Time-dependent biological responses of juvenile yellow perch (Perca flavescens) exposed in situ to a major urban effluent

Municipal wastewater treatment plant (WWTP) effluents are significant sources of organic and inorganic pollutants to aquatic ecosystems. Several studies have shown that the health of aquatic organisms can be adversely impacted following exposure to these complex chemical mixtures. The objective of this study was to examine the effects of in situ exposure in the St. Lawrence River (QC, Canada) of juvenile yellow perch (Perca flavescens) to a major WWTP effluent. Perch were caged at a reference site in the St. Lawrence River and downstream of a WWTP effluent-influenced site for one, three, and six weeks. Fish kept in controlled laboratory setting were also examined at the beginning of the experiment to evaluate the potential effect of caging on fish. Liver metabolites and gill oxidative stress biomarkers as well as body condition of perch were investigated at four time points (zero, one, three, and six weeks). Nitrogen (δ¹⁵N) and carbon (δ¹³C) stable isotopes as well as tissue concentrations of halogenated flame retardants and trace metals were also analyzed. Results indicated that body condition of perch caged in the effluent increased after three and six weeks of exposure compared to that of reference fish. Perch caged at the WWTP effluent-influenced site also had higher muscle δ¹³C and slightly depleted muscle δ¹⁵N after three and six weeks of exposure, suggesting differences in sewage-derived nutrient assimilation between sites. Concentrations of Σ₃₄ polybrominated diphenyl ether (PBDE) were 2-fold greater in perch exposed downstream of the WWTP compared to those caged at the reference site. Metal concentrations in kidney of perch after three weeks of exposure were significantly lower at the effluent-influenced site. Kidney concentrations of Cd, Cu, Se, As, Zn and Fe were, however, higher after six weeks of exposure, supporting that metal accumulation is time- and element-specific. The metabolomes of perch from the effluent-influenced and reference sites were similar, but were distinct from the laboratory control fish, suggesting a caging effect on fish. Seven liver metabolites (glucose, malate, fumarate, glutamate, creatinine, histamine, and oxypurinol) were significantly more abundant in perch from cages than in the laboratory control perch. The combination of metabolomics and physiological variables provides a powerful tool to improve our understanding of the mechanisms of action of complex environmental pollutant mixtures in wild fish.

Diagnosis and management of heart failure from hospital admission to discharge: A practical expert guidance

Heart failure (HF) has high event rates, mortality, and is challenging to manage in clinical practice. Clinical management is complicated by complex therapeutic strategies in a population with a high prevalence of comorbidity and general frailty. In the last four years, an abundance of research has become available to support multidisciplinary management of heart failure from within the hospital through to discharge and primary care as well as supporting diagnosis and comorbidity management. Within the hospital setting, recent evidence supports sacubitril-valsartan combination in frail, deteriorating or de novo patients with LVEF≤40%. Furthermore, new strategies such as SGLT2 inhibitors and vericiguat provide further benefit for patients with decompensating HF. Studies with tafamidis report major clinical benefits specifically for patients with ATTR cardiac amyloidosis, a remaining underdiagnosed and undertreated disease. New evidence for medical interventions supports his bundle pacing to reduce QRS width and improve haemodynamics as well as ICD defibrillation for non-ischemic cardiomyopathy. The Mitraclip reduces hospitalisations and mortality in patients with symptomatic, secondary mitral regurgitation and ablation reduces mortality and hospitalisations in patients with paroxysmal and persistent atrial fibrillation. In end-stage HF, the 2018 French Heart Allocation policy should improve access to heart transplants for stable, ambulatory patients and, mechanical circulatory support should be considered to avoid deteriorating on the waiting list. In the community, new evidence supports that improving discharge education, treatment and patient support improves outcomes. The authors believe that this review fills the gap between the guidelines and clinical practice and provides practical recommendations to improve HF management.

POS1450 PATIENTS’ SAFETY SKILLS ASSESSMENT WITH BIOLOGICS AND JAK INHIBITORS: UPDATE OF THE BIOSECURE QUESTIONNAIRE

Background:

Biologic disease-modifying anti-rheumatic drug (bDMARDs) and JAK inhibitors (JAKi) may lead to an increased risk of infections, which could be prevented by enhancing patients’ safety skills (ref). We developed a self-administered questionnaire (BioSecure1, ref) in 2013 to assess the patients’ safety skills (Table 1). Following the appearance of new bDMARDs and JAKi and new information on safety, this questionnaire needed updating.

Table 1.

Nine domains of core safety skills and number of corresponding questions in BioSecure questionnaires.

Domain of competenceBioSecure1BioSecure2General knowledge42Dealing with infectious symptoms and fever1011Dealing with other infectious symptoms44Dealing with injuries, preventing infectious complications, vaccinations88Dental hygiene, preventing infectious complications, information to share with the dentist22Planning surgery, information to share with the surgeon/anesthesiologist77Planning child conception21Communication: who to contact?22Subcutaneous treatments: cold chain/cold storage, subcutaneous injection techniques30

Objectives:

To update the BioSecure questionnaire assessing patients’ safety skills

Methods:

Four steps by a 10 participants multidisciplinary steering committee. Step1: critical analysis of content and formulations of BioSecure1 on the basis of i) the participants’ own experience of the questionnaire use in current practice (5/10 participants) or research (6/10 participants) ii) assessment of BioSecure1 consistency with current guidelines for management of targeted drugs. Step2: development of a first updated version by a core group of 10 persons. Step3: comments by an extended panel of rheumatology teams interested in therapeutic patient education (TPE). Step4: testing of the final version (Biosecure2) by ten patients through cognitive debriefing.

Results:

In total, 10 rheumatologists, 6 rheumatology nurses, 1 pharmacist and 1 patient from a patient association participated. Inadequate formulations were reported regarding some situations for which recommendations had the most shifted since Biosecure1 development such as planning pregnancy, remission management and prevention measures before surgery. Features of some infectious conditions were clarified; barriers measures against infection and complications such as sigmoiditis and Herpes Zoster infection were added. BioSecure2 continues to assess the 9 domains of core safety skills (Table 1). The questionnaire was shortened to 50 items (mean filling in time is 10 minutes) with a good understanding and scoring was simplified (mean scoring time 3.5 minutes).

Conclusion:

BioSecure2 represents an updated outcome measure to evaluate the patient’s skills to prevent adverse events with targeted therapies. This questionnaire can be useful in the context of patient-health professional communication, and as a tool to measure TPE on safety issues.

References:

[1]Gossec et al, Joint Bone Spine. 2013;80:471–476

Disclosure of Interests:

None declared

FRI0630-HPR ONE-YEAR FOLLOW-UP OF A NURSE-LED TEAM INTERVENTION EFFECTIVE IN REDUCING THE NOCEBO EFFECT WHEN SWITCHING FROM ORIGINATOR INFLIXIMAB TO A BIOSIMILAR

Background:

Nonspecific subjective adverse effects and symptoms (NSAE/NSS), usually considered as related to a nocebo effect (NE), have been identified as a barrier to the acceptability of switches from biologic originators (BO) to biosimilars (BS) in rheumatology. A multidisciplinary team intervention with a prominent role of nurses has provided a reduction of the NE assessed in the short-term during a systematic switch from originator Infliximab (OI) to the biosimilar infliximab SB2 (ref.1).

Objectives:

To assess the intervention outcomes after one-year follow up in comparison with a historical cohort.

Methods:

The intervention was developed after a literature search and semi-directive interviews of patients, and included consensual communication towards patients, with a prominent role of nurses (Ref.1). All patients with chronic inflammatory rheumatic diseases (CIRD) treated by OI were included and followed-up in routine care. The outcomes were I) SB2 retention rate (RR) II) SB2 discontinuation rate due to a presumed NE, defined as lack of efficacy with no objective criteria for increased inflammation or non-objective and non-specific adverse event, either occurring after the switch and disappearing after back-switch or change of biologic. Criteria for NSAE/NSS in the historical cohort were the same lack of efficacy or subjective adverse events and disappearance after change of biologic BD. Medium-term (12 months) SB2 outcomes were assessed and compared with I) the data obtained in the short-term (34 weeks) II) the data from an historical cohort of CIRD patients treated by OI in the same rheumatology department, using Kaplan-Meier survival curve.

