Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Retrospective study of tetanus in 18 dogs-Causes, management, complications, and immunological status

Objective

Tetanus is a severe neurologic disease caused by Clostridium tetani, resulting in spastic paralysis. Canine tetanus is associated with serious complications such as aspiration and a high mortality rate of up to 50%.

Materials and methods

Medical records of all dogs diagnosed with tetanus over 8 years (2014-2022) were analyzed for severity grade, treatment protocols, nutritional management, and complications, as well as outcome, vaccination, and antibody production in some dogs. No medical records were excluded. Normality was analyzed by the D'Agostino-Pearson test. Parametric, normally distributed data were presented as mean ± standard deviation. Non-parametric, non-normally distributed data were presented as median (m) and range (minimum-maximum). The association between tetanus grade, progression of diseases, and duration of hospitalization was analyzed using the t-test, Mann-Whitney U test, and Kruskal-Wallis test. A P ≤ 0.05 was considered significant.

Results

Eighteen dogs were identified. Most affected dogs were classified into severity grade II (66.7%, 12 of 18). Clinical signs deteriorated in 55.6% of dogs (10 of 18). A source was identified in 88.9% of dogs (16 of 18). Nine dogs required surgical wound revision. A percutaneous endoscopic gastropexy tube was placed in 83.3% of dogs (15 of 18) for nutritional support. Medical treatment included metronidazole, methocarbamol, and combinations of different sedatives adapted to the patient's requirements. Tetanus antitoxin was used in 72.2% of dogs (13 of 18) without reported adverse events. The survival rate was 88.9% (16 of 18). Complications, such as hypertension, aspiration pneumonia, and laryngeal spasm occurred in 12 of 18 dogs. Median hospitalization time (8 days; range 0-16 days) was associated with the maximum tetanus severity grade (p = 0.022). Rapid eye movement behavior disorder was observed in 72.2% of dogs (13 of 18). In 5 dogs, antibodies were measured after recovery, and in 4 of 5 dogs, no antibodies were detectable despite generalized tetanus disease. Vaccination with tetanus toxoid was performed in five dogs following the disease.

Conclusion

In the present study, the mortality rate was lower than previously reported. Tetanus is still a life-threatening disease, but the prognosis may be good if adequate management and monitoring can be ensured.

[Refractory thrombotic thrombocytopenic purpura]

Thrombotic thrombocytopenic purpura (TTP) remains a serious illness with potentially life-threatening complications. The following case of a TTP patient describes a serious relapse with exacerbation in spite of adequately initiated therapy and highlights the necessity of interdisciplinary expertise in the treatment of the disease.

Inflammatory and diabetic conditions trigger SHP2 tyrosine phosphatase expression and subsequent aberrant activation of primary human monocytes

Purpose

Atherosclerosis is an inflammatory process that is particularly accelerated in diabetics, leading to increased incidence of cardiovascular diseases such as CAD and PAD in diabetic patients. Monocytes are the main component of atherosclerosis development. SHP-2 tyrosine phosphatase has been identified as an important regulator of monocyte function. The present study therefore aims to investigate the regulation of SHP-2 in inflammatory and diabetic conditions.

Methods

Primary human monocytes were isolated from the peripheral blood of type 2 Diabetes mellitus (T2DM) patients and healthy individuals. Monocytes were incubated with pro-inflammatory cytokine TNFa. For diabetic conditions, monocytes were incubated with methylglyoxal (MG), a highly reactive side product of glycolysis, or Receptor for advanced glycation end product (RAGE) ligand AGE-bovine serum (AGE-BSA). Monocyte migration was studied with Transwell migration assays. Expression of important molecules was investigated with Western Blot, RT-qPCR or FACS. Pharmacological inhibitors for SHP2, RAGE or NFκB were used.

Results

First, we could detect a significant correlation between SHP-2 mRNA and TNFa levels in T2DM monocytes in comparison to monocytes from healthy individuals. In line with that, incubation of monocytes with TNFa lead to an enhanced expression of SHP-2. Co-incubation with NFκB-inhibitor blocked TNFa-induced SHP-2 upregulation. Interestingly, incubation of monocytes with methylglyoxal caused increased release of TNFa and also augmented expression of SHP-2, indicating a pro-inflammatory effect of diabetic conditions.

Moreover, AGE-BSA treatment induced enhanced SHP-2 expression, reflecting an inflammatory-independent pathway which regulates SHP-2 additionally. This could be supported by the observation that pharmacological inhibition of RAGE attenuated both AGE-BSA and MG-induced SHP-2 activation. On a functional level, increased expression of SHP-2 in each treatment resulted in a pro-migratory phenotype that could be completely reversed by inhibition of RAGE, respectively. Fittingly, monocytes from T2DM patients showed increased migration, which normalized to an ordinary level after application of a SHP-2 inhibitor.

Conclusions

The present results reveal a new mechanism for accelerated atherosclerosis development in diabetic patients. MG and advanced glycated end products, as crucial components of the diabetic milieu, lead to increased expression of SHP-2 via the RAGE-NFkB signalling axis. Interestingly, this diabetic environment causes an increased inflammatory response through the release of TNFa cytokine, which itself leads to enhanced SHP-2 expression through activation of the NFkB transcription factor. Finally, by pharmacological inhibition of each component in this outlined SHP-2 regulatory pathway, we were able to prevent the pro-migratory activation of monocytes, offering a new approach to the treatment of diabetes-induced atherosclerosis.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): IZKF SEED Project 14/20

Einfluss der Verordnung über Tierärztliche Hausapotheken auf den Antibiotikaeinsatz bei Hund und Katze in Bayern

Gegenstand und Ziel Ziel der Studie war es, Daten über den Einsatz von Antibiotika (AB) bei Hunden und Katzen in Tierarztpraxen und -kliniken in Bayern zu erheben. Dabei sollte evaluiert werden, ob sich Änderungen hinsichtlich des Antibiotikaeinsatzes nach Novellierung der Verordnung über Tierärztliche Hausapotheken (TÄHAV) im März 2018 ergeben haben.

Material und Methoden Mittels zweier anonymisierter Online-Umfragen wurden 2017 und 2020 Tierärzte/-innen (TÄ) in Bayern, zu deren Patienten Hunde und Katzen zählen, zur Anwendung von AB sowie zur Einschätzung der Resistenzsituation befragt. Die Ergebnisse der beiden Umfragen wurden anschließend miteinander verglichen.

Ergebnisse Für 2017 konnten 238 Fragebögen ausgewertet werden; 2020 waren es 160. Die 3 am häufigsten zur systemischen Therapie beim Kleintier angewendeten AB waren 2017 Amoxicillin/Clavulansäure (74,8 % der TÄ), Enrofloxacin (56,7 %) und Amoxicillin (53,4 %). 2020 wurden Amoxicillin/Clavulansäure (88,8 %), Amoxicillin (67,5 %) und Metronidazol (33,8 %) genannt. Die teilnehmenden TÄ gaben an, signifikant weniger Cephalosporine der 3. und 4. Generation (von 20,2 % der teilnehmenden TÄ in 2017 auf 9,4 % in 2020, p = 0,005) und Fluorchinolone (von 80,3 % auf 33,1 %, p < 0,001) einzusetzen. Die Wahl eines AB wurde 2020 bei 83,8 % der befragten TÄ durch rechtliche Vorgaben beeinflusst; weitere Einflussfaktoren waren Verträglichkeit (81,3 %), Applikationsart (76,9 %), Akzeptanz durch den Patienten (70,0 %) und Häufigkeit der Anwendung (64,4 %), wobei letzterer von TÄ aus der Praxis (83,8 %, p = 0,004) signifikant häufiger genannt wurden als von TÄ aus Kliniken.

Schlussfolgerung Im Vergleich zu 2017 gaben TÄ 2020 einen signifikant geringeren Einsatz von Fluorchinolonen und Cephalosporinen der 3. und 4. Generation bei Hund und Katze an. Diese Änderungen im Verschreibungsverhalten könnten Folgen der Novellierung der TÄHAV sein, die ein Umwidmungsverbot sowie eine Antibiogrammpflicht dieser AB-Klassen vorgibt.

Klinische Relevanz Rechtliche Vorgaben können möglicherweise einen positiven Einfluss auf die Menge und Art der in der Kleintiermedizin eingesetzten Antibiotika haben und somit bei der Vermeidung von Antibiotikaresistenzen helfen.

AB1353 VESSEL AFFECTION AND THE INFLUENCE OF GLUCOCORTICOIDS ON 18F-FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY/COMPUTED TOMOGRAPHY IN GIANT CELL ARTERITIS

Background

18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) represents one of the standard imaging modalities in the detection of giant cell arteritis (GCA). Detailed data regarding the vessel involvement in GCA are not available.

Objectives

The aim of this study was to quantify arterial vessel involvement at the onset of GCA by 18F-FDG PET/CT and to verify the influence of glucocorticoid treatment on the diagnostic performance of 18F-FDG PET/CT.

Methods

This study included 60 patients (44 women and 16 men, mean age 72.8 ± 8.8 years) at the onset of GCA. All patients received a PET/CT. 44 patients were glucocorticoid naïve. 16 patient were treated with glucocorticoid (prednisone median dose 60 mg) 3.5 ± 4.4 days before the 18F-FDG PET/CT was performed. All 18F-FDG PET/CT scans were scored regarding the active inflammation of the large arteries.

Results

The most affected arteries were the aorta ascendens (72 %), followed by truncus brachiocephalicus (62 %), acrus aortae (60 %), aorta descendens (60 %), left and right arteria sublcavia (60 % and 58 %). The aorta and their outgoing arteries presented an involvement in 39 GCA patients (89 %). A singular affection of the aorta was shown in 9 patients (20 %). glucocorticoid naïve patients (89 %) showed affected arteries more frequently than glucocorticoid treated patients (38 %).

Conclusion

The study showed that the thoracic aorta (in particular aorta ascendens) is the most involved vascular segment in GCA. The use of glucocorticoids was associated with a marked decrease of vascular inflammation. Consequently, the imaging of the thoracic aorta should be included in the diagnostic procedure of GCA. 18F-FDG PET/CT should be performed without glucocorticoid treatment, if the clinical situation allowed this proceeding.

Disclosure of Interests

Leander Malich: None declared, Falk Gühne: None declared, Tobias Hoffmann: None declared, Ansgar Malich: None declared, Peter Oelzner: None declared, Gunter Wolf: None declared, Martin Freesmeyer: None declared, Alexander Pfeil Grant/research support from: This study is a part of the Investigator Initiated study Retrospective analysis of clinical and imaging parameters to predict flair in patients with giant cell arteritis.” which is supported by Chugai Pharma Germany GmbH, Lyoner Straße 15, 60528 Frankfurth am Main.

AB1374 INTERSTITIAL LUNG DISEASE IN ASYMPTOMATIC PATIENTS AT THE ONSET OF INFLAMMATORY RHEUMATIC DISEASES

Background

Interstitial lung disease (ILD) in inflammatory rheumatic diseases (IRD) is associated with increased mortality. Moreover, the lung is one of the most effected organs on IRD, but the clinical manifestations and severity can vary from subclinical abnormality to dyspnoea, respiratory failure, and death.

Objectives

The objective of the following study is to evaluate the frequency and type of ILD in asymptomatic patients at the onset of IRD.

Methods

The study represents a sub-analysis of a case-control study performed earlier, and includes 126 patients with a newly diagnosed IRD. The study cohort was divided in two groups (ILD group: n = 63 and control group: n = 63). The patients were evaluated for respiratory symptoms (cough, sputum, dyspnea) and sclerosiphonia. If possible, all patients received a lung function test and optional a chest x-ray. Patients with pathological findings in the screening tests (chest x-ray or reduced diffusing capacity for carbon monoxide (DLCO) < 80 %) maintained a high-resolution computer tomography (HR-CT) of the lung. The sub-analysis includes 20 patients with asymptomatic ILD at the onset of IRD.

Results

The asymptomatic ILD group consists out of 75 % female (n = 15) and 25 % male (n = 5) patients, with median age of 51.8 years (SD ± 17.1 years). In comparison, asymptomatic ILD patients are significant younger (t(27.4) = 2.36, p = 0.026), but the distribution of gender is similar. The mean values in different pulmonary function parameter are: FVC: 89.9% ± 19.3%; DLCO: 69.9% ± 21.2%; FEV1: 87.9% ± 21.4%; TLC: 91.0% ± 16.5% and TLCO: 82.1% ± 20.6% (FVC = Forced Vital Capacity, FEV1 = Forced Expiratory Volume in 1 second, TLC = Total Lung Capacity, TLCO = Transfer factor of the Lung for carbon monoxide). The observed CT patterns are pure ground glass opacities (GGO) (50%, n = 10), non-specific interstitial pneumonia (NSIP) (25%, n = 5), granuloma/proliferations (15%, n = 3), usual interstitial pneumonia (UIP) (5%, n = 1) and lymphocytic interstitial pneumonia (LIP) (5%, n = 1). The distribution of CT pattern was not significant to the symptomatic ILD group (χ2(6) = 10.224, p = 0.116).

Conclusion

The study highlighted that also clinical asymptomatic patients have ILD in IRD at the onset of the IRD. Frequently, a reduced DLCO is detectable in PFT as a sign of early lung involvement, so this represents a potential screening parameter. Moreover, asymptomatic patients are often younger than symptomatic patients. No significant difference was found in CT pattern, but further research is needed as the number of patients is quite small.

Disclosure of Interests

None declared

Bacterial urinary tract infection and subclinical bacteriuria in dogs receiving antineoplastic chemotherapy

Background

Immunosuppressive treatment with glucocorticoids and cyclosporine increases the risk for positive urine cultures (PUCs) in dogs.

Objective

To investigate the prevalence and incidence of PUC in dogs diagnosed with cancer and treated with antineoplastic chemotherapy while distinguishing between subclinical bacteriuria (SB) and urinary tract infection (UTI).

Animals

Forty‐six client‐owned dogs with nonurogenital cancer treated with antineoplastic chemotherapy.

Methods

Prospective observational longitudinal clinical study. Dogs in which a urine culture was performed before the start of and at least once during antineoplastic chemotherapy were included. A McNemar's test was used to investigate if the prevalence of PUC increased during antineoplastic chemotherapy. Positive urine cultures were categorized into SB and UTI and multiple PUCs from the same dog and category were grouped together as 1 episode of PUC.

Results

Urine culture was positive in 21/185 urine samples in 8/46 dogs. Antineoplastic chemotherapy did not influence the prevalence of PUC (P = 1.00), which was 11% (5/46 dogs; 95% confidence interval: 5‐23%) before the start of and 13% (6/46 dogs; 95% confidence interval: 6‐26%) during antineoplastic chemotherapy. Eight dogs had 10 episodes of PUC; 7/10 episodes were classified as SB, and in 3/10 episodes UTI (chronic prostatitis, prostatic abscess, and emphysematous cystitis) was diagnosed. Escherichia coli was the most common pathogen, isolated in 9/10 episodes.

Conclusions and Clinical Importance

We did not find evidence that antineoplastic chemotherapy is a major predisposing factor for the development of PUC. Most dogs with PUC had SB.

Corynebacterium rouxii, a recently described member of the C. diphtheriae group isolated from three dogs with ulcerative skin lesions

Corynebacterium (C.) diphtheriae is one of the two etiological pathogens for human diphtheria with significant morbidity and mortality. Recently, members of its biovar Belfanti have been described as two novel species, C. belfantii and C. rouxii. The most important virulence factor and also the premise to cause diphtheria is the isolate’s capacity to encode and express the diphtheria toxin (DT). In contrast to C. ulcerans, which represents a potentially zoonotic pathogen, C. diphtheriae (incl. the novel deduced species) has almost exclusively been found to comprise a human pathogen. We here report three rare cases of C. rouxii isolation from dogs suffering from disseminated poly-bacterial exsudative to purulent dermatitis and a traumatic labial defect, respectively. The isolates were identified as C. diphtheriae based on commercial biochemistry and matrix-assisted laser desorption/ionisation–time of flight mass spectrometry (MALDI-TOF MS) analysis. However, recently described specific spectral peaks were highly similar to spectra of C. rouxii, which was confirmed by whole genome sequencing. Further investigations of the dog isolates for the presence of DT by tox gene qPCR revealed negative results. The findings from this study point out that skin infections in companion animals can be colonized by uncommon and so believed human specific pathogens, thereby resembling the clinical signs of cutaneous diphtheria.

AB0796 THE EVALUATION OF LUNG DIAGNOSTIC PROCEDURE AT THE ONSET OF INFLAMMATORY RHEUMATIC DISEASES WITH INTERSTITIAL LUNG DISEASE

Background:

Interstitial lung disease (ILD) in inflammatory rheumatic diseases (IRD) is associated with increased mortality. Moreover, the lung is one of the most effected organs on IRD. Consequently, screening methods were required to the detect ILD in IRD.

Objectives:

The objective of the following study is to evaluate the diagnostic value of lung function test, chest x-ray and HR-CT of the lung in the detection of ILD at the onset of IRD.

Methods:

The study is designed as a case-control study and includes 126 patients with a newly diagnosed IRD. It was matched by gender, age and the performance of lung function test and chest x-ray. The sensitivity and specificity were verified by crosstabs and receiver operating characteristic (ROC) curve analysis. The study cohort was divided in two groups (ILD group: n = 63 and control group: n = 63). If possible, all patients received a lung function test and optional a chest x-ray. Patients with pathological findings in the screening tests (chest x-ray or reduced diffusing capacity for carbon monoxide (DLCO) < 80 %) maintained a high-resolution computer tomography (HR-CT) of the lung. Additionally, an immunological bronchioalveolar lavage was performed in the ILD group as gold standard for the detection of ILD.

Results:

The DLCO (< 80 %) revealed a sensitivity of 83.6 % and specificity of 45.8 % for the detection of ILD. Other examined parameter of lung function test showed no sufficient sensitivity as screening test (FVC = Forced Vital Capacity, FEV1 = Forced Expiratory Volume in 1 second, TLC = Total Lung Capacity, TLCO = Transfer factor of the Lung for carbon monoxide). Also, a combination of different parameter did not increase the sensitivity. The sensitivity and specificity of chest x-ray for the verification of ILD was 64.2 % versus 73.6 %. The combination of DLCO (< 80 %) and chest x-ray showed a sensitivity with 95.2 % and specificity with 38.7 %. The highest sensitivity (95.2 %) and specificity (77.4 %) was observed for the combination of DLCO (< 80 %) and HR-CT of the lung.

Conclusion:

The study highlighted that a reduced DLCO in lung function test is associated with a lung involvement in IRD. DLCO represented a potential screening parameter for lung manifestation in IRD. Especially patients with suspected vasculitis should receive an additional chest x-ray. Based on the high sensitivity of DLCO in combination with chest x-ray or HR-CT for the detection of ILD in IRD, all patients with a reduced DLCO (< 80%) should obtained an imaging of the lung.

Disclosure of Interests:

None declared

OP0075 EVALUATION OF A VIRTUAL REALITY TEACHING CONCEPT FOR MEDICAL STUDENTS DURING THE SARS-COV-2 PANDEMIC

Background:

The ongoing COVID-19 pandemic has disrupted face-to-face teaching of medical students and forced efforts in finding alternative approaches. In order to help maintain high-quality education, a new virtual reality (VR)-based concept for training medical students in rheumatic and musculoskeletal diseases (RMD) has been developed. This VR training concept is based on the integration of real patient data with two- and three-dimensional visualized pathological joints from X-ray and computed tomography generated images.

Objectives:

To evaluate the practicability and acceptance of the VR training application in the digital curricular education of medical students during the COVID-19 pandemic.

Methods:

A short refresher lecture on rheumatic diseases (duration 60 minutes) was followed by presenting the VR training concept to the students. The VR training concept included the demonstration of three virtual patients with early rheumatoid arthritis, rheumatoid arthritis psoriatic arthritis regarding the symptoms, current medical problems, disease patterns at the imaging (conventional radiographs and high-resolution computed tomography) and therapy options. The practicability and acceptance of the VR was evaluated by medical students using a survey.

Results:

The study encompassed 237 medical students (163 female, 73 male, one diverse, age range 20 to 40 years). 72 % of the participants rated the virtual teaching as good or very good. 87 % presented an expanded knowledge for rheumatoid arthritis and psoriatic arthritis through the VR. Moreover, 91 % reported that the lecture provided a deeper understanding of RMD. Furthermore, 60 % of the students asked for additional courses by VR.

Conclusion:

The study highlighted the usefulness of innovative VR tools for teaching medical students digitally about RMD. VR applications can be a complementary educational modality for medical students, especially during the COVID-19 pandemic, to provide students with the best possible clinical experience while ensuring that patient, student, and staff safety is not compromised.

Figure 1.

A Screen view of virtual reality included three virtual patients with early rheumatoid arthritis (RA), RA, and psoriatic arthritis (PsA) and B demonstration of structural damage in RA and PsA using hand X-ray and high-resolution quantitative computed tomography images.

