Comorbidities in Chilean Psoriasis Patients ‐ a Global Healthcare Study on Psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory skin disease associated with several important medical comorbidities. There are scant data available on the comorbidities of patients with psoriasis in South America.

AIM

To examine the comorbidity profile of adult patients with psoriasis in Chile and its association with severity of psoriasis.

METHODS

This was a multicentre, cross-sectional study involving 16 hospitals and clinics in Chile, which used a 48-item questionnaire to study clinician- and patient-reported outcomes and comorbidities. Inferential analyses were performed by psoriasis severity, using Fisher exact test, Student t-test and multivariable logistic regression.

RESULTS

In total, 598 adult patients with psoriasis were included (51.1% male; mean age 49.2 ± 15.1 years); 48.5% mild and 51.4% moderate to severe; Psoriasis Area and Severity Index 11.6 ± 11.5; body surface area 14.7 ± 18.2%. Plaque psoriasis was the most common phenotype (90.2%), followed by guttate (13.4%). Psoriatic arthritis occurred in 27.3% of patients. Comorbidities were reported in 60.2% of all patients with psoriasis. Frequent concomitant diseases were obesity (25.3%), hypertension (24.3%), Type 2 diabetes mellitus (T2DM) (18.7%), dyslipidaemia (17.4%), metabolic syndrome (16.7%) and depression (14.4%). After adjustment, significant associations were found between moderate to severe psoriasis and obesity, T2DM and nonalcoholic fatty liver disease (NAFLD) compared with mild psoriasis.

CONCLUSIONS

We report a large study of comorbidities, including depression, dyslipidaemia, T2DM and NAFLD, in people with psoriasis in Chile. The prevalence of comorbidities with psoriasis in Chile appears similar to that found in Western countries, and emphasizes the importance of assessing patients with psoriasis for risk factors for and presence of, comorbid disease in a multidisciplinary setting.

AB0152 PROSPECTIVE ANALYSIS OF OBSTRUCTIVE SLEEP APNEA IN NEWLY DIAGNOSED PATIENTS WITH RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS AND PERIPHERAL SPONDYLOARTHRITIS – A SCREENING STUDY

Background:

An increased prevalence of obstructive sleep apnea (OSA) in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and partially in peripheral spondylarthritis (pSpA) has been noted and described for nearly two decades. Until now, there is no study yet on the occurrence of OSA in patients with these entities at the point of first diagnosis. Identifying and treating OSA could prove pivotal in improving cardiovascular risk and quality of life. Furthermore, clinicians require insights into whom to screen.

Objectives:

To assess the prevalence of OSA in early RA, PsA and pSpA and strategies for targeted screening.

Methods:

We performed a prospective study on patients with first diagnosis of RA, PsA or pSpA, who were screened for day sleepiness (assessed by the Epworth sleepiness scale) and tested for obstructive sleep disorders by out-of-center sleep apnea polygraphy (employing Embletta® MPR-PG devices) at the University Hospital of Bonn, Germany. Findings were assessed by three physicians, always including an attending physician responsible for the certified sleep laboratory.

Results:

A total of 22 patients with RA (52.38%), 15 with PsA (35.7%), and 5 (11.9%) with pSpA were included. Day sleepiness screening was unremarkable (ESS <10) in 29 (69%) patients and suspicious for a sleep disorder (ESS≥10) in 13 patients (31%). Subsequent sleep studies of five patients (11.9%) were suspicious for severe sleep apnea (AHI >15/h), eight (19.1%) for low-to-moderate sleep apnea (AHI 5-15/h) and 29 (69.1%) were unremarkable (AHI <5). Of the eight low-to-moderate results, none were symptomatic as in ESS ≥10, resulting in a total of five (11.9%) guideline-confirming referrals for inpatient polysomnography/ventilation therapy. In comparison with the PsA/pSpA group, a diagnosis of RA had no significant relationship with ESS results (p≈0.23), nor AHI results ≥5/h (p≈0.14). The male cohort yielded more pathological sleep studies, but the result was not significant (16% vs. ~5.9%, p≈0.32). Higher ESS scores (≥10) were not predictive for findings which require a referral (p≈0.37). Increased BMI (≥25 kg/m2) was not associated with an AHI > 5/h (p≈0.63).

Conclusion:

From the point of screening, a number needed to screen of 8.4 (6.25 in the male, 17 in the female group), speaks in favor of overall cost-efficient screening for OSA in newly diagnosed male patients with arthritis diseases. A different study design, comparing early vs. established arthritis cohorts is necessary to assess the role of disease duration in the possible development of OSA.

References:

[1]Chung W-S, Lin C-L. Sleep disorders associated with risk of rheumatoid arthritis. Sleep Breath [Internet]. 2018 Dec 10 [cited 2018 Dec 11];22(4):1083–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29428977.

[2]Vakil M, Park S, Broder A. The complex associations between obstructive sleep apnea and auto-immune disorders: A review. Med Hypotheses [Internet]. 2018;110:138–43. Available from: https://doi.org/10.1016/j.mehy.2017.12.004.

[3]Wali S, Mustafa M, Manzar D, Bawazir Y, Attar S, Fathaldin O, et al. Prevalence of obstructive sleep apnea in patients with rheumatoid arthritis. J Clin Sleep Med. 2020.

Table 1.

Patient characteristics

Total (n=42)RA (n=22)PsA (n=15)pSpA (n=5)AgeMedian (IQR)49 (36-61)58 (39-64)43 (30-55)39 (39-46)SexMale25 (59.5%)15 (68.2%)6 (40%)4 (80%)Female17 (40.5%)7 (31.8%)9 (60%)1 (20%)Obesity by BMI (<25/≥25)Normal weight/Underweight19 (45.2%)10 (45.5%)7 (46.6%)2 (40%)Overweight/Obesity23 (54.8%)12 (55.5%)8 (53.3%)3 (60%)ESS Score<1029 (69%)17 (77.3%)8 (53.3%)4 (80%)≥1013 (31%)5 (22.7%)7 (46.7%)1 (20%)AHI<5/h29 (69%)13 (59.1%)12 (80%)4 (80%)5-15/h8 (19.1%)6 (27.3%)1 (6.7%)1 (20%)>15/h5 (11.9%)3 (13.6%)2 (13.3%)0 (0%)

RA – rheumatoid arthritis, PsA – psoriatic arthritis, pSpA – peripheral spondyloarthritis, IQR – interquartile range, BMI – body mass index, ESS – Epworth Sleepiness Scale, AHI – Apnea/Hypopnea Index

Disclosure of Interests:

None declared

Association of proangiogenic and profibrotic serum markers with lung function and quality of life in sarcoidosis

Background

Sarcoidosis is a systemic inflammatory granulomatous disease, frequently affecting the lung. If left untreated, it may end in lung fibrosis. Proangiogenic and profibrotic vascular endothelial growth factor (VEGF), transforming growth factor (TGF)-β1, fibroblast growth factor (FGF)-2 and platelet-derived growth factor (PDGF)-AB are a known therapeutical target in pulmonary fibrosing diseases, e.g. IPF, but there is no targeted therapy option for pulmonary fibrosis in sarcoidosis.

Objectives

The aim of our study was to determine the association of these markers’ serum levels on lung function and the patients’ quality of life in a long-term follow-up of sarcoidosis patients, to provide further information for finding targeted therapy options for pulmonary sarcoidosis.

Methods

54 patients with sarcoidosis underwent blood sampling, pulmonary function testing and answered the King’s Brief Interstitial Lung Disease (K-BILD) questionnaire at baseline and at three-years follow-up. Serum levels of profibrotic and angiogenic markers were assessed at baseline by enzyme-linked immunosorbent assay.

Results

Between 2015 and 2018, 54 patients with biopsy proven sarcoidosis were enrolled. Throughout the observation period, there was a significant decrease in the diffusion capacity for carbon monoxide (DLCO) [%] (-6.5504 ± 13,39, p = 0.001) and forced expiratory volume in one second predicted (FEV1) [%] (-6.07 ± 12.09, p = 0.001). Patients with greater impairment of forced vital capacity (FVC) did have significantly higher serum levels of VEGF (p = 0.03) and PDGF-AB (p<0.001). The K-BILD questionnaire did not change significantly during follow-up. However, patients with worsening K-BILD scores did have significantly higher serum-levels of PDGF-AB (2.67 pg/ml ± 0.93 vs. 1.88 pg/ml ± 0.60, p = 0.004) at baseline, compared to those with unchanged or increasing K-BILD scores.

