Clinical and ultrasound features of difficult-to-treat rheumatoid arthritis: A multicenter RA ultrasound cohort study

OBJECTIVE

The optimal strategy for difficult-to-treat (D2T) rheumatoid arthritis (RA) has not been identified, and the ultrasound characteristics of D2T RA have not been reported. We investigated the clinical characteristics and factors contributing to the outcome in D2T RA in a multicentre RA ultrasound observational cohort.

METHOD

We reviewed 307 Japanese patients diagnosed with RA who underwent treatment with biological and targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs). We compared the differences in patient characteristics between the D2T RA and non-D2T RA groups. We examined the factors contributing to a good response [defined as b/tsDMARD continuation and Clinical Disease Activity Index (CDAI) ≤ 10 at 12 months] in the D2T RA patient group.

RESULTS

Forty-three patients (14%) were categorized as D2T RA and the remaining 264 (86%) as non-D2T RA at baseline. The grey-scale (GS) score, disease duration, and CDAI at the initiation of treatment were significantly higher in the D2T RA group than in the non-D2T RA group. In contrast, the power Doppler (PD) score was not significantly different between the two groups. Of the 43 D2T RA patients, 20 achieved a good response. The introduction of CTLA4-Ig (n = 5) was significantly associated with a good response in analysis based on inverse probability weighting with propensity score. GS and PD scores at baseline were not significantly associated with therapeutic response at 12 months in D2T RA patients.

CONCLUSIONS

Patients with D2T RA had high clinical and ultrasound activity and poor responses to treatment with b/tsDMARDs. CTLA4-Ig was associated with a good response at 12 months in D2T RA patients.

How coronal malalignment affects the surgical outcome in corrective spine surgery for adult symptomatic lumbar deformity

PURPOSE

The importance of coronal alignment is unclear, while the importance of sagittal alignment in the treatment of adult patients with spinal deformities is well described. This study sought to elucidate the impact of global coronal malalignment (GCMA) in surgically treated adult symptomatic lumbar deformity (ASLD) patients.

METHODS

A multicentre retrospective analysis of a prospective ASD database. GCMA was defined as GCA (C7PL-CSVL) ≥ 3 cm. GCMA is categorized based on the Obeid-Coronal Malalignment Classification (O-CM). Demographic, surgical, radiographic, HRQOL, and complication data were analysed. The risk for postoperative GCMA was analysed by univariate and multivariate analyses.

RESULTS

Of 230 surgically treated ASLD patients, 96 patients showed GCMA preoperatively and baseline GCA was correlated with the baseline SRS-22 pain domain score (r = - 30). Postoperatively, 62 patients (27%, O-CM type 1: 41[18%], type 2: 21[9%]) developed GCMA. The multivariate risk analysis indicated dementia (OR 20.1[1.2-304.4]), diabetes (OR 5.9[1.3-27.3]), and baseline O-CM type 2 (OR 2.1[1.3-3.4]) as independent risk factors for postoperative GCMA. The 2-year SRS-22 score was not different between the 2 groups, while 4 GCMA patients required revision surgery within 1 year after surgery due to coronal decompensation (GCMA+ vs. GCMA- function: 3.6 ± 0.6 vs. 3.7 ± 0.7, pain: 3.7 ± 0.8 vs. 3.8 ± 0.8, self-image: 3.6 ± 0.8 vs. 3.6 ± 0.8, mental health: 3.7 ± 0.8 vs. 3.8 ± 0.9, satisfaction: 3.9 ± 0.9 vs. 3.9 ± 0.8, total: 3.7 ± 0.7 vs. 3.7 ± 0.7). Additionally, the comparisons of 2-yr SRS-22 between GCMA ± showed no difference in any UIV and LIV level or O-CM type.

CONCLUSIONS

In ASLD patients with corrective spine surgery, GCMA at 2 years did not affect HRQOL or major complications at any spinal fusion extent or O-CM type of malalignment, whereas GCA correlated with pain intensity before surgery. These findings may warrant further study of the impact of GCMA on HRQOL in the surgical treatment of ASLD patients.

Structural basis of hepatitis B virus receptor binding

Hepatitis B virus (HBV), a leading cause of developing hepatocellular carcinoma affecting more than 290 million people worldwide, is an enveloped DNA virus specifically infecting hepatocytes. Myristoylated preS1 domain of the HBV large surface protein binds to the host receptor sodium-taurocholate cotransporting polypeptide (NTCP), a hepatocellular bile acid transporter, to initiate viral entry. Here, we report the cryogenic-electron microscopy structure of the myristoylated preS1 (residues 2-48) peptide bound to human NTCP. The unexpectedly folded N-terminal half of the peptide embeds deeply into the outward-facing tunnel of NTCP, whereas the C-terminal half formed extensive contacts on the extracellular surface. Our findings reveal an unprecedented induced-fit mechanism for establishing high-affinity virus-host attachment and provide a blueprint for the rational design of anti-HBV drugs targeting virus entry.

Optimal dose for the efficacy of asenapine in patients with schizophrenia: Real-world data

AIMS

A meta-analysis of short-term studies revealed no significant differences between the doses of asenapine, 10 and 20 mg/day, in the acute treatment of schizophrenia. However, it should be noted that many patients from clinical practice were excluded, and the dose-response to asenapine in a real-world setting is still unclear. Additionally, the dose-response in the maintenance phase is not clear. This study aimed to evaluate the differences in the efficacy of different asenapine doses in patients with maintenance phase of schizophrenia in a real-world setting.

METHODS

This study conducted post-marketing surveillance of asenapine in clinical settings in Japan. It followed patients diagnosed with schizophrenia who received asenapine for the first time for a maximum of 52 weeks. These patients were divided into two categories based on their average daily asenapine dosage: ≤10 mg/day and >10 mg/day. Asenapine efficacy was assessed by adjusting for patient demographics using multivariate logistic regression analysis, employing the Clinical Global Impression-Global Improvement (CGI-I) scale, which has seven categories.

RESULTS

A total of 2774 patients were included in the analysis. Of these, 1689 and 1085 patients were treated with asenapine ≤10 mg/day and >10 mg/day, respectively. The CGI-I improvement rate was significantly higher in the asenapine >10 group (p = 0.012) after adjusting for patient background factors.

CONCLUSION

These results suggest that asenapine doses >10 mg/day may be more effective than 10 mg/day in the treatment of schizophrenia; however, further studies are needed to confirm these findings.

