A novel estimate of biological aging by multiple fitness tests is associated with risk scores for age-related diseases

Introduction: Recent research highlights the need for a correct instrument for monitoring the individual health status, especially in the elderly. Different definitions of biological aging have been proposed, with a consistent positive association of physical activity and physical fitness with decelerated aging trajectories. The six-minute walking test is considered the current gold standard for estimating the individual fitness status in the elderly. Methods: In this study, we investigated the possibility of overcoming the main limitations of assessing fitness status based on a single measure. As a result, we developed a novel measure of fitness status based on multiple fitness tests. In 176 Sardinian individuals aged 51-80 years we collected the results of eight fitness tests to measure participants' functional mobility, gait, aerobic condition, endurance, upper and lower limb strength, and static and dynamic balance. In addition, the participants' state of health was estimated through validated risk scores for cardiovascular diseases, diabetes, mortality, and a comorbidity index. Results: Six measures contributing to fitness age were extracted, with TUG showing the largest contribution (beta = 2.23 SDs), followed by handgrip strength (beta = -1.98 SDs) and 6MWT distance (beta = -1.11 SDs). Based on fitness age estimates, we developed a biological aging measure using an elastic net model regression as a linear combination of the results of the fitness tests described above. Our newly developed biomarker was significantly associated with risk scores for cardiovascular events (ACC-AHA: r = 0.61; p = 0.0006; MESA: r = 0.21; p = 0.002) and mortality (Levine mortality score: r = 0.90; p = 0.0002) and outperformed the previous definition of fitness status based on the six-minute walking test in predicting an individual health status. Discussion: Our results indicate that a composite measure of biological age based on multiple fitness tests may be helpful for screening and monitoring strategies in clinical practice. However, additional studies are needed to test standardisation and to calibrate and validate the present results.

Diagnostic accuracy of ultrasound signs for detecting adnexal torsion: systematic review and meta-analysis

OBJECTIVE

To evaluate the diagnostic accuracy of different ultrasound signs for diagnosing adnexal torsion, using surgery as the reference standard.

METHODS

This was a systematic review and meta-analysis of studies published between January 1990 and November 2021 evaluating ovarian edema, adnexal mass, ovarian Doppler flow findings, the whirlpool sign and pelvic fluid as ultrasound signs (index tests) for detecting adnexal torsion, using surgical findings as the reference standard. The search for studies was performed in PubMed/MEDLINE, CINAHL, Scopus, The Cochrane Library, ClinicalTrials.gov and Web of Science databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to evaluate the quality of the studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios were calculated separately, and the post-test probability of adnexal torsion following a positive or negative test was also determined.

RESULTS

The search identified 1267 citations after excluding duplicates. Eighteen studies were ultimately included in the qualitative and quantitative syntheses. Eight studies (809 patients) analyzed the presence of ovarian edema, eight studies (1044 patients) analyzed the presence of an adnexal mass, 14 studies (1742 patients) analyzed ovarian Doppler flow, six studies (545 patients) analyzed the whirlpool sign and seven studies (981 patients) analyzed the presence of pelvic fluid as ultrasound signs of adnexal torsion. Overall, the quality of most studies was considered to be moderate or good. However, there was a high risk of bias in the patient-selection and index-text domains (with the exception of the whirlpool sign) in a significant proportion of studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios of each ultrasound sign were 58%, 86%, 4.0 and 0.49 for ovarian edema, 69%, 46%, 1.3 and 0.67 for adnexal mass, 65%, 91%, 7.6 and 0.38 for the whirlpool sign, 53%, 95%, 11.0 and 0.49 for ovarian Doppler findings and 55%, 69%, 1.7 and 0.66 for pelvic fluid. Heterogeneity was high for all analyses.

CONCLUSIONS

The presence of an adnexal mass or pelvic fluid have poor diagnostic accuracy as ultrasound signs of adnexal torsion, while the presence of ovarian edema, the whirlpool sign and decreased or absent ovarian Doppler flow have good specificity but moderate sensitivity for detecting adnexal torsion. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

AB0260 ASSOCIATION BETWEEN INFLAMMATION AND DEPRESSIVE SYMPTOMS IN RHEUMATOID ARTHRITIS PATIENTS

Background

Rheumatoid arthritis (RA) is an autoimmune, progressive disease characterized by an inflammatory process mediated by CD4+T lymphocytes leading to damage of the synovial membrane1. Its prevalence is estimated between 0.2 and 1.2% worldwide, affecting women in the fourth and fifth decades2. In 2013, the Mexican College of Rheumatology estimated a 1.6% prevalence3 in Mexico.

RA may affect patients´ social, psychological, economic and physical areas. Among its psychological implications, depression is one of the most important (with a prevalence of 40%) beyond the general population4. Several studies assess either prevalence or prognosis, despite its higher prevalence and a lesser likelihood of remission in these patients. Some investigations looked for a relationship between inflammation and depressive symptoms considering only clinical or biochemical parameters, despite the evidence supporting better results with imaging methods, such as musculoskeletal ultrasound (MSU).

Objectives

To identify the association between MSU demonstrated inflammation and the presence of depressive symptoms in RA patients.

