CD99 Expression and Prognostic Impact in Glioblastoma: A Single-Center Cohort Study

Glioblastoma is the most frequent and aggressive brain tumor in adults. This study aims to evaluate the expression and prognostic impact of CD99, a membrane glycoprotein involved in cellular migration and invasion. In a cohort of patients with glioblastoma treated with surgery, radiotherapy and temozolomide, we retrospectively analyzed tumor expression of CD99 by immunohistochemistry (IHC) and by quantitative real-time polymerase chain reaction (qRT-PCR) for both the wild type (CD99wt) and the truncated (CD99sh) isoforms. The impact on overall survival (OS) was assessed with the Kaplan-Meier method and log-rank test and by multivariable Cox regression. Forty-six patients with glioblastoma entered this study. Immunohistochemical expression of CD99 was present in 83%. Only the CD99wt isoform was detected by qRT-PCR and was significantly correlated with CD99 expression evaluated by IHC (rho = 0.309, p = 0.037). CD99 expression was not associated with OS, regardless of the assessment methodology used (p = 0.61 for qRT-PCR and p = 0.73 for IHC). In an exploratory analysis of The Cancer Genome Atlas, casuistry of glioblastomas CD99 expression was not associated with OS nor with progression-free survival. This study confirms a high expression of CD99 in glioblastoma but does not show any significant impact on survival. Further preclinical studies are needed to define its role as a therapeutic target in glioblastoma.

A focus on the multiple interfaces between action and perception and their neural correlates

Successful behaviour relies on the appropriate interplay between action and perception. The well-established dorsal and ventral stream theories depicted two distinct functional pathways for the processes of action and perception, respectively. In physiological conditions, the two pathways closely cooperate in order to produce successful adaptive behaviour. As the coupling between perception and action exists, this requires an interface that is responsible for a common reading of the two functions. Several studies have proposed different types of perception and action interfaces, suggesting their role in the creation of the shared interaction channel. In the present review, we describe three possible perception and action interfaces: i) the motor code, including common coding approaches, ii) attention, and iii) object affordance; we highlight their potential neural correlates. From this overview, a recurrent neural substrate that underlies all these interface functions appears to be crucial: the parieto-frontal circuit. This network is involved in the mirror mechanism which underlies the perception and action interfaces identified as common coding and motor code theories. The same network is also involved in the spotlight of attention and in the encoding of potential action towards objects; these are manifested in the perception and action interfaces for common attention and object affordance, respectively. Within this framework, most studies were dedicated to the description of the role of the inferior parietal lobule; growing evidence, however, suggests that the superior parietal lobule also plays a crucial role in the interplay between action and perception. The present review proposes a novel model that is inclusive of the superior parietal regions and their relative contribution to the different action and perception interfaces.

Depth and direction effects in the prediction of static and shifted reaching goals from kinematics

The kinematic parameters of reach-to-grasp movements are modulated by action intentions. However, when an unexpected change in visual target goal during reaching execution occurs, it is still unknown whether the action intention changes with target goal modification and which is the temporal structure of the target goal prediction. We recorded the kinematics of the pointing finger and wrist during the execution of reaching movements in 23 naïve volunteers where the targets could be located at different directions and depths with respect to the body. During the movement execution, the targets could remain static for the entire duration of movement or shifted, with different timings, to another position. We performed temporal decoding of the final goals and of the intermediate trajectory from the past kinematics exploiting a recurrent neural network. We observed a progressive increase of the classification performance from the onset to the end of movement in both horizontal and sagittal dimensions, as well as in decoding shifted targets. The classification accuracy in decoding horizontal targets was higher than the classification accuracy of sagittal targets. These results are useful for establishing how human and artificial agents could take advantage from the observed kinematics to optimize their cooperation in three-dimensional space.

AB0925 Advantages of combined Derma-Rheumatological evaluation in Early Psoriatic Arthritis

Background

Psoriatic Arthritis (PsA) is a challenging diagnosis both for the absence of specific biomarkers and for its clinical heterogeneity, especially in its initial phases. Early onset of PsA is mostly characterized by mono-oligoarthritis, enthesitis, dactylitis, onychopathy, modest cutaneous involvement. At least 50% of early-PsA patients initially come at dermatologist’s attention because they carry only few musculoskeletal symptoms such as enthesitis and dactylitis. Rheumatological evaluation and ultrasound (US) demonstration of articular and entheseal inflammation allows to augment the probability of an early diagnosis in a short period of time.

Objectives

We described patients referred to our derma-rheumatological clinic. We focused our attention on the main affected domain and on the advantages of a combined evaluation in terms of diagnosis, access to advanced therapies and short-term outcome.

Methods

All patients referred to our derma-rheumatological clinic by dermatologists from July 2017 to July 2019 for suspected PsA were considered in the present study. 55% of them were studied with US, according to clinical necessity. All the suspected domains were studied using both B-mode and Power Doppler.

Results

81 patients, sent to our attention for suspected PsA, were included. In 18 (37%) of them diagnosis was confirmed (Caspar criteria were satisfied). In these patients oligoarthritis (80%), enthesitis (40%), dactylitis (23%), sometimes in combination, were the most frequent presentations. In 25% of cases enthesitis was the only clinical feature. Articular disease activity was low to moderate in most of patients (DAPSA 14,83 ± 10,08). Disease duration at the diagnosis was 12 months in 90% of cases and the time occurring between symptoms and the first advanced therapy was 18 months in 50% of cases. US study allowed to redefine disease status in 30% of cases. Arthritis and enthesitis were the main domains where US evaluation gave more diagnostic value.

Conclusion

literature reports a mean time to diagnosis and to start advanced pharmacological therapy respectively of 1,5 and 5 years. In our report, time to start advanced therapy was much lower than expected, falling in the so-called window of opportunity. US study importantly contributed to reach this target, allowing us to identify as soon as possible sub-clinical and pauci-symptomatic forms (low disease activity, prevailing entheseal domain), which could otherwise be misdiagnosed or have an important diagnostic delay. The attention of dermatologist and integrated evaluation allowed us to optimize our diagnostic-therapeutic work-up in patients affected by early PsA, allowing them to receive sooner advanced therapies, according to recent EULAR and GRAPPA recommendations.

References

[1]Lubrano E, et al. Residual Disease Activity and Associated Factors in Psoriatic Arthritis. J Rheumatol. 2020 Oct 1;47(10):1490-1495. Clinical Rheumatology (2020)

[2]GRAPPA Treatment Recommendations: An Update From the 2020 GRAPPA Annual Meeting LC Coates et al. The Journal of Rheumatology Feb 2021, jrheum.201681.

Disclosure of Interests

None declared

OP0125 THE MANAGEMENT OF PREGNANCY IN AUTOIMMUNE RHEUMATIC DISEASES: ANALYSIS OF 758 PREGNANCIES FROM THE PROSPECTIVE NATIONWIDE P-RHEUM.IT STUDY (THE ITALIAN REGISTRY OF PREGNANCY IN THE RHEUMATIC DISEASES)

Background

Pregnancy is a topic of fundamental importance for women living with autoimmune rheumatic diseases (ARD). Efforts at national and international levels have been put in the collection and harmonization of data in order to implement an evidence-based management of pregnant patients.

Objectives

The P-RHEUM.it study was designed as a nationwide, web-based longitudinal observational cohort study to collect data about pregnancy in ARD in 26 centers in Italy. The study started in May 2018 and has been supported by the Italian Society for Rheumatology.

Methods

Pregnant patients with a definite rheumatic disease according international criteria were enrolled up to gestational week (GW) 20. The course of maternal disease activity, the use of medications, fetal and maternal complications, and the quality of life (EuroQoL questionnaire) were collected for each trimester, as well as pregnancy outcome, mode of delivery, neonatal complications, and maternal and children’s follow-up to 6 months after delivery, including the screening for post-partum depression by means of EPDS (Edinburgh Postnatal Depression Scale).

Results

As of December 2021, 758 pregnancies had been enrolled, 205 (27%) ongoing and 553 (73%) with outcome. Pregnancy loss occurred in 54 (9.8%) cases (40 spontaneous miscarriages; 6 voluntary terminations). Live births were 495 (89.5%), perinatal death occurred in 4 (0.7%) cases. Table 1 reports on the group of 495 live births, along with subgroups of Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE), the two most represented diseases. Regarding treatments, 166 (30%) pregnancies were exposed to corticosteroids, 239 (43%) to hydroxychloroquine, 59 (10.7%) to csDMARDs, 84 (15.2%) to TNF inhibitors, 1 (0.2%) to non-TNFi bDMARDs, 299 (54%) to low dose acetylsalicylic acid, and 126 (22.8%) to heparin.

Table 1.PREGNANCIES WITH LIVE BIRTHS, EXCLUDING PERINATAL DEATHSTotal pregnancies (n=495)RA pregnancies (n=69)SLE pregnancies (n=93)Age at conception (years)34 (31 - 37)34.5 (32 - 38)34 (31 - 36)Disease duration (years)6.1 (2.2 - 11.1)7.1 (4.3 - 11.6)9.3 (5.9 - 15.9)Caucasian431 (87.8%)53 (79.1%)75 (80.6%)Never smokers358 (73.8%)53 (80.3%)66 (71.7%)Body Mass Index >3045 (9.5%)7 (10.3%)5 (5.6%)Arterial Hypertension6 (1.2%)0 (0%)2 (2.2%)Time to pregnancy (months)3 (1 - 6)3 (1 - 6)3 (0 - 10)Physician-reported flares in the 12 months prior to conception107 (23%)22 (34.4%)13 (14.8%)Physician global assessment at enrolment (VAS 0-100)5 (0 - 17)5 (0 - 20)4 (0 - 10)Patient global health at enrolment (VAS 0-100)18 (7 - 30)10 (5 - 29)10 (5 - 25)EuroQoL at enrolment (-1.6 – 1)1 (0.8 - 1)1 (0.8 - 1)1 (0.8 - 1)Flares during pregnancy35 (7.1%)6 (8.7%)7 (7.5%)Hypertensive disturbances*8 (1.7%)1 (1.6%)6 (6.6%)Delivery at term (≥37 GW)410 (85.1%)53 (77.9%)74 (80.4%)Spontaneous vaginal delivery173 (35.9%)23 (33.8%)23 (25.3%)Congenital malformations11 (2.4%)2 (3.1%)1 (1.1%)Small for gestational age (SGA) neonate24 (4.9%)1 (1.4%)9 (9.9%)Breastfeeding in the first 4 weeks after delivery341 (79.7%)45 (77.6%)59 (76.6%)EPDS score at risk for post-partum depression22 (14.1%)0 (0%)3 (10.3%)

Continuous variables are expressed as median (interquartile range); *gestational hypertension/preeclampsia/HELLP syndrome/eclampsia.

Conclusion

Multiple factors may have contributed to the high rate of live births, including good disease control before and during pregnancy thanks to the use of anti-rheumatic drugs and low frequency of general risk factors. SLE pregnancy was affected by a higher frequency of complications (hypertensive disturbances, SGA babies) as compared to RA pregnancy. Nearly 80% of patients breastfed in the first month after delivery. For the first time, data about the screening questionnaire for post-partum depression were collected, showing at least 1 out 10 patients can be at risk.

References

[1]Meissner Y et al. Arthritis Res Ther;21(1):241; Ann Rheum Dis. 2021;80(1):49-56.

Acknowledgements

P-RHEUM.it study is supported by the Italian Society for Rheumatology (SIR). All the Investigators are acknowledged for their contribution.

Disclosure of Interests

None declared

POS0476 CAN LOW-DOSE ASPIRIN DURING PREGNANCY PREVENT THE DEVELOPMENT OF ADVERSE PREGNANCY OUTCOMES IN WOMEN WITH ARTHRITIS? DATA FROM THE P-RHEUM.it STUDY

Background:

In rheumatic diseases, specifically in chronic inflammatory arthritis (IA), there are no data about the effectiveness of LDA in preventing pregnancy complications.

Objectives:

To assess the potential benefit of LDA administration during pregnancy to prevent adverse pregnancy outcomes (APO) in IA.

To compare pregnancy outcomes in IA pregnancies treated during pregnancy with LDA with those untreated.

Methods:

Italian P-RHEUM.it register is designed as a nationwide, web-based longitudinal observational cohort study collecting data on pregnancies in inflammatory rheumatic diseases. At baseline, socio-demographic parameters, obstetric history, comorbidities and clinical/laboratoristic characteristics are registered. During pregnancy, the course of maternal disease, medications, development of fetus and complications are collected for each trimester.

Results:

From May 2018 to May 2020, 349 patients were enrolled. Forty-five patients with IA had completed their pregnancy with known outcome (20 Rheumatoid Arthritis, 10 Psoriatic Arthritis, 6 Ankylosing spondylitis, 5 Juvenile Idiopathic Arthritis, 4 Undifferentiated Arthritis): 13 (28.89%) treated with LDA during pregnancy and 32 (71.11%) without LDA prophylaxis. LDA was used with a higher frequency in women with previous APO, anti-phospholipid positivity and on biological DMARDs even if it’s not statistically significant (Table 1). All the LDA-treated women had a live-birth rate of 100%, whereas among women not treated with LDA the live birth rate was of 84.4% with 27 live-birth pregnancies, 3 early miscarriages, 1 fetal loss and 1 stillbirth observed. There were no significant differences between the LDA and the not LDA groups regarding pregnancy/peripartum obstetric complications (p=0.14), although less adverse pregnancy/peripartum outcomes were registered in LDA patients’ group (Table 1).

Conclusion:

The preliminary data of this prospective cohort study show that LDA improve pregnancy outcome in IA even if women treated with LDA had more risk factors for APO. The extension of this cohort will allow us to further investigate these important results.

References:

[1]Roberge S, et al. AmJObstetGynecol.2017;216:110-120.e6.

[2]Andreoli L et al. Annals of the Rheumatic Diseases 2017;76: 476–85.

[3]Sammaritano L et al. Arthritis & Rheumatology 2020; 72: 529–56.

Table 1.

Comparison between inflammatory arthritis pregnancies treated with low-dose aspirin and those untreated.

LDA (n 19)Not LDA (n 39)pMaternal age at conception, median (IQR)33 (30.5 - 36.5)33 (28.2 - 35)BMI, median (IQR)25.4 (22.9 - 28.5)22.5 (20.4 - 24.5)Smoking, n (%)3 (15.8%)4/36 (11.1%)0.68Previous APO, n (%)7/11 (63.7%)7/13 (56.1%)0.34aPL+, n (%)3 (15.8%)1/36 (2.8%)0.1CRP+, n (%)5/15 (33.3%)11/27 (40.7%)0.75GC at baseline, n (%)9 (47.4%)15/34 (44.1%)0.82cDMARDs at baseline, n (%)1 (5.3%)3/34 (8.8%)1bDMARDs at baseline, n (%)6 (31.6%)11 (28.2%)0.79Live-birth pregnancy, n (%)18 (94.7%)32 (82.1%)0.25Pregnancy loss, n (%)1 (5.3%)7 (17,9%)0.25Hypertensive disorders, n (%)2/18 (11.1%)6/38 (15,8%)1HELLP syndrome, n (%)0 (0%)0 (0%)1PROM, n (%)0 (0%)3/38 (7.9%)0.54Preterm delivery, 34-37 GW, n (%)2 (10.5%)2 (5.2%)0.59Preterm delivery, <34 GW, n (%)1 (5.3%)1 (2.6%)1IUGR, n (%)0 (0%)3 (7.8%)0.54SGA, n (%)0 (0%)0 (0%)1Pregnancy/Peripartum complications, n (%)3 (15.8%)11 (28.9%)0.35

Legend: aPL, Antiphospholipid syndrome; bDMARDs, biological disease-modifying antirheumatic drugs; BMI, Body mass index; cDMARDs, Conventional disease-modifying antirheumatic drugs; CRP, C-reactive protein; GC, Glucocorticoids; GW, gestational week; HELLP, haemolysis, elevated liver enzymes, and low platelets; Hypertensive disorder defined as gestational hypertension, preeclampsia and eclampsia; IQR, Interquartile range; IUGR, intrauterine growth restriction; LDA, Low-dose Aspirin; Pregnancy loss defined as early fetal-loss, miscarriage and still-birth; PROM, Premature rupture of membranes; SGA, Small for gestational age.

Acknowledgements:

I would like to acknowledge the Epidemiology Unit of the Italian Society for Rheumatology and the Investigators of the Italian Registry.

Disclosure of Interests:

None declared

POS0760 MONITORING C3 AND C4 VARIATIONS IN SYSTEMIC LUPUS ERYTHEMATOSUS PREGNANCIES IS USEFUL TO RECOGNIZE COMPLICATIONS. DATA FROM 2 ITALIAN CENTERS

Background:

In SLE pregnancies adverse pregnancy outcomes (APO) are more frequent than in general obstetric population (GOP). In clinical practice, low C3 and C4 levels are associated with active disease and, during pregnancy, complement activation products are shown to be associated with APO.

Objectives:

To analyse complement variations during SLE pregnancies, focusing on disease flares and APO.

Methods:

Data on SLE pregnancies prospectively-followed by multidisciplinary team in 2 Italian Centers from 1987 to 2018 were retrospectively analysed. C3 and C4 normal levels were calculated in general obstetric population (GOP) as previously described1, and related to maternal and fetal outcome. Non categorical variables were compared using Mann-Whitney test or Wilcoxon test when appropriate.

Results:

Two hundred forty-six pregnancies in 172 SLE patients were analysed (mean age at conception 31.3 ±4.9 years; mean disease duration 8.3 ±7.1). Anti-Ro antibodies were positive in 64 patients (37%) and anti-phospholipid antibodies (aPL) were positive in 84 (48%), with single positivity in 54%, double in 24% and triple in 21%; 9 patients (5%) had also a diagnosis of obstetric-antiphospholipid syndrome (APS) and 8 (4%) had thrombotic-APS. Seventy-one patients (41%) had history of Lupus Nephritis.

Thirty-five flares were recorded in 30 pregnancies (12%). APO occurred in 47 pregnancies (19%) and were: 27 fetal loss (20 early miscarriage <10th week and 7 intrauterine fetal death), 11 severe preterm birth (<34th week) and 15 hypertensive disorder (11 pre-eclampsia and 5 pre-eclampsia+HELLP syndrome).

In GOP, C3 progressively increased throughout pregnancy and C4 increase from the 1st trimester to the 2nd trimester, as well as in SLE pregnancies without flares and without APO, from preconception (Fig 1). In the other SLE groups, C3 and C4 showed a different trend: in pregnancies with flares, they did not increase from preconception to the 1st trimester; in fetal losses and severe pre-term births, they remained stable throughout pregnancy; in hypertensive disorders they increased only between preconception and the 1st trimester.

C3 and C4 levels were higher in GOP than in all SLE pregnancies groups (including those without flares and without APO) in each trimester. SLE pregnancies without flares showed higher C3 and C4 levels than pregnancies with flares, at preconception and in each trimester. SLE pregnancies without APO had higher C3 and C4 levels than pregnancies with fetal death at 2nd trimester, higher C3 levels than severe pre-term births in each trimester and higher C4 at 3rd trimester (Fig.1).

At preconception, pregnancies with flares showed a higher frequency of low C3 and of low C4 than in pregnancies without flares (76% vs 42%, p=0.01; 76% vs 26%, p<0.001, respectively). Using the normality range previously calculated in GOP, SLE pregnancies with flares had higher frequency of low C4 in every trimester as compared with pregnancies without flares (1st: 82% vs 48%, p=0.003; 2nd: 82% vs 64%, p=0.01; 3rd: 64% vs 30%, p=0.002). At multivariate analysis, low C4 at preconception was associated with flare (OR [95% CI]: 10.34 [2.52-42.39]; p=0.001).

Figure 1.

Variations of C3 and C4 median levels (mg/dL) throughout pregnancy in GOP1 and in SLE pregnancies without and with flare (a) and without and with APO (b).

* p <0.05

^as compared with SLE groups: p<0.05; § as compared with SLE pregnancies without flare: p<0.05; + as compared with SLE pregnancies without APO: p<0.05

Conclusion:

In SLE pregnancies, monitoring of C3 and C4 is important: its failure to increase can be useful to recognize potential risk situations which deserve particular monitoring.

References:

[1]Reggia R. et al. Rheumatology 2012;51:2186-2190.

Disclosure of Interests:

None declared

AB0822 BREASTFEEDING AMONG WOMEN WITH RHEUMATIC DISEASES: ANALYSIS OF DATA FROM THE P-RHEUM.IT STUDY

Background:

The World Health Organization recommends that infants should be exclusively breastfed until the age of 6 months. The aim of this study was to assess the ratio of breastfeeding patients with Rheumatic Diseases (RD) and to identify possible causes of its discontinuation.

Objectives:

The aim of this study was to assess the ratio of breastfeeding patients with Rheumatic Diseases (RD) and to identify possible causes of its discontinuation.

Methods:

This study was embedded in the P-RHEUM.it register, as a nationwide prospective cohort study collecting data of pregnancies in inflammatory RD. Pregnancies, enrolled until the 20th week of pregnancy, are followed from pregnancy until 6 months postpartum. At baseline, sociodemographic parameters, obstetric history, comorbidities are reported. During pregnancy, the course of maternal disease, development of foetus and complications are reported. After delivery, the pregnancy outcome, data on lactation and child development are collected.

Results:

From May 2018 to May 2020 data of 349 patients were available. Data on lactation were available in 44 pregnancies. Two months after delivery 37 were continuing breastfeeding (n=26) or mixed feeding (n=11), while 7 were using formula feeding. Among patients using formula feeding 2 had a diagnosis of rheumatoid arthritis (RA), 1 of juvenile idiopathic arthritis, 1 of undifferentiated arthritis (UA), 1 of anti-phospholipid syndrome (APS), 1 of vasculitis and 1 of systemic lupus erythematosus. The reasons of formula feeding were the following: 2 for agalactia, 2 for personal preferences, 3 for drug-related concerns (1 for physician’s decision in a patient with APS; 2 for maternal concerns about drugs in patients with RA and UA treated respectively with Adalimumab and Tocilizumab). At 6 months 30 continued breastfeeding (n=23) or mixed feeding (n=7) and 14 formula feeding. The reasons of formula feeding were available in 9 patients: 3 for agalactia, 2 for personal preferences, 2 for physician’s decision in a patient with APS and in a patient positive for anti-phospholipid antibodies; 2 for maternal concerns about drugs.

Conclusion:

Preliminary data of this prospective study demonstrate a high percentage of breastfeeding/mixed feeding after delivery and after 6 months among women with RD. Drug related concerns are the main reason of discontinuation of breastfeeding, although medication results compatible with lactation. Using our results, strategies supporting patients with RD whishing to breastfeed may be developed.

References:

[1]Carina Gotestam Sporken et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis 2016.

[2]Sammaritano et al. 2020 American College of Rheumatology Guideline for the management of reproductive health in rheumatic and muscoloskeletal diseases, Arthritis Rheumatol. 2020.

Acknowledgements:

Authors would like to thank SIR study center and all patients who accepted to partecipate to our study

Disclosure of Interests:

None declared

Decoding of standard and non-standard visuomotor associations from parietal cortex

OBJECTIVE

Neural signals can be decoded and used to move neural prostheses with the purpose of restoring motor function in patients with mobility impairments. Such patients typically have intact eye movement control and visual function, suggesting that cortical visuospatial signals could be used to guide external devices. Neurons in parietal cortex mediate sensory-motor transformations, encode the spatial coordinates for reaching goals, hand position and movements, and other spatial variables. We studied how spatial information is represented at the population level, and the possibility to decode not only the position of visual targets and the plans to reach them, but also conditional, non-spatial motor responses.

APPROACH

The animals first fixated one of nine targets in 3D space and then, after the target changed color, either reached toward it, or performed a non-spatial motor response (lift hand from a button). Spiking activity of parietal neurons was recorded in monkeys during two tasks. We then decoded different task related parameters.

MAIN RESULTS

We first show that a maximum-likelihood estimation (MLE) algorithm trained separately in each task transformed neural activity into accurate metric predictions of target location. Furthermore, by combining MLE with a Naïve Bayes classifier, we decoded the monkey's motor intention (reach or hand lift) and the different phases of the tasks. These results show that, although V6A encodes the spatial location of a target during a delay period, the signals they carry are updated around the movement execution in an intention/motor specific way.

SIGNIFICANCE

These findings show the presence of multiple levels of information in parietal cortex that could be decoded and used in brain machine interfaces to control both goal-directed movements and more cognitive visuomotor associations.

