Genetic insight into a polygenic trait using a novel genome-wide association approach in a wild amphibian population

Body size variation is central in the evolution of life-history traits in amphibians, but the underlying genetic architecture of this complex trait is still largely unknown. Herein, we studied the genetic basis of body size and fecundity of the alternative morphotypes in a wild population of the Greek smooth newt (Lissotriton graecus). By combining a genome-wide association approach with linkage disequilibrium network analysis, we were able to identify clusters of highly correlated loci thus maximizing sequence data for downstream analysis. The putatively associated variants explained 12.8% to 44.5% of the total phenotypic variation in body size and were mapped to genes with functional roles in the regulation of gene expression and cell cycle processes. Our study is the first to provide insights into the genetic basis of complex traits in newts and provides a useful tool to identify loci potentially involved in fitness-related traits in small data sets from natural populations in non-model species.

Expression patterns of heat-shock genes during stopover and the trade-off between refueling and stress response in a passerine migrant

Migrating birds are often exposed to variable environments and face a multitude of stress exposures along their long-distance flights. During stopover refueling, migratory birds must balance the need to accumulate energy reserves to continue their migration with the need to respond to environmental and physiological stressors. We examined the gene expression patterns of different Heat Shock Proteins (HSPs) in migrating birds during stopover at different body condition states (lean vs. fat), to provide some first insights on the role of HSPs in bird migration and explore the concept of a trade-off between refueling and stress response. Our results showed upregulation of HSP expression at release that could be associated with muscle growth and increased cholesterol and lipid synthesis needed for birds to fuel their upcoming migration. On the other hand, during capture, upregulation of HSP5 could be attributed to physiological recovery from the non-stop endurance flight when crossing the Sahara Desert-Mediterranean Sea ecological barrier. All birds significantly increased their fuel loads up to 48% of lean body mass and we provide evidence for muscle rebuilding during stopover as flight muscle mass increased by 10%, highlighting the fact that stopover sites can play a major role in the physiological recovery of migrants.

Adaptive regulation of stopover refueling during bird migration: insights from whole blood transcriptomics

Migration is one of the most energy-demanding tasks in avian life cycle. Many birds might not have sufficient fuel stores to cover long-distances, so they must stop to rest and refuel at stopover sites, especially after the crossing of large ecological barriers. There, birds undergo several behavioral, morphological and physiological trait adjustments to recover from and prepare for their journey, however regulation of such processes at the molecular level remains largely unknown. In this study we used transcriptomic information from the whole blood of migrating Garden warblers (Sylvia borin) to identify key regulatory pathways related to adaptations for migration. Birds were temporarily caged during spring migration stopover and then sampled twice at different refuelling states (lean vs fat), reflecting different migratory stages (stopover arrival vs departure) after the crossing of an extended ecological barrier. Our results show that top expressed genes during migration are involved in important pathways regarding adaptations to migration at high altitudes such as increase of aerobic capacity and angiogenesis. Gene expression profiles largely reflected the two experimental conditions with several enzymes involved in different aspects of metabolic activity being differentially expressed between states providing several candidate genes for future functional studies. Additionally, we identified several hub genes, upregulated in lean birds that could be involved in the extraordinary phenotypic flexibility in organ mass displayed by avian migrants. Finally, our approach provides novel evidence that regulation of water homeostasis may represent a significant adaptive mechanism, allowing birds to conserve water during long-distance flight, mainly through protein catabolism.

Genetic diversity and detection of candidate loci associated with alternative morphotypes in a tailed amphibian

Phenotypic changes in response to environmental cues allow organisms to adapt and enhance their fitness in a given habitat. Despite the significance of phenotypic plasticity in the evolution and ecology of natural populations and the ongoing development of new genomic tools, the underlying genetic basis is still largely unknown. Herein, we examined the underlying mechanisms of genetic and phenotypic divergence among alternative morphs of a natural population of the Greek smooth newt (Lissotriton graecus). The studied population consists of fully aquatic individuals exhibiting facultative paedomorphosis, the retention of larval traits such as gills, and individuals that have passed metamorphosis (paedomorphic vs. metamorphic newts). Based on the single nucleotide polymorphisms (SNPs) obtained, we observed low genetic divergence between the two alternative morphs and similar levels of gene diversity on neutral markers. Despite the observed high gene flow between the morphs, an Fst approach for outliers detected candidate loci putatively associated with the alternative morphs that mapped to four genes. These identified genes have functional roles in metabolic processes that may mediate the persistence of alternative ontogenetic trajectories.

Arriving depleted after crossing of the Mediterranean: obligatory stopover patterns underline the importance of Mediterranean islands for migrating birds

Hundreds of millions of birds reach the Mediterranean islands or Mediterranean coast of Europe every spring after having crossed the Sahara Desert and the Mediterranean Sea. Using data from three small insular stopover sites, we calculated body mass without fuel for 18 trans-Saharan passerine migrants. We subsequently used arrival fuel loads coupled with potential flight range estimates to assess the percentage of birds that are forced to perform an obligatory stopover after crossing the Mediterranean Sea due to fuel depletion. Average arrival fuel loads were among the lowest ever recorded in the Mediterranean region and minimum body mass values recorded for several species were lower than any other individual value reported. The percentage of birds that needed to replenish their energy stores before resuming their northward migration journey varied from 0% to 50% depending on the species and locality studied. Based on conservative estimates at least 180 million birds of our study species are expected to migrate through Greece, 14% of which would not be able to resume their migration without refueling. The significance of small islands and coastal sites in the Mediterranean as obligatory refuelling sites is discussed and their conservation value for migratory birds is highlighted under the perspective of climate change.

Recovery of RNA from avian nucleated whole blood stored under field conditions: an evaluation of commercial methods

1. Whole blood can be used to gain insights on several molecular mechanisms involved in animal physiology. However, its use to extract RNA from organisms that carry nucleated red blood cells is limited due to its high nuclease content and instability under field conditions.

2. Here, we evaluate three commercially available RNA preservation and extraction methods applied to avian whole blood samples kept in different storage conditions to identify the most suitable ones for use in field studies.

3. Whole blood starting volume was the most important factor; only samples with a starting volume of 50 µl yielded RNA whereas all 100 µl samples failed to provide any RNA regardless of the method used. RNA concentration decreased with storage time in every method employed. Samples stored at -20 °C yielded higher RNA concentration than the ones stored at 4°C although some possible effects of freeze-thaw cycles were observed.

4. For the two out of three methods it is likely that DNA contamination and/or extensive degradation of RNA could have taken place. Only whole blood stored and extracted using the Quick RNA Whole Blood kit provided high quality RNA in every condition tested.

Global COVID-19 lockdown highlights humans as both threats and custodians of the environment

The global lockdown to mitigate COVID-19 pandemic health risks has altered human interactions with nature. Here, we report immediate impacts of changes in human activities on wildlife and environmental threats during the early lockdown months of 2020, based on 877 qualitative reports and 332 quantitative assessments from 89 different studies. Hundreds of reports of unusual species observations from around the world suggest that animals quickly responded to the reductions in human presence. However, negative effects of lockdown on conservation also emerged, as confinement resulted in some park officials being unable to perform conservation, restoration and enforcement tasks, resulting in local increases in illegal activities such as hunting. Overall, there is a complex mixture of positive and negative effects of the pandemic lockdown on nature, all of which have the potential to lead to cascading responses which in turn impact wildlife and nature conservation. While the net effect of the lockdown will need to be assessed over years as data becomes available and persistent effects emerge, immediate responses were detected across the world. Thus, initial qualitative and quantitative data arising from this serendipitous global quasi-experimental perturbation highlights the dual role that humans play in threatening and protecting species and ecosystems. Pathways to favorably tilt this delicate balance include reducing impacts and increasing conservation effectiveness.

AB0537 PSORIATIC ARTHRITIS BURDEN, QUALITY OF LIFE AND FUNCTIONAL ABILITY IMPAIRMENTS IN PATIENTS INITIATED ON APREMILAST IN THE ROUTINE CARE IN GREECE: INTERIM RESULTS FROM THE MULTICENTER PROSPECTIVE STUDY “APROACH”

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with substantial psychosocial burden and health-related quality of life (HRQoL) and functional ability impairments.

Objectives:

To characterize the profile of patients with PsA initiating therapy with apremilast in routine care settings, in terms of the physician-assessed clinical disease burden and the patient-reported generic and disease-related HRQoL and functional disability.

Methods:

This is an ongoing 52-week multicenter, prospective study conducted in the Greek healthcare environment. Eligible patients are bio-naïve adults with active peripheral PsA, inadequate (within the first 12 months of treatment) response/intolerance to a prior conventional synthetic disease-modifying antirheumatic drug (csDMARD), and no prior use of tofacitinib, initiating apremilast as per the approved label. Data are being collected by physician assessments, as performed in routine clinical practice, and by patient-reported outcomes. 170 patients enrolled in the study; data at apremilast initiation (baseline) from the first 100 eligible consenting patients are presented in this interim analysis as per protocol.

Results:

99 evaluable patients were consecutively enrolled in 19 rheumatology departments between 15-Apr-2019 and 13-Jan-2020. At baseline (Table 1) [mean (SD) age: 53.8 (11.7) years], 43.4% of the patients had at least one (30.3% had ≥2) ongoing comorbidity other than PsA/PSO. The median [interquartile range (IQR)] PsA and psoriasis duration were 1.9 (1.0-3.5) and 7.5 (3.9-16.8) years, respectively. All subjects were on csDMARD while 24.2% received combination therapy, oral non-steroid anti-inflammatory drugs (32.3%), topical treatments (20.2%) and systemic steroids (11.1%). Based on the Clinical Disease Activity in PsA (cDAPSA) score, 58.6% of the patients had moderate, and 29.3% high disease activity. In the EuroQol (EQ) 5-Dimensions (5D) 5-Levels questionnaire, 93.9, 82.8, 82.8, 73.7, and 51.5% of the patients reported problems in ‘pain/discomfort’, ‘anxiety/depression’, ‘usual activities’, ‘mobility’, and ‘self-care’, respectively. The median (IQR) baseline UK-weighted EQ-5D index and EQ-Visual Analogue Scale scores were 0.55 (0.44-0.70) and 50.0 (40.0-70.0), respectively. The median (IQR) Health Assessment Questionnaire-Disability Index (HAQ-DI) and mean (SD) PsA Impact of Disease 12-item (PsAID12) scores were 1.0 (0.5-1.4) and 4.6 (2.0), respectively.

Conclusion:

More than 8 out of 10 bio-naïve patients initiated on apremilast in the routine clinical care in Greece have at least moderate disease activity, active psoriasis, and problems with pain/discomfort, anxiety/depression, and performance of usual activities at a median of 2 years post-diagnosis. HAQ-DI and PsAID12 scores indicate moderate impairment of physical functionality and PsA-related HRQoL. The findings underscore considerable disease burden early in the disease course.

Table 1.

Baseline characteristics

N%/Mean/MedianWomen, %57/9957.6Peripheral joint involvement only, %92/9992.9Polyarthritis (≥5 joints), %69/9969.7cDAPSA (range: 0-154), median (IQR)9922.0 (16.0-29.0)Number of SJC (0-66) / TJC (0-68), median (IQR)994 (2-8) / 6 (2-10)Active psoriasis (BSA>0%), %83/9983.8BSA score, median (IQR)77/835.0 (2.0-12.0)Nail involvement, %38/9639.6Enthesitis and/or dactylitis, %30/9531.6Dactylitis, %11/9511.6Finger and toe Dactylitis Severity Score (DSS) (range: 0-60), median (IQR)10/112.0 (1.0-6.0)Enthesitis, %22/9523.2 LEI score (range: 0-14), median (IQR)222.0 (1.0-2.0)Extra-articular manifestations (mainly fatigue), %10/9910.1Comorbidities in ≥15% of the patientsHypertension, Essential hypertension, %23/9923.2Dyslipidemia, hypercholesterolemia, (type V) hyperlipidemia, %15/9915.2Total PsAID12 score (range: 0-10), mean (SD)984.6 (2.0)Total HAQ-DI score (range: 0-3), median (IQR)991.0 (0.5-1.4)

Disclosure of Interests:

PELAGIA KATSIMPRI Speakers bureau: Janssen, Genesis pharma, Novartis, Abbvie, UCB, Hospital Line, Actelion Pharmaceuticals, Pfizer, Consultant of: Janssen, Genesis pharma, Novartis, Abbvie, UCB, Hospital Line, Actelion Pharmaceuticals, Pfizer, Dimitrios Vassilopoulos Speakers bureau: AbbVie, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Grant/research support from: AbbVie, GenesisPharma, Νovartis, Pfizer, Roche, UCB, Janssen, MSD, Gkikas Katsifis Speakers bureau: Abbvie, Aenorasis, Amgen, Genesis Pharma, Bausch Health, BMS, Celgene, Janssen, MSD, Novartis, Roche, Pfizer, UCB, Grant/research support from: Abbvie, Aenorasis, Amgen, Genesis Pharma, Bausch Health, BMS, Celgene, Janssen, MSD, Novartis, Roche, Pfizer, UCB, GEORGIOS VOSVOTEKAS Speakers bureau: MSD, Consultant of: AbbVie, Novartis, Dimitrios Bogdanos Speakers bureau: Menarini, Novartis, Consultant of: Fresenius Kabi Hellas, Novartis, Grant/research support from: Aenorasis, Elpen, Genesis Pharma, GlaxoSmithKline, Boehringer Ingelheim, Lilly, Prodromos Sidiropoulos Grant/research support from: University of Crete Special Account for Research and pharma, Periklis Vounotrypidis Speakers bureau: Genesis Pharma, MSD, Novartis, Grant/research support from: Genesis Pharma, MSD, Novartis, Athanasios Georgountzos Grant/research support from: AbbVie, Genesis Pharma, Janssen, Mylan SAS, Pfizer, Roche, UCB, Andreas Bounas: None declared., Alexandros Garyfallos Speakers bureau: AbbVie, BGP, Roche, Consultant of: Genesis Pharma, UCB, Pfizer, Sousana Gazi: None declared., Panagiotis Georgiou Grant/research support from: Janssen-Cilag, Novartis, UCB, Evaggelia Kataxaki Speakers bureau: Novartis, Charalampos Papagoras Speakers bureau: Abbvie, Novartis, Genesis, Lilly, Biogen, Aenorasis, GSK, Pfizer, ANTONIA ELEZOGLOU: None declared., Stamatis-Nick Liossis: None declared., Athanasios Tzioufas Grant/research support from: AbbVie, Genesis Pharma, GSK, Horizon, Lilly, Novartis, Pfizer, Paraskevi Voulgari Speakers bureau: GlaxoSmithKline, Novartis, UCB, Consultant of: GlaxoSmithKline, Novartis, UCB, FOTEINI SATRA TZOUFRA Employee of: GENESIS PHARMA S.A., ZAFEIRIOS ANAGNOSTOPOULOS Employee of: GENESIS PHARMA S.A., NIKOLAOS ANTONAKOPOULOS Employee of: GENESIS PHARMA S.A., Petros Sfikakis Speakers bureau: AbbVie, Boehringer Ingelheim, GenesisPharma, Novartis, Pfizer, UCB, Consultant of: AbbVie, Boehringer Ingelheim, GenesisPharma, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Boehringer Ingelheim, GenesisPharma, Novartis, Pfizer, UCB.

Differential survival throughout the full annual cycle of a migratory bird presents a life-history trade-off

Long-distance migrations are among the most physically demanding feats animals perform. Understanding the potential costs and benefits of such behaviour is a fundamental question in ecology and evolution. A hypothetical cost of migration should be outweighed by higher productivity and/or higher annual survival, but few studies on migratory species have been able to directly quantify patterns of survival throughout the full annual cycle and across the majority of a species' range. Here, we use telemetry data from 220 migratory Egyptian vultures Neophron percnopterus, tracked for 3,186 bird months and across approximately 70% of the species' global distribution, to test for differences in survival throughout the annual cycle. We estimated monthly survival probability relative to migration and latitude using a multi-event capture-recapture model in a Bayesian framework that accounted for age, origin, subpopulation and the uncertainty of classifying fates from tracking data. We found lower survival during migration compared to stationary periods (β = -0.816; 95% credible interval: -1.290 to -0.318) and higher survival on non-breeding grounds at southern latitudes (<25°N; β = 0.664; 0.076-1.319) compared to on breeding grounds. Survival was also higher for individuals originating from Western Europe (β = 0.664; 0.110-1.330) as compared to further east in Europe and Asia, and improved with age (β = 0.030; 0.020-0.042). Anthropogenic mortalities accounted for half of the mortalities with a known cause and occurred mainly in northern latitudes. Many juveniles drowned in the Mediterranean Sea on their first autumn migration while there were few confirmed mortalities in the Sahara Desert, indicating that migration barriers are likely species-specific. Our study advances the understanding of important fitness trade-offs associated with long-distance migration. We conclude that there is lower survival associated with migration, but that this may be offset by higher non-breeding survival at lower latitudes. We found more human-caused mortality farther north, and suggest that increasing anthropogenic mortality could disrupt the delicate migration trade-off balance. Research to investigate further potential benefits of migration (e.g. differential productivity across latitudes) could clarify how migration evolved and how migrants may persist in a rapidly changing world.

Mining citizen science data to explore stopover sites and spatiotemporal variation in migration patterns of the red-footed falcon

Citizen science data have already been used to effectively address questions regarding migration, a fundamental stage in the life history of birds. In this study, we use data from eBird and from 3 additional regional citizen science databases to describe the migration routes and timing of the red-footed falcon Falco vespertinus in the Mediterranean region across 8 years (2010–2017). We further examine the seasonal and yearly variation in migration patterns and explore sites used during the species migration. Our results suggest that the autumn passage is spatially less variable and temporally more consistent among years than in spring and that birds migrate faster in spring than in autumn. The species seems to be more prevalent along the Central Mediterranean during spring migration, probably as a result of the clockwise loop migration that red-footed falcons perform. There was a high variation in annual median migration dates for both seasons as well as in migration routes across years and seasons. Higher variation was exhibited in the longitudinal component thus indicating flexibility in migration routes. In addition, our results showed the species’ preference for lowlands covered with cropland and mosaics of cropland and natural vegetation as stopover sites during migration. Stopover areas predicted from our distribution modeling highlight the importance of the Mediterranean islands as stopover sites for sea-crossing raptors, such as the red-footed falcon. This study is the first to provide a broad-scale spatiotemporal perspective on the species migration across seasons, years and flyways and demonstrates how citizen science data can inform future monitoring and conservation strategies.