Positional relationships between a tracheal diverticulum and the tracheal tube under general anesthesia: a single-center observational and simulation study

BACKGROUND

Incomplete sealing of tracheal diverticula by a tracheal tube cuff during positive-pressure ventilation causes barotrauma but the concrete possibility of incomplete sealing has not been indicated. We aimed to assess the possibility of incomplete sealing in a simulated situation of tracheal intubation for patients with tracheal diverticula with tube fixation where the tracheal tube's vocal cord guide overlaps with the patient's vocal cord.

METHODS

We retrospectively assessed the characteristics of tracheal diverticula based on thoracic computed tomography data in our institution from January 2018 to July 2020. Then, we assessed the structural parameters of three single-lumen tracheal tubes (Parker Flex-Tip [Parker Medical, Bridgewater, CT, USA], Portex Soft Seal [ICU Medical, San Clemente, CA, USA], and Shiley TaperGuard [Medtronic, Dublin, Ireland]; 6.0-8.0 mm inner diameter size) and simulated the positional relationships between tracheal diverticula and the tracheal tube during tracheal intubation where the vocal cord guide overlaps with the patient's vocal cord. We assessed each tube product's possibility of incompletely sealing tracheal diverticula and the possibility of unintended bronchial intubation.

RESULTS

In 5,854 patients, the prevalence of tracheal diverticula was 5.7%. The mean (SD) length from the vocal cord to the distal end of the tracheal diverticula was 52.2 (12.8) mm. Tracheal tubes with length from the distal end of the tracheal cuff to the vocal cord guide of ≥ 70 mm had a low risk of incompletely sealing tracheal diverticula (< 5%) and length from the distal end of the tube to the vocal cord guide of ≤ 95 mm had a low risk of unintended bronchial intubation (< 5%). No products in this study satisfied both outcomes.

CONCLUSIONS

Tube fixation, where the vocal cord guide overlaps with the patient's vocal cord, is associated with risk of incompletely sealing of tracheal diverticula depending on the tube's manufacturer and tube's inner diameter size, although it was not a high risk. The use of small inner diameter sized tube relative to patient's body size is high risk of incomplete sealing of tracheal diverticula.

TRIAL REGISTRATION

This trial was prospectively registered at University Hospital Medical Information Network (UMIN).

CLINICAL TRIAL NUMBER AND REGISTRY URL

UMIN000043317 (URL: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000048055 ).

A screening method for visual attention disabilities in cerebral palsy with periventricular leukomalacia

PURPOSE

Patients with periventricular leukomalacia (PVL) have been reported to have a variety of complications; however, whether these involve impaired visual attention disabilities remains unclear. Therefore, this study aimed to investigate the presence or absence and degree of visual attention disabilities in patients with PVL and propose a screening test that would allow anyone to check for visual attention disabilities easily.

METHODS

The study participants were 14 patients with PVL and seven controls with dyskinetic cerebral palsy. All participants performed three types of visual attention tasks: spatial attention tasks, feature-based attention tasks, and object-based attention tasks. The participants also performed counting tasks to determine how many squares of the same size and color could be counted (up to nine). Receiver operating characteristic analysis was used to calculate cutoff values, with disability as the objective variable and the value of the counting task as the explanatory variable.

RESULTS

The results revealed that patients with PVL often had visual attention disabilities, as indicated by a significant reduction in tasks requiring divided attention. Visual attention disabilities could be detected by a score of ≤8 in the square counting task.

CONCLUSIONS

These findings suggest that family members and teachers of patients with PVL can easily screen for visual attention disabilities at home and school to improve mobility precautions in patients with this disability.

A novel Toll-like receptor 7/8-specific antagonist E6742 ameliorates clinically relevant disease parameters in murine models of lupus

The sensing of self RNA by the endosomal Toll-like receptors (TLRs) 7 and 8 initiates pathogenic mechanisms underlying the autoimmune disease lupus. A blockade of the TLR7/8 signals may, therefore, be a novel therapeutic intervention for lupus. To test the hypothesis, a novel compound E6742 that blocks TLR7/8 activation was identified. The mode of action of E6742 was investigated by analysis of the tertiary structure of TLR7 and 8 in complex with E6742. The in vitro activities of the compound were examined in cellular systems and its therapeutic potential was evaluated in murine lupus models. Tertiary structures of the extracellular domain of TLR7 and 8 in complex with E6742 showed that E6742 binds specifically and non-covalently to the hydrophobic pocket located at the interface of TLR7 or TLR8 homodimers. E6742 potently and selectively inhibited several TLR7/8-mediated cytokine responses in human PBMC. In two mouse models of lupus, oral dosing of E6742 after the onset of disease suppressed increase in autoantibodies and blocked the advance of organ damage. Collectively, the data show that TLR7/8 activation contributes to disease progression and its blocking by E6742 has potential as a therapeutic intervention for lupus.

Structural basis for thioredoxin-mediated suppression of NLRP1 inflammasome

Inflammasome sensors detect pathogen- and danger-associated molecular patterns and promote inflammation and pyroptosis1. NLRP1 was the first inflammasome sensor to be described, and its hyperactivation is linked to autoinflammatory disease and cancer2-6. However, the mechanism underlying the activation and regulation of NLRP1 has not been clearly elucidated4,7,8. Here we identify ubiquitously expressed endogenous thioredoxin (TRX) as a binder of NLRP1 and a suppressor of the NLRP1 inflammasome. The cryo-electron microscopy structure of human NLRP1 shows NLRP1 bound to Spodoptera frugiperda TRX. Mutagenesis studies of NLRP1 and human TRX show that TRX in the oxidized form binds to the nucleotide-binding domain subdomain of NLRP1. This observation highlights the crucial role of redox-active cysteines of TRX in NLRP1 binding. Cellular assays reveal that TRX suppresses NLRP1 inflammasome activation and thus negatively regulates NLRP1. Our data identify the TRX system as an intrinsic checkpoint for innate immunity and provide opportunities for future therapeutic intervention in NLRP1 inflammasome activation targeting this system.

Discovery of a cystathionine γ-lyase (CSE) selective inhibitor targeting active-site pyridoxal 5'-phosphate (PLP) via Schiff base formation

D,L-Propargylglycine (PAG) has been widely used as a selective inhibitor to investigate the biological functions of cystathionine γ-lyase (CSE), which catalyzes the formation of reactive sulfur species (RSS). However, PAG also inhibits other PLP (pyridoxal-5'-phosphate)-dependent enzymes such as methionine γ-lyase (MGL) and L-alanine transaminase (ALT), so highly selective CSE inhibitors are still required. Here, we performed high-throughput screening (HTS) of a large chemical library and identified oxamic hydrazide 1 as a potent inhibitor of CSE (IC50 = 13 ± 1 μM (mean ± S.E.)) with high selectivity over other PLP-dependent enzymes and RSS-generating enzymes. Inhibitor 1 inhibited the enzymatic activity of human CSE in living cells, indicating that it is sufficiently membrane-permeable. X-Ray crystal structure analysis of the complex of rat CSE (rCSE) with 1 revealed that 1 forms a Schiff base linkage with the cofactor PLP in the active site of rCSE. PLP in the active site may be a promising target for development of selective inhibitors of PLP-dependent enzymes, including RSS-generating enzymes such as cystathionine β-synthase (CBS) and cysteinyl-tRNA synthetase 2 (CARS2), which have unique substrate binding pocket structures.

TLR7/8 stress response drives histiocytosis in SLC29A3 disorders

Loss-of-function mutations in the lysosomal nucleoside transporter SLC29A3 cause lysosomal nucleoside storage and histiocytosis: phagocyte accumulation in multiple organs. However, little is known about the mechanism by which lysosomal nucleoside storage drives histiocytosis. Herein, histiocytosis in Slc29a3-/- mice was shown to depend on Toll-like receptor 7 (TLR7), which senses a combination of nucleosides and oligoribonucleotides (ORNs). TLR7 increased phagocyte numbers by driving the proliferation of Ly6Chi immature monocytes and their maturation into Ly6Clow phagocytes in Slc29a3-/- mice. Downstream of TLR7, FcRγ and DAP10 were required for monocyte proliferation. Histiocytosis is accompanied by inflammation in SLC29A3 disorders. However, TLR7 in nucleoside-laden splenic monocytes failed to activate inflammatory responses. Enhanced production of proinflammatory cytokines was observed only after stimulation with ssRNAs, which would increase lysosomal ORNs. Patient-derived monocytes harboring the G208R SLC29A3 mutation showed enhanced survival and proliferation in a TLR8-antagonist-sensitive manner. These results demonstrated that TLR7/8 responses to lysosomal nucleoside stress drive SLC29A3 disorders.

Recommendations for the use of next-generation sequencing in patients with metastatic cancer in the Asia-Pacific region: a report from the APODDC working group

INTRODUCTION

Next-generation sequencing (NGS) diagnostics have shown clinical utility in predicting survival benefits in patients with certain cancer types who are undergoing targeted drug therapies. Currently, there are no guidelines or recommendations for the use of NGS in patients with metastatic cancer from an Asian perspective. In this article, we present the Asia-Pacific Oncology Drug Development Consortium (APODDC) recommendations for the clinical use of NGS in metastatic cancers.

METHODS

The APODDC set up a group of experts in the field of clinical cancer genomics to (i) understand the current NGS landscape for metastatic cancers in the Asia-Pacific (APAC) region; (ii) discuss key challenges in the adoption of NGS testing in clinical practice; and (iii) adapt/modify the European Society for Medical Oncology guidelines for local use. Nine cancer types [breast cancer (BC), gastric cancer (GC), nasopharyngeal cancer (NPC), ovarian cancer (OC), prostate cancer, lung cancer, and colorectal cancer (CRC) as well as cholangiocarcinoma and hepatocellular carcinoma (HCC)] were identified, and the applicability of NGS was evaluated in daily practice and/or clinical research. Asian ethnicity, accessibility of NGS testing, reimbursement, and socioeconomic and local practice characteristics were taken into consideration.

RESULTS

The APODDC recommends NGS testing in metastatic non-small-cell lung cancer (NSCLC). Routine NGS testing is not recommended in metastatic BC, GC, and NPC as well as cholangiocarcinoma and HCC. The group suggested that patients with epithelial OC may be offered germline and/or somatic genetic testing for BReast CAncer gene 1 (BRCA1), BRCA2, and other OC susceptibility genes. Access to poly (ADP-ribose) polymerase inhibitors is required for NGS to be of clinical utility in prostate cancer. Allele-specific PCR or a small-panel multiplex-gene NGS was suggested to identify key alterations in CRC.

CONCLUSION

This document offers practical guidance on the clinical utility of NGS in specific cancer indications from an Asian perspective.

Structural insight into the activation of an Arabidopsis organellar C-to-U RNA editing enzyme by active site complementation

RNA-binding pentatricopeptide repeat (PPR) proteins catalyze hundreds of cytidine to uridine RNA editing events in plant organelles; these editing events are essential for proper gene expression. More than half of the PPR-type RNA editing factors, however, lack the DYW cytidine deaminase domain. Genetic analyses have suggested that their cytidine deaminase activity arises by association with a family of DYW1-like proteins that contain an N-terminally truncated DYW domain, but their molecular mechanism has been unclear. Here, we report the crystal structure of the Arabidopsis thaliana DYW1 deaminase domain at 1.8 Å resolution. DYW1 has a cytidine deaminase fold lacking the PG box. The internal insertion within the deaminase fold shows an α-helical fold instead of the β-finger reported for the gating domain of the A. thaliana ORGANELLE TRANSCRIPT PROCESSING 86. The substrate-binding pocket is incompletely formed and appears to be complemented in the complex by the E2 domain and the PG box of the interacting PPR protein. In vivo RNA editing assays corroborate the activation model for DYW1 deaminase. Our study demonstrates the common activation mechanism of the DYW1-like proteins by molecular complementation of the DYW domain and reconstitution of the substrate-binding pocket.

Effect of Blonanserin on the Proliferation and Migration of Glioblastoma Cells

Glioblastoma is a highly malignant and invasive brain tumor, and there is an urgent need to establish a treatment option that prevents its growth and metastasis. Blonanserin is an antipsychotic drug widely used in the treatment of schizophrenia. It has recently been reported to inhibit the growth of breast cancer cells. In this study, we investigated the effect of blonanserin on the proliferation and migration of glioblastoma cells. The anti-proliferative activity of blonanserin was evaluated in terms of cell viability, competition, and cell death pathways in glioblastoma. Cell viability studies showed that blonanserin had growth inhibitory ability regardless of the malignancy of glioblastoma cells, but at concentrations close to its IC₅₀, it only had a slight cell death-inducing effect. Blonanserin showed growth inhibitory activity without D₂ antagonism following an independent competition analysis using blonanserin and D₂ antagonists. When the anti-migration activity of U251 cells was measured, blonanserin was found to attenuate cell migration. Furthermore, treatment with blonanserin at concentrations close to its IC₅₀ value inhibited extensive filament actin formation. In conclusion, blonanserin inhibited the proliferation and migration of glioblastoma cells independent of D₂ antagonism. The present study shows that blonanserin may serve as a seed compound for the discovery of new glioblastoma therapeutics to prevent the growth and metastasis of glioblastoma.