Results:

Forty-five patients were prospectively included for the switch from March 2018 to August 2018: 17 with rheumatoid arthritis (RA), 28 with spondylarthritis (SpA); 55% were women, mean age was 53.2 (SD: 2,1), and mean time under OI was 113.5 (SD9.3). For the historical cohort, the 52 patients treated with OI between December 2016 and January 2017 were included and their data collected at baseline and one year. Fifty-nine percent were women, mean age at inclusion was 50.25 (1.2), and mean time under OI was 94.8 (9.4).

SB2 RR did not differ from the OI RR in the historical cohort: 91.2% and 96.2% respectively at 34 weeks (p = 0.41); 84.4% and 88.5% respectively at 12 months (p = 0.52) (figure 1). The SB2 RR was significantly higher than in three other European cohorts at 34 weeks (mean RR 73.6%, p<0.05, ref.1) but not at 12 months (mean RR 80.9%, ref.2,3,4).

SB2 and OI discontinuations due to NSAE/NSS at 34 weeks were 2,2 % and 1.9% respectively; at 12 months 6,6% and 1.9% respectively (p= 0.6).

Conclusion:

An intervention based on a tailored communication with a prominent role of nurses was effective in reducing the NE when switching from OI to SB2 in the short term, compared with an historical cohort and other European cohorts. The one-year follow-up showed no statistical difference in RR or NE compared with our historical cohort. The present study shows that appropriate interventions may be developed to improve the outcome of switches to biosimilars.

Figure 1:

Treatment withdrawal free survival curves (SB2 in switched cohort and OI in historical cohort).

Kaplan Meir survival curves. Comparison with Log-Rank test between OI to SB2 cohort and historical OI cohort, p = 0.520. OI : original infliximab.

References:

[1] Petit J. Ann Rheum Dis, volume 78, supplement 2, year 2019, page A1447

[2] Glintborg B. et al. Ann Rheum Dis 2017;76:1426–31.

[3] Nikiphorou E. et al. Expert Opin Biol Ther 2015;15:1677–83.

[4] Boone NW. et al. Eur J Clin Pharmacol 2018;:1–7.

Acknowledgments:

Dr Margaux Boisson Service de rhumatologie du Professeur Kahan, Hôpital Cochin, APHP.

Disclosure of Interests:

Juliette Petit: None declared, Marie Antignac: None declared, Karine Louati: None declared, Sandra Desouches: None declared, Nathalie DEPARIS: None declared, Regine Baratto: None declared, Rosemarie POILVERD: None declared, Sylvie Dartout: None declared, Francis Berenbaum Grant/research support from: TRB Chemedica (through institution), MSD (through institution), Pfizer (through institution), Consultant of: Novartis, MSD, Pfizer, Lilly, UCB, Abbvie, Roche, Servier, Sanofi-Aventis, Flexion Therapeutics, Expanscience, GSK, Biogen, Nordic, Sandoz, Regeneron, Gilead, Bone Therapeutics, Regulaxis, Peptinov, 4P Pharma, Paid instructor for: Sandoz, Speakers bureau: Novartis, MSD, Pfizer, Lilly, UCB, Abbvie, Roche, Servier, Sanofi-Aventis, Flexion Therapeutics, Expanscience, GSK, Biogen, Nordic, Sandoz, Regeneron, Gilead, Sandoz, Catherine Beauvais Speakers bureau: Abbvie, MSD, Roche, UCB, Mylan, Sanofi

THU0577 INFLUENCE OF THE ROUTE OF ADMINISTRATION ON SAFETY AND ADHERENCE PRACTICES OF RHEUMATOID PATIENTS TREATED BY JAK-INHIBITORS AND OTHER DMARDS. AN ETHNOGRAPHIC STUDY FOR AN APP-BASED EDUCATION TOOL

Background:

JAKi (JAK inhibitors) seem simpler of use than injected biologic agents due to their oral administration route. Safety and adherence issues remain and may need to modify patients’ counseling.

Objectives:

To understand the influence of the DMARDs’ route of administration on these issues for both patients and physicians in order to update the Hiboot®education tool (ref1).