SAT0630-HPR EFFECTS OF GOLIMUMAB ON WORK PRODUCTIVITY AMONG WORK-ACTIVE ANKYLOSING SPONDYLITIS, NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS PATIENTS IN GREECE: THE ‘GO-UP’ STUDY

Background:

Golimumab is a tumor necrosis inhibitor (TNFi) approved for the treatment of axial SpA (axSpA) and psoriatic arthritis (PsA), both falling under the Spondyloarthritis (SpA) domain. Real-world data regarding its effect on work productivity (WP) and activity impairment (AI) are limited

Objectives:

To assess the impact of golimumab on WP and AI over 12 months of treatment in patients with SpA, overall, and in the axSpA and PsA subpopulations

Methods:

A 12-month non-interventional, multicenter, prospective study performed in the routine clinical care. Data were collected at baseline (BL: prior to treatment onset), 3, 6 and 12 months. Adult work-active consented patients with axSpA [ankylosing spondylitis (AS) or non-radiographic axSpA (nr-axSpA)] or PsA, newly initiated on golimumab as per approved label, were concequetively enrolled by 20 sites. Patients prior in >1 biologic agent, or switched from another TNFi due to primary non-response or safety were excluded. WP and AI was assessed with the Work Productivity and Activity Impairment: Specific Health Problem (WPAI:SHP) instrument

Results:

Between Apr-2017 and May-2018, 121 (51: PsA, 70: axSpA) eligible patients (mean age: 45.4 years; 49.6% males; 69.0% overweight/obese; median disease duration: 11.3 months), (Figure 1), were enrolled. Median study duration participation: 11.9 months. Overall, 60.3% of the patients had previously received disease-modifying antirheumatic drugs and 16.5% biologics. At BL, the mean (standard deviation: SD) DAS28-ESR of the SpA population and PsA and axSpA subpopulations was 4.0 (1.3), 4.5 (1.2), and 3.6 (1.2), while the mean (SD) BASDAI score of patients with axSpA was 5.6 (1.9). At BL 94.1 and 96.7% of the SpA population reported WP loss and AI due to their SpA respectively, and at 3 months 87.3, and 88.0% respectively. In SpA population, the median BL WP loss and AI were 70.0% and 65.0% and decreased by a median of 31.4% and 40.0% at 3 months, by 44.2% and 40.0% at 6 months and by 50.0% and 50.0% at 12 months, respectively (Table 1). Improvements in WP loss and AI were noted in patients with PsA, axSpA, AS and nr-axSpA (Table 1). 12-month golimumab retention rate: 91.7%. No new safety signals emerged

Table 1.

Decreases from BL at 3, 6 and at 12 months in WP loss and overall AI with the WPAI:SHP instrument

WP loss (%)AI (%)Decrease from BL,median (n)Decrease from BL,median (n)3 months6 months12 months3 months6 months12 monthsOverall SpA populationa31.4a(n=102)44.2a(n=94)50.0a(n=87)40.0a(n=107)40.0a(n=101)50.0a(n=92)PsA31.4b(n=46)51.4a(n=42)53.6a(n=40)40.0a(n=47)50.0a(n=44)60.0a(n=40)axSpA33.0b(n=56)30.4b(n=52)45.5b(n=47)40.0a(n=60)40.0b(n=57)40.0b(n=52)ASc25.1 (n=35)29.9 (n=32)39.8 (n=29)20.0 (n=39)30.0 (n=37)30.0 (n=34)nr-axSpAc47.4 (n=21)55.4 (n=20)53.2 (n=18)50.0 (n=21)55.0 (n=20)50.0 (n=18)

aSignificant decreases (p<0.001; Wilcoxon signed-ranked test)

bSignificant decreases (p<0.001; t-test)

cStatistical significance of the change from baseline was not examined due to the small observations’ number

Conclusion:

Patients in the SpA population and axSpA and PsA subpopulations treated with golimumab in a routine care setting experienced significant improvements in work productivity and daily activities at 3, 6 and 12 months after treatment initiation

Acknowledgments:

The authors thank the following investigators: Ampatziadis E., Voulgari P., Gazi S., Georgiou P., Georgountzos A., Karokis D., Mpotzoris V., Mpournazos E., Sakkas L., Sidiropoulos P., and Vassilopoulos D. The study was Sponsored by MSD, Greece.

Disclosure of Interests:

Panagiotis Athanassiou Grant/research support from: MSD, Genesis pharma, Janssen, Consultant of: Roche, Genesis pharma, Janssen, Speakers bureau: MSD, Janssen, Roche, Genesis pharma, Anastassios Kotrotsios Grant/research support from: MSD, Novartis, Roche, Consultant of: Bristol Myers Squibb, UCB pharma, Speakers bureau: Genesis pharma, UCB pharma, MSD, Ioannis Kallitsakis Grant/research support from: MSD, Speakers bureau: Genesis pharma, Bristol-Myers Squibb, Andreas Bounas Grant/research support from: MSD, AbbVie, Novartis, Genesis pharma, Consultant of: MSD, Bristol-Myers Squibb, UCB pharma, AbbVie, Speakers bureau: MSD, Bristol-Myers Squibb, Pfizer, Alexandros Garyfallos Grant/research support from: MSD, Aenorasis SA, Speakers bureau: MSD, Novartis, gsk, Maria Tektonidou Grant/research support from: AbbVie, MSD, Novartis and Pfizer, Consultant of: AbbVie, MSD, Novartis and Pfizer, GEORGIOS VOSVOTEKAS Grant/research support from: MSD, Janssen, Consultant of: MSD, Novartis, Roche, UCB pharma, Bristol-Myers Squibb, AbbVie, Speakers bureau: UCB pharma, Menarini, Bristol-Myers Squibb, MSD, Evangelia Petrikkou Employee of: MSD, Bristol Myers Squibb, Vianex SA, Gkikas Katsifis Grant/research support from: UCB Pharma, Janssen, Abbvie, Novartis, MSD, Aenorasis, Genesis Pharma, Pfizer, Roche, Consultant of: UCB Pharma, Janssen, Abbvie, Novartis, MSD, Aenorasis, Genesis Pharma, Pfizer, Roche, Speakers bureau: UCB Pharma, Janssen, Abbvie, Novartis, MSD, Aenorasis, Genesis Pharma, Pfizer, Roche

Cardiovascular magnetic resonance detects silent heart disease missed by echocardiography in systemic lupus erythematosus

Background

Accurate diagnosis of cardiovascular involvement in systemic lupus erythematosus (SLE) remains challenging, due to limitations of echocardiography. We hypothesized that cardiovascular magnetic resonance can detect cardiac lesions missed by echocardiography in SLE patients with atypical symptoms.

Aim

To use cardiovascular magnetic resonance in SLE patients with atypical symptoms and investigate the possibility of silent heart disease, missed by echocardiography.

Patients/methods

From 2005 to 2015, 80 SLE patients with atypical cardiac symptoms/signs (fatigue, mild shortness of breath, early repolarization and sinus tachycardia) aged 37 ± 6 years (72 women/8 men), with normal echocardiography, were evaluated using a 1.5 T system. Left and right ventricular ejection fractions, T2 ratio (oedema imaging) and late gadolinium enhancement (fibrosis imaging) were assessed. Acute and chronic lesions were defined as late gadolinium enhancement-positive plus T2>2 and T2<2, respectively. Lesions were characterized according to late gadolinium enhancement patterns as: diffuse subendocardial, subepicardial and subendocardial/transmural, due to vasculitis, myocarditis and myocardial infarction, respectively.

Results

Abnormal cardiovascular magnetic resonance findings were identified in 22/80 (27.5%) of SLE patients with normal echocardiography, including 4/22 with recent silent myocarditis, 5/22 with past myocarditis (subepicardial scar in inferolateral wall), 9/22 with past myocardial infarction (six inferior and three anterior subendocardial infarction) and 4/22 with diffuse subendocardial fibrosis due to vasculitis. No correlation between cardiovascular magnetic resonance findings and inflammatory indices was identified.

Conclusions

Cardiovascular magnetic resonance in SLE patients with atypical cardiac symptoms/signs and normal echocardiography can assess occult cardiac lesions including myocarditis, myocardial infarction and vasculitis that may influence both rheumatic and cardiac treatment.

Mycobacterium kansasii cutaneous infection in a patient with sarcoidosis treated with anti-TNF agents

We describe a Mycobacterium kansasii cutaneous infection that was diagnosed in a 52-year-old female patient with sarcoidosis receiving anti-TNF agents. The diagnosis was based on the positive culture of the foot ulcerative tissue. The isolation and identification of bacterium was based on phenotypic and molecular methods. Therapy and follow-up of the patient is discussed.

Mycophenolate mofetil as first-line treatment improves clinically evident early scleroderma lung disease

OBJECTIVE

To find an effective, safe immunosuppressive regimen as an alternative to cyclophosphamide (Cy) for the treatment of clinically evident diffuse scleroderma (dSSc)-associated alveolitis of recent onset.

METHODS

Five consecutive patients with dSSc and recent-onset alveolitis were enrolled and treated with mycophenolate mofetil (MMF) and small (< or =10 mg/day) doses of predinisolone in this open-label trial. One patient with long-standing fibrosing alveolitis was later added to our cohort. Pulmonary function tests [carbon monoxide diffusing capacity (DLCO) and forced vital capacity (FVC)], pulmonary high-resolution computed tomography (HRCT) scans and clinical assessment were performed before and at specified time-points after enrolment. Cases of significant infections, leucopenia and abdominal pain were recorded.

RESULTS

After 4-6 months of MMF therapy, DLCO improved significantly compared with pre-treatment (mean DLCO 75.4% vs 64.2% of predicted value, respectively, P = 0.033). Values of FVC also improved, with the difference almost reaching levels of statistical significance (mean FVC 76.2% vs 65.6% of predicted value, P = 0.057). Ground glass opacities cleared in three of four patients with recent-onset alveolitis and were reduced in one patient after 6-8 months of treatment. Breathlessness and cough improved by 3 months. A possible treatment failure was seen in one patient. However, in five patients functional and clinical improvement was sustained during the study period. No adverse events were recorded in this ongoing clinical trial.

