Outcome of an elective readmission policy in patients receiving acute myeloid leukaemia consolidation therapy and implications for an outpatient management programme

Safe outpatient management of acute leukaemia consolidation cycles may enable substantial savings in admission costs. Safety involves the prompt administration of antibiotics in patients with neutropenic fever. Our unit in a metropolitan tertiary referral hospital analysed a cohort of patients spanning a 10-year period, with two key observations: (i) a high proportion of patients living a substantial distance from hospital and (ii) the high incidence and generally prompt onset of fever after severe neutropenia, suggesting this broad applicability of this approach is unfeasible without addressing travel issues and potentially reducing and/or delaying neutropenic fever with prophylactic antibiotics.

POS0123 MAJOR SALIVARY GLAND ULTRASONOGRAPHY AND MRI WITH DIFFUSION WEIGHTED IMAGING (DWI) AS COMPLEMENTARY TOOLS TO IDENTIFY FEATURES OF MALT IN PRIMARY SJÖGREN’S SYNDROME (pSS): A SINGLE CENTER CROSS SECTIONAL STUDY

Background

Salivary MALT lymphoma represents the major complication of primary Sjögren’s Syndrome (pSS). However, the early recognition of MALT lymphoma may be challenging due to its indolent, slow clinical course.

Objectives

1. to identify salivary gland ultrasonographic (SGUS) features and magnetic resonance (MRI) abnormal findings with Diffusion Weighted Imaging (DWI) and Apparent Diffusion Coefficient (ADC) of MALT in pSS patients 2. To evaluate the correlation between salivary gland ultrasonography (SGUS) and MRI in pSS patients with suspected lymphoma.

Methods

consecutive patients with pSS (2016 ACR/EULAR criteria) and suspected MALT lymphoma undergoing histological examination were included in this cross sectional study from September 2017 to November 2021. The US echostructure of each gland on B-mode images was graded using the latest 2019 OMERACT semiquantitative SGUS scoring systems (0-3). Sonographic features of focal lesions were described. Conventional MRI techniques (i.e T1WI, T2WI, and STIR images) combined with MR sialography was performed in all the cases. DWI was acquired at b-value 0, 500 and 1000. ADC values were calculated. Patients’ clinical and histological data were collected. Data were presented as mean±SD, or percent frequency as appropriate. Intergroup comparisons were made using the t-test/Mann–Whitney test for continuous variables and Fisher’s exact test for categorical variables.

Results

45 pSS (mean age, S.D=55±15 yrs) were included. MALT lymphoma was histologically confirmed in 14/45 pSS patients and, specifically in 18/180 major salivary glands (17 parotids and 1 submandibular glands). At SGUS examination, MALT salivary glands presented an OMERACT grade 3 in 16/18 and a grade 2 in 2/18, significantly higher than the OMERACT scoring observed in no-MALT pSS glands (p=0.0001). The sonographic features more commonly detected in MALT were: hypoecoich macroareas with posterior enhancement, presence of septa or hyperechogenic strands and anarchic intralesional vascularization. At MRI, 15/18 (83.3%) MALT lymphoma appeared as intraglandular solid lesions: 9/15 (60%) were solid-cystic lesions and 6/15 (40%) were solid lesions without cystic changes. The frequency of solid lesions in pSS patients without lymphoma was 3/124 (2.4%), significanlty lower than in MALT-pSS. Furthermore 15/18 (83.3%) MALT lymphoma showed glandular fatty substitution. The presence of fatty substitution did not differ in MALT lymphoma and in no-MALT pSS glands. The mean (SD) ADC value of MALT lesions was significantly lower than the ADC of the parotid glands in pSS without lymphoma (0.63±0.07 x 10^-3 mm2/s vs 1.13± 0.19 x 10^-3 mm2/s, p =0.001). A negative correlation between SGUS OMERACT score and mean glandular ADC values (r = – 0.776, p < 0.001) was found; patients with OMERACT score 3 presented the lowest mean salivary gland ADC when compared to the other OMERACT scores (0-2) (p=0.001).

Conclusion

OMERACT semiquantitative SGUS scoring systems and MRI with DWI represent promising complementary tools in the differential diagnosis of pSS MALT lymphoma, particularly useful to guide parotid biopsy. Patients with an OMERACT score 3 in their SGUS deserve a careful screening for lymphoma.

Disclosure of Interests

None declared

POS0771 ULTRA HIGH-FREQUENCY ULTRASOUND (UHFUS) OF MINOR LABIAL SALIVARY GLANDS (MLSGS): DIAGNOSTIC ACCURACY IN ANTI-Ro/SSA POSITIVE AND ANTI-Ro/SSA NEGATIVE PATIENTS WITH PRIMARY SJÖGREN’S SYNDROME (pSS)

Background

Last-generation Ultra High-frequency ultrasound (UHFUS) transducers are highly sensitive tools for the study of tiny superficial structures such as minor labial salivary glands (MLSGs). Compared to conventional ultrasound, UHFUS operates with higher frequencies allowing for outstanding image resolution, up to 30 µm.

Objectives

To determine the diagnostic accuracy of MLSG UHFUS in primary Sjogren’s syndrome (pSS) and to assess its contribution in anti-Ro/SSA positive and anti-Ro/SSA negative patients

Methods

Consecutive patients undergoing a MLSG biopsy for clinically suspected pSS were included in this cross-sectional study from January 2018 to October 2021. MLSG UHFUS was performed by using a 70 MHz probe, evaluating parenchymal inhomogeneity (score 0-3, similar to major salivary glands four-grade OMERACT scoring system). Patients’ clinical, biological, and histological features were collected. Anti-Ro/SSA antibody specificity was determined by immunoblotting. Receiver operating characteristic (ROC) curves, optimal cut-off point, AUC (area under curve), sensitivity (SE), specificity (SP), positive (PPV) and negative predictive values (NPV) were identified.

Results

A total of 194 patients were enrolled. Out of them, 88 patients fulfilled the ACR/EULAR 2016 criteria for pSS and 74 were anti-Ro/SSA+ (69 pSS and 5 no-SS). The distribution of UHFUS grades was significantly different in patients with pSS than in no-SS subjects: grade 0: 0/88 (0) vs 17/106 (16%); grade 1: 28/88 (31.8%) vs 55/106 (51.9%); grade 2: 46/88 (52.3%) vs 31/106 (29.2%); grade 3: 14 (15.9%) vs 3(2.8%); p<0.0001. ROC curve analysis indicated that at the optimal cut-off value of 2, UHFUS identified pSS and no-SS patients with a SE=68.2%, a SP=67.9%, a PPV= 63.8%, and a NPV= 72% (AUC=0.722, 95%CI: 0.651-0.793) and can predict a FS≥1 at the MLSG biopsy with a SE =73%, a SP=63.4%, a PPV= 48.9% and a NPV = 83% (AUC= 0.732, 95% CI: 0.657-0.806). Subgroup analyses highlighted significant differences in UHFUS diagnostic accuracy between anti-Ro/SSA+ and anti-Ro/SSA- patients. Particularly, in the latter group UHFUS showed a higher diagnostic accuracy (AUC= 0.754, 95% CI: 0.641-0.867) with a NPV increased up to 93.3%; similarly, UHFUS showed a higher accuracy (AUC= 0.755, 95% CI: 0.650-0.860) in predicting a MLSG FS≥1 with a NPV raised up to 90.7%.

Conclusion

MLSG UHFUS score system presents a good SE and SP in distinguishing pSS from no-SS subjects. The diagnostic accuracy of MLSG UHFUS may be significantly enhanced when combined with anti-Ro/SSA antibodies status. If anti-SSA antibodies are negative and UHFUS grade is 0 or 1, the diagnosis of pSS is very improbable and MLSG biopsy could be avoided. Further studies are in progress to define the added value of UHFUS with respect to major salivary gland ultrasonography.

Table 1.

UHFUS diagnostic accuracy in pSS (A) and for predicting a MLSG FS≥1 in all the cases and in anti-Ro/SSA negative patients. OCP, optimal cut-off value.

SESPPPVNPVAUC (95%CI)OCPpSS diagnosis (all pts)60/88 (68.2%)72/106 (67.9%)60/94 (63.8%)72/100 (72%)0.722 (0.651-0.793)2FS≥1 prediction (all pts)46/63 (73%)83/131 (63.4%)46/94 (48.9%)83/100 (83%)0.732 (0.657-0.806)2pSS diagnosis (SSA- pts)14/19 (73.7%)70/101 (63.9%)14/45 (31.1%)70/75 (93.3%)0.754 (0.641-0.867)2FS≥1 prediction (SSA- pts)17/24 (70.8%)68/96 (70.8%)17/45 (37.9%)68/75 (90.7%)0.755 (0.650-0.860)2Figure 1.

ROC curves showing UHFUS diagnostic accuracy in pSS (A) and for predicting a MLSG FS≥1

Disclosure of Interests

None declared

POS0767 GLANDULAR INVOLVEMENT IN PRIMARY SJÖGREN SYNDROME PATIENTS WITH INTERSTITIAL LUNG DISEASE (ILD) ONSET: A SINGLE CENTER CROSS-SECTIONAL STUDY

Background

Primary Sjögren Syndrome (pSS) is an autoimmune exocrinopathy classically presenting with sicca symptoms. Nonetheless, disease onset with extraglandular manifestations, particularly interstitial lung disease (ILD), is increasingly reported and probably underestimated. However, studies investigating pSS patients presenting with ILD (pSS-ILD) are limited.

Objectives

Aim of this study was to better characterize the phenotype of pSS patients presenting with ILD in comparison to pSS patients with classical sicca-onset. We especially investigated whether the two groups differed in glandular involvement comparing functional, imaging and histologic findings, as well as patient reported outcome (PRO).

Methods

Consecutive newly diagnosed pSS patients, all fulfilling the ACR/EULAR 2016 criteria, were included in this cross-sectional study from September 2016 to October 2021. Clinical, serological and histological initial features where compared in pSS-ILD patients and in pSS patients without ILD involvement, diagnosed during the same time period. Presence of ILD at pSS diagnosis was defined based on clinical findings, imaging assessment and pulmonary function tests. In addition to functional tests, a minor salivary gland biopsy was performed in all cases, recording number of foci and GC-like structures and focus score (FS). Salivary glands ultrasonography (SGUS) was graded using the OMERACT semiquantitative scoring system (0-3) based on parenchyma inhomogeneity. PRO including ESSPRI, OHIP and OSSDI were collected. Extraglandular clinical features and biological abnormalities included in the ESSDAI were recorded. Data were presented as mean±SD, or percent frequency as appropriate. Intergroup comparisons were made using the t-test/Mann–Whitney test for continuous variables and Fisher’s exact test for categorical variables.

Results

We included 178 newly diagnosed pSS patients (F:M=158:20). ILD was the first pSS manifestation in 11 (6%) cases, 8 F and 3 M, with a median time from ILD onset to pSS diagnosis of 2 ± 2 years. At HRCT, the following patterns were observed: NSIP (4/11), UIP (4/11), NSIP+OP (2/11) and LIP (1/11). Dyspnea on exertion or chronic cough were reported by 7/11 (63.6%) patients.

In comparison to sicca-onset patients, pSS-ILD patients presented an older age at diagnosis (55±13 vs 70±7, p= 0.001) and a higher ESSDAI (3.9±4.7 vs 12.3±4.3, p=0.001) driven by the pulmonary domain. Regarding glandular involvement, pSS-ILD patients reported milder xeropthalmia (VAS 5.8±3.1 vs 2.8±3.5, p=0.002), and significative lower scores in OSDI (35.6±24.9 vs 15.3±22.9, p=0.04) and OHIP (4.8±4.4 vs 1.4±3.8, p=0.04), despite no significant differences observed between the two groups in ocular tests and unstimulated salivary flow rate. With respect to histology, no significant differences were found in number of foci and GC-like structures, and FS. Notably, there was a trend towards a different distribution of the SGUS OMERACT score in the two groups. Particularly, none of pSS-ILD patients presented OMERACT score 3 in parotid and submandibular glands, in contrast to 26/167 (15.5%) and 18/167 (10.8%) of classic sicca-onset pSS patients respectively. Finally, no significant differences were observed between the two groups with respect to non-pulmonary extraglandular manifestations, serologic features and other biological parameters.

Conclusion

ILD-onset pSS patients represent an atypical phenotypic subset, with less pronounced sialadenitis sonographic changes in salivary glands, and with sicca symptoms probably overshadowed by the respiratory disease.

Disclosure of Interests

None declared

OP0146 ISOLATED ANTI-Ro52 ANTIBODIES IN SJÖGREN’S SYNDROME: A MILDER INFLAMMATORY PHENOTYPE AT HIGHER RISK FOR FIBROTIC ORGAN INVOLVEMENT

Background

Autoimmune response against the Ro antigen (Ro52 and/or Ro60 subunits) represents a distinctive serological hallmark in primary Sjögren Syndrome (pSS). The double positivity for anti-Ro60 and anti-Ro52 has been associated with a higher glandular inflammation and B-cell hyperactivity. By contrast, the clinical significance of isolated anti-Ro52 antibodies in pSS remains controversial.

Objectives

To investigate the association between isolated anti-Ro52 antibodies and glandular and extra-glandular pSS features in order to explore whether anti-Ro52 antibodies may help to identify a specific subset of pSS.

Methods

In this retrospective study we included unselected pSS patients prospectively followed at our Unit between 2012 to 2021. Of them, anti-Ro/SSA positive patients were identified and stratified by the presence of anti-Ro52 isolated, anti-Ro60 isolated and both anti-Ro60 and anti-Ro52. Demographics, clinical, biological and histological data were compared between the three groups. Data were presented as mean±SD, or percent frequency as appropriate. Intergroup comparisons were made using the t-test/Mann–Whitney test for continuous variables and Fisher’s exact test for categorical variables.

Results

Out of a study cohort of 432 pSS patients, we included 300 anti-Ro/SSA positive patients (21 M: 279 F, mean age 57±14 yrs) followed for a mean follow-up of 6.5±6.7 years. Of them, 59/300 (19.7%) presented isolated Ro52 antibodies, 214/300 (71.3 %) both anti-Ro60 and anti-Ro52 and 27/300 (9%) had isolated Ro60 antibodies. At diagnosis, patients with anti-Ro52 alone were older than those with double positivity (57.4±13.2 vs 48.8±13.8, p=0.0001) and presented a lower focus score (FS) in their minor salivary gland biopsies (MSGBs) (p=0.9±1.0 vs 1.6±0.9, p=0.02). No differences in demographic and glandular infiltrate were detected between anti-Ro52 alone and anti-Ro60 alone patients. Similarly, the three subgroups did not differ in oral and ocular function tests as well as in the patient reported outcomes (ESSPRI, OHIP and OSDI). Salivary gland ultrasonography showed a decreasing trend of the OMERACT scoring system with the highest grade detected more commonly in anti-Ro60 and anti-Ro52 patients and the lowest grade in anti-Ro60 alone. Regarding extraglandular manifestations significant differences were observed among the three subgroups as shown in the heat map (Figure 1). Patients with anti-Ro52 alone presented the highest frequency of interstitial lung disease (ILD) and primary biliary cirrhosis (PBC) and the lowest prevalence of lymphadenopathy, anti-La/SSB and hyper-IgG (p<0.05). By contrast, patients presenting anti-Ro52 in association with anti-Ro60 had a prominent B cell hyperactivity with higher levels of serum IgG, anti-La SSB antibodies and Rheumatoid factor positivity (p<0.05). Finally, patients with isolated anti-Ro60 presented a milder disease activity and an ESSDAI (3.4±4.5 vs 6.3±4.8 vs 5.2±5.1, p=0.009) significantly lower than the other two subgroups.

Conclusion

Patients with isolated anti-Ro52 seems to represent a specific subset of pSS with milder tissue focal inflammation but at higher risk for systemic fibrotic changes, particularly in the lungs. The identification of molecular pathogenetic processes, common to both isolated anti-Ro52 pSS and other anti-Ro52 positive connective tissue diseases may offer new insights into our understanding of disease etiology, and facilitate the development of targeted therapeutic approaches.

Disclosure of Interests

None declared

POS0782 FOLLICULAR DENDRITIC CELL NETWORKS IN MINOR SALIVARY GLAND BIOPSIES: A MARKER OF DISEASE ACTIVITY AT BASELINE AND DURING THE FOLLOW-UP IN SJÖGREN’S SYNDROME

Background:

Minor salivary gland biopsy (MSGB) has been increasingly recognized as an important tool for the stratification of patients with primary Sjögren’s syndrome (pSS). Recently, the presence of follicular dendritic cell (FDC) networks in the inflammatory infiltrate has been associated with more severe biological and serological abnormalities compared with less organized infiltrates.

Objectives:

To investigate the associations between the presence and number of FDC networks in foci and pSS glandular and extra-glandular disease activity at baseline and during the follow-up.

Methods:

Consecutive MSGBs performed in daily practice for clinically suspected pSS from January 2017 to October 2020 were reviewed. Patients’ demographic, clinical, biological and serological data were obtained from medical records. The ESSDAI was used to measure disease activity at baseline and at the end of the follow-up in pSS patients. For histopathology, 3 µm sections were cut from each formalin-fixed paraffin-embedded block of MSGBs and stained with haematoxylin and eosin (H&E). Immunohistochemical stainings were performed on additional 3 μm sections in order to detect T lymphocytes (CD3), B lymphocytes (CD20) and follicular dendritic cells (CD21). Glandular tissue areas, number of foci, focus score (FS) and the presence and number of FDC networks were assessed.

Results:

We reviewed 330 consecutive MSGBs from patients with suspected pSS: out of them 146/330 (44%) were classified as nonspecific chronic sialadenitis (NSCS) whereas 184/330 (56%) as focal lymphocytic sialadenitis (FLS). According to the ACR/EULAR criteria the diagnosis of pSS was confirmed in 130 patients (117 F:13 M, age 56±13 yrs). The mean (S.D) surface area of the MSGBs was 7.8 (3.9) mm2. The number of foci in the FLS samples ranged from 1 to 12 (mean (S.D)=3.1 (2.6)), whereas the FS ranged from 0.3 to 9.0 (mean (S.D) = 1.4 (1.2)).The presence of FDC networks was documented in 106/330 (32%) of the samples; in 54/106 (51%) of these MSGBs the number of FDC networks ranged from 2 to 8 (mean (S.D)=3.1 (1.4)). The number of FDC networks significantly correlated with the number of foci (r=0.721**) and FS (r=0.707**). Patients with FDC networks in the inflammatory infiltrate presented more serological abnormalities (i.e anti-Ro/SSA, anti-LA/SSB, Rheumatoid factor) and elevated IgG levels (p<0.001). In pSS patients, the number of FDC networks slightly correlated also with C4 levels (r=-0.216*), peripheral lymphocyte count (r=-0.274**) and with glandular (r=0.213*), and biological (r=0.230**) domains of the ESSDAI at baseline. After a mean (S.D) follow-up of 21(13) months, the number of FDC networks still correlated with the final total ESSDAI (r=0.312**).

Conclusion:

The presence and number of FDC networks in foci represent a useful histopathological parameter able to reflect disease activity at baseline and during the follow-up, thus allowing more personalized interventions.

Disclosure of Interests:

None declared

POS0778 ULTRA HIGH-RESOLUTION ULTRASOUND (UHFUS) OF LABIAL GLANDS IS A STRONG PREDICTOR OF SALIVARY GLAND HISTOPATHOLOGY IN SJÖGREN’S SYNDROME (PSS)

Background:

Last-generation ultra high-resolution ultrasound (UHFUS) transducers, producing frequencies up to 70 MHz and achieving tissue resolution up to 30 μm, are opening up new possibilities for the study of labial salivary glands (LSG) in patients clinically suspected with primary Sjögren’s syndrome (pSS).

Objectives:

To explore the value of LSG-UHFUS as a predictor of the intensity of the histological inflammation in LSG biopsy in an inception cohort of patients with sicca symptoms derived from daily clinical practice.

Methods:

Consecutive patients undergoing a LSG for clinically suspected pSS were included in this study from January 2018 to October 2020. UHFUS of LSG was performed by using VEVO MD, equipped with a 70 MHz probe, scanning first the central compartment of the inferior lip, and then both peripheral compartments. Parenchymal homogeneity was graded on a scale of 0 (normal) to 3 (evident). UHFUS imaging was used to locate the LSG for the US-guided biopsy. For each of the LSG specimens the area of the glandular tissue, the presence and number of foci and the focus score (FS) were assessed. Immunostaining for CD21 was performed to evaluate the presence of follicular dendritic cells (FDC) in foci.

Results:

We included a total of 171 patients with suspected pSS: out of them, 83 (48.5%) received a diagnosis of pSS (ACR 2016 criteria) and 88 (51.5 %) were diagnosed as no-SS sicca controls. Out of the 171 LSG biopsies, 73/171 (42.7%) were characterized by a nonspecific chronic sialadenitis (NSCS) whereas a focal lymphocytic sialadenitis (FLS) was described in the remaining 98/171 (57.3%). UHFUS-LSG scores were differently distributed in pSS patients with respect to no-SS sicca controls: a score 0 was detected in 16/88 no-SS sicca controls and in none of the 83 pSS patients, whereas a score 3 was detected in 12/83 pSS and in none of no-SS sicca controls. (p<0.001). The higher was the UHFUS grading, the higher was the number of foci (from a mean (S.D) = 0.38 (0.72) in UHFUS-score 0 to 4.58 (3.11) in UHFUS-score 3, p<0.001) and the focus score (from 0.17 (0.32) in UHFUS-score 0 to 1.88 (0.90) in UHFUS-score 3, p<0.001) of the samples. Overall, out of the 16 no-SS controls with LSG-UHFUS score 0, only 4/16 showed histological features of focal lymphocytic infiltrate; however, the mean FS of those 4/16 samples was 0.17 (0.32). In fact, considering a FS≥1, negative UHFUS-LSG was highly predictive of a negative histology (100 %). By contrast, out of the 12 pSS patients with the highest score at LSG-UHFUS (score 3), 10/12 presented FDC networks in their biopsies, with a positive predictive value of 83% of the severity of the infiltrate.

Conclusion:

UHFUS of LSG appeared feasible and sensitive in pSS; due to its striking negative predictive value this novel tool can help to identify negative patients on subsequent lip biopsy, thus avoiding invasive procedures in selected cases. Besides its diagnostic role, considering the association with the presence of FDC networks, UHFUS-LGS may also have a role in patients prognostic stratification.

Disclosure of Interests:

None declared

FRI0150 USEFULNESS OF SALIVARY GLAND ULTRASONOGRAPHY IN THE ASSESSMENT OF SALIVARY GLAND ACTIVITY AND DAMAGE IN PRIMARY SJÖGREN’S SYNDROME: A SINGLE CENTER EXPERIENCE

Background:

Salivary gland ultrasonography (SGUS) has an emerging role in the diagnosis of primary Sjögren’s syndrome (pSS); however, it is still an open issue whether distinct sonographic abnormalities may indicate reversible glandular activity or irreversible disease-induced damage.

Objectives:

to assess the association between SGUS abnormalities, salivary gland disease activity and loss of function in pSS patients over a long-term follow-up.

Methods:

Patients with pSS fulfilling the AECG 2002 criteria were included in this observational study. Both parotid and submandibular glands were examined at the time of the study inclusion and during the follow-up. SGUS findings (i.e gland size, echogenicity, homogeneity, hyperechoic bands, number and location of the hypoechoic/anechoic areas, number of lymph nodes, calcification, posterior border visibility) were defined according to previous studies and monitored over the time. Patients demographics, clinical, histological and laboratory data were routinely collected. ESSDAI and ESSPRI were used to asses disease activity and PROs.

Results:

We included 419 (402 F:17 M) pSS patients: 206/419 at the diagnosis and 213/419 with a median disease duration of 7 (IQR 4-11) years. SGUS examination was repeated in 81/206 and in 108/213 patients, after a median follow-up of 30 (IQR 12-42) months, respectively. Noteworthy, 18/419 pSS patients were treated with rituximab (RTX) during the study period. The overall SGUS score correlated directly with the minor salivary focus score (r=0.366, p=0.000) and with the ESSDAI (r=0.482, p=0.000); the parotid inhomogeneity score correlated directly with the glandular domain of the ESSDAI (r=0.530, p=0.000). The unstimulated salivary flow rate (USFR) correlated inversely with the overall SGUS score (r=-257, p=0.000) and with the presence of hyperechoic bands in both the parotid (r=-210, p=0.03) and the submandibular glands (r=-316, p=0.000). When compared to patients with an established pSS, newly diagnosed patients presented less frequently a gross inhomogeneity in their parotid glands (30/206, 14.6% vs 53/213, 24.9%, p=0.01) and less hyperechoic bands in both their parotid (33/206, 16% vs 61/213, 29%, p=0.001) and submandibular glands (53/206, 26% vs 110/213, 52%, p=0.001). However, over a median 30 month-follow-up we did not observe any significant change neither in the number of hypo-anechoic areas nor in the inhomogeneity score in both newly diagnosed patients and in those with an established disease. Out of the 18 pSS patients treated with RTX, 14 (78%) presented at the baseline a moderate to gross inhomogeneity in their glands: no changes in the number of hypo-anechoic areas were observed also in these patients with the exception of a variation in the number of intra-parotid lymph nodes.

Conclusion:

SGUS abnormalities appeared to be associated to both salivary gland disease activity and damage. Namely, the presence of hyperechoic bands significantly correlated with salivary loss function. Diffuse-scattered hypoechoic areas did not change over a median 30-month followed-up indicating that additional studies are required to better elucidate the correlation between SGUS abnormalities and the corresponding histopathologic lesions.

Disclosure of Interests:

Francesco Ferro: None declared, Gianmaria Governato: None declared, Valentina Donati: None declared, Giovanni Fulvio: None declared, Silvia Fonzetti: None declared, Elena Elefante: None declared, Nicoletta Luciano Speakers bureau: Paid as speaker for Eli Lilly, Sanofi, Marta Mosca: None declared, Antonella Cecchettini: None declared, Chiara Baldini: None declared

FRI0153 ULTRA HIGH-RESOLUTION ULTRASOUND (UHFUS) OF LABIAL SALIVARY GLANDS: POTENTIAL APPLICATIONS IN PRIMARY SJÖGREN’S SYNDROME

Background:

Major salivary gland ultrasonography has an established role in diagnosis and assessment of pSS. Nowadays, however, interest is also growing in last-generation ultra high resolution ultrasound (UHFUS) transducers, which can produce frequencies up to 70 MHz and achieve tissue resolution up to 30 μm, opening up new possibilities for the study labial salivary glands (LSG).

Objectives:

To investigate the usefulness of UHFUS in LSG ultrasound-guided biopsy and preoperative planning.

Methods:

Consecutive patients undergoing a LSG for clinically suspected pSS were included in this study from January 2018 to December 2019. UHFUS of LSG was performed by using VEVO MD, equipped with a 70 MHz probe, scanning first the central compartment of the inferior lip, and then both peripheral compartments. The following parameters were evaluated: distribution of the glands, parenchymal inhomogeneity (score 0-3, from normal to evident), and fibrosis. UHFUS imaging was used to help locate the LSG for the US-guided biopsy. The same expert pathologist calculated the surface area of gland sections examined, the LSG focus score (FS), the number of foci and evaluated the presence of ectopic germinal centers (GCs). Consecutive patients that had undergone a traditional LSG biopsy from December 2016 to December 2017 were included as controls.

Results:

We included a total of 249 patients with suspected pSS: 137 undergoing the UHFUS-guided LSGs and 112 the traditional LSG biopsy procedure. No demographic differences were observed between the two groups. No differences were also observed in the distribution of the final diagnosis. A diagnosis of pSS according the ACR 2016 criteria was made in 60/137 (43.8%) and 36/112 (32.1%) patients, respectively whereas a diagnosis of no-SS sicca was made in 44/137 (32.1%) and in 43/112 (38.4%) patients; the remaining diagnosis included secondary SS (4/137, 3% and 9/112, 8%) and undifferentiated connective tissue disease (UCTD) (29/137, 21.2%, and 24/112, 21.4%). With respect to no-SS sicca controls and UCTD patients, pSS patients presented higher UHFUS inhomogeneity scores in both central and peripheral labial compartments (p=0.001). There were no complications from the HUFUS-guided LSG biopsy. The mean glandular surface area obtained was significantly higher than the area obtained by traditional LSG biopsy procedure (7.4 ±4.0 mm2vs 6.3±3.7 mm2, p=0.02) thus facilitating the assessment of the FS. Interestingly, the latter showed a good correlation with the UHFUS inhomogeneity (r=0.509**, p=0.000).

Conclusion:

UHFUS of LSG appeared feasible and sensitive in pSS, potentially offering unique advantages in LSG ultrasound-guided biopsy.

Disclosure of Interests:

None declared

OP0096 THE DIFFERENCES BETWEEN SJÖGREN’S SYNDROME PATIENTS WITH COMBINED SERONEGATIVITY AND ANTI-RO/SSA SEROPOSITIVITY

Background:

Sjögren’s syndrome (SS) is characterized by B cell hyperactivity reflected by hypergammaglobulinemia as well as a plethora of autoantibodies including antinuclear antibodies (ANA), anti-Ro/SSA, anti-La/SSB and rheumatoid factors (RF). Previous studies have focused on the phenotype of single positive (ANA or anti-Ro/SSA or anti-La/SSB) or double positive (anti-Ro/SSA and anti-La/SSB positive) SS patients, showing differences regarding the age of diagnosis, sicca manifestations and specific extraglandular manifestations. To our knowledge, no study has ever explored the clinical spectrum of triple seronegative (anti-Ro/SSA + anti-La/SSB + RF negative) and quadruple seronegative (ANA +anti-Ro/SSA + anti-La/SSB + RF negative) SS patients.

Objectives:

To study the differences in the clinical phenotype of triple and quadruple seronegative (SS) patients in a large cohort of well characterized patients, after comparison with anti-Ro/SSA positive patients.

Methods:

From a total cohort of 1723 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 4 clinical centers ([Universities of Pisa and Athens, Harokopio and Ioannina, (PAHI)], those who have been found triple or quadruple seronegative were identified and compared with matched anti-Ro/SSA positive SS patients according to age of SS onset, disease duration and gender, in 1:1 and 1:2 ratio respectively. Glandular (dry mouth, dry eyes, parotid gland enlargement) and extra-glandular manifestations (Raynaud’s phenomenon, chronic fatigue arthralgias/myalgias, arthritis, palpable purpura, liver involvement, kidney involvement, lung involvement, neurologic involvement, long standing lymphadenopathy and lymphoma) were compared between the 2 seronegative groups and the anti-Ro/SSA positive control group. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Two hundred and four SS patients (11,8%) were identified as triple negatives and 53 (3,0%) as quadruple, with a median disease duration of 6 years (range: 0-41) and 5 years (range: 0-32) respectively. The matched anti-Ro/SSA controls were 204 for the triple and 103 for the quadruple negatives. Triple negatives had lower frequency of monoclonal gammopathy (5,5% vs 12,1% p=0,04), low C4 serum levels (23% vs 36%, p=0,009) and lymphoma (3,4% vs 9,8%, OR= 3,06, 95% CI =1,27-7,85) while quadruple negatives exhibited higher prevalence of dry eyes (100% vs 90%) and lower prevalence of long standing lymphadenopathy (2,7% vs 19,5%, p=0,001) and lymphoma (0% vs 15%, p=0,001) compared to anti-Ro/SSA matched controls.

Conclusion:

Combined seronegativity account for more than 10% of SS population and is associated with lower prevalence of lymphoma compared to anti-Ro/SSA positive patients.

Disclosure of Interests:

Loukas Chatzis: None declared, Vasileios Pezoulas: None declared, Francesco Ferro: None declared, Valentina Donati: None declared, Aliki Venetsanopoulou: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Dimitris Fotiadis: None declared, Fotini Skopouli: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Chiara Baldini: None declared, Haralampos M. Moutsopoulos: None declared, Athanasios Tzioufas: None declared, Andreas Goules: None declared

FRI0149 THE CLINICAL FEATURES OF SJÖGREN’S SYNDROME PATIENTS WITH EARLY AND LATE DISEASE ONSET

Background:

Sjögren’s syndrome (SS) affects mainly individuals of the 4thor 5thdecade of life, although patients with early (≤35 years old) or late (≥65 years old) disease onset have been described in the literature. The clinical spectrum of the disease extends from mild dryness to severe systemic vasculitis and lymphoproliferative disorders. The phenotypic diversity of SS is defined by many factors, including age, since many parameters related to age may affect the clinical expression of the disease. Few studies have been conducted to study the effect of age on the clinical phenotype of SS, though with limited number of patients. Large and well-defined groups of SS are required to address such questions.

Objectives:

To study the clinical phenotype of SS patients with early and late disease onset and to explore the association of age with lymphoma development in a unified multicenter cohort.

Methods:

From a total cohort of 1997 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 5 clinical centers ([Universities ofUdine,Pisa andAthens,Harokopio andIoannina, (UPAHI)], those with either early (≤35 years) or late (≥65 years) disease onset were identified and matched according to gender and disease duration with middle aged controls whose disease onset was at the 4thor 5thdecade of life. Glandular manifestations, extra-glandular manifestations, serologic characteristics and histologic features were compared between the 2 age groups and the middle-aged control groups. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Three hundred seventy-nine (19%) SS patients with early and 293 (15%) with late disease onset were identified and compared with 353 and 285 middle aged SS controls respectively. The median disease duration of patients with early onset was 12 years (range:0-68) and for those with late disease onset was 5 years (range: 0-27). SS patients with early disease onset had statistically significant higher frequency of Raynaud’s phenomenon, lymphadenopathy, hypergammaglobulinemia, anti-Ro/SSA, anti-La/SSB, rheumatoid factor, salivary gland enlargement, low C4 complement levels, leukopenia and lymphoma (10,3% vs 5,7%, p= 0.03, OR= 1,91, 95% CI: 1,11-3,27) while SS patients with late disease onset had more frequently dry mouth, interstitial lung disease and lymphoma (6,8% vs 2,1%, p=0,01, OR= 3,4. 95%CI: 1,35-1,81).

Conclusion:

In a multicenter cohort of 1997 consecutive SS patients, those with early and late disease onset comprise more than one third of the total SS population. Patients with early disease onset, exhibit robust B cell responses with traditional risk factors for lymphoma as opposed to patients with late disease onset. Both age groups have increased lymphoma prevalence but presumably for different reasons, since late onset patients lack classical predictors of lymphoma. Therefore, these predictors deserve further study in different disease subsets.

Disclosure of Interests:

Andreas Goules: None declared, Ourania Argyropoulou: None declared, Vasileios Pezoulas: None declared, Francesco Ferro: None declared, Saviana Gandolfo: None declared, Valentina Donati: None declared, Marco Binutti: None declared, Sara Zandonella Callegher: None declared, Loukas Chatzis: None declared, Aliki Venetsanopoulou: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Chiara Baldini: None declared, Fotini Skopouli: None declared, Dimitris Fotiadis: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Haralampos M. Moutsopoulos: None declared, Athanasios Tzioufas: None declared

THU0294 THE DIFFERENCES IN THE CLINICAL SPECTRUM OF CRYOGLOBULINEMIC VASCULITIS BETWEEN SJÖGREN’S SYNDROME AND HCV HEPATITIS

Background:

Cryoglobulinemic vasculitis (CV) is a serious complication of Sjögren’s syndrome (SS) and is closely associated with type II IgMk cryoglobulins. CV has been well documented in HCV patients without SS, and shares common features with CV in SS. So far, few studies have described the clinical picture of CV in HCV negative SS, but the number of studied patients was rather small and CV was not well defined. To better describe the clinical spectrum of CV in SS and explore the differences compared to HCV-related CV, a large cohort of well characterized patients is required.

Objectives:

To study the clinical phenotype of CV in HCV-negative SS patients, in a large cohort of well characterized patients, after applying stringent classification CV criteria and in comparison with the classical CV of HCV patients.

Methods:

From a total cohort of 1997 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 5 clinical centers ([Universities ofUdine,Pisa andAthens,Harokopio andIoannina, (UPAHI)], those who fulfil the 2011 classification criteria for CV were identified and compared with matched HCV-CV patients according to age and gender. Glandular, extra-glandular manifestations and serologic features were compared between the 2 CV groups. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Among the 1083 SS patients who have been evaluated for cryoglobulins, 114 (9,8%) were found positive. Seventy-one (6,5%) SS patients met the 2011 CV criteria while 44 patients presented with type II IgMk cryoglobulinemia without CV. Sixty nine of 71 (97%) SS related CV patients were females and 2 of 71 (3%) males. Forty eight of 71 (68%) had SS disease onset >35 and <65 years old while 14/71 (19,7%) and 9/71 (12,7%) had SS disease onset <35 and >65 years old respectively. The most common clinical manifestations of CV among SS patients were purpura (90%) followed by arthralgias (70%), fatigue (59%), Raynaud’s phenomenon (48%), lymphadenopathy (31%), peripheral neuropathy (22,3%), vasculitic ulcer (11,3%) and glomerulonephritis (11,3%). Interestingly, almost 50% of SS related CV patients developed lymphoma and displayed high frequency of strong predictors including purpura, low C4 complement (88,6%) and salivary gland enlargement (SGE). Compared to HCV-CV patients, SS-CV patients had higher frequency of sicca manifestations, SGE, fatigue, arthritis, Raynaud’s phenomenon, lymphadenopathy, type II IgMk cryoglobulins and lymphoma.

Conclusion:

The prevalence of cryoglobulinemia and CV among SS patients is about 10% and 6-7% respectively. SS-CV patients are mainly middle-aged females with purpura as the main clinical manifestation, and up to one half of them may develop lymphoma, which is rarer in HCV-CV. Compared to HCV-CV patients, SS patients with CV have more frequently sicca symptoms, SGE and type II IgMk cryoglobulins.

Disclosure of Interests:

Ourania Argyropoulou: None declared, Vasileios Pezoulas: None declared, Luca Quartuccio: None declared, Francesco Ferro: None declared, Saviana Gandolfo: None declared, Valentina Donati: None declared, Aliki Venetsanopoulou: None declared, Loukas Chatzis: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Chiara Baldini: None declared, Fotini Skopouli: None declared, Dimitris Fotiadis: None declared, Massimo Galli: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Haralampos M. Moutsopoulos: None declared, Andreas Goules: None declared, Athanasios Tzioufas: None declared

FRI0161 PHENOTYPIC DIFFERENCES BETWEEN SJÖGREN’S SYNDROME PATIENTS WITH LOW AND HIGH-GRADE INFLAMMATION BASED ON SALIVARY GLAND FOCUS SCORE

Background:

Sjögren’s syndrome (SS) is characterized by the presence of lymphocytic infiltration around the ductal epithelium of the salivary and lachrymal glands. The periepithelial inflammatory lesions and the enclosed B cell component are responsible for the glandular and extraglandular manifestations of the disease. Previous studies have shown that the severity of inflammation observed within the salivary glands is correlated with the occurrence of extraglandular manifestations. However, in these studies either the number of patients is small or the SS criteria are not well defined. To explore the association between the degree of inflammation within the salivary glands and the phenotype of the disease, large and well characterized cohorts of SS patients is required.

Objectives:

To compare the phenotypic features of SS patients with low and high degree of inflammation within the minor salivary glands as reflected by the focus score (FS).

Methods:

From a total cohort of 1723 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 4 clinical centers ([Universities ofPisa,Athens,Harokopio andIoannina, (PAHI)], those who had performed a lip biopsy and the focused score was available, were classified into low grade (FS<3) or high grade (FS≥3). Glandular (dry mouth, dry eyes, parotid gland enlargement) and extra-glandular manifestations (Raynaud’s phenomenon, arthralgias/myalgias, arthritis, palpable purpura, liver involvement, kidney involvement, lung involvement, neurologic involvement, long standing lymphadenopathy and lymphoma) as well as serologic features (ANA, RF, anti-Ro/SSA, anti-La/SSB) were compared between the 2 groups. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Eight hundred and eight minor salivary gland biopsies were available and evaluated based on focus score at the initial evaluation of SS patients, of whom 753 had low grade (FS<3) and 153 high grade (≥3) inflammation. The median disease duration after SS diagnosis was not statistically significant different for the 2 groups (median: 4 years, range: 0-36 years). SS patients with high grade inflammation displayed higher prevalence of salivary gland enlargement (SGE) (40% vs 25%, p=0,0002), long standing lymphadenopathy (22% vs 14%, p=0,02), ANA (97% vs 88%, p=0,0001), anti-La/SSB (52% vs 32%, p<0,0001), RF (61,5% vs 48%, p=0,003), peripheral neuropathy (PN) (5,3% vs 1,5, p=0,01) and of lymphoma (26% vs 8%, p<0,0001, OR=4,142, 95%CI=2,65 to 6,47) compared to those with low grade inflammation.

Conclusion:

SS patients with FS ≥3 at the initial evaluation, display higher prevalence of lymphoma as well as higher B cell hyperactivity and certain clinical manifestations (SGE, PNS, lymphadenopathy) that constitute risk factors for lymphoma development.

Disclosure of Interests:

Loukas Chatzis: None declared, Vasileios Pezoulas: None declared, Francesco Ferro: None declared, Valentina Donati: None declared, Aliki Venetsanopoulou: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Dimitris Fotiadis: None declared, Fotini Skopouli: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Gorgoulis Vassilis: None declared, Chiara Baldini: None declared, Haralampos M. Moutsopoulos: None declared, Andreas Goules: None declared, Athanasios Tzioufas: None declared

The P2X7 receptor-NLRP3 inflammasome complex predicts the development of non-Hodgkin's lymphoma in Sjogren's syndrome: a prospective, observational, single-centre study

BACKGROUND

P2X7 receptor (P2X7R), trigger of acute inflammatory responses via the NLRP3 inflammasome, is hyperfunctioning in patients with Sjögren's syndrome (SS), where it stimulates IL-18 production. Some patients with SS develop a mucosa-associated lymphoid tissue non-Hodgkin's lymphoma (MALT-NHL).

OBJECTIVES

To prospectively evaluate the involvement and the putative prognostic role of this inflammatory pathway in the development of MALT-NHL.

METHODS

A total of 147 women with SS have been prospectively followed for a mean of 52 months, relating the expression and function of the P2X7R-inflammasome axis in salivary glands and circulating lymphomonocytes to the prognosis and the degree of the disease.

RESULTS

At baseline, gene expression of P2X7R and of the inflammasome components NLRP3, caspase-1 and IL-18 increased according to the presence of germinative centres and was higher in autoantibody-positive individuals and strongly higher in those developing a MALT-NHL over the follow-up. Glandular expression of IL-18 was threefold higher in MALT-NHL than in controls or in the other patients with SS. P2X7R did not colocalize with generic markers of inflammatory infiltrate, like CD20, being selectively expressed by epithelial cells. P2X4R, sharing functional characteristics with P2X7R, did not differ in SS and controls. The increased P2X7R gene and protein expression was tissue specific, no difference being observed in peripheral lymphomonocytes between SS with MALT-NHL and SS not developing MALT-NHL.

CONCLUSION

We propose the P2X7R-inflammasome axis as a novel potential pathway involved in both SS exocrinopathy and lymphomagenesis, reinforcing the hypothesis of a key role of IL-18, via its increased P2X7R-mediated production, in the pathogenesis of lymphoproliferative malignancies, and opening novel opportunities for the early diagnosis of lymphoproliferative complications and the development of potential targeted therapies.

The P2X7 receptor-inflammasome complex has a role in modulating the inflammatory response in primary Sjögren's syndrome

OBJECTIVE

Innate and adaptive immunity may contribute to gland dysfunction in patients with primary Sjögren's syndrome (pSS). The P2X7 receptor (P2X7 R)-NLRP3 inflammasome complex modulates the release of the inflammatory cytokines IL-1β and IL-18. The presence of P2X7 R in salivary glands suggests an interesting scenario for the initiation and amplification of the innate immune response in pSS. Therefore, the aim of this study was to assess the role of the P2X7 R-NLRP3 inflammasome in pSS.

SUBJECTS AND METHODS

Twenty-one consecutive patients with pSS according to the American-European Consensus Group criteria and 15 patients with sicca syndrome (i.e. without Sjögren's syndrome, non-SS) were enrolled in this study, together with six control (CTL) subjects. Expression of the P2X7R-NLRP3 platform and IL-18 was determined by real-time PCR and western blotting in gland specimens and peripheral lymphomonocytes; data were related to patients\x92 clinical, serological and histopathological characteristics. The presence of IL-18 was determined in gland and saliva samples.

RESULTS

P2X7 R expression was significantly higher in salivary glands from individuals with pSS than in those from non-SS and CTL subjects. Accordingly, the gene expression levels of the inflammasome components NLRP3, ASC and caspase-1 were significantly higher in pSS gland specimens, and this was paralleled by an increased expression of mature IL-18 in pSS saliva samples. The expression of both the P2X7 R and the inflammasome components was a marker of disease-related glandular involvement, being increased in patients with anti-Ro/SSA positivity and correlated with focus score.

CONCLUSION

The results of this study suggest an involvement of the P2X7 R-inflammasome-caspase-1-IL-18 axis in the development of pSS exocrinopathy. This finding provides the basis for studying the complex mechanisms underlying pSS, as well as for developing novel potential therapeutic strategies.

Cranial osteolytic metastases as the only recurrence of gastric carcinoma

The purpose of this case report is to increase the knowledge about bone metastatic pattern in gastric cancer. A 59-year-old man presented with headache three years after a total gastrectomy for signet-ring cell carcinoma. Head computed tomography and magnetic resonance imaging showed multiple osteolytic lesions of the cranial vault and base, consistent with metastatic or haematological disease. Bone scintigraphy confirmed areas of accumulation only in the skull. An extensive search didn't show any other tumor. Bone biopsy revealed metastatic signet-ring cell carcinoma. In gastric cancer, bone metastases are generally associated with metastases in lymph nodes, liver, and lung, and have a higher frequency in the thoracolumbar spine. However, cranial bone metastases presenting with headache may be the only manifestation of gastric cancer recurrence.

Bosentan treatment for Raynauds phenomenon and skin fibrosis in patients with Systemic Sclerosis and pulmonary arterial hypertension: an open-label, observational, retrospective study

Raynaud?s phenomenon (RP) and cutaneous fibrosis are the distinctive manifestations of scleroderma, in which Endothelin-1 plays a fundamental pathogenetic role. Bosentan, an Endothelin-1 receptor antagonist used for the treatment of pulmonary arterial hypertension, retards the beginning of new sclerodermic digital ulcers (DU). This open-label, observational, retrospective study verified the effect of Bosentan on RP and skin fibrosis in sclerodermic outpatients affected by pulmonary arterial hypertension without DU. Fourteen subjects (13 women, 1 man; mean age 60 ± 7.5 years; ten with limited and four with diffuse scleroderma) were observed at baseline (T0) and after four (T1), twelve (T2), twenty-four (T3) and forty-eight (T4) weeks during treatment with Bosentan. They were evaluated for daily quantity and duration of RP attacks and skin thickness (using modified Rodnan total skin score, MRSS). Videocapillaroscopic evaluation was performed at T0 and T4. Bosentan decreased significantly the number and duration of RP attacks, beginning at T2 (p<0.05). Videocapillaroscopy showed significant improvement of microcirculatory patterns at T4 (p<0.05). MRSS decreased throughout the study, reaching the statistical significance at T3 and T4 (p<0.01) in the whole cohort. The present data suggest that Bosentan is effective in stabilizing the microcirculation involvement and in improving skin fibrosis irrespective of scleroderma patterns.

