Acute physiological responses and muscle recovery in females: a randomised controlled trial of muscle damaging exercise in hypoxia

BACKGROUND

Studies have investigated the effects of training under hypoxia (HYP) after several weeks in a male population. However, there is still a lack of knowledge on the acute hypoxic effects on physiology and muscle recovery in a female population.

METHODS

This randomized-controlled trial aimed to investigate the acute effects of muscle damaging exercise, performed in HYP and normoxia (CON), on physiological responses and recovery characteristics in healthy females. Key inclusion criteria were recreationally active female participants between the age of 18 to 35 years without any previous surgeries and injuries, whilst key exclusion criteria were acute pain situations, pregnancy, and medication intake. The females conducted a muscle-damaging protocol, comprising 5 × 20 drop-jumps, in either HYP (FiO2: 12%) or CON (FiO2: 21%). Physiological responses, including capillary oxygenation (SpO2), muscle oxygenation (SmO2), heart rate (HR), core- (Tcore) and skin- (Tskin) temperature were assessed at the end of each exercise set. Recovery characteristics were quantified by taking venous blood samples (serum creatine-kinase [CK], C-reactive protein [CRP] and blood sedimentation rate [BSR]), assessing muscle swelling of the quadriceps femoris muscle, maximum voluntary isometric contraction (MVIC) of the knee extensor muscles, countermovement jump (CMJ) performance and muscle soreness ratings (DOMS) at 24-, 48- and 72-hrs post-exercise.

RESULTS

SpO2 (HYP: 76.7 ± 3.8%, CON: 95.5 ± 1.7%, p < 0.001) and SmO2 (HYP: 60.0 ± 9.3, CON: 73.4 ± 5.8%, p = 0.03) values were lower (p < 0.05) in HYP compared to CON at the end of the exercise-protocol. No physiological differences between HYP and CON were observed for HR, Tcore, and Tskin (all p > 0.05). There were also no differences detected for any recovery variable (CK, CRP, BSR, MVIC, CMJ, and DOMS) during the 72-hrs follow-up period between HYP and CON (all p > 0.05).

CONCLUSION

In conclusion, our results showed that muscle damaging exercise under HYP leads to reduced capillary and muscle oxygenation levels compared to normoxia with no difference in inflammatory response and muscle recovery during 72 h post-exercise.

TRIAL REGISTRATION

NCT04902924, May 26th 2021.

Performances of HEART score to predict 6-month prognostic of emergency department patients with chest pain: a retrospective cohort analysis

Chest pain is a frequent cause of patient admissions in emergency departments (EDs). Clinical scores can help in the management of chest pain patients with an undefined impact on the appropriateness of hospitalization or discharge when compared to usual care. The aim of this study was to assess the performances of the HEART score to predict the 6-month prognostic of patients presenting to the ED of a tertiary referral university hospital with non-traumatic chest pain. From 7040 patients presenting with chest pain from 1 January 2015 to 31 December 2017, after applying exclusion criteria (ST-segment elevation >1 mm, shock, absence of telephone number) we selected a sample of 20% chosen randomly. We retrospectively assessed the clinical course, definitive diagnosis, and HEART score according to ED final report. Follow-up was made by telephone interview with discharged patients. In hospitalized patients, clinical records were analyzed to evaluate major adverse cardiac events (MACE) incidence. The primary endpoint was MACE, comprising cardiovascular death, myocardial infarction, or unscheduled revascularization at 6 months. We assessed the diagnostic performance of the HEART score in ruling out MACE at 6 months. We also assessed the performance of ED usual care in the management of chest pain patients. Of 1119 screened, 1099 were included for analysis after excluding patients lost to follow-up; 788 patients (71.70%) had been discharged and 311 (28.30%) were hospitalized. Incident MACE was 18.3% (n = 205). The HEART score was retrospectively calculated in 1047 patients showing increasing MACE incidence according to risk category (0.98% for low risk, 38.02% for intermediate risk, and 62.21% for high risk). Low-risk category allowed to safely exclude MACE at 6 months with a negative predictive value (NPV) of 99%. Usual care diagnostic performance showed 97.38% sensitivity, 98.24% specificity, 95.5% positive predictive value, and 99% NPV, with an overall accuracy of 98.00%. In ED patients with chest pain, a low HEART score is associated with a very low risk of MACE at 6 months.

Asymptomatic bacteriuria in candidates for active treatment of renal stones: results from an international multicentric study on more than 2600 patients

The occurrence of asymptomatic bacteriuria concomitant to urolithiasis is an issue for patients undergoing renal stone treatment. Disposing of a preoperative urine culture is essential to reduce the risk of septic events. The endpoint of the study is to report which characteristics of candidates for renal stone treatment are frequently associated with positive urine culture. 2605 patients were retrospectively enrolled from 14 centers; inclusion criteria were age > 18 and presence of a single renal stone 1-2 cm in size. The variables collected included age, gender, previous renal surgery, comorbidities, skin-to-stone distance, stone size, location, density, presence of hydronephrosis. After a descriptive analysis, the association between continuous and categorical variables and the presence of positive urine culture was assessed using a logistic regression model. Overall, 240/2605 patients (9%) had preoperative bacteriuria. Positive urine culture was more frequent in females, patients with previous renal interventions, chronic kidney disease, congenital anomalies, larger stones, increased density. Multivariate analysis demonstrated that previous renal interventions (OR 2.6; 95% CI 1.9-3.4; p < 0.001), renal-related comorbidities (OR 1.31; 95% CI 1.19-1.4; p < 0.001), higher stone size (OR 1.06; 95% CI 1.02-1.1; p = 0.01) and density (OR 1.00; 95% CI 1.0-1.00; p = 0.02) were associated with bacteriuria; male gender and lower caliceal location were inversely related to it. Beyond expected risk factors, such as female gender, other parameters are seemingly favoring the presence of positive urine culture. The awareness of variables associated with bacteriuria allows to assess which individuals are at increased risk of presenting bacteriuria and reduce the rate of septic complications.

Cardiomyocyte stretch mediates the relation between left ventricular amyloid burden and adverse outcomes in light chain amyloidosis: a 18F-florbetapir positron emission tomography study

Background

Patients with light chain (AL) amyloidosis and cardiac involvement have poor prognosis. Mayo stage accounts for severity of plasma cell dyscrasia and cardiac biomarker release, and provides powerful risk stratification. Myocardial amyloid burden can be quantified by 18F-florbetapir positron emission tomography (PET), but its prognostic value is not known.

Purpose

To test our hypothesis that (1) myocardial amyloid burden predicts adverse outcomes and (2) the relationship between amyloid burden and adverse outcomes is mediated by cardiomyocyte stretch and injury. Amyloid burden was estimated by left ventricular 18F-florbetapir retention index (RI) and cardiomyocyte stretch and injury by NT proBNP and troponin T respectively.

Methods

We performed 18F-florbetapir PET (median dose 9.05 mCi) in prospectively enrolled subjects with newly diagnosed AL amyloidosis with abnormal cardiac biomarkers or with normal cardiac biomarkers and normal left ventricular wall thickness (NCT02641145). Left ventricular RI was calculated as the activity concentration between 10 and 30 min. after injection divided by the integral of the left atrial blood time-activity curve from 0 to 20 min. RI was categorized as normal (&lt;0.06/min, based on controls), increased (0.06–0.12/min), or high risk (&gt;0.12/min, based on log-rank statistic maximization). Mayo stages I–IV were based on elevated serum cardiac biomarkers: NT-proBNP ≥1800 pg/ml, troponin T ≥0.025 ng/ml, and difference in free light chains ≥180 mg/l. Adverse outcomes of all-cause death or heart failure hospitalization were evaluated. Survival analysis was performed using Kaplan-Meier and Cox regression including Mayo stage and RI. Mediation analysis was used to elucidate the role of cardiomyocyte stretch (as NT-proBNP) and injury (as troponin T) in the association between amyloid burden estimated by RI and adverse outcomes.

Results

We studied 80 subjects with median age 62 years (IQR 57–67), 46 men (57%), 60 with abnormal cardiac biomarkers (75%), and median RI of 0.10/min (IQR 0.06–0.16). At follow-up (median 15 months), adverse outcomes occurred in 34 subjects (42%), with 17 deaths (21%) and 23 heart failure hospitalizations (29%). The incidence of adverse outcomes increased across Mayo stages from 9% to 44% (log-rank p&lt;0.001), and across RI levels from 29% to 57% (log-rank p=0.037, Figure 1). In multivariable Cox regression, only Mayo stage independently predicted adverse outcomes (HR 2.0 [95% CI 1.4–3.0], p&lt;0.001). Multivariable mediation analysis showed that 83% of the association between RI and adverse outcomes was mediated by NT-proBNP (p&lt;0.001, Figure 2), without contribution from troponin T.