Tuberculous spondylitis following intravesical Bacillus Calmette-Guérin therapy for bladder cancer surgically treated through the anterior approach

Intravesical BCG therapy is commonly used to treat superficial bladder cancer. Although various complications associated with this therapy have been reported, tuberculous spondylitis is uncommon. Here, we report a rare case of tuberculous spondylitis that occurred after intravesical BCG therapy for bladder cancer. A man in his 80s received BCG immunotherapy for bladder cancer and developed low back pain after treatment. Remarkably, he presented with neurological symptoms. Spondylitis was suspected on imaging. CT-guided biopsy was performed to confirm the diagnosis. Consequently, Mycobacterium bovis was identified as the causative pathogen by multiplex PCR. Multidrug therapy, administered for several months, was ineffective. Therefore, surgery was performed through an anterior approach. The symptoms, including low back pain, improved and postoperative C reactive protein tests were within the normal range. Tuberculous spondylitis following BCG therapy should be considered in cases with a history of bladder cancer treatment.

The DPP4 inhibitor linagliptin exacerbated heart failure due to energy deficiency via downregulation of glucose absorption and utilization in mice

Background

It was reported that glucagon-like peptide-1 has cardio-protective effects, however, the occurrence of heart failure was increased with DPP4 inhibitor in some large clinical trials.

Purpose

The purpose of the present work was to clarify whether DPP4 inhibitor had any effects on chronic, dilated heart failure and to identify the mechanisms.

Methods

Heart / Muscle-specific Manganese superoxide dismutase (Mn-SOD)-deficient mice, (H/M-Sod−/−) which exert dilated cardiomyopathy were randomized to receive low dose (1 mg/kg) linagliptin, HF-L group; high dose (10 mg/kg) linagliptin, HF-H group; mixed with food, or normal food, HF group; for eight weeks. Then, evaluation was performed in cardiac function and pathophysiological changes.

Result

Interestingly, the mice treated with linagliptin treatment exhibited shorter life span and greater heart/body weight ratio. Echocardiographic studies showed decreased contractility in the HF-H group with compared to the HF control group. In Sirius Red staining, severer fibrosis was also observed in the linagliptin groups. HbA1c levels did not change among three groups, however, glycogen content in the liver was significantly decreased in the linagliptin groups. Similarly, indirect calorimetry showed decreased carbohydrate consumption in the HF-H group compared to the HF control group, suggesting worsening of heart failure was due to unavailability of carbohydrates as an energy source. Therefore, we fed a diet containing 33 wt% glucose to the HF-H group as complementary experiments. As a result, adequate glucose supplementation reduced cardiac fibrosis and cardiac function, while worsened life span, HbA1c levels and CHO consumption were not changed. Therefore, we hypothesized that there might be a change in the absorption of glucose in intestine or utilization ability of glucose in body another experiments were performed. 13C, which was released from mice after the oral administration of 13C glucose and measured by respiratory gas analysis, was significantly reduced in HF-H mice. The measurements the amount of 13C in feces revealed increased levels of unabsorbed glucose by linagliptin treatment in HF. In addition, GLUT2, a glucose transporter, in small intestine, was downregulated in the HF-H and the HF-HG groups. On the other hand, the cardiac uptake of Deoxy-D-glucose, 2-[1,2-3H(N)] (3H-2DG), which was injected from mice tail vein, was not different between in the HF-H group and in the HF control group. Taken together, linagliptin treatment may inhibit glucose transport in intestine in HF.

Conclusions

Linagliptin treatment exacerbated heart failure, resulting in shortened life span, worsened cardiac function, and fibrosis of the myocardium. DPP4 inhibitor may promote the cardiac cachexia and exacerbate heart failure at least, in part, through modification of glucose absorption and utilization.

Funding Acknowledgement

Type of funding sources: None.

The impact of right atrium and left atrium reverse remodeling for functional regurgitation of atrioventricular valve among patients who were underwent ablation for atrial fibrillation

Background

Atrial fibrillation (AF) is a risk factor of Regurgitation of Atrioventricular Valve and Regurgitation of Atrioventricular Valve is improved after ablation for AF. However, Mechanism of improvement of Tricuspid regurgitation (TR) and Mitral regurgitation (MR) after ablation for AF were unclear.

Methods

The one hundred fifty-seven cases consecutive patients who were underwent ablation for persistent AF were examined in this study. These patients were performed Holter ECG and Echocardiography 6 months after ablation for persistent AF. The area of the Right Atrium (RA), Left Atrium (LA), diameter of the tricuspid valve anulus and Mitral valve annulus, were measured by echocardiography at before and 6 months after ablation for AF. The reverse remodeling index (RRI) was defined as divided post area of RA and LA by pre area of RA and LA. The Improved group was defined as one or more than regurgitation grade improvements.

Results

TR improved in 56 cases (35.7%) of 157 cases and MR improved in 25 (16.6%) cases of 157 cases. The ratio of improved TR was significantly higher than ratio of improved MR (p&lt;0.01). The difference in tricuspid annulus diameter before and after ablation for AF was significantly longer in TR improved group than in TR non-improved group. (4.9±5.3 mm vs 1.6±5.4 mm, p&lt;0.01). The RRI of RA in TR improved group was significantly smaller than in TR non-improved group (0.73±0.19 vs 0.89±0.26 p&lt;0.01). The difference in mitral annulus diameter before and after ablation for AF was not significant differences between MR improved group and MR non-improved group. The RRI of LA in MR improved group was significantly smaller than in MR non-improved group (0.79±0.22 vs 0.90±0.25 p&lt;0.01). The RRI of RA was significantly smaller than RRI of LA among patients who were able to maintain sinus rhythm after ablation for persistent AF (0.79±0.23 vs 0.85±0.24 p=0.04).

Conclusion

Reverse remodeling of RA was higher than Reverse remodeling of LA among patients who were able to maintain sinus rhythm after ablation for persistent AF and Reverse remodeling of RA and LA were important factors of improvement of TR and MR after ablation for persistent AF. These results considered to be the cause why the improvement rate of TR was higher than the Improvement rate of MR after persistent AF.

