Spatial aggregation patterns in four mistletoe species: ecological and environmental determinants

Plant spatial distribution is an important topic in ecology as it determines species coexistence and biodiversity dynamics. Usually, plants show clustered distributions in nature. Mistletoes are a good example of aggregated distributions, as they form dense aggregations due to several factors (availability of competent hosts, seed dispersal vectors, microclimate conditions). We analysed four native mistletoe species with divergent life histories and host ranges: Desmaria mutabilis and Tristerix corymbosus from the temperate rainforests of southern Chile; and Tristerix aphyllus and Tristerix verticillatus from the northern semi-desert zone. While T. corymbosus and T. verticillatus have a wide host range, T. aphyllus and D. mutabilis are specialists that can parasitize only a few plant species. We hypothesized that specialized species would be more aggregated due to ecological and environmental restrictions. We used heterogeneous Poisson models to quantify spatial aggregation. Three of the four mistletoe species were spatially clustered at both environments, with aggregation being stronger in the temperate rainforest of southern Chile and particularly in the host-specialist species. Our results suggest that environmental constraints are more important than ecological constraints (host range) in shaping mistletoe spatial structure. Mistletoe aggregated spatial distribution depends primarily on the environment that they inhabit, which conditions host spatial availability, and arrangement.

Inhibition of vaccinia virus L1 N-myristoylation by the host N-myristoyltransferase inhibitor IMP-1088 generates non-infectious virions defective in cell entry

We have recently shown that the replication of rhinovirus, poliovirus and foot-and-mouth disease virus requires the co-translational N-myristoylation of viral proteins by human host cell N-myristoyltransferases (NMTs), and is inhibited by treatment with IMP-1088, an ultrapotent small molecule NMT inhibitor. Here, we examine the importance of N-myristoylation during vaccinia virus (VACV) infection in primate cells and demonstrate the anti-poxviral effects of IMP-1088. N-myristoylated proteins from VACV and the host were metabolically labelled with myristic acid alkyne during infection using quantitative chemical proteomics. We identified VACV proteins A16, G9 and L1 to be N-myristoylated. Treatment with NMT inhibitor IMP-1088 potently abrogated VACV infection, while VACV gene expression, DNA replication, morphogenesis and EV formation remained unaffected. Importantly, we observed that loss of N-myristoylation resulted in greatly reduced infectivity of assembled mature virus particles, characterized by significantly reduced host cell entry and a decline in membrane fusion activity of progeny virus. While the N-myristoylation of VACV entry proteins L1, A16 and G9 was inhibited by IMP-1088, mutational and genetic studies demonstrated that the N-myristoylation of L1 was the most critical for VACV entry. Given the significant genetic identity between VACV, monkeypox virus and variola virus L1 homologs, our data provides a basis for further investigating the role of N-myristoylation in poxviral infections as well as the potential of selective NMT inhibitors like IMP-1088 as broad-spectrum poxvirus inhibitors.

Complex high-risk indicated percutaneous coronary interventions (CHIP-PCI) in elderly patients

Introduction

Complex high-risk indicated percutaneous coronary intervention (CHIP-PCI) is a poorly defined concept. A recent large-scale study identified various patient- and procedure-related factors that were associated with in-hospital major adverse cardiac or cerebrovascular events (MACCE), which were used to construct a CHIP-score [1].

Purpose

To investigate the predictive value of patient- and procedure related risk factors, based on the CHIP-score, in a large cohort of elderly patients.

Methods

This is a retrospective multicenter study of 20 centers, including patients of ≥75 years of age, that underwent PCI in the period of 2012–2019. The primary endpoint of MACCE was defined as cardiovascular death, myocardial infarction, revascularization or stroke. The follow-up time was 1 year. We created univariate and multivariate Cox regression models in order to investigate the predictive value of the CHIP-score variables (other than age, Table 2).

Results

A total of 2724 patients with a mean age of 81 (± 4.3) years were included in the study. Baseline characteristics are depicted in Table 1. The mean CHIP score was 1.74 (± 1.2) and 2262 (83%) had at least one CHIP criteria. At 1-year follow-up, 267 (9.8%) met the primary endpoint. Out of 11 investigated CHIP-score variables, only 5 were independent predictors of 1-year MACCE in adjusted regression models: Prior myocardial infarction (HR 1.56 (95% CI: 1.10–1.90), p=0.009), left ventricular ejection fraction <30% (HR: 2.02 (95% CI: 1.34–3.0, p<0.001), chronic kidney disease (HR 1.55 (95% CI: 1.21–2.02, p<0.001), left main coronary PCI (HR: 2.35 (95% CI: 1.29–4.89, p<0.001) and non-radial access (HR: 1.57 (95% CI: 1.19–1.85, p=0.002). See Table 2 for details. Overall MACCE was 4.5% when CHIP was 0, as compared to 10.7% with any CHIP factor present (p<0.001) (Figure 1). A CHIP of 4+ or higher was present in 246 (9%) patients and was associated with a three-fold increase in 1-year MACCE (HR: 2.9 (95% CI: 2.1–3.9), p<0.001).

Conclusions

The CHIP-score retains significant prognostic value in the elderly population. The implication of a CHIP-score might be a future tool for risk stratification in clinical practice, not only for in-hospital MACCE but also on long-term follow-up. In the special population of elderly patients, 3 patient related and 2 procedure related factors showed to be especially helpful for risk assessment.

Funding Acknowledgement

Type of funding sources: None.

Association between distance to tertiary hospital and cardiovascular outcomes in coronary artery disease patients

Background

The impact of distance from residence to Tertiary Referral Hospital and cardiovascular (CV) outcomes in patients with coronary artery disease (CAD) is unknow. Despite longer travel distances hinder access to healthcare and may worsen CV outcomes, we hypothesize that Mediterranean lifestyle and behaviors in distant rural areas may be associated with a reduced risk of CV death and events.

Purpose

To investigate the association between travel distance to Tertiary Hospital and mid-term cardiovascular outcomes in a population of CAD patients in Southern Spain.

Methods

Retrospective study including all patients discharged after percutaneous coronary intervention (PCI) at a high-volume center in Southern Spain during 2018. Those belonging to another healthcare area were excluded. One-way driving distances from residence to hospital were computed using Google Maps Distance Matrix API with R package “gmapsdistance”. Patients were stratified into tertiles according to travel distance (short, STD; intermediate, ITD; and long, LTD). Kaplan-Meier (KM) and Multivariable Cox regression (adjusted for age, sex, atrial fibrillation, cancer history, prior revascularization and clinical presentation) were used to assess the impact of travel distance on CV death and a composite outcome of MACE (Myocardial Infarction, unplanned PCI and CV death).

Results

Of 1005 patients discharged after PCI during the study period, 966 met the selection criteria. Flowchart and baseline characteristics by distance groups are presented in Figure 1. Median travel distance tertiles were 6.1 (STD), 41.7 (ITD) and 78.4 (LTD). During a median follow-up of 31 (IQR 28–35) months, 50 cardiovascular deaths [STD 27 (8.4%), ITD 13 (4%), LTD 10 (3.1%), p=0.006)] and 63 MACE occurred [STD 45 (13.9%), ITD 37 (11.5%), LTD 26 (8.1%), p=0.060)]. KM curves for the three distance groups are shown in Figure 2. In univariable and multivariable Cox models, longer travel distances were associated with better outcomes, as for every 10 Km increase, there was a 11% and 7% decrease in the hazards of CV death (HR adj: 0.89, CI 0.82–0.98, p=0.029) and of MACE (HR adj: 0.93, CI 0.87–0.99, p=0.025), respectively.

Conclusion

Travel distance was inversely associated with CV events in a population of CAD patients in Southern Spain. Patients in the first tertile of distance had a higher rate of CV death. Multicenter studies involving other Mediterranean regions are needed to confirm these findings and to look for explanations.