Conclusion

Myocardial amyloid burden estimated by F-18 florbetapir RI predicts adverse outcomes in AL amyloidosis, but not independently of Mayo stage. Cardiomyocyte stretch mediates the relationship between myocardial amyloid burden and adverse outcomes in AL amyloidosis.

Funding Acknowledgement

Type of funding sources: Private company.

Role of cardiological specialistic evaluation in patients with chest pain presenting in the emergency department

AIMS

Aim of this study was to evaluate the impact of cardiological and echocardiographic evaluation in addition to a standard clinical and instrumental approach on diagnostic and prognostic accuracy in patients presenting in the emergency department (ED) with chest pain (CP). Acute coronary syndromes, pulmonary embolism and acute aortic syndromes (AAS) (triple-rule-out/TRO) were considered.

METHODS

From 7040 patients presenting with CP from 1 January 2015 to 31 December 2017, we randomly selected a sample of 1119. We retrospectively evaluated the clinical course and definitive diagnosis according to the ED final report. A 6-month follow-up to assess incident acute cardiovascular events was made by telephone interview in discharged patients; in hospitalized patients, clinical records were analyzed to evaluate the appropriateness of admissions. Diagnostic and prognostic accuracy wasd estimated through sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, according to the presence or absence of cardiological and echocardiographic consultation.

RESULTS

Complete information of 1099 patients out of 1119 was retrieved. Seven hundred and eighty-eight patients (71.70%) had been discharged, eight inappropriately (0.73%). Three hundred eleven (28.30%) had been hospitalized, 14 (1.27%) inappropriately. Diagnostic performance showed 97.38% sensitivity, 98.24% specificity, 95.5% PPV and 99% NPV, with an overall accuracy of 98.00%. In patients evaluated by the cardiologist in addition to the ED physician (n = 387) we observed an improvement of sensitivity and NPV at the expense of specificity. Among improperly discharged patients, 7/8 had normal troponin, 7/8 normal ECG and only 1 was evaluated by a cardiologist. Only one inappropriately hospitalized patient was not evaluated by a cardiologist.

CONCLUSIONS

Early consultation with a cardiologist and echocardiography improves clinical judgment in doubtful cases of CP, increasing diagnostic performance mainly by reducing inappropriate patient discharge and guaranteeing a low rate of inappropriate hospitalizations.

AB1211 DOES BODY MASS INDEX AND METABOLIC SYNDROME IMPACT ON FIBROMYALGIA?

Background

Fibromyalgia (FBM), obesity and the metabolic syndrome (MTB) are common conditions with significant impact on health and quality of life, producing relevant economic burden for healthcare systems. Although obesity represents a negative prognostic factor for FBM, the relation between body mass index (BMI) or MTB and FBM severity is still unclear.

Objectives

The aim of our ongoing study was to evaluate the relationship between BMI or prevalent MTB and FBM severity, estimated with 3 different severity scores.

Methods

We included the first 100 women presenting with FBM, defined according to the ACR2016 diagnostic criteria, consecutively evaluated during the period of 1 year in 2 Clinic in Italy. On enrolment were assessed/recorded demographic, clinical and pharmacological characteristics, weight, height, physical activity, tenderness, pain and symptoms. The following scores were calculated: tender points count (TP), Widespread Pain Index (WPI), Polysymptomatic Distress Scale (PDS), Fibromyalgia Impact Questionnaire (FIQ) and modified Fibromyalgia Assessment Status (mFAS). BMI was calculated, and the presence of MTB was evaluated according to current definition. Patients were categorized as presenting with severe disease or moderate/mild disease according to recent definition validated in an Italian population. The prevalence of MTB and the mean ± standard deviation (SD) BMI in subgroups defined according to severity were estimated.

Results

Mean age ±SD was 57.5±12.7 years, mean BMI ±SD was 25.3±5.1, and 9.5% presented with MTB. FBM severity (mean±SD) calculated by PDS, FIQ and mFAS was respectively 25.3±9.3, 63.2±23.1, and 30.1±7.7. Patients with the highest FBM severity according to PDS (>25) were less likely to present with MTB (2.4%) compared to those with a PDS of 0-25 (20.0%, P=.026), with an adjusted (age and BMI) OR (95%CI) for presenting with MTB in patients with less severe FBM of 8.2 (0.962-69.925, P=.054). Similar results were found when the specific conditions characterizing the MTB were considered separately, except for excessive body fat around the waist (not related to severity). The BMI ±SD was comparable between patients with severe disease (25.8±5.8) according to PDS and those with less severe FBM (24.8±4.4, P=.388), with no correlation between BMI and PDS (Rho: 0.083, P=.454). Considering all other characteristics of the two groups defined according to PDS categories (PDS >25 versus PDS 0-25) a significant difference was found in mean age ±SD, greater in patients with less severe FBM (60.2±13.2) compared to those with highest FBM severity (54.8±11.6, P=.046). Similar but less significant findings were found also with FIQ and mFAS. The prevalence of MTB according to the FIQ was 7.3% for highest severity versus 14.3% for less severe FBM (P=.200), with a comparable BMI ±SD between the two groups (respectively 26.2±6.1 versus 24.4±3.7, P=.125). Corresponding figures for MTB or BMI and FBM severity according to the mFAS were respectively: prevalence of MTB in highest severity 3.0% versus 16.3% in the less severe FBM (P=.078); mean ±SD BMI in highest severity 26.4±6.2 versus 24.6±4.2 in less severe patients (P=.121).

Conclusion

The preliminary results of our ongoing analysis demonstrated a slightly inverse relationship between FBM severity and the prevalence of MTB, trending to significance, while no relationship was found between severity and BMI.

References

[1]Salaffi F. Fibromyalgia Criteria and Severity Scales for Clinical and Epidemiological Studies: A Modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. Rheumatology. Volume 60, Issue 2, February 2021, Pages 728–736,

[2]Migliorini F. BMI but not age and sex negatively impact on the outcome of pharmacotherapy in fibromyalgia: a systematic review. Expert Rev Clin Pharmacol. 2021 Aug;14:1029-1038.

[3]D’Onghia M. Fibromyalgia and obesity: A comprehensive systematic review and meta-analysis. Semin Arthritis Rheum. 2021 Apr;51:409-424.

[4]Aparicio VA. Fibromyalgia’s key symptoms in normal-weight, overweight, and obese female patients. Pain Manag Nurs. 2013 Dec;14:268-276.

Disclosure of Interests

None declared

Cardiac involvement in athletes infected by SARS COV-2 disease

Objectives

The aim of the present study was to conduct a review of the current literature evaluating the available evidence to date in terms of epidemiology, pathophysiology and clinical presentation of COVID-19 in relation to cardiovascular involvement, with a special focus on the myocarditis model, in the population of athletes (professional and recreational) who are preparing to return to competitions, with the ultimate aim of guaranteeing maximum safety for resuming sports activities.

News

The COVID-19 pandemic has resulted in the inevitable cancellation of most sports activities, practiced at both a professional and amateur level, in order to minimize the risk of spreading the infection. Since the number of athletes who tested positive was rather high, the potential cardiac involvement in this peculiar population of subjects contracting the disease in a mild (asymptomatic, slightly symptomatic) or moderate form, has recently raised concerns following the observation of cases of recorded myocardial damage, myocarditis, arrhythmias and a first reported case of Sudden Cardiac Death (SCD) in a 27-year-old professional basketball player. Several studies even seem to confirm the possibility of permanent impairment of the cardiorespiratory system following the infection. Medical history, biomarkers, electrocardiographical and cardiac imaging features appear to be crucial in distinguishing cardiovascular alterations related to COVID-19 infection from typical adaptations to exercise related to athletes' heart.

Prospects and Projects

Clarifications and prospective data based on long-term follow-ups on larger populations of athletes are still needed to exclude the development of myocardial damage capable of negatively affecting prognosis and increasing cardiovascular risk in athletes recovered from COVID-19 in asymptomatic (simple positivity to SARS-COV-2) or in a mild form.

Conclusion

From a clinical point of view extreme caution is necessary when planning the return to sport (Return To Play-RTP) of athletes recovered from a mild or asymptomatic form of COVID-19: a careful preliminary medical-sports evaluation should be carried out in order to assess the potential development of myocardial damage that would increase their cardiovascular risk.

Primary mitral valve regurgitation scheduled for cardiac surgery: no longer need for coronary angiography? A clinical retrospective & HTA analysis

Introduction

In patients (pts) undergoing cardiac surgery for primary mitral regurgitation (PMR), coronary angiography (CA) is always scheduled shortly before surgery to rule out significant coronary artery disease (CAD), despite this population is often young and with relatively low risk for CAD. Computed Tomography Coronary Angiography (CTCA) could be an alternative approach to evaluate coronary arteries, at least ruling out significant CAD in selected pts, due to its high negative predictive value.

Purpose

A safer, more appropriate and efficient clinical and diagnostic pathway for patients undergoing cardiac surgery for PMR by stratifying patients prior cardiac surgery according to pretest probability score (PTP) and therefore shifting imaging of epicardial coronary arteries from invasive to noninvasive in specific patients subsets.