Funding Acknowledgement

Type of funding sources: None.

AB0157 EFFICACY AND SAFETY OF FILGOTINIB IN ACTIVE RHEUMATOID ARTHRITIS PATIENTS WITH INADEQUATE RESPONSE TO METHOTREXATE: COMPARATIVE STUDY WITH FILGOTINIB AND TOCILIZUMAB EXAMINED BY CLINICAL INDEX AS WELL AS MUSCULOSKELETAL ULTRASOUND ASSESSMENT (TRANSFORM STUDY): STUDY PROTOCOL

Background

The administration of Janus kinase (JAK) inhibitors as well as biological disease-modifying anti-rheumatic drugs has dramatically improved even the clinical outcomes in rheumatoid arthritis (RA) patients with inadequate response to methotrexate (MTX). The dysregulation of JAK- signal transducer and activator of transcription (STAT) pathways via overproduction of cytokines, such as interleukin-6 (IL-6) is involved in the pathogenesis of RA (1). Filgotinib, a preferential JAK1 inhibitor, is effective in suppressing disease activity and preventing the progression of joint destruction due to inhibition of the JAK-STAT pathway. IL-6 inhibitors such as tocilizumab also inhibit the JAK-STAT pathways due to inhibition of IL-6 signaling. Thus, it should be desirable to investigate whether the effectiveness of filgotinib monotherapy is non-inferior to those of tocilizumab monotherapy in RA patients with inadequate response to MTX. In addition, it is important to accurately evaluate disease activity at the joint level by using musculoskeletal ultrasound (MSUS) and clinical disease activity indices, including subjective parameters (2).

Objectives

This study’s principal objective is to evaluate the effects of filgotinib monotherapy is non-inferior to those of tocilizumab monotherapy in RA patients with inadequate response to MTX. In addition, we will evaluate changes in patients’ parameters, including clinical disease activity indices, MSUS scores, serum biomarkers, patient-reported outcome (PRO), and modified total Sharp score (mTSS) after the administration of filgotinib or tocilizumab. Herein, we describe the study protocol for this study.

Methods

This study is an interventional, multicenter, randomized, open-label, parallel-group and non-inferiority clinical trial with a 52-week follow-up. In total, 400 RA patients with at least moderate disease activity during treatment with MTX will be included. Patients will be randomized in a 1:1 ratio to administration of filgotinib 200mg/day monotherapy or subcutaneous tocilizumab 162mg/biweekly monotherapy switched from MTX (Figure 1). We will evaluate disease activity by measuring clinical disease activity indices and by using MSUS. The primary endpoint is the proportion of patients who achieve an American College of Rheumatology 50 response at week 12. Important secondary endpoints are the changes from the baseline of the MSUS scores, PRO, and mTSS. We will also comprehensively analyze the serum levels of multiple biomarkers such as cytokines and chemokines.

Figure 1.

Results

Although the study results cannot be shown because the research entry is in progress, they are expected to show the non-inferiority of filgotinib monotherapy to tocilizumab monotherapy in RA patients with inadequate response to MTX.

Conclusion

The strength of this study is its prospective evaluation of therapeutic efficacy using not only clinical disease activity indices but also MSUS, which accurately and objectively evaluate disease activity at the joint level among patients drawn from multiple centers with a standardized evaluation by MSUS. In addition, we will evaluate the effectiveness of both drugs by integrating multilateral assessments, i.e., clinical disease activity indices, MSUS findings, and serum biomarkers.

References

[1]Gadina M, Le MT, Schwartz DM, Silvennoinen O, Nakayamada S, Yamaoka K, et al. Janus kinases to jakinibs: from basic insights to clinical practice. Rheumatology (Oxford). 2019;58(Suppl 1):i4-i16.

[2]Colebatch AN, Edwards CJ, Ostergaard M, van der Heijde D, Balint PV, D’Agostino MA, et al. EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis. Ann Rheum Dis. 2013;72(6):804-14.

Disclosure of Interests

Toshimasa Shimizu: None declared, Shin-ya Kawashiri: None declared, Shimpei Morimoto: None declared, Yurika Kawazoe: None declared, Shohei Kuroda: None declared, Rina Kawasaki: None declared, Yasuko Ito: None declared, Shuntaro Sato: None declared, Hiroshi Yamamoto: None declared, Atsushi Kawakami Grant/research support from: Gilead Sciences, Inc.

Structure of the bile acid transporter and HBV receptor NTCP

Chronic infection with hepatitis B virus (HBV) affects more than 290 million people worldwide, is a major cause of cirrhosis and hepatocellular carcinoma, and results in an estimated 820,000 deaths annually^1,2. For HBV infection to be established, a molecular interaction is required between the large glycoproteins of the virus envelope (known as LHBs) and the host entry receptor sodium taurocholate co-transporting polypeptide (NTCP), a sodium-dependent bile acid transporter from the blood to hepatocytes³. However, the molecular basis for the virus-transporter interaction is poorly understood. Here we report the cryo-electron microscopy structures of human, bovine and rat NTCPs in the apo state, which reveal the presence of a tunnel across the membrane and a possible transport route for the substrate. Moreover, the cryo-electron microscopy structure of human NTCP in the presence of the myristoylated preS1 domain of LHBs, together with mutation and transport assays, suggest a binding mode in which preS1 and the substrate compete for the extracellular opening of the tunnel in NTCP. Our preS1 domain interaction analysis enables a mechanistic interpretation of naturally occurring HBV-insusceptible mutations in human NTCP. Together, our findings provide a structural framework for HBV recognition and a mechanistic understanding of sodium-dependent bile acid translocation by mammalian NTCPs.

OP0090 PRECLINICAL STUDIES OF A NOVEL CATHEPSIN C INHIBITOR IN MPO-ANCA-ASSOCIATED VASCULITIS MODEL

Background

MPO-ANCA-associated vasculitis (MPO-AAV) is a systemic small vessel vasculitis with the production of MPO-ANCA in the serum. This disease develops necrotizing and crescent glomerulonephritis (NCGN) and peritubular capillaritis-mediated interstitial damages in the kidneys, and pulmonary hemorrhage due to capillaritis in the lungs. Recent studies have revealed that neutrophil extracellular traps (NETs) induced by MPO-ANCA are critically involved in its pathogenesis,1 and neutrophil elastase (NE) plays an essential role in the formation of NETs.2 Cathepsin C (CatC) functions as a key enzyme in the activation process of several neutrophil serine proteases (NSPs) such as NE, proteinase 3 and cathepthin G by converting the inactive forms of the NSPs to the active forms by digesting dipeptides at the N-terminus of the enzymes.3

Objectives

Although glucocorticoids and immunosuppressive drugs used as the standard of cares can lead remission in MPO-AAV patients, there are remaining unmet medical needs such as severe side effects, resistance to the treatment and relapse. Therefore, development of new therapeutic strategies is awaited. The aim of this study is to demonstrate the efficacy of MOD06051, a novel CatC inhibitor, against MPO-AAV, using an MPO-AAV rat model established previously.4

Methods

In vitro studies: Cathpsins and NE inhibitory activity was measured using recombinant enzymes and fluorescent substrates. Cellular NE activity in the granulocytes differentiated from the primary human bone marrow-derived hematopietic stem cells under the presence or absence of MOD06051 was determined using fluorescent substrates.

In vivo studies: 4-week-old Wistar Kyoto (WKY) rats were immunized with human MPO according to Little’s protocol.4 The rats were divided into three groups (n=8 in each group), and vehicle (0.5% methylcellulose) or MOD06051 (0.3 or 3 mg/kg bid) was orally administered every day for 42 days. All rats were euthanized at the end of the study for serological and histological evaluations.

Results

In vitro studies: MOD06051 inhibited the enzymatic activity of human recombinant CatC with an IC50 value of 1.5 nM, and no other cathepsins nor NE inhibition was observed at 10 μM. The NE activity in primary human granulocytes was suppressed by MOD06051 with an IC50 value of 18 nM.

In vivo studies: MPO-ANCA was induced in all groups at the same level. The percentage of affected glomeruli including those with NCGN, NET-forming neutrophils in the peripheral blood and glomeruli, and glomerular neutrophil counts were significantly suppressed by MOD06051 treatment in a dose-dependent manner. Furthermore, hematuria score, urinary NGAL (Neutrophil Gelatinase-Associated Lipocalin), tubular erythrocyte cast counts, and pulmonary hemorrhage foci were significantly decreased in the 3 mg/kg of MOD06051 treated group with the similar trends in 0.3 mg/kg group.

Conclusion

MOD06051 showed sepcific inhibition of CatC activity. This compound suppressed the serine proteases activation in primary human neutrophils and NET formation in the MPO-AAV model rats, resulting in amelioration of MPO-ANCA-induced tissue destruction, including NCGN and tubular interstitial damages in the kidneys, and disorder of alveolar septal capillaries in the lungs. MOD06051 appears to be a promising agent for treatment of MPO-AAV patients.

References

[1]Nakazawa D, et al. Nat Rev Rheumatol 15: 91-101, 2019.

[2]Papayannopoulos V, et al. J Cell Biol 191: 677-691, 2010.

[3]Korkmaz B, et al. Pharmacol Ther 190: 202-236, 2018.

[4]Little MA, et al. Am J Pathol 174: 1212-1220, 2009.

Disclosure of Interests

Akihiro Ishizu Grant/research support from: Modulus Discovery, Inc., Mai Taniguchi: None declared, Suishin Arai: None declared, Yuka Nishibata Grant/research support from: Modulus Discovery, Inc., Sakiko Masuda Grant/research support from: Modulus Discovery, Inc., Utano Tomaru: None declared, Takafumi Shimizu Shareholder of: Modulus Discovery, Inc., Employee of: Modulus Discovery, Inc., William Sinko Shareholder of: Modulus Discovery, Inc., Employee of: Modulus Discovery, Inc., Tadashi Nagakura Shareholder of: Modulus Discovery, Inc., Employee of: Modulus Discovery, Inc., Yoh Terada Shareholder of: Modulus Discovery, Inc., Employee of: Modulus Discovery, Inc.

Normal pressure hydrocephalus due to an iatrogenic giant lumbar pseudomeningocele after posterior lumbar interbody fusion: illustrative case

BACKGROUND

Iatrogenic pseudomeningocele incidence after lumbar surgery is 0.068%–2%, and most lumbar pseudomeningoceles are smaller than 5 cm; however, in rare cases, “giant” pseudomeningoceles greater than 8 cm in size may develop. Normal pressure hydrocephalus (NPH) is another rare condition in which the ventricles expand despite the presence of normal intracranial pressure. To date, pseudomeningocele associated with NPH has not been reported.

OBSERVATIONS

An 80-year-old woman underwent L3–5 laminectomy and posterior lumbar interbody fusion, and her symptoms improved after surgery. However, dementia appeared 1 month after surgery. Repeated brain computed tomography showed ventricular enlargement, and lumbar magnetic resonance imaging showed a long pseudomeningocele in the subcutaneous tissues at the L4 level. Here, the authors report a rare case of an iatrogenic giant pseudomeningocele accompanied by NPH after lumbar surgery. The symptoms of NPH in the present case occurred after spinal surgery and recovered after dural repair surgery, indicating that the changes in cerebrospinal fluid circulation and/or pressure due to pseudomeningoceles may cause NPH.

LESSONS

The prevention of dural tears through precise surgical technique and primary repair of dural tears are the best approaches to prevent pseudomeningocele incidence and subsequent events.

Assessment of anthracycline-induced cardiotoxicity in patients with childhood cancer survivor for long-term follow-up

Funding Acknowledgements

Type of funding sources: None.

Background

 Anthracycline cardiotoxicity is an important prognostic determinant in childhood cancer survivors (CCSs). That has been reported to improve with early therapeutic intervention, and because it is dose-dependent and progressive, early diagnosis and long-term follow-up are important. In adult survivors of cancer, the longitudinal strain (LS) is useful as a sensitive index of cardiac function. In childhood cancer survivors, strain abnormalities are also observed at both short-term and long-term follow-up. Global longitudinal strain (GLS) abnormalities are common during or early after chemotherapy, whereas changes in global circumferential strain (GCS) are more significant and consistent on long-term follow-up.

Purpose

 In this study, we aimed to conduct a cross-sectional study using strain analysis in childhood cancer survivors of a wide age range to clarify the mode of progression of anthracycline-induced cardiotoxicity and to identify useful indicators for long-term follow-up.

Methods

 In total, 116 patients (median age: 15.5 [range: 4.7-40.2] years) with childhood cancer who had passed at least 1 year after chemotherapy with anthracycline, and 116 control patients of similar age. Strain measurements were assessed for longitudinal strain (LS) and circumferential strain at the apical, papillary and basal levels using speckle tracking imaging. Estimated value at 5, 15, 25 and 35 years old were mathematically calculated.

Results

 Results were shown in tables and figures. Most of conventional echocardiographic parameters were not significantly different between CCCs and controls. LS, papillary CS and basal CS in CCCs decreased compared to normal controls at all age. The difference of estimated value between CCCs and normal controls in LS at all age were relatively constant. However, those in basal CS tended to increase with aging. Furthermore, basal CS in CCCs decreased with aging (r = 0.212, p &lt; 0.001) and the duration after completion of anthracycline treatment (r = -0.244, p &lt; 0.008).

Conclusions

 In childhood cancer survivors, strain analysis is a more sensitive indicators of cardiac function than conventional parameters. In addition, basal CS may decrease most markedly over time and could be useful indicator in long-term follow-up. Longitudinal studies should be conducted in the future to improve the accuracy of predicting anthracycline cardiotoxicity. These are new findings regarding the decline in cardiac function in childhood cancer survivors. Abstract Figure. Relationship between age and strains  Abstract Figure. Estimated values for each age group

The structure of NLRP9 reveals a unique C-terminal region with putative regulatory function

Nucleotide-binding and oligomerization domain-like receptors (NLRs) can form inflammasomes that activate caspase-1 and pro-interleukin-1β and induce pyroptosis. NLR family pyrin domain-containing 9 (NLRP9) forms an inflammasome and activates innate immune responses during virus infection, but little is known about this process. Here, we report the crystal and cryo-electron microscopy structures of NLRP9 in an ADP-bound state, revealing inactive and closed conformations of NLRP9 and its similarities to other structurally characterised NLRs. Moreover, we found a C-terminal region interacting with the concave surface of the leucine-rich repeat domain of NLRP9. This region is unique among NLRs and might be involved in the specific function of NLRP9. These data provide the structural basis for understanding the mechanism of NLRP9 regulation and activation.

Gymkhana and pylon slalom driving training effects on the cerebellum structure

To develop a suitable automobile design as per each driver's characteristics and state, it is important to understand the brain function in acquiring driving skills. Reportedly, the brain structures of professionals, such as athletes and musicians, and those who have received training in special skills, undergo changes with training. However, the development process of the brain in terms of acquiring driving skills has not yet been clarified. In this study, we evaluated the effects of driving training on the brain and observed an increase in the volume of the right cerebellum after short-term training (3 days). The right cerebellum is responsible for controlling the right hand and right foot, which are important for driving. Drivers train to control a vehicle smoothly at high speeds at gymkhana and pylon slalom courses, which are often used in motor sports. The brain structure was analyzed before and after training using magnetic resonance imaging. Voxel-based morphometry was used to assess possible structural changes. First, the lap times after training were clearly shortened and vehicle dynamics were more stable, indicating that the drivers' skill level clearly improved. Second, brain structural analysis revealed a volumetric increase in the right cerebellum. The cerebellum is involved in the process of learning sensory motor skills, such as smooth steering and pedal operations, driving course shape, and vehicle size perception. These results suggest a new inner model for driving operation and support the hypothesis that motor learning affects the cerebellum during vehicle driving training.

Empagliflozin improves prognosis and energetic properties through modulating mitochondrial function in failing murine hearts

Background/Introduction

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been reported to have beneficial effects on heart failure in large clinical trials; however, the underlying mechanism is still unclear.

Purpose

The purpose of this study is to elucidate the mechanism of cardioprotective effect of empagliflozin in heart failure.

Methods

Eight-week-old mice deficient in cardiac and skeletal muscle-specific manganese superoxide dismutase, a mouse model of dilated cardiomyopathy (MnSOD-cKO mice), were given food mixed with or without 10 mg/kg empagliflozin for seven weeks and evaluated. Mitochondrial function in the cardiac muscle were measured by a high-resolution respirometer, Oxygraph-2K. Respiratory gas analysis were performed by indirect calorimetry (ARCO 2000) to estimate the energy consumption and energetic substrates.

Results

The survival rate (P=0.015) and cardiac fibrosis (P=0.036) were significantly improved in the empagliflozin group. The capacity of oxidative phosphorylation in cardiac mitochondria was significantly improved by empagliflozin. Blood lactate levels were decreased in the empagliflozin group, indicating that energy such as ATP could be produced without resorting to anaerobic metabolism.

Respiratory gas analysis revealed significant improvement in energy expenditure along with increase in food intake. Respiratory quotient was not different between the two groups, showing the consumption of the carbohydrate to fat rate was not changed by empagliflozin in this study. Ketone levels in blood and HbA1c were neither significantly different between the two groups. Although a moderate amount glucose was excreted in urine in the empagliflozin group (128.3±20.4 mg/day, 0.51±0.08 kcal/day), the available energy substrates in the whole body nonetheless expanded because of the increased caloric intake (10.58±0.72 in control group vs. 13.55±0.08 kcal/day in empagliflozin group, P=0.018).

Conclusion(s)

We have shown that empagliflozin improved myocardial mitochondrial function and increased energy metabolism, which was accompanied by adequate energy intake and uptake, even in heart failure. Empagliflozin decreased myocardial fibrosis and improved prognosis in failing murine hearts through positive energetical properties including mitochondrial function. The finding that empagliflozin modulates cardiac metabolism in a positive way provides a novel mechanism for the cardioprotective effect of SGLT2 inhibitors in heart failure.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boehringer Ingelheim Empa improved prognosis in HFEmpa improved mitochondrial function

Ultrasound efficacy of targeted-synthetic disease-modifying anti-rheumatic drug treatment in rheumatoid arthritis: a multicenter prospective cohort study in Japan

OBJECTIVE

This study investigated the effectiveness of treatment with Janus kinase (JAK) inhibitors in rheumatoid arthritis (RA) assessed by ultrasonography (US) activity, and the influence of patient characteristics and previous treatments.

METHOD

This prospective study assessed 60 treatment initiations among 53 Japanese patients diagnosed with RA who underwent treatment with JAK inhibitors during June 2013 to February 2020. Of the 53 patients, seven patients were enrolled in duplicate because they were treated with two different JAK inhibitors at different periods. For each case, the improvement rate on the power Doppler (PD) score was assessed at 6 month follow-up. Median improvement rate of PD score was used to classify cases as either US responders or non-responders, and patient characteristics were compared between the two groups.

RESULTS

All indicators of clinical disease activity and US activity showed a significant improvement at 3 months compared with baseline. Although the JAK inhibitor-cycler group and the interleukin-6 (IL-6) inhibitor inadequate response (IR) group tended to show a later improvement for US activity, all indicators of clinical disease activity and US activity showed a significant improvement at 6 months compared with baseline for both groups. Multivariate analysis showed that concomitant methotrexate use and an IR to the previous biologic or targeted-synthetic disease-modifying anti-rheumatic drug (b/tsDMARD) treatment were independently and significantly associated with US responders.

CONCLUSION

Use of a JAK inhibitor in combination with methotrexate and an absence of IR to any previous b/tsDMARDs demonstrated superior effectiveness for patients with RA.

Start-up of a trickling photobioreactor for the treatment of domestic wastewater

A stand-alone trickling photobioreactor (TPBR) was seeded with activated sludge and microalgae to treat domestic wastewater. The TPBR was started-up at 12-h hydraulic retention time at room temperature with 12:12 h light:dark cycle. The light was provided by blue LED strips. The reactor has a total volume of 30 L and is divided into six segments. Each segment is 30 cm long and has a diameter of 15 cm. Each segment was packed with polyurethane foam sponge cubes (2.5 × 2.5 × 2.5 cm³ ) with 40% occupancy. The chemical oxygen demand (COD), total organic carbon (TOC), total nitrogen (TN), and phosphorus (P) of domestic wastewater varied in the range of 164-256 mg/L, 84.4-133.8 mg/L, 34.2-55.6 mg/L, and 24.7-39.3 mg/L, respectively, during this period. The COD, TOC, TN, and P concentrations in the effluent after 45 days of operation were 30.24 ± 3.36 mg/L, 7.69 ± 0.09 mg/L, 16.67 ± 0.39 mg/L, and 17.48 ± 0.5 mg/L, respectively. The chlorophyll-to-biofilm biomass ratio increased during the experimental period. The above results indicate that the algal-bacterial symbiotic relationship is beneficial for carbon and nutrient removal from domestic wastewater. PRACTITIONER POINTS: Trickling photobioreactor works on natural ventilation and has low power requirements and a small footprint. The porous sponge media helped in immobilizing and subsequent harvesting of biomass. The reactor conditions favored the growth of diatoms (brown algae) over green algae.

Improving particle quality in cryo-EM analysis using a PEGylation method

Cryo-electron microscopy (cryo-EM) is widely used for structural biology studies and has been developed extensively in recent years. However, its sample vitrification process is a major limitation because it causes severe particle aggregation and/or denaturation. This effect is thought to occur because particles tend to stick to the "deadly" air-water interface during vitrification. Here, we report a method for PEGylation of proteins that can efficiently protect particles against such problems during vitrification. This method alleviates the laborious process of fine-tuning the vitrification conditions, allowing for analysis of samples that would otherwise be discarded.

POS0718 CLINICAL CHARACTERISTICS ASSOCIATED WITH GLANDULAR INVOLVEMENT EVALUATED BY SALIVARY GLAND ULTRASONOGRAPHY IN SJÖGREN’S SYNDROME

Background:

Sjögren’s syndrome (SS) is a systemic autoimmune disease characterized by periductal lymphocytic infiltration of the salivary and lacrimal glands, which results in reduced secretory functions and oral and ocular dryness (1). In addition, patients often have extraglandular manifestations, such as interstitial pneumonia and interstitial nephritis, and the appearance of autoantibodies such as anti-Ro/SS-A and La/SS-B antibodies. Salivary gland ultrasonography (SGUS) is typically used to evaluate the findings of salivary glands; thus, we can evaluate the severity of salivary gland disorders due to SS using SGUS in real time (2).

Objectives:

To identify clinical indices, including disease activity, associated with glandular involvement evaluated using SGUS in patients with SS.

Methods:

We enrolled patients with SS (n=115) and non-SS sicca subjects (n=90) who visited Nagasaki University Hospital between 1995 and 2019. The patients’ SS classifications were based on the 2002 American–European Consensus Group (AECG) SS classification criteria (3). The non-SS sicca subjects exhibited sicca symptoms but did not fulfill the AECG SS classification criteria. SGUS and clinical indices such as age, sex, the focus score (FS), sicca symptoms, the Saxon test results, Schirmer’s test results, anti-SS-A/Ro antibody positivity, anti-SS-B/La antibody positivity, anti-centromere antibody (ACA) positivity, serum immunoglobulin G levels, and the clinical European League Against Rheumatism SS disease activity index were examined. The ultrasonography (US) score was calculated based on SGUS imaging (hypoechoic area, hyperechoic band, and irregular border) (4).

Results:

The US score was significantly higher in patients with SS than that in non-SS sicca subjects. In addition, we found significant correlations between the US score and FS in patients with SS. Multivariate analysis revealed the FS, Saxon test positivity, and ACA positivity as the variables independently associated with the US score in patients with SS. These results were the same in the primary SS patient group (n=96). Patients with ACA positivity had significantly higher US scores compared to those in patients with ACA negativity, whereas the FS was not significantly high. In addition, patients with ACA positivity had significantly greater positivity of hyperechoic bands than that in patients with ACA negativity.

Conclusion:

This study indicated that ACA positivity, which is not reflected in sialadenitis of SS, is associated with the US score in patients with SS. These results suggest that US findings of patients with ACA positivity might show specific changes in salivary glands, such as fibrosis, and not only sialadenitis (5).

References:

[1]Ramos-Casals M, Tzioufas AG, Font J. Primary Sjogren’s syndrome: new clinical and therapeutic concepts. Ann Rheum Dis. 2005;64(3):347-54.

[2]van Ginkel MS, Glaudemans A, van der Vegt B, Mossel E, Kroese FGM, Bootsma H, et al. Imaging in Primary Sjogren’s Syndrome. J Clin Med. 2020;9(8).

[3]Vitali C, Bombardieri S, Jonsson R, Moutsopoulos HM, Alexander EL, Carsons SE, et al. Classification criteria for Sjogren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis. 2002;61(6):554-8.

[4]Takagi Y, Nakamura H, Sumi M, Shimizu T, Hirai Y, Horai Y, et al. Combined classification system based on ACR/EULAR and ultrasonographic scores for improving the diagnosis of Sjogren’s syndrome. PLoS One. 2018;13(4):e0195113.

[5]Nakamura H, Kawakami A, Hayashi T, Iwamoto N, Okada A, Tamai M, et al. Anti-centromere antibody-seropositive Sjögren’s syndrome differs from conventional subgroup in clinical and pathological study. BMC Musculoskelet Disord. 2010;11:140.

Disclosure of Interests:

None declared