Myositis Multidisciplinary Clinic in a Tertiary Referral Center

Background

Idiopathic inflammatory myopathies (IIM) are a rare heterogeneous group of diseases characterised by chronic skeletal muscle inflammation, but other organs are also frequently involved. IMM represent a diagnostic challenge and a multidisciplinary approach is important to ensure successful diagnosis and adequate follow-up of these patients.

Objective

To describe the general functioning of our multidisciplinary myositis clinic, highlighting the benefits of multidisciplinary team management in patients with confirmed or suspected IIM and to characterise our clinical experience.

Methods

Description of the organization of a dedicated multidisciplinary myositis outpatient clinic, supported by IMM specific electronic assessment tools and protocols based on our Portuguese Register - Reuma.pt. In addition, an overview of our activity between 2017 and 2022 is provided.

Results

An IIM multidisciplinary care clinic, based on a close collaboration between Rheumatologists, Dermatologists and Physiatrist is detailed in this paper. One hundred and eighty-five patients were assessed in our myositis clinic; 138 (75%) of those were female, with a median age of 58 [45-70] years. At the last appointment, 130 patients had a confirmed IIM diagnosis, and the mean disease duration was 4 [2-6] years. The most frequent diagnosis was dermatomyositis (n = 34, 26.2%), followed by antisynthetase syndrome (n = 27, 20.8%) and clinically amyopathic/paucimyopathic dermatomyositis (n = 18, 13.8%). Twenty-four patients (18.5%) were on monotherapy and 94 (72.3%) were on combination therapy.

Conclusion

A multidisciplinary approach is important to ensure the correct diagnosis and follow-up of these patients. A myositis clinic, with a standardised practice at a tertiary hospital level, contributes to a standardization of care and opens research opportunities.

Clinical characterisation of a multicentre nationwide cohort of patients with antisynthetase syndrome

BACKGROUND

Antisynthetase syndrome (ASyS) is characterised by the association of inflammatory myopathy, interstitial lung disease (ILD), arthritis, Raynaud's phenomenon (RP) or mechanic's hands (MH), with the presence of anti-aminoacyl-tRNA-synthetase antibodies (anti-ARS). It has been suggested that different anti-ARS may be associated with distinct clinical pictures.

OBJECTIVE

To characterise the clinical and immunological features of a multicentric nationwide cohort of ASyS patients.

METHODS

This is a multicentre retrospective cohort study including patients with ASyS from nine Portuguese rheumatology centres. Data on patients' demographics, signs and symptoms, laboratory results, pulmonary imaging findings and treatment with immunomodulators were collected. Comparison between patients with different anti-ARS antibodies was made using the Chi-square test for categorical variables and Student's t-test or Man-Whitney test for continuous variables, considering anti-Jo1 positive patients as the reference group.

RESULTS

Seventy patients were included (70% female) with a median age in years at disease onset of 52 (15-75) years and median follow-up time of 3 years (range 0-32). The three most common clinical manifestations were ILD (n=53, 75.7%), followed by arthritis (n=43, 61.4%) and myositis (n=37, 52.9%). Forty-three patients were positive for anti-Jo1 (61.4%), 11 for anti-PL12 (15.7%), 10 for anti-PL7 (14.3%), 4 for anti-EJ (5.7%), and 2 for anti-OJ (2.9%) antibodies. Antibody co-positivity with anti-Ro52 antibodies was found in 15 patients (21.4%) and was more prevalent in anti-Jo1 patients. ILD prevalence was similar in the different anti-ARS subgroups, without statistically significant differences. Patients positive for anti-PL7 antibodies had significantly lower risk of presenting arthritis (p =< 0.05) and those positive for anti-PL-12 antibodies had a significantly lower risk of presenting myositis than the reference group of anti-Jo1 positive patients (p =< 0.05). RP was more frequently found in patients positive for anti-PL-12 than in anti-Jo1-positive patients (p =< 0.05). Malignancies were reported in four (5.7%) patients, none of whom were anti-Ro52-positive, and one of such patients had a double malignancy. Only three deaths were reported. Corticosteroids were the most frequently prescribed therapy and the use of immunosuppressive drugs was decided according to the type of predominant clinical manifestation.

CONCLUSION

The three most common clinical manifestations were ILD, followed by arthritis and myositis. Patients positive for anti-PL7 antibodies had significantly lower risk of presenting arthritis and those positive for anti-PL-12 antibodies had a significantly lower risk of presenting myositis than the reference group of anti-Jo1 positive patients. RP was more frequently found in patients positive for anti-PL-12 than in anti-Jo1-positive patients. Corticosteroids were the most frequently prescribed therapy. These results are generally concordant with data retrieved from international cohorts.

AB0696 Prevalence and clinical associations of different autoantibodies in the Reuma.pt systemic sclerosis cohort: is it all really set in stone?

Background

Different autoantibodies (Ab) have been associated with distinct systemic sclerosis (SSc) phenotypes. Most of these associations have not been confirmed in Portuguese patients.

Objectives

To evaluate SSc immuno-clinical associations in the Rheumatic Diseases Portuguese Register (Reuma.pt) cohort.

Methods

Multicentre open cohort study including adult SSc patients registered in Reuma.pt up to February 2021. The associations between Ab expression and clinical data were established using Chi-Square, Fischer’s Exact or Mann-Whitney U tests. The Bonferroni correction for multiple comparisons was applied to get α≤0.05. Definite associations were defined by p≤0.002, and likely associations by p≤0.05.

Results

1080 patients were included, with a mean age and disease duration of 60.2±14.6 and 12.4±10.0 years, respectively. Most were females (87.5%) and had white European ancestry (WEA, 93.2%). The most common disease subtypes were limited cutaneous (lcSSc, 57.4%), diffuse cutaneous (dcSSc, 17.7%), and very early diagnosis of SSc (VEDOSS, 12.3%). Most patients expressed antinuclear Ab (ANA, 93.4%), and the most frequent were anti-centromere (ACA, 54.6%), anti-topoisomerase I (Scl70, 21.8%), and anti-Pm/Scl Ab (PmScl, 4.7%).

ACA had definite positive associations with female sex, older age at diagnosis, lcSSc, lower modified Rodnan skin score (mRSS, median 0 vs 4), and isolated sclerodactyly, and likely associations with a higher diagnosis delay, WEA and VEDOSS. ACA had definite inverse associations with flexion contractures (FC), myositis, digital ulcers (DU), and interstitial lung disease (ILD), and likely inverse associations with pitting scars (PS) and oesophageal involvement (OI).

Scl70 had definite positive associations with male sex, dcSSc, higher mRSS, FC, DU, PS, ILD, and OI, and likely associations with younger age at diagnosis, tendon friction rubs, active scleroderma pattern in capillaroscopy, and heart involvement.

PmScl had a definite association with myositis and likely associations with male sex, calcinosis, joints involvement, and ILD. Anti-U1RNP Ab had definite associations with younger age at diagnosis, MCTD and myositis, and likely associations with a lower diagnosis delay, African ancestry and joint involvement. Anti-RNA polymerase III Ab (RP3) had likely associations with higher mRSS and renal involvement. Anti-U3RNP Ab had a definite association with dcSSc and likely associations with calcinosis and renal involvement. Anti-Th/To Ab had likely associations with male sex and myositis. Anti-Ku Ab had likely associations with systemic lupus erythematosus and mixed connective tissue disease (MCTD) overlap syndromes.

Conclusion

There was a higher prevalence of ACA and PmScl compared to other cohorts, most likely due to the high proportion of WEA patients. Most immuno-clinical associations described in the literature apply, including ACA with lcSSc and Scl70 with dcSSc, DU, PS and ILD. However, Scl70+ patients did not have an increased risk of renal involvement, and ACA+ patients did not have an increased risk for calcinosis, PAH or OI, contrary to what was described in the literature. New findings included the association of PmScl with ILD and Scl70 with an active pattern in capillaroscopy. Also, anti-U3RNP+ and Th/To+ patients did not have an increased risk of ILD or PAH, contrarily to what was previously reported. These nuances may be specific to the Portuguese SSc population or signal previously reported associations as geographically specific.