Methods

In 2021 a cross-sectional study on RA patients (according to ACR/EULAR 2010 criteria) was conducted. The subjects were from the Instituto Nacional de Rehabilitación “Luis Guillermo Ibarra Ibarra” and Hospital Juárez de México Rheumatology out-patient clinic. Each patient underwent a clinical (SDAI, CDAI, and EVA), psychological (PHQ9 and InCaViSa questionnaires), and MSU assessment (7 joints score). Data described with central tendency and dispersion measures for quantitative variables and frequencies and proportions for qualitative variables. Kruskal Wallis, U Mann-Whitney and Spearman correlation tests for analysis done.

Results

Fifty-two patients (94% women) were evaluated, with a mean age of 56.06 (±12.31) years and duration of disease 13.66 (±9.44) years. Depression prevalence was 54%. Patients with disease activity had the highest depression scores (p=0.009), those with triggering events in the last six months (p=0.177), the leading event was the death of a close relative in 30% of the patients. A moderate correlation between the depression score (PHQ9) and clinical disease activity scores (SDAI, CDAI, VAS, and painful joints) (rho=0.553 [p<0.001], 0.559 [p<0.001], 0.492 [p<0.001], and 0.57 [p<0.001], respectively) were found. Furthermore, we found a moderate correlation between depression scores and psychological, social and physical quality of life. A mild correlation between MSU synovitis and depression scores (rho=0.315 [p=0.03]) found.

Conclusion

Patients with disease activity reported higher depression scores in comparison to remission patients. We demonstrated a relationship between depressive symptoms, social factors, disease perception and ultrasound synovitis. It is crucial to conduct longitudinal studies with a large number of patients, including a control group, and perform an adequate stratification of the demographic characteristics of the patients and their confounding variables.

References

[1]Karimzadeh H, Karami M, Bazgir N, Karimifar M, Yadegarfar G, Mohammadzadeh Z. Ultrasonographic findings of rheumatoid arthritis patients who are in clinical remission. J Res Med Sci 2018;23(1):38.

[2]García de Yébenes M de J, Loza E. Artritis reumatoide: epidemiología e impacto sociosanitario. Reumatol Clin Supl 2018;14(2):3–6.

[3]Hérnandez L del C, Querol J, De la Garza AL, Férnandez C. Artritis Reumatoide su impacto social y económico. Boletín Epidemiológico 2016;33(12):1–4.

[4]Maldonado G, Ríos C, Paredes C, Ferro C, Intriago MJ, Aguirre C, et al. Depresión en artritis reumatoide. Rev Colomb Reumatol 2017;24(2):84–91.

Disclosure of Interests

None declared

OP0260 RESPONSIVENESS OF A COMBINED POWER DOPPLER AND GREYSCALE ULTRASOUND SCORE FOR ASSESSING SYNOVITIS AT JOINT LEVEL IN PSORIATIC ARTHRITIS PATIENTS WITH INADEQUATE RESPONSE TO csDMARDs: DATA FROM THE ULTIMATE TRIAL

Background

Power Doppler ultrasound (PDUS) is a sensitive non-invasive imaging tool that allows the visualisation of articular and periarticular inflammation in patients with psoriatic arthritis (PsA).1 ULTIMATE (NCT02662985) was the first large randomised clinical trial that showed the responsiveness of the Global OMERACT-EULAR ultrasound synovitis score (GLOESS) in PsA and confirmed the rapid and continued benefits of secukinumab through 52 weeks.2,3

Objectives

To report the distribution of ultrasound-detected synovitis at joint level, by degree of severity at baseline and over time, and the contribution of each core component of GLOESS, synovial hypertrophy (SH) by greyscale (GS; B-mode) and power Doppler (PD) signal, to responsiveness.3

Methods

This was a 52-week study with a 12-week double-blind, placebo-controlled treatment period followed by a 12-week open-label period and a 6-month open-label extension secukinumab treatment period.3 The number of joints with synovitis measured by GLOESS2 was assessed up to Week 52. The assessments included distribution of synovitis based on composite PDUS score across 24 pairs of joints (with worse score of the pair of the joints used) by grade of severity (0-3) and change from baseline to Week 52 in each core component of GLOESS.3-5 Data are presented as observed.

Results

A total of 166 patients (mean age, 46.7 years; males, 45.2%) were enrolled, of which 90% (75/83) of secukinumab and 83% (69/83) of placebo-secukinumab participants completed 52 weeks. The mean (SD) number of PDUS detected synovitis at baseline was 9.2 (4.9) and 10.2 (5.2) in the secukinumab and placebo group, respectively. The most frequent locations with synovitis at baseline were: wrist, metatarsophalangeal (MTP), knees and metacarpophalangeal (MCP) joints (Table 1). An early and continued improvement in GLOESS was observed in both secukinumab and placebo-secukinumab groups after switching to active therapy, as previously reported at Week 12 and through Week 52.2,3 Among the two core components of GLOESS, SH was mainly responsible for the change in GLOESS from baseline to Week 52, in contrast with PD signal in this dataset. The distribution of synovitis by grade of severity showed that MTP joints, wrist, knee, MCP1/2 and tibiotalar joints mostly contributed to the composite PDUS at Week 12 (Figure 1). Similar patterns were observed through 52 weeks.

Table 1.