Funding Acknowledgement

Type of funding sources: None. Flowchart and baseline characteristicsSurvival curves by distance groups

Antithrombotic strategies in elderly patients with atrial fibrillation revascularized with drug-eluting stents: PACO-PCI (EPIC-15) registry

Background

The strategy of antithrombotic therapy in patients with atrial fibrillation (AF) after revascularization with drug-eluting stents continues to be debated. The evidence in elderly population in this scenario is particularly scarce.

Purpose

We sought to investigate the antithrombotic regimens applied and their prognostic effects in patients over 75 years old with AF after revascularization with drug-eluting stents.

Methods

Retrospective registry in 20 centers including consecutive patients over 75 years with AF treated with drug-eluting stents. A primary endpoint of MACCE and a co-primary endpoint of major bleeding by ISTH criteria were considered at 12 months.

Results

Out of 41,000 patients undergoing PCI 1,249 patients (81.1±4.2 years, 33.1% women, 66.6% ACS, 30.6% complex PCI) were included. Triple antithrombotic therapy (TAT) was prescribed in 81.7% and dual antithrombotic therapy (DAT) in 18.3%. TAT was based on direct oral anticoagulants (DOAC) in 48.4% and maintained for only 1 month in 52.2%, and DAT included DOAC in 70.6%. Primary endpoint of MACCE was met in 9.6% and primary endpoint of major bleeding in 9.4%. TAT was significantly associated with more bleeding (10.2% vs. 6.1%, p=0.04) but less MACCE (8.7% vs. 13.6%, p=0.02) than DAT and the use of DOAC was significantly associated to less bleeding (8% vs. 11.1%, p=0.03) and similar MACCE (9.8% vs. 9.4%, p=0.8). TAT over 1 month or with VKA was associated with more major bleeding but comparable MACCE rates.

Conclusions

Despite advanced age TAT prevails, but prolonged durations or use of VKA are associated with increased bleeding without additional MACCE prevention. DAT reduces bleeding but with a trade-off in terms of ischemic events. DOAC use was significantly associated to less bleeding and similar MACCE rates.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bristol-Myers-Squibb/Pfizer

Instantaneous wave-free ratio for the assessment of nonculprit lesions in patients with acute coronary syndrome

Background

A physiological assessment with the fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) is strongly recommended by the European Guidelines of Revascularization to guide percutaneous coronary intervention (PCI) decision making in intermediate coronary stenosis. However, data supporting its use in the pro-inflammatory setting of ACS is weak.

Purpose

To analyze the usefulness of a physiological coronary evaluation with iFR of nonculprit lesions in patients with ACS.

Methods

Retrospective multicenter study including patients with ACS and underwent successful revascularization of the culprit vessel and had other nonculpritlesions physiologically evaluated with the iFR between January 2017 and December 2019. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction, stent thrombosis and new revascularization (MACEs).

Results

A total of 356 patients with 472 nonculprit lesions were included. The mean age was 66±11 years. The clinical presentation was non-ST-segment elevation myocardial infarction (NSTEMI) in 235 patients and ST-segment elevation myocardial infarction (STEMI) in 121 patients. After a mean follow-up period of 22±10 months, the primary endpoint occurred in 32 patients (9%). There were no differences in outcomes regarding iFR induced treatment strategy (patients with all lesions revascularized vs. patients with at least one lesion deferred for revascularization, 10.5 vs 8.4%, p=0.476).

Conclusion

The use of the iFR to guide percutaneous coronary intervention decision making in nonculprit lesions seems to be safe, with an acceptable percentage of MACEs at the mid-term follow-up.

Funding Acknowledgement

Type of funding sources: None. FlowchartSurvival curves by iFR and ACS group

Spontaneous coronary artery dissection in the elderly: clinical features, angiographic findings, management and outcomes

Background

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Clinical features, angiographic findings, management and outcomes of SCAD in elderly patients remain unknown.

Methods

The Spanish multicenter prospective SCAD registry included 318 consecutive patients with SCAD diagnosis. Patients were classified according to age in two groups: <65 and ≥65 years old.

Results

A total of 55 patients (17%) were 65 or older (Table). Elderly patients had more often hypertension (29% vs 76%, p<0.01) and dyslipidemia (30% vs 56%, p<0.01), and less smoking history (51% vs 7%, p<0.01). Previous history of coronary artery disease was also more frequent in older patients (4% vs 11%, p=0.044). Interestingly, an identifiable trigger was more often found among patients under 65. Coronary artery tortuosity (1±0.99 vs 1.4±1, p=0.027) and coronary artery ectasia (9% vs 24%, p<0.01) were both more frequent in elderly patients, who were more often managed conservatively (75% vs 89%, p=0.025). A trend toward a higher mortality rate was found among patients ≥65, with no differences in terms of in hospital stay, new acute myocardial infarction, unplanned coronariography or heart failure.

Conclusions

Elderly patients with SCAD show different clinical and angiographic characteristics and they receive distinct management. Short-term outcomes do not significantly differ from those seen in younger patients.

Funding Acknowledgement

Type of funding source: None

OP0323 INCIDENCE OF CLINICAL FRAGILITY FRACTURES IN POSTMENOPAUSAL WOMEN WITH RHEUMATOID ARTHRITIS. A MULTICENTRIC CASE-CONTROL STUDY

Background:

Incidence of clinical fractures in rheumatoid arthritis (RA) is not as well-known as hip or vertebral fracture incidence.

Objectives:

1. To estimate the incidence of clinical fragility fractures in a population of postmenopausal women diagnosed with RA and compare it with that of the general population; 2. To analyze the risk factors for fracture.

Methods:

330 postmenopausal women with RA from 19 Spanish Rheumatology Departments, randomly selected from the registry of RA patients in each center. The control group consisted of 660 Spanish postmenopausal women from the Camargo Cohort. Clinical fractures during the previous 5 years were recorded. Assessed risk factors for fracture were: sociodemographic characteristics, BMD and variables related to RA.

Results:

Median age of RA patients was 64 yrs. vs. 63 yrs. in controls (ns). Evolution of the disease was 8 yrs. 78% and 76% had RF and ACPA+, respectively. 69% of patients were in remission or low activity. 85% had received glucocorticoids and methotrexate and 40% at least one biological DMARD. We identified 105 fractures (87 fragility and 18 traumatic) in 75 patients. Fifty-four patients and 47 controls had at least one major fracture (MF) (p< 0.001). Incidence of MF was 3.55 per 100 patient-year in patients and 0.72 in controls. Risk factors for MF in RA patients were age, previous fracture, parental hip fracture, postmenopausal period, hip BMD and cumulative dose of glucocorticoids. In controls, risk factors were age, age at menopause and lumbar BMD.

Among RA-associated factors, MFs were associated with erosions, disease activity and disability. Previous fracture in RA patients was a strong risk for MF (HR: 10.37 [95% CI: 2.95-36.41]).

Conclusion:

Between 3 and 4 of every 100 postmenopausal women with RA have a major fracture per year, four times more than the general population. Disease activity and disability associated with RA, the cumulative dose of glucocorticoids and mainly previous fracture are associated with the development of fragility fractures.

References:

None

Acknowledgments:

Funded in part by ISCIII (PI18/00762) that included FEDER funds from the EU.