Prevalence and concentration of Verotoxigenic Escherichia coli O157:H7 in adult sheep at slaughter from Italy

A 1-year study on the animal-level prevalence and concentration of Escherichia coli O157 in adult sheep at slaughter was performed, to collect qualitative and quantitative information on the diffusion of the pathogen in adult sheep from Italy. A total 533 samples were collected, with a similar distribution in the four seasons. For prevalence estimates, a simple random sampling technique was used. An immuno-magnetic separation technique was used for sample screening, with enumeration of the pathogen in positive samples, along with molecular and serological identification of isolates. An overall prevalence of 7.1% (38/ 533, 95% CI 4.9-9.3%) was observed for fully virulent E. coli O157. A wide interval of VTEC O157 per gram was observed (< 100 to 6 x 10(5) CFU g(-1)), with 28.9% (11/38) of positive samples > or = 1 x 10(3) CFU g(-1), set as the threshold for those animals defined 'active shedders' for the purpose of the study. Eight per cent (3/38) of animals shed > 1 x 10(4) g(-1) VTEC O157, which represents > 96% of the total VTEC O157 bacteria cultured from all animals tested. The prevalence estimate of active shedders was therefore 2.1% (95% CI 0.9-3.3%). Most (34/38, 89.5%) of the positive animals were found in summer (July-September). Prevalence and concentrations of virulent VTEC O157 obtained in this study contribute to the demonstration that adult sheep represent a relevant source of environmental contamination from virulent VTEC O157, as well as a source of VTEC O157 contamination for food of ovine origin (meat and dairy products), especially during warm months.

Management of a case of arhinia

Arhinia is a rare condition characterised by the congenital absence of nasal structures, with different patterns of presentation, and often associated with other craniofacial or somatic anomalies. To date, about 30 surviving cases have been reported. We report the case of a female patient aged 6 years, who underwent internal and external nose reconstruction using a staged procedure: a nasal airway was obtained through maxillary osteotomy and ostectomy, and lined with a local skin flap and split-thickness skin grafts; then the external nose was reconstructed with an expanded frontal flap, armed with an autogenous rib framework.

Prognostic significance of osteopontin expression in early-stage non-small-cell lung cancer

Osteopontin (OPN) is a multifunctional protein, which has recently been shown to be linked to tumorigenesis, progression and metastasis in different malignancies. Since non-small-cell lung cancer (NSCLC)'s prognosis remains bad, with few predictors of outcome, the purpose of this study was to evaluate if OPN might be involved in NSCLC's biology and therefore represent a prognostic marker and a target for new therapeutic trials. Immunohistochemistry was used to detect OPN expression, evaluated as percentage of neoplastic cells with cytoplasmic immunoreactivity, in a wide cohort of patients with stage I NSCLC (136 cases). The median value of this series (20% of positive cells) was used as the cutoff value to distinguish tumours with low (<20%) from tumours with high (⩾20%) OPN expression. A statistically significant correlation between high levels of OPN and shorter overall (P=0.034) and disease-free (P=0.011) survival in our patients was shown. Our results support the hypothesis that high OPN expression is a significantly unfavourable prognostic factor for the survival of patients with stage I NSCLC. This conclusion has notable importance in terms of the biological characterization of early-stage tumours and therapeutic opportunities.

[Evaluation of the Surveillance System of Acute Flaccid Paralysis in Puglia: 5 years of work]

Surveillance of acute flaccid paralysis (AFP) is the milestone to monitor the progress toward poliomyelitis eradication aim, fixed by WHA in 1988. Active AFP surveillance started in Apulia in 1997; this work evaluates five-year period activities. In this period, the total number of cases notified was 48, 7 of which were resident out of Apulia. Twenty-five were males and 23 females; the age ranged between 1 month and 15 years. Any collected serum specimens showed protective antibody levels against polioviruses. Polioviruses type 1 and type 2 Sabin-like were isolated from stool samples collected from two AFP patients. AFP surveillance targets improved in the years, with only exception, in 2001, of second serum specimen collected within 14 days because of children were discharged earlier form the hospitals. Apulia experience demonstrates the achievement of good levels of AFP surveillance targets. System sensitivity has been optimal in 2001 with a number of notified cases threefold the expected value and adequate specimen sampling (80%). Additional involved hospitals and availability of increased and dedicated human resources contributed to this outcome. The effort to achieve WHO targets for AFP surveillance needs to be maintained in next years until global certification of eradication will be declared.

Evaluation of telomerase in the development and progression of colon cancer

Telomerase activity, a cardinal requirement for immortalization, is a crucial step in the development of cancer and has been studied in many kinds of malignant tumours for clinical diagnostic and/or prognostic utilities. Using a PCR-based TRAP assay, we investigated telomerase activity in 8 adenomatous polyps, 9 dysplastic polyps, and in 36 paired cancer-normal mucosa specimens, one liver and one spleen metastasis from patients resected for sporadic colorectal cancer. Telomerase was absent or very low in normal mucosa and in adenomatous polyps. Dysplastic polyps and adenocarcinoma samples showed telomerase activity, with higher levels in cancer tissues compared to dysplastic lesions. A high telomerase activity was shown to be associated with late-staged cancers and metastasis, providing arguments supporting the role of telomerase not only in the development but also in the progression of colorectal carcinoma. Moreover, telomerase evaluation may help to confirm the malignant transformation in polypoid colorectal lesions with different levels of dysplastic alterations.

Evaluation of telomerase mRNA (hTERT) in colon cancer

Telomerase activation, a cardinal requirement for immortalization, is a crucial step in the development of malignancy and requires the induction of the catalytic component, human telomerase reverse transcriptase (hTERT), encoded by the hTERT gene. By reverse transcription-PCR, using primers within the reverse transcriptase domain of hTERT, we investigated telomerase messenger in 8 adenomatous and 9 dysplastic polyps, and in 32 paired cancer-normal mucosa specimens, one liver and one spleen metastasis from patients resected for sporadic colorectal cancer. Telomerase messenger was absent or very low in normal mucosa and in adenomatous polyps. Dysplastic polyps and adenocarcinoma samples showed hTERT mRNA, with higher levels in cancer tissues compared to dysplastic lesions. A high telomerase messenger level was shown to be associated with late-staged cancers and with metastasis; thus, detection of telomerase messenger may be useful in the early diagnosis of colon cancer, and telomerase may be a new target for therapeutic intervention.

Reparation of a severe case of aplasia cutis congenita with engineered skin

Aplasia cutis congenita (ACC) is an uncommon congenital malformation. It is characterized by defects of the skin that occur most frequently on the scalp along the midline, but can also be localized on the trunk, face and limbs, usually with a symmetrical distribution. When it is localized in the skull it can extend to the dura mater, leaving only the thin pia mater to protect the brain. The most common complications related to this disorder are infection, hemorrhage, and, in defects localized on the vertex, meningitis and bleeding from the sagittal sinus can occur with dramatic consequences. In those cases some authors suggest the use of local flaps even if this implies a surgical procedure. In this case a 2.540-kg baby was delivered at 40 weeks of gestation by eutocic delivery, and good adaptation to extrauterine life. At birth the baby showed a large cutaneous and osseous defect at the vertex measuring 68 cm(2), equal to almost one third of the calvarial surface, and extended to the dura mater through which it was possible to see the sagittal sinus and the brain surface with its vessels. Skull X-rays showed loss of normal radioopacity of the cranial vault with lack of ossification especially at the parietal level. In our patient we therefore decided to use a composite graft of cultured autologous fibroblasts and keratinocytes to provide coverage, avoiding any surgical procedure and patient morbidity. This technique consists first in an autograft of cultured fibroblasts which has proved to promote the production of type IV collagen, fibronectin and laminin whereby creating an ideal bed for the taking of the graft of cultured keratinocytes, to be put in place a week later. The use of a composite graft with both the derma-like and epithelial components has been also suggested to diminish scarring. Two months after the last graft area was completely closed.