Methods:

Hiboot®is a free smartphone application developed by the French Society of Rheumatology to enhance the patient’s safety, adherence to treatment, self-assessment and to give periodic counseling messages (ref1). This ethnographic study involved i)18 patients with rheumatoid arthritis (RA) recruited by 3 rheumatologists considering diversity of clinical and sociological profiles. The panel included i) 14 women and 4 men, median age 56 years-old, median disease duration 10 years. Four patients were treated by methotrexate (MTX) monotherapy, 5 with MTX-bDMARDs or MTX-JAKi combo, 1 by bDMARDs monotherapy, 8 by JAKi monotherapy; ii) 9 rheumatologists with hospital or mixed hospital-private practice from 6 cities in France.

The interviews were conducted by 2 anthropologists using in-depth semi directive and biographical methods (enough to reach saturation), registered and transcribed. The semi-directive interviews dealt with: i) the patient history with RA and its treatments, ii) the daily medication management, iii) the evolution of patients’ perceptions and knowledge over time.

Results:

For patients, adherence and safety behaviors were guided by their representations of 3 risks: disease-related, treatment-related, physician-related. When the disease-related risk was perceived greater than the treatment-related risk, patients tended to report better adherence. Beliefs on efficacy and safety depended more on the patient’s experience with RA over time (severity, activity, control) than on the route of administration (oral vs sub-cutaneous). However, patients treated with JAKi needed to update their lay knowledge and skills regarding their daily constraints and medication management.

For rheumatologists, JAKi were considered a promising therapeutic option, but rarely prescribed so far due to a lack of personal experience. Owing to their recent introduction on the market (~2 years in France), JAKi were prescribed to patients with longer disease duration and after several DMARDs lines. The rheumatologists’ conservative attitude towards JAK-i depended on risk perceptions similar to the patients’: disease-related, treatment-related and patient-related i.e their perception of patients’ abilities to manage their care (presumed skills, autonomy…).

This study confirms the importance of patients’ beliefs of the balance between medication necessity and risks regarding safety and adherence (ref2) which are shared with the rheumatologists. This study unexpectedly emphasized a doctor-related risk in patients as well as a patient-related risk in rheumatologists. One limitation is a bias in the recruitment of patients with long-standing RA.

Conclusion:

Rheumatologist-patient collaboration needs a shared vision of medication risks, independently of the route of administration. However new skills are needed for patients treated with JAKi. This qualitative study will serve to modify the Hiboot application to include the JAKi issues such as the reminders or daily life management.

References:

[1]Beauvais C et al EULAR 2019.

[2]Neame R et al. Oxford Rheumatology. 2005.

Acknowledgments:

French Society of Rheumatology with institutional funding by Abbvie, Lilly, Pfizer.

Disclosure of Interests:

Guillaume Montagu: None declared, Sophie Gleizes: None declared, Thao Pham Speakers bureau: Novartis, Janssen, Lilly, Jérémie SELLAM: None declared, Catherine Beauvais Speakers bureau: Abbvie, MSD, Roche, UCB, Mylan, Sanofi

Argon plasma coagulation treatment of anal high-grade squamous intraepithelial lesions in men who have sex with men living with HIV: results of a 2-year prospective pilot study

OBJECTIVES

Men who have sex with men (MSM) living with HIV are at high risk for anal high-grade squamous intraepithelial lesions (HSILs) and cancer. The best management of anal HSIL remains unclear. Our objective was to assess whether argon plasma coagulation (APC) could be safe, well tolerated and efficient to treat anal HSILs in MSM living with HIV.

METHODS

A prospective phase II, open-label, pilot study was conducted to evaluate APC to treat anal HSILs in 20 HIV-positive MSM. Participants were followed for 2 years after their first treatment.

RESULTS

Twenty men with persistent HSILs completed the 2-year study. Their baseline median CD4 count was 490 cells/μL and 85% had undetectable HIV viral loads. Overall, 65% (13/20) of participants were clear of HSILs at their 24-month visit. The initial response rates after the first, second and third APC treatments were 45%, 44% and 67%, respectively, but recurrences were common. The main side effect was pain during and within 1 week after the treatments. There were no long-term side effects, nor serious adverse events related to the procedure. Cost is a drawback.

CONCLUSIONS

APC can be used to treat anal HSILs in HIV-seropositive MSM, and requires repeated treatment because of a high recurrence rate. As successful treatment of human papillomavirus (HPV) infection or eradication of the anal transitional zone remains impossible, HSIL treatment is challenging and requires long-term follow-up.