Methods

A retrospective analysis (Jan 2014–Dec 2020) was carried out through the extraction of 7343 electronic medical records of pts who underwent cardiac valve surgery. In 1556 pts with PMR (1195 with no-CAD and 361 with CAD) a PTP was retrospectively calculated according to Genders, 2012, to stratify their risk of CAD.

A Decision oriented Health Technology Assessment (DoHTA) and a cost analysis were also performed to support the analysis results. A survey was distributed to a team of experts with a multidisciplinary background to analyze the most significant evaluation areas (Economic Aspects, Clinical Effectiveness, Safety, Innovation) and the sub-criteria related to them.

Following the Core Model Eunethta as a guideline, a Rapid Report HTA has been drawn up to identify the best solution.

Results

Patients characteristics are listed in Picture 1. Pts with normal coronary arteries showed a PTP low-to intermediate while pts with high PTP had CAD and therefore had a real pretest need for a CA (average 11 percent ± 9 in noCAD group vs 20 percent ± 14 in the CAD group). In two thirds of PMR population coronary angiography could have been avoided according to a PTP score &lt;15 percent.

The cost analysis results were significantly lower in CTCA (1,315.00 EUR vs 180.00 EUR, CA vs CTCA respectively), The Decision Oriented HTA conducted by a multidisciplinary team showed a relevant preference for the new pathway (Picture 2) with a score of 70.23 percent of preference among the Team.

Conclusions

This new pathway, already proposed for selected pts in ESC guidelines on valve diseases (class IIA, LOE C) could be always adopted in PMR pts with low-to intermediate PTP score undergoing cardiac surgery. It could improve workflow efficiency and reduce LOS, and last but not least, avoid an invasive test, reduce radiation exposure and AKI risk in in a relatively young population

The DoHTA provided a more effective and efficient support to the decision-making process.

Funding Acknowledgement

Type of funding sources: None. Picture 1. Patients characteristics (noCAD-CAD)Picture 2. HTA Score CTCA vs CA

AB0379 BARICITINIB IN POLYMYALGIA RHEUMATICA AND GIANT CELL ARTERITIS: REPORT OF SIX CASES

Background:

Glucocorticoids (GC) are the cornerstone of the treatment of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA), but they are associated with several adverse events (AEs). Moreover, a considerable proportion of patients relapse during GC tapering.

Objectives:

To describe the efficacy and safety of the JAK-inhibitor baricitinib (BARI) in a group of patients with PMR and/or GCA.

Methods:

Case series of patients with PMR and/or GCA with a refractory disease course, despite several lines of therapy, including methotrexate (MTX) and tocilizumab (TCZ), started treatment with BARI. All patients underwent periodic, standardised clinical and laboratory examinations, and also FDG-PET/CT. PMR-activity score (AS) was calculated at each visit except in patients with isolated large vessel vasculitis (LVV) or GCA.

Results:

A total of six patients (five females and one male, median age 64 years, range 50-83) were treated with BARI. Two of them had isolated PMR (patients #1 and #6), two had PMR with associated LVV (patients #2 and #5), and one (patient #3) had cranial-GCA. Demographic and clinical characteristics are provided in Table 1. At the time of starting BARI, patients were taking a median prednisone dose of 8.75 mg/day (range 0-25), and the 4 patients with PMR±LVV had a median PMR-activity score (PMR-AS) of 23.3 (indicating high disease activity), which decreased to 1.58 after 6 months of treatment with BARI. Two of them could stop GC and continued BARI monotherapy (in one case, BARI was tapered down to 2 mg/day after 12 months).

After starting BARI, patient #3 (GCA) could gradually taper prednisone from 25 mg/day to 10 mg/day in six months, without reporting fever or headache. After one year of treatment, she feels well while taking prednisone 7.5 mg/day.

Patient #4 (LVV) remained clinically stable during the treatment with BARI, but a follow-up FDG-PET/CT showed LVV, and we decided to stop BARI and restart TCZ. After 4 months of treatment with BARI, patient #5 suffered from pneumonia, while she was also taking prednisone 15 mg/day. BARI was therefore stopped. No other AEs attributable to BARI were detected.

Conclusion:

BARI appears as an appealing option for treating patients with PMR and/or GCA. Although these preliminary results should be confirmed by a RCT, BARI lowered rapidly disease activity and exerted a significant steroid-sparing effect, allowing GC withdrawal in 2 out of 6 patients.

Table 1.

Demographic and clinical characteristics of patients.

Patient #SexAgeDiagnosisPrevious treatmentDisease duration (months)PMR-AS1F66PMRMTX, HCQ, SSZ25.540.52F78PMR+LVVTCZ, MTX41.828.83F61GCACYC, MMF, TCZ119.8N/A4F60LVVTCZ16.4N/A5F83PMR+LVVMTX, TCZ24.415.26M50PMRMTX24.617.8

CYC: cyclophosphamide, GCA: giant cell arteritis, HCQ: hydroxychloroquine, LVV: large vessel vasculitis, MMF: mycophenolate mofetil, MTX: methotrexate, N/A: not applicable, PMR: polymyalgia rheumatica, PMR-AS: PMR-activity score, SSZ: sulfasalazine, TCZ: tocilizumab.

Disclosure of Interests:

Dario Camellino Speakers bureau: Medac, Eli Lilly, Paid instructor for: Mylan, Consultant of: Accord, Celgene, Novartis, Sanofi, Christian Dejaco Speakers bureau: Eli Lilly (<10.000€), Andrea Giusti Speakers bureau: UCB, Amgen, Kyowa Kirin, Abiogen Pharma, and Eli Lilly, Consultant of: EffRx, Abiogen Pharma, FRANCO MARTINI: None declared, Renzo Cosso: None declared, Giuseppe Girasole: None declared, Gerolamo Bianchi Speakers bureau: Amgen, MSD, Novartis, Pfizer, Roche, Sanofi, Genzyme, and Servier, Consultant of: Abbvie, Abiogen Pharma, BMS, Celgene, Eli Lilly, GSK, Janssen-Cilag, Medac

POS1105 EFFECTS OF CHOLECALCIFEROL AND CALCIFEDIOL IN OSTEOPOROTIC WOMEN WITH SECONDARY HYPERPARATHYROIDISM DUE TO SEVERE VITAMIN D DEFICIENCY UNDERGOING ZOLEDRONIC ACID TREATMENT: A RANDOMIZED-CONTROLLED TRIAL

Background:

Secondary hyperparathyroidism (sHPTH) due to vitamin D deficiency impairs the bone mineral density (BMD) response to alendronate,1-2 but the optimal strategy for its correction in postmenopausal osteoporotic women (PMO) about to start zoledronic acid (ZOL) therapy is still unknown.

Objectives:

To evaluate the effects of cholecalciferol (D3) and calcifediol (25OHD) on serum 25-OH-vitamin D (s25OHD), parathyroid hormone (PTH) and BMD in PMO presenting with sHPTH due to vitamin D deficiency.

Methods:

PMO with s25OHD <20 ng/ml, sHPTH (PTH >65 pg/ml) and BMD T-score at the lumbar spine (LS), femoral neck (FN) or total hip (TH) < -2.5, or between -1 and -2.5 plus one vertebral/femoral fracture, were randomly assigned to receive a therapeutic dose of D3 (300.000 IU bolus) followed by 175 mcg/weekly of D3, or 175 mcg/weekly of 25OHD alone, 2 months before receiving a single intravenous infusion of ZOL (5 mg). BMD at the LS, FN and TH was assessed at baseline and after one year from ZOL. Serum calcium, PTH and s25OHD were measured at baseline, and 6- and 12-month after ZOL. Adverse and clinical events were ascertained by 3-and 9-month telephone interviews, and by 6- and 12-month clinical evaluation.

Results:

45 PMO (25OHD N=23, D3 N=22) were enrolled over one year and 32 subjects (mean age ±SD 75±10 years, range 51-91) completed the 1-year of treatment/follow-up (25OHD N=17, D3 N=15). Most PMO discontinued for protocol violation, while three deceased before study ending (25OHD N=1, D3 N=2) for reasons not related to the agents investigated. The baseline characteristics were comparable in both groups. At baseline mean s25OHD (±SE) was 8±1 ng/ml in the 25OHD group and 8±1 ng/ml in the D3 group. The corresponding figures for PTH were 111±6 pg/ml (25OHD) and 117±5 pg/ml (D3). Mean s25OHD (±SE) increased in both groups at 6- and 12-month, being significantly greater in the 25OHD group (12-month, 56±2 ng/ml) compared to the D3 group (12-month, 34±2 ng/ml, P<.001) at both time points (Figure 1). PTH (mean ±SE) decreased in both groups, being significantly lower in the 25OHD group at 12-month (25OHD 46±6 pg/ml versus D3 70±6 pg/ml, P=.007), as shown in Figure 1. BMD at the LS, FN and TH increased in both groups (with significant increases versus baseline only at the FN) without significant differences between s25OHD and D3. In PMO receiving D3 serum calcium remained stable over time, while those receiving s25OHD demonstrated a significant increase of serum calcium, with 2 PMO presenting a value close to the upper limit of the reference range at 12-month. No patient reported incident fractures or adverse events.

Conclusion:

Calcifediol 175 mcg weekly appears more potent in improving s25OHD and decreasing PTH concentrations compared to cholecalciferol therapeutic dose (300’000 IU) plus 175 mcg weekly in PMO presenting with sHPTH due to severe vitamin D deficiency about to start ZOL therapy. Further studies are warranted to clarify implications on BMD improvements on the long-term of similar 25OHD and D3 regimens.

References:

[1]Barone A et al., J Am Geriatr Soc 2007.

[2]Kincse G et al., BMC Musculoskelet Disord 2012.

Disclosure of Interests:

Giulia Botticella: None declared, Monica Pizzonia: None declared, Barbara Cossu: None declared, Roberta Bruno: None declared, Dario Camellino Speakers bureau: AbbVie, Celgene, Janssen-Cilag, Eli Lilly, Medac, Mylan, Novartis, and Sanofi, outside the submitted work, Giuseppe Girasole Speakers bureau: Abiogen Pharma and Novartis, outside the submitted work, Andrea Giusti Speakers bureau: UCB, Amgen, Kyowa Kirin, Abiogen Pharma, and Eli Lilly, outside the submitted work, Consultant of: EffRx and Abiogen Pharma, outside the submitted work, Mario Pedrazzoni: None declared, Simona Alexovits: None declared, Franco Pleitavino: None declared, Federico Santolini: None declared, Alessio Nencioni: None declared, Gerolamo Bianchi Speakers bureau: Abbvie, Abiogen Pharma, Amgen, BMS, Celgene, Eli Lilly, GSK, Janssen-Cilag, Medac, MSD, Novartis, Pfizer, Roche, Sanofi, Genzyme, and Servier, outside the submitted work.

AB0488 SPONDYLOARTHRITIS DISEASE BURDEN AS PERCEIVED BY PATIENTS: BASELINE PATIENT-REPORTED OUTCOME DATA FROM THE ITALIAN PROSPECTIVE SIRENA STUDY

Background:

Previous studies have compared Patient-Reported Outcomes (PROs) in Spondyloarthritis (SpA); a recent one has found similarity in Psoriatic Arthritis (PsA) and axial patients1.

Objectives:

To describe PROs at SpA diagnosis (new or confirmed), by type of SpA and by gender.

Methods:

SIRENA is an Italian, prospective Registry of SpA patients diagnosed according to ASAS criteria and naïve to any DMARDs. At inclusion, patients were classified as predominant axial (AxSpA) or mainly peripheral (pSpA). PROs showed in the Table 1 were collected and analysed descriptively.

Table 1.

PhGA and PROs at diagnosis*

AxSpA*pSpAAll(n=123)Women(n=64)Men(n=58)All(n=227)Women(n=109)Men(n=118)PhGA, n1156054222105117mean (SD)50.2 (28.6)54.8 (26.7)45.0 (30.1)45.4 (25.9)49.9 (25.6)41.3 (25.6)median (min, max)52.0 (0-100)62.0 (0-100)43.5 (0-100)48.5 (0-100)50.0 (1.0-100)40.0 (0-95.0)PtGA, n1125952209102107mean (SD)56.4 (27.8)61.5 (25.8)50.3 (29.2)50.3 (26.2)56.4 (23.1)44.5 (27.7)median (min, max)63.0 (0-100)70.0 (2.0-100)50.0 (0-100)50.0 (0-100)58.5 (7.0-100)47.0 (0-100)Pain VAS score, n1136052207101106mean (SD)56.7 (28.3)61.1 (26.6)50.6 (29.1)51.9 (26.8)57.4 (25.3)46.8 (27.3)median (min, max)60.0 (0-100)69.5 (2.0-100)50.0 (0-100)53.0 (0-100)61.0 (0-100)48.5 (0-100)Sleep VAS score, n1136052211103108mean (SD)55.3 (29.3)57.4 (29.5)52.3 (29.2)44.0 (30.1)50.4 (29.8)37.9 (29.2)median (min, max)59.0 (0-100)61.5 (0-100)53.0 (0-100)44.0 (0-100)53.0 (0-100)34.0 (0-100)BASFI, n11058511336568mean (SD)4.6 (2.8)5.2 (2.6)3.9 (2.8)3.5 (2.6)4.0 (2.6)3.1 (2.4)median (min, max)5.1 (0-9.7)5.8 (0-9.4)3.6 (0-9.6)2.9 (0-10.0)3.9 (0-10.0)2.45 (0-8.9)BASDAI, n11259521397069mean (SD)5.2 (2.4)5.8 (2.3)4.5 (2.3)5.2 (2.3)5.8 (2.1)4.6 (2.3)median (min, max)5.5 (0-9.3)6.2 (0-9.3)4.5 (0.3-9.2)5.5 (0.2-10.0)6.1 (1.0-10.0)4.8 (0.2-9.2)HAQ-DI score, n109585020399104mean (SD)0.9 (0.7)1.1 (0.7)0.6 (0.6)0.7 (0.7)0.9 (0.7)0.6 (0.6)median (min, max)0.8 (0.0-2.5)1.1 (0-2.5)0.5 (0-2.3)0.6 (0.0-2.8)0.8 (0-2.8)0.4 (0-2.6)WPAI% work time missed, n4919301074562mean (SD)7.3 (21.4)4.2 (9.5)9.2 (26.3)8.8 (24.7)8.6 (25.6)8.9 (24.3)median (min, max)0 (0-100)0 (0-35.1)0 (0-100)0 (0-100)0 (0-100)0 (0-100)% impairment at work, n6733341346173mean (SD)48.2 (31.9)58.5 (26.6)38.2 (33.7)39.7 (31.4)45.4 (30.9)34.9 (31.2)median (min, max)50.0 (0-100)60.0 (0-100)25.0 (0-100)40.0 (0-100)50.0 (0-100)30.0 (0-100)% overall work impairment, n4819291064561mean (SD)44.1 (33.0)52.4 (27.9)38.7 (35.3)40.1 (33.0)45.1 (33.1)36.4 (32.7)median (min, max)45.0 (0-100)60.0 (0-100)20.0 (0-100)40.0 (0-100)50.0 (0-100)30.0 (0-100)% activity impairment, n10053461839390mean (SD)56.7 (28.6)63.4 (23.9)48.0 (31.0)48.5 (30.3)55.3 (28.7)41.4 (30.4)median (min, max)60.0 (0-100)70.0 (0-100)50.0 (0-100)50.0 (0-100)60.0 (0-100)40.0 (0-100)

* The sum does not add up to the total because of some missing values.

Results:

From 23 sites, 123 AxSpA and 227 pSpA patients were analysed. Diagnosis was new in 58% of AxSpA and 77% of pSpA. 85.5% of the pSpA had PsA, while in AxSpA the most frequent type was Ankylosing Spondylitis (48.8%). Time from symptom onset to diagnosis was higher in AxSpA than in pSpA (median 36 vs 24 months, respectively). At inclusion, composite disease activity measures showed high disease activity for AxSpA (mean ASDAS-CRP 3.1) and moderate disease activity for pSpA (mean DAS28 3.6; mean DAPSA 22.5). AxSpA patients had numerically worse values than pSpA in all the PROs collected, except for BASDAI score that was similar (mean 5.2). For both AxSpA and pSpA, all PROs were worse in women than men, except for the % of work time missed. PtGA scores were higher than PhGA, in each group and gender.

Conclusion:

At diagnosis, SpA patients perceive a slightly higher disease burden than assessed by Physicians. For PROs other than BASDAI, AxSpA reported a worse impact than pSpA. Overall, women showed a higher disease impact than men.

References:

[1]Michelsen B. et al. PLoS ONE 2015; 10(4): e0123582.