Disclosure of Interests:

Carmen Gómez Vaquero: None declared, Jose Manuel Olmos: None declared, J. Luis Hernández: None declared, Dacia Cerda: None declared, Cristina Hidalgo: None declared, JA Martínez López: None declared, Luis Marcelino Arboleya Rodríguez: None declared, Javier Aguilar del Rey: None declared, Silvia Martinez Pardo: None declared, Inmaculada Ros: None declared, Xavier Surís: None declared, Dolors Grados Canovas: None declared, Chesús Beltrán Audera: None declared, Evelyn Suero-Rosario: None declared, Inmaculada Gómez Gracia: None declared, Asunción Salmoral: None declared, Irene Martín-Esteve: None declared, Helena Florez: None declared, Antonio Naranjo Grant/research support from: amgen, Consultant of: UCB, Speakers bureau: AMGEN, Santos Castañeda: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO, S García Carazo: None declared, Alberto García-Vadillo: None declared, Laura López Vives: None declared, À Martínez-Ferrer: None declared, Helena Borrell Paños: None declared, Pilar Aguado: None declared, Raul Castellanos-Moreira: None declared, Cristian Tebé: None declared, Núria Guañabens: None declared

FRI0528 INDICATORS OF EFFECTIVENESS AFTER 6 YEARS OF FOLLOW-UP OF PATIENTS IN THE FLS DR. NEGRIN

Background:

Data on the effectiveness of FLS in the medium and long term in Spain are needed

Objectives:

To analyze the indicators of long-term persistence to treatment, refracture and mortality in our Fracture Liaison Service (FLS)

Methods:

Throughout 2019, the medical records of patients with an indication of treatment to prevent new fractures whose baseline visit took place between 2012 and 2014 were reviewed. The data included those of the baseline visit (age, sex, type of index fracture, FRAX scale and DXA results) and for the follow-up (death and date, refracture including revision of spine x-rays - it was considered only the first refracture and, in the case of several fractures the most serious was chosen-, prescribed treatment, persistence of treatment trough electronic prescription on the date of review or death, and MPR or proportion of days covered by treatment).

Results:

399 patients were included, 335 of them women (84%), mean age 73.8 years (range 51-93) and average follow-up of 6 years (range 5.5-7 years).

Baseline visit.- The average FRAX was 15 and 7 for major fracture and femoral fracture respectively. DXA was normal in 22 patients (5.5%), osteopenia in 143 (35.8%) and osteoporosis in 234 (58.6%). 78 patients (19.5%) had a previous fragility fracture.

Type of fracture index: femur 126 (31.5%), forearm 119 (29.8%), humerus 76 (19%), vertebra 24 (6%), others 54 (13.5%). 80 patients (20%) had received prior treatment for osteoporosis.

Follow-up.- The persistence of treatment was assessed in 394 patients; 245 patients (62%) were prescribed a treatment on the most recent date, 200 (51%) with MPR≥80%. When analyzing patients with prescribed treatment, in 176 cases (72%) it was a bisphosphonate in a sustained manner, in 23 cases (9%) a bisphosphonate was prescribed and subsequently changed to denosumab, while in 45 cases (18%) it was initiated and maintained denosumab.

71 of 397 patients presented a new fracture (17.8%). The type of incident fracture was as follows: femur in 24 patients (34%), vertebra in 20 patients (28%), forearm in 9 patients (12%) and other fractures in 18 patients (25%). Refracture occurred in 9 patients in the first year, 16 in 2nd, 12 in the 3rd, 9 in 4th, 14 in 5th, 6 in 6th and 3 in 7th year. The persistence of treatment with MPR≥80% was similar in patients with and without refracture (52 vs 51%). The average baseline age and FRAX for major fracture in the fractured and non-fractured were 75 vs. 73 years (p = 0.10) and 17 vs. 14 respectively (p <0.01).

92 patients (23%) died, 25% of them in the two years that followed the baseline visit and 61% in the following 4 years. The persistence of treatment was 37% in those who died and 69% in those who remained alive (p <0.01).

Conclusion:

After an average of 6 years after the assessment in an FLS, the persistence of treatment was 62% (MPR≥80% in 51%), the mortality was 23% and the percentage of refractured patients was 17%.

Disclosure of Interests:

Antonio Naranjo Grant/research support from: amgen, Consultant of: UCB, Speakers bureau: AMGEN, Amparo Molina Speakers bureau: AMGEN, STADA, Cristina Sepúlveda: None declared, Francisco Rubiño: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO

AB1180 THE EVOLUTION OF AN FLS IN SEARCH OF EXCELLENCE: THE EXPERIENCE OF GRAN CANARIA

Background:

The implementation of an FLS in the Spanish public health system is not an easy task since there are no official plans for the incorporation of personnel dedicated to the unit

Objectives:

To expose the consolidation and improvement of an FLS after its implementation as well as the problems that have arisen over time.

Methods:

The health program for secondary fracture prevention was implemented in 2012. Initially worked with the same staff assigned to the Rheumatology service, since 2016 we have a part-time support nurse. Patients are identified from the emergency registry and, more recently, from patients admitted for hip fracture and treated in a monographic osteoporosis clinic. The baseline visit consists of consultation with the nurse, DXA and bone metabolism analytics. Falling patients are referred to a fall prevention school. Most patients are referred to their primary care physician to start a treatment.

Results:

Of the 2,416 patients attended the baseline visit, 30% were forearm fractures, 27% hip, 20% humerus, 10% spine and 11% other fractures. In comparison to 2012, in 2019 the monthly average of patients has doubled, increased the number of hip and spine fractures, and increased the percentage of captured patients (Table). In spite of consolidating the unit, getting a support nurse for the admitted patients and establishing a solid alliance with primary care, it is pending the involvement of Primary Care Nurses and start first prescription at the hospital.

Table.

Comparison of the first year with the last year of implementation of our FLS.

20122019Mean monthly number of fractures, N2242Type of fracture: forearm/hip/spine, %37/20/628/40/11Captured patients of elegible, %5777Delay in weeks until first visit to FLS, median1412Patient origin: emergency list/inpatient/outpatient, %100/0/059/31/9DXA performed, %10061Referral to fall prevention school, %026Criteria to start a treatment, %6790*Referral to the osteoporosis clinic, %377

*We apply the 2019 recommendations of the Spanish Society of Rheumatology

Conclusion:

We present the achievements made by our FLS along 8 years and the difficulties within the Spanish public health system.

Disclosure of Interests:

Antonio Naranjo Grant/research support from: amgen, Consultant of: UCB, Speakers bureau: AMGEN, Amparo Molina Speakers bureau: AMGEN, STADA, Cristina Sepúlveda: None declared, Candelaria Torres: None declared, Fabiola Santana: None declared, Francisco Rubiño: None declared, Rubén López: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO

FRI0487 APREMILAST IN MONOTHERAPY OR COMBINED IN NON-ULCER MANIFESTATIONS OF BEHÇET’S DISEASE. NATIONAL MULTICENTER STUDY OF 34 REFRACTORY CASES OF CLINICAL PRACTICE

Background:

Apremilast (APR) has demonstrated efficacy in orogenital ulcers of Behçet´s disease (BD). Response of other clinical manifestations remains unknown.

Objectives:

To assess the efficacy and safety of APR in monotherapy or combined with disease-modifying anti-rheumatic drugs (DMARDs) in non-aphthous ulcers of BD.

Methods:

National multicenter open-label study on 34 BD patients treated with APR at maintained standard dose of 30 mg twice daily.

Results:

From a cohort of 51 patients with APR by refractory orogenital ulcers of BD, we selected 34 (24 women/10 men, mean age 43.8±14.3 years), cases with another clinical manifestation/s.

Excluding CTs, colchicine or NSAIDs, APR was given in monotherapy (n=21) or combined with conventional and/or biologic DMARDs in 13 cases (5 methotrexate, 3 azathioprine, 3 hydroxychloroquine, 1 sulfasalazine, 1 dapsone, 2 tocilizumab, 1 IFX). Other active manifestations present at APR onset were: arthralgia/arthritis (16, true arthritis in 5), folliculitis/pseudofolliculitis (14), erythema nodosum (3), furunculosis (2), paradoxical psoriasis by TNFi (2), intestinal ileitis (2), deep venous thrombosis (2), leg ulcers (1), erythematosus and scaly skin lesions (1), fever (1), unilateral anterior uveitis (1) and neurobehçet (1).

After a median follow-up of 6 [3-12] months, folliculitis and ileitis improved, neurobehçet remained stable and musculoskeletal manifestations evolved in a variable way.(TABLE)

TABLE.

