Osteoporosis identification among previously undiagnosed individuals with vertebral fractures

Because osteoporosis is under-recognized in patients with vertebral fractures, we evaluated characteristics associated with osteoporosis identification. Most patients with vertebral fractures did not receive evaluation or treatment for osteoporosis. Black, younger, and male participants were particularly unlikely to have had recognized osteoporosis, which could increase their risk of negative outcomes.

INTRODUCTION

Vertebral fractures may be identified on imaging but fail to prompt evaluation for osteoporosis. Our objective was to evaluate characteristics associated with clinical osteoporosis recognition in patients who had vertebral fractures detected on their thoracolumbar spine imaging reports.

METHODS

We prospectively identified individuals who received imaging of the lower spine at primary care clinics in 4 large healthcare systems who were eligible for osteoporosis screening and lacked indications of osteoporosis diagnoses or treatments in the prior year. We evaluated characteristics of participants with identified vertebral fractures that were associated with recognition of osteoporosis (diagnosis code in the health record; receipt of bone mineral density scans; and/or prescriptions for anti-osteoporotic medications). We used mixed models to estimate adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

A total of 114,005 participants (47% female; mean age 65 (interquartile range: 57-72) years) were evaluated. Of the 8579 (7%) participants with vertebral fractures identified, 3784 (44%) had recognition of osteoporosis within the subsequent year. In adjusted regressions, Black participants (OR (95% CI): 0.74 (0.57, 0.97)), younger participants (age 50-60: 0.48 (0.42, 0.54); age 61-64: 0.70 (0.60, 0.81)), and males (0.39 (0.35, 0.43)) were less likely to have recognized osteoporosis compared to white participants, adults aged 65 + years, or females.

CONCLUSION

Individuals with identified vertebral fractures commonly did not have recognition of osteoporosis within a year, particularly those who were younger, Black, or male. Providers and healthcare systems should consider efforts to improve evaluation of osteoporosis in patients with vertebral fractures.

OP0232 HIGH PLASMA C4d/C4 IDENTIFIES LUPUS NEPHRITIS PATIENTS WITH DISEASE MEDIATED BY ACTIVATION OF THE CLASSICAL COMPLEMENT PATHWAY

Background

Proliferative lupus nephritis (LN) involves immune complex deposition in the kidney that can severely impact normal renal clearance mechanisms. Immune complexes can activate C1q and the classical complement cascade, and along with pathogenic anti-C1q antibodies (PACAs), may amplify inflammation and disease progression. Martin et al reported that circulating C4d, a marker of complement activation downstream of the C1 complex, correlated well with C4d immunohistochemistry score in kidney tissue and could be a sensitive and specific biomarker for diagnosing active LN.1

Objectives

To confirm and extend observations by Martin et al, and to extend a link between C4d, C1q activation, and PACA levels to identify patients most likely to have the classical complement pathway as a driving component of disease. Such patients would be potential candidates for anti-C1q therapy, such as ANX009, to dampen disease activity and slow disease progression (NCT04535752).

Methods

Plasma samples were collected from a cohort of 40 LN patients (20 with disease flare and 20 without disease flare) from the California Lupus Epidemiology Study (CLUES), a multi-racial/ethnic cohort of individuals with physician-confirmed systemic lupus erythematosus, and 20 healthy controls (Table 1). A panel of complement factors, including 15 complement protein and relevant complexes, were measured using an enzyme-linked immunosorbent assay. Clinical disease activity was measured using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and proteinuria was evaluated by a random spot urine protein to creatinine ratio (UPCR).

Table 1.

Patient Demographics

CharacteristicsHealthy Control(n=20)LN Flare(n=20)LN Without Flare(n=20)Median age (years)*50 (31-60.8)28.5 (26-34.5)43.5 (33.5-52)Sex, n (%)Female18 (90)17 (85)18 (90)Demographics, n (%)Caucasian8 (40)1 (5)5 (25)Hispanic3 (15)9 (45)4 (20)African American1 (5)3 (15)3 (15)Asian8 (40)7 (35)8 (40)Median UPCR (mg/mg)*N/A1.8 (1.3-6.5)0.4 (0.2-0.6)Median SLEDAI*N/A12 (9-16)2 (2-4)

*Reported as median (IQR).

LN, lupus nephritis; N/A, not applicable; SLEDAI, Systemic Lupus Erythematosus Disease Activity Index; UPCR, urine protein:creatinine ratio.