Autocrine-acting early secreted mitogenic activity: production and responsiveness in cultures of normal human keratinocytes as a function of in vivo and in vitro age

Cultured epithelial grafts are used in the clinical treatment of both non-healing and acute partial-thickness wounds, owing to their ability to stimulate endogenous re-epithelialization. We have previously demonstrated that during the first 24 h following plating, human epidermal keratinocytes secrete an autocrine-acting mitogenic activity. Since the biological activity of cultured grafts is believed to decrease with cellular age, the effect of both in vivo and in vitro keratinocyte age on the secretion of this mitogenic activity, as well as on responsiveness to this activity, was studied. Keratinocytes from donors ranging in age from 2 to 81 years were analysed at increasing in vitro population doublings. Secretion into the medium of the mitogenic activity was not affected by either in vivo or in vitro cellular ageing, while responsiveness of keratinocytes to this mitogenic activity was age-related. These results suggest that cultured grafts from elderly donors may be effective in wound treatment.

Antigenic sites of poliovirus type 3 eliciting IgA monoclonal antibodies in orally immunized mice

A panel of neutralizing IgA monoclonal antibodies was produced from mice orally inoculated with poliovirus type 3 Sabin and cholera toxin as adjuvant. Low levels of neutralizing antibodies were elicited in mice after several boosts, but only in the presence of cholera toxin. Characterization of IgA MAbs by neutralization-escape virus mutants showed that all but one neutralizing MAbs against type 3 poliovirus were directed to antigenic site N-AgIII, which was previously found by us to be the major target of mucosal immune response to Sabin 1 in the mouse. Our data indicate that residue 236 of VP3, not previously reported, is also involved in forming site N-AgIII in addition to formerly described VP3 (aa 58-59) and VP1 (aa 286-290) residues. Unlike poliovirus type 1 IgA MAbs, all IgA MAbs herein described neutralized the wild-type parental poliovirus.

Repair of the pharyngocutaneous fistula with a fasciocutaneous island flap pedicled on the superficial temporalis artery

The case of an 84-year-old man with a pharyngocutaneous fistula after radiotherapeutic treatment and total laryngectomy for a squamous cell carcinoma was reported. Treatment with local flaps failed and normal flaps were not likely to succeed because of general and locally poor conditions considering that intensive radiotherapy had been administered. We therefore decided to use a fasciocutaneous island flap from the temporoparietal region pedicled on the parietal branch of the superficial temporalis artery. We obtained efficient and stable repair of the lesion both from a cosmetic and a functional point of view. We were forced to use this procedure for lack of another choice; however, we think that this could become a useful option in covering substance loss in this area when simpler solutions are not available.

Comparison of different membranes with cultures of keratinocytes from man for percutaneous absorption of nitroglycerine

The permeability barrier function of cell-culture membranes to the permeation of nitroglycerine was evaluated to find an alternative to skin from man for ex-vivo skin-permeation tests. The membranes were prepared, under submerged conditions, by inducing the growth of keratinocytes, from different donors, on a film of esterified jaluronic acid for different times (10, 20 and 30 days). Their permeability barrier functions were compared with those of some of the most widely used artificial membranes, silicone rubber (Silastic), cellulosic material (Cuprophan, Millipore HAWP), polysulphone membrane (Supor) and polytetrafluoroethylene membrane (TF-PTFE), and with those of biological membranes such as fresh and frozen skin, stratum corneum and epidermis from man, and hairless mouse skin. For each membrane the permeation profile was obtained and the flux was calculated. The permeation profiles for nitroglycerine were similar and linear in the first 2-3 h for all the synthetic membranes tested except TF-PTFE. For this membrane the profile was linear throughout the period considered and the amount permeating in 24 h (1603 microg cm(-2)) was significantly lower than those obtained for the other artificial membranes (between 1926 and 2508 microg cm(-2)). The amounts permeating through all the biological membranes in 24 h were in the range 520 to 781 microg cm(-2), except those for the keratinocyte-culture membranes, which were in the range 1730 to 2553 microg cm(-2). Prolonging the growth period of cultured keratinocytes did not affect nitroglycerine permeation. The findings suggest that these keratinocyte-culture membranes have some advantages--good reproducibility if obtained from the same donor; many membranes can be obtained from the same donor; the preparation is simple; they can be handled more easily than traditional cell-culture membranes; and they afford constant penetration rates for a longer period than synthetic membranes. The membranes could be used for preliminary in-vitro permeation studies.

Interaction of liposomes composed of phospholipids, GM1 ganglioside and cholesterol with human keratinocytes in culture

We studied the possibility of supplementing human keratinocytes with exogenous lipids (phospholipids, sphingolipids and cholesterol) and evaluated their influence on cell proliferation, using cells cultured in vitro. Experiments carried out with liposomes composed of cholesterol/GM1 ganglioside and different phospholipids (5:1.5:10, M/M/M), showed that liposomes associated with cells more efficiently when they contained soya lecithin. The treatment with liposomes made of the ternary mixture did not modify the rate of cell proliferation, as assessed by the incorporation of [3H]-thymidine. In contrast, the proliferation rate strongly decreased (65% with respect to the control) using the same liposomes without GM1. Experiments carried out with GM1 alone showed a strong stimulation of the proliferation rate (144% with respect to the control). Fluorescence dequenching experiments, carried out with the probe octadecyl rhodamine B chloride, showed that fusion was the main mechanism of liposome-cell interaction. Metabolic studies established that exogenously administered GM1--either embedded in liposomes or as a pure glycolipid dispersion--led to the production of several products, including ceramide. Altogether, these results show that different, opposing effects can be exerted on cell proliferation by the administration of lipids, separately or in mixtures, to human keratinocytes, and indicate the importance of a correct formulation for supplementing human keratinocytes with exogenous lipids.

Anatomical study of the temporal fasciae and fat pads

BACKGROUND AND AIM

Although a great number of studies have been published on the anatomy of the various fascial layers in the temporal region and the interposed fat pads, there is still uncertainty regarding the organization of the temporal fasciae, above all at the level of the zygomatic arch, and the relationships between the latter and the frontal branch of the facial nerve. This study aimed to describe the anatomy of the temporal fasciae and their relationships both with the interposed fat pads and with the frontal branch of the facial nerve.

METHODS

The study was carried out in 10 heads from fresh cadavers which were used to dissect the different tissue layers at the level of the temporo-zygomatic arch.

RESULTS

The results of the dissections made in this study confirm the existence of three over-lying fascial layers (superficial temporal fascia, intermediate temporal fascia and deep temporal fascia), interposed by the same number of fat pads (superficial, intermediate and deep). The frontal branch runs below the superficial fat pad in close contact with the periosteum of the zygomatic arch.

CONCLUSIONS

The authors suggest adopting a single nomenclature to describe the fasciae and the fat pads in the temporal region.

Ten-year experience with craniofacial implants: clinical and experimental results

The choice of bone substitute to be used in the cranio-maxillofacial districts raises several problems relating to the biocompatibility and mechanical resistance of the material. Over the past 10 years a total of 245 cranio-maxillofacial skeletal implants have been performed by the Department of Plastic Surgery at Niguarda Ca' Granda Hospital in Milan. The choice of material varied depending on the market availability of products and the experience acquired of both positive results and the onset of short-term and long-term complications. All patients were monitored with a minimum follow-up of 2 years and a maximum of 10 (mean 36 months). The following parameters were taken into account: complications linked to graft contamination, graft extrusion and decubitus, resorption times, degradable materials, resorption of underlying bone tissue and reactivity of the surrounding tissues. Studies on the cell cytohistotoxicity of materials used were performed in parallel by the cell culture laboratory at the Department of Plastic Surgery of Niguarda Hospital, using human keratinocyte and fibroblast cultures.

Unstable-stable resonators with toroidal mirrors

A resonator with toroidal mirrors is described. This resonator behaves like an off-axis unstable confocal resonator in one transverse dimension and like an on-axis concave-convex stable resonator in the other orthogonal dimension. Some experimental results are reported for a fast flow high power cw-CO(2) laser whose transverse cross section is restricted in the stable-resonator direction. These cavities allow an output laser beam with a fully illuminated cross section which is well suited for focusing. Moreover, the fraction of the available laser power which may be concentrated in the central lobe of the focal plane intensity distribution is 2.5-4.5 times higher than other unstable resonators with similarly restricted modal volumes. Finally the alignment requirements are examined.