Conclusion:

In addition of orogenital ulcers, APR in monotherapy or combined, seems to be useful in skin manifestations of BD

Disclosure of Interests:

Alba Herrero Morant: None declared, Belen Atienza Mateo: None declared, J. Loricera: None declared, Vanesa Calvo del Rio Grant/research support from: MSD and Roche, Speakers bureau: Abbott, Lilly, Celgene, Grünenthal, UCB Pharma, José Luis Martín-Varillas Grant/research support from: AbbVie, Pfizer, Janssen and Celgene, Speakers bureau: Pfizer and Lilly, Gerard Espinosa: None declared, Jenaro Graña: None declared, Clara Moriano: None declared, Trinidad Pérez Sandoval: None declared, Manuel Martín Martínez: None declared, Elvira Diez: None declared, María Dolores García-Armario: None declared, Esperanza Martínez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, Patricia Moya Alvarado: None declared, Francisca Sivera: None declared, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Isabel de la Morena: None declared, Francisco Ortiz Sanjuán: None declared, José Andrés Román Ivorra: None declared, Ana Pérez Gómez: None declared, Alejandro Olive: None declared, Carolina Díez: None declared, Juan José Alegre: None declared, D Ybáñez-García Speakers bureau: Lilly, Roche, Sanofi, Ángels Martínez-Ferrer: None declared, Javier Narvaez: None declared, Ignasi Figueras: None declared, Ana Isabel Turrión: None declared, Susana Romero-Yuste: None declared, Pilar Trénor: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO, Miguel Á. González-Gay Grant/research support from: AbbVie, MSD and Roche, Speakers bureau: AbbVie, MSD and Roche, Ricardo Blanco Grant/research support from: Abbvie, MSD and Roche, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD

THU0307 RESPONSE OF BEHÇET’S REFRACTORY ORAL AND/OR GENITAL ULCERS TO APREMILAST IN COMBINATION VS MONOTHERAPY. NATIONAL MULTICENTER STUDY OF 51 CASES OF CLINICAL PRACTICE

Background:

Apremilast (APR) has demonstrated efficacy in the treatment of oral and/or genital aphthous ulcers in Behçet´s disease (BD). Combination of APR to other disease-modifying anti-rheumatic drugs (DMARDs) has not been assessed.

Objectives:

To compare the efficacy and safety of APR in monotherapy or combined with DMARDs in refractory BD.

Methods:

National multicenter open-label study on 51 BD patients with oral and/or genital ulcers refractory to conventional treatment.

Results:

We included 51 patients (35 women/16 men), mean age 44.7±13.2 years. Before APR, all patients had received several systemic conventional drugs. The main clinical symptoms for starting APR were oral (n=19) and genital (2) aphthous ulcers or both (30).

Excluding corticosteroids, colchicine or NSAIDs, APR was given at standard dose of 30 mg twice daily in monotherapy (n=31), or combined with conventional DMARDs in 16 cases (6 azathioprine, 5 methotrexate, 4 hydroxychloroquine, 4 sulfasalazine, 1 dapsone) or with biologic DMARDs in 4 (2 tocilizumab, 1 adalimumab, 1 infliximab). There were not found statistically significant differences in demographic features, previous therapy, clinical manifestations or reported adverse effects.

After a median follow-up of 6 [3-12] months, most of the patients experienced improvement of the orogenital ulcers in both groups (89.8% in the first 2 weeks), without statistically significant differences.(TABLE)

Conclusion:

APR leads to a rapid and maintained improvement in most patients with refractory BD orogenital ulcers. APR seems as effective and safe in monotherapy as combined.

TABLE:Week 1-2Week 4Month 6Month 12Month 24Outcome of oral and/or genital ulcers n, (%)Cn=19Mn=30Cn=19Mn=26Cn=12Mn=17Cn=7Mn=6Cn=1Mn=1 Complete resolution8 (42.1)11 (36.7)12 (63.2)20 (77)7 (58.4)14 (82.4)3 (42.8)3 (50)1 (100)1 (100) Partial resolution9 (47.4)16 (53.4)7 (36.8)3 (11.5)5 (41.6)2 (11.7)4 (57.2)3 (50)00 No response2 (10.5)3 (9.9)03 (11.5)01 (5.9)0000p value0.90.10.10.80.7

Abbreviations: C= combined; M= monotherapy; n= available data.

Disclosure of Interests:

Alba Herrero Morant: None declared, Belen Atienza Mateo: None declared, J. Loricera: None declared, Vanesa Calvo del Rio Grant/research support from: MSD and Roche, Speakers bureau: Abbott, Lilly, Celgene, Grünenthal, UCB Pharma, José Luis Martín-Varillas Grant/research support from: AbbVie, Pfizer, Janssen and Celgene, Speakers bureau: Pfizer and Lilly, Jenaro Graña: None declared, Gerard Espinosa: None declared, Clara Moriano: None declared, Trinidad Pérez Sandoval: None declared, Manuel Martín Martínez: None declared, Elvira Diez: None declared, María Dolores García-Armario: None declared, Esperanza Martínez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, Patricia Moya Alvarado: None declared, Francisca Sivera: None declared, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Isabel de la Morena: None declared, Francisco Ortiz Sanjuán: None declared, José Andrés Román Ivorra: None declared, Ana Pérez Gómez: None declared, Sergi Heredia: None declared, Alejandro Olive: None declared, Águeda Prior: None declared, Carolina Díez: None declared, Juanjo J Alegre-Sancho Consultant of: UCB, Roche, Sanofi, Boehringer, Celltrion, Paid instructor for: GSK, Speakers bureau: MSD, GSK, Lilly, Sanofi, Roche, UCB, Actelion, Pfizer, Abbvie, Novartis, D Ybáñez-García Speakers bureau: Lilly, Roche, Sanofi, Ángels Martínez-Ferrer: None declared, J. Narváez: None declared, Ignasi Figueras: None declared, Ana Isabel Turrión: None declared, Susana Romero-Yuste: None declared, Pilar Trénor: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO, Miguel Á. González-Gay Grant/research support from: AbbVie, MSD and Roche, Speakers bureau: AbbVie, MSD and Roche, Ricardo Blanco Grant/research support from: Abbvie, MSD and Roche, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD

Best Practice Framework of Fracture Liaison Services in Spain and their coordination with Primary Care

The coordination of Fracture Liaison Services (FLS) with Primary Care (PC) is necessary for the continuity of care of patients with fragility fractures. This study proposes a Best Practice Framework (BPF) and performance indicators for the implementation and follow-up of FLS-PC coordination in clinical practice in Spain.

PURPOSE

To develop a BPF for the coordination of FLS with PC in Spain and to improve the continuity of care for patients with fragility fractures.

METHODS

A Steering Committee selected experts from seven Spanish FLS and related PC doctors and nurses to participate in a best practice workshop. Selection criteria were an active FLS with an identified champion and prior contact with PC centres linked to the hospital. The main aim of the workshop was to review current FLS practices in Spain and their integration with PC. A BPF document with processes, tools, roles, and metrics was then generated.

RESULTS

Spanish FLS consists of a multidisciplinary team of physicians/nurses but with low participation of other professionals and PC staff. Evaluation and treatment strategies are widely variable. Four desired standards were agreed upon: (1) Effective channels for FLS-PC communication; (2) minimum contents of an FLS clinical report and its delivery to PC; (3) adherence monitoring 3 months after FLS baseline visit; and (4) follow-up by PC. Proposed key performance indicators are (a) number of FLS-PC communications, including consensus protocols; (b) confirmation FLS report received by PC; (c) medical/nursing PC appointment after FLS report received; and (d) number of training sessions in PC.

CONCLUSIONS

The BPF provides a comprehensive approach for FLS-PC coordination in Spain, to promote the continuity of care in patients with fragility fractures and improve secondary prevention. The implementation of BPF recommendations and performance indicator tracking will benchmark best FLS practices in the future.

P5753Jailed pressure wire to assess the side branch result for bifurcation lesions treated by provisional stenting strategy: iFR as a new index

Purpose

To analyze the feasibility and efficacy of the jailed pressure wire technique for bifurcation lesions treated by provisional stenting strategy and to assess the physiological side branch (SB) result using instantaneous wave free ratio (iFR).

Methods

Between June 2017 and December 2018, 50 patients who presented a bifurcation lesion considered appropriate for provisional stenting strategy were included in the study. Pressure wire was passed to side branch before treatment. Main vessel (MV) and side branch (SB) was predilated at the operator criteria. iFR determination was obtained in the SB baseline and after MV stenting (leaving the pressure wire jailed). Afterwards, the wire was removed to MV ostium to discard the possibility of drift. SB postdilation was performed if SB iFR was less than 0,89 (according to vessel thresholds established in clinical trials), evaluating the result by a new iFR determination.

Results

The mean age was 64±10 years. Sixteen patients (32%) had diabetes. Clinical presentation was stable angina in 26 patients (52%), non-STEMI in 19 patients (38%) and STEMI (non culprit lesion) in 5 patients (10%). The most frequent bifurcation type according to Medina classifications was 1,1,0 (21 patients, 42%). Seventeen patients (34%) had a true bifurcation lesion. The MV and SB reference diameter was 3,0±0,5 mm and 2,25±0,5 mm respectively. Most of the bifurcations were located at the left anterior descending artery/diagonal branch (27 bifurcations, 54%). Ten patients (20%) presented a distal left main bifurcation. Baseline SB iFR was 0,78±0,2. Under continuous SB iFR monitoring MV stenting was performed by trapping the pressure wire. After MV stenting, the SB iFR changed to 0,90±0,1. We confirmed the presence of drift in 5 patients (10%). In these cases, recalibration of the wire and SB rewiring was performed in 4 cases. In the remaining patient, rewiring was not possible even using specific coronary wires.

According to SB IFR, postdilation was necessary in 14 patients (28%). Final SB iFR was 0,94±0,03. A second stent was not necessary in any patient because final SB iFR was higher than 0.89 in all cases. We observed discordance between angiographic and physiological result in 17 cases (34%). All the wires could be removed. Forty wires (80%) were microscopically analyzed. Some grade of microscopic damage was found in 32 wires (80%), all of them distal to the pressure sensor. However, only one of these wires (2%) presented severe damage, and no case of fracture was observed.

After a mean follow up time of 10±6 months only one patient (2%) presented a major cardiac adverse event (acute coronary syndrome due to voluntary cessation of dual antiplatelet therapy).

Conclusions

The use of jailed pressure wire to monitor SB results for bifurcations treated by provisional stenting seems to be safe. The iFR index seems to provide new physiological information about the significance of the SB stenosis.

Comparison of viral Env proteins from acute and chronic infections with subtype C human immunodeficiency virus type 1 identifies differences in glycosylation and CCR5 utilization and suggests a new strategy for immunogen design

Understanding human immunodeficiency virus type 1 (HIV-1) transmission is central to developing effective prevention strategies, including a vaccine. We compared phenotypic and genetic variation in HIV-1 env genes from subjects in acute/early infection and subjects with chronic infections in the context of subtype C heterosexual transmission. We found that the transmitted viruses all used CCR5 and required high levels of CD4 to infect target cells, suggesting selection for replication in T cells and not macrophages after transmission. In addition, the transmitted viruses were more likely to use a maraviroc-sensitive conformation of CCR5, perhaps identifying a feature of the target T cell. We confirmed an earlier observation that the transmitted viruses were, on average, modestly underglycosylated relative to the viruses from chronically infected subjects. This difference was most pronounced in comparing the viruses in acutely infected men to those in chronically infected women. These features of the transmitted virus point to selective pressures during the transmission event. We did not observe a consistent difference either in heterologous neutralization sensitivity or in sensitivity to soluble CD4 between the two groups, suggesting similar conformations between viruses from acute and chronic infection. However, the presence or absence of glycosylation sites had differential effects on neutralization sensitivity for different antibodies. We suggest that the occasional absence of glycosylation sites encoded in the conserved regions of env, further reduced in transmitted viruses, could expose specific surface structures on the protein as antibody targets.

Cardiac condition in young chagasic women

RATIONALE

Chagas disease is a complex disorder caused by Trypanosoma cruzi. Most patients remain asymptomatic for several years and 30% of them progress quietly to developing cardiomyopathy. The factors that lead to chronic myocardial lesions are not fully understood.

OBJECTIVE

To investigate the association between clinical symptoms and single nucleotide polymorphisms in chagasic and non-chagasic women younger and older than 55 years of age.

METHODS AND RESULTS

we analyzed Ala-9Val and Ile58Thr polymorphisms of the SOD-Mn gene, 138ex1ins/del A of the endothelin-1 gene (ET-1) and H323H (T/C) of the endothelin receptor A gene (ETA), by PCR-RFLP using genomic DNA from leukocyte of 85 women. We also evaluated serum lipid profile, renal and liver function, chest X-rays, electrocardiograms (ECGs) and echocardiography (EchoCG). Biochemical profiling did not show differences between chagasic and non-chagasic patients. The polymorphisms analyses showed a significant association in the distribution of frequencies of the Mn-SOD Ile58Thr gene between both groups. Young chagasic patients had a significantly higher prevalence of abnormalities in X-rays, in ECGs and they showed grade II and III of NYHA functional classes. The chance of having an abnormal EchoCG was 5.87 higher in young chagasic patients (OR=5.87, 95% CI 1.47-23.4).

DISCUSSION

We concluded that the parasite affects young females by accelerating the deterioration of cardiac function, independent of other cardiovascular risk factors and the cardioprotective action of estrogens present in the premenopausal stage.

A novel Ku70 function in colorectal homeostasis separate from nonhomologous end joining

Ku70, a known nonhomologous end-joining (NHEJ) factor, also functions in tumor suppression, although this molecular mechanism remains uncharacterized. Previously, we showed that mice deficient for DNA ligase IV (Lig4), another key NHEJ factor, succumbed to aggressive lymphoma in the absence of tumor suppressor p53. However, the tumor phenotype is abrogated by the introduction of a hypomorphic mutant p53(R172P), which impaired p53-mediated apoptosis but not cell-cycle arrest. However, Lig4(-/-)p53(R172P) mice succumbed to severe diabetes. To further elucidate the role of NHEJ and p53-mediated apoptosis in vivo, we bred Ku70(-/-) p53(R172P) mice. Unexpectedly, these mice were free of diabetes, although 80% of the mutant mice had abnormally enlarged colons with pronounced inflammation. Remarkably, most of these mutant mice progressed to dysplasia, adenoma and adenocarcinoma; this is in contrast to the Lig4(-/-)p53(R172P) phenotype, strongly suggesting an NHEJ-independent function of Ku70. Significantly, our analyses of Ku70(-/-)p53(R172P) colonic epithelial cells show nuclear stabilization of β-catenin accompanied by higher expression of cyclin D1 and c-Myc in affected colon sections than in control samples. This is not due to the p53 mutation, as Ku70(-/-) mice share this phenotype. Our results not only unravel a novel function of Ku70 essential for colon homeostasis, but also establish an excellent in vivo model in which to study how chronic inflammation and abnormal cellular proliferation underlie tumorigenesis and tumor progression in the colon.

Short communication: HIV type 1 subtype C variants transmitted through the bottleneck of breastfeeding are sensitive to new generation broadly neutralizing antibodies directed against quaternary and CD4-binding site epitopes

Mother-to-child transmission of HIV-1 subtype C can occur in utero, intrapartum, or via breast milk exposure. While not well understood, there are putative differences in the mechanisms involved with the distinct routes of vertical HIV transmission. Here, we address the question of whether specific viral characteristics are common to variants transmitted through breastfeeding that may facilitate evasion of innate or adaptive immune responses. We amplified the envelope gene (env) from the plasma of six infants during acute infection who were infected with HIV-1 subtype C through breastfeeding, and from three available matched maternal samples. We sequenced the full-length env genes in these subjects revealing heterogeneous viral populations in the mothers and homogeneous populations in the infants. In five infants, the viral population arose from a single variant, while two variants were detected in the remaining infant. Infant env sequences had fewer N-linked glycosylation sites and shorter sequences than those of the available matched maternal samples. Though the small size of the study precluded our ability to test statistical significance, these results are consistent with selection for virus with shorter variable loops and fewer glycosylation sites during transmission of HIV-1 subtype C in other settings. Transmitted envs were resistant to neutralization by antibodies 2G12 and 2F5, but were generally sensitive to the more broadly neutralizing PG9, PG16, and VRC01, indicating that this new generation of broadly neutralizing monoclonal antibodies could be efficacious in passive immunization strategies.

Transcriptional repression and RNA silencing act synergistically to demonstrate the function of the eleventh component of the vaccinia virus entry-fusion complex

Poxviruses have an elaborate system for infecting cells comprising several proteins for attachment and a larger number dedicated to membrane fusion and entry. Thus far, 11 proteins have been identified as components of the vaccinia virus (VACV) entry-fusion complex (EFC), and 10 of these proteins have been shown to be required for entry. J5, the remaining functionally uncharacterized component of the complex, is conserved in all poxviruses, has a predicted C-terminal transmembrane domain, and is an N-terminally truncated paralog of two other EFC proteins. To determine the role of J5, we constructed a mutant that inducibly regulates J5 transcription. Although the virus yield was reduced only about 80% without inducer, the inability to isolate a J5 deletion mutant suggested an essential function. To enhance stringency, we employed RNA silencing alone and together with transcriptional repression of the inducible mutant. The yield of infectious virus was reduced 4- to 5-fold by repression, 2-fold by silencing, and 60-fold by the combination of the two. Virus particles made under the latter conditions appeared to contain a full complement of proteins excluding J5 but had very low infectivity. Further studies indicated that after binding to cells, J5-deficient virions had a defect in core entry and an inability to induce syncytium formation. In addition, we confirmed that J5 is associated with the EFC by affinity purification. These data indicate that J5 is a functional component of the EFC and highlights the advantage of combining transcriptional repression and RNA silencing for stringent reduction of gene expression.

Limited value of ultrasound assessment in patients with poor outcome after carpal tunnel release surgery

OBJECTIVE

To determine the value of ultrasonography in the assessment of patients with idiopathic carpal tunnel syndrome (CTS) and poor outcome after carpal tunnel release.

METHODS

A total of 88 consecutive patients with CTS (104 hands) underwent open surgical release of the median nerve. Ultrasound (US) examination was performed blind to any patient's data. The median nerve area at tunnel inlet and outlet, the retinaculum distance, and the flattening ratio were measured. The main outcome variable was the patient's overall satisfaction using a five-point Likert scale (1 = worse, 2 = no change, 3 = slightly better, 4 = much better, 5 = cured) at 3 months postoperatively. Pre- and postoperative ultrasonographic findings in relation to clinical outcome were analysed.

RESULTS

Improvement (scores 4 or 5 on the Likert scale) was recorded in 75 hands (72%). After carpal tunnel release, the cross-sectional area at tunnel inlet decreased from a mean of 14.2 to 13.3 mm2 in the group with clinical improvement and also from a mean of 12.5 to 11.6 mm2 in the group with no change or slight improvement. No significant changes in the cross-sectional area at tunnel outlet, retinaculum distance, and flattening ratio were observed.

CONCLUSION

Reduction of the median nerve cross-sectional area at tunnel inlet at 3 months after carpal tunnel release was similar in patients reporting cure or great improvement and in those with slight or no improvement. Ultrasonography is of limited value in assessment of patients with poor outcome after median nerve release.

Usefulness of clinical findings, nerve conduction studies and ultrasonography to predict response to surgical release in idiopathic carpal tunnel syndrome

OBJECTIVES

To assess the usefulness of clinical findings, nerve conduction studies and ultrasonography performed by a rheumatologist to predict success in patients with idiopathic carpal tunnel syndrome (CTS) undergoing median nerve release.

METHODS

Ninety consecutive patients with CTS (112 wrists) completed a specific CTS questionnaire and underwent physical examination and nerve conduction studies. Ultrasound examination was performed by a rheumatologist who was blind to any patient's data. Outcome variables were improvement >25% in symptoms of the CTS questionnaire and patient's overall satisfaction (5-point Likert scale) at 3 months postoperatively. Success was defined as improvement in both outcome variables. Receiver operating characteristics (ROC) curves and logistic regression analyses were used to assess the best predictive combination of preoperative findings.

RESULTS

Success was achieved in 63% of the operated wrists. Utility parameters and area under the ROC curve (AUC) for individual findings was poor, ranging from 0.481 of the nerve conduction study to 0.634 of the cross-sectional area at tunnel outlet. Logistic regression identified the preoperative US parameters as the best predictive variables for success after 3 months. The best predictive combination (AUC=0.708) included a negative Phalen maneuver, plus absence of thenar atrophy, plus less than moderately abnormalities on nerve conduction studies plus a large maximal cross-sectional area along the tunnel by ultrasonography.

CONCLUSION

Although cross-sectional area of the median nerve was the only predictor of success after three months of surgical release, isolated preoperative findings are not reliable predictors of success in patients with idiopathic CTS. A combination of findings that include ultrasound improves prediction.

Factors involved in the progress of preclinical atherosclerosis associated with systemic lupus erythematosus: a 2-year longitudinal study

Objectives

To assess the changes in carotid intima-media thickness (IMT) and the associated risks factors in patients with low severity systemic lupus erythematosus (SLE).

Methods

Common carotid IMT measurements were obtained by ultrasound from 101 patients with SLE at an interval of 2 years. Cardiovascular risk factors, disease activity, accumulated damage, severity (Katz index) and biochemical parameters (including high sensitivity C-reactive protein, interleukin 6, C3a, C4a, C5a and homocysteine) were also assessed. Multiple linear regression was used to assess the effect of these variables on the end IMT measurement (eIMT) adjusted to the baseline measurement (bIMT).

Results

The cohort comprised 94.1% women, with a mean age at entry of 41.5 years and a mean disease duration of 12.1 years. An increase of 0.078 mm in IMT was detected over 2 years, from a mean bIMT of 0.37 mm to a mean eIMT of 0.44 mm (p<0.001). When adjusted for the bIMT, multiple linear regression identified bIMT, age at diagnosis, homocysteine, C3 and C5a as risk factors for IMT progression.

Conclusions

IMT significantly increases over 2 years in patients with SLE. Age, baseline IMT, C3, C5a anaphylatoxin and homocysteine are all associated risk factors, supporting a role for complement and homocysteine in the early stages of premature SLE-associated atherosclerosis.

What is the diagnostic value of ultrasonography compared to physical evaluation in patients with idiopathic carpal tunnel syndrome?

OBJECTIVE

Our hypothesis is that sonography performed by the rheumatologist in patients with suspected carpal tunnel syndrome (CTS) has higher diagnostic value compared to physical evaluation.

METHODS

Adult patients with suspected idiopathic CTS, defined by sensory symptoms over the distribution of the median nerve with or without positive results with the Phalen and/or the Tinel's maneuvers were included. The diagnosis of CTS was indicated by typical symptoms daily for at least 3 months and a positive nerve conduction study. One rheumatologist unaware of the clinical and electrodiagnostic results performed an ultrasound examination of the median nerve for the area ranging from the inlet to the outlet of the carpal tunnel. Mean cross-sectional area at each level, flattening ratio and bowing of flexor retinaculum were obtained.