Results

We observed evidence of coordinated complement activation in LN patients relative to healthy controls. Specifically, levels of C4d and the C4d/C4 ratio were highly increased in LN patients with flare, while levels of C1q, C1s, and C4 were decreased, consistent with activation of the classical complement pathway (increased activation and component consumption). The C4d/C4 ratio also correlated with levels of PACA isotypes 1 and 3 that are known to activate the classical pathway. Improvements in C4 and C4d/C4 ratio were associated with improvements in proteinuria and SLEDAI following treatment for disease flare, indicating their potential value as biomarkers of treatment response.

Conclusion

A subset of LN patients exhibited high C4d/C4 ratio along with specific markers of classical pathway activation, indicating that the classical complement pathway may be a driving component of their disease. Reduction in this ratio appears to correlate with treatment response, but its levels are generally not normalized, suggesting an insufficient resolution of complement-mediated inflammation by currently available treatments. Our data support a clinical hypothesis that a subset of LN patients may benefit from a precision medicine approach targeting the classical complement pathway (Figure 1). This hypothesis will be evaluated in a forthcoming clinical trial testing the subcutaneously administered C1q inhibitor ANX009 in patients with active LN.

References

[1]Martin M, Trattner R, Nilsson SC, et al. Plasma C4d Correlates With C4d Deposition in Kidneys and With Treatment Response in Lupus Nephritis Patients. Front Immunol. 2020;11:582737.

Acknowledgements

Supported by: Annexon Biosciences

Disclosure of Interests

Ann Mongan Employee of: Annexon Biosciences, Poojan Suri Employee of: Annexon Biosciences, Maze Therapeutics, Dean Richard Artis Shareholder of: Annexon Biosciences, Bristol Myer Squibb, Roche, Sanofi, BMS, J&J, Employee of: Annexon Biosciences, Ellen Cahir-McFarland Shareholder of: Annexon Biosciences, Employee of: Annexon Biosciences, Biogen, Henk-André Kroon Shareholder of: Annexon Biosciences, Employee of: Annexon Biosciences, Yaisa Andrews-Zwilling Employee of: Annexon Biosciences, Shawn Rose Employee of: Annexon, Johnson & Johnson, Sanjay Keswani Shareholder of: Annexon Biosciences, Nura Bio, Employee of: Annexon Biosciences, Nura Bio, Maria Dall’Era Consultant of: GSK, AstraZeneca, Biogen, Annexon Biosciences, Pfizer, Aurinia, Grant/research support from: Annexon Biosciences, GSK, Ted Yednock Shareholder of: Annexon Biosciences, Consultant of: Cortexyme, Employee of: Annexon Biosciences

Long-term effectiveness of epidural steroid injections after new episodes of low back pain in older adults

BACKGROUND

There is limited research on the long-term effectiveness of epidural steroid injections (ESI) in older adults despite the high prevalence of back and leg pain in this age group. We tested the hypotheses that older adults undergoing ESI, compared to patients not receiving ESI: 1) have worse pain, disability and quality of life ("outcomes") pre-ESI, 2) have improved outcomes after ESI, and 3) have improved outcomes due to a specific ESI effect.

METHODS

We prospectively studied patients ≥65 years old presenting to primary care with new episodes of back pain in three US healthcare systems (BOLD registry). Outcomes were leg and back pain intensity, disability and quality of life, assessed at baseline and 3-, 6-, 12- and 24-month follow-ups. We categorized participants as: 1) ESI within 6 months from the index visit (n=295); 2) no ESI within 6 months (n=4,809); 3) no ESI within 6 months, propensity-score matched to group 1 (n=483). We analyzed the data using linear regression and Generalized Estimating Equations.

RESULTS

Pain intensity, disability and quality of life at baseline were significantly worse at baseline in ESI patients (group 1) than in group 2. The improvement from baseline to 24 months in all outcomes was statistically significant for group 1. However, no statistically significant differences were observed between outcome trajectories for the propensity-score matched groups 1 and 3.

CONCLUSIONS

Older adults treated with ESI have long-term improvement. However, the improvement is unlikely the result of a specific ESI effect.

