P-selectin-dependent leukocyte adhesion is governed by endolysosomal two-pore channel 2

Upon proinflammatory challenges, endothelial cell surface presentation of the leukocyte receptor P-selectin, together with the stabilizing co-factor CD63, is needed for leukocyte capture and is mediated via demand-driven exocytosis from the Weibel-Palade bodies that fuse with the plasma membrane. We report that neutrophil recruitment to activated endothelium is significantly reduced in mice deficient for the endolysosomal cation channel TPC2 and in human primary endothelial cells with pharmacological TPC2 block. