Liquid biopsy-based monitoring of residual disease in multiple myeloma by analysis of the rearranged immunoglobulin genes-A feasibility study

The need for sensitive monitoring of minimal/measurable residual disease (MRD) in multiple myeloma emerged as novel therapies led to deeper responses. Moreover, the potential benefits of blood-based analyses, the so-called liquid biopsy is prompting more and more studies to assess its feasibility. Considering these recent demands, we aimed to optimize a highly sensitive molecular system based on the rearranged immunoglobulin (Ig) genes to monitor MRD from peripheral blood. We analyzed a small group of myeloma patients with the high-risk t(4;14) translocation, using next-generation sequencing of Ig genes and droplet digital PCR of patient-specific Ig heavy chain (IgH) sequences. Moreover, well established monitoring methods such as multiparametric flow cytometry and RT-qPCR of the fusion transcript IgH::MMSET (IgH and multiple myeloma SET domain-containing protein) were utilized to evaluate the feasibility of these novel molecular tools. Serum measurements of M-protein and free light chains together with the clinical assessment by the treating physician served as routine clinical data. We found significant correlation between our molecular data and clinical parameters, using Spearman correlations. While the comparisons of the Ig-based methods and the other monitoring methods (flow cytometry, qPCR) were not statistically evaluable, we found common trends in their target detection. Regarding longitudinal disease monitoring, the applied methods yielded complementary information thus increasing the reliability of MRD evaluation. We also detected indications of early relapse before clinical signs, although this implication needs further verification in a larger patient cohort.

Specific Antibody and the T-Cell Response Elicited by BNT162b2 Boosting After Two ChAdOx1 nCoV-19 in Common Variable Immunodeficiency

Common variable immunodeficiency (CVID) patients have markedly decreased immune response to vaccinations. In this study we evaluated humoral and T cell-mediated responses against severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2) with additional flow cytometric changes in CVID patients receiving booster vaccination with BNT162b2 after two ChAdOx1 nCoV-19. The BNT162b2 vaccine raised the anti-spike protein S immunoglobulin G over the cut-off value from 70% to 83% in CVID, anti-neutralizing antibody had been raised over a cut-off value from 70% to 80% but levels after boosting were significantly less in both tests than in healthy controls (*p=0.02; **p=0.009 respectively). Anti-SARS-CoV-2 immunoglobulin A became less positive in CVID after boosting, but the difference was not significant. The cumulative interferon-γ positive T cell response by ELISpot was over the cut-off value in 53% of the tested individuals and raised to 83% after boosting. This and flow cytometric control of cumulative CD4+ and CD8+ virus-specific T cell absolute counts in CVID were also statistically not different from healthy individuals after boosting. Additional flow cytometric measures for CD45+ lymphocytes, CD3+, and CD19+ cells have not shown significant differences from controls except for lower CD4+T cell counts at both time points (**p=0.003; **p=0.002), in parallel CD4+ virus-specific T-cell ratio was significantly lower in CVID patients at the first time point (*p: 0.03). After boosting, in more than 33% of both CVID patients and also in their healthy controls we detected a decrease in absolute CD45+, CD3+, CD3+CD4+, and CD3+CD8+, CD19+, and CD16+56+ cell counts. CD16+CD56+ cell counts were significantly lower compared to controls before and after boosting (*p=0.02, *p=0.02). CVID patients receiving immunosuppressive therapy throughout the previous year or autologous stem cell transplantation two years before vaccination had worse responses in anti-spike, anti-neutralizing antibody, CD3+CD4+T, CD19+ B, and natural killer cell counts than the whole CVID group. Vaccinations had few side effects. Based on these data, CVID patients receiving booster vaccination with BNT162b2 after two ChadOx1 can effectively elevate the levels of protection against COVID-19 infection, but the duration of the immune response together with COVID-19 morbidity data needs further investigation among these patients.

AB0059 Src-LIKE ADAPTOR PROTEIN DEFICIENCY DOSE-DEPENDENTLY PROTECTS MICE AGAINST COLLAGEN-INDUCED ARTHRITIS

Background

Src-like adaptor protein (SLAP), an adaptor between E3 ubiquitin ligase c-Cbl and the TCR complex, is a negative regulator of T-cell activation. SLAP regulates the expression of the CD3 ζ-chain. In accordance with our previous data, SLAP expression is increased in the CD4+ T-cells of patients with rheumatoid arthritis (RA). Recent data demonstrate that SLAP deficiency can prevent zymosan-induced arthritis in mice.

Objectives

We investigated the role of SLAP in collagen-induced arthritis (CIA).

Methods

Homozygous and heterozygous SLAP knock out and wild type (WT) C57BL/6J mice were used. After the isolation of genomial DNA, the genotype of the mice was determined. Then the animals were injected once (primary immunization) or twice (secondary immunization) with type II. collagen, or left untreated (the first injection was applied together with complete Freund’s adjuvant). Mice were monitored twice a week for 70 days, and the severity scores were evaluated. The scores were calculated for each limb (1 limb score: 0=no swelling; 4=the severe swelling).

Results

SLAP deficiency provided almost complete protection from the primary immunization of CIA. By contrast secondary immunization led to similar arthritis of the SLAP-KO, heterozygous or WT mice.

Conclusion

The authors’ present data suggest that SLAP deficiency protects dose-dependently from CIA.

Acknowledgements

This work was supported by OTKA/NKFIHO NN 111023; OTKA/NKFIHN K 131479.

Disclosure of Interests

None declared

Effects of one-year tofacitinib therapy on bone metabolism in rheumatoid arthritis

Janus kinase (JAK) inhibitors are used to treat rheumatoid arthritis (RA). We assessed the effects of tofacitinib on bone density and bone markers in association with clinical and laboratory parameters in RA. Tofacitinib stabilized bone density and resulted in a positive balance of bone turnover.

INTRODUCTION

Janus kinase (JAK) inhibitors emerged as new therapeutic options in rheumatoid arthritis (RA). We have little information on how it affects areal and volumetric bone mineral density (BMD) and bone turnover markers. The aim of this study was to assess the effects of 1-year tofacitinib therapy on bone metabolism in RA.

METHODS

Thirty RA patients with active disease were treated with either 5 mg bid or 10 mg bid tofacitinib for 12 months. We determined DAS28, CRP, IgM rheumatoid factor (RF), and anti-cyclic citrullinated peptide (CCP) levels, as well as serum levels of sclerostin, osteocalcin (OC), P1NP, DKK-1, OPG, RANKL, and 25-hydroxy-vitamin D3. Areal and volumetric BMD were assessed by DXA and peripheral quantitative CT (QCT), respectively.

RESULTS

Twenty-six patients (13 on each arm) completed the study. Tofacitinib was clinically effective by suppressing DAS28, CRP, and HAQ. This was accompanied by the attenuation of further bone loss. Tofacitinib therapy significantly increased OC, OPG, and vitamin D3, while decreased CTX levels (p < 0.05). Age and multiple bone markers (OC, CTX, P1NP, RANKL) inversely correlated with L2-4 and femoral neck BMD by DXA. CRP, DAS28, and RANKL inversely determined volumetric BMD by QCT. Age, CRP, anti-CCP, and DKK-1 influenced the effects of tofacitinib therapy on BMD changes.

CONCLUSIONS

One-year tofacitinib treatment stabilized BMD in RA patients and resulted in a positive balance of bone turnover as indicated by bone biomarkers. Further studies are needed to evaluate the potential beneficial effects of JAK inhibitors on inflammatory bone loss.

Synthesis, radiolabeling, and pre-clinical evaluation of [44Sc]Sc-AAZTA conjugate PSMA inhibitor, a new tracer for high-efficiency imaging of prostate cancer

PURPOSE

The aim of this work was to demonstrate the suitability of AAZTA conjugated to PSMA inhibitor (B28110) labeled with scandium-44 as a new PET tracer for diagnostic imaging of prostate cancer.

BACKGROUND

Nowadays, scandium-44 has received significant attention as a potential radionuclide with favorable characteristics for PET applications. A polyaminopolycarboxylate heptadentate ligand based on a 1,4-diazepine scaffold (AAZTA) has been thoroughly studied as chelator for Gd³⁺ ions for MRI applications. The excellent results of the equilibrium, kinetic, and labeling studies led to a preliminary assessment of the in vitro and in vivo behavior of [⁴⁴Sc][Sc-(AAZTA)]^- and two derivatives, i.e., [⁴⁴Sc][Sc (CNAAZTA-BSA)] and [⁴⁴Sc][Sc (CNAAZTA-cRGDfK)].

RESULTS

B28110 was synthesized by hybrid approach, combining solid-phase peptide synthesis (SPPS) and solution chemistry to obtain high purity (97%) product with an overall yield of 9%. Subsequently, the radioactive labeling was performed with scandium-44 produced from natural calcium target in cyclotron, in good radiochemical yields (RCY) under mild condition (pH 4, 298 K). Stability study in human plasma showed good RCP% of [⁴⁴Sc]Sc-B28110 up to 24 h (94.32%). In vivo PET/MRI imaging on LNCaP tumor-bearing mice showed high tracer accumulation in the tumor regions as early as 20 min post-injection. Ex vivo biodistribution studies confirmed that the accumulation of ⁴⁴Sc-PSMA-617 was two-fold lower than that of the radiolabeled B28110 probes.

CONCLUSIONS

This work demonstrated the suitability of B28110 for the complexation with scandium-44 at room temperature and the high performance of the resulting new tracer based on AAZTA chelator for the diagnosis of prostate cancer using PET.

FRI0047 STRATEGIES REGARDING GOAL SETTING AND SELF-MANAGEMENT IN DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS: PRELIMINARY RESULTS OF A SYSTEMATIC LITERATURE REVIEW INFORMING THE 2020 EULAR RECOMMENDATIONS FOR THE MANAGEMENT OF DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) patients treated according to European League Against Rheumatism (EULAR) recommendations failing ≥2 biological or targeted synthetic disease-modifying antirheumatic drugs with a different mode of action who still have complaints which may be suggestive of active disease and for whom management is perceived as problematic by patient and/or rheumatologist have been defined as suffering from ‘difficult-to-treat RA’. A mismatch in goal setting between patient and health care professional, and suboptimal self-management may contribute to this disease state, while specific management recommendations regarding these factors are currently lacking.1

Objectives:

To systematically summarise evidence in the literature on the identification and optimisation of a mismatch in goal setting and suboptimal self-management in difficult-to-treat RA patients, informing the 2020 EULAR recommendations for the management of difficult-to-treat RA.

Methods:

A systematic literature review (SLR) was performed: PubMed, Embase and Cochrane databases were searched up to December 2018. Relevant papers were selected and appraised. Effect sizes were extracted or calculated.

Results:

Three studies were selected on the identification and four on the optimisation of a mismatch in goal setting (Figure 1). No accurate measures were found to identify a mismatch in goal setting, but patients expressed a desire to take their quality of life goals more explicitly into account. Education was found to improve goal setting (4 of 4 studies, effect size not calculable).

Five studies were selected on the identification and 31 on the optimisation of suboptimal self-management (Figure 1). Although formal evaluations in high quality studies were lacking, the Arthritis Self-Efficacy Score was found to be the most reliable tool to identify suboptimal self-management. Patients were found to desire more education on nutrition, the disease and the diagnostic process to be able to improve self-management. Self-management programs, educational and psychological interventions were found to improve self-management (Table 1).

Table 1:

Effect sizes of studies on the optimisation of self-management

OutcomeType of interventionBenefit of intervention compared to control1innofnselected studiesStudies with effect size (n)Effect size per study2Self-efficacySelf-management programs12/1360.18−0.39; 0.23−0.67; 0.37; 0.43−0.53; 0.49;37.52−8.25Education6/630.05−0.17; 0.22−0.59; 1.23Psychological2/220.20−0.35; 0.45AnxietyPsychological1/210.173Depressive symptomsPsychological1/210.15−0.333RA knowledgeEducation3/320.34−0.47; 0.84

n: number of studies; RA: rheumatoid arthritis.

1. Mostly usual care or wait list; 2. If different outcome measures were used the range in effect sizes over these measures is reported; 3. Pooled effect size, reported in systematic literature review.

Conclusion:

In difficult-to-treat RA patients, limited evidence was found on a mismatch in goal setting and suboptimal self-management, especially regarding their identification. Non-pharmacological interventions were found to improve goal setting and self-management.

References:

[1]Smolen JSet al. Ann Rheum Dis2020. Epub ahead of print.

Disclosure of Interests:

Nadia M. T. Roodenrijs: None declared, Attila Hamar: None declared, Melinda Kedves: None declared, György Nagy: None declared, Jacob M. van Laar Grant/research support from: MSD, Genentech, Consultant of: MSD, Roche, Pfizer, Eli Lilly, BMS, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Paco Welsing: None declared

THU0356 DISEASE ACTIVITY ASSESSMENT IN SYSTEMIC SCLEROSIS PATIENTS BASED ON THE CURRENTLY AVAILABLE ACTIVITY INDICES AND THE PHYSICIAN GLOBAL ASSESSMENT

Background:

Disease activity assessment is crucial in defining the appropriate therapy and to monitor the efficacy of treatment in systemic sclerosis.

Objectives:

We aimed to test the performance of the ’old’ European Scleroderma Trials and Research Group (EUSTAR) Activity Index (old-AI) (1), the ’new’ EUSTAR activity index (new-AI) (2), and the scleroderma activity index derived from the old-AI (Pecs-AI) (3). We compared the three indices to the disease activity based on the physician’s global assessment (PGA). We also assessed the correlations with the change in modified Rodnan Skin Score (MRSS), FVC and arthritis after one year follow-up.

Methods:

We evaluated 77 patients (50 diffuse /dcSSc/ and 27 limited cutaneous SSc /lcSSc/ patients) from a single tertiary clinical center. Cohort enrichment was performed to increase the number of patients with early disease and dcSSc. Seventy-two patients were re-evaluated after one year. Nine patients had overlap syndromes: rheumatoid arthritis (n=3), Sjögren syndrome (n=2), polymyositis (n=2), and mixed connective tissue disease (n=2). The overall disease activity was evaluated using both composite indices (old-AI, Pecs-AI, new-AI) and the PGA of disease activity, based on the blinded evaluation of a single physician (LV). In addition to the minimal essential data from the EUSTAR database we also performed detailed assessment of the musculoskeletal involvement evaluating measures of hand function, DAS28 scores, and the Clinical Disease Activity Index (CDAI) (4).

Results:

Three times more patients with active disease were identified by the new-AI compared to the old-AI at baseline investigation (n=37, 48.7%, vs. n=11, 14.3%). Two patients (18%) with active disease based on the old-AI were missed by the new-AI. Pecs-AI index identified 15 patients (19.5%) with active disease (cut-off >2.75 points). Active disease was equally frequent in dcSSc and lcSSc patients based on old-AI, but was more frequent in dcSSc patients based on the new-AI in the whole cohort, and also after excluding overlap cases.

Patients with active disease based on the old-AI had more frequently rheumatoid factor (6/9, vs. 12/45, p=0.047), and DLCO<70% (11/11, vs. 36/65, p<0.01). Active disease based on the new-Al was associated with current cyclophosphamide treatment (9/37, vs.2/39, p=0.023), and diabetes mellitus (7/30, vs. 0/39, p<0.01). The PGA correlated moderately at both baseline and one year follow-up examination with the old-AI (rho: 0.519, and rho: 0.692, respectively, p<0.001), the new-AI (rho: 0.401, and rho: 0.429, respectively, p<0.001), and the Pecs-AI (rho: 0.425, and rho: 0.593, respectively, p<0.001).

CDAI correlated significantly with the old-AI (rho: 0.345, and rho: 0.283, respectively, p<0.05) and the Pecs-AI (rho: 0.363, and rho: 0.324, respectively, p<0.05) at both the baseline and one-year follow-up investigations, but showed no consistent correlation to the new-AI or PGA.

Conclusion:

The two validated disease activity indices indentify different patient groups. Joint involvement is potentially underrepresented in the new EUSTAR activity index. Active disease is also present in lcSSc and should be assessed regularly in these patients.

References:

[1]Valentini G, et al. Ann Rheum Dis 2003; 62: 901-3.

[2]Valentini G, et al. Ann Rheum Dis 2017;76:270–276.

[3]Minier T, et al. Rheumatology (Oxford) 2010;49(6):1133-45.

[4]Lorand V, et al. Rheumatology (Oxford). 2016;55(10):1849-58.

Acknowledgments:

This work was supported by the EU Seventh Framework Program [FP7/2007-2013] under Grant Agreement n° 305495 (DeSScipher), by the Hungarian Scientific Research Fund (contract n°: 112939), and the EU under the Grant Agreement n° PEPSYS GINOP-232-15-2016-00050.