Disclosure of Interests

None declared

Rituximab in the treatment of anti-MDA5 dermatomyositis-associated interstitial lung disease: a case-based literature review

Interstitial lung disease (ILD) occurs with Idiopathic Inflammatory Myopathy (IIM) as a life-threating complication and is considered the most important prognostic determinant in this disease group. The antibody anti-melanoma differentiation-associated gene 5 (anti-MDA5) is associated to rapidly progressive ILD and poor overall survival. Rituximab (RTX) is becoming a drug of choice in management of refractory IIM-ILDs and rapidly progressive ILDs, despite its low level of evidence. We report the case of a 49-year-old man with new-onset clinically amyopathic dermatomyositis (CADM) with severe respiratory symptoms and mixed radiologic pattern of non-specific interstitial and organizing pneumonia, refractory to high dose corticosteroids and intravenous immunoglobulin and oxygen dependent. He was started on RTX 375mg/m2/week of which he completed 4 perfusions, with significant clinical improvement, and has been on maintenance to date with the rheumatology RTX standard protocol with no need for oxygen supplementation. RTX may represent a rescue therapy for patients with severe anti-MDA5-related CADM-ILD refractory to conventional immunotherapies. We identified reports of a total of 12 patients treated with RTX. Infection was the only reported adverse event (25%). Respiratory improvement (defined by symptoms, imaging or PFTs) was observed in 75% of patients, with 2 (17%) having achieved clinical remission. A total of three deaths occurred (25%), all resulting from ILD progression despite treatment. No therapeutic protocol with RTX seems to be more efficient nor associated with more adverse events than the others. Comparative studies are necessary.

Clinical features and outcome of 1054 patients with Systemic Sclerosis: analysis of Reuma.pt/SSc registry

BACKGROUND

Systemic sclerosis (SSc) is a rare connective tissue disorder with heterogeneous manifestations and outcomes. Besides differences in disease characteristics among distinct ethnic groups and geographical regions, several questions regarding the impact of the disease and the effectiveness of treatments remain unanswered. To address these questions, the Rheumatic Diseases Portuguese Register (Reuma.pt) launched a specific protocol for the prospective follow-up of SSc patients.

OBJECTIVES

To describe the baseline characteristics, disease subsets, treatments used and survival of SSc patients registered in Reuma.pt/SSc.

METHODS

Data from adult patients with SSc included in Reuma.pt up to November 2020 were analysed. Demographic features, SSc subsets, fulfilment of classification criteria, main clinical and immunological features, comorbidities, treatments used and survival data were described and compared between diffuse cutaneous (dc) and limited cutaneous (lc) disease subsets. Survival was calculated for patients included in Reuma.pt within the first two years of diagnosis.

RESULTS

In total, 1054 patients were included, 87.5% female, with a mean age at diagnosis of 52.7 +/- 14.8 years. The most common subset was lcSSc (56.3%), followed by dcSSc (17.5%), preclinical SSc (13%), overlap syndrome (9.8%) and SSc sine scleroderma (3.3%). Raynaud's phenomenon (93.4%) and skin thickening (76.9%) were the most frequently observed clinical manifestations. Gastrointestinal (62.8% versus 47.8%), pulmonary (59.5% versus 23%) and cardiac (12.8% versus 6.9%) involvements were significantly more prevalent in dcSSc than lcSSc. Ninety per-cent of patients were Antinuclear antibody positive, 52.5% were Anti-centromere antibody positive and 21% anti-topoisomerase positive, with significant differences between lcSSc and dcSSc. One-third of patients were treated with immunomodulators, 53.6% with vasodilators, 23% with glucocorticoids and 2.3% with biologics. During follow-up, 83 deaths (7.9%) were reported. The overall 1-, 2- and 5-year survivals were 98.0%, 96.8% and 92.6%, respectively, without significant differences between lcSSc and dcSSc.

CONCLUSION

Reuma.pt/SSc data highlights the importance of registries in improving knowledge about rare and complex diseases, such as SSc. Clinical features of Portuguese SSc patients are similar to those of other populations. In recently diagnosed patients, 5-year survival is over 92%. To the best of our knowledge, this is the first study showing that clinical features of Portuguese SSc are similar to those of other cohorts.

Gender differences in clinical features and outcomes of a Portuguese systemic sclerosis cohort

Evidence for the role of sex in the clinical manifestations of systemic sclerosis (SSc) patients is emerging. Some multicenter cohorts have shown that male SSc patients have more severe disease and worse survival. To assess the differences in clinical manifestations and survival in Portuguese SSc patients according to gender. Data from male and female adult SSc patients included in the Rheumatic Diseases Portuguese Register (Reuma.pt) were analysed and compared. Survival was calculated for patients included in Reuma.pt. within the first two years of diagnosis (inception cohort). In total, 1054 adult patients with SSc were included, 12.5% males. No differences in demographic features and comorbidities were found between the sexes, except for a higher rate of cigarette smokers among men. Diffuse cutaneous SSc and anti-topoisomerase antibodies were more prevalent in males than females. Additionally, male patients presented significantly more myositis, interstitial lung disease and gastric involvement. There were no differences in the patterns of drug use between the sexes. During follow-up, more deaths were reported in men than women (12.1% vs 7.3%, p = 0.04). The overall 1-, 3-, and 5-year survivals from diagnosis of the inception cohort (N = 469) for men vs women were 96.4% vs 98.2%, 93% vs 95.9%, and 75.8% vs 93.2%, respectively, with statistically significant differences (p < 0.01). This study confirms the existence of gender differences in clinical and immunological SSc features. Although SSc is less common in men than women, men have a more severe expression of skin and internal organ involvement and worse survival. Key Points • There are differences in SSc disease manifestations between sexes. • Males more commonly have diffuse cutaneous SSc, anti-topoisomerase antibodies, pulmonary and musculoskeletal involvement. • In the inception cohort, men had worse survival rates than women.

Happiness, quality of life and their determinants among people with systemic sclerosis: a structural equation modelling approach

BACKGROUND

Patients' objectives and experiences must be core to the study and management of chronic diseases, such as SSc. Although patient-reported outcomes are attracting increasing attention, evaluation of the impact of disease on the overall subjective well-being, equivalent to 'happiness', is remarkably lacking.

OBJECTIVES

To examine the determinants of happiness and quality of life in patients with SSc, with emphasis on disease features and personality traits.

METHODS

Observational, cross-sectional multicentre study, including 142 patients, with complete data regarding disease activity, disease impact, personality, health-related quality of life (HR-QoL) and happiness. Structural equation modelling was used to evaluate the association between the variables.

RESULTS

The results indicated an acceptable fit of the model to the data. Perceived disease impact had a significant negative direct relation with HR-QoL (β = -0.79, P < 0.001) and with happiness (β = -0.52, P < 0.001). Positive personality traits had a positive relation with happiness (β = 0.36, P = 0.002) and an important indirect association upon QoL (β = 0.43) and happiness (β = 0.23). Perceived disease impact is influenced by body image, fatigue and SSc-related disability to a higher degree (β = 0.6-0.7) than by disease activity (β = 0.28) or form (β = 0.17). Impact of disease had a much stronger relation with HR-QoL than with happiness.

CONCLUSIONS

The results suggest that treatment strategies targeting not only disease control but also the mitigation of relevant domains of disease impact (body image, fatigue, global disability) may be important to improve patients' experience of the disease. The reinforcement of resilience factors, such as positive psychological traits, may also play a contributory role towards better patient outcomes.

Ten years of a systemic sclerosis clinic in a tertiary referral centre - insights and future directions

Systemic sclerosis (SSc) is an uncommon condition, with a wide range of manifestations, characterized by specific antibody production, vasculopathy and fibrosis of the skin and other internal organs. It is a complex disease, which is estimated to be rare in Portugal, although specific incidence data are missing. The aetiology of SSc remains unknown, but is likely to be multifactorial, involving genetic and environmental aspects. Its management is challenging and often requires a multidisciplinary approach. In 2011, we established a dedicated outpatient clinic for patients with SSc. Clinical data of every patient with a confirmed diagnosis of SSc is prospectively registered in Reuma.pt/SSc. In this manuscript, we aim to describe the general functioning of our SSc outpatient clinic, and to characterise the population of patients with SSc who are followed herein.

AB0445 FIRST CLINICAL ANALYSIS OF MYOSITIS PATIENTS REGISTERED AT REUMA.PT/MYOSITIS PROTOCOL: DATA FROM A SINGLE-CENTER

Background:

Idiopathic inflammatory myopathies are a group of rare heterogeneous diseases that require a multidisciplinary and standardized approach.

Objectives:

To clinically characterize patients with inflammatory myopathies followed at an hospital’s Rheumatology Department, using the Rheumatic Diseases Portuguese Register (Reuma.pt).

Methods:

An observational transversal study was performed. Data on demographic variables, clinical features, antibodies and treatment were collected.

Results:

Of the 121 included patients, 78% were female, with a median age of 56 [44-68] years and a median disease duration of 2 [0-4] years. The most frequent diagnosis was dermatomyositis (DM; n=28, 23%) followed by antisynthetase syndrome (ASyS; n=21, 17.4%). At the time of the analysis, the median Manual Muscle Test (MMT-8) was 80 [78-80], the median modified skin Disease Activity Score was 0 [0-2] and global disease activity was 0.5 [0-0.75]. Calcinosis was found in 6% of the patients (n=7), mostly DM cases. Interstitial lung disease (ILD) was present in 29 patients (24%), of those, 52% (n=15) had antisynthetase syndrome (ASyS). Three patients presented as a paraneoplastic syndrome. Ninety-nine patients (82%) had a myositis autoantibody identified: antisynthetase autoantibodies were the most commonly identified (n=20, 16%). 62% of the patients were treated with steroids and 35% with ≥2 disease-modifying anti-rheumatic drugs.

Table 1 depicts the main clinical characteristics and the immunologic profile for each diagnosis

Conclusion:

In our cohort the most frequent myositis subtype was DM. Almost a quarter of patients had associated ILD, which is an important cause of morbidity and mortality. ILD was more frequent in ASyS patients and was most commonly related to anti-Jo1 antibodies, which is consistent with the literature.

Table 1.

Clinical characteristics and immunological profile of the patients.

Diagnosis (n)Clinical featuresMyositis antibodies (n)Skin disease, median [IQR]/ (n)MMT-8, median [IQR]Lung disease (n)Others (n)Malignancy (n)Definite DM (28)DAS Skin 2 [0-2]Calcinosis (3)Mechanic hands (2)80 [75-80]NSIP (2);COP (1)Arthritis (6)Breast cancer (1)anti-Ro52 (6); anti-Mi2b (5); anti-PmScl100 (4); anti-MI2a (3); anti-NXP2 (3); anti-SAE (2); anti-MDA5 (2); anti-Ku (2); anti-Tif1g (1)Antisynthetase syndrome (21)DAS Skin 0 [0-0]Calcinosis (1)Mechanic hands (4)80 [80-80]NSIP (11);UIP (3);LIP (1)Arthritis (15);RP (10)–anti-Jo1 (14); anti-Ro52 (12); anti-Mi2b (1); anti-PL7 (3); anti-PL12 (1)Probable DM (19)DAS Skin 0 [0-0]80 [78-80]COP (1)Arthritis (5);RP (6)–anti-Mi2a (4); anti-Mi2b (2); anti-Tif1g (2); anti-Ku (2); anti-PmScl75 (2)CADM (16)DAS Skin 1 [0-2]Calcinosis (1)Mechanic hands (1)80 [77-80]NSIP (1); COP (1)Arthritis (5);RP (4)–anti-Mi2b (5); anti-Ro52 (2); anti-Mi2a (1); anti-MDA5 (1); anti-EJ (1); anti-SAE (1); anti-SRP (1); anti-Ku (1); anti-Tif1g (1)MCTD (12)DAS Skin 0 [0-1]80 [79-80]NSIP (1)Arthritis (8);RP (10)–anti-U1 RNP (12); anti-Ro52 (7)PM (7)DAS Skin 0 [0-0]Calcinosis (1)80 [72-80]NSIP (1)Arthritis (1)Ovarian cancer (1); non-Hodgkin lymphoma (1)anti-Ro52 (2); anti-SRP (1)UCTD (5)DAS Skin 0 [0-2]Calcinosis (1)Mechanic hands (1)80 [79-80]NSIP (2)Arthritis (1);RP (5)–anti-ThTo (2); anti-SRP (1); anti-PL12 (1)Overlap syndromes (12)DAS Skin 0 [0-2]Mechanic hands (2)80 [77-80]NSIP (3);UIP (1)Arthritis (4);RP (8)–anti-PmScl75 (4); anti-PmScl100 (1); anti-Ro52 (1); anti-Ro60 (1); anti-RNAPIII (1); anti-NOR90 (1); anti-MDA5 (1); anti-Ku (1)Necrotizing myopathy (1)DAS Skin 080––––

DM – dermatomyositis; CADM – clinically amyopathic dermatomyositis; MCTD – mixed connective tissue disease; PM – polymyositis; UCTD – undifferentiated connective tissue disease; ILD – interstitial lung disease; NSIP – nonspecific interstitial pneumonia; LIP – lymphocytic interstitial pneumonitis; UIP – usual interstitial pneumonia; COP – cryptogenic organizing pneumonia; RP – Raynaud phenomenon

Disclosure of Interests:

None declared.

POS0870 CLINICAL CHARACTERIZATION OF PORTUGUESE PATIENTS WITH ANTISYNTHETASE SYNDROME

Background:

Antisynthetase syndrome (ASyS) may have different clinical phenotypes and outcomes associated with different anti-aminoacyl RNA-synthetase (anti-ARS) antibodies. Its wide clinical spectrum can include inflammatory myopathy, interstitial lung disease (ILD), arthritis, fever, mechanic’s hands, and Raynaud phenomenon (RP).

Objectives:

To describe a nationwide, multicentre cohort of Portuguese patients with ASyS.

Methods:

Retrospective analysis of patients with ASyS from nine Portuguese Rheumatology centers. Data on patients’ signs and symptoms, laboratory results, pulmonary radiological findings (computed tomography) and treatment (immunomodulators) were collected.

Results:

Among the 70 patients included, 42 patients (60%) were anti-Jo1–positive, 11 (15.7%) were anti-PL12–positive, 10 (14.3%) were anti-PL7–positive, 4 (5.7%) were anti-EJ–positive and 2 (2.9%) were anti-OJ positive. In one patient it was not possible to identify the type of antibody. Antibody overlap was found in 15 patients (21.4%), who were positive for anti-Ro52 antibodies. The general clinical characteristics are shown in Table 1. The diagnostic delay was greater in patients positive for anti-OJ, followed by anti-Jo-1 and anti-PL12. The follow-up was shorter for anti-PL7 and anti-OJ-positive patients. Anti-PL7-positive patients had lower rates of arthritis when compared to anti-Jo1 (p< 0.01). When compared with anti-Jo-1 ARS, myositis was less common in anti-PL12 (p < 0.01). ILD prevalence was similar in the different ARS subgroups. Glucocorticoids (GCs) were the most frequently used class of drugs. A more conservative treatment plan (e.g. GCs plus methotrexate or azathioprine) was the treatment of choice in ASyS with myositis and/or arthritis involvement. Rituximab or mycophenolate mofetil were preferred when lung involvement occurred. Only two deaths were reported, being one associated with lung neoplasia.

Conclusion:

This is the first study investigating the clinical phenotypes of Portuguese patients with ASyS. These results are generally concordant with data retrieved from international cohorts.

References:

[1]Mahler M, Miller FW, Fritzler MJ. Idiopathic inflammatory myopathies and the anti-synthetase syndrome: a comprehensive review. Autoimmun Rev 2014;13:367–71.

Table 1.

Patient characteristics according to the anti-ARS. ILD - interstitial lung disease; IQR- interquartile range; NSIP - Non-specific interstitial pneumonia; UIP - Usual interstitial pneumonia; yrs - years

VariablesOverall, n=70Jo-1, n=42(60%)PL-12, n=11 (15.7%)PL-7, n=10 (14.3%)EJ, n=4 (5.7%)OJ, n=2 (2.9%)Mean age at onset, yrs52 ± 1546.6 ± 14.455.2 ± 14.756.5±12.556.3±11.273.5±2.1Female, n (%)49 (70)29 (69)9 (81.8)7 (70)2 (50)2 (100)Median age in years at disease onset (IQR)52 (15-75)48 (15-70)59 (20-70)62 (39-73)60 (40-65)73.5 (72-75)Median follow-up time in yrs (IQR)3 (0-32)5 (0-32)3 (0-13)1 (1-4)4 (2-21)1 (0-2)Median diagnostic delay in yrs (IQR)6 (1-33)7 (1-33)7 (2-19)4 (1-23)1.5 (1-2)12.5 (2-21)Myositis, n (%) and Comparison Anti-Jo.1 ARS vs PL-12 and PL-736 (51.4)25 (59.5)3 (27.3)*p < 0.014 (40)p=0.73 (75)-0-ILD, n (%) and Comparison Anti-Jo.1 ARS vs PL-12 and PL-753 (75.7)33 (78.6)8 (72.7)p = 0.986 (60) p=0.564 (100)-1 (50)- ILD pattern - NSIP, n (%)30 (56.6)18 (54.5)6 (75)3 (50)1 (25)0 ILD pattern - UIP, n (%)6 (11.3)3 (9.1)1 (12.5)1 (16.7)1 (25)0 ILD pattern - other specific pattern, n (%)6 (11.3)4 (12.1)02 (33.3)1 (25)0 ILD pattern - non-specific pattern, n (%)11 (15.7)8 (24.2)1 (12.5)01 (25)1 (100)Mechanic’s hands (%), n (%)23 (32.9)14 (33.3)3 (27.3)2 (20)01 (50)General impairment, n (%)18 (25.7)11 (26.2)3 (27.3)2 (20)2 (50)0Fever, n (%)7 (10)4 (9.5)2 (20.2)01 (25)0Raynaud phenomenon, n (%)22 (31.4)11 (26.2)7 (63.6)02 (50)0Arthritis, n (%) and Comparison Anti-Jo.1 ARS vs PL-12 and PL-743 (61.4)29 (69)5 (45.4)p=0.072 (20)*p < 0.012 (50)-1 (50)-Malignancy, n (%)4 (5.7)3 (7.1)1 (9.1)000Deaths, n (%)2 (2.9)2 (2.4)0001 (50)

Disclosure of Interests:

None declared

POS0872 CLINICAL FEATURES AND OUTCOME OF 1054 PATIENTS WITH SYSTEMIC SCLEROSIS: AN ANALYSIS OF THE PORTUGUESE REUMA.PT REGISTRY FOR SCLERODERMA (REUMA.PT/SSC)

Background:

Systemic sclerosis (SSc) may present distinctive manifestations and survival in different ethnic and geographic groups.

Objectives:

To describe the clinical features, treatments, and survival of adult SSc patients registered in Reuma.pt/SSc.

Methods:

Demographic features, SSc subsets, fulfilment of classification criteria, clinical and immunologic characteristics, comorbidities, medication and deaths were reviewed. Survival was calculated for patients included in the registry within the first 2 years of diagnosis.

Results:

In total, 1054 patients were included, 87.5% female, mean age at diagnosis 52.7 ± 14.8 years. The most common subset was limited cutaneous (lc)SSc (56.3%), followed by diffuse cutaneous (dc)SSc (17.5%), preclinical SSc (13%), overlap syndrome (9.8%) and SSc sine scleroderma (3.3%). Raynaud’s phenomenon (93.4%) and skin thickening (76.9%) were the most observed manifestations. Gastrointestinal (62.8% vs 47.8%), pulmonary (59.5% vs 23%) and cardiac (12.8% vs 6.9%) involvement were significantly more prevalent in dcSSc compared to lcSSc (Table 1). 52.5% of patients were ACA positive and 21% anti-topoisomerase positive, with significant differences between lcSSc and dcSSc. One third of patients was treated with immunomodulators, 53.6% with vasodilators, 23% received glucocorticoids and 2.3% biologics.

During the median follow-up 12.4 years, 83 deaths (7.9%) were verified. The overall 1, 2 and 5 years survival was 98.0%, 96.8% and 92.6% respectively, without significant differences between lcSSc and dcSSc (Figure 1).

Conclusion:

Reuma.pt/SSc register is useful in routine patient monitoring and contributes to improve knowledge about this rare and complex disease. Clinical features of Portuguese SSc patients are similar to what has been described in other populations although the overall 5-year survival in recently diagnosed patients appears to be higher than previously reported.

Table 1.

Cumulative clinical and immunologic characteristics of Portuguese SSc patients

Clinical and immunologic featuresTotalN=1054Limited cutaneous SScN= 576 (56.3%)Diffuse cutaneous SScN=180 (17.5%)P valueSkin involvement – N(%) N=987688 (90.6)525 (90.7)180 (100)<0.01Skin thickening * – N (%) N= 962680 (76.9)512 (88.9)180 (100)<0.01Digital ulcers – N (%) N=970325(33.5)186 (34.7)4 (51.5)<0.01Raynaud’s Phenomenon – N (%) N=1010943 (93.4)539 (95.7)157 (92.4)0.06Musculoskeletal involvement – N(%) N=972346 (45.6)247 (42.7)99 (55)<0.01Cardiac involvement –N(%) – N=92471 (7.7)36 (6.9)19 (12.8)0.02Renal involvement –N(%) – N= 91717 (1.9)8!1.5)6 (4.1)0.07Gastrointestinal involvement - N(%) N=933508 (48.2)277 (47.8)113 (62.8)<0.01Pulmonary involvement – N(%) N=915261 (28.5)119 (23)88 (59.5)<0.01PAH – N(%) N= 87114 (1.6)10 (2)1 (0.7)0.23Intersticial lung disease – N(%) N=765218 (28.5)100 (22.7)75 (57.7)<0.01Antinuclear antibodies - N(%) N=1040934 (89.8)522 (90.2)154 (88.5)0.57Anti-centromere – N(%) N= 1027540 (52.6)383 (67.1)16 (9.5)<0.01Anti-Scl70 – N(%) N=1020214 (21)12 (3.3)104 (60.1)<0.01Anti-RNA polymerase III – N(%) N=71025 (3.5)12 (3.3)7 (5.6)0.38ComorbiditiesHypertension – N(%) N=431117 (27.1)76 (29.7)67 (20.7)0.1Hyperlipidemia – N(%) N=43171 (13.4)72 (12.2)24 (15.9)0.08Neoplasia – N(%) N=105429 (2.8)12 (2.1)7 (3.9)0.14

PDE-5 (phosdiasterase-5); PPIs (proton pump inhibitors); PAH-Pulmonary arterial hypertension confirmed by right heart catheterization. Immunomodulators includes Metothrexate, Leflunomide, Hydroxycloroquine; Azathioprine, Mycophenolate Mofetil and Cyclophosphamide; * Does not include sclerodactyly.

Figure 1.

Panel A - Survival in years from diagnosis of patients with SSc included in Reuma.pt in the first 2 years of disease (N=472). Panel B - survival according to SSc subset (lcSSc and dcSSC).

Disclosure of Interests:

None declared

THU0632-HPR DETERMINANTS OF HAPPINESS AND QUALITY OF LIFE IN PEOPLE WITH SYSTEMIC SCLEROSIS: A STRUCTURAL EQUATION MODELLING APPROACH

Background:

In recent years more attention has been given to patients reported outcomes (PROs). Systemic sclerosis (SSc) is no exception. As there is no effective treatment or cure to SSc, it is important to recognize the relevance to patients of the different features of the disease to improve quality and enjoyment of life: the ultimate targets of therapy. Remarkably lacking in PROs is the evaluation of the overall perspective of subjective well being, equivalent to ‘happiness’ or “positive psychological dimensions”.

Objectives:

To examine the determinants of happiness and quality of life (QoL) in patients with SSc with emphasis on disease activity, disease impact and personality traits.

Methods:

This is an observational, cross-sectional and multicenter study from six rheumatology clinics in Portugal. A total of 113 patients with SSc with a complete set of data on disease activity, disease impact, personality, quality of life and happiness were included.

Structural equation modelling (latent variable structural model) was used to estimate the association between the variables using a maximum likelihood estimation with Satorra-Bentler’s correction and performed with STATA® 15.0. Two hypotheses were pursued: H1 – Disease activity and impact of disease are negatively associated to overall QoL and happiness; H2 – ‘Positive’ personality traits are related to happiness both directly and indirectly through perceived disease impact.

Results:

Results obtained in the structural equation measurement model indicated a good fit [χ2/df=1.44; CFI=0.93; TLI=0.90; RMSEA=0.06] and supported all driving hypotheses (Figure 1). Happiness was positively related to ‘positive’ personality (β=0.45, p=0.01) and, to a lesser extent, negatively related with impact of disease (β=-0.32; p=0.01). This impact, in turn, was positively related to EUSTAR activity score (β=0.37; p<0.001) and mitigated by ‘positive’ personality traits (β=-0.57; p<0.001). Impact of disease had a much stronger relation with QoL than with happiness (β=-0.78, p<0.001). Quality of life and happiness had no statistically significant relationship.

Conclusion:

Optimization of Qol and happiness in people with SSc requires effective control of the disease process. Personality and its effects upon the patient´s perception of the disease impact, seems to play a pivotal mediating role in these relations and should deserve paramount attention if happiness and enjoyment of life is taken as the ultimate goal of health care.

Disclosure of Interests:

Tânia Santiago: None declared, Eduardo Santos: None declared, Ana Catarina Duarte: None declared, Patrícia Martins: None declared, Marlene Sousa: None declared, Franscisca Guimarães: None declared, Soraia Azevedo: None declared, Raquel Ferreira: None declared, Miguel Guerra: None declared, Ana Cordeiro Consultant of: Ana Cordeiro has acted as a consultant for Roche, Speakers bureau: Ana Cordeiro has received speaker fees from Boehringer Ingelheim, Lilly, and Vitoria, Inês Cordeiro: None declared, Sofia Pimenta: None declared, Patrícia Pinto: None declared, Maria Joao Salvador: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis

Rheumatology practice amidst the COVID-19 pandemic: a pragmatic view

The coronavirus disease 2019 (COVID-19) pandemic has come with many challenges for healthcare providers and patients alike. In addition to the direct burden it has placed on societies and health systems, it had a significant impact in the care of patients with chronic diseases, as healthcare resources were deployed to fight the crisis, and major travel and social restrictions were adopted. In the field of rheumatology, this has required notable efforts from departments and clinicians to adapt to the novel status quo and assure the follow-up of patients with rheumatic and musculoskeletal diseases. In the present viewpoint, we provide a practical approach to tackle this reality. Key measures include setting up preventive team management strategies, optimising communication with patients and reorganising patient care in all its dimensions. We then anticipate the nuances of rheumatology practice as restrictive measures are progressively lifted, while an effective vaccine is still pending. This includes the need to reimpose the same strategy as further waves unfold. Finally, we look ahead and address the lessons we can incorporate into post-COVID-19 rheumatology.

AB0589 THE IMPORTANCE OF A SYSTEMIC SCLEROSIS CLINIC IN A TERTIARY REFERRAL CENTER – A PORTUGUESE EXPERIENCE

Background:

Systemic sclerosis (SSc) is a rare systemic rheumatic disease (SRD) characterized by small vessel inflammation and fibrosis of skin and internal organs. Pulmonary and cardiac involvement contribute to both morbidity and mortality associated with the disease. A multidisciplinary approach with strict monitoring is therefore key to attain clinical success.

Objectives:

To describe the organization and patient pathways of our SSc outpatient clinic.

Methods:

Observational study using data extracted from Reuma.pt/SSc (a subset of the Rheumatic Diseases Portuguese Register). Data extracted included demographic variables and clinical and immunological manifestations. The disease was classified according to the 2013 ACR/EULAR criteria. Our SSc clinic is managed by two dedicated Rheumatologists and up to two Rheumatology residents on a weekly basis, but it is a dynamic multidisciplinary clinic where various medical specialties collaborate closely. There are two associated subspecialty clinics (pulmonary hypertension and pulmonary fibrosis) where the Rheumatologists engage with pneumologists and cardiologists, allowing greater collaboration in the management of these patients. Patients’ data is systematically registered in Reuma.pt/SSc as a part of the routine activity of this clinic, contributing to real-world data on SSc.

Results:

A total of 220 patients were registered between July 2011 and June 2019. 196 (89.1%) were female, with a mean age of 58.9±14 years and a mean disease duration of 14.6±9 years. Ninety-seven patients (44.1%) had limited cutaneous SSc, 52 (23.6%) had diffuse cutaneous SSc, 35 (15.9%) had overlap SSc, 24 (10.9%) had preclinical SSc and 12 (5.4%) had SSc sine scleroderma. Raynaud phenomenon was present in 92% of the SSc patients and 40% had a history of digital ulcers. Gastrointestinal manifestations included esophageal dismotility in 39.5% of patients, gastric disease in 24.4% and intestinal involvement in 15.5%. Pulmonary involvement was found in 47.6% of SSc patients, heart disease in 43.6% and kidney involvement in only two patients. Antinuclear antibodies were positive in 92.2% of the patients, anti-centromere in 44.1%, anti-topoisomerase I antibodies in 39.1%, anti-U1RNP in 4.5% and only three patients had anti-PM-Scl and one had anti-RNA polymerase III. 31 patients were lost to follow-up and 32 died. 18 patients are currently being followed up in the pulmonary hypertension clinic and seven in the pulmonary fibrosis clinic.

Conclusion:

The implementation of a standardized approach with regular multidisciplinary work has proven very helpful in evaluating patients with SSc. The continuous registry of patients in Reuma.pt/SSc has been essential for patient care, research and healthcare planning.

Disclosure of Interests:

None declared

AB0590 CLINICAL AND DEMOGRAPHIC CHARACTERISTICS OF PATIENTS WITH ANTISYNTHETASE AUTOANTIBODIES: DATA FROM A PORTUGUESE TERTIARY OUTPATIENT CLINIC

Background:

Antisynthetase syndrome (AS) may have different clinical phenotypes and outcomes associated with different anti-aminoacyl RNA-synthetase (anti-ARS). Patients may also present with incomplete/early phenotypes that do not fulfil the classification criteria.

Objectives:

To evaluate the clinical and demographic characteristics of patients positive for anti-ARS in our Myositis clinic.

Methods:

Observational study using data from the Portuguese Rheumatic Diseases Register (Reuma.pt/Myositis protocol). Data extracted included demographic variables, clinical features and immunological expression of the disease.

Results:

17 patients were identified. All met the criteria for AS according to Connors criteria, while 3 did not met according to the Solomon criteria. Mean age at diagnosis was 60.1 years (26 - 80) and 76.5% were female. Mean follow-up time was 2.8 (0.5-9) years. Only 3 patients had history of smoking in the past. The autoantibodies expressed were anti-Jo1 (n=12), anti-PL12 (n=2), anti-OJ (n=2) and anti-PL7 (n=1). 4 patients positive for anti-Jo-1 also expressed anti-Ro52. The clinical information and treatment are described in table 1. One patient presented as a paraneoplastic syndrome associated with anti-Jo-1.

Table 1.

Demographic and clinic characteristics of our cohort. AZA – azathioprine; CYC – Cyclophosphamide; DM – dermatomyositis; GS – Gottron’s sign; ILD – Interstitial lung disease; PM – Polymyositis; NSIP - Nonspecific interstitial pneumonia; MH – mechanic hands; MMF - Mycophenolate mofetil; MTX – Methotrexate; PDN – prednisolone; RP – Raynaud phenomenon; RTX – Rituximab; UIP - Usual interstitial pneumonia; Y – yes; N – no. Connors criteria – anti-ARS plus one or more of RP, MH, arthritis, ILD, fever. Solomon criteria – anti-ARS plus 2 major criteria or 1 major and 2 minor criteria. *induction therapy.