CONCLUSION

Our preliminary data suggest that in patients with dSSc and recent, clinically apparent alveolitis, early treatment with MMF and small doses of corticosteroids (CS) may represent an effective, well-tolerated and safe alternative therapy.

Asymptomatic gastrocnemius muscle biopsy: an extremely sensitive and specific test in the pathologic confirmation of sarcoidosis presenting with hilar adenopathy

OBJECTIVE

To evaluate asymptomatic gastrocnemius muscle biopsy as a tool in the histologic confirmation of the diagnosis of sarcoidosis.

METHODS

Twenty-two patients admitted over a 2-year period to our department with bilateral hilar adenopathy and a variety of symptoms compatible with sarcoidosis were studied prospectively. Besides a complete history and physical, serum angiotensin converting enzyme (SACE) determination, pulmonary function, slit lamp eye examination, PPD skin test, gallium 67 scan and gastrocnemius muscle biopsy were performed.

RESULTS

The biopsy revealed non-caseating granuloma in all patients, confirming the diagnosis of sarcoidosis. No other patient in our department received this diagnosis over the 2-year period of the study. The procedure was well tolerated by all patients and almost zero morbidity was noted. Erythema nodosum was present in 68.2% of the patients, PPD was negative in all of them, SACE was elevated in 59.1% and pulmonary function was normal in the majority.

CONCLUSION

The impressive sensitivity of asymptomatic gastrocnemius muscle biopsy, its safety and ease of performance, along with the extreme rarity of muscle involvement by other granulomatous diseases included in the differential diagnosis, may render it the procedure of choice for the histologic confirmation of sarcoidosis presenting with hilar adenopathy.

Bronchiectasis in systemic sclerosis. A study using high resolution computed tomography

OBJECTIVE

To detect noninvasively the presence of bronchiectasis in patients with systemic sclerosis (SSc), through the use of high resolution chest computed tomography (HRCT).

METHODS

Twenty two patients with SSc, of whom 13 with diffuse and 9 with limited disease, besides a complete history, physical and routine laboratory and immunologic profile, were evaluated by pulmonary function testing and HRCT. The chi square test with Yates' correction, the Fisher's exact test, the Fisher's test (F test) and the "t" test were used for statistical analysis of the results.

RESULTS

Eleven patients (50.0%) had decreased carbon monoxide diffusing lung capacity (DLCO) and, out of these, four had restrictive lung disease, based on a combined decrease of forced vital capacity (FVC) and total lung capacity (TLC). Another two patients exhibited this pattern without DLCO impairment. HRCT revealed a ground glass picture in 15 patients (68.2%), fibrosis in 9 (40.9%) (of which 5 with ground glass as well), and cylindrical bronchiectasis in 13 (59.1%). Bronchiectasis was more common in diffuse than in limited SSc, and the difference approached but did not reach the level of statistical significance. On the other hand, it was not correlated with either decreased DLCO, presence of ground glass and fibrosis, or with patients' age and disease duration.

CONCLUSION

Although the number of patients included in our study is relatively small, our data, for the first time in the literature, indicate a significant association between scleroderma and bronchiectasis. Bronchiectasis should be included in the list of pulmonary manifestations of SSc, and SSc in the list of conditions causing bronchiectasis.

Autonomic cardiovascular neuropathy in Sjögren's syndrome. A controlled study

OBJECTIVE

To test patients with primary Sjögren's syndrome (SS) for evidence of autonomic neuropathy.

METHODS

Thirty-two patients with primary SS and 22 age and sex matched healthy individuals were asked specific questions about symptoms suggestive of autonomic neuropathy, and were subjected to a battery of 5 cardiovascular tests: response of blood pressure to sustained hand grip, Valsalva maneuver, heart rate response to deep breathing, and heart rate and blood pressure response to standing up. The chi-squared test with Yates' correction and 95% confidence intervals were used for statistical analysis of the results.

RESULTS

Sixteen patients (50%) had symptoms of autonomic neuropathy when specifically asked versus none of the controls (p < 0.0005). The frequency of abnormal responses to the tests was 68.8% in patients and 12.7% in controls (p < 0.0001). Severe autonomic cardiovascular neuropathy was found in 87.5% of the patients but in none of the healthy individuals (p < 0.0001).

CONCLUSION

Our results suggest that autonomic neuropathy is a feature of a significant portion of the SS population, and such patients should have appropriate evaluation. Similarly, patients with unexplained autonomic neuropathy should be investigated for evidence of SS.