Sulfonylurea herbicides in an agricultural catchment basin and its adjacent wetland in the St. Lawrence River basin

The use of sulfonylurea herbicides (SU) has increased greater than 100 times over the past 30 years in both Europe and North America. Applied at low rates, their presence, persistence and potential impacts on aquatic ecosystems remain poorly studied. During late-spring to early fall in 2009-2011, concentrations of 9 SU were assessed in two agricultural streams and their receiving wetland, an enlargement of the St. Lawrence River (Canada). Six SU in concentrations >LOQ (10 ng L(-1)) were detected in 10% or less of surface water samples. Rimsulfuron was detected each year, sulfosulfuron and nicosulfuron in two years and the others in one year only, suggesting that application of specific herbicides varied locally between years. Detection frequency and concentrations of SU were not significantly associated with total precipitation which occurred 1 to 5d before sampling. Concentrations and fate of SU differed among sites due to differences in stream dynamics and water quality characteristics. The persistence of SU in catchment basin streams reflected the dissipation effects associated with stream discharge. Maximum concentrations of some SU (223 and 148 ng L(-1)) were occasionally above the baseline level (100 ng L(-1)) for aquatic plant toxicity, implying potential toxic stress to flora in the streams. Substantially lower concentrations (max 55 ng L(-1)) of SU were noted at the downstream wetland site, likely as a result from dilution and mixing with St. Lawrence River water, and represent less toxicological risk to the wetland flora. Sporadic occurrence of SU at low concentrations in air and rain samples indicated that atmospheric deposition was not an important source of herbicides to the study area.

Pesticides in fluvial wetlands catchments under intensive agricultural activities

A survey on pesticides (73 compounds) in the Bay St. François wetland and its catchment (part of the wetlands of Lake St. Pierre area [St. Lawrence River, Québec]) was achieved in 2006. The metabolites as well as the active ingredients of pesticides (11 compounds) were detected in the wetland and its catchment. This wetland ecosystem was active in the degradation of agricultural pesticides (e.g., atrazine). The measured pesticides were individually below the criteria for aquatic species in natural water, except chlorpyrifos. Overall, the pesticides lost from agricultural field towards the streams were <1% of the quantity applied. The environmental fates of the pesticides were found to vary according to the size of the watershed. Over large catchments, half-life times were important in terms of global loss from the agricultural lands to wetlands whereas over small catchments, soil organic carbon/water distribution coefficient (Koc) was an important term for pesticides losses to water system since half-life times were not limiting factors.

Pesticides measured in air and precipitation in the Yamaska Basin (Québec): occurrence and concentrations in 2004

Air and precipitation samples were collected and analyzed for 91 pesticides or metabolites from May to September 2004 at St. Damase, an agricultural site located in Yamaska basin in Québec, Canada. A broad range of pesticides was detected during this experiment where 40 different compounds were measured. Most of the samples showed more than 10 simultaneous pesticide detections and sometimes reaching 19 simultaneous detections. The most detected pesticides in air were trifluralin, metolachlor and captan, which were found in all the samples during the 5 months of measurements. For the detected compounds, the average concentrations ranged from 4 pg/m3 to 8 ng/m3. Some of the pesticides detected in air were found in precipitation samples as well showing that wet deposition can occur and have an impact on aquatic ecosystems. The most important pesticides detected were related to corn and soya cultivations, the two main cultures in this region highlighting that the major sources come from local applications. On the other hand, the detection of some pesticides in precipitation which were undetectable in air implies that some compounds may have a long range transport origin.

Dynamics of concentrated colloidal suspensions during drying--aging, rejuvenation and overaging

We report on the slow dynamics of concentrated colloidal suspensions during drying and rewetting under conditions of reversible concentration changes without coalescence or aggregation. We used multispeckle diffusing-wave spectroscopy to monitor the slow dynamics of particles. We found that the alpha relaxation of the suspensions exhibits successively slowing-down, acceleration and a stationary regime during drying at constant rates. Under rewetting conditions, we observed slowing-down and a stationary regime. The characteristic time of the stationary regime is inversely proportional to the rate of concentration change and identical for both drying and rewetting. We explain these regimes as aging (overaging), rejuvenation and plastic flow of the suspensions induced by a deviatoric stress (a combination of compressive and elongational stresses) which is induced by the uniaxial compressive strain generated by evaporation.