CaseSerologyMajor criteria (ILD [NSIP/UIP/non-specific] or PM/DM)Minor criteria (Arthritis, MH, RP)Other manifestationsConnors (2010)/ Solomon (2011) criteriaPDNDMARDcs (MTX/MMF/AZA)CYC/RTX1Jo1PMMH, arthritisGSY/YYMMF-2Jo1NSIPRP, MHAstheniaY/YYAZA-3Jo1NSIPMH, arthritisCalcinosis, astheniaY/YYAZA-4Jo1NSIP; DM-GSY/YY--5Jo1/Ro52PMMH, arthritisGS, astheniaY/YYMTX-6Jo1UIPRP, arthritisAstheniaY/YY-RTX7Jo1/Ro52NSIP; PMarthritis-Y/YYMMFCYC*8Jo1NSIP; PM--Y/YYMMF-9Jo1/Ro52NSIP; PM--Y/YYAZA-10PL7-RP, arthritis, MHDysphagiaY/NY--11Jo1-RPAstheniaY/N---12Jo1/Ro52PMMH, arthritisGS, astheniaY/YYMMF-13PL12PMRP, arthritisGS, astheniaY/YYMMF-14Jo1UIPRP, arthritisWeight loss, astheniaY/YY-RTX15OJNon-specific pattern--Y/NYMMF-16OJNSIP--Y/YY--17PL12PMRP, MH-Y/Y---

Conclusion:

The most frequent autoantibody was anti-Jo-1, which is consistent with the literature. Interestingly, patients with anti-PL, usually described as having severe lung disease, in our series do not have it. Additionally, we found a trend for a younger age at diagnosis in Jo1 positive patients and remarkably more than half of these patients have been diagnosed with ILD, being the NSIP pattern the most frequently reported.

Disclosure of Interests:

None declared

Reuma.pt/vasculitis - the Portuguese vasculitis registry

Background

The vasculitides are a group of rare diseases with different manifestations and outcomes. New therapeutic options have led to the need for long-term registries. The Rheumatic Diseases Portuguese Register, Reuma.pt, is a web-based electronic clinical record, created in 2008, which currently includes specific modules for 12 diseases and > 20,000 patients registered from 79 rheumatology centres. On October 2014, a dedicated module for vasculitis was created as part of the European Vasculitis Society collaborative network, enabling prospective collection and central storage of encrypted data from patients with this condition. All Portuguese rheumatology centres were invited to participate. Data regarding demographics, diagnosis, classification criteria, assessment tools, and treatment were collected. We aim to describe the structure of Reuma.pt/vasculitis and characterize the patients registered since its development.

Results

A total of 687 patients, with 1945 visits, from 13 centres were registered; mean age was 53.4 ± 19.3 years at last visit and 68.7% were females. The most common diagnoses were Behçet’s disease (BD) (42.5%) and giant cell arteritis (GCA) (17.8%). Patients with BD met the International Study Group criteria and the International Criteria for BD in 85.3 and 97.2% of cases, respectively. Within the most common small- and medium-vessel vasculitides registered, median [interquartile range] Birmingham Vasculitis Activity Score (BVAS) at first visit was highest in patients with ANCA-associated vasculitis (AAV) (17.0 [12.0]); there were no differences in the proportion of patients with AAV or polyarteritis nodosa who relapsed (BVAS≥1) or had a major relapse (≥1 major BVAS item) during prospective assessment (p = 1.00, p = 0.479). Biologic treatment was prescribed in 0.8% of patients with GCA, 26.7% of patients with AAV, and 7.6% of patients with BD. There were 34 (4.9%) deaths reported.

Conclusions

Reuma.pt/vasculitis is a bespoke web-based registry adapted for routine care of patients with this form of rare and complex diseases, allowing an efficient data-repository at a national level with the potential to link with other international databases. It facilitates research, trials recruitment, service planning and benchmarking.

Phylogeny and biogeography of Astraea with new insights into the evolutionary history of Crotoneae (Euphorbiaceae)

We investigated species relationships in Astraea, a primarily Neotropical genus of tribe Crotoneae centered in Brazil, using data from the nuclear ribosomal ITS, and the plastid trnL-trnF and psbA-trnH spacers. With all species of Astraea sampled, along with representatives from across Crotoneae, the evolutionary history of Astraea was interpreted in a broader framework, as well as divergence time estimates and reconstructions of ancestral areas and morphological character states for Crotoneae. Our results show that Astraea is monophyletic, consisting of three main clades, and that most of its diversification took place from the Oligocene to the Pliocene, coincident with the formation of the South American "dry diagonal". As for Crotoneae, our data show incongruent phylogenetic positions between the nuclear and chloroplast data for most of its genera, and that the ancestor of the tribe was probably arborescent and might have occupied the Amazon Basin, most likely in moist forest, from which it spread throughout South America in the early Eocene. Ancestral state reconstruction recovered deeply lobed leaves and staminate petals bearing moniliform trichomes as putative synapomorphies for Astraea, whereas the absence or strong reduction of pistillate petals is widespread in Crotoneae and may be a synapomorphy for the tribe.

Structure and development of flowers and inflorescences in Peraceae and Euphorbiaceae and the evolution of pseudanthia in Malpighiales

Pseudanthia are reduced and compact inflorescences which apparently had independent evolution in Euphorbiaceae and Peraceae within Malpighiales. In order to analyze the hypothesis that the different pseudanthia found in Malpighiales have non-homologous developmental steps, we studied the inflorescence and flower development in the three Malpighiales genera that present this type of inflorescence–Dalechampia (Acalyphoideae/Euphorbiaceae), Euphorbia (Euphorbioideae/Euphorbiaceae), and Pera (Peraceae)–and compared them to that of Joannesia (Crotonoideae/Euphorbiaceae), which does not present a pseudanthium. Inflorescences and flowers were analyzed using light microscopy and scanning electron microscopy. Dalechampia and Euphorbia have protogynic bisexual pseudanthia, with unisexual perianthed flowers in Dalechampia, and achlamydeous flowers in Euphorbia. Pera has unisexual pseudanthia and the male flowers have a vestigial calyx and the female flowers are achlamydeous. Joannesia flowers are very distinct when compared to the pseudanthia flowers, as they are composed of all the whorls and there is no reduction. In the early stages of development, the first structures to be formed in the pseudanthia are the different series of bracts, including outer, involucral and involucel bracts. The floral primordia are initiated almost simultaneously with the involucre. Although the different morphology, the early inflorescence followed the same branching pattern in all studied genera, and the number and elongation of the branches were affected by the early female flower development in the terminal position. We suggest that the different pseudanthia evolved via process of floral whorl reduction and reorganization of flowers in the inflorescence axes, especially the position of female and male flowers and elongation or shortening of the branches. The sex of the terminal flower is a developmental key, i.e., the protogynic development deeply affects the pseudanthia growth, reducing the ramification and elongation of the axes.

Telerheumatology - breaking barriers to access care in Rheumatology

Telehealth applied to rheumatology, known as telerheumatology, is an emerging trend in healthcare in many countries. It constitutes a promising approach with the potential to anticipate the contact of patients from remote areas with Rheumatologists, leading to earlier diagnosis and treatment, and thus probably to better long-term outcomes. Telerheumatology under the scope of International collaborations may also improve the access of the PALOP population to Rheumatology care, resulting in proper shared decisions for patient's evacuation, preventing family separation and reducing the costs associated to intercontinental dislocations.

Flora do Espírito Santo: Phyllanthus (Phyllanthaceae)

Resumo Phyllanthus, com cerca de 1.270 espécies, é pantropical, mas também ocorre em regiões temperadas de todo o planeta. No Brasil são registradas cerca de 100 espécies, que ocorrem em florestas, cerrados, campos e nas caatingas. O objetivo do presente trabalho foi estudar a taxonomia das espécies do gênero ocorrentes no estado do Espírito Santo. Para cada uma delas é indicada a coleções tipo, descrição, ilustração, chave de identificação, distribuição geográfica, período de floração e frutificação, além de comentários sobre caracteres morfológicos diagnósticos.

Chemical Composition, Antifungal and Antioxidant Activities of Hedyosmum brasiliense Mart. ex Miq. (Chloranthaceae) Essential Oils

Background: Hedyosmum brasiliense Mart. ex Miq. (Chloranthaceae) is a dioecious shrub popularly used in Brazil to treat foot fungi and rheumatism. This work investigated the chemical composition, antifungal, and antioxidant activities of flowers and leaves of H. brasiliense essential oils; Methods: H. brasiliense male and female flowers and leaves were collected at Ilha do Cardoso (São Paulo) and the essential oils were extracted by hydrodistillation and analyzed by GC/MS and their similarity compared by Principal Component Analysis. Antifungal activity was performed by bioautography and antioxidant potential by 2,2-diphenyl-2-picrylhydrazyl hydrate (DPPH) free radical scavenging and β-carotene/linoleic acid system; Results: The major compounds for all oils were sabinene, curzerene, and carotol, but some differences in their chemical composition were discriminated by Principal Component Analysis (PCA) analysis. Bioautography showed two antifungal bands at Rf's 0.67 and 0.12 in all samples, the first one was identified as curzerene. The oils presented stronger antioxidant potential in β-carotene/linoleic acid bioassay, with IC₅₀'s from 80 to 180 μg/mL, than in DPPH assay, with IC₅₀'s from 2516.18 to 3783.49 μg/mL; Conclusions: These results suggested that curzerene might be responsible for the antifungal activity of H. brasiliense essential oils. Besides, these essential oils exhibited potential to prevent lipoperoxidation, but they have a weak radical scavenger activity.