Disclosure of Interests:

Rosario Foti Speakers bureau: Speaker bureau honoraria from Eli Lilly, Sanofi, MSD, Janssen, AbbVie, Bristol-Myers Squibb, Celgene, Roche, Consultant of: Consultancy fees from Eli Lilly, Sanofi, MSD, Janssen, AbbVie, BMS, Celgene, Roche, Gabriella Cardinale: None declared., Luisa Costa: None declared., Franco Franceschini: None declared., Francesco Ciccia Speakers bureau: Speaker bureau honoraria from AbbVie, Abiogen, Bristol-Myers Squibb, Celgene, Janssen, Eli Lilly, Pfizer, Novartis, Roche, Consultant of: Consultancy fees from Novartis, Pfizer, Janssen, Eli Lilly, Roche, Celgene, Grant/research support from: Grant/research support from Pfizer, Novartis, Celgene, Janssen, Roche, Antonio Marchesoni: None declared., Giuliana Guggino Speakers bureau: Speaker bureau honoraria from Celgene, Sandoz, Pfizer, Grant/research support from: Grant/research support from Pfizer, Celgene, Maurizio Rossini: None declared., Ennio Lubrano Di Scorpaniello: None declared., Bruno Frediani: None declared., Maria Sole Chimenti: None declared., Gerolamo Bianchi: None declared., Giuseppe Galfo: None declared., Silvia Marelli Employee of: Employee of Janssen-Cilag SpA Italy, Ennio Favalli Speakers bureau: Consulting fees and/or speaking engagements from AbbVie, Bristol-Myers Squibb, Lilly, Merck Sharp & Dohme, Pfizer, Galapagos, Sanofi-Genzyme, and UCB.

POS1447 LOW-INTENSITY PULSED ELECTROMAGNETIC FIELDS IMPROVE PHYSICAL PERFORMANCE IN A DOSE-DEPENDENT MANNER: AN OBSERVATIONAL STUDY IN OLDER ADULTS WITH RHEUMATIC DISEASES

Background:

Low-intensity pulsed electromagnetic fields (PEMF) have been shown to improve gait parameters in frail older adults.1 Furthermore, the continuous exposure to PEMF (up to 1 year) have been demonstrated to produce progressive improvements in self-selected gait speed in older adults at risk of falling.2

Objectives:

To investigate the effects of two different treatment regimens of PEMF on physical performances in older adults presenting with rheumatoid arthritis (RA), osteoarthritis (OA) or severe osteoporosis (OP).

Methods:

Older adults presenting with RA, OA or OP, at increased risk of falls, evaluated in our Falls Prevention Clinic, were considered for a prospective observational study investigating the effects of PEMF on physical performances. PEMF were supplied by the THS 280 E device (THS-Therapeutic Solutions Srl, Milan, Italy). It provides a new therapeutic approach, named TEPS (Triple Energy Postural Stabilization), that represents an evolution of physical therapy.1,2 On the basis of the physician judgment, PEMF were administered following an intensive protocol, every 45 days (PEMF-45), or a standard validated protocol1,2, every 60 days (PEMF-60). All subjects were assessed at baseline and every 3 months with the following tests: 4 meters gait speed test [4MGS, seconds (sec)], timed up and go test (TUG, sec), chair stand test (CST, sec), short physical performance battery (SPPB, score), and hand grip strength (HGS) by hand dynamometer (Kg). Demographic, anthropometric and clinical characteristics, including pharmacological treatments and functional status were evaluated at baseline. Clinical and adverse events were assessed every 45 or 60 days after PEMF administration.

Results:

Overall, 94 patients were enrolled between January and December 2020. Of these, 43 subjects (N=33 PEMF-45, N=11 PEMF-60) with a valid 6-month follow-up assessment were considered for the current analysis. The two groups were comparable regarding the main baseline characteristics, and similar % of patients presented with RA, OA or OP. Mean age (±SE) was 78±7 in PEMF-45 and 77±7 in PEMF-60. As expected, all physical performance tests improved significantly from baseline to 6 months in both groups. Mean (±SE) 4MGS increased significantly more in PEMF-45 (from 3.24±0.12 sec to 2.83±0.18 sec) compared to PEMF-60 (from 3.22±0.21 sec to 3.02±0.30 sec, p=.018). Likewise, mean (±SE) CST improved more in PEMF-45 (from 12.4±0.9 sec to 8.7±0.4 sec) compared to PEMF-60 (from 11.1±1.5 sec to 9.8±0.7 sec, p=.002). No significant difference between groups was found for the other tests, although a trend toward better results in PEMF-45 was manifest: SPPB improved by 6.4% in PEMF-45 and by 3.0% in PEMF-60, and TUG decreased by 7.8% in PEMF-45 and by 6.1% in PEMF-60. During the 6 months observation period no adverse event was observed.

Conclusion:

Preliminary results of our ongoing prospective observational study suggest that a more frequent administration of PEMF produces greater improvements in some but not all physical performance parameters compared to a standard validated regimen1,2.

References:

[1]Giusti A et al., Geriatr Gerontol Int 2013. 2Giusti A et al., J Am Geriatr Soc 2014.

Disclosure of Interests:

Massimo Giovale: None declared, Giuseppina Tramontano: None declared, Rossana Galli: None declared, Simone Rando: None declared, Andrea Giusti Speakers bureau: UCB, Amgen, Kyowa Kirin, Abiogen Pharma, and Eli Lilly, outside the submitted work, Consultant of: EffRx and Abiogen Pharma, outside the submitted work, Lorenzo Bandi: None declared, Francesca Russo: None declared, Stefano Rampoldi Employee of: THS Therapeutic Solutions SRL, Luigi Carlo Bottaro: None declared, Gerolamo Bianchi Speakers bureau: Abbvie, Abiogen Pharma, Amgen, BMS, Celgene, Eli Lilly, GSK, Janssen-Cilag, Medac, MSD, Novartis, Pfizer, Roche, Sanofi, Genzyme and Servier, outside the submitted work

SERCA2a stimulation by istaroxime improves intracellular Ca2+ handling and diastolic dysfunction in a model of diabetic cardiomyopathy

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by CVie Therapeutics Limited (Taipei, Taiwan) and Windtree Therapeutics (Warrington, USA)

Diabetic cardiomyopathy is a multifactorial disease characterized by an early onset of diastolic dysfunction (DD) that precedes the development of systolic impairment. Mechanisms that can restore cardiac relaxation improving intracellular Ca2+ dynamics represent a promising therapeutic approach for cardiovascular diseases associated to DD. Istaroxime has the double property to accelerate Ca2+ uptake into sarcoplasmic reticulum (SR) through the SR Ca2+ pump (SERCA2a) stimulation and to inhibit Na+/K+ ATPase (NKA). The project aims to characterize istaroxime effects at a concentration (100 nM) marginally affecting NKA, in order to highlight its effects dependent on the stimulation of SERCA2a in a model of mild diabetes.

Streptozotocin (STZ) treated diabetic rats were studied at 9 weeks after STZ injection in comparison to controls (CTR). Istaroxime effects were evaluated in vivo and in left ventricular (LV) preparations. STZ animals showed 1) marked DD not associated to cardiac fibrosis, 2) LV mass reduction associated to reduced LV cell dimension and T-tubules loss, 3) reduced LV SERCA2 protein level and activity and 4) slower SR Ca2+ uptake rate, 5) LV action potential (AP) prolongation and increased short-term variability (STV) of AP duration, 6) increased diastolic Ca2+, 7) unaltered SR Ca2+ content and stability in intact cells. Acute istaroxime infusion (0.11 mg/kg/min for 15 min) reduced DD in STZ rats. Accordingly, in STZ myocytes istaroxime (100 nM) stimulated SERCA2a activity and blunted STZ-induced abnormalities in LV Ca2+ dynamics. In CTR myocytes, istaroxime increased diastolic Ca2+ level due to NKA blockade albeit minimal, while its effects on SERCA2a were almost absent.

SERCA2a stimulation by istaroxime improved STZ-induced DD and intracellular Ca2+ handling anomalies. Thus, SERCA2a stimulation can be considered a promising therapeutic approach for DD treatment. Abstract Figure.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

Can the Charlson Comorbidity Index be used to predict the ASA grade in patients undergoing spine surgery?

BACKGROUND

The American Society of Anaesthesiologists' Physical Status Score (ASA) is a key variable in predictor models of surgical outcome and "appropriate use criteria". However, at the time when such tools are being used in decision-making, the ASA rating is typically unknown. We evaluated whether the ASA class could be predicted statistically from Charlson Comorbidy Index (CCI) scores and simple demographic variables.

METHODS

Using established algorithms, the CCI was calculated from the ICD-10 comorbidity codes of 11'523 spine surgery patients (62.3 ± 14.6y) who also had anaesthetist-assigned ASA scores. These were randomly split into training (N = 8078) and test (N = 3445) samples. A logistic regression model was built based on the training sample and used to predict ASA scores for the test sample and for temporal (N = 341) and external validation (N = 171) samples.

RESULTS

In a simple model with just CCI predicting ASA, receiver operating characteristics (ROC) analysis revealed a cut-off of CCI ≥ 1 discriminated best between being ASA ≥ 3 versus < 3 (area under the curve (AUC), 0.70 ± 0.01, 95%CI,0.82-0.84). Multiple logistic regression analyses including age, sex, smoking, and BMI in addition to CCI gave better predictions of ASA (Nagelkerke's pseudo-R² for predicting ASA class 1 to 4, 46.6%; for predicting ASA ≥ 3 vs.  < 3, 37.5%). AUCs for discriminating ASA ≥ 3 versus < 3 from multiple logistic regression were 0.83 ± 0.01 (95%CI, 0.82-0.84) for the training sample and 0.82 ± 0.01 (95%CI, 0.81-0.84), 0.85 ± 0.02 (95%CI, 0.80-0.89), and 0.77 ± 0.04 (95%CI,0.69-0.84) for the test, temporal and external validation samples, respectively. Calibration was adequate in all validation samples.