Disclosure of Interests:

Tünde Minier Speakers bureau: Actelion, Abbvie, MSD, Pfizer, Lilly, Roche, Veronika Lóránd: None declared, Zsófia Bálint: None declared, Dalma Komjati: None declared, Gabriella Nagy Speakers bureau: MSD, Antonietta Kovács: None declared, Orsolya Koncz: None declared, Cecília Varjú Consultant of: Boehringer Ingelheim RCV GmbH & Co KG, Speakers bureau: Lilly, László Czirják Consultant of: Actelion, BI, Roche-Genentech, Lilly, Medac, Novartis, Pfizer, Bayer AG, Gabor Kumanovics Consultant of: Boehringer, Teva, Speakers bureau: Roche, Lilly, Novartis, Balazs Nemeth: None declared

THU0181 SOLUBLE VASCULAR BIOMARKERS IN RHEUMATOID ARTHRITIS AND ANKYLOSING SPONDYLITIS: EFFECTS OF ONE-YEAR ANTI-TNF-Α THERAPY

Background:

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) have been associated with inflammatory atherosclerosis, increased cardiovascular (CV) morbidity and mortality. Numerous proteins may serve as biomarkers of inflammatory atherosclerosis. The treatment of arthritis by tumour necrosis factor α (TNF-α) inhibitors may decrease the serum concentrations of these biomarkers.

Objectives:

In this study we wished to determine circulating levels of oxidized LDL (oxLDL) - β2 glycoprotein I (β2GPI) complexes (AtherOx), anti-hsp60 antibodies, soluble urokinase plasminogen activator receptor (sUPAR) and N-terminal B-type natriuretic peptide (NT-proBNP) in sera of RA and AS patients. We also wished to assess the effects of anti-TNF treatment on these biomarkers.

Methods:

Altogether 53 arthritis patients including 36 RA patients treated with either etanercept (ETN) or certolizumab pegol (CZP) and 17 AS patients treated with ETN were included in a 12-month follow-up study.Circulating oxLDL/β2gpI complexes, anti-human Hsp60 immunoglobulin G (IgG) levels and BNP8-29fragment levels were assessed by ELISA. suPAR levels were assessed by suPARnostic®Quick Triage test. All laboratory assessments were performed at baseline, as well as 6 and 12 months after treatment initiation. Results were associated with DAS28, BASDAI, CRP.

Results:

In the mixed cohort of 53 arthritis patients, the circulating levels of oxLDL/β2gpI significantly decreased after 12 months of anti-TNF therapy (0.20±0.11 U/ml) compared to baseline (0.24±0.10 U/ml; p=0.014). There was a tendency of non-significant decrease after 6 months (0.23±0.14 U/ml) versus baseline. Anti-Hsp60 antibody levels did not change after 6 months (158.6±138.6 AU/ml) and 12 months (167.3±143.3 AU/ml) compared to baseline (170.3±140.4 AU/ml). Among the patients, 21.2% had low, 36.4% “observe”, 9.1% high and 33.3% critical suPAR levels. suPAR levels showed a tendency of non-significant decrease after 6 months (11.3±17.7 ng/ml) and 12 months (10.3±15.3 ng/ml) versus baseline (11.5±16.4 ng/ml). However, when the four serum level categories described above were considered, suPAR concentrations exerted significant decrease in RA patients with critical suPAR levels (>9ng/ml) (p=0.04). Similarly, BNP fragment levels showed only a tendency of decrease after 6 months (518.2±422.4 pmol/l) and 12 months (484.1±418.2 pmol/l) versus baseline (530.8±441.8 pmol/l). However, serum BNP levels at baseline and after 12 months were significantly increased in CCP positive compared to CCP negative RA patients (baseline: 670.6±323.0 versus 138.0±436.4 pmol/l; p=0.030 and 12 months: 652.9±283.2 versus 456.5±423.1 pmol/l; p=0.021), as well as in RF positive compared to RF negative RA patients (baseline: 680.6±381.6 versus 292.9±198.3 pmol/l; p=0.007 and 12 months: 668.9±346.5 versus 312.2±207.0 pmol/l; p=0.001).

Conclusion:

One-year anti-TNF therapy significantly decreased circulating oxLDL/β2gpI complex levels. This therapy also decreased suPAR levels in patients with critically high suPAR. BNP fragment levels were associated with seropositivity in RA. These vascular biomarkers may reflect the effects of TNF inhibition on endothelial activation.

Acknowledgments:

This study was sponsored by an investigator-initiated grant from Pfizer.

Disclosure of Interests:

Anita Pusztai: None declared, Attila Hamar: None declared, Ágnes Horváth: None declared, Edit Végh: None declared, Nóra Bodnár: None declared, György Kerekes: None declared, Monika Czókolyová: None declared, Szilvia Szamosi: None declared, Levente Bodoki: None declared, Katalin Hodosi: None declared, Andrea Domjan: None declared, Gábor Nagy: None declared, Ibolya Szöllösi: None declared, Luis Lopez Employee of: Retired employee of Corgenix Inc., Eiji Matsuura: None declared, Zoltán Prohászka: None declared, Sándor Szántó: None declared, Zoltán Nagy: None declared, Yehuda Shoenfeld: None declared, Zoltán Szekanecz Grant/research support from: Pfizer, UCB, Consultant of: Sanofi, MSD, Abbvie, Pfizer, Roche, Novertis, Lilly, Gedeon Richter, Amgen, Gabriella Szücs: None declared

SAT0052 THERAPEUTIC STRATEGIES IN DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS: PRELIMINARY RESULTS OF A SYSTEMATIC LITERATURE REVIEW INFORMING THE 2020 EULAR RECOMMENDATIONS FOR THE MANAGEMENT OF DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) patients treated according to European League Against Rheumatism (EULAR) recommendations failing ≥2 biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) with a different mode of action who still have complaints which may be suggestive of active disease may be defined as suffering from ‘difficult-to-treat RA’. Management recommendations for RA focus predominantly on the earlier phases of the disease and specific recommendations for difficult-to-treat RA patients are currently lacking.1

Objectives:

To systematically summarise evidence in the literature on pharmacological and non-pharmacological therapeutic strategies for difficult-to-treat RA patients, informing the 2020 EULAR recommendations for the management of difficult-to-treat RA.

Methods:

A systematic literature review (SLR) was performed: PubMed, Embase and Cochrane databases were searched up to December 2019. Relevant papers were selected and appraised.

Results:

Thirty articles were selected for therapeutic strategies in patients with limited DMARD options due to contraindications, 73 for patients in whom previous b/tsDMARDs were not effective (‘true refractory RA’), and 51 for patients with predominantly non-inflammatory complaints. For patients with limited DMARD options, limited evidence was found on effective DMARD options for patients with concomitant obesity, and on safe DMARD options for patients with concomitant hepatitis B and C. In patients who failed ≥2 bDMARDs, tocilizumab, tofacitinib, baricitinib, upadacitinib and filgotinib were found to be more effective than placebo, but evidence was insufficient to prioritise. In patients who failed ≥1 bDMARD, there was a tendency of non-tumour necrosis factor inhibitor (TNFi) bDMARDs to be more effective than TNFi (Figure 1). Generally, b/tsDMARDs become less effective when patients failed more bDMARDs, this tendency was not clear for upadacitinib and filgotinib (Figure 2). In patients with predominantly non-inflammatory complaints (mainly function, pain and fatigue), exercise, education, psychological and self-management interventions were found to be of additional benefit.

Conclusion:

This SLR underscores the scarcity of evidence on the optimal treatment of difficult-to-treat RA patients. As difficult-to-treat RA is a newly defined disease state, all evidence is to an extent indirect. Several b/tsDMARDs were found to be effective in patients who failed ≥2 bDMARDs and generally effectiveness decreased with a higher number of failed bDMARDs. Additionally, a beneficial effect of non-pharmacological interventions was found on non-inflammatory complaints.

References:

[1] Smolen JSet al. Ann Rheum Dis2020. Epub ahead of print.

Disclosure of Interests:

Nadia M. T. Roodenrijs: None declared, Attila Hamar: None declared, Melinda Kedves: None declared, György Nagy: None declared, Jacob M. van Laar Grant/research support from: MSD, Genentech, Consultant of: MSD, Roche, Pfizer, Eli Lilly, BMS, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Paco Welsing: None declared

Abdominal Compartment Syndrome After Liver Transplant in Drug-Induced Acute Liver Failure: A Case Report

The incidence of drug-induced acute liver failure (ALF) has been increasing in recent years. Despite the complex intensive treatment, liver transplant should be performed in progressive cases. A systemic inflammatory response syndrome and the burden of surgical intervention promote abdominal compartment syndrome (ACS); observed preoperatively, they are significant negative prognostic factors. THE CASE: We demonstrate a young woman with liver transplant after ALF and a consecutive ACS. We presumed drug toxicity in the background of the rapidly progressive ALF, based on the preoperative hematologic examination and the histology of the removed liver. An ACS has occurred in the postoperative period that must have been resolved with mesh, and later, anatomic segment 2-3 resection had to be performed to further decrease the pressure. The patient left the hospital after 62 days with good graft function. DISCUSSION: A complex intensive care is mandatory in the case of orthotopic liver transplant for ALF. Outcomes are good after orthotopic liver transplant. An ACS might occur after surgery. In these rare cases a delayed abdominal closure or even a liver resection can be the only solution and sometimes an urgent need to resolve the life-threatening problem.

Effect of preoperative injection of superparamagnetic iron oxide particles on rates of sentinel lymph node dissection in women undergoing surgery for ductal carcinoma in situ (SentiNot study)

Background

One-fifth of patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS) have invasive breast cancer (IBC) on definitive histology. Sentinel lymph node dissection (SLND) is performed in almost half of women having surgery for DCIS in Sweden. The aim of the present study was to try to minimize unnecessary SLND by injecting superparamagnetic iron oxide (SPIO) nanoparticles at the time of primary breast surgery, enabling SLND to be performed later, if IBC is found in the primary specimen.

Methods

Women with DCIS at high risk for the presence of invasion undergoing breast conservation, and patients with DCIS undergoing mastectomy were included. The primary outcome was whether this technique could reduce SLND. Secondary outcomes were number of SLNDs avoided, detection rate and procedure-related costs.

Results

This was a preplanned interim analysis of 189 procedures. IBC was found in 47 and a secondary SLND was performed in 41 women. Thus, 78·3 per cent of patients avoided SLND (P &lt; 0·001). At reoperation, SPIO plus blue dye outperformed isotope and blue dye in detection of the sentinel node (40 of 40 versus 26 of 40 women; P &lt; 0·001). Costs were reduced by a mean of 24·5 per cent in women without IBC (€3990 versus 5286; P &lt; 0·001).

Conclusion

Marking the sentinel node with SPIO in women having surgery for DCIS was effective at avoiding unnecessary SLND in this study. Registration number: ISRCTN18430240 (http://www.isrctn.com).

Multidimensional Analysis of 16 Glucose Isomers by Ion Mobility Spectrometry

Diastereomeric adducts comprising an enantiomerically pure monosaccharide analyte, a peptide, and/or an amino acid and a divalent metal ion (for 16 different monosaccharide isomers) are generated by electrospray ionization and analyzed by combined ion mobility spectrometry-mass spectrometry (IMS-MS) techniques. Mobility distributions of [l-Ser + M + H](+) (where l-Ser is l-serine and M is a given monosaccharide), [l-Phe-Gly + M + H](+) (where l-Phe-Gly is l-phenylalanine-glycine), and [Mn(II) + (l-Phe-Gly - H) + M](+) complex ions are used to determine collision cross sections (ccs in Å(2)), and groups of cross sections for different clusters are proposed as means of identifying the sugar isomers. Within one type of complex, variations in ccs do not always allow delineation between the 16 glucose isomers, but interestingly, when ccs of three different ions are combined as a spatial vector, enantiomers are partially resolved. As a result of this analysis, l-glucose, d-glucose, l-allose, d-allose, d-gulose, d-galactose, and l-mannose are delineated, and for all eight enantiomeric pairs, d and l entities display different coordinates. In addition, different combinations of amino acids, peptide, and metal ions are surveyed, and the potential for yielding unique coordinates for the generated diastereomeric complexes is assessed.

Radiosurgery for cerebral cavernomas

The role of stereotactic radiosurgery (SRS) in the management of cerebral cavernomas (CCMs) remains controversial. However, during the last decade the increasing knowledge on natural history and numerous publications from SRS centers using modern treatment protocols has been changing the initial resistance of the neurosurgical community. Unfortunately, the quality of publications on CCM SRS remains heterogeneous. Controversies arise from the lack of control groups, the different definition of hemorrhage, heterogeneous patient populations, and poor definition of treatment protocols. The key for proper interpretation of results is the understanding of the natural history of CCMs, which is varied both according to anatomical location and the presence or absence of previous hemorrhage. Hemispheric lesions appear to be more benign with lower annual bleed rate and risk of persisting disability, whereas those found in the thalamus, basal ganglia and brainstem typically have higher rebleed risk resulting in higher cumulative morbidity following subsequent hemorrhages. However, we are still unable at presentation to predict the future behavior of an individual lesion. In the present paper we critically review and analyze the modern SRS literature on CCMs. The expanding number of available data with current treatment protocols strongly supports the initial intuition that SRS is an effective treatment alternative for deep-seated CCMs with multiple hemorrhages reducing pretreatment annual rebleed rates from 32% pre-treatment to 1.5% within 2 years after treatment (N.=197). Moreover, it appears to stabilize lesions with no more than one bleed, and it is also effective for CCMs causing therapy resistant epilepsy especially if applied within 3 years after presentation. In modern SRS series the rate of persisting adverse radiation effects is low, resulting only in mild morbidity even in deep-seated lesions (4.16%, N.=376), and morbidity caused by post-treatment hemorrhages is also low (5.3%, N.=132). Admittedly, there is no high quality evidence to define the relative roles of microsurgery, SRS and wait-and-see policy in the management of detected CCMs at present. However, based on increasing positive experience, we recommend early SRS soon after presentation in neurologically intact or minimally disabled patients harboring deep-seated CCMs, because waiting for the cumulative morbidity of the natural history to justify an otherwise low-risk intervention does not serve the patient well.

Dynamic Reorganization of Vortex Matter into Partially Disordered Lattices

We report structural evidence of dynamic reorganization in vortex matter in clean NbSe(2) by joint small-angle neutron scattering and ac susceptibility measurements. The application of oscillatory forces in a transitional region near the order-disorder transition results in robust bulk vortex lattice configurations with an intermediate degree of disorder. These dynamically originated configurations correlate with intermediate pinning responses previously observed, resolving a long-standing debate regarding the origin of such responses.

Severe skin inflammation and filaggrin mutation similarly alter the skin barrier in patients with atopic dermatitis

BACKGROUND

Filaggrin (FLG) deficiency is a well-known predisposing factor for the development of atopic dermatitis (AD). Decreased FLG expression can be the result of haploinsufficiency or severe inflammation, which can cause acquired FLG alterations. FLG mutations are related to several clinical and laboratory parameters of AD; however, some recent data seem to contradict these associations.

OBJECTIVES

Our aim was to determine which clinical and biochemical parameters are connected to FLG haploinsufficiency and which ones are also associated with acquired FLG alterations due to severe skin symptoms in patients with AD.

METHODS

We introduced a novel classification of patients with AD, based on FLG mutations and SCORAD (SCORing Atopic Dermatitis). Based on these parameters, we created three groups of patients with AD: mild-to-moderate wild-type (A), severe wild-type (B) and severe mutant (C). In all groups, we assessed laboratory and clinical parameters and performed immunohistochemical analyses.

RESULTS

Groups B and C contained patients with equally severe symptoms based on the SCORAD. The two severe groups did not differ significantly with respect to barrier-specific parameters, whereas group A had significantly better results for the barrier function measurements. However, significant differences were detected between groups B and C with respect to the allergic sensitization-specific parameters.

CONCLUSIONS

These findings suggest that skin barrier function correlates with the severity of skin inflammation and can be equally impaired in patients with FLG mutant- and wild-type AD with severe symptoms. Nevertheless, our results also suggest that patients with FLG mutant-type AD may have a higher risk of allergic sensitization compared with patients with the wild-type.

Electric-field-induced Skyrmion distortion and giant lattice rotation in the magnetoelectric insulator Cu2OSeO3

Uniquely in Cu2OSeO3, the Skyrmions, which are topologically protected magnetic spin vortexlike objects, display a magnetoelectric coupling and can be manipulated by externally applied electric (E) fields. Here, we explore the E-field coupling to the magnetoelectric Skyrmion lattice phase, and study the response using neutron scattering. Giant E-field induced rotations of the Skyrmion lattice are achieved that span a range of ∼25°. Supporting calculations show that an E-field-induced Skyrmion distortion lies behind the lattice rotation. Overall, we present a new approach to Skyrmion control that makes no use of spin-transfer torques due to currents of either electrons or magnons.