Chemical Composition, Antimicrobial and Antioxidant Activities of Essential Oils from Two Avicennia schaueriana Stapf & Leechm. Ex Moldenke (Acanthaceae) Populations

BACKGROUND

Avicennia schaueriana Stapf &amp; Leechm. ex Moldenke (Acanthaceae) is a native species from the Brazilian mangroves presenting ecological and economic significance. This study compared the composition and the biological activities from the essential oils obtained from two A. schaueriana populations collected at Jureia-Itatins and Ilha do Cardoso.

METHODS

Essential oils were obtained by conventional means, and their compositions were analyzed by GC-MS. Screening assays for antimicrobial activity were carried out by the microdilution method and the antioxidant potential was assessed by the DPPH scavenging method.

RESULTS

The GC-MS analysis indicated that the Jureia oil (1) was composed mostly of the fatty acids palmitic (46.5%) and myristic (11.6%) acids, while the main components for the Ilha do Cardoso oil (2) were eugenol (19.7%), eugenol acetate (12.9%) and palmitic acid (15.1%). The oils showed an IC50 of 0.9 ± 0.011 mg/mL for 1 and 1.13 ± 0.028 mg/mL for 2 in the DPPH assay. The antimicrobial assay indicated MIC > 217 µg/mL for all tested microorganisms.

CONCLUSIONS

The different essential oil composition may indicate the presence of chemotypes for A. schaueriana. The antioxidant activity of the oils was weak if compared with flavonoids. Despite the high MIC values, these oils presented some antibacterial potential against Pseudomonas aeruginosa.

Efficacy and Safety of Vaccination in Pediatric Patients with Systemic Inflammatory Rheumatic Diseases: a systematic review of the literature

INTRODUCTION

Children and adolescents with systemic rheumatic diseases have an increased risk of infections. Although some infections are vaccine-preventable, immunization among patients with juvenile rheumatic diseases is suboptimal, partly due to some doubts that still persist regarding its efficacy and safety in this patient population.

OBJECTIVES

To review the available evidence regarding the immunological response and the safety of vaccination in children and adolescents with systemic inflammatory rheumatic diseases (SIRD).

METHODS

A systematic review of the current literature until December 2014 using MEDLINE, EMBASE and abstracts from the American College of Rheumatology and European League Against Rheumatism congresses (2011-2014), complemented by hand search was performed. Eligible studies were identified and efficacy (seroprotection and/or seroconversion) and safety (reactions to vaccine and relapse of rheumatic disease) outcomes were extracted and summarized according to the type of vaccine.

RESULTS

Twenty-eight articles concerning vaccination in pediatric patients with SIRDs were found, that included almost 2100 children and adolescents, comprising nearly all standard vaccinations of the recommended immunization schedule. Children with SIRDs generally achieved seroprotection and seroconversion; nevertheless, the antibody levels were often lower when compared with healthy children. Glucocorticoids and conventional disease-modifying anti-rheumatic drugs do not seem to significantly hamper the immune responses, whereas TNF inhibitors may reduce antibody production, particularly in response to pneumococcal conjugate, influenza, meningococcal C and hepatitis A vaccine. There were no serious adverse events, nor evidence of a relevant worsening of the underlying rheumatic disease. Concerning live attenuated vaccines, the evidence is scarce, but no episodes of overt disease were reported, even in patients under biological therapy.

CONCLUSIONS

Existing literature demonstrates that vaccines are generally well tolerated and effective in stable SIRD patients, yet antibody titers are frequently lower than in healthy controls. There is some evidence that biological therapy could hamper the immune response. Data on safety of live attenuated vaccines is limited. Although the available literature covers most vaccines included in the national immunization plan, there is a need for more information regarding new vaccines and new anti-rheumatic therapies.

Juvenile idiopathic arthritis in adulthood: fulfilment of classification criteria for adult rheumatic diseases, long-term outcomes and predictors of inactive disease, functional status and damage

Objectives

To determine how adult juvenile idiopathic arthritis (JIA) patients fulfil classification criteria for adult rheumatic diseases, evaluate their outcomes and determine clinical predictors of inactive disease, functional status and damage.

Methods

Patients with JIA registered on the Rheumatic Diseases Portuguese Register (Reuma.pt) older than 18 years and with more than 5 years of disease duration were included. Data regarding sociodemographic features, fulfilment of adult classification criteria, Health Assessment Questionnaire, Juvenile Arthritis Damage Index—articular (JADI-A) and Juvenile Arthritis Damage Index—extra-articular (JADI-E) damage index and disease activity were analysed.

Results

426 patients were included. Most of patients with systemic JIA fulfilled criteria for Adult Still's disease. 95.6% of the patients with rheumatoid factor (RF)-positive polyarthritis and 57.1% of the patients with RF-negative polyarthritis matched criteria for rheumatoid arthritis (RA). 38.9% of the patients with extended oligoarthritis were classified as RA while 34.8% of the patients with persistent oligoarthritis were classified as spondyloarthritis. Patients with enthesitis-related arthritis fulfilled criteria for spondyloarthritis in 94.7%. Patients with psoriatic arthritis maintained this classification. Patients with inactive disease had lower disease duration, lower diagnosis delay and corticosteroids exposure. Longer disease duration was associated with higher HAQ, JADI-A and JADI-E. Higher JADI-A was also associated with biological treatment and retirement due to JIA disability and higher JADI-E with corticosteroids exposure. Younger age at disease onset was predictive of higher HAQ, JADI-A and JADI-E and decreased the chance of inactive disease.

Conclusions

Most of the included patients fulfilled classification criteria for adult rheumatic diseases, maintain active disease and have functional impairment. Younger age at disease onset was predictive of higher disability and decreased the chance of inactive disease.

Recommendations for Vaccination in Adult Patients with Systemic Inflammatory Rheumatic Diseases from the Portuguese Society of Rheumatology

BACKGROUND

Serious infections are a major cause of morbidity and mortality in systemic inflammatory rheumatic disease (SIRD) patients. Although vaccination may prevent numerous infections, vaccination uptake rates are low in this group of patients.

OBJECTIVES

To develop evidence-based recommendations for vaccination in SIRD patients.

METHODS

We searched MEDLINE (until 31 October 2014) and EMBASE (until 14 December 2014) databases, as well as the ACR and EULAR congress abstracts (2011-2014). Patients with any systemic inflammatory rheumatic disease were included and all vaccines were considered. Any safety and efficacy outcomes were admitted. Search results were submitted to title and abstract selection, followed by detailed review of suitable studies. Data were subsequently pooled according to the type of vaccine and the SIRD considered. Results were presented and discussed by a multidisciplinary panel and systematic literature review (SLR)-derived recommendations were voted according to the Delphi method. The level of agreement among rheumatologists was assessed using an online survey.

RESULTS

Eight general and seven vaccine-specific recommendations were formulated. Briefly, immunization status should routinely be assessed in all SIRD patients. The National Vaccination Program should be followed and some additional vaccines are recommended. To maximize the efficacy of vaccination, vaccines should preferably be administered 4 weeks before starting immunosuppression or, if possible when disease activity is controlled. Non-live vaccines are safe in SIRD, including immunosuppressed patients. The safety of live attenuated vaccines in immunosuppressed patients deserves further ascertainment, but might be considered in particular situations.

DISCUSSION

The present recommendations combine scientific evidence with the multidisciplinary expertise of our taskforce panel and attained desirable agreement among Portuguese rheumatologists. Vaccination recommendations need to be updated on a regular basis, as more scientific data regarding vaccination efficacy and safety, emergent infectious threats, new vaccines as well as new immunomodulatory therapies become available.