RESULTS

Sixty-eight patients with 105 affected wrists were examined. Tinel's and Phalen's signs had a closer sensitivity (73% and 67% respectively) and specificity (40% and 30% respectively). The best swelling nerve cut-off by sonography was 9.7 mm2 at the tunnel inlet, with a sensitivity of 86%, a specificity of 48% and accuracy of 77%. A 100% positive predictive value was reached with a cross-sectional area of 13 mm2, involving 33 hands (31% of the whole sample). Maximal cross sectional area and the measurement of flexor retinaculum had an accuracy of 72% and 73% respectively. Combination of physical maneuvers and sonography not yielded more accuracy than cross-sectional area itself.

CONCLUSION

In patients with clinical history of idiopathic CTS and positive nerve conduction study, sonography performed by the rheumatologist has higher diagnostic value than physical maneuvers.

Entry of vaccinia virus and cell-cell fusion require a highly conserved cysteine-rich membrane protein encoded by the A16L gene

The vaccinia virus A16L open reading frame encodes a 378-amino-acid protein with a predicted C-terminal transmembrane domain and 20 invariant cysteine residues that is conserved in all sequenced members of the poxvirus family. The A16 protein was expressed late in infection and incorporated into intracellular virus particles with the N-terminal segment of the protein exposed on the surface. The cysteine residues were disulfide bonded via the poxvirus cytoplasmic redox system. Unsuccessful attempts to isolate a mutant virus with the A16L gene deleted suggested that the protein is essential for replication. To study the role of the A16 protein, we made a recombinant vaccinia virus that has the Escherichia coli lac operator system regulating transcription of the A16L gene. In the absence of inducer, A16 synthesis was repressed and plaque size and virus yield were greatly reduced. Nevertheless, virus morphogenesis occurred and normal-looking intracellular and extracellular virus particles formed. Purified virions made in the presence and absence of inducer were indistinguishable, though the latter had 60- to 100-fold-lower specific infectivity. A16-deficient virions bound to cells, but their cores did not penetrate into the cytoplasm. Furthermore, A16-deficient virions were unable to induce low-pH-triggered syncytium formation. The phenotype of the inducible A16L mutant was similar to those of mutants in which synthesis of the A21, A28, H2, or L5 membrane protein was repressed, indicating that at least five conserved viral proteins are required for entry of poxviruses into cells as well as for cell-cell fusion.

Steroids and bone density in patients with functioning kidney allografts

INTRODUCTION

Osteopenia and osteoporosis after renal transplantation have been associated with factors related to the cause of end-stage renal disease, as well as to clinical events and therapeutic factors in the posttransplant period. We studied the prevalence of low bone density (LBD) according to WHO criteria.

METHODS

A cross-sectional study was performed in a cohort of 106 patients (54 men and 52 women) with functioning renal allografts, who underwent bone densitometry (DEXA) of the lumbar spine and femoral neck. Patients were grouped according to DEXA into those with normal bone density (NBD) or LBD. We studied clinical, analytical, and therapeutic variables.

RESULTS

Thirtysix patients (34%) had NBD and 70 patients (66%) LBD. Weight was the only parameter showing a significant difference (P = .034), namely, among NBD it was 80.44+/-15.13 versus LBD 73.94 +/- 14.54 kg, respectively. Creatinine clearance (CCr) tended to be lower among patients with LBD 59.62 +/- 22.73 versus 69.59 +/- 28.15 mL/min in patients with NBD (P = .052). PTHi levels were higher in patients with LBD (149.39 +/- 110.75) than those with NBD (110.94 +/- 82.61) (P = .069). In the multivariate analysis the important determinants were weight Exp(ss) = 0.967 [CI = 0.939 to 0.996] (P = .036); CCr Exp(ss) = 0.982 [CI = 0.965 to 1.000] (P = .055); and PTHi levels Exp(ss) = 1.003 [CI = 0.932 to 0.994] (P = .059).

CONCLUSIONS

Osteopenia and osteoporosis are frequent among kidney transplant patients (66%), with a similar distribution between the lumbar spine and femoral neck. Excess weight and possibly better renal function may be protective factors. The cumulative steroid dose showed a significant effect on bone density. As expected, secondary hyperparathyroidism in patients with renal impairment seemed to be a risk factor for LBD.

Vaccinia virus G9 protein is an essential component of the poxvirus entry-fusion complex

The vaccinia virus G9R gene (VACWR087) encodes a protein of 340 amino acids with the following structural features that are conserved in all poxviruses: a site for N-terminal myristoylation, 14 cysteines, and a C-terminal transmembrane domain. Previous studies showed that G9 is one of eight proteins associated in a putative entry-fusion complex. Our attempt to isolate a mutant without the G9R gene was unsuccessful, suggesting that it is essential for virus replication. To further investigate its role, we constructed a recombinant vaccinia virus in which G9R is regulated by addition of an inducer. Induced G9 protein was associated with mature infectious virions and could be labeled with a membrane-impermeant biotinylation reagent, indicating surface exposure. Omission of inducer reduced the infectious-virus yield by about 1.5 logs; nevertheless, all stages of virus morphogenesis appeared normal and extracellular virions were present on the cell surface. Purified virions assembled without inducer had a specific infectivity of less than 5% of the normal level and a comparably small amount of G9, whereas their overall polypeptide composition, including other components of the entry-fusion complex, was similar to that of virions made in the presence of inducer or of wild-type virions. G9-deficient virions bound to cells, but penetration of cores into the cytoplasm and early viral RNA synthesis were barely detected, and cell-cell fusion was not triggered by low pH. Of the identified components of the multiprotein complex, G9 is the sixth that has been shown to be required for entry and membrane fusion.

Poxvirus multiprotein entry-fusion complex

Poxviruses have evolved elaborate mechanisms for cell entry, assembly, and exocytosis. Recently, four vaccinia virus membrane proteins, namely A21, A28, H2 and L5, were reported to be necessary for cell entry and virus-induced cell-cell fusion but not for virion morphogenesis or attachment of virus particles to cells. Using immunoaffinity purification followed by mass spectrometry, we now show that these four proteins as well as four additional previously uncharacterized putative membrane proteins (A16, G3, G9, and J5) form a stable complex. These proteins fall into two groups: A21, A28, G3, H2, and L5 have an N-terminal transmembrane domain, 0-2 intramolecular disulfide bonds, and no sequence similarity, whereas A16, G9, and J5 have a C-terminal transmembrane domain and 4-10 predicted disulfide bonds and are homologous. Studies with conditional-lethal null mutants indicated that the viral membrane was crucial for assembly of the complex and that the absence of individual polypeptide components profoundly decreased complex formation or stability, suggesting a complicated interaction network. Analysis of purified virions, however, demonstrated that the polypeptides of the complex trafficked independently to the viral membrane even under conditions in which the complex itself could not be isolated. All eight proteins comprising the entry-fusion complex are conserved in all poxviruses, suggesting that they have nonredundant functions and that the basic entry mechanism evolved before the division between vertebrate and invertebrate poxvirus species.

Percutaneous interventions on severe coarctation of the aorta: a 21-year experience

Different percutaneous interventions can be used to treat coarctation of the aorta. However, a great amount of information is still needed regarding the long-term course. This article reviews our experience spanning 21 years in the percutaneous treatment of aortic coarctation. Four different conditions for treatment were considered. The first condition 1 (group 1) was balloon angioplasty in neonates and infants with untractable heart failure (n = 54; mean age, 1.2 +/- 1.4 months). After balloon angioplasty, most infants sustained significant clinical improvement. However, 9 patients died in the hospital (17%). As a result, we monitored the course of the 45 survivors during a mean period of 10 +/- 6 years (range, 1-19). During this follow-up period, 17 patients needed a single additional intervention on coarctation (8 underwent surgery and 9 were treated percutaneously). After this second treatment, 11 patients needed one or more further interventions. The actuarial survival probability was 83% at 19 years, with 43% of patients remaining surgery free and 23% reintervention free. The second condition (group 2) was balloon angioplasty in children and adults with coarctation of the aorta before the stenting era (n = 28; mean age, 13 +/- 8 years). After treatment, serial hemodynamic and angiographic studies were performed. The long-term relief was higher in patients with a discrete type of coarctation. The rate of late aneurysm formation was 6%. The third condition (group 3) was stent palliation in infants and children younger than the age of 6 years (n = 17; mean age, 2.1 +/- 1.7 years). The stent was implanted for nondilatable stenoses, as a nondefinitive procedure. Stent palliation provides complete initial relief in hypoplastic coarctations or life-threatening conditions. However, further stent expansion is required to ensure adequate stent diameter in the growing aortic wall. In addition, late intrastent proliferation may occur in small stent diameters (18%) and aneurysm formation in hypoplastic coarctations (18%). Both late complications can be managed percutaneously. The fourth condition (group 4) was stent repair of severe aortic coarctation in adults, adolescents, and children older than the age of 6 years (n = 73; mean age, 20 +/- 12 years). Significant relief was observed after treatment, which persisted at follow-up. One patient died at treatment (1.3%). After a mean follow-up of 5 +/- 3 years, all 72 patients remained symptom free and no restenosis or late aneurysm were detected.