Conclusions

Among patients with pulmonary sarcoidosis, baseline serum levels of VEGF and PDGF-AB were associated with pulmonary function impairment. Furthermore, PDGF-AB was associated with worsening K-BILD scores. No such association was observed for FGF-2 and TGF-ß1. VEGF and PDGF-AB may be possible prognostic and therapeutic targets in sarcoidosis as a fibrosing ILD beyond IPF.

Atherosclerotic Vessel Changes in Sarcoidosis

Sarcoidosis is a systemic granulomatous disease. Atherosclerosis is a chronic inflammatory vessel disease. The aim of our present study was to investigate whether sarcoidosis could be associated with increased risk of atherosclerotic vessel changes. Angiological analysis and blood tests were performed in 71 sarcoidosis patients and 12 matched controls in this prospective cross-sectional study. Specifically, angiological measurements comprised ankle brachial index (ABI), central pulse wave velocity (cPWV), pulse wave index (PWI), and duplex sonography of central and peripheral arteries. Sarcoidosis activity markers (angiotensin converting enzyme, soluble interleukin-2 receptor) and cardiovascular risk parameters such as cholesterol, lipoprotein(a), C-reactive protein, interleukin 6, fibrinogen, d-dimer, and blood count were analyzed in blood. We found no relevant differences in ABI, cPWV, and plaque burden between the sarcoidosis and control groups (1.10 ± 0.02 vs. 1.10 ± 0.02, 6.7 ± 0.5 vs. 6.1 ± 1.2, 53.7 % vs. 54.5 %, respectively). However, PWI was significantly higher in sarcoidosis patients (146.2 ± 6.8) compared with controls (104.9 ± 8.8), irrespectively of the activity of sarcoidosis and immunosuppressive medication. Except for increased lipoprotein(a) and d-dimer in sarcoidosis, the remaining cardiovascular markers were similar in both groups. We conclude that sarcoidosis is associated with increased pulse wave index, which may indicate an early stage of atherosclerosis.

Impaired Vascular Function in Sarcoidosis Patients

A common feature of sarcoidosis and atherosclerosis is a chronic systemic inflammatory reaction. Our hypothesis was that sarcoidosis may negatively influence the vessel status. We addressed the issue by examining preatherosclerotic vascular alternations using an ultrasound-based speckle-tracking method in 72 sarcoidosis patients and 15 matched controls. To find potential factors which may have a deleterious influence on arterial performance, different subgroups of sarcoidosis, such as sarcoidosis with or without cortisone therapy, pulmonary sarcoidosis in early and advanced stages, pulmonary sarcoidosis alone or combined with extrapulmonary sarcoidosis, and sarcoidosis with or without elevated blood levels of angiotensin converting enzyme (ACE)/soluble interleukin 2 receptor (sIL-2R) were investigated. We found in the general collective of sarcoidosis patients that circumferential strain (2.68 ± 0.19%), circumferential strain rate (0.21 ± 0.01 1/s), and radial displacement (0.10 ± 0.01 mm) were significantly decreased compared to controls (3.77 ± 0.35%, 0.28 ± 0.02 1/s, and 0.14 ± 0.02 mm, respectively). Vascular strains were more impaired in patients with cortisone therapy, pulmonary sarcoidosis in stages III-IV, and in pulmonary sarcoidosis accompanied by extrapulmonary involvement. The level of ACE/sIL-2R had no relevant influence on the angiological parameters. In conclusion, sarcoidosis is associated with increased vascular stiffness. Cortisone therapy and advanced stages of pulmonary sarcoidosis with extrapulmonary manifestations may account for the impaired vascular function in this patient collective.

Determination of kinetic parameters for biomass combustion

The aim of this work is to provide a wide database of kinetic data for the most common biomass by thermogravimetric analysis (TGA) and differential thermogravimetry (DTG). Due to the characteristic parameters of DTG curves, a two-stage reaction model is proposed and the kinetic parameters obtained from model-based methods with energy activation values for first and second stages in the range 1.75·10(4)-1.55·10(5)J/mol and 1.62·10(4)-2.37·10(5)J/mol, respectively. However, it has been found that Flynn-Wall-Ozawa and Kissinger-Akahira-Sunose model-free methods are not suitable to determine the kinetic parameters of biomass combustion since the assumptions of these two methods were not accomplished in the full range of the combustion process.

