (50.7%) RA cases and in 85 of 1566 (5.4%) controls, indicating its high specificity for RA. Survivin was association with an increase in RA risk in the patients having neither SE-alleles nor ACPA (OR = 5.40, 95% CI 3.81-7.66). For the patients combining survivin, SE, and ACPA, the estimated risk for RA was 16-folds higher compared to the survivin negative patients with SE and ACPA(OR = 16.21, 95% CI 5.70-46.18). To conclude, detection of survivin in blood provides a simple test to improve diagnostic and to increase predictability for RA.

Antimicrobial resistance in Staphylococcus aureus, Streptococcus uberis and Streptococcus dysgalactiae from dairy cows with mastitis

AIMS

To determine the minimal inhibitory concentrations (MIC) of antimicrobials for common mastitis pathogens from dairy cows in New Zealand; and to assess the effect of source of the isolates, i.e. commercial veterinary laboratories or collected as part of research studies; the clinical status of the cow, i.e. subclinical or clinical mastitis; cow age and herd on the distribution of the MIC.

METHODS

Minimal inhibitory concentrations for Staphylococcus aureus (n=364), Streptococcus dysgalactiae (n=65) and Streptococcus uberis (n=102) isolated from milk samples from dairy cows were determined for a variety of antimicrobials using broth microdilution. Isolates of S. aureus were sourced from research studies from both subclinically (n=161) and clinically (n=104) affected cows, as well as from commercial veterinary laboratories (n=101); while all the streptococcal isolates were from commercial laboratories. Resistance was defined using the cut-points provided by the Clinical and Laboratory Standards Institute (CLSI).

RESULTS

The distribution of MIC varied among the bacterial species for every antimicrobial tested (p<0.001). Of the S. aureus isolates, 28, 2 and 0.5% were resistant to penicillin, ampicillin and trimethoprim/sulfamethoxazole, respectively. For S. dysgalactiae and S. uberis isolates, 17 and 13% were resistant to trimethoprim/sulfamethoxazole, respectively. One isolate (1%) of S. uberis was resistant to penicillin. The distribution of MIC of S. aureus varied with clinical status, between herds, and with age of cow (p<0.05). The distribution of MIC for S. aureus for penicillin, amoxicillin/clavulanic acid, cloxacillin and ampicillin were lower from clinical than subclinical cases, and those for amoxicillin/clavulanic acid and oxytetracycline from isolates from veterinary laboratories were lower than for those from research studies.

CONCLUSIONS

Resistance to some beta-lactam antimicrobials and trimethoprim/sulfamethoxazole were found in isolates from cases of bovine mastitis. The distribution of MIC for isolates of S. aureus varied with clinical status of the cow, the age of the cow, the herd and with the source of isolate.

CLINICAL SIGNIFICANCE

Resistance to penicillin was found in a quarter of S. aureus isolates, but in virtually no Streptococcus isolates; therefore microbial identification and sensitivity testing would be beneficial when assessing treatment options. The source of the isolates affected the estimated MIC, suggesting that selection of isolates for monitoring of resistance requires care and that use of routine submissions to commercial laboratories to assess antimicrobial resistance patterns may result in biased estimates of prevalence of resistance.

Risk of tuberculosis with anti-tumor necrosis factor-α therapy: substantially higher number of patients at risk in Asia

AIM

To assess the potential risk of tuberculosis (TB) in patients treated with anti-tumor necrosis factor-alpha (TNF-α) agents in Asia.

METHODS

Absolute risk increase (ARI) of TB was estimated for three widely used anti-TNF-α therapies using published standardized incidence ratios (SIR) from the French Research Axed on Tolerance of bIOtherapies registry and incidence (absolute risk [AR]) of TB in Asia. Assuming an association of increased TB risk with anti-TNF-α therapy and country TB AR (incidence), the ARI of TB by country was calculated by multiplying the SIR of the anti-TNF-α therapy by the country's TB AR. The numbers needed to harm (NNH) for each anti-TNF-α agent and numbers needed to treat (NNT) to reduce one TB event using etanercept therapy instead of adalimumab or infliximab were also calculated for each country.

RESULTS

The ARI of TB with anti-TNF-α therapies in Asian countries is substantially higher than Western Europe and North America and the difference between etanercept versus the monoclonal antibodies becomes more evident. The NNH for Asian countries ranged from 8 to 163 for adalimumab, 126 to 2646 for etanercept and 12 to 256 for infliximab. The NNT to reduce one TB event using etanercept instead of adalimumab therapy ranged from 8 to 173, and using etanercept instead of infliximab therapy the NNT ranged from 13 to 283.

CONCLUSION

Higher numbers of patients are at risk of developing TB with anti-TNF-α therapy in Asia compared with Western Europe and North America. The relative lower risk of TB with etanercept may be particularly relevant for Asia, an endemic area for TB.

Antinuclear antibodies in primary osteoarthritis of the knee: a case-control study

Objective: Although osteoarthritis (OA) is widely accepted as a degenerative disease, autoimmune processes are believed to be involved in the pathogenesis. There are limited studies in this area and most of them focused on antibodies against chondrocyte membrane. In an attempt to address the paucity of evidence in this regard, we explored the clinical significance of antinuclear antibody (ANA) in primary osteoarthritis of the knee (OAK). Method: We studied 106 patients with primary osteoarthritis of at least 1 knee and 63 healthy controls from two tertiary centres in Malaysia from September 2005 to May 2012. All subjects were tested for ANA by immunofluorescence testing, and a titer of 1:40 and above was considered positive. Besides, the radiographs of bilateral knees were evaluated for grading, tibiofemoral compartment involvement and total knee replacement (TKR) implants. We compared the clinical characteristics between the ANA positive and ANA negative OAK cases. Results: The incidence of ANA positivity among the cases (39.4 %) was higher than the controls (27 %) but this difference was statistically insignificant (p=0.754). ANA positive cases showed significantly higher incidence of bilateral and Grade IV OAK with higher frequency of TKR. In the multiple regression analysis, bilateral OAK (p< 0.0001; odds ratio 9.00), Grade IV OAK (p<0.001, odds ratio 3.44) and TKR (p=0.009; odds ratio 2.97) remained associated with ANA positivity. Conclusions: ANA test is a potential prognostic tool in primary OAK and its positivity is associated with the clinical outcomes of bilateral, Grade IV OAK and TKR.

The sensitivity of human mesenchymal stem cells to vibration and cold storage conditions representative of cold transportation

In the current study, the mechanical and hypothermic damage induced by vibration and cold storage on human mesenchymal stem cells (hMSCs) stored at 2-8°C was quantified by measuring the total cell number and cell viability after exposure to vibration at 50 Hz (peak acceleration 140 m s(-2) and peak displacement 1.4 mm), 25 Hz (peak acceleration 140 m s(-2), peak displacement 5.7 mm), 10 Hz (peak acceleration 20 m s(-2), peak displacement 5.1 mm) and cold storage for several durations. To quantify the viability of the cells, in addition to the trypan blue exclusion method, the combination of annexin V-FITC and propidium iodide was applied to understand the mode of cell death. Cell granularity and a panel of cell surface markers for stemness, including CD29, CD44, CD105 and CD166, were also evaluated for each condition. It was found that hMSCs were sensitive to vibration at 25 Hz, with moderate effects at 50 Hz and no effects at 10 Hz. Vibration at 25 Hz also increased CD29 and CD44 expression. The study further showed that cold storage alone caused a decrease in cell viability, especially after 48 h, and also increased CD29 and CD44 and attenuated CD105 expressions. Cell death would most likely be the consequence of membrane rupture, owing to necrosis induced by cold storage. The sensitivity of cells to different vibrations within the mechanical system is due to a combined effect of displacement and acceleration, and hMSCs with a longer cold storage duration were more susceptible to vibration damage, indicating a coupling between the effects of vibration and cold storage.