Foliar secretory structures in Crotoneae (Euphorbiaceae): Diversity, anatomy, and evolutionary significance

PREMISE OF THE STUDY

Phylogenetic and morphological studies have helped clarify the systematics of large and complex groups such as the tribe Crotoneae (Euphorbiaceae). However, very little is known about the diversity, structure, and function of anatomical features in this tribe. Crotoneae comprises the species-rich pantropical genus Croton and six small neotropical genera. Here we characterized the anatomy of leaf secretory structures in members of this tribe and explored their function and evolutionary significance.

METHODS

Young and mature leaves of 26 species were studied using standard anatomical light microscopy techniques. Three sections of Croton and one representative of Brasiliocroton and Astraea were sampled.

KEY RESULTS

We identified five types of secretory structures: laticifers, colleters, extrafloral nectaries, idioblasts, and secretory trichomes. Laticifers were present in all species studied except Croton alabamensis, which instead presented secretory parenchyma cells. Articulated laticifers are reported in Crotoneae for the first time. Colleters of the standard type were observed in the majority of the sampled taxa. Extrafloral nectaries were present in section Cleodora and in B. mamoninha, but absent in section Lamprocroton and Astraea lobata. Idioblasts were spread throughout the palisade and/or spongy parenchyma in most of the studied species. Secretory trichomes were restricted to Lamprocroton except for C. imbricatus.

CONCLUSIONS

This study revealed a high diversity of secretory structures, including novel ones, in one of the largest clades of Euphorbiaceae. Our results are promising for investigations on the anatomical and ecophysiological bases of species diversification within Euphorbiaceae.

Growing knowledge: an overview of Seed Plant diversity in Brazil

Abstract An updated inventory of Brazilian seed plants is presented and offers important insights into the country's biodiversity. This work started in 2010, with the publication of the Plants and Fungi Catalogue, and has been updated since by more than 430 specialists working online. Brazil is home to 32,086 native Angiosperms and 23 native Gymnosperms, showing an increase of 3% in its species richness in relation to 2010. The Amazon Rainforest is the richest Brazilian biome for Gymnosperms, while the Atlantic Rainforest is the richest one for Angiosperms. There was a considerable increment in the number of species and endemism rates for biomes, except for the Amazon that showed a decrease of 2.5% of recorded endemics. However, well over half of Brazillian seed plant species (57.4%) is endemic to this territory. The proportion of life-forms varies among different biomes: trees are more expressive in the Amazon and Atlantic Rainforest biomes while herbs predominate in the Pampa, and lianas are more expressive in the Amazon, Atlantic Rainforest, and Pantanal. This compilation serves not only to quantify Brazilian biodiversity, but also to highlight areas where there information is lacking and to provide a framework for the challenge faced in conserving Brazil's unique and diverse flora.

Phyllanthus (Phyllanthaceae) no estado do Rio de Janeiro

Phyllanthus ocorre em quase todas as regiões do planeta. No Brasil são registradas cerca de 100 espécies, que ocorrem em florestas, cerrados, campos e nas caatingas. O objetivo do presente trabalho foi estudar as espécies de Phyllanthus ocorrentes no estado do Rio de Janeiro, contribuindo para o Projeto "Flora Fanerogâmica do Estado do Rio de Janeiro". Para cada uma das espécies é indicada a obra original, coleções-tipo, distribuição geográfica, período de floração e frutificação, além de comentários sobre caracteres morfológicos diagnósticos. Além disso, foram propostos alguns novos sinônimos e apresentadas ilustrações originais de algumas espécies, bem com uma chave de identificação para as 20 espécies do gênero encontradas no estado.

Portuguese recommendations for the diagnosis and management of gout

OBJECTIVE

To develop Portuguese evidence-based recommendations for the Diagnosis and Management of Gout.

METHODS

As part of the 3e Initiative (Evidence, Expertise and Exchange), a panel of 78 international rheumatologists developed 10 relevant clinical questions which were investigated with systematic literature reviews. MEDLINE, EMBASE, Cochrane CENTRAL and abstracts from 2010-2011 EULAR and ACR meetings were searched. Based on the evidence found in the published literature, rheumatologists from 14 countries developed national recommendations that were merged and voted into multinational recommendations. We present the Portuguese recommendations for the Diagnosis and Management of Gout which were formulated and voted by Delphi method in April 2012, in Lisbon. The level of agreement and potential impact in clinical practice was also assessed.

RESULTS

Twelve national recommendations were elaborated from 10 international and 2 national questions. These recommendations addressed the diagnosis of gout; the treatment of acute flares and urate-lowering therapy; monitoring of gout and comorbidity screening; the influence of comorbidities in drug choice; lifestyle; flare prophylaxis; management of tophi and asymptomatic hyperuricaemia; the role of urine alkalinization; and the burden of gout. The level of agreement with the recommendations ranged from 6.8 to 9.0 (mean 7.7) on a 1-10 point visual analogue scale, in which 10 stands for full agreement.

CONCLUSION

The 12 Portuguese recommendations for the Diagnosis and Management of Gout were formulated according to the best evidence and endorsed by a panel of 42 rheumatologists, enhancing their validity and practical use in daily clinical practice.

The Portuguese Society of Rheumatology position paper on the use of biosimilars

Biotechnological drugs have become a fundamental resource for the treatment of rheumatic patients. Patent expiry of some of these drugs created the opportunity for biopharmaceutical manufacturers to develop biosimilar drugs intended to be as efficacious as the originator product but with a lower cost to healthcare systems. Due to the complex manufacturing process and highly intricate structure of biologicals, a biosimilar can never be an exact copy of its reference product. Consequently, regulatory authorities issued strict preclinical and clinical guidelines to ensure safety and efficacy equivalence and, in September 2013, the biosimilar of infliximab was the first biosimilar monoclonal antibody to be authorized for use in the European Union. The current document is a position statement of the "Sociedade Portuguesa de Reumatologia" (Portuguese Society of Rheumatology) on the use of biosimilar drugs in rheumatic diseases. Two systematic literature reviews were performed, one concerning clinical trials and the other one concerning international position papers on biosimilars. The results were presented and discussed in a national meeting and a final position document was discussed, written and approved by Portuguese rheumatologists. Briefly, this position statement is contrary to automatic substitution of the originator by the biosimilar, defends either a different INN or the prescription by brand name, supports that switching between biosimilars and the originator molecule should be done after at least 6 months of treatment and based on the attending physician decision and after adequate patient information, recommends the registration of all biosimilar treated patients in Reuma.pt for efficacy, safety and immunogenicity surveillance, following the strategy already ongoing for originators, and opposes to extrapolation of indications approved to the originator to completely different diseases and/or age groups without adequate pre-clinical, safety or efficacy data.

Pharmacology of biosimilar candidate drugs in rheumatology: a literature review

OBJECTIVE

To review current evidence concerning pharmacology of biosimilar candidates to be used in rheumatology.

METHODS

A PubMed search up to August 2013 was performed using relevant search terms to include all studies assessing pharmacological properties of biosimilar candidates to be used in rheumatology. Data on study characteristics, type of intervention, pharmacokinetics (PK), pharmacodynamics (PD) and bioequivalence ratios was extracted.

RESULTS

Of 280 articles screened, 5 fulfilled our inclusion criteria. Two trials, PLANETAS and PLANETRA, compared CT-P13 and infliximab in patients with active ankylosing spondylitis and rheumatoid arthritis, respectively. PK bioequivalence was demonstrated in the phase 1 PLANETAS trial by highly comparable area under the curve (AUC) and maximum drug concentrations (Cmax), whose geometric mean ratios fell between the accepted bioequivalence range of 80-125%. Equivalence in efficacy and safety was demonstrated in the phase 3 PLANETRA trial. Two phase 1 trials comparing etanercept biosimilar candidates TuNEX and HD203 in healthy volunteers showed a high degree of similarity in AUC and Cmax, with respective geometric mean ratios between PK bioequivalence range. The last included trial referred to GP2013, a rituximab biosimilar candidate, which demonstrated PK and PD bioequivalence to reference product in three different dosing regimens in cynomolgus monkeys.

CONCLUSION

Infliximab, etanercept and rituximab biosimilar candidates have demonstrated PK bioequivalence in the trials included in this review. CT-P13 has recently been approved for use in the European market and the remaining biosimilar candidates are currently being tested in patients with rheumatoid arthritis.