CONCLUSIONS

It was possible to predict ASA from CCI. In a simple model, CCI ≥ 1 best distinguished between ASA ≥ 3 and < 3. For a more precise prediction, regression algorithms were created based on CCI and simple demographic variables obtainable from patient interview. The availability of such algorithms may widen the utility of decision aids that rely on the ASA, where the latter is not readily available.

AB0283 REDUCED HOSPITAL ADMISSION IN RA PATIENTS TAPERING BIOLOGIC DMARDS: PRELIMINARY ANALYSIS OF A RETROSPECTIVE STUDY

Background:

bDMARDs are among the most effective therapies in the management of inflammatory arthritides, but they are associated with potentially severe adverse events (AEs), particularly infection. Tapering strategies of bDMARDs for patients in remission/low disease activity (R/LDA) have demonstrated comparable efficacy to standard-dose treatments, but their safety profile has not been studied yet.

Objectives:

To compare the number and the causes of hospital admissions in RA patients in R/LDA continuing or tapering bDMARDs.

Methods:

Consecutive patients with rheumatoid arthritis (RA) evaluated between 2011 and 2017, were assigned, based on treating physician’s discretion, to continue the standard dose (STD) of bDMARDs or to undergo a predetermined tapering strategy (TAP), after being in R/LDA for two consecutive visits at least 3 months apart. Down-titration of bDMARDs was obtained by a stepwise increase of the dosing interval to achieve a reduction of about 30% (e.g. administration of etanercept every 10 days instead of weekly). Demographic, clinical data and concomitant treatments were retrospectively retrieved from the electronic charts of the outpatient clinics. Information about hospital admissions, including main diagnosis, period and duration of hospitalization, and death were retrieved from the Regional Healthcare System Database.

For the STD group, the observation period started with the occurrence of remission and finished with one of these events: loss of remission, switch to another bDMARD, withdrawal of the bDMARD, severe AE, death, end of the study period in (December 2017). For the TAP group, the observation period started with tapering onset and finished with one of these events: reduction of the dosing interval due to either a relapse (according to a DAS28 increase) or to a subjective, symptomatic relapse (according to the patient’s definition), switch to another bDMARD, withdrawal of the bDMARD, severe AE, death, end of the study period in (December 2017).

Results:

81 patients were included, of whom 40 underwent TAP. Demographic, clinical and treatment data are shown in table 1. Baseline characteristics were comparable between the two groups, except for the number of previous bDMARDs before observational period entry that was slightly higher in the STD group (STD 1.0±0.9 versus TAP 0.5±0.8, P=0.11).

Table 1.

Baseline demographic and clinical characteristics of the patients in remission or low disease activity.

NO TAPERING(n=41)TAPERING(n=40)p valueMean age (yrs)57±1158±130.563Mean disease duration (yrs)12±912±70.897Starting bDMARD to tapering/monitoring (months)52±4567±410.128Mean monitoring period (months)22±2419±230.632Taking sDMARD at any time ((n (%))40 (98%)37 (92%)0.359Taking glucocorticoids29 (71%)28 (70%)0.999Mean prednisone dose (mg/day)2.5±2.92.1±2.70.527DAS28 at the time of tapering or first LDA/REM2.3±0.82.3±0.90.863Previous bDMARDs >1 (n (%))10 (24.4%)4 (10%)0.140

In the STD group, 14 hospital admissions occurred, while in the TAP group there were 7 admissions (p=0.128). The corresponding figures for hospital admission due to infectious diseases were 6 in the STD group and 0 in the TAP group (p=0.026).

Conclusion:

Tapering bDMARDs in RA patients in R/LDA is associated with fewer hospital admissions, with a possible protective effect especially toward infections.

Acknowledgments:

The authors are indebted with Mrs Rosella Gramuglia and Mrs Cristina Olivieri for the management and analysis of the data on the flow of the drugs, and with Mrs Anna Consigliere, Mrs Anna Cosso, Mrs Romina Petralito and Mrs Laura Ravaschio for helping in retrieving clinical data.

Disclosure of Interests:

Dario Camellino Consultant of: I have received consultancy fees from Celgene, Sanofi, Novartis, Janssen-Cilag, Accord, Paid instructor for: I have served as a paid instructor for Mylan, Andrea Giusti Consultant of: UCB, Amgen, Janssen, Eli Lilly, Abiogen, EffRx, Speakers bureau: UCB, Amgen, Janssen, Eli Lilly, Abiogen, EffRx, Alfa-Sigma, Chiesi, Giuseppe Girasole: None declared, Chiara Craviotto: None declared, Paola Diana: None declared, Antonia Locaputo: None declared, Tiziana Caviglia: None declared, Lacramioara Luca: None declared, Gerolamo Bianchi Consultant of: Amgen, Janssen, Merck Sharp & Dohme, Novartis, UCB, Speakers bureau: Abbvie, Abiogen, Alfa-Sigma, Amgen, BMS, Celgene, Chiesi, Eli Lilly, GSK, Janssen, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi Genzyme, Servier, UCB

AB1082 INFLUENCE OF THE VARIATION OF THE OPERATOR, PATIENT POSITION AND DEVICE ON THE MEASUREMENT PERFORMANCE OF RADIOFREQUENCY ECHOGRAPHIC MULTI SPECTROMETRY (REMS)

Background:

The monitoring of bone mineral density (BMD) is a key aspect for patients undergoing pharmacological treatments that might cause BMD changes at non-physiological rates. At present, the short-term follow-up of patients under treatment in terms of BMD change with time remains an unmet clinical need, since the current techniques, including the gold standard dual X-ray absorptiometry (DXA), require at least 1 year between two consecutive measurements [1]. Therefore, an effective strategy for the assessment of BMD should guarantee high accuracy, precision and repeatability of the measurements.

Objectives:

The aim is to assess the influence of the variation 1) in patient position, 2) operator (both intra- and inter-) and 3) device on the REMS performance at lumbar spine and femoral neck.

Methods:

210 women were enrolled, divided in 7 groups of 30-patient each for the assessment of the parameters of interest, i.e. inter-device, intra- and inter-operator repeatability for lumbar spine scans and inter-patient position, inter-device, intra- and inter-operator repeatability for femoral neck scans.

All patients underwent 2 REMS scans at lumbar spine or femoral neck, performed by the same operator or by 2 different operators or by the same operator using 2 different devices or in different patient position (i.e. supine without constraints or with a constrained 25°-rotation of the leg). The percentage coefficient of variation (CV%) with 95% confidence interval and least significant change for a 95% confidence level (LSC) have been calculated.

Results:

For lumbar spine, intra-operator repeatability resulted in CV%=0.37% (95%CI: 0.26%-0.48%), with LSC=1.02%, inter-operator repeatability resulted in CV%=0.55% (95% CI: 0.42%-0.68%), with LSC=1.52%, inter-device repeatability resulted in CV%=0.53% (95% CI: 0.40%-0.66%), with LSC=1.47%.

For femoral neck, intra-operator repeatability resulted in CV%=0.33% (95%CI: 0.23%-0.43%), with LSC=0.91%, inter-operator repeatability resulted in CV%=0.47% (95% CI: 0.35%-0.59%), with LSC=1.30%, inter-device repeatability resulted in CV%=0.42% (95% CI: 0.30%-0.51%), with LSC=1.16%, inter-patient position repeatability resulted in CV%=0.24% (95% CI: 0.18%-0.30%), with LSC=0.66%.

Conclusion:

REMS densitometry is highly precise for both anatomical sites, showing high performance in repeatability. These results suggest that REMS might be a suitable technology for short-term monitoring. Moreover, thanks to its ionizing radiation-free approach, it might be applied for population mass investigations and prevention programs also in paediatric patients and pregnant women.