SAT0202 C4 LEVELS AS PREDICTOR OF DISEASE FLARES AND ADVERSE PREGNANCY OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS PREGNANCIES

Background:

SLE pregnancies have an increased risk of Adverse Pregnancy Outcomes (APO). In clinical practice, low C3 and C4 levels are associated with active disease and, during pregnancy, complement activation products are shown to be associated with APO.

Objectives:

To analyse potential association between C3 and C4 variations and disease flares and APO during SLE pregnancies.

Methods:

Demographic, clinical and laboratory data on SLE pregnancies prospectively-followed by a multidisciplinary team in a pregnancy clinic from 1987 to 2015 were retrospectively analysed at preconception and at each trimester. Hypocomplementemia was defined according to the normality range calculated in healthy pregnancies by Reggia et al1. APO were defined as: early miscarriage (<10thweek), intrauterine fetal death (>10thweek), perinatal death (<30thday of life), pre-eclampsia (PE), severe preterm birth (<34thweek).

Results:

134 pregnancies in 98 SLE patients were analysed. APO occurred in 22 (16%) pregnancies: 9 early miscarriages, 4 intrauterine fetal deaths, 3 severe preterm births, 6 PE (hesitated in 1 intrauterine fetal death, 1 perinatal death; 2 preterm birth between 34thand 37thweeks and 2 term births). 13 flares (2 renal, 4 articular, 6 cutaneous and 1 neurological) were recorded in 11 (8%) pregnancies.

The mean C3 and C4 levels at each trimester are shown in table 1.

Table 1.

C3 and C4 mean levels (mg/dL) at pre-conceptional visit (T0), 1sttrimester (T1), 2ndtrimester (T2) and 3rdtrimester (T3).

C3 T0C3 T1C3 T2C3 T3p T0-T1p T1-T2p T2-T3Pregnancies with flares73.282.283.897.50.040.020.06Pregnancies without flares85.391.8104.4114.7<0.001<0.001<0.001Pregnancies with APO*84.791.598.5106.30.030.030.89Pregnancies without APO*84.590.9102.8112.8<0.001<0.001<0.001C4 T0C4 T1C4 T2C4 T3p T0-T1p T1-T2p T2-T3Pregnancies with flares8.611.810.911.40.010.430.27Pregnancies without flares13.214.716.316.6<0.001<0.0010.98Pregnancies with APO**13.116.115.914.70.010.30.13Pregnancies without APO**12.914.215.816.1<0.001<0.0010.42

Comparison of C3 and C4 mean levels between pregnancies with APO vs without APO:

* T0, T1, T2, T3: ns; ** T0, T1, T2, T3: ns

Both in pregnancies with flares and with APO, there was no increase of C3 between the 2ndand the 3rdtrimester and of C4 between the 1stand the 2ndtrimester.

At preconception, mean levels of C4 were lower in pregnancies with flares compared to those without flares (images 1 and 2); during the 2ndand the 3rdtrimesters the mean levels of both C3 and C4 were lower in pregnancies with flares.

In pregnancies with APO, the variation of C4 levels between the 2ndand the 3rdtrimester was lower than in pregnancies without APO (-3.18 vs 0.27; p=0.01).

A higher frequency of low C4 was observed at pre-conceptional visit, 1sttrimester and 3rdtrimester (6/7 vs 25/103 p=0.002; 8/9vs56/106 p=0.04; 9/11 vs 33/96 p=0.003) in pregnancies with flare as compared with pregnancies without flares.

Figure 1.

Image 1: comparison of C3 mean levels between pregnancies with faresvswithout flares

Figure 2.

Image 2: comparison of C4 mean levels between pregnancies with faresvswithout flares

Conclusion:

In our cohort of prospectively-followed SLE pregnancies, low C4 levels at preconception seems to predict flares during pregnancy. Low increase of C4 levels between the 2ndand the 3rdtrimester could predict an APO.

References:

[1]Reggia R. et al. Rheumatology 2012;51:2186-90

Disclosure of Interests:

None declared

AB0678 RISK FACTORS FOR ADVERSE PREGNANCY OUTCOMES IN SPONDYLOARTHRITIS: DISEASE PHENOTYPE AND DISEASE ACTIVITY MAY PLAY A ROLE

Background:

Pregnant patients (pts) with spondyloarthritis (SpA) seem at increased risk for adverse pregnancy outcomes (APO), however limited and conflicting data have been published so far and risk factors for APO in these pts remain poorly understood.

Objectives:

To assess APO and identify possible risk factors for those in a cohort of SpA pregnant pts.

Methods:

Data on SpA pts prospectively-followed in a pregnancy clinic from 2010 to 2019 were retrospectively analysed before conception and during each trimester. Pregnancies complicated by APO were compared with those that were uneventful for demographic and clinical variables. Active disease was defined as a DAS-28-CRP>3.2 or an ASDAS-CRP ≥ 2.1 according to peripheral or axial dominant disease respectively.

Results:

56 pregnancies (mean age 34±5 years; median disease duration 60 months, IQR 24-123) in 47 pts were analysed: 37 psoriatic arthritis, 7 axial SpA, 6 undifferentiated SpA, 3 enteropathic SpA, 2 reactive arthritis and 1 enthesitis-related juvenile idiopathic arthritis. APO were recorded in 23/56 (41%) pregnancies: 5 (9%) early miscarriages, 1 (2%) medical abortion (central nervous system malformation), 3 (5%) preterm births (≥34 gestational week, all for preterm premature rupture of membranes - PROM); 2 (4%) PROM; 7 (13%) small for gestational age newborns (SGA); 3 gestational diabetes and 2 cholestasis of pregnancy. Table 1 displays the comparison between pregnancies with and without APO. A higher number of pts with active disease were detected during the 2ndtrimester in both groups, however differences between those were only significant at the 3rdtrimester (p=0.03). History of inflammatory bowel symptoms (IBS) was also associated with an increased risk for APO (p=0.02). Although not reaching statistical significance, APO occurred more frequently in pts with a previous use of > 1 conventional synthetic (cs) or biological (b) disease-modifying antirheumatic drug (DMARD) (p=0.05), suggesting a more difficult to treat phenotype. Likewise, pts with APO were less often treated with low dose aspirin (LDA) during pregnancy.

Conclusion:

SGA was the main APO recorded. History of IBS, a more difficult to treat phenotype and the presence of active disease during pregnancy influenced APO in this cohort, reinforcing the need for tight disease control before and during pregnancy. Larger and prospective data are warranted to confirm these results and to assess the potential protective role of LDA.

References:

[1]Molto 2018; Zbinden 2018.

Table 1.

Differences between patients with and without APO

Pregnancieswith APOPregnancies without APOpN, %23, 41.133, 58.9Maternal age at conception,mean±SD (years)33.8±533.8±4.9NSHx previous APO– N, %4,17.43, 9.1NSDisease duration,median (IQR), (months)96 (36-132)48 (24-96)NSAxial dominant disease– N, %6, 26.16, 18.2NSPeripheral dominant disease –N, %11, 47.820, 60.6NSHx enthesitis– N, %9, 39.113, 39.4NSHx dactylitis– N, %5, 21.711, 33.3NSHx psoriasis– N, %10, 43.518, 54.5NSHx uveitis–N, %1, 4.34, 12.1NSHx inflammatory bowel symptoms– N, %4, 17.40, 00.02HLA-B27– N, %8, 34.87, 21.2NS>1 cs or bDMARDs before conception –N, %13, 56.510, 30.30.05LDA during pregnancy– N, %7, 30.417, 51.5NSActive disease before conception- N, %5, 21.72, 6.1NSActive disease 1sttrimester- N, %1, 4.34, 12.1NSActive disease 2ndtrimester- N, %6, 26.15, 15.2NSActive disease 3rdtrimester- N, %3, 130, 00.03

Legend: Hx – history of; NS – non significant.

Disclosure of Interests:

None declared

SAT0368 PREGNANCY IN WOMEN WITH SPONDYLOARTHRITIS: WHO ARE THE PATIENTS AT RISK OF DISEASE FLARE?

Background:

Patients with Spondyloarthritis (SpA) can experience flares during pregnancy and postpartum even though the available data are limited and not conclusive.

Objectives:

To assess disease activity and treatment modification during pregnancy and postpartum in patients with SpA and to identify risk factors for disease flare.