Is a purified protein derivative skin test and subsequent antituberculous chemoprophylaxis really necessary in systemic rheumatic disease patients receiving corticosteroids?

Our objective was to determine whether a purified protein derivative (PPD) skin test and subsequent isoniazid administration to patients with systemic rheumatic disease, who react positively and are about to receive corticosteroids, is necessary. For this purpose, 451 unselected patients with systemic rheumatic diseases, such as rheumatoid arthritis, giant cell arteritis, polymyalgia rheumatica, systemic lupus erythematosus, scleroderma, poly- and dermatomyositis, mixed connective tissue disease, eosinophilic fasciitis, systemic necrotising vasculitis and Behçet's disease, were observed over a 6-year period. All patients had been started on steroids after commencement of the study and had received the drug for at least 1 year by the end of the study. A chest X-ray was performed before entry, every 6 months for the first year and yearly thereafter. A PPD skin test had been performed in 40 patients by other physicians, but it was our policy to omit the test. We divided our patients into age groups by decades. Steroid dosage varied according to diagnosis and severity. An initial chest X-ray revealed old inactive tuberculosis in 65 patients. During the follow-up period, none of the patients exhibited clinical or radiological evidence of reactivations of tuberculosis. However, at least 184 of the patients would have had a positive PPD skin test reaction, if tested. This figure is derived from the results of several studies on Greek army recruits whose current ages correspond to those of our patients. In conclusion, our results suggest that screening with a PPD and isoniazid prophylaxis, with all the potential risks for those who test positive, may not be necessary in patients with systemic rheumatic disease who will receive steroids.

Sjögren's syndrome in patients with newly diagnosed untreated non-Hodgkin's lymphoma

The purpose of the study was to detect cases of Sjögren's syndrome among newly diagnosed untreated patients with non-Hodgkin's lymphoma and, furthermore, to identify in such cases clinical and serologic features known to occur more frequently in Sjögren's syndrome patients who evolve into lymphoma. Accordingly, thirty-three cases of newly diagnosed non-Hodgkin's lymphoma, prior to any treatment administration, were thoroughly studied for evidence of Sjögren's syndrome. Immunophenotyping for T and B cells and kappa and lambda light chains was concomitantly performed on both lymphomatous tissues and minor salivary glands. There were 5 patients with T cell and 28 with B cell lymphoma of various histologic subtypes and grades. Two of the latter (7.1%) had a positive for Sjögren's syndrome minor labial salivary gland biopsy, positive responses to the specific questionnaires for both eye and mouth dryness and abnormal Schirmer's and rose Bengal eye tests, substantiating the diagnosis of Sjögren's syndrome. Both were male with lung and stomach non-Hodgkin's lymphoma respectively, enlargement of the lacrimal glands, monoclonal gammapathy of the IgM kappa type and, one of them had high titer and of fine speckled pattern positive antinuclear antibodies and anti-Ro(SSA) and anti-La(SSB) antibodies in his serum. A monotypic infiltrate with kappa light chain restriction, identical to that in the lymphomatous tissue of these two patients, was present in their minor salivary gland biopsy as well. Such a finding was not encountered in any of the remaining patients. Although our sample is relatively small, our results confirm the relationship between Sjögren's syndrome and non-Hodgkin's lymphoma, looked at from the opposite direction. Obviously, studies involving larger populations would be more definitive, regarding the issue of what percentage of this lymphoma patients originates from Sjögren's syndrome.

Baker's cyst in rheumatoid arthritis: an ultrasonographic study with a high resolution technique

OBJECTIVE

To determine the prevalence of popliteal cyst (Baker's cyst) in rheumatoid arthritis (RA), through the use of a very sensitive and non-invasive method, high resolution ultrasonography. The present is the first such report in the literature.

METHODS

Ninety-nine unselected consecutive patients with RA, after undergoing routine clinical and laboratory evaluation, had knee radiographs and ultrasound examinations of both knees, the popliteal fossae and calves, using an Ultramark 9ATL apparatus with a 3 MHz curved array and 10 MHz linear array heads and color doppler ability.

RESULTS

A Baker's cyst was detected in 47 patients (47.5%) and in a total of 67 out of the 198 knees (33.8%). Four of the 67 cysts were ruptured. Only 29 of the 67 cysts (43.3%) had been diagnosed clinically. A statistically significant correlation was found between the presence of a Baker's cyst and clinical and radiologic involvement of the knee by rheumatoid arthritis (p < 0.025, and p < 0.05 respectively). There was a highly significant correlation between the presence of a cyst and ultrasonographically demonstrated joint effusion (p < 0.001).

CONCLUSION

Baker's cyst is very common in RA but it may escape clinical detection. High resolution ultrasound scanning of the area is a simple, highly sensitive and non-invasive technique able to overcome this problem. Therefore, it should be more widely employed by clinicians in the diagnosis of popliteal cysts, which may sometimes be accompanied by significant morbidity.