References:

Note:Carla Caffarelli, Giovanni Adami§, Giovanni Arioli§, Gerolamo Bianchi§, Maria Luisa Brandi§, Sergio Casciaro§, Luisella Cianferotti§, Delia Ciardo§, Francesco Conversano§, Davide Gatti§, Giuseppe Girasole§, Monica Manfredini§, Maurizio Muratore§, Paola Pisani§, Eugenio Quarta§, Laura Quarta§, Stefano Gonnelli

§Equal contributors listed in alphabetical order

Disclosure of Interests:

Carla Caffarelli: None declared, Giovanni Adami: None declared, Giovanni Arioli *: None declared, Gerolamo Bianchi Grant/research support from: Celgene, Consultant of: Amgen, Janssen, Merck Sharp & Dohme, Novartis, UCB, Speakers bureau: Abbvie, Abiogen, Alfa-Sigma, Amgen, BMS, Celgene, Chiesi, Eli Lilly, GSK, Janssen, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi Genzyme, Servier, UCB, Maria Luisa Brandi: None declared, Sergio Casciaro: None declared, Luisella Cianferotti: None declared, Delia Ciardo: None declared, Francesco Conversano: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Giuseppe Girasole: None declared, Monica Manfedini: None declared, Maurizio Muratore: None declared, Paola Pisani: None declared, Eugenio Quarta: None declared, Laura Quarta: None declared, Stefano Gonnelli: None declared

SAT0455 RADIOFREQUENCY ECHOGRAPHIC MULTI SPECTROMETRY (REMS) FOR THE IDENTIFICATION OF FRAIL BONES

Background:

Radiofrequency Echographic Multi Spectrometry (REMS) is the first clinically available approach for direct non-ionizing measurement of bone mineral density (BMD) at lumbar spine (LS) and femoral neck (FN). Available scientific evidences describe BMD estimated by REMS as an accurate parameter for the diagnosis of osteoporosis [1].

Objectives:

To investigate the effectiveness of the T-score values provided by REMS scans at FN and LS in the identification of frail patients at risk for osteoporotic fractures and to compare the performance of REMS with the dual-energy X-ray absorptiometry (DXA) one.

Methods:

The patients underwent DXA and REMS scans at FN and at LS. Five clusters of fractures occurred during a median 3.5-year follow-up were identified whether involving the upper limb (forearm, elbow, humerus, wrist, hand), lower limb (tibia, ankle, metatarsus), thorax (shoulder blade, shoulder, rib), hip (femur or pelvis bones), or vertebrae. The ability of REMS and DXA T-score values to assess the incidence and site of fractures was evaluated through an analysis of covariance.

Results:

Seven hundred twenty-one Caucasian women were enrolled. Ninety-five fractures occurred, in particular 41 at upper limb, 16 at hip, 15 at thorax, 14 at lower limb, 9 at vertebrae. Patients characteristics are reported in table. Considering subcategories of fractured patients, there were not statistically significant differences for age, height, weight and BMI.

In the analysis of covariance including age and BMI as covariates, the difference of T-score values between fractured and non-fractured patients is statistically significant for REMS and DXA at both sites.

Lower FN T-score values were found for patients with fractures at hip or vertebra with respect to non-fractured patients both for REMS and DXA (p<0.001). Considering LS T-score, lower values were found for patients with fractures at hip, vertebra or upper limb with respect to non-fractured patients both for REMS and DXA (p<0.001, Figure).

Conclusion:

REMS T-score measured at axial sites is an effective parameter for identification of patients at the risk of incident fragility fractures, in particular occurring at hip, vertebra or upper limb in a population-based sample of female subjects.

References:

[1]Diez-Perez, Aging Clin Exp Res 2019;31(10):1375–89

Table 1.

Baseline patient characteristics, expressed as median (25th– 75thpercentiles).

Patients with incident fragility fracturePatients without incident fragility fracturep-value*Age [years]70 (60-73)59 (54-64)<0.001Height [cm]159 (155-164)160 (156-165)0.08Weight [kg]63 (58-70)62 (57-69)0.42BMI [kg/m2]24.97 (23.13-26.86)24.24 (22.22-26.59)0.04FN REMS T-score-2.3 (-2.8 – -1.7)-1.8 (-2.3 – -1.1)<0.001FN DXA T-score-2.2 (-2.8 – -1.6)-1.7 (-2.3 – -1.1)<0.001LS REMS T-score-3.0 (-3.5 – -2.0)-2.0 (-2.8 – -1.0)<0.001LS DXA T-score-2.8 (-3.4 – -1.8)-1.9 (-2.7 – -1.0)<0.001

* Wilcoxon ranksum test

Figure.

Boxplot of the distribution of T-score values estimated REMS and DXA at FN and LS among patients without incident fragility fracture and patients with incident fragility fractures at different sites.

Note:G. Adami, G. Arioli§, G. Bianchi§, M.L. Brandi§, C. Caffarelli§, L. Cianferotti§, G. Girasole§, S. Gonnelli§, M. Manfredini§, M. Muratore§, E. Quarta§, L. Quarta§, D. Gatti§ equal contributors listed in alphabetical order.

Disclosure of Interests:

Giovanni Adami: None declared, Giovanni Arioli *: None declared, Gerolamo Bianchi Grant/research support from: Celgene, Consultant of: Amgen, Janssen, Merck Sharp & Dohme, Novartis, UCB, Speakers bureau: Abbvie, Abiogen, Alfa-Sigma, Amgen, BMS, Celgene, Chiesi, Eli Lilly, GSK, Janssen, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi Genzyme, Servier, UCB, Maria Luisa Brandi: None declared, Carla Caffarelli: None declared, Luisella Cianferotti: None declared, Giuseppe Girasole: None declared, Stefano Gonnelli: None declared, Monica Manfedini: None declared, Maurizio Muratore: None declared, Eugenio Quarta: None declared, Laura Quarta: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work.

AB0681 COMPARISON BETWEEN DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF PREDOMINANT AXIAL VS MAINLY PERIPHERAL SPONDYLOARTHRITIS (SpA) PATIENTS, ENROLLED IN THE ONGOING SIRENA STUDY

Background:

SIRENA is an Italian, prospective Registry in Spondyloarthritis (SpA) patients, naïve to conventional, targeted and biological DMARDs. Patients are diagnosed, newly or confirmed, according to ASAS criteria and classified in subjects with predominant axial(AX) or with mainly peripheral manifestations(PER).

Objectives:

To compare descriptively AX vs PER subgroups of patients.

Methods:

Demographic data, diagnostic delay and subtypes of SpA as well as clinical features and comorbidities are collected.

Results:

282 patients were enrolled: 101 (35.8%) AX and 181 (64.2%) PER. Baseline data are shown in Table 1. There were more obese patients in AX (21.4% AX vs 16.1% PER) and more overweight ones in PER (19.4% AX vs 23.8% PER). The % of subjects with diagnostic delay was higher in AX (65.7% vs 53.9% PER) and the delay longer (mean of 73.1 months vs 47.8). In both groups, main reason of the delay was incorrect referrals (41.5% for AX and 45.3% for PER). Noteworthy the fact that in PER, the 75.7% of patients had a newly diagnosed SpA. In PER, the most frequent SpA type was PsA (82.3%), followed by undifferentiated SpA (8.8%) and enteropathic SpA (7.5%), while in AX, 49.5% were ankylosing spondylitis, 21.8% nr-ax-SpA and only 4% PsA. The majority of PER patients reported as first symptom peripheral arthritis (80/181), psoriasis (57/181) and enthesitis while in AX referred inflammatory back pain (80/101). High percentages of comorbidities were reported: psoriasis (65.8%) and cardiometabolic diseases (34.8%) were higher in PER while depression/anxiety and GI diseases were higher in AX (Table 2). At the baseline, the mean PhGA score (0-100) was 51.5 for AX and 43.8 for PER.

Conclusion:

SIRENA study highlights relevant differences in AX vs PER patients, expecially in terms of diagnostic delay, clinical presentation and comorbidities.

Table 1.MeanAX n=101MeanPER n=181Age (years)47.352.8Sex (female/male - %)50.5/49.547.5/52.5Weight (Kg)73.073.9BMI25.325.4Diagnostic Delay (yes - %)65.7%53.9%Time of delay (mean - months)71.347.8Newly SpA diagnosis (%)55.5%75.7%Table 2.A) First Symptom(more than 1 symptom referred)AX n=101N. PatientsPER n=181N. PatientsArthritis23122Enthesitis1654Dactylitis728Inflammatory Back Pain8034Psoriasis skin1057Psoriasis nails219Uveitis41IBD79B) Comorbidities(more than 1 comorbidity referred)% Patients% PatientsCardiometabolic20.8%34.8% -Hypertension19.8%30.9% -Dyslipidemia17.8%11.6% -Diabetes6.0%7.7% -MetS5.0%6.6%Psoriasis22.8%65.8%Gastrointestinal20.8 (16.9% CD)12.8 (4.4% CD)Depression/Anxiety11.9%2.2%Endocrine6.9%11.1%Osteoporosis3%5.5%Hepatic4% (3% NAFLD)4.4% (2.2% NAFLD)Infections3%3.9%Malignancies0%4.4%

Acknowledgments:

This study was sponsored by Janssen Italy.

We thank the Investigators and their staff at all of the study sites.