Proportion of patients with PDUS detected synovitis at baseline*

Synovitis joint, data presented as n (%)Secukinumab (N=83)Placebo (N=83)Wrist66 (80)66 (80)MTP256 (68)65 (78)MTP158 (70)60 (72)MTP352 (63)60 (72)MTP446 (55)59 (71)Knee50 (60)47 (57.)MCP136 (43)52 (63)MCP235 (42)41 (49)MTP530 (36)41 (49)

*Data for top nine pairs of joints with most frequently detected power Doppler ultrasound (PDUS) synovitis are presented here. Synovitis was scored by a OMERACT-EULAR synovitis composite score >0 for each paired joint (irrespective of right or left side). The OMERACT-EULAR composite PDUS score (for individual joints) ranged from 0 to 3 and was composed of the two core components synovial hypertrophy and power Doppler.

N, total number of randomised patients; n, number of evaluable patients

Conclusion

The distribution of synovitis at baseline reflected a predominance of small joints (feet and hands) and large joints (wrist and knee) and were mostly responsive to secukinumab over time in the ULTIMATE trial. Synovial hypertrophy was the most responsive core component of GLOESS driving an early and continued reduction of synovitis with secukinumab through Week 52. This finding could be useful to select a restricted number of joints in future ultrasound trials in PsA.

References

[1]D’Agostino MA and Coates LC. J Rheumatol. 2019;46:337–9.

[2]D’Agostino MA et al. Arthritis Rheumatol. 2021;73(10).

[3]D’Agostino MA, et al. Rheumatology (Oxford) 2021;keab628.

[4]D’Agostino MA and Coates LC. RMD Open 2017;3:e000428.

[5]Uson J, et al. Rheumatol Clin. 2018;14:27–35.

Disclosure of Interests

Maria-Antonietta D’Agostino Speakers bureau: Sanofi, Novartis, BMS, Janssen, Celgene, Roche, AbbVie, UCB, and Eli Lilly, Consultant of: Sanofi, Novartis, BMS, Janssen, Celgene, Roche, AbbVie, UCB, and Eli Lilly, Maarten Boers Consultant of: Novartis, Corine Gaillez Shareholder of: Novartis and BMS, Employee of: Novartis, Carlos Gamez: None declared, LUCIO VENTURA: None declared, Javier Rosa Speakers bureau: Abbvie, Pfizer, Lilly, Janssen, Novartis and BMS, Ilaria Padovano: None declared, Peter Mandl Speakers bureau: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Roche and UCB, Grant/research support from: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Roche and UCB, Arnd Kleyer Speakers bureau: Abbvie, Lilly, Novartis, MEDAC; Janssen, Consultant of: Abbvie, Lilly, UCB, Novartis, BMS, Sanofi, Galapagos, Catherine Bakewell Speakers bureau: AbbVie, Novartis, Pfizer, Janssen, UCB, and Sanofi Genzyme/Regeneron, Consultant of: AbbVie, Novartis, Pfizer, Janssen, UCB, and Sanofi Genzyme/Regeneron, Weibin Bao Shareholder of: Novartis, Employee of: Novartis, Punit Goyanka Employee of: Novartis, Philip G Conaghan Speakers bureau: AbbVie, Amgen, AstraZeneca, Eli Lilly, Galapagos, Gilead, Novartis, Pfizer and UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Eli Lilly, Galapagos, Gilead, Novartis, Pfizer and UCB, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Lilly, Novartis, Roche and UCB

Hybrid capture 2 and cobas® 4800: Comparison of performance of two clinically validated tests for human papillomavirus primary screening of cervical cancer

OBJECTIVE

To compare, in a primary human papillomavirus screening setting, two different validated human papillomavirus tests, considering their analytical and clinical screening performances.

METHODS

In Tuscany, a human papillomavirus screening program was implemented in 2013. Hybrid capture 2 (Qiagen) was used for testing until May 2016, when it was replaced by the cobas^® 4800 human papillomavirus test (Cobas; Roche). We evaluated the performance of Hybrid capture 2 and Cobas on: the same screening population in two different periods (before and after changing to Cobas); the same Hybrid capture 2-positive consecutive samples. Discordant samples (Hybrid capture 2-positive/Cobas negative) were typed on the L1 gene (reverse line blot, AB Analitica) and E6/E7 genes (BD Onclarity assay).

RESULTS

In the considered time period (n = 37,775), human papillomavirus positivity was 9.8% and 7.4%, respectively, for Hybrid capture 2 and Cobas (p < 0.0001). At immediate colposcopy, the cervical intraepithelial neoplasia, grade 2 positive predictive value was, respectively, 23.8% and 34% (p < 0.001). At one-year recall, human papillomavirus persistence was, respectively, 40.6% and 62.2% (p < 0.0001). Of Hybrid capture 2-positive re-tested samples (n = 620), 32.4% were Cobas negative. Of discordant samples typed on L1, 7% were positive for the 12 high-risk human papillomavirus. Of the samples found to be negative for the 12 high-risk human papillomavirus types on L1, 14.5% were positive on E6/E7 typing. Among the discordant samples, the only two cervical intraepithelial neoplasia (CIN) grade 3 lesions were non-high-risk human papillomavirus positive on both L1 and E6/E7 typing.