Sulfation of chitosan from Sepia kobiensis as potential anticoagulant and antibacterial molecule

The present work aimed to synthesis of chitin, chitosan and sulfation of chitosan from cuttlebone of cuttlefish Sepia kobiensis. Principally chitin was extracted through sequential processes of demineralisation and deproteinzation. Then chitosan was synthesized by a deacetylation and finally sulfated at semi-heterogeneous condition using chlorosulfonic acid in N,N-dimethylformamide. The synthesized macromolecules were characterized for its structural, physical and thermal (CHN, DDA, FT-IR, NMR, XRD, Viscometric analysis, SEM and DSC) properties. Apart from anticoagulant potential of the sulfated chitosan was tested using human plasma by means of activated partial thromboplastin time (APTT) and prothrombin time (PT). Further sulfated chitosan was tested for antibacterial potential by well diffusion method against eleven human pathogenic clinical isolates of both Gram positive and Gram-negative strains and minimum inhibitory concentrations (MIC) was calculated accordingly. The results of this study revealed the effectiveness of the sulfated chitosan at semi-heterogeneous conditions as a potent antibacterial and anticoagulant molecule.

Presence and extent of severe facet joint osteoarthritis are associated with back pain in older adults

OBJECTIVE

To determine whether the presence and extent of severe lumbar facet joint osteoarthritis (OA) are associated with back pain in older adults, accounting for disc height narrowing and other covariates.

DESIGN

Two hundred and fifty-two older adults from the Framingham Offspring Cohort (mean age 67 years) were studied. Participants received standardized computed tomography (CT) assessments of lumbar facet joint OA and disc height narrowing at the L2-S1 interspaces using four-grade semi-quantitative scales. Severe facet joint OA was defined according to the presence and/or degree of joint space narrowing, osteophytosis, articular process hypertrophy, articular erosions, subchondral cysts, and intraarticular vacuum phenomenon. Severe disc height narrowing was defined as marked narrowing with endplates almost in contact. Back pain was defined as participant report of pain on most days or all days in the past 12 months. We used multivariable logistic regression to examine associations between severe facet joint OA and back pain, adjusting for key covariates including disc height narrowing, sociodemographics, anthropometrics, and health factors.

RESULTS

Severe facet joint OA was more common in participants with back pain than those without (63.2% vs 46.7%; P = 0.03). In multivariable analyses, presence of any severe facet joint OA remained significantly associated with back pain (odds ratio (OR) 2.15 [95% confidence interval (CI) 1.13-4.08]). Each additional joint with severe OA conferred greater odds of back pain [OR per joint 1.20 (95% CI 1.02-1.41)].

CONCLUSIONS

The presence and extent of severe facet joint OA on CT imaging are associated with back pain in community-based older adults, independent of sociodemographics, health factors, and disc height narrowing.

Abstracts of the 13th European Conference on Eye Movements 2005

This issue contains the abstracts submitted for presentation at the Thirteenth European Conference on Eye Movements (ECEM13), Bern, August 14 – 18, 2005, and reviewed by the Scientific Board, consisting of W. Becker, Ulm; C.J. Erkelens, Utrecht; J.M. Findlay, Durham; A.G. Gale, Derby; C.W. Hess, Bern; J. Hyönä, Turku; A. Kennedy, Dundee; K. Koga, Nagoya; G. Lüer, Göttingen; M. Menozzi, Zürich; W. Perrig, Bern; G. d’Ydewalle, Leuven; D. Zambarbieri, Pavia. A quarter of a century ago, in 1980 initiated by Rudolf Groner and Dieter Heller, a transdisciplinary network called European Group of Scientists active in Eye Movement Research was founded. This group included scientists who used eye movement registration as a research tool and developed models based on oculomotor data obtained from a wide spectrum of phenomena, ranging from the neurophysiological to the perceptual and the cognitive level. The group was intended to serve the purpose of (1) exchanging information about current research, equipment and software, (2) organizing a conference (ECEM) at a different location all over Europe every other year. Over the years ECEM has grown. At the first conference in Bern the relatively small number of participants made it possible for the organisers to avoid conflicting parallel sessions, whereas with the ECEM’s steady growth, the introduction of parallel sessions soon became necessary. Although we are very happy about this year’s new record of 273 scientific contributions, we regret at the same time that this large number of participants necessitated the introduction of no less than four parallel sessions for oral presentations. Part of the ECEM culture are the books with a selection of edited contributions which have traditionally always been published after the conferences. Unfortunately, over the years the sale prices of books have become prohibitively expensive and book chapters have increasingly been given a low rating in comparison to publications in peer reviewed journals. As a consequence of this trend, we are now considering to launch an online journal Eye Movement Research which would publish scientific papers either on the base of individual submissions by the authors or as a follow-up of workshops or thematic sessions at ECEM. In either case, a fair peer reviewing process should guarantee a high quality of the contributions. Acknowledgements Last but not least, we are happy to express our deep gratitude to the main sponsors of our conference and to all the people who helped to keep it going. The Max and Elsa Beer-Brawand Foundation generously funded the invited speakers. The Swiss Academy of Humanities and Social Sciences (SAGW) sponsored the organization of workshops and made it possible for us to reduce fees for students. Novartis Neuroscience sponsored the reception at the Zentrum Paul Klee Bern. The University of Bern hosted the conference in its magnificent historical building. A team of devoted young scientists acted as staff during the conference: Eva Siegenthaler, Liliane Braun, Miriam Lörtscher, Esther Schollerer, Daniel Stricker, Simon Raess, Philipp Sury, Bartholomäus Wissmath, Linda Bodmer, Martina Brunnthaler, Daniela Häberli, Nadine Messerli, Felicie Notter, Didier Plaschy, Svetlana Ognjanovi, David Weibel, Yves Steiner and Dominik Moser. We dedicate this book to the memory of two important men in eye movement research: Dieter Heller as one of the founders of the ECEM group, and Lawrence W. Stark as pioneer in cognitive modelling of oculomotor control. In an early planning stage of ECEM13 both had been invited as keynote speakers, but their untimely death made this plan impossible. In many sessions of ECEM13 the influence of their work will prevail.

Immunoprecipitation analysis of radiolabelled protein antigens biosynthesized in vitro by S. mansoni. I. Identification of antigens uniquely recognized by protective antibodies

Protein antigens from 4-wk worms were metabolically radiolabelled with [3H]leucine or [35S]methionine. Three freeze-thaw cycles released a large proportion (50% to 60%) of the TCA-precipitable radioactivity from the worms. Immune serum from twice-infected Fischer rats (F-2x), which was shown to confer resistance in a passive immunization assay, and immune serum from twice-infected Wistar Furth rats (W-2x), which does not confer resistance, were used for analyzing antigens in this worm fraction. Antibodies in these antisera differed in their titers to the freeze-thaw released antigens (W-2x greater than F-2x) and in their relative affinities for these antigens (F-2x greater than W-2x). Gradient slab gel electrophoresis of immunoprecipitates of radiolabelled antigens under denaturing conditions revealed many components, which could be categorized into two main types: unique antigens, recognized only by F-2x antibodies, and nonunique antigens, recognized by both F-2x and W-2x antibodies. The potential relevance of these antigens in resistance was further examined by antibody absorption experiments in which 4-wk worms were used as an immunoabsorbent to remove 90% to 95% of the immunoprecipitating activity and 65% to 70% (p less than 0.005) of the capacity to confer resistance in a passive immunization assay. It was concluded that loss of both anti-schistosome activities was specific since antigen released by worms during absorption could account for only 16% of the reduction in antigen-binding capacity and the titer of antibodies directed against beta-galactosidase did not significantly change during absorption. Antigens recognized uniquely by F-2x antibodies are therefore candidates for immunization studies examining induction of resistance against Schistosoma mansoni.

Immunoprecipitation analysis of radiolabelled protein antigens biosynthesized in vitro by S. mansoni. I. Identification of antigens uniquely recognized by protective antibodies

Protein antigens from 4-wk worms were metabolically radiolabelled with [3H]leucine or [35S]methionine. Three freeze-thaw cycles released a large proportion (50% to 60%) of the TCA-precipitable radioactivity from the worms. Immune serum from twice-infected Fischer rats (F-2x), which was shown to confer resistance in a passive immunization assay, and immune serum from twice-infected Wistar Furth rats (W-2x), which does not confer resistance, were used for analyzing antigens in this worm fraction. Antibodies in these antisera differed in their titers to the freeze-thaw released antigens (W-2x greater than F-2x) and in their relative affinities for these antigens (F-2x greater than W-2x). Gradient slab gel electrophoresis of immunoprecipitates of radiolabelled antigens under denaturing conditions revealed many components, which could be categorized into two main types: unique antigens, recognized only by F-2x antibodies, and nonunique antigens, recognized by both F-2x and W-2x antibodies. The potential relevance of these antigens in resistance was further examined by antibody absorption experiments in which 4-wk worms were used as an immunoabsorbent to remove 90% to 95% of the immunoprecipitating activity and 65% to 70% (p less than 0.005) of the capacity to confer resistance in a passive immunization assay. It was concluded that loss of both anti-schistosome activities was specific since antigen released by worms during absorption could account for only 16% of the reduction in antigen-binding capacity and the titer of antibodies directed against beta-galactosidase did not significantly change during absorption. Antigens recognized uniquely by F-2x antibodies are therefore candidates for immunization studies examining induction of resistance against Schistosoma mansoni.