Disclosure of Interests:

Rosario Foti Speakers bureau: Abbvie, BMS, ROCHE, Janssen, Celgene, Gabriella Cardinale: None declared, Luisa Costa: None declared, Franco Franceschini Consultant of: Eli-Lilly, Janssen, Pfizer, Sanofi-Genzyme, UCB Pharma, GSK, Francesco Ciccia Grant/research support from: Pfizer, Novartis, Celgene, Janssen, Consultant of: Lilly, Novartis, Pfizer, Janssen, Roche, Celgene, Speakers bureau: Pfizer, Novartis, Celgene, Janssen, Roche, Abiogen, BMS, Antonio Marchesoni Speakers bureau: Abbvie, Pfizer, UCB, Novartis, Celgene, Eli Lilly, Giuliana Guggino Grant/research support from: Pfizer, Celgene, Speakers bureau: Celgene, Sandoz, Pfizer, Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB, Ennio Lubrano: None declared, Mauro Galeazzi: None declared, Mariasole Chimenti: None declared, Gerolamo Bianchi Grant/research support from: Celgene, Consultant of: Amgen, Janssen, Merck Sharp & Dohme, Novartis, UCB, Speakers bureau: Abbvie, Abiogen, Alfa-Sigma, Amgen, BMS, Celgene, Chiesi, Eli Lilly, GSK, Janssen, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi Genzyme, Servier, UCB, Giuseppe Galfo: None declared, Silvia Marelli Employee of: Janssen, Ennio Favalli Speakers bureau: BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis and Abbvie

AB0958 LOW-ENERGY PULSED ELECTROMAGNETIC FIELD THERAPY REDUCES PAIN IN FIBROMYALGIA: A RANDOMIZED SINGLE-BLIND CONTROLLED PILOT STUDY

Background:

Fibromyalgia is a clinical condition characterized by diffuse chronic muscle-skeletal pain, fatigue, sleep/mood disorders and muscular stiffness. The pathogenesis of fibromyalgia remains poorly understood but numerous lines of evidence suggest a role for alterations of both the central and peripheral nervous systems leading to heightened pain sensitivity along with acorollariumof other symptoms1. Low-energy pulsed electromagnetic field (PEMF) has promising data in the prevention of falls in senior individuals and is believed to promote osteogenesis and angiogenesis thus proving promising to treat bone diseases with chronic pain2. No data is available in fibromyalgia.

Objectives:

To investigate the efficacy and safety of PEMF on fibromyalgia symptoms in a randomized single-blind pilot study.

Methods:

We enrolled 21 women (median age 59 years, IQR 16,5) affected by fibromyalgia according to the 2010 ACR classification criteria3not receiving chronic medical treatment for pain; patients were randomly allocated to receive PEMF TEPT (triple energy pain treatment) / New Sunrise 280 (THS - Therapeutic Solutions, Milan, Italy) on the selected points (10 agopuncture points) or scrambled points for 20 minutes at baseline (T0) and after 4 (T4) and 8 (T8) weeks. Outcome measures were recorded at T0, T4 and T8 and included FIQ (fibromyalgia impact questionnaire), WIP (widespread pain index), VAS pain, SS (symptom severity scale), and SF-36 (short form 36 health survey questionnaire).

Results:

Patients receiving the active treatment had a deep reduction of WIP from T0 to T8 (-76% vs -13% in placebo) with a statistically significant difference compared to the placebo group (p=0.0025) (Figure 1). In all endpoints, we observed a general reduction at T4 and T8 compared to T0 also for FIQ, VAS pain, SS, SF-36, regardless of the treatment arm and the decrease was higher in the active treatment arm compared to the placebo group, albeit not reaching statistical significance (Figure 2).

Conclusion:

The results of our pilot study show that PEMF is more effective than placebo in reducing widespread pain in fibromyalgia while confirming that a placebo effect is clear in this complex disease.

References:

[1]Targeting network hubs with noninvasive brain stimulation in patients with fibromyalgia Chelsea M. Kaplan, R.E. Harris, UnCheol Lee, Alexander F. DaSilva, George A. Mashour, Steven E. Harte. PAIN: January 2020 - Volume 161 - Issue 1 - p 43-46

[2]Yuan J, Xin F, Jiang W. Underlying Signaling Pathways and Therapeutic Applications of Pulsed Electromagnetic Fields in Bone Repair.Cell Physiol Biochem. 2018;46(4):1581-1594

[3]Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken).2010;62:600-61

Disclosure of Interests:

Massimo Giovale: None declared, Lucia Novelli: None declared, Stefano Rampoldi: None declared, Rossana Galli: None declared, Patrizia Monteforte: None declared, Marica Doveri: None declared, Gerolamo Bianchi Grant/research support from: Celgene, Consultant of: Amgen, Janssen, Merck Sharp & Dohme, Novartis, UCB, Speakers bureau: Abbvie, Abiogen, Alfa-Sigma, Amgen, BMS, Celgene, Chiesi, Eli Lilly, GSK, Janssen, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi Genzyme, Servier, UCB, Luigi Carlo Bottaro: None declared, Carlo Selmi Grant/research support from: AbbVie, Janssen, MSD, Novartis, Pfizer, Celgene, and Leo Pharma, Consultant of: Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and Sanofi-Regeneron, Speakers bureau: AbbVie, Aesku, Alfa-Wassermann, Bristol-Myers Squibb, Biogen, Celgene, Eli-Lilly, Grifols, Janssen, MSD, Novartis, Pfizer, Roche, Sanofi-Genzyme, UCB Pharma

[Osteoarthicular injuries in orthopedic surgeons. How do we deal with it?]

INTRODUCTION

Therapeutic decision-making is a complex process in which multiple variables must be considered. There is a growing trend towards surgical indication, although scientific evidence is not always blunt. Understanding how surgeons make decisions can improve our understanding of treatment variability.

OBJECTIVES

To expose the demographic situation of osteoarticular injuries in orthopedic surgeons in Uruguay and how they deal with their own injury and identify those variables that influence therapeutic decision-making in the orthopedist.

MATERIAL AND METHODS

Using the Uruguayan Society of Orthopedics and Traumatology database, residents and surgeons who had at least one osteoarticular injury were identified. Each of the selected ones was interviewed by telephone, obtaining the variables of interest.

RESULTS

In a total of 274 residents and Orthopedic surgeons, we include 56 professionals and 69 osteoarticular injuries. We highlight the existence of multiple injuries of controversial treatment, according to current scientific evidence. The surgeon did not always indicate the same treatment to himself, in respect of the one that would indicate a patient with the same injury. Fear of complications, rapid job reimbursement, opinion of an expert colleague, among others were some of the variables found in the therapeutic decision.

CONCLUSIONS

When the lesion settles on the surgeon itself, a different action was observed with respect to a patient with equal injury.

P5672Diagnostic accuracy and clinical utility of point-of-care ultrasound among syncope patients in the emergency department

Background/Introduction

Syncope is still a challenge for risk stratification in the Emergency Department (ED), and the indication to discharge is not well established for all patients.

Purpose

To evaluate diagnostic accuracy and clinical utility of integration of clinical assessment and point-of-care ultrasound (POCUS) in evaluating non high-risk syncopes in the ED.

Methods

This observational prospective cohort study enrolled patients between February 2016 and January 2019.

All adult patients presenting in the ED for a non-high risk syncope were eligible (defined according to the 2015 ESC consensus on management of syncope in the ED). Subject for whom event etiology was identified right after the clinical assessment (i.e. history, physical exam, and EKG) or showing a clinical high risk for short term serious outcomes or refuse to participate in the study were excluded.

After the initial clinical assessment, the physician responsible for patient care was asked to categorize the syncope as low or neither high nor low risk. Immediately after, the same physician performed POCUS, and a new risk assessment, based on the results of both clinical and sonographic findings, was recorded. Thirty days after the ED evaluation, all participants were telephonically followed up by the investigators in order to assess the risk of short-term outcomes as defined in the San Francisco Syncope Rule cohorts. Both diagnostic accuracy, defined as sensitivity (SE) and specificity (SPE), and clinical utility, evaluated as net reclassification index (NRI) and net benefit were evaluated for clinical and POCUS-integrated assessment.

Results

A total of 415 patients with a syncope were eligible. Of these, 194 were enrolled (107 women - 55.2%). Median age was 63 years (interquartile range, IQR, 30 years). During the follow up, 21 patients experienced 28 events.

SE and SPE of the clinical evaluation were 33.3% (95% confidence interval, CI, 14.6–57%) and 79.5% (95% CI 72.7–85.3%), and they were 42.9% (95% CI 21.8–66%), and 92.4% (95% CI 87.4–95.9) for the POCUS-integrated evaluation (p<0.01 for SE and 0.05 for SPE).

NRI for events and non-events during follow up was 9.5% and 12.7%, respectively.

Using the prevalence of events in our cohort (10.8%) as the threshold probability, the use of the POCUS-integrated approach would reduce the diagnostic error of the clinical evaluation by 4.6 cases/100 patients.

The median time between clinical and POCUS-integrated evaluation was 15 minutes (iqr 20 minutes).

Conclusion

The results of our study suggest that the integration of the clinical evaluation with POCUS for patients presenting to the ED for non high-risk syncope might be able to increase the diagnostic accuracy and the utility of the clinical assessment alone.