Disclosure of Interests:

Alexander Pfeil Speakers bureau: Lilly Pharma Deutschland GmbH, Franz Marcus: None declared, Tobias Hoffmann: None declared, Philipp Klemm Consultant of: Lilly Pharma Deutschland GmbH, Peter Oelzner: None declared, Ulf Müller-Ladner Consultant of: Lilly Pharma Deutschland GmbH, Axel Hueber Consultant of: Lilly Pharma Deutschland GmbH, Uwe Lange: None declared, Gunter Wolf: None declared, Georg Schett: None declared, David Simon Consultant of: Lilly Pharma Deutschland GmbH, Arnd Kleyer Consultant of: Lilly Pharma Deutschland GmbH

[Effects of the SARS-CoV‑2 pandemic on the otolaryngology university hospitals in the field of research, student teaching and specialist training]

Hintergrund

Ab Frühjahr 2020 kam es zur weltweiten Verbreitung von SARS-CoV‑2 mit der heute als erste Welle der Pandemie bezeichneten Phase ab März 2020. Diese resultierte an vielen Kliniken in Umstrukturierungen und Ressourcenverschiebungen. Ziel unserer Arbeit war die Erfassung der Auswirkungen der Pandemie auf die universitäre Hals-Nasen-Ohren(HNO)-Heilkunde für die Forschung, Lehre und Weiterbildung.

Material und Methoden

Die Direktorinnen und Direktoren der 39 Universitäts-HNO-Kliniken in Deutschland wurden mithilfe einer strukturierten Online-Befragung zu den Auswirkungen der Pandemie im Zeitraum von März bis April 2020 auf die Forschung, Lehre und die Weiterbildung befragt.

Ergebnisse

Alle 39 Direktorinnen und Direktoren beteiligten sich an der Umfrage. Hiervon gaben 74,4 % (29/39) an, dass es zu einer Verschlechterung ihrer Forschungstätigkeit infolge der Pandemie gekommen sei. Von 61,5 % (24/39) wurde berichtet, dass pandemiebezogene Forschungsaspekte aufgegriffen wurden. Von allen Kliniken wurde eine Einschränkung der Präsenzlehre berichtet und 97,5 % (38/39) führten neue digitale Lehrformate ein. Im Beobachtungszeitraum sahen 74,4 % der Klinikdirektoren die Weiterbildung der Assistenten nicht gefährdet.

Schlussfolgerung

Die Ergebnisse geben einen Einblick in die heterogenen Auswirkungen der Pandemie. Die kurzfristige Bearbeitung pandemiebezogener Forschungsthemen und die Einführung innovativer digitaler Konzepte für die studentische Lehre belegt eindrücklich das große innovative Potenzial und die schnelle Reaktionsfähigkeit der HNO-Universitätskliniken, um auch während der Pandemie ihre Aufgaben in der Forschung, Lehre und Weiterbildung bestmöglich zu erfüllen.

[Effects of the SARS-CoV-2 pandemic on the otorhinolaryngology university hospitals in the field of medical care]

INTRODUCTION

Since December 2019, the SARS-CoV-2 virus has been rapidly spreading worldwide. In Germany, an exponential increase in the number of infections was registered at the beginning of March 2020 and led to a call of the Ministry of Health to create more capacity for intensive medical treatment in hospitals. The aim of the present study was to determine the effects of the SARS-CoV-2 pandemic on Oto-Rhino-Laryngology (ORL) university hospitals regarding patient care.

MATERIALS AND METHODS

An online survey was sent out to all chairmen of the 39 ORL university hospitals in Germany. The answers to the questions referred to the defined period from March 15^th to April 15^th 2020 and were carried out using the online survey tool "SurveyMonkey". 87 questions focused on general information, health care, and structural effects in the respective institution.

RESULTS

All chairmen of the 39 university hospitals in Germany participated in the survey. The collected data prove the considerable impact on organizational, structural and medical aspects of patient care. For example, the surveyed clinics reported a decrease in outpatient cases by 73.8 % to 26.2 ± 14.2 % and in surgical treatments by 65.9 % to 34.1 ± 13.9 %. In contrast, emergency treatment remained unchanged or even increased in 80 % of the facilities and surgical treatment of emergency patients remained unchanged or even increased in more than 90 %. Emergency outpatient and surgical treatment of patients was provided throughout the pandemic in all facilities. In total, about 35 000 outpatients and about 12 000 surgical cases were postponed. As a result of the acute structural changes, the potential danger of falling below current treatment standards was seen in individual areas of patient care.

DISCUSSION

The assessment of the impact of the SARS-CoV-2 pandemic is heterogeneous. The majority of the chairmen are critically aware of the risk of falling below current medical treatment standards or guidelines. In the phase of an exponential increase in the number of infections, significant changes in treatment processes had to be accepted for understandable reasons. However, with the currently significantly reduced number of infections, falling below treatment standards and guidelines should not be allowed to remain constant and tolerated.

SUMMARY

This study shows a differentiated picture with regard to the effects of the SARS-CoV-2 pandemic on outpatient, inpatient and operative patient care at the ORL university hospitals in Germany and illustrates the importance of these institutions for ensuring patient care during this critical phase.

AB0822 WHICH CLINICAL FACTORS INFLUENCE MINERALIZATION OF THE METACARPAL BONES AND FINGER JOINT SPACE WIDTH IN PSORIATIC ARTHRITIS?

Background:

Metacarpal bone mineral density as measured by digital x-ray radiogrammetry (DXR-BMD) and finger joint space width quantified by computer-aided joint space analysis presented computer based and observer independent parameters for the evaluation of radiographic damage of the hand skeleton.

Objectives:

The aim of this study was to quantify clinical parameter which potential influence periarticular mineralisation of the metacarpal bones and finger joint space width in Psoriatic Arthritis (PsA)-patients.

Methods:

The study includes 201 PsA-patients. All patients received a radiograph of the hand. Bone mineral density was measured by DXR (Pronosco X-Posure System™, Version 2.0; Sectra; Sweden) and finger joint space width of all finger joints were evaluated by computer-aided joint space analysis (CAJSA, Radiogrammetry Kit, Version 1.3.6; Sectra; Sweden). The Z-Score was used as an age- and gender-independent parameter for the quantification finger joint space narrowing.

Results:

Regarding gender, the DXR-BMD was significant reduced with -0.028 g/cm2in women. An equivalent significant result was evaluated for finger joint space width (Z-ScoreMCP -1.07, Z-ScorePIP -0.81 and Z-ScoreDIP -0.76). The DXR-BMD was significantly lowert (-0.011 g/cm2) between the disease duration < 2 years (0.545±0.076 g/cm2) and >10 years (0.509±0.070 g/cm2). The Z-Score showed no significant change regarding the disease duration. Inflammatory activity as measured by c-reactive protein presented no impact on DXR-BMD and the Z-Score of all finger joints. Additionally, the use of corticosteroids was associated with a reduced DXR-BMD (-0.037 g/cm2) and an absence of finger joint space narrowing.

Conclusion:

The study highlights that the demineralisation of the metacarpal bones was associated with female gender, disease duration and the use of corticosteroids. Whereas, the prior mentioned parameters had no influence on finger joint space width. Consequently, periarticular demineralisation and finger joint space narrowing presented two different and independent radiological signs in PsA.