Methods:

Data on SpA pregnancies prospectively-followed in a pregnancy clinic from 2010 to 2019 were retrospectively analysed. Disease activity was assessed during each trimester and postpartum using ASDAS-CRP or DAS28-CRP. Flare was defined as an increase of disease activity leading to treatment modification (introduction or increase ≥5mg/day of prednisone, introduction of cDMARD or bDMARD)1.

Results:

Data on 50 pregnancies in 46 patients were collected (mean age at conception 33±4.7 years; median disease duration: 60 months (IQR 24-132); 33 psoriatic arthritis, 6 axialSpA, 2 reactive arthritis, 2 IBD-related SpA; 6 undifferentiated SpA, 1 juvenile idiopathic arthritis). Six pregnancies ended in miscarriage, so they weren’t considered for the analysis of flares during pregnancy (table 1). Fifteen out of 44 (34%) pregnancies had at least one flare during pregnancy (6, 7 and 4 during 1st, 2ndand 3rdtrimester respectively; 2 pregnancies had multiple flares). A higher rate of flare was observed in pregnancies of patients with axial involvement (p=0.01), on treatment with bDMARDs at preconceptional visit (p=0.03) and who stopped TNFi at positive pregnancy test (p=0.03). Peripheral involvement was associated with a lower rate of flares (p=0.02). Medications resumed during pregnancy were steroids (in 6 pregnancies), cDMARDs (2 sulfasalazine, 1 cyclosporine) and bDMARDs (4 certolizumab, 4 etanercept). During postpartum period flares were recorded in 46% of patients.

Table 1.

clinical features, medication and disease activity in pregnancies with flare vs without flare

CLINICAL FEATURESFLARE (15)NO FLARE (29)pAxial involvement, n (%)11/15 (73)9/29 (31)0.01Peripheral arthritis, n (%)8/15 (53)26/29 (90)0.02Enthesitis, n (%)5/15 (33)14/29 (48)nsDactilitis, n (%)3/15 (20)8/29 (28)nsPsoriasis, n (%)6/15 (40)17/29 (59)nsIBD, n (%)2/15 (13)0nsUveitis, n(%)1/15 (7)3/29 (10)nsHLAB27 +7/11 (64)5/12 (42)nsMEDICATION HISTORYbDMARDs, n (%)11/15 (73)7/29 (24)0.003bDMARDs at preconception visit, n (%)8/15 (53)6/29 (21)0.04bDMARDs stopped at positive pregnancy test, n (%)7/15 (47)4/29 (14)0.03cDMARDs, n (%)12/15 (80)25/29 (86)nsDISEASE ACTIVITYACTIVE DISEASE* preconception visit, n(%)3/14 (21)4/23 (17)nsACTIVE DISEASE 1sttrimester, n(%)6/15 (40)1/29 (3)0.004ACTIVE DISEASE 2ndtrimester, n(%)8/15 (47)2/29 (7)0.001ACTIVE DISEASE 3rdtrimester, n(%)2/15 (13)1/29 (3)ns

*DAS28-CRP>3.2 or ASDAS-CRP≥2.1

Conclusion:

In our cohort of prospectively-followed SpA pregnancies, 34% experienced a flare during pregnancy and 46% during postpartum. Flares occurred especially in those patients who discontinued TNFi early in pregnancy and with axial involvement. When resumed during pregnancy, TNFi was able to control the disease. At preconception counselling, the continuation of TNFi during pregnancy should be considered to ensure a better control of disease.

References:

[1]Fischer-Betz R et al.Arthritis Rheumatol. 2015; 67.

Disclosure of Interests: :

None declared

Is higher nursing home quality more costly?

Widespread issues regarding quality in nursing homes call for an improved understanding of the relationship with costs. This relationship may differ in European countries, where care is mainly delivered by nonprofit providers. In accordance with the economic theory of production, we estimate a total cost function for nursing home services using data from 45 nursing homes in Switzerland between 2006 and 2010. Quality is measured by means of clinical indicators regarding process and outcome derived from the minimum data set. We consider both composite and single quality indicators. Contrary to most previous studies, we use panel data and control for omitted variables bias. This allows us to capture features specific to nursing homes that may explain differences in structural quality or cost levels. Additional analysis is provided to address simultaneity bias using an instrumental variable approach. We find evidence that poor levels of quality regarding outcome, as measured by the prevalence of severe pain and weight loss, lead to higher costs. This may have important implications for the design of payment schemes for nursing homes.

Assessing the impact of national antibiotic campaigns in Europe

Because of evidence of causal association between antibiotic use and bacterial resistance, the implementation of national policies has emerged as a interesting tool for controlling and reversing bacterial resistance. The aim of this study was to assess the impact of public policies on antibiotic use in Europe using a differences-in-differences approach. Comparable data on systemic antibiotics administered in 21 European countries are available for a 11-year period between 1997 and 2007. Data on national campaigns are drawn from the public health literature. We estimate an econometric model of antibiotic consumption with country fixed effects and control for the main socioeconomic and epidemiological factors. Lagged values and the instrumental variables approach are applied to address endogeneity aspects of the prevalence of infections and the adoption of national campaigns. We find evidence that public campaigns significantly reduce the use of antimicrobials in the community by 1.3-5.6 defined daily doses per 1,000 inhabitants yearly. This represents an impact of roughly 6.5-28.3 % on the mean level of antibiotic use in Europe between 1997 and 2007. The effect is robust across different measurement methods. Further research is needed to investigate the effectiveness of policy interventions targeting different social groups such as general practitioners or patients.

A randomized double-blind study of low-molecular-weight heparin (parnaparin) for superficial vein thrombosis: STEFLUX (Superficial ThromboEmbolism and Fluxum)

BACKGROUND

Optimal doses and duration of low-molecular-weight heparin (LMWH) for the treatment of superficial vein thrombosis (SVT) are still uncertain.

OBJECTIVES

To compare the efficacy and safety of different doses and durations of LMWH parnaparin for symptomatic lower limb SVT.

PATIENTS AND METHODS

Outpatients with at least a 4-cm-long SVT of long or short saphenous veins or their collaterals were randomized to receive parnaparin either 8500 UI once daily ( o.d.) for 10 days followed by placebo for 20 days (group A) or 8500 UI o.d. for 10 days followed by 6400 UI once daily (o.d.) for 20 days (group B) or 4250 UI o.d. for 30 days (group C) in a double-blind fashion in 16 clinics. Primary outcome was the composite of symptomatic and asymptomatic deep vein thrombosis (DVT), symptomatic pulmonary embolism (PE) and relapse and/or symptomatic or asymptomatic SVT recurrence in the first 33 days with 60 days follow-up.

RESULTS

Among 664 patients, primary outcome occurred in 33/212 (15.6%), 4/219 (1.8%) and 16/217 (7.3%) subjects in groups A, B and C, respectively (B vs. A: absolute risk reduction [ARR]: 13.7%, 95% confidence intervals [CI]: 8-18.9 P<0.001; B vs. C: ARR: 5.5%; 95% CI: 1.6-9.4 P= 0.011; C vs. A: ARR: 8.2%, 95% CI: 2-14 P=0.012). During days 0-93, the event rate was higher in group A (22.6%) than either in group B (8.7%; P=0.001) or C (14.3%, P=0.034). No major hemorrhages occurred.

CONCLUSIONS

An intermediate dose of parnaparin for 30 days is superior to either a 30-day prophylactic dose or a 10-day intermediate dose for lower limb SVT treatment.

European attempts for the standardisation of the antiphospholipid antibodies

According to the Sydney criteria, antiphospholipid syndrome (APS) diagnosis is closely related to the demonstration of antiphospholipid antibodies (aPL) in patients sera. For this purpose, three different assays are conventionally accepted: lupus anticoagulant (LA), anticardiolipin (aCL) and anti-β2 glycoprotein I (β2GPI) antibodies. LA, described in the 1950s is a coagulation-based functional assay, which indirectly detects the presence of aPL. The aCL ELISA was developed in 1985; the identification of β2GPI as a major target of aPL, allowed the introduction of anti-β2GPI ELISA. Even if the diagnostic criteria for APS have been well defined, the laboratory detection of aPL is not always reproducible for many reasons. To achieve a univocal diagnostic definition of APS, efforts were made to reduce the inter- and/or intra-laboratory variability of the diagnostic tests. In this article, we analyse the studies performed to standardise aPL assays that were developed within the European Forum on Antiphospholipid Antibodies.

Efficacy and safety of anti-TNF agents in the Lombardy rheumatoid arthritis network (LORHEN)

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by chronic synovitis and bone damages, which consist of joint destruction. Clinical trials have shown that anti-tumour necrosis factor (TNF) drugs are effective in patients with rheumatoid arthritis (RA) refractory to disease-modifying antirheumatic drugs (DMARDs). At about the same time as the European approval of the third anti-TNF agent for treating rheumatoid arthritis (RA) patients, the Italian Society of Rheumatology (Società Italiana di Reumatologia [SIR]) started a database for the registration and active follow-up of patients with RA treated with biological response modifiers. Since 1999, all patients with RA (ACR criteria) and treated with at least one dose of an anti-TNF agent at four Rheumatology Centres in Lombardy (northwest Italy) have been included in the Lombardy Rheumatology Network (LORHEN) registry in order to track the efficacy and safety of the three available TNF inhibitors during the first three years of treatment.

[Anti-TNFalpha agents in elderly patients with rheumatoid arthritis: a study of a group of 105 over sixty five years old patients]

OBJECTIVE

To evaluate the efficacy and the safety of anti-TNF alfa treatment in elderly patients (>/=65 years old) with active rheumatoid arthritis (RA), in comparison with younger (17-65 years old).

METHODS

We considered retrospectively 295 patients, affected by RA and treated with anti-TNF alfa drugs. They were divided in two groups, according to their age, and followed up for two years: over-65-years old patients (190) and under-65-years old patients (105). Effectiveness of drugs was assessed analyzing RA disease activity (DAS28, DAS44, SDAI), functional status (HAQ) and serological parameters (CRP) before and after anti-TNF alfa therapy. Safety was studied considering discontinuation rate of biological disease-modifying antirheumatic drugs, and collateral events rate.

RESULTS

At baseline, elderly patients showed higher disease activity's score (DAS 28, DAS44, SDAI, HAQ) with important loss of articular function (worse quality of life, HAQ) than younger patients (p<0.05). During the therapy, improvement in clinical parameters was observed (DAS28, DAS44 and SDAI) with no significant difference between the two groups. In elderly patients disability index, on the contrary, improved less than in younger (p<0.05). After treatment, also CRP decreased less in elderly patients (p<0.05). During the follow-up, 74 over-65-years old patients (38.95%) and 116 under-65-years old patients (38.05%) discontinued anti-TNF alfa therapy because of loss of efficacy (20.52% vs 11.42%), severe adverse events (17.34% vs 25.67%), voluntary discontinuation or good clinical response (1% vs 0.95%). No differences were shown about the frequency and reasons of anti-TNF alfa withdrawal (p>0.05).

CONCLUSIONS

Anti-TNF alfa treatment was efficacious and safe in both groups of patients. These drugs induced improvement in disease activity, apart from the age. No functional improvement was observed in HAQ, showing the irreversible loss of articular function and the incomplete recovery in elderly patients. Age doesn't interfere with the possibility to treat elderly patients with anti-TNF alfa drugs.

[Post-radiation pelvic disease and ureteral stenosis: physiopathology and evolution in the patient treated for cervical carcinoma. Review of the literature and experience of the Radium Institute]

Ureteral stenosis secondary to radiation-induced fibrosis is a well-known, late complication of radiation treatment in patients with carcinoma of the uterine cervix. This paper focuses on epidemiological data, physiopathology and treatment modalities reviewed from Internet-published literature. Experience from a single institution (Institute of Radiotherapy of Brescia) is reported. Ureteral stenosis has an incidence of 15% in patients treated with standard doses of radiotherapy for carcinoma of the uterine cervix. An asymptomatic low-grade fibrotic ureteral stenosis establishes at doses of 20 Gy in experimental animal models, and both incidence and severity rise with increasing of doses. An emerging role for Transforming Growth Factor beta 1 (TGF-beta 1) is recognized in determining chronic activation of fibroblast/fibrocyte lineage and remodelling extracellular matrix which are known mechanisms in the genesis of any fibrotic disease. Experience of the radiotherapy Institute of Brescia, Italy, is reported. A series of 191 patients with stage IB-IIA cervix carcinoma was treated with radical radiotherapy. About 10% of patients developed late urinary tract complications related to post-actinic fibrosis with only 1% of grade III-IV ureteral fibrosis. These data are consistent with those published by other institutions. In conclusion, late ureteral fibrosis is a common and distressing treatment-related complication in patients treated with radiotherapy for cervix carcinoma. Newer strategies in better defining the target for radiotherapy, conformational radiotherapy and better understanding of biologic factors will contribute to further reducing the frequency of such a complication.

Comparison of ultrasound-secretin test and sphincter of Oddi manometry in patients with recurrent acute pancreatitis

Manometry is considered the gold standard for evaluating sphincter of Oddi dysfunction. It has recently been demonstrated that the ultrasound (US) secretin test proposed a few years ago as a noninvasive test for the study of sphincter of Oddi dysfunction yields a substantial percentage of pathological findings in patients with acute recurrent pancreatitis. The aim of this study was to compare the results of the US secretin test with sphincter of Oddi manometry findings in a consecutive series of patients with recurrent acute pancreatitis. Forty-seven patients admitted to our gastrointestinal unit suffering from recurrent acute pancreatitis underwent ultrasonographic measurement of the main pancreatic duct at baseline and for 60 min after maximal stimulation with secretin at 1 IU/kg. According to the US secretin test findings in 35 healthy control subjects, the test results were considered to indicate pathology when the duct was still dilated after 20 min. Within three to seven days the same patients underwent perendoscopic manometry. Thirty-six patients (17 men, 19 women; mean age 41 +/- 15 years) had a successful US secretin test and sphincter of Oddi manometry. Eleven patients (30.6%) presented normal manometric findings. Two of these had an abnormal US secretin test. Twenty-five patients had abnormal manometry findings, revealing stenosis in 19 (52.7%) (17 with abnormal US secretin test) and dyskinesia in six (five with an abnormal US secretin test). Compared to manometry findings, the US secretin test sensitivity and specificity for sphincter of Oddi dysfunction were 88% and 82%, respectively. In conclusion, most patients with recurrent acute pancreatitis have sphincter of Oddi dysfunction documented by both at the US secretin test and sphincter of Oddi manometry; results of the US secretin test are reliable compared to sphincter of Oddi manometry, and therefore the US secretin test may offer a valid alternative to the more expensive and invasive manometric procedure for assessing sphincter of Oddi dysfunction in patients with recurrent acute pancreatitis.

In vitro drug assays and statistical analysis

The development of in vitro drug tests to assess the efficacy of drugs against Pneumocystis carinii has been hindered by the lack of efficient methods for continuous cultivation of the microorganism. However, different short-term culture systems have been proposed by many teams. In the present contribution an in vitro microplate drug assay and two statistical programs allowing the analysis of results are presented.

Long-term follow-up of patients with chronic pancreatitis in Italy

BACKGROUND

We investigated the epidemiologic, clinical, and radiologic aspects of a mixed medicosurgical series of chronic pancreatitis patients observed at the University of Verona Centre for the Study of Pancreatic Diseases over the period 1971-1995.

METHODS

Even though the pathogenesis of chronic pancreatitis has yet to be clarified and the classification is still debatable, the patients were subdivided in accordance with the Marseilles-Rome classification into those with alcoholic, obstructive, familial, and idiopathic forms of the disease. A total of 715 patients were analysed with a median follow-up period of 10 years (range, 1-25 years).

RESULTS AND CONCLUSIONS

At the end of follow-up the dropout rate amounted to 7.1% (51 patients), and 176 patients (24.6%) had died. Data are reported about the type of chronic pancreatitis, sex, and age distribution at the onset of the disease, drinking and smoking habits before onset and during follow-up, and incidence of calcifications, pain, diabetes, steatorrhoea, and pseudocysts. Surgical aspects, survival curves, and causes of death are also analysed, and the most frequent concomitant diseases in chronic pancreatitis sufferers are discussed.

Effect of medium-term supplementation with a moderate dose of n-3 polyunsaturated fatty acids on blood pressure in mild hypertensive patients

Several studies have shown that n-3 polyunsaturated fatty acids (n-3 PUFA) are able to lower blood pressure (BP) in humans, but large doses of fish oils have been often used. Moreover, most of the studies available in the literature were not able to evaluate the specific effects of n-3 PUFA because they employed fish oils which contain, together with n-3 PUFA, many other different components. The aim of this preliminary study was to evaluate if medium-term supplementation with a moderate dose of highly purified eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) ethyl esters is able to reduce BP in mild hypertensive patients. Sixteen mild essential hypertensive (diastolic BP: 95-104 mm Hg), non-diabetic, normolipidemic male outpatients and 16 normotensive male controls were recruited to participate in the study. Both hypertensive and control subjects were randomly assigned to receive either EPA and DHA ethyl esters (2.04 g EPA and 1.4 g DHA) as active treatment or olive oil (4 g/day) as a placebo for a period of 4 months. These subjects were followed up with 24-hour ambulatory BP monitoring and blood chemistry analyses at 2 and 4 months of treatment and 2 months after its discontinuation. The intake of n-3 PUFA was checked by red blood cell (RBC) phosphatidylcholine (PC) fatty acid composition. The effect of n-3 PUFA on BP in the active group was maximum after 2 months. Both systolic (-6 mm Hg, p<0.05) and diastolic (-5 mm Hg, p<0.05) BP significantly decreased during the n-3 PUFA ethyl ester supplementation. No further effect was observed at 4 months with a return to baseline values during the recovery period. These data indicate that 4 g/day of highly purified EPA + DHA ethyl esters are able to favorably affect BP in mild hypertensives.

Calcium-PTH relationship in dialysis patients: the pitfalls of using a constant dialysate calcium concentration during the dynamic tests

The calcium-PTH relationship in uremic patients has been often studied during dialysis sessions with high or low dialysate calcium concentration (CaD). This method has been used because it is less complex and invasive than i.v. infusion of calcium salts and calcium chelating agents. However, the constancy of CaD during the tests does not allow for the control of the serum calcium profile and, given that the blood calcium concentration is only one factor of a more complex calcium-related mechanism of the PTH release, the calcium-PTH curve may become dependent on the unpredictable rate at which the ionized calcium changes. Dynamic testing of the parathyroid gland was performed in 9 dialysis patients comparing constant CaD of 1.0 and 2.0 mmol/l (A) with a linear change in CaD (B). The rate of serum calcium change remained constant over time only in experiment B. The total decrease in calcemia (0-0.38 +/- 0.03 vs -0.14 +/- 0.1 mmol/l) and PTHmax (748.25 +/- 124.76 vs 374.89 +/- 53.03 pg/ml) were significantly higher in B, whereas the total increase in calcemia (+0.26 +/- 0.03 vs +0.28 +/- 0.02 mmol/l) and the minimum value of PTH (59.15 +/- 9.53 vs 55.64 +/- 9.08 pg/ml) were similar in both experiments. The calcium-PTH curves were clearly different in A and B. The setpoint and the slope were significantly higher in A (1.196 +/- 0.01 vs 1.142 +/- 0.02 mmol/l; 840.54 +/- 96.85 vs 542.43 +/- 112.26%/mmol). For similar serum calcium values (1.084 +/- 0.01 vs 1.059 +/- 0.02 in the stimulation test and 1.325 +/- 0.02 vs 1.336 +/- 0.02 mmol/l in the inhibition test) the PTH secretion was significantly different (335.86 +/- 44.36 vs 647.65 +/- 104.09 in the stimulation test and 76.35 +/- 12.57 vs 105.03 +/- 20.59 pg/ml in the inhibition test). In conclusion, the way of inducing serum calcium change affected the calcium-PTH curve and the value of the set point and the slope was a function of the way in which the blood calcium changes were achieved. The modulated CaD dialysis was shown to be a more correct method of studying the calcium-PTH relationship in dialysis patients, as well as an alternative to the more complex and invasive infusional methodology.

Ultrasonography-secretin test pattern after acute administration of octreotide in healthy persons and in patients with recurrent acute pancreatitis

The intravenous administration of octreotide stimulates sphincter of Oddi activity and impairs pancreatic flow into the duodenum. Postsecretin ultrasonography (US-S test) has revealed an increase in the caliber of the main pancreatic duct, which disappears in healthy persons approximately 10 minutes later as a result of the opening of the sphincter of Oddi and passage of stimulated fluids into the duodenum. We have assessed US-S test patterns after octreotide in healthy persons and in patients with recurrent acute pancreatitis. The study sample consisted of 16 participants: alcohol-abstinent, nonsmoking, healthy volunteers (four men, three women; mean age: 28 +/- 2.5 years) and nine patients with recurrent acute pancreatitis (six men, three women; mean age: 32.1 +/- 7.1 years). All participants underwent measurement of the main pancreatic duct at 1-min intervals for 60 min after secretin stimulation (1 IU/kg intravenous bolus). On a different day the same persons had repeated US-S tests 1 hour after administration of 0.1 mg octreotide intramuscularly. In both controls and patients with recurrent acute pancreatitis, octreotide administration induced an appreciable dilatation of the main pancreatic duct before secretin stimulation, and the caliber remained significantly increased throughout the duration of the test. These results suggest that a single administration of octreotide at the dose used (a) does not inhibit pancreatic secretion of basal and secretin-stimulated fluid within the first 60 min and (b) probably exerts an inhibitory effect on sphincter of Oddi relaxation. These findings warrant more intensive study given their therapeutic implications for acute pancreatic disease.

Food intake of patients with chronic pancreatitis after onset of the disease

The food intake of 40 male patients with chronic pancreatitis followed up at our center for > or = 10 y were compared with that of 75 healthy control subjects. Patients had significantly lower anthropometric values and serum triacylglycerol and cholesterol concentrations than control subjects (P < 0.001). Subjects with pancreatitis had higher carbohydrate and energy intakes than control subjects but no significant differences were observed in protein, fat, fiber, or cholesterol intakes. The results show that although those with chronic pancreatitis consumed carbohydrates with a more balanced variety of nutrients, they were thinner and had lower serum lipid concentrations, which suggests that they had latent digestion disorders or malabsorption.

Effect of octreotide on sphincter of Oddi motility in patients with acute recurrent pancreatitis: a manometric study

Sphincter of Oddi dysfunction has been reported as a cause of acute idiopathic recurrent pancreatitis (IRP). Octreotide, a long-acting somatostatin analogue, is an antisecretory drug used in the treatment and prevention of acute pancreatitis. Its action on sphincter of Oddi motility is controversial and no data are available for IRP patients. The aim of this study was to assess sphincter of Oddi motor response to acute administration of octreotide in patients with past attacks of acute pancreatitis without identification of any evident aetiological factor. Six patients (four male, two female; mean age +/-SD, 38.8+/-9 years) suffering from acute pancreatitis for at least 3 months before the examination were submitted to sphincter of Oddi manometry. After a basal recording lasting at least 2 min, octreotide, 0.05 mg i.v., was administered and the recording repeated. Intraduodenal pressure was taken as the zero reference and the basal sphincter of Oddi pressure and amplitude and frequency of phasic contractions were calculated before and after octreotide administration. No significant pre- vs post-octreotide differences were observed in basal pressure (41.9+/-24 vs 47.5+/-33 mm Hg, respectively) or in amplitude of phasic contractions (164.6+/-33 vs 170.8+/-18 mm Hg). With a latency of about 1 min, octreotide administration caused a high-frequency phasic activity in all cases (mean frequency, 5.5+/-2.2 contractions/min before and 9.8+/-2 after octreotide; P < 0.04). After the procedure acute pancreatitis (prolonged abdominal pain and serum amylase levels more than three-fold the normal values) developed in five patients. In conclusion, our data suggest that acute administration of octreotide may induce tachyoddia and thus a rise in sphincter of Oddi pressure, with possible impairment of biliary-pancreatic outflow.

Chronic obstructive pancreatitis in humans is a lithiasic disease

In humans chronic obstructive pancreatitis (COP) is thought to be a disease devoid of ductal stones. The aim of this study was to verify the presence and frequency of calcifications in patients with COP and compare them with those found in patients with chronic calcifying/calcific pancreatitis (CCP). We conducted a retrospective ERCP investigation in 115 patients with documented chronic pancreatitis. Only 75 could be safely classified as COP or CCP. Fifty-three patients (M:F ratio, 5.6:1; mean age, 36.1 +/- 12.2 years) had CCP, 46 of whom (86.8%) with calcifications. Twenty-two patients (M:F ratio, 3.4:1; mean age, 45.3 +/- 16.2 years; p < 0.05 vs. CCP) presented COP at endoscopic retrograde cholangiopancreatography, 8 (36.4%) with ductal calcifications (p < 0.0001 vs. CCP). COP was secondary to acute pancreatitis in nine cases, to odditis in 11 cases, and to malignant tumor and hypertrophy of Oddi's sphincter, respectively, in the other two cases. The two patient groups showed no significant differences in drinking and smoking habits, number of painful relapses, disease duration, and incidence of diabetes, gallstones, and need for surgery. In conclusion, formation of ductal stones is by no means rare in COP and should be classified as a form of lithiasic pancreatitis. Early restoration of pancreatic outflow by removing the obstruction, or by shunt-type operations and abstinence from drinking and smoking, should resolve this type of disease.

n-3 PUFA supplementation, monocyte PCA expression and interleukin-6 production

n-3 polyunsaturated fatty acids (PUFA) can affect several monocyte functions and the biochemistry of blood cells, thus possibly influencing the initiation of thrombosis, inflammatory disease and atherosclerosis. In this study, we have investigated the effect of dietary supplementation with n-3 PUFA ethyl esters on procoagulant activity (PCA) and interleukin-6 (IL-6) production by human mononuclear cells. Nine healthy volunteers received 4 g/d of n-3 PUFA ethyl esters (4 x 1 g capsules with at least 85% eicosapentaenoic + docosahexaenoic acid ethyl esters) for 18 weeks. Before and at the end of the treatment, mononuclear cells were obtained from peripheral citrated blood by Ficoll-Hypaque density gradient centrifugation. Cellular suspensions (10(7) cells/ml) were incubated at 37 degrees C for 4 h in the absence and presence of lipopolysaccharide (10 micrograms/ml); PCA was determined by one-stage clotting assay and IL-6 concentrations were assayed in supernatants by specific ELISA. After 18-week treatment, both unstimulated and stimulated monocyte PCA were significantly reduced by 66% and 63%, respectively (P < 0.01). Similarly, a significant inhibitory effect by n-3 PUFA treatment on basal and LPS-stimulated IL-6 monocyte production was observed (50% and 46%, respectively, P < 0.05). These data indicate that 18-week n-3 PUFA supplementation may influence monocyte activities, which play a specific role in atherosclerosis and its thrombotic complications.

Effect of n-3 polyunsaturated fatty acid intake on phospholipid fatty acid composition in plasma and erythrocytes

To characterize the time course of plasma and red blood cell (RBC) changes after n-3 polyunsaturated fatty acid (PUFA) supplementation, 20 healthy male volunteers were randomly assigned to receive either four 1-g capsules of n-3 PUFA ethyl esters or four 1-g capsules of olive oil (as placebo) for a period of 4 mo, followed by a 3-mo washout period. Fatty acids of plasma and RBC phospholipid fractions were analyzed at 0, 2, and 4 mo of treatment and at 1, 2, and 3 mo of washout. During n-3 PUFA supplementation, accumulations of eicosapentaenoic (EPA), docosapentaenoic (DPA), and docosahexaenoic (DHA) acids were marked after 2 mo with differences among different fractions of plasma and RBCs in further accumulation up to 4 mo. During the first and second months of the washout, slight differences were observed in changes of various fatty acids among different phospholipid fractions, but after 3 mo of washout, only minor alterations were still detectable with respect to pretreatment values. These data confirm the complex relations among different fatty acid pools after n-3 PUFA supplementation.

Fibrin generation and digestion in patients with angina pectoris

Fibrin generation and lysis were studied in 28 patients with angina pectoris (14 with active disease and 14 with inactive disease) and in 14 normal controls. The fibrinolytic response was evaluated by comparing the ratio between the plasma levels of fibrinopeptide A and fibrin degradation products. Levels of both were higher in patients than in controls (P < 0.001), with higher levels in active than in inactive disease (P < 0.001). The fibrinopeptide A/fibrin degradation products ratio was much higher (P < 0.001) in the active group than in other groups. Thus, in patients with angina pectoris, especially in the active state, the increased thrombin generation is not paralleled by an equivalent increase in fibrinolytic activity.

Platelet activation and platelet lipid composition in pulmonary cancer

In order to investigate the possible mechanisms underlying platelet functional changes in patients affected by neoplasms, platelet lipid composition, plasma beta-thromboglobulin (Beta-TG) and serum thromboxane B2 (TXB2) were investigated in 16 male patients affected by pulmonary carcinoma and in 16 comparable control subjects. In patients high levels of plasma Beta-TG (67 +/- 9 versus controls 14 +/- 4 ng/ml, p < 0.001) and serum TXB2 (434 +/- 56 versus 223 +/- 48 ng/ml, p < 0.001) were observed. Also platelet lipid composition was found altered in patients with respect to controls (lower percent levels in n-3 fatty acids and in linoleic acid esterified in the main platelet phospholipid fractions: at least p < 0.05). These results indicate that in vivo platelet activation is detectable in neoplastic patients and it is associated with alterations in platelet lipid composition. In the light of the important role played by membrane lipids in platelet functions related to thrombosis and haemostasis we conclude that platelet lipid changes could cooperate in platelet activation and increased thrombotic risk so frequently observed in neoplastic disease.

Effect of n-3 fatty acid ethyl ester supplementation on fatty acid composition of the single platelet phospholipids and on platelet functions

Twenty healthy male volunteers were randomly assigned to receive either four 1-g capsules of n-3 polyunsaturated fatty acids (PUFA) ethyl esters or four 1-g capsules of olive oil (as placebo) for a period of 4 months, followed by a 3-month wash-out period. Fatty acids of platelet phospholipid fractions, platelet aggregation, and thromboxane B2 (TXB2) formation were analyzed at 0, 2, and 4 months of treatment and at 1, 2, and 3 months of wash-out. During n-3 PUFA supplementation, accumulations of eicosapentaenoic (EPA), docosapentaenoic (DPA), and docosahexaenoic (DHA) acids were markedly increased after 2 months, with slight differences in further accumulation up to 4 months among the various phospholipid fractions. Significant decreases in platelet sensitivity to collagen, serum TXB2 levels, and urinary TXB2 metabolites were also observed following n-3 PUFA treatment. During the first and second month of wash-out, slight differences were observed in changes of various fatty acids among different phospholipid fractions, but after 3 months of wash-out, alterations were no longer detectable with respect to pretreatment values. After 3 months of wash-out, platelet function parameters also were returned to baseline. Thus, both platelet lipids and function are influenced by n-3 PUFA ethyl ester supplementation, and significant alterations are still detectable after 2 months of wash-out.

Influence of protein catabolic rate on nutritional status, morbidity and mortality in elderly uraemic patients on chronic haemodialysis: a prospective 3-year follow-up study

It has been recently reported that elderly chronic haemodialysis (CHD) patients have a reduced protein catabolic rate (PCRn) in spite of an adequate Kt/V. However until now the long-term consequences of this fact on the nutritional status, morbidity, and mortality were not known. This prospective study evaluates, over a period of 3 years, the effect of the reduced PCRn on some nutritional parameters, morbidity mortality in CHD patients older than 65 years with adequate and stable Kt/V. Over the period 1990-1993 we evaluated 42 CHD patients over 65 years (mean +/- SD 72 +/- 5 years). PCRn, total serum proteins, serum albumin concentration, body weight, body mass index (BMI) and serum transferrin were determined at the start of the study and followed yearly until the end of observation. The incidence of hospitalization/patient-year, the mortality rate and the causes of death were also recorded. All the patients were managed to maintain a Kt/V > 0.9 throughout the study. Twenty-two patients (Group A), mean age 70 +/- 4 years, completed the entire period of observation. Their Kt/V was 1.10 +/- 0.12, PCRn was 0.95 +/- 0.12 g/kg/day, and serum albumin concentration was 40.2 +/- 1.5 g/l, and these did not change significantly. The other parameters also remained stable over time. Twenty patients (Group B) died. Their mean age was 74 +/- 6 years. This group's Kt/V was 1.11 +/- 0.15, PCRn was 0.94 +/- 0.18 g/kg/day, and serum albumin concentration was 39 +/- 3.1 g/l, and there were no significant variations between the start and the end of observation for all the parameters studied.(ABSTRACT TRUNCATED AT 250 WORDS)