[Nutritional status in older adults beneficiaries of a social programme with food component implemented in the city of Cordoba. Year 2000]

The nutritional status in older aged persons is the resulting of their living conditions and health. The demographic growing of this part of population is a challenge to health professionals, to know which are the characteristics of the normality in this stage of life.

OBJECTIVE

To know the nutritional status of the older aged persons beneficiaries of the ASOMA programme and identify from a qualitative focus, their food consumption standards.

MATERIAL AND METHOD

Descriptive, co-relational and transversal field study. Universe: 10214 persons from three different food assistance programmes. Sampling method: aleatory stratified respecting the universe proportion resulting n = 162 from ASOMA programme. Equation: Chumlea's was used to check height-taking reference from knee height and BMI.

TECHNIQUES

Observation and measurement (anthropometric)

CONCLUSIONS

The group has been represented into 2/3 parts of women n:108 and the age category older-young persons, low education level, temporary incomes always under $200 monthly. One quarter of them still work. The food consumption standard is signed by three basic foods: bread, oil and sugar and a frequent consumption of rice and chicken. Cow-meat, three-kind vegetables, pasta and "A" fruits appear as less frequents. The 83.9% of older-persons have a monotonous diet (weekly consumption < or = 5 different foods) that belong to the ASOMA programme. The middle value for BMI was 27.4 for the entire group, SD 5.33. The 24.1% of de population were situated in BMI values status that indicate normal nutritional. Analyzing the values by sex, men values were all around the middle value of the group. Among the women the values showed more dispersion. The BMI for women (middle value 28.4 with SD 5.88) was higher than for men (middle value 25.9 with SD 3.60). It was found positive co relation between BMI and body fat percentage and negative for BMI and body water percentage. Therefore was founded a negative significant co relation between the body fat and body water percentages.

Abnormal sonographic findings in the asymptomatic arthritic shoulder

OBJECTIVE

To assess the diagnostic value of ultrasonography (US) in the evaluation of arthritic shoulder joints, especially in painless shoulders.

METHODS

US examinations were performed in 57 consecutive patients with rheumatoid arthritis (114 shoulders) and in 32 controls (32 shoulders), using a 7.5 MHz linear probe and a standardized study protocol. US findings were compared with clinical, laboratory, and radiological data to find any relationship.

RESULTS

Abnormal sonographic findings were found in 80 shoulders (70%); the most common were lesions in the supraspinatus tendon (38%), subacromial-subdeltoid bursitis (29%), bone erosions of the humeral head (20%), glenohumeral joint ellusion (19%), and biceps tendinitis (13%). Although US abnormalities were most frequent in patients with painful shoulders or abnormal findings on physical examination or radiography, a high rate of alterations was found in asymptomatic shoulders (51%), in normal shoulders on physical examination (44%) and in normal shoulders on radiographic assessment (61%). Differences of US findings in relation to time of evolution of rheumatoid arthritis, patient's age, and radiographic stage in hand and/or wrist joints were not found.

CONCLUSION

US abnormalities in the shoulder joint are frequent in rheumatoid arthritis, both in patients with and without shoulder complaints as well as in patients with normal findings on physical examination.

A segment and epithelium specific messenger ribonucleic acid fragment up-regulated by estradiol in the rat oviduct

Estradiol accelerates oviductal embryo transport in the rat through changes of genomic expression in oviductal cells. However, the genes involved are unknown. We used a differential display by reverse transcription-polymerase chain reaction to detect estradiol (E2)-dependent genes in the rat oviduct. Rats on day 2 of pregnancy were untreated or treated with 10 micrograms of E2 and the oviducts were extracted at 30, 180 and 360 min later and used to isolate RNA. Products of reverse transcriptase-PCR, made with pairs of arbitrary and oligo-deoxythymidine primers, were separated on denaturing polyacrylamide gels and candidate bands were excised and reamplified. Truly positive cDNA fragments determined by a single strand conformation polymorphism assay were cloned and sequenced. A ribonuclease protection assay confirmed that clone 25 is up-regulated by E2 in the oviduct at 30, 180 and 360 min. This clone exhibited no homology with known genes and in situ hybridization showed it is only expressed in the epithelial cells of the isthmic segment. Clone 25 is likely to represent a new gene, which is up-regulated by E2 in the epithelium of the isthmic segment of the rat oviduct. Its time frame of response is compatible with a mediator of the effect of E2 on oviductal embryo transport.

[Heart failure caused by severe systolic ventricular dysfunction of hypertensive origin. Long-term clinical and functional course]

AIMS

The aims of our study were to evaluate survival and evolution of functional class and ventricular function in patients with severe congestive heart failure due to dilated cardiomyopathy.

METHODS

Inclusion criteria were: class III or IV heart failure, dilated left ventricle with ejection fraction < 40%, history of poor controlled hypertension, and exclusion of other etiologies for heart failure. We studied 17 patients with these features; mean age was 64 +/- 7 years and 70% were male. They were followed up during a mean period of 3.3 +/- 1 years (2 to 6; median 3 years).

RESULTS

Baseline left ventricular ejection fraction was 30 +/- 5% (20 to 40); 35% of patients were in functional class III and 65% in class IV; 100% of patients received ACE inhibitors and diuretics, 53% betablockers, and 35% calcium-antagonists. Survival was 100%. Left ventricular ejection fraction increased from 30 +/- 5% to 44 +/- 11% at one year, to 50 +/- 11% at 3 years and 51 +/- 10% at the end of follow-up (p < 0.001). This improvement was mainly due to a reduction in systolic left ventricular diameter (from 51 +/- 4 mm to 42 +/- 11 mm, p < 0.01), since diastolic diameter did not significantly changed (63 +/- 4 to 59 +/- 11 mm).

CONCLUSIONS

The evolution of severe systolic left ventricular dysfunction due to arterial hypertension is favourable at long-term, with null mortality and clinical ejection fraction and functional improvement. Nevertheless, the persistence of left ventricular dilatation suggests that myocardial damage caused by chronic pressure overload does not disappear.

[Histocompatibility antigens and acute vascular purpura]

INTRODUCTION

Some kidney diseases are associated to HLA antigens. Nyulassy found an increase in HLA-B35 in patients with Henoch-Schönlein's purpura suffering nephritis (HSP-N). Our study searched for associations of HLA antigens and anaphylactoid purpura nephritis in Mexican mestizo patients.

MATERIAL AND METHODS

HLA-A,B, and C antigens were detected by two-step microcytotoxicity in 22 patients with HSP-N and compared to those of 665 healthy subjects of the same ethnic background.

RESULTS

A significant association was found between HSP-N and HLA-Aw19 single (pc less than 0.05) or in haplotype form (Aw19-B35) (pc less than 0.005). HLA B35 alone was associated to HSP-N but only at non corrected level (pc less than 0.05).

DISCUSSION

The significant association between HLA-Aw19 and Aw19-B35 and HSP-N may indicate a risk factor in Mexican mestizo patients to develop this case.