References:

N/A

Disclosure of Interests:

Alexander Pfeil Grant/research support from: This study Investigator Initiated Study “Automatic assessment of joint space narrowing in rheumatoid arthritis based on the Post-hoc analysis” (number: IIS-2016-110818) is a part of the of the Investigator Initiated Study “The quantification of inflammatory related periarticular bone loss in certolizumab pegol treated patients with rheumatoid arthritis” (number: IIS-2014-101458) which is supported by UCB Pharma GmbH, Monheim, Germany., Marcus Heinz: None declared, Diane Renz: None declared, Joachim Böttcher: None declared, Gunter Wolf: None declared, Peter Oelzner: None declared

THU0146 DAS28-REMISSION IS ASSOCIATED WITH AN INCREASE OF FINGER JOINT SPACE WIDTH IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

The reduction of finger joint space width in patients with rheumatoid arthritis (RA) is associated with joint destruction. Anti-TNF treatment with certolizumab pegol is an effective therapy in RA-patients. The computer-assisted joint space analysis is a new computer based technique to measure joint space width on hand radiographs.

Objectives:

The aim of this post-hoc analysis of the data set used in the RAPID 1 trial was to quantify finger joint space width of RA patients treated with Certolizumab pegol in Association to DAS28-remission.

Methods:

The post-hoc analysis includes 297 patients. These patients were treated with certolizumab pegol 200 mg (every two weeks) plus methotrexate and certolizumab pegol 400 mg (every two weeks) plus methotrexate. All patients underwent x-rays of the hand at baseline and week 52 as well as the quantification of finger joint space width of the metacarpal-phalangeal articulations (MCP) using the computer-assisted joint space analysis (Version 1.3.6; Sectra; Sweden). The joint space distance is expressed as mean joint space width of the MCP joints I to V (JSD-MCP total). Remission was defined with a Disease Activity Score 28 < 2.6.

Results:

The group with DAS28-remission (DAS28 < 2.6) presented a significant joint space increase with 3.3 % for JSD-MCP total from 0.152 ± 0.033 cm (baseline) to 0.157 ± 0.033 cm (week 52) treated with certolizumab pegol 200 mg as well as with 3.9 % for JSD-MCP total from 0.152 ± 0.031 cm (baseline) to 0.158 ± 0.032 cm (week 52). For the patients without DAS28-remission (DAS28 > 2.6) under the treatment with certolizumab pegol 400 mg a non-significant change of JSD-MCP total from 0.145 ± 0.034 cm (baseline) to 0.144 ± 0.036 cm (week 52) was observed. A similar result was evaluated for the certolizumab pegol 200 mg group (JSD-MCP total: 0.146 ± 0.037 cm [baseline] to 0.143 ± 0.037 cm [week 52]).

Conclusion:

The study highlights that patients treated with certolizumab pegol plus methotrexat and a DAS-Remission showed an increase of joint space width of the metacarpal-phalangeal articulations which is potentially associated with reparative effects of the cartilage under the anti-TNF treatment with certolizumab pegol.

References:

N/A

Disclosure of Interests:

Alexander Pfeil Grant/research support from: This study Investigator Initiated Study “Automatic assessment of joint space narrowing in rheumatoid arthritis based on the Post-hoc analysis” (number: IIS-2016-110818) is a part of the of the Investigator Initiated Study “The quantification of inflammatory related periarticular bone loss in certolizumab pegol treated patients with rheumatoid arthritis” (number: IIS-2014-101458) which is supported by UCB Pharma GmbH, Monheim, Germany., Anica Nussbaum: None declared, Diane Renz: None declared, Ansgar Malich: None declared, Joachim Böttcher: None declared, Peter Oelzner: None declared, Gunter Wolf: None declared

Effect of amoxicillin-clavulanic acid on clinical scores, intestinal microbiome, and amoxicillin-resistant Escherichia coli in dogs with uncomplicated acute diarrhea

Background

Despite limited evidence of efficacy, antibiotic treatment is still frequently prescribed in dogs with uncomplicated acute diarrhea (AD).

Objective

To assess whether amoxicillin‐clavulanic acid has a clinical benefit, an effect on the fecal microbiome, and the proportion of amoxicillin‐resistant Escherichia coli in dogs with AD.

Animals

Sixteen dogs with AD of <3 days duration.

Methods

Prospective, placebo‐controlled, double‐blinded study. Clinical scores were compared between client‐owned dogs randomly assigned to an antibiotic (AG) or a placebo (PG) group. The intestinal microbiome was analyzed using quantitative PCR assays. Amoxicillin‐resistant fecal E. coli were assessed semiquantitatively with microbiological methods.

Results

There was no difference in clinical recovery between treated dogs or controls (CADS index day 10: AG group median: 2 (range: 1‐3; CI [1.4; 2.6]); PG group median: 1.6 (range: 1‐3; CI [1.1; 2.4]); P > .99). All dogs gained normal clinical scores (CADS index ≤3) after 1 to 6 days (median 2 days) after presentation. There was no significant difference in the fecal dysbiosis index (during treatment: AG mean −2.6 (SD 3.0; CI [−5.1; 0.0]); PG mean −0.8 (SD 4.0; CI [−4.2; 2.5]; P > .99) or its bacterial taxa. The proportion of resistant fecal E. coli increased (to median: 100%; range: 35%‐100%) during treatment with amoxicillin‐clavulanic acid and was still increased (median: 10%; range 2%‐67%) 3 weeks after treatment, both of which were significantly higher proportions than in the placebo group for both time points (during treatment AG median 100% versus PG median 0.2% (P < .001); after treatment AG median 10% versus PG median 0.0% (P = .002)).

Conclusions and Clinical Importance

Our study suggests that treatment with amoxicillin‐clavulanic acid confers no clinical benefit to dogs with AD, but predisposes the development of amoxicillin‐resistant E. coli, which persist for as long as 3 weeks after treatment. These findings support international guideline recommendations that dogs with diarrhea should not be treated with antimicrobials unless there are signs of sepsis.

Evaluation of different cleaning methods for feline inhalation chambers after bacterial contamination

OBJECTIVES

Inhalation chambers are commonly used for the delivery of aerosol drugs to cats with respiratory disease. The aim of the study was to identify successful cleaning methods for inhalation devices after standardised bacterial contamination.

METHODS

Spacer devices of two different manufacturers were used: RC Chamber (Cegla Medizintechnik) and Aerokat (Trudell Medical International). The bacterial contamination was performed using Pseudomonas aeruginosa. Previously marked areas of the chamber were contaminated with 50 μl of bacterial solution, containing between 2.2 ×10⁵ and 2.1 ×10⁸ colony-forming units/ml each. After cleaning the devices as recommended by each manufacturer (RC Chamber: special microwave cleaning bag [n = 5] or boiling water with liquid dish detergent for 15 mins [n = 5]; Aerokat: rinsing in a solution of lukewarm water and liquid dish detergent for 15 mins), chambers were air-dried for 24 h and samples for bacterial culture were taken from three defined areas. Sample material was applied on Müller-Hinton agar plates and subsequently incubated for 24 h at 37°C.

RESULTS

Bacterial contamination was not detected in any of the examined inhalation devices using the recommended cleaning methods.

CONCLUSIONS AND RELEVANCE

If inhalation chambers are cleaned following the manufacturers' recommendations, successful bacterial decontamination can be expected.

[Analysis of referral diagnoses to the rheumatology department]

BACKGROUND

The initial presentation of patients with symptoms indicative of a rheumatic disease is in most cases not directly to a rheumatologist. This study evaluated the following questions: I. Which medical specialists refer patients to a department of rheumatology? II. Evaluation of the accordance of the presumptive referral diagnosis and the final diagnosis by a rheumatologist.

METHODS

A total of 947 patients (279 men and 668 women) who initially presented to a university hospital for rheumatological diagnostics were included in the study. The referring medical specialist fields were identified. Furthermore, a kappa analysis was performed to evaluate the accordance of the presumptive referral diagnosis and the final diagnosis generated after a rheumatological evaluation of the patients.

RESULTS

Of the referrals 73% were initiated by general practitioners or internists functioning as general practitioners. The other referrers were 5% specialists in internal medicine (excluding rheumatology), 4% orthopedic/trauma surgeons, 1% other surgeons and 4% other specialist fields. A rheumatological diagnosis was made in 58% of the patients and rheumatological inflammatory joint diseases (26%), collagenosis (14%) and vasculitides (5%) were the most frequently diagnoses. The accordance of the presumptive diagnosis of the general practitioners and the final diagnosis after rheumatological evaluation was a kappa coefficient of κ = 0.304. Lower kappa values were evaluated for orthopedic surgeons (κ = 0.277) and other specialists (κ = 0.200).

CONCLUSION

The referrals to a rheumatology institution were frequently initiated by general practitioners and internists functioning as general practitioners. In this context the presumptive diagnosis of general practitioners showed a low accordance with the final rheumatological diagnosis. In contrast, a detailed presumptive diagnosis is desirable for optimal use of the limited resources for rheumatological care.

Canine Brucellosis: Insights Into the Epidemiologic Situation in Europe

Brucella canis is one of many responsible pathogens of discospondylitis in dogs and infections require specific management. Little is known about the epidemiologic situation in Europe. The purpose of the study was to get insights into the occurrence of brucellosis in dogs in Europe. The database of a European veterinary laboratory was screened for Brucella positive samples. Additionally, medical records of a veterinary hospital in Germany were screened for diagnosis of discospondylitis and brucellosis. The laboratory received samples from 20 European countries for Brucella testing in dogs: 3.7% of submitted samples were Brucella spp. PCR-positive (61/1,657), and Brucella canis antibodies were identified in 5.4% of submitted samples (150/2,764). Brucella spp. PCR-positive samples originated from Spain (11.1% of submitted samples), Poland (6.7% of submitted samples) and rarely from Italy and France. Samples with Brucella canis antibodies originated from 13 European countries (Sweden, Belgium, Austria, Switzerland, Italy, Finland, Germany, Denmark, Hungary, Norway, Poland, France, Netherlands). Young dogs (0–24 months) had a 5.4-fold increased risk of PCR positive samples. The supplementary medical records search identified four young female dogs (7–30 months) with Brucella canis discospondylitis in Germany. The four dogs had been imported to Germany from Eastern European countries (Moldavia, Romania, Macedonia). In conclusion, infection with Brucella canis needs to be considered in dogs in Europe and diagnostics for Brucella canis infection appear indicated in young dogs with discospondylitis.

Determination of minimum inhibitory concentrations for silver sulfadiazine and other topical antimicrobial agents against strains of Pseudomonas aeruginosa isolated from canine otitis externa

BACKGROUND

Otitis externa is a common presenting complaint in practice. Ear infections by Pseudomonas aeruginosa are particularly problematic due to the organism's high level of resistance and ability to damage the tympanum. Treatment should be based on susceptibility testing although minimum inhibitory concentrations (MICs) are not available for all treatment options. Silver sulfadiazine has been used in cases of recurrent P. aeruginosa otitis, although a MIC for silver sulfadiazine as a single agent has not been established.

OBJECTIVES

To describe susceptibility patterns of P. aeruginosa isolated from canine otitis externa and determine the MIC for silver sulfadiazine and other topical antimicrobials.

ANIMALS

Thirty-six P. aeruginosa isolates were collected from client-owned dogs, suffering from otitis externa.

METHODS AND MATERIALS

Susceptibility patterns were established using disc diffusion susceptibility testing against 17 antimicrobial agents. For determination of the MIC, selected strains were tested against increasing concentrations of marbofloxacin, enrofloxacin, gentamicin, polymyxin B and silver sulfadiazine using broth microdilution.

RESULTS

For nine of 17 antimicrobial agents, complete resistance was seen in all isolates tested via disk diffusion susceptibility testing. Approximately 94% and 96% of isolates were susceptible to gentamicin and imipenem, respectively. These findings were consistent with broth dilution, where all strains were susceptible to gentamicin. Resistance was higher against polymyxin B and the fluoroquinolones. Silver sulfadiazine was effective in vitro with a MIC ranging from 1 to 64 μg/mL.

CONCLUSIONS AND CLINICAL SIGNIFICANCE

As the MIC of silver sulfadiazine was lower than the concentration in a 1% preparation, such a product potentially represents a treatment option for dogs with P. aeruginosa otitis.

[Sonographic analysis of swallowing in the cervical section of the esophagus]

BACKGROUND

Dysphagia is a common symptom reported by patients in various medical fields, raising the question of diagnosis. In addition to otorhinolaryngologic examination with a mirror, the current gold standards videofluoroscopy and fiber optic endoscopic evaluation of swallowing (FEES) are available. Ultrasound is frequently used in everyday clinical practice, although its application for swallowing diagnostics needs addressing.

MATERIALS AND METHODS

Between April 2012 and February 2014, 81 subjects (age 19-66 years) with no indication of a swallowing disorder were sonographically examined. The anatomic representation of swallowing structures was evaluated and videos of the cervical part of the esophagus during swallowing of different consistencies (saliva, water, jelly) were recorded and analyzed. In a pilot study, the examination was tested on 3 dysphagia patients.

RESULTS

The base of the tongue, the intralaryngeal structures, the cervical spine, and the thyroid glands were well visualized. Sonographic representation of the cervical esophagus section was particularly successful. Its length could be detected at 5.78 ± 1.66 cm, the diameter measured at 0.88 ± 0.10 cm. Sonographic inspection of the sinus piriformis was most difficult; it could not be seen in 39.5% of cases. Visualization of the sinus piriformis was better in cases of normal weight and age <25 years (odds ratios 5.6 and 11.3, respectively). In the examination of patients with a swallowing disorder, three different pathologies (Forestier's disease, esophageal stenosis, and motor neuron disease) were identified as the cause of complaints.

CONCLUSION

Sonography enables very good visualization of swallowing and evaluation of the cervical esophagus. Where available, the otorhinolaryngologist should consider ultrasound as a diagnostic option, as it enables repeated evaluation of swallowing and can complement previously available diagnostic tools.

Intestinal lesions in dogs with acute hemorrhagic diarrhea syndrome associated with netF-positive Clostridium perfringens type A

Acute hemorrhagic diarrhea syndrome (AHDS), formerly named canine hemorrhagic gastroenteritis, is one of the most common causes of acute hemorrhagic diarrhea in dogs, and is characterized by acute onset of diarrhea, vomiting, and hemoconcentration. To date, histologic examinations have been limited to postmortem specimens of only a few dogs with AHDS. Thus, the aim of our study was to describe in detail the distribution, character, and grade of microscopic lesions, and to investigate the etiology of AHDS. Our study comprised 10 dogs with AHDS and 9 control dogs of various breeds, age, and sex. Endoscopic biopsies of the gastrointestinal tract were taken and examined histologically (H&E, Giemsa), immunohistochemically ( Clostridium spp., parvovirus), and bacteriologically. The main findings were acute necrotizing and neutrophilic enterocolitis (9 of 10) with histologic detection of clostridia-like, gram-positive bacteria on the necrotic mucosal surface (9 of 10). Clostridium perfringens isolated from the duodenum was identified as type A (5 of 5) by multiplex PCR (5 of 5). In addition, each of the 5 genotyped isolates encoded the pore-forming toxin netF. Clostridium spp. (not C. perfringens) were cultured from duodenal biopsies in 2 of 9 control dogs. These findings suggest that the pore-forming netF toxin is responsible for the necrotizing lesions in the intestines of a significant proportion of dogs with AHDS. Given that the stomach was not involved in the process, the term "acute hemorrhagic diarrhea syndrome" seems more appropriate than the frequently used term "hemorrhagic gastroenteritis."

Prevalence of feline urinary tract pathogens and antimicrobial resistance over five years

The aim of this retrospective study was to document the prevalence of bacterial species in cats with significant bacteriuria and to compare their antimicrobial susceptibilities over five years. One hundred sixty-nine positive urine cultures from 150 cats were included. Fifty-five per cent showed clinical signs, while 40 per cent had subclinical bacteriuria. Escherichia coli, Staphylococcus species, Enterococcus species, Streptococcus species and Proteus mirabilis accounted for 50.5 per cent, 22.9 per cent, 15,1 per cent, 3.6 per cent and 2.6 per cent, respectively. Enterococcus species was significantly more common in cats with subclinical bacteriuria. Enterococcus species and Proteus mirabilis isolates were resistant to a significantly higher number of antimicrobials than other isolates. Applying the formula to select rational antimicrobial therapy, bacterial isolates were most likely to be susceptible to imipenem, nitrofurantoin, gentamicin and amoxicillin clavulanic acid. Over the study period, only minor differences were noted for the antimicrobial impact factors (IFs) between years and between cats with and without clinical signs. The cumulative IF increased significantly compared with the previous 10 years. Empirical treatment of bacterial cystitis should be avoided whenever possible and, if needed, based on the locally determined bacterial spectrum and antibiotic susceptibility.

18F-FDG PET: early postoperative period of oro-maxillo-facial flaps

Aim: We addressed the feasibility of FDG-PET to differentiate between viability and non-viability in the immediate postoperative assessment of flaps (autologous microvascular anastomosed pedicled flaps) in oro-maxillo-facial surgery. Methods: 3-7 days after surgery, FDG-PET was done in 38 patients who had received flaps for reconstruction of the mandible after partial resection. The studies were done on a dedicated full ring PET-scanner (ECAT EXACT HR+, Siemens/CTI). Acquisition started between 60 and 80 min post injection. The findings of the soft tissue component of the flaps were grouped using a three point scale: (I) no defect, (II) small defects, (III) one large defect. The results of PET were compared with the clinical course for at least 3 months. Results: “No defect” on the FDG-PET study identified viability of the flap and predicted normal clinical follow-up (22/38 patients). “Small defects” visualized areas of decreased perfusion and decreased glucose metabolism indicating risk of non-viability (13/38 patients); adapting the postsurgical management led to delayed but uncomplicated healing of the flaps in these patients. “One large defect” demonstrated early necrosis of the flap (3/38 patients). After removal and replacement of this necrotic portion of the flap the second FDG-PET scan of these 3 patients demonstrated the uncomplicated post-operative healing. Conclusion: FDG-PET facilitated the assessment of viability and non viability of flaps in the immediate postsurgical period, and demonstrated the usefulness of FDG-PET for postoperative care and prognosis.

Untersuchungen zur ultraschallgeführten Lungenbiopsie beim Schwein

Ziel dieser Arbeit war eine Beurteilung der ultraschallgeführten Lungenbiopsie bezüglich ihrer Eignung zur Diagnostik von Pneumonien des Schweines. Ultraschalluntersuchungen und Biopsien der Lunge wurden in Allgemeinanästhesie bei insgesamt 60 Schweinen mit klinisch manifesten Lungenerkrankungen durchgeführt. Dabei handelte es sich um Tiere mit einem Körpergewicht zwischen 6 und 81 kg, die zur Diagnostik in die Tierklinik eingeliefert wurden. Das Risiko der Lungenbiopsie und die Folgen bis zu neun Tagen nach der Punktion wurden anhand klinischer, pulsoximetrischer und labordiagnostischer Untersuchungen der Tiere sowie sonographischer, pathologisch-anatomischer und histologischer Beurteilung der Biopsiestellen ermittelt. Eine Einschätzung des diagnostischen Wertes von Ultraschalluntersuchungen und Biopsie der Lunge erfolgte durch einen Vergleich der sonographischen und makroskopischen Lungenbefunde sowie durch vergleichende histologische und mikrobiologische Untersuchungen der Bioptate und des Lungengewebes post mortem. Risiken der Lungenbiopsie stellten die Narkose und Blutungen unmittelbar nach der Punktion dar. Im Verlauf der Anästhesie entwickelten 18% der Tiere eine lebensbedrohliche Dyspnoe. Mittel- bis hochgradige Blutungen traten bei 9,6% der punktierten Tiere auf. Als Risikofaktoren erwiesen sich Hämostasestörungen sowie ein geringes Körpergewicht. Pathologisch- anatomisch diagnostizierte pneumonische Verdichtungen wurden mit einer Sensitivität von 94% sonographisch erkannt und waren mit wenigen Ausnahmen hinsichtlich Art und Lokalisation der Veränderungen zu differenzieren. Als histologisch auswertbar erwiesen sich 78% der untersuchten Bioptate. Bei 43% der untersuchten, zu einem großen Teil antibiotisch vorbehandelten Tiere konnten aus den Lungenbioptaten ein oder zwei Keimarten nachgewiesen werden. Eine gute Übereinstimmung mit den Befunden des Sektionsmaterials bestand bezüglich der Häufigkeit isolierter lungenpathogener Keime. Unspezifische Keime waren häufig in den Sektionsproben nachweisbar, konnten dagegen aus keinem der Bioptate isoliert werden.

Bakterielle Harnwegsinfektionen bei Katzen

Ziel: Ermittlung der Prävalenz prädisponierender Begleiterkrankungen (BE) bei Katzen mit bakteriellen Harnwegsinfektionen (HWI) und der Prävalenz von Bakterienspezies bei verschiedenen BE sowie deren Sensibilität gegenüber den bei HWI häufig eingesetzten Antibiotika Doxycyclin, Trimethoprim-Sulfamethoxazol (TMS), Amoxicillin-Clavulansäure (AMC), Cephalothin und Enrofloxacin. Material und Methoden: In die retrospektive Studie wurden Katzen mit positiver Urinkultur im Zeitraum 2003–2009 eingeschlossen. Basierend auf den Daten der Krankenakten erfolgte eine Einteilung in vier Gruppen: Katzen mit systemischen prädisponierenden BE, Katzen mit lokalen prädisponierenden BE, Katzen mit Harnblasendauerkathetern (HBDK) und Katzen ohne dokumentierte BE. Zur Ermittlung der wahrscheinlichen Effektivität der Antibiotika wurden deren antimikrobielle Impact-Faktoren berechnet. Ergebnisse: In die Studie gingen 194 Katzen mit 219 bakteriellen Isolaten ein. Davon wiesen 78,4% (152/194) eine BE auf. 49,5% (96/194) hatten eine systemische BE und 28,9% (56/194) hatten eine lokale BE oder einen HBDK. Katzen mit systemischen BE waren signifikant älter als Katzen der anderen Gruppen und häufiger weiblich als Katzen mit lokaler BE und HBDK. Mehr als 50% der Katzen mit systemischer BE zeigten keine klinischen Symptome einer Erkrankung des unteren Harntrakts. Escherichia (E.) coli, gefolgt von Streptococcus spp., Staphylococcus spp. und Enterococcus spp. waren die am häufigsten vorkommenden Isolate. Dabei lag der Anteil der E.-coli-Isolate bei Katzen mit systemischer BE signifikant höher, während bei Katzen mit HBDK und Katzen mit anderen lokalen BE der Anteil an Streptococcus- und Staphylococcus-spp.-Isolaten signifikant höher war. Bei Katzen mit lokaler BE und Katzen mit HBDK ergaben sich niedrigere antimikrobielle Impact-Faktoren als bei Katzen der anderen Gruppen. Schlussfolgerung und klinische Relevanz: Ein Großteil der Katzen mit HWI leidet unter einer prädisponierenden BE. Katzen mit systemischer BE zeigen häufig keine Symptome einer Erkrankung des unteren Harntrakts. AMC und TMS waren in dieser Katzenpopulation die Antibiotika mit den höchsten antimikrobiellen Impact-Faktoren.

Noninvasive assessment and quantification of tumour vascularisation using MRI and CT in a tumour model with modifiable angiogenesis - An animal experimental prospective cohort study

Background

To investigate vascular-related pathophysiological characteristics of two human lung cancers with modifiable vascularisation using MRI and CT.

Methods

Tumour xenografts with modifiable vascularisation were established in 71 rats (approval by the Animal Care Committee was obtained) by subcutaneous transplantation of two human non-small-cell lung cancer (NSCLC) cells (A549, H1299) either alone or co-transplanted with vascular growth promoters. The vascularity of the tumours was assessed noninvasively by MRI diffusion-weighted-imaging (DWI), T2-weighted, and time-of-flight (TOF) sequences) as well as contrast-enhanced CT (CE-CT), using clinical scanners. As a reference standard, histological examinations (CD-31, fluorescent beads) were done after explantation.

Results

Microvessel density (MVD) was higher in co-transplanted tumours (171 ± 19 number/mm²) than in non-co-transplanted tumours (111 ± 11 number/mm²; p = 0.002). Co-transplanted tumours showed higher growth rates and larger tumour vessels at TOF-MRI as well as larger necrotic areas at CE-CT. In co-transplanted tumours, DWI revealed higher cellularity (lower minimal ADC_diff 166 ± 15 versus 346 ± 27 mm²/s × 10⁻⁶; p < 0.001), highly necrotic areas (higher maximal ADC_diff 1695 ± 65 versus 1320 ± 59 mm²/s × 10⁻⁶; p < 0.001), and better-perfused tumour stroma (higher ADC_perf 723 ± 36 versus 636 ± 51 mm²/s × 10⁻⁶; p = 0.005). Significant correlations were found using qualitative and quantitative parameters: maximal ADC_perf and MVD (r = 0.326); maximal ADC_diff and relative necrotic volume on CE-CT (r = 0.551); minimal ADC_diff and MVD (r = −0.395).

Conclusions

Pathophysiological differences related to vascular supply in two human lung cancer cell lines with modifiable vascularity are quantifiable with clinical imaging techniques. Imaging parameters of vascularisation correlated with the results of histology. DWI was able to characterise both the extent of necrosis and the level of perfusion.

[Detection of Salmonella Choleraesuis var. Kunzendorf in a fattening pig with septicaemic salmonellosis. A case report]

The present case reports the detection of Salmonella (S.) Choleraesuis var. Kunzendorf and porcine circovirus type 2 in an organic fattening pig suffering from septicaemic salmonellosis and porcine dermatitis and nephropathy syndrome. Six weeks after pigs had been housed in an organic fattening farm, an increase in mortality, diarrhea and coughing was observed. In recent years, S. choleraesuis var. Kunzendorf has been frequently detected in wild boars in Germany, whereas the same serovar did not play an important role in the Western European domestic pig population. A direct transmission of this serovar from wild boars to domestic pigs in this case could not be proven. However, because wild boars are important reservoirs for the spread of epizootic diseases to the domestic pig population, this case emphasises the importance of taking epidemiological relationships under consideration and to comply with biosecurity measures according to German law (Schweinehaltungshygieneverordnung).

European multicenter study on antimicrobial resistance in bacteria isolated from companion animal urinary tract infections

BACKGROUND

There is a growing concern regarding the increase of antimicrobial resistant bacteria in companion animals. Yet, there are no studies comparing the resistance levels of these organisms in European countries. The aim of this study was to investigate geographical and temporal trends of antimicrobial resistant bacteria causing urinary tract infection (UTI) in companion animals in Europe. The antimicrobial susceptibility of 22 256 bacteria isolated from dogs and cats with UTI was determined. Samples were collected between 2008 and 2013 from 16 laboratories of 14 European countries. The prevalence of antimicrobial resistance of the most common bacteria was determined for each country individually in the years 2012-2013 and temporal trends of bacteria resistance were established by logistic regression.

RESULTS

The aetiology of uropathogenic bacteria differed between dogs and cats. For all bacterial species, Southern countries generally presented higher levels of antimicrobial resistance compared to Northern countries. Multidrug-resistant Escherichia coli were found to be more prevalent in Southern countries. During the study period, the level of fluoroquinolone-resistant E. coli isolated in Belgium, Denmark, France and the Netherlands decreased significantly. A temporal increase in resistance to amoxicillin-clavulanate and gentamicin was observed among E. coli isolates from the Netherlands and Switzerland, respectively. Other country-specific temporal increases were observed for fluoroquinolone-resistant Proteus spp. isolated from companion animals from Belgium.

CONCLUSIONS

This work brings new insights into the current status of antimicrobial resistance in bacteria isolated from companion animals with UTI in Europe and reinforces the need for strategies aiming to reduce resistance.