CONCLUSION

At baseline, Hybrid capture 2 showed greater human papillomavirus positivity and a lower CIN2+ positive predictive value than Cobas, which was more specific than Hybrid capture 2 in detection of high-risk human papillomavirus: 80% of discordant samples were confirmed as high-risk human papillomavirus negative. This higher analytical specificity determined the non-identification of two CIN3 lesions.

Bridging the information gap on cancer survivors in Europe: results from the iPAAC Joint Action

Background

Due to demographic transition cancer survivors are dramatically growing and challenging the sustainability of public health systems. Despite accurate indicators are increasingly needed for Health Technology Assessment and health care planning, population-based cancer prevalence is not systematically available in many countries. The European Joint Action “Innovative Partnership for Action Against Cancer” (iPAAC) aims at bridging this gap by supporting the inclusion of indicators on prevalence to complement the cancer burden statistics already available in the European Cancer Information System (ECIS).

Methods

Analysis of a European-wide standardized dataset gathering information on 26 million patients from 100 cancer registries in 29 countries (EUROCARE-6). Methods to estimate and project complete and limited duration population-based prevalence indicators by demographic variables, cancer type and phase of care.

Results

Cancer survivors are mostly women (about 55%) and people over-60 years. Highest crude prevalence proportions in women are observed for breast, colon-rectum, corpus uteri, skin melanoma and cervical cancer (from 1,600 to 200 x 100,000). Prostate, colon-rectum, bladder, non-Hodgkin lymphoma and skin melanoma were the most frequent cancers among male survivors (from 1,000 to 200 x 100,000). Between-country differences are wide, consistently with varying demographic structure, incidence and survival patterns. Impact of long-term survivorship strongly depends on disease lethality.

Conclusions

Cancer survivors are a quite heterogenous population in respect of age, sex, cancer type and disease duration. Reliable and comparable prevalence indicators are essential to improve cancer care planning in European countries. Joint analysis of European wide population-based datasets strengthens the impact of cancer registries information and foster the release of complete statistics on cancer survivors.

Key messages

Cancer survivors are a growing and heterogeneous population to be monitored in public health. Detailed and comparable indicators on cancer prevalence are proposed to complement the cancer burden statistics of the European Cancer Information System (ECIS) through improved collaborative efforts.

Benign Granular Cell Tumor of the Breast: A Misleading Disease

Granular cell tumor (GCT) is a relatively rare neoplasm, and almost always benign in its prognostic behavior. Location of this tumor in the breast presents serious problems for differential diagnosis, both from a clinical point of view and at gross pathological examination, because of its resemblance to carcinoma. Fine needle aspiration biopsy and intraoperative frozen section examination may not be of any further help. The histogenesis of these lesions has been widely debated in the past, but no universally accepted conclusion has been reached. Most GCTs appear to be derived from Schwann cells, but many different neoplastic and non-neoplastic lesions show granular cell changes. Therefore, GCT should not be considered as a single entity but as the result of a cytoplasmic change due to still unknown metabolic alterations that may occur in various cell types. No firm conclusions can be drawn regarding the suspected hormonal influence on the development of breast GCT.

The authors describe three typical cases of breast GCT that occurred in patients of different ages, and discuss the most important questions concerning this lesion.

Abstract P2-09-11: PAM50 intrinsic subtyping as a predictor of pathological complete response to neoadjuvant trastuzumab-based chemotherapy in early HER2-positive breast cancer

Background: HER2-positive breast cancer (BC) is a heterogeneous disease from a clinical and biological perspective. Intrinsic subtype defined by gene expression has an important role in determining response to treatment, as seen in several neoadjuvant trials (e.g. CALGB40601, CherLOB, NeoALTTO and PAMELA). However, limited data exist in an off-trial setting. The objective of this study was to evaluate the association of intrinsic subtypes with pathological completed response (pCR) and survival outcomes of a series of HER2-positive patients (pts) homogeneously treated with trastuzumab-based primary chemotherapy (PC) in a single comprehensive cancer center.

Methods: Clinical-pathological data were evaluated in a series of 150 consecutive stage II-IIIC (T4d included) HER2-positive BC pts treated in ICO-Hospitalet (Spain) from August-2009 to December-2012 with weekly paclitaxel x12 followed by FEC/3w x 4 and concurrent trastuzumab for a total of 24w. HER2-positivity was considered according to ASCO-CAP 2007 guidelines. pCR was defined as ypT0/isypN0. The expression of 105 BC-related genes, including the PAM50 genes, was determined in baseline and residual formalin-fixed paraffin-embedded tumor samples using the nCounter platform. Intrinsic subtypes were determined by the research-based PAM50 gene expression predictor. Association of variables with pCR or disease-free survival (DFS) was evaluated using logistic regression analyses and cox proportional hazard models.All statistical tests were two-sided and considered significant when p≤0.05.

Results: Most pts had T2 (64%) and T4 (20%) tumors and clinically node-positive disease (77%). 53% had hormonal receptor (HR)+ disease. 84 of the 150pts (56%) achieved a pCR; HR-neg was associated with higher pCR rates (72.5%vs 42% in HR+ P&lt;0.001). 90 of the 150 (60%) baseline samples were evaluated. Baseline subtype distribution: HER2-enriched (HER2-E) 63%, Luminal A 11%, Basal-like 8.9%, Normal-like 8.9% and Luminal B 7.8%. Although HER2-E predominated in HR-neg tumors (74%), 53% of HR+ tumors were HER2-E. pCR rates varied according to intrinsic subtype (P&lt;0.001). HER2-E tumors were associated with higher pCR rates compared to non-HER2-E (68.4% vs 33.3%, P&lt;0.001) regardless HR-status. Five of the 8 PAM50 signatures (HER2E, ROR-S, ROR-P, Basal-like and Proliferation score) were associated with pCR, whereas Luminal A was associated with no-pCR (P&lt;0.001). With a median follow-up of 6.6 years, HER2-E subtype was associated with a better DFS compared to non-HER2-E (5-year DFS 92.4% vs 75.9%; HR= 0.27; 95% CI 0.08-0.91; P=0.034). Finally, 28 of the 66 (42.4%) surgical specimens with residual disease were studied. Residual subtype distribution was: Normal-like (50.0%), Luminal A (32.1%), HER2-E (14.3%) and Luminal B (3.5%).

Conclusions: In this consecutive series of HER2-positive BCtreated homogeneously with neoadjuvant trastuzumab-based PC, all of the main intrinsic molecular subtypes were identified with a predominance of HER2-E. HER2-E was significantly associated with pCR and survival outcome. Distribution of the intrinsic subtypes in residual disease differed from untreated tumors.

Citation Format: Pernas S, Petit A, Climent F, Pare L, Perez-Martin J, Ventura L, Galvan P, Falo C, Morilla I, Fernandez-Ortega A, Stradella A, Pascual T, Gil-Gil M, Prat A. PAM50 intrinsic subtyping as a predictor of pathological complete response to neoadjuvant trastuzumab-based chemotherapy in early HER2-positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-11.

Genetic Predisposition to Rheumatoid Arthritis in a Tuscan (Italy) Ancient Human Remain

Rheumatoid arthritis (RA) is currently believed to have originated in America, and after the discovery of this continent in 1492, to have been exported to the Old World. We evaluated the genetic predisposition to RA in the “Braids Lady” from Arezzo (Italy), a partially mummified woman's body dating back to the end of 1500 AD which presents the anatomical and pathological features of this disease. The study of the polymorphic HLA-DRB1 locus, which includes alleles strongly associated with RA onset, has received much attention over recent years, especially the loci codifying for the DR1 and DR4 antigens, widely represented in the Mediterranean population, and for DR14, widespread among Native Americans. Molecular analysis was performed on extracts of DNA from the mummy, firstly from histological bone sections and then from the whole bone. Two different HLA typing techniques, PCR-sequence-specific oligonucleotides (PCR-SSO) and PCR-sequence-specific primers (PCR-SSP), were employed to identify HLA-DRB alleles. Both genotyping methods showed that the “Braids Lady” carried the DRB1*0101 allele, the serological equivalent of the DR1 antigen. Although the possession of RA risk factor genes cannot be considered a diagnostic marker, the positive result of the Italian mummy for DRB1*0101 and the RA features present, support the idea that this pathology was present in the Old World from at least the mid-16th century. A pathogenetic hypothesis of RA which might well explain its worldwide diffusion is the “molecular mimicry”, resulting from a cross-reactive antibody response between certain microbial antigens and shared epitopes of specific HLA-DR1, DR4 and DR14 susceptibility alleles, the frequency of which varies among different ethnic groups.

Comparison of the cough reflex test and water swallowing test in healthy participants and neurological patients

Comparison of the cough reflex test and water swallowing test in healthy participants and neurological patients.

BACKGROUND

Silent aspiration is poorly identified by traditional clinical swallowing evaluations. Recently, sevral studies have proposed the use of a cough reflex test (CRT) for screening patients at risk of aspirations. The first aithis study is to investigate the CRT thresholds of citric acid concentration for identifying cough responses in healthy participants and neurological patients. The second aim is to compare the results of the CRT with the water swallowing test (WST), a standard screening test for identifying cough responses in neurological patients.

METHODS

The CRT and then the WST were administered to 100 neurological patients and 100 healthy participants. For the CRT, we administered incremental solutions of citric acid interspersed with placebo doses. We used the results of the CRT in healthy participants to define a citric acid concentration cut-off, which could be used with neurological patients as a screening for aspirations.

RESULTS

As all controls coughed at a concentration of 0.1 mol/L, this was used as a cut-off in patients to identify coughing as a screening for aspiration risk. Patients showed cough reflexes at concentrations significantly higher than controls (p=0 .001). The WST was not administered to 17 patients, due to cognitive deficits and severe clinical conditions. Thirty six patients had a cough response above the screening cut-off (> 0.1 mol/L), 25 of which (30.1%) also had a positive cough response during the WST.

CONCLUSION

The CRT correlated significantly with the WST. Unlike the WST, the CRT could be easily administered to severely impaired patients. Our results indicate the use of the CRT as a screening test for silent aspirators.

The bone anabolic therapy

Teriparatide (TPTD), the amino-terminal parathyroid hormone recombinant peptide [PTH (1–34)], is a drug with a proven anabolic action on the bone, effective in preventing vertebral and non-vertebral fragility fractures. Recent publications have investigated in great detail the TPTD action on the cortical bone, highlighting the increased strength in the critical zone of the hip with high risk of fracture in osteoporotic patients Poole (PLoS ONE 6:e16190, 2011). In November 2002, TPTD was approved by the FDA for use in post-menopausal women and men with osteoporosis at high risk of fracture and in patients with glucocorticoid-induced osteoporosis and, since then, has been used to treat more than 1 million patients worldwide (J Bone Miner Res 27(12):2429-2437, 2012). The unchanged safety profile and the well-known mechanism of action of this drug have led doctors to explore the use of TPTD in other conditions such as delayed fracture healing, non-union, osteonecrosis of the jaw, etc. The positive reports that have resulted from these studies are helping to hypothesize a new perspective on the wider use of this drug, but warrant further clinical investigation to consolidate these results.

DNA profiling, telomere analysis and antioxidant properties as tools for monitoring ex situ seed longevity

BACKGROUND AND AIMS

The germination test currently represents the most used method to assess seed viability in germplasm banks, despite the difficulties caused by the occurrence of seed dormancy. Furthermore, seed longevity can vary considerably across species and populations from different environments, and studies related to the eco-physiological processes underlying such variations are still limited in their depth. The aim of the present work was the identification of reliable molecular markers that might help in monitoring seed deterioration.

METHODS

Dry seeds were subjected to artificial ageing and collected at different time points for molecular/biochemical analyses. DNA damage was measured using the RAPD (random amplified polymorphic DNA) approach while the seed antioxidant profile was obtained using both the DPPH (1,1-diphenyl, 2-picrylhydrazyl) assay and the Folin-Ciocalteu reagent method. Electron paramagnetic resonance (EPR) provided profiles of free radicals. Quantitative real-time polymerase chain reaction (QRT-PCR) was used to assess the expression profiles of the antioxidant genes MT2 (type 2 metallothionein) and SOD (superoxide dismutase). A modified QRT-PCR protocol was used to determine telomere length.

KEY RESULTS

The RAPD profiles highlighted different capacities of the two Silene species to overcome DNA damage induced by artificial ageing. The antioxidant profiles of dry and rehydrated seeds revealed that the high-altitude taxon Silene acaulis was characterized by a lower antioxidant specific activity. Significant upregulation of the MT2 and SOD genes was observed only in the rehydrated seeds of the low-altitude species. Rehydration resulted in telomere lengthening in both Silene species.

CONCLUSIONS

Different seed viability markers have been selected for plant species showing inherent variation of seed longevity. RAPD analysis, quantification of redox activity of non-enzymatic antioxidant compounds and gene expression profiling provide deeper insights to study seed viability during storage. Telomere lengthening is a promising tool to discriminate between short- and long-lived species.

A rare case of intracranial rosai-dorfman disease mimicking multiple meningiomas. A case report and review of the literature

Rosai-Dorfman disease (RDD) was firstly described in 1969 as a benign proliferative disorder of histiocytes with systemic symptoms and lymphadenopathy. This disease is of uncertain pathogenesis and mostly occurs in children and young adults. The typical clinical features of RDD include bilateral painless cervical lymphadenopathy, but extranodal involvement may also be present. The most common extranodal sites include organs such as the respiratory tract, skin, nasal cavity, orbit and bone. Isolated central nervous system (CNS) manifestations are extremely rare. In case of CNS involvement, the commonest imaging findings are dural-based extra-axial enhancing masses. We describe a case of intracranial RDD mimicking multiple meningiomas both clinically and radiologically in a 57-year-old man presenting with a six-year history of progressive right visual and hearing loss and tinnitus. In cases of multiple extra-axial lesions it is worth bearing in mind the possible differential diagnosis for intracranial RDD and eventually propose to the patient further investigations.

Rheumatoid arthritis in Cardinal Carlo de' Medici (1595-1666): a confirmed macroscopic, radiologic and molecular diagnosis

OBJECTIVES

The paleopathological study of the skeletal remains belonging to Cardinal Carlo de' Medici (1595-1666), son of Ferdinando I (1549-1609) and Cristina of Lorena (1565-1637), has been presented previously. A diagnosis of Klippel-Feil syndrome, tuberculosis and a polyarthopathy, interpreted as rheumatoid arthritis, was suggested. A revision of this case based on the analysis of the historical documents and of some radiological images of Carlo's bones has been proposed recently; according to the Authors, the Cardinal was affected by the 'Medici syndrome', a combined Psoriatic-DISH arthropathy. This revision offers us the opportunity to discuss this complex case, comparing different points of view, and to present the results of the molecular analyses carried out on Carlo's bone samples. We looked for the genetic risk factors of rheumatoid arthritis (RA) and psoriatic arthritis (PsA). We also searched for the primary candidate genes of RA and PsA, i.e. DR4 or DR1 and Cw6 or DR7 respectively, the latter predisposing also for psoriasis.

METHODS

An original molecular protocol was applied to achieve an aDNA uncontaminated by exogenous sources and almost intact, starting from one of the Cardinal's rib pieces. The allele risk factors for both diseases were identified by PCR-SSP assay as HLA genotyping methodology.

RESULTS

Our data assigned Carlo the genotype DRB1*04/*11 for HLA-DRB locus and Cw*04/*12 for HLA-C locus.

CONCLUSIONS

Since Carlo was infected by M. tuberculosis during infancy and was carrying the DR4 variant but not the Cw6, he surely had a predisposition to RA, not to PsA and/or psoriasis. The diagnosis of RA is thus confirmed.

Carbamoyl phosphate synthetase 1 deficiency in Italy: clinical and genetic findings in a heterogeneous cohort

Carbamoyl Phosphate Synthetase 1 deficiency (CPS1D) is a rare autosomal recessive urea cycle disorder, potentially leading to lethal hyperammonemia. Based on the age of onset, there are two distinct phenotypes: neonatal and late form. The CPS1 enzyme, located in the mitochondrial matrix of hepatocytes and epithelial cells of intestinal mucosa, is encoded by the CPS1 gene. At present more than 220 clear-cut genetic lesions leading to CPS1D have been reported. As most of them are private mutations diagnosis is complicated. Here we report an overview of the main clinical findings and biochemical and molecular data of 13 CPS1D Italian patients. In two of them, one with the neonatal form and one with the late form, cadaveric auxiliary liver transplant was performed. Mutation analysis in these patients identified 17 genetic lesions, 9 of which were new confirming their "private" nature. Seven of the newly identified mutations were missense/nonsense changes. In order to study their protein level effects, we performed an in silico analysis whose results indicate that the amino acid substitutions occur at evolutionary conserved positions and affect residues necessary for enzyme stability or function.

[Guidelines for the diagnosis, prevention and treatment of osteoporosis]

The guidelines for the osteoporosis management were first drafted by a working group and then critically evaluated by the board of SIOMMMS. The most relevant points are:

DEFINITION

Osteoporosis is defined as a quantitative and qualitative deterioration of bone tissue leading to increased risk of fracture. Postmenopausal and senile osteoporosis are defined as primitive.

DIAGNOSIS

The cornerstone for the diagnosis of osteoporosis is the measurement of bone mineral density (BMD) by DXA (dual-energy X-ray absortiometry) at the femoral neck with T-score values <-2.5, following the WHO definition. Other DXA sites or technologies for measuring bone mass are also acceptable when the former is not accessible. A BMD evaluation is recommended to all women above 65 years of age. At younger age or in man the bone assessment is recommended only in subjects with specific risk factors. A control of bone mass measurement is seldom required before 2 years.

DIFFERENTIAL DIAGNOSIS

A few biochemical tests such as serum and urinary calcium, protein electrophoresis, serum creatinine and ESR are usually sufficient to exclude most secondary types of osteoporosis. The value of the so called bone turnover markers for the diagnosis and follow-up of osteoporosis remains uncertain. Several secondary forms of osteoporosis require a specific diagnostic and therapeutic management.

PREVENTION

The osteoporosis prevention should be based on the elimination of specific risk factors such as inadequate calcium and vitamin D intake, smoking and sedentary life. The use of pharmacological agents in subjects with BMD values >-2.5 is usually not justified. Pharmacological intervention: The use of drugs registered for the treatment of osteoporosis are recommended when the benefits overcome the risk. This is the case only when the risk of fracture is rather high. FRAX is recognized as a useful tool for easily estimate the long-term fracture risk. SIOMMMS with these guidelines is committed to validate and further develop this diagnostic tool.

Ultrasound in rheumatology. The Mexican experience

Over the last few years, a growing number of rheumatologists has taken great interest in ultrasonography for its well known advantages and wide spectrum of validated applications in daily rheumatological practice. Most rheumatologists actively performing ultrasonography have had a training experience mainly based on attendance in sonographic courses and/or in radiological or rheumatological units. At present, in Mexico ultrasonography has a still limited diffusion among rheumatologists even if it may play a key role as a first line imaging technique also because of the restricted availability for rheumatic patients for other imaging modalities. This report describes the Mexican experience in education and training on musculoskeletal ultrasound. In 2003, the Mexican School of Musculoskeletal Ultrasound of the Mexican College of Rheumatology (ECOMER) was founded with the intention of joining efforts to launch musculoskeletal ultrasound in Mexico. Essential requirements shared by all the members of ECOMER include: to own an ultrasound machine, to incorporate ultrasonography into clinical daily practice and to keep up-to-date in musculoskeletal ultrasound. The motto of ECOMER is una clara imagen de la reumatologia which means a clear picture of rheumatology. The statute of ECOMER can be read in its web site: www.ecomer.org.mx. This web site also provides a forum for case discussion, consultation and image review.

[Portrait of the artist as a sick man. Rheumatological pathography of James Joyce (1882-1941)]

James Joyce, unanimously considered one of the greatest novelists of the 20th century, suffered from several diseases. A series of adverse circumstances progressively deteriorated his health, already precarious because of his very disorderly life habits. Aim of the present study is to summarize the various organic diseases Joyce suffered during his lifetime, as long as the main diagnostic conclusions found in scientific literature. Severe eye problems, caused by recurrent iritis attacks even complicated by glaucoma and cataracts, led him almost to blindness. Undernourishment and irregular eating, great anxiety and alcohol abuse were the major causes of the peptic ulcer which tortured him for many years, causing his final death. To these conditions should also be added dental caries, venereal diseases and recurrent polyarthritis. The hypothesis according which Joyce suffered from neurosyphilis is still debated and should be sufficiently demonstrated, whereas a spondyloarthropathy, either Reiter's syndrome or ankylosing spondylitis, appears more likely. Therapies against these diseases, easily treated today, did not result efficient because of his poor compliance, as well as the state of the art of medical science during his lifetime. A detailed paleopathologic study of Joyce's human remains could allow to solve the diagnostic doubts concerning his main disease.