Identification of a polymorphic microsatellite marker in the mouse Fas ligand gene

We describe the characterization of a polymorphic microsatellite marker, located 1.8 kb downstream of exon 4 in the mouse Fas ligand gene. This (GT) repeat sequence allows the identification of four alleles which can very easily be distinguished by simple agarose electrophoresis.

Multidisciplinary day hospital treatment of rheumatoid arthritis patients. Evaluation after two years

The availability of multidisciplinary care for rheumatoid arthritis is still limited. The Raoul Dufy Program offered by the Saint-Antoine Teaching Hospital in Paris provides one-on-one personalized care in a day hospital setting as an adjunct to conventional medical follow-up. Listening and providing information and education are major objectives of the nurse, rheumatologist and physical therapist participating in the program. The team also includes a social worker, a surgeon, a dietician, a podiatrist and a psychologist, who intervene as needed. Seventy patients attended the program between December 1993 and September 1995 and were asked to complete a baseline and a three-month questionnaire designed to evaluate the effects of the program in terms of new therapeutic interventions, patient knowledge and quality of life. The patient knowledge score increased significantly (P < 0.0001). Many therapeutic interventions were initiated after program attendance, especially in the fields of podiatry, psychology and physical therapy. However, the quality of life score failed to improve. These results and the substantial patient demand for appointments are encouraging. Further work is needed on the methodology of multidisciplinary care evaluation. Coping strategy evaluation tools may allow to identify some of the specific benefits provided by the multidisciplinary approach.

[Destructive arthritis of the hip in Crohn disease. 10 cases]

OBJECTIVES

Destructive arthritis of the hip joint is a rare manifestation of Crohn's disease. We evaluated its frequency and clinical features in comparison with spondylarthritis and assessed the clinical course.

METHODS

One hundred patients with Crohn's disease were followed prospectively in search of destructive arthritis of the hip joint. Patients with both Crohn's disease and manifestations of inflammatory joint disease hospitalized in three rheumatology units were also evaluated retrospectively.

RESULTS

The prevalence of destructive hip disease was 2% in patients with Crohn's disease. Ten patients had destructive arthritis of the hip. Three had ankylosing spondylitis, 5 had spondylarthritis not responding to the criteria of ankylosing spondylitis and 2 had no axial joint disease. In all patients, signs of hip joint disease were a narrowed intra-articular space, bone condensation, osteophytosis and features of joint destruction. Manifestations were similar to those in patients with hip joint disease related to idiopathic ankylosing spondylarthritis. The clinical course was poorly controlled by anti-inflammatory drugs or treatment of the inflammatory bowel disease. Synoviorthesis were required and were effective in most cases. Total hip replacement was required in 3 cases.

CONCLUSION

Destructive arthritis of the hip in patients with Crohn's disease is a rare complication causing severe functional impairment further handicapping the patient with a chronic bowel disease.

[Present status of Poncet's tuberculous rheumatism. A new case]

A case of noninfectious polyarthritis of over one year's duration with calcaneal enthesopathy in a patient with visceral tuberculosis is reported. This pattern, termed Poncet's disease, shares pathophysiologic mechanisms with Freund's complete adjuvant-induced arthritis. Future studies should include polymerase chain reaction studies to look for the tubercle bacillus in joint fluid or synovial biopsy specimens.

Cutaneous vasculitis and IgA glomerulonephritis in ankylosing spondylitis

Two patients with ankylosing spondylitis were found to have IgA nephropathy and leucocytoclastic cutaneous vasculitis. Immunofluorescence showed perivascular deposition of IgA in the skin of one patient and in the mesangium of both patients. Such an association has been reported only once before. This supports the concept of abnormal IgA immune stimulation in the pathogenesis of ankylosing spondylitis.

Early diagnosis of vertebral osteomyelitis due to a rare pathogen: Haemophilus parainfluenzae

Bone and joint infections due to Haemophilus parainfluenzae are unusual. We describe a case of hematogenous vertebral osteomyelitis caused by this commensal microorganism of nose and oropharynx. Early diagnosis and therapy were possible within a week using sensitive radiologic methods: technetium bone scanning, computed tomography and magnetic resonance imaging.