Lymphoid metastasis of rat My2/De leukemia

By grafting spontaneous leukemia tumor cells, the myeloid My2/De leukemia rat model was established. Death was caused by impaired functions of heavily infiltrated organs. In vitro culturing of tumor cells, blood and bone marrow counts and cytochemic reactions indicated the leukemic the origin resembling human myeoloblastic leukemia. Metastatic spread was followed after i.v. and i.p. injection, and by implantation of leukemia cells under the renal capsule of rats. Primary tumor and metastasis formation was visualized by (18)FDG or (11)C-methionine administration and MiniPET. The accumulation of radiotracers was measured in different organs and expressed as Differential Absorption Ratios (DARs). Subrenal implantation of My2/De cells resulted in their appearance in other abdominal organs and in parathymic lymph nodes. The release of tumor cells from the primary kidney to the peritoneum was mimicked by the i.p. administration of ink particles. Ink particles deposited in the abdominal organs and in the thoracal lymph nodes, preferentially in parathymic lymph nodes, confirming the notion of lymphatic spread of metastasis.

Effects of dietary sodium butyrate on hepatic biotransformation and pharmacokinetics of erythromycin in chickens

Butyrate, a commonly applied feed additive in poultry nutrition, can modify the expression of certain genes, including those encoding cytochrome P450 (CYP) enzymes. In comparative in vitro and in vivo experiments, the effect of butyrate on hepatic CYP genes was examined in primary cultures of chicken hepatocytes and in liver samples of chickens collected from animals that had been given butyrate as a feed additive. Moreover, the effect of butyrate on the biotransformation of erythromycin, a marker substance for the activity of enzymes of the CYP3A family, was investigated in vitro and in vivo. Butyrate increased the expression of the avian-specific CYP2H1 both in vitro and in vivo. In contrast, the avian CYP3A37 expression was decreased in hepatocytes following butyrate exposure, but not in the in vivo model. CYP1A was suppressed by butyrate in the in vitro experiments, and overexpressed in vivo in butyrate-fed animals. The concomitant incubation of hepatocytes with butyrate and erythromycin led to an increased CYP2H1 expression and a less pronounced inhibition of CYP3A37. In in vivo pharmacokinetic experiments, butyrate-fed animals given a single i.m. injection of erythromycin, a slower absorption phase (longer T(half-abs) and delayed T(max)) but a rapid elimination phase of this marker substrate was observed. Although these measurable differences were detected in the pharmacokinetics of erythromycin, it is unlikely that a concomitant application of sodium butyrate with erythromycin or other CYP substrates will cause clinically significant feed-drug interaction in chickens.

Description of patients with IgG4-related disease from a Hungarian centre

OBJECTIVES

Although most reported patients with immunoglobulin G4-related disease (IgG4-RD) are from the Far East, we aimed to identify patients suffering from IgG4-RD in our University Centre in Debrecen, Hungary.

METHOD

Serum IgG4 levels were measured at 51 of our 800 patients followed up because of Sjögren's syndrome (SS) if one or more clinical signs during the disease course raised the possibility of IgG4-RD (persisting salivary gland swelling, absence of anti-Ro/SSA and anti-La/SSB antibodies in the serum, and positive salivary gland biopsy, coexistence of autoimmune pancreatitis, autoimmune hepatitis, or primary sclerosing cholangitis, persisting lymphadenopathy). Where available, histological samples of small salivary gland biopsies were revised to detect the particular features of IgG4-RD. Pathologists and surgeons were informed about the disease and asked to refer suspicious cases.

RESULTS

Based on our survey, eight patients were identified with IgG4-RD. Pancreatic, salivary gland, aortic, and retroperitoneal manifestations were detected. Of the 51 patients with SS, four appeared to have IgG4-RD, but eventually one was excluded.

CONCLUSIONS

Although IgG4-RD is not yet well known to physicians of Western countries, it occurs in Caucasians and probably in other races as well. Moreover, our eight cases diagnosed with IgG4-RD demonstrate a relatively large European patient population collected in a single centre. European clinicians, and especially rheumatologists, should be informed and at least certain laboratories should be prepared to investigate patient samples if the suspicion of IgG4-RD is raised. The main clinical significance of an accurate diagnosis is the extreme corticosteroid sensitivity of IgG4-RD.

The ultrastructure and flexibility of thylakoid membranes in leaves and isolated chloroplasts as revealed by small-angle neutron scattering

We studied the periodicity of the multilamellar membrane system of granal chloroplasts in different isolated plant thylakoid membranes, using different suspension media, as well as on different detached leaves and isolated protoplasts-using small-angle neutron scattering. Freshly isolated thylakoid membranes suspended in isotonic or hypertonic media, containing sorbitol supplemented with cations, displayed Bragg peaks typically between 0.019 and 0.023Å(-1), corresponding to spatially and statistically averaged repeat distance values of about 275-330 Å⁻¹. Similar data obtained earlier led us in previous work to propose an origin from the periodicity of stroma thylakoid membranes. However, detached leaves, of eleven different species, infiltrated with or soaked in D2O in dim laboratory light or transpired with D2O prior to measurements, exhibited considerably smaller repeat distances, typically between 210 and 230 Å⁻¹, ruling out a stromal membrane origin. Similar values were obtained on isolated tobacco and spinach protoplasts. When NaCl was used as osmoticum, the Bragg peaks of isolated thylakoid membranes almost coincided with those in the same batch of leaves and the repeat distances were very close to the electron microscopically determined values in the grana. Although neutron scattering and electron microscopy yield somewhat different values, which is not fully understood, we can conclude that small-angle neutron scattering is a suitable technique to study the periodic organization of granal thylakoid membranes in intact leaves under physiological conditions and with a time resolution of minutes or shorter. We also show here, for the first time on leaves, that the periodicity of thylakoid membranes in situ responds dynamically to moderately strong illumination. This article is part of a special issue entitled: photosynthesis research for sustainability: keys to produce clean energy.

Decrease in cold ischemic times as a result of protocol changes of urgent immunogenetic testing during cadaveric kidney transplantation in Hungary

BACKGROUND

Based on national ethics committee permission, the procedure of urgent immunogenetics testing prior to cadaveric kidney transplantation was changed in Hungary from January 1, 2011 allowing HLA typing of the donor and prospective crossmatching using peripheral blood samples from the donor prior to the definitive declaration of brain death. The aim of the current study was to compare key indicators of transplantation primarily cold ischemic time [CIT], between time periods with outcomes.

METHODS

The following indicators were systematically collected prospectively and retrospectively for each deceased heart-beating donor transplantation between January 1, 2010 and October 31, 2010 (n = 114) versus January 1, 2011 and October 31, 2011 (n = 91): CIT for the first and second kidney; laboratory turnaround times (TAT), and time for final preparation of the selected recipient.

RESULTS

As a result of the new procedure, the CIT for the first kidney decreased from 16.5 ± 3.5 to 12.4 ± 3.2 hours (P < .001). Similarly, for the second kidney the parameters were a 19.8 ± 3.4 versus 16.0 ± 3.8 hours (P < .001). As a consequence of more hands-on time in the laboratory, the TAT increased from 5.6 ± 0.8 hours to 7.2 ± 1.1 hours (TAT1) followed by an additional 4.2 ± 1.0 hours (TAT2). We also compared the times necessary for preparation of immunologically suitable recipients for transplantation, namely, 9.5 ± 2.3 hours in the earlier system, increasing to 15.5 ± 4.3 hours during the new procedure.

CONCLUSION

As a consequence of the procedural change, the CIT parameter decreased significantly for both kidneys, which may have contributed to improved short-term outcomes of transplantation. The time available for final preparation of selected recipients was increased allowing improvements in CIT.

Investigation of JAK2, STAT3 and CCR6 polymorphisms and their gene-gene interactions in inflammatory bowel disease

Genome-wide association studies identified many loci associated with the two forms of inflammatory bowel disease (IBD), Crohn's disease (CD) and ulcerative colitis (UC). Components of the interleukin-23 signalling pathway, such as IL23R, JAK2 and STAT3, have been implicated in both diseases. In addition, emerging evidence supports the role of IL23-driven Th17 cells in inflammation. Here, we studied the susceptibility nature of three components of IL23 signalling and Th17 cell differentiation: JAK2 rs10758669, STAT3 rs744166 and CCR6 rs2301436 initially associated with CD in Hungarian CD and UC patients. A total of 616 unrelated subjects with either form of IBD and 496 healthy controls were genotyped with PCR-RFLP methods. We also tested the genetic interactions of JAK2, STAT3 and CCR6 polymorphisms in a pairwise fashion with regard to disease risk. We could confirm the susceptibility of STAT3 rs744166 TT homozygotes for UC (OR: 1.483, 95% CI: 1.103-1.992, P = 0.009). Data on genetic interaction reveals that the above JAK2 and STAT3 risk alleles contribute to CD susceptibility in combination with each other (OR: 2.218; 95% CI: 1.097-4.487; P = 0.024), while the JAK2 variant shows a tendency to confer UC risk only on a wild-type STAT3 background (OR: 1.997, 95%CI: 0.994-4.009, P = 0.049). Our results may help in understanding how these natural variants contribute to development of IBD through their genetic association.

Occurrence of Downy Mildew Caused by Peronospora belbahrii on Sweet Basil in Hungary

Sweet basil (Ocimum basilicum L.) is an important medicinal and aromatic plant in Hungary that is cultivated over a large area. During field surveys conducted in 2010, significant incidence of downy mildew was observed in two plant stands at Budapest-Soroksár and Tordas. In 2003, the disease occurred in a greenhouse at Albertirsa as well. By the end of September, on full-grown leaves of two sweet basil cultivars, the frequency of disease occurrence and the percentage of infected leaf area reached 80 to 90% and 17 to 20%, respectively, at Budapest-Soroksár. Symptoms appeared mainly on cvs. Genovese and Milita among others. On leaves, large chlorotic lesions with soft margins developed, followed by necrotization from the middle. Chlorosis often involved the entire leaf surface. Necrotic spots were irregular, variable in diameter, and limited by the main veins. A typical grayish white furry growth could be observed mainly on abaxial leaf surfaces both in chlorotic and necrotic regions. Most abundant growth developed on the leaves of cv. Genovese. Premature leaf fall on diseased plants occurred as well. The fungus was identified as Peronospora belbahrii Thines on the basis of morphological investigation suggested by Thines et al. (4). Sporangiophores were colorless with a long, straight trunk and monopodially branched five to seven times with a length of 416 to 784 μm (average 572 μm). Sporangiophores ended with two slightly curved acute branchlets, the longer one measured 12.5 to 25.0 μm (average 17.1 μm) and the shorter one measured 5.0 to 18.8 μm (average 9.5 μm) long. Ratio of longer to shorter branchlets was 0.7 to 3.0, the average ratio was 1.9. Sporangia were rounded or slightly ovoid, olive to dark brown, and measured 29.3 × 25.6 (23.8 to35.0 × 20.0 to 31.3 μm). Length/width ratio was 1.2 (1.0 to 1.4). Molecular investigation of two isolates was performed. DNA extraction from sporangiophores was followed by PCR using ITS5 and ITS4 primers. The obtained sequence (GenBank Accession No. HQ702191) showed 99.8 to 100.0% similarity with sequences of P. belbahrii (e.g., Accession Nos. FJ394335 and HN462241) and Peronospora sp. (e.g., Accession Nos. AY884605, AY919301, and FJ346561) isolated from sweet basil. In Europe, the disease was reported from Italy (2), France (3), Germany (4), and Switzerland (1). To our knowledge, this is the first report of downy mildew on sweet basil in Hungary. References: (1) L. Belbahri et al. Mycol. Res. 109:1276, 2005. (2) A. Garibaldi et al. Plant Dis. 88:312, 2004. (3) A. Garibaldi et al. Plant Dis. 89:683, 2005. (4) M. Thines et al. Mycol. Res. 113:532, 2009.