High prevalence of peripheral arterial disease in patients with obstructive sleep apnoea

INTRODUCTION

Obstructive sleep apnoea (OSA) merits increasing attention as cardiovascular risk factor. Whereas carotid and coronary artery disease have been associated with OSA, occurrence of peripheral arterial disease (PAD) in OSA remains undefined.

METHODS

We screened 100 patients with suspected OSA for PAD. After polysomnography, each patient underwent standardized angiological testing including ankle-brachial index (ABI), central pulse wave velocity, pulse wave index and duplex sonography.

RESULTS

Among total study population, PAD prevalence accounted for 88%, of those 68% had asymptomatic plaques and 20% were symptomatic Fontaine ≥ IIa. In confirmed OSA, prevalence raised up to 98%. Except for smoking habits, distribution of established risk factors did not differ between OSA groups (patients without, mild, intermediate and severe OSA). Presence of plaque, Fontaine PAD stages and intermittent claudication exhibited significant gain with increasing AHI. A logistic regression model revealed that age (OR = 1.199, 95% CI [1.066; 1.348]) and the logarithmically transformed AHI (OR = 5.426, 95% CI [1.068; 27.567]) had the strongest influence on plaque presence. Central pulse wave velocity as marker of arterial stiffness was positively correlated with AHI.

CONCLUSION

OSA is associated with a high prevalence of PAD. This implies substantial diseasés under-recognition and a presumable atherogenic role of OSA in the pathogenesis of PAD. However, vasoprotective impact of OSA treatment remains to be determined.

[New therapeutic approaches to pulmonary embolism: trials' results and significance of direct oral anticoagulants]

Venous thromboembolisms (VTE) are frequently encountered emergencies that sometimes run a fatal course. Diagnostic and therapeutic strategies in patients with suspected pulmonary embolism (PE) are based on the presence of shock and hypotension. Oral anticoagulation is recommended for at least three months, extended anticoagulation should be considered for patients with unprovoked PE and low bleeding risk. As an alternative to vitamin K antagonists, direct oral anticoagulants are recommended. The present review discusses the mode of action, current data, and the status of rivaroxaban, dabigatran, apixaban and edoxaban in the treatment of PE - taking into account the new guidelines of the European Society of Cardiology and their clinical implementation.

[Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) in a 67-year-old patient with chronic coughing]

HISTORY AND CLINICAL FINDINGS

A 67-year-old woman with a history of chronic obstructive pulmonary disease and breast cancer developed an increase in size and number of pulmonary nodules that had previously been stable over the course of 9 years.

INVESTIGATIONS

Thoracic computed tomography revealed a well-defined pulmonary lesion with a diameter of 1,1 × 1,1 cm, accompanied by multiple bilateral pulmonary nodules with a maximum size of 5 mm. Thoracoscopic resection of the major nodule was extended to a completive resection of an adjacent lung area that operatively showed a macroscopically noticeable hypervascularity. Histopathological examination assigned the larger lesion to a typical carcinoid; the additionally resected hypervascular lung parenchyma confirmed an accumulation of hyperplastic neuroendocrine cells in terms of a diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH).

TREATMENT AND COURSE

Since histological examination showed an entirely resected neuroendocrine tumor classified as typical carcinoid, and considering DIPNECH to be a preinvasive lesion, the therapeutic management consisted of serial imaging by computed tomography. During the last two years, no progression of either the pulmonary lesions or of the obstructive disease was observed.

CONCLUSION

DIPNECH is a rare, primary pulmonary process with proliferation of hyperplastic neuroendocrine cells, affecting principally middle-aged, non-smoking women. It is considered to be a precursor lesion to pulmonary carcinoid tumors. Given its only minor risk of invasive metastatic spread, serial imaging for timely detection of progressing lesions and optimizing of concomitant obstructive pulmonary disease are the preferred treatment approaches.

