Pathogenesis and therapeutic approaches for improved topical treatment in localized scleroderma and systemic sclerosis

SSc is a chronic progressive disorder of unknown aetiology characterized by excess synthesis and deposition of collagen and other extracellular matrix components in a variety of tissues and organs. Localized scleroderma (LS) differs from SSc in that with LS only skin and occasionally subcutaneous tissues are involved. Although rarely life threatening, LS can be disfiguring and disabling and, consequently, can adversely affect quality of life. There is no known effective treatment for LS, and various options, including, as examples, corticosteroids and other immunomodulatory agents, ultraviolet radiation and vitamin D analogues, are of unproven efficacy. Clinical trials evaluating combination therapy such as corticosteroids with MTX or UVA1 exposure with psoralens have not been established as consistently effective. New immunomodulators such as tacrolimus and thalidomide are also being evaluated. A better understanding of the molecular and cellular mechanisms of LS has led to evaluation of new treatments that modulate profibrotic cytokines such as TGF-beta and IL-4, regulate assembly and deposition of extracellular matrix components, and restore Th1/Th2 immune balance by administering IL-12 or IFN-gamma. IFN-gamma acts by directly inhibiting collagen synthesis and by restoring immune balance. In this review, we evaluate current and future treatment options for LS and cutaneous involvement in SSc. Recent advances in therapy focus mainly on anti-fibrotic agents. Delivery of these drugs into the skin as the target tissue might be a key factor in developing more effective and safer therapy.

Effects of IL-12 on immune responses induced by transcutaneous immunization with antigens formulated in a novel lipid-based biphasic delivery system

The development of non-invasive methods for the delivery of proteins through the permeability barriers, such as the intact skin, will greatly facilitate the administration of human and veterinary vaccines. In the present study we used recombinant Pasteurella haemolytica leukotoxin (Lkt) and hen egg lysozyme (HEL) as model antigens to investigate the ability of transdermal administration of vaccine antigens to induce humoral and cellular responses in mice and to assess the immunomodulatory effects of IL-12 on these antigen-specific immune responses. Mice were immunized by the transdermal route with Lkt or HEL formulated in a novel lipid-based biphasic delivery system (BPDS). Transdermal delivery of Lkt or HEL induced strong polarized Th2 responses characterized by enhancement of antigen-specific IgG1 antibody subclass and predominant induction of antigen specific IL-4 over IFN-gamma in spleen and draining lymph nodes cells. Animals immunized by topical application of formulations containing antigen and IL-12 developed significantly lower antibody titres without significant changes in IL-4 or IFN-gamma secreting cells (SC) in the draining lymph nodes or spleen cells. Our results indicated that application of antigens formulated in BPDS induced antigen-specific immune responses. Furthermore, incorporation of IL-12 to the vaccine formulation influences the induction of antibody responses induced by transdermal immunization. We demonstrated the feasibility of using this technology for the development of non-invasive methods of vaccine administration.

COVID‑19: Main findings after a year and half of unease and the proper scientific progress (Review)

Since the emergence of the disease in late December 2019, numerous studies have been published to date regarding clinical, laboratory and treatment aspects associated with COVID-19. The present study attempts to compare and unify the clinical, para-clinical and therapeutic aspects that have come to light regarding coronavirus disease-19 (COVID 19), mainly in adults. Between April 2020 and September 2021, a comprehensive systematic literature review was performed, which we added to from our own medical experiences. The search was performed on the PubMed, Scopus and Google Scholar databases, comprising studies with analyzable data that were identified alongside studies and documents containing general scientific data. All published studies were written in English, and were from different countries. A 95% confidence interval (CI95) was also calculated for almost each study using the Wilson formula. When compared with preliminary reports between December 2019 and January 2020, the most frequent symptoms were still identified as being fever (68.6%; CI95: 67.5-69.7) and cough (72.7%; CI95: 71.7-73.8). Nevertheless, asymptomatic cases also increased (by 21.4%; CI95: 16.6-27.1). Severe and critical cases accounted for 10.4% (CI95: 9.6-11.1) of all cases. The mean fatality rate was found to be 4% (CI95: 3.6-4.5). The primary co-morbidity found was hypertension (28.9%; CI95: 27-30.8), followed by other underlying cardiovascular diseases (15.4%; CI95: 13.9-16.9) and diabetes (14.5%; CI95: 13.1-16.1). The majority of studies showed lower white blood cell numbers with neutropenia and lymphopenia, and lower platelet levels. The levels of the biomarkers C-reaction protein and erythrocyte sedimentation rate were positive in all studied cases alongside other lab tests, such as examining the D-dimer levels and those of other hepatic, cardiac and renal injury markers. The procalcitonin level was also found to be elevated in many cases, resulting in high usage of antibiotics (83.7%; CI95: 81.2-85.9). Approximately 31.6% (CI95: 29.1-34.1) of the patients required non-invasive ventilation, whereas 9.9% (CI95: 8.1-12.1) of the patients were intubated or placed on extracorporeal membrane oxygenation. The most used antivirals were ribavirin (67.3%; CI95: 63.4-70.9), oseltamivir (52.5%; CI95: 49.4-55.5) and Arbidol™ (34.5%; CI95: 32-37.1). General admittance to the intensive care unit was ~7.2% (CI95: 6.5-7.9) of patients.

Imaging Retrospective Study Regarding the Variability of the Osseous Landmarks for IAN Block

Background/Objectives: The aim of this study is to identify the most accurate and consistent landmarks for determining the precise location of the mandibular foramen (MF) and the mandibular ramus, suggesting appropriate adjustments to anesthesia techniques based on these variations in order to improve the success rate of the inferior alveolar nerve (IAN) block. Methods: CT scans of the mandibles from 100 patients were analyzed to measure the distance between the MF and various landmarks, including the sigmoid notch, gonion, posterior and anterior margins of the ramus, temporal crest, and the mandibular ramus height from the condyle to the gonion. The width of the mandibular ramus was also assessed, with correlations made to age and gender. Results: The MF was found to be closer to the sigmoid notch (mean = 21.2 mm), p = 0.393, than to the gonion (mean = 22.6 mm), p = 0.801, and closer to the posterior margin of the ramus (mean = 13.1 mm), p = 0.753, than to the anterior margin of the ramus. Additionally, the MF was closer to the temporal crest. Age also influenced the position of the MF, with a posterior and superior movement of the foramen, reducing the distance between the MF and the posterior margin of the ramus as well as the MF and the sigmoid notch (p < 0.001). Conclusions: A precise understanding of the MF's location will help dentists and oral and maxillofacial surgeons improve the success of the IAN block, avoid injury to the inferior alveola neurovascular bundle, and minimize surgical complications such as paresthesia, permanent anesthesia, and hemorrhage.

Cervical intraepithelial neoplasia and HPV infection

Human papillomavirus (HPV) infection has been recognized as the major cause of cervical cancer [1]. The transformation zone of the cervix is the most frequent target of the high risk HPV types. In our study infection with HPV16 and 18 was investigated in the cervical scrapes of 28 subjects with cervical intraepithelial neoplasia. The DNAs isolated from the samples were amplified by dot-blot hybridization with fragmented digoxygenin labelled probes. Eighteen of 28 patients (64.3%) were found positive for HPV-16, eleven (39.3%) were found positive for HPV-18 and six patients (21%) were infected with both HPV types. This method is practical and sensitive for determining patients with a higher risk of developing HPV-related cancer.

AB0322 LESSONS LEARNED FROM THE PAST THAT SHOULD IMPROVE THE FUTURE: 18 YEARS OF EXPERIENCE WITH BIOLOGIC THERAPIES IN RHEUMATOID ARTHRITIS IN A TERTIARY RHEUMATOLOGY CENTER IN ROMANIA

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory disease, which affects approximately 1% of the population. Although diagnostic, monitoring and treatment strategies have improved noticeably over the last decades, allowing an early and sustained clinical and radiological remission, both direct and indirect costs of treatment and disease still create an economic burden for patients and society. The last few years have brought many therapeutic options and knowledge about them, which has led to the 2019 updated EULAR recommendations for the management of RA (1).

Objectives:

This study aimed to evaluate the trends in prescribing of biologic therapies in RA over time, the factors that influenced them and the persistence of patients on these treatments.

Methods:

In this retrospective study we evaluated patients with RA treated with biologic therapies in the last 18 years, who presented for routine clinical and biological evaluation, performed according to the standard of care principles in RA.

Results:

244 patients were enrolled in this study. Baseline characteristics are presented in Table 1.

Table 1.

Baseline characteristics of the 244 patients evaluated

ParametersRA patients (n=244)Gender (Female); n(%)202 (82,8%)Age (Mean±SD)61,09±11,86Age at RA onset (Mean±SD)46,16±13,12Disease duration (years); (Mean±SD)14,93 ±8,78Number of biologic therapies received; n(%)1 line244 (100%)2 lines152 (62,29%)3 lines31 (12,70%)4 lines2 (0,81%)5 lines1 (0,40%)

There is a significant decrease in the persistence period on the first biological therapy after 2010 (60.67 ± 50.53 months before 2010 vs. 37.02 ± 34.92 months after 2010, p <0.001, 95% CI = - 34,464 - -12,838).

There is a significant increase in the period from diagnosis to the initiation of biological therapy after 2012 (6.88 ± 6.75 years before 2012 vs. 9.25 ± 9.33 years after 2012, p <0.001, 95% CI = 0.341-4.406).

Overall, regardless of the therapeutic line in which they were used, persistence on anti-CD20 (44,89±43,02 months (mean±SD)) therapies was significantly higher than that on TNFi (81,85±42,17 months (mean±SD)) (p<0,001, CI=27.806-46.129). (Image 1)

Figure 1.

Image 1. Persistence on TNFi and anti CD20 therapies

Conclusion:

The two trends observed in this study: the decrease in persistence on biologic therapy, in 2010, and the increase of the period between RA diagnosis and the initiation of a biologic therapy, in 2012, were generated by the appearance of new molecules, thus reducing the boundaries generated by the previously limited number of options, and by the major changes in national health insurance system regulations.

Anti-CD20 therapy proved to be non-inferior to TNFi therapies regarding persistence on therapy and did not result in higher adverse events than TNFi, justifying the inclusion of RTX therapy as one of the biological therapies used in the first line in 2019 RA treatment recommendations.

A limitation of this study is the small number of patients who received other therapies (JAKi, T cell co-stimulation blockers, anti IL6), which did not allow a correct analysis of other therapeutic lines compared to those previously mentioned.

References:

[1]Smolen JS, et al. Ann Rheum Dis 2020;0:1–15. doi:10.1136/annrheumdis-2019-216655

Disclosure of Interests:

None declared