Disseminação do vírus da doença de Aujeszky, envolvendo o comércio de reprodutores suínos de reposição

Relata-se a disseminação da infeção pelo vírus da doença de Aujeszky (VDA) a partir da comercialização de reprodutores suínos oriundos de duas granjas de reprodutores suídeos certificada (GRSC) que tiveram surto da DA. Após a confirmação do diagnóstico de DA, os suínos comercializados 37 a 45 dias anteriores aos surtos foram recolhidos, submetidos ao exame sorológico para o VDA e enviados ao abate. Nos rebanhos-destino foram realizados exames sorológicos para o VDA 17 a 37 dias após o recolhimento, naqueles que estavam lojados nas baias vizinhas àquelas onde haviam sido alojados os suínos comprados; seis meses mais tarde, foi realizada outra sorologia por amostragem dos reprodutores. No total, 52 rebanhos compraram suínos das duas granjas, e, destes, 37 (69,8%) receberam, pelo menos, um animal com sorologia positiva para o VDA. Somente sete (18,9%) deles apresentaram sorologia positiva para o VDA, e em 30 (81,1%), não houve indícios de disseminação da infecção. A contaminação pelo VDA de granjas GRSC representa enorme potencial para a disseminação da infecção, por meio do comércio de suínos de reposição. A rastreabilidade dos animais comercializados em um período anterior ao diagnóstico, com imediata remoção dos lotes de suínos dos rebanhos-destino, evitou a disseminação da infecção.

Differential expression of neurogenins and NeuroD1 in human pituitary tumours

Basic helix-loop-helix (bHLH) transcription factors are involved in neuroendocrine cell growth and differentiation. Though NeuroD1 is viewed as corticotroph specific, its overexpression in non-corticotroph pituitary adenomas (PAs) may reflect the activation of molecular pathways involving other bHLH factors, like neurogenins. To search for neurogenin-NeuroD1 molecular pathways in the human normal and tumoural pituitary. Fifty-one PAs--22 clinically non-secreting (CNS) and 29 secreting respectively--and normal human pituitaries (NP) were studied for NeuroD1 and neurogenins (Ngn1, Ngn2 and Ngn3) gene expression by RT-PCR and quantitative real-time RT-PCR (qRT-PCR). Immunohistochemistry for Ngn2/3 was performed in some cases. NeuroD1, Ngn2, Ngn3 and Ngn1 were observed in up to 84.3, 76.5, 30.4 and 9.1% of PA respectively, only NeuroD1 and Ngn2 being frequently overexpressed when compared with NP. Whereas NeuroD1 expression was higher in corticotroph and CNS adenomas (P=0.0001 versus Pit-1-dependent PA), Ngn2 expression was higher in secreting PA, especially in Pit-1-dependent PA (P=0.007 and P=0.0006 versus CNS respectively). Pit-1-dependent PA which received pre-operative pharmacological treatment expressed higher Ngn2 levels than untreated cases (P=0.025). Nuclear Ngn2 was observed in NP and in most PA, especially ACTH- and GH-secreting adenomas. Nuclear Ngn3 was observed in a minority of secreting PA. Ngn2 is normally expressed in the anterior pituitary and frequently expressed in PA, but does not account for NeuroD1 overexpression where present. Owing to their low and inconstant expression, the biological significance of Ngn1/3 in the adult pituitary is uncertain.

Comparação entre métodos de tuberculinização no diagnóstico da infecção por agentes do complexo Mycobacterium avium ou M. bovis em suínos

Avaliou-se a eficiência do teste de tuberculina intradérmico comparado, para identificar rebanhos suínos infectados com o complexo Mycobacterium avium (MAC), seu poder de discriminação entre rebanhos infectados com MAC e Mycobacterium bovis, e para estudar diferentes critérios de leitura e interpretação. Foram realizados três experimentos com rebanhos infectados naturalmente com MAC, com suínos inoculados com MAC e com suínos inoculados com M. bovis. Os testes foram comparados com a presença ou não de lesões macro e/ou microscópicas nos linfonodos de suínos em idade de abate. Verificaram-se reações cruzadas entre os testes intradérmicos, tanto com animais infectados com o MAC como com M. bovis. Reações acima de 0,5cm de diâmetro ou acima de 0,20cm no aumento da espessura da dobra da pele, entre a aplicação e a leitura, foram consideradas positivas no cálculo da média para rebanhos. Rebanhos infectados com MAC podem ser identificados por meio do teste intradérmico com PPD aviário e bovino. Tanto a medida do diâmetro quanto o aumento da espessura da dobra da pele das reações foram eficientes no diagnóstico da infecção por MAC. Recomenda-se a utilização do método da medição do diâmetro.