Experimental design approach to evaluate the impact of oak chips and micro-oxygenation on the volatile profile of red wines

A chemometric strategy based on combining an experimental design approach and response surface methodology was applied to gain further knowledge on the influence of chip maceration and micro-oxygenation related factors (oxygen doses, chip doses, wood origin, toasting degree and maceration time) on the volatile profile of red wines during the accelerated ageing process. The results obtained indicated that the volatile profile of wines could be modulated by applying different combinations of factor conditions. Thus, these results would be used to obtain wines with specific volatile profiles that would lead to particular olfactory attributes according to consumers' preferences. Moreover, it was shown that combining wood from different origins helped enhance the quality of the elaborated wines. To the best of our knowledge, this is the first time that an experimental design methodology has been applied to simultaneously evaluate the influence of five different ageing parameters on the volatile profile of red wines.

Endobronchial valve-induced pneumatocele: a case report

We report a 75-year old female patient with advanced emphysema. After endoscopic lung volume reduction with endobronchial valves (EBV), a huge pneumatocele has occured and resolved spontaneously within a few weeks. Albeit rare, pneumatoceles should be considered in patients with relapsing dyspnoe after EBV treatment.

Regional variation in survival before and after pediatric heart transplantation--an analysis of the UNOS database

Geographic variation occurs in a variety of health outcomes. Regional influences on outcomes before and after listing for pediatric heart transplantation have not been assessed. Review of the UNOS dataset identified 5398 pediatric (≤ 18 years) patients listed for heart transplantation 2000-2011. Patients were stratified based on the region of listing. Regional-level variables were correlated with individual risk-adjusted outcomes. Mean time spent on the waitlist varied from 91.0 ± 163 days (Region 6 [R6]) to 248.1 ± 493 days (R4, p < 0.0001). Regions with more transplant centers (p < 0.0001) and fewer transplants (p = 0.0015) had higher waitlist mortality. Risk-adjusted individual waitlist mortality varied from 6.9% (R1, CI 6.2-7.8) to 19.2% (R5, CI 18.0-20.6). Waitlist mortality was higher for individuals awaiting transplant in regions with more listings per center (OR 1.04, CI 1.01-1.08) and lower in regions with more donors per center (OR 0.95, CI 0.90-0.99 per donor). Posttransplant risk-adjusted survival varied across regions (R4: 5.4%, CI 4.2-7.4; R7: 18.0%, CI 12.4-32.5), but regional variables were not correlated with outcomes. Outcomes among children undergoing heart transplantation vary by region. Factors leading to increased competition for donor allografts are associated with poorer waitlist survival. Equitable allocation of cardiac allografts requires further investigation of these findings.

Atriplex atacamensis and Atriplex halimus resist As contamination in Pre-Andean soils (northern Chile)

The Pre-Andean area of Chile exhibits saline soils of volcanic origin naturally contaminated with arsenic (As), and we hypothesise that revegetation with resistant species may be a valid alternative for soil management in this area. Thus, the xerophytic and halophytic shrubs Atriplex halimus and Atriplex atacamensis were cultivated in containers for 90 days in Pre-Andean soil, As-soil, (111±19 mg As kg(-1), pH8.4±0.1) or control soil (12.7±1.1 mg As kg(-1), pH7.8±0.1) to evaluate As accumulation and resistance using stress bioindicators (chlorophylls, malondialdehyde (MDA) and total thiols). Sequential extraction of As-soil indicated that 52.3% of As was found in the most available fraction. The As distribution was significantly different between the species: A. halimus translocated the As to leaves, whilst A. atacamensis retained the As in roots. At 30 and 90 days, A. halimus showed similar As concentrations in the leaves (approximately 5.5 mg As kg(-1)), and As increased in stems and roots (up to 4.73 and 16.3 mg As kg(-1), respectively). In A. atacamensis, As concentration was lower (2.6 in leaves; 3.2 in stems and 6.9 in roots in mg As kg(-1)). Both species exhibited a high concentration of B in leaves (362-389 mg kg(-1)). If the plants are used for animal feed, it should be considered that A. halimus accumulates higher concentration of As and B in the leaves than A. atacamensis. Neither plant growth nor stress bioindicators were negatively affected by the high levels of available As, with the exception of MDA in the leaves of A. halimus. The results indicate that these plants resist contamination by arsenic, accumulating mainly the metalloid in the roots and can be recommended to generate plant cover in As-contaminated soils in the Pre-Andean region, under saline conditions controlled, preventing the dispersion of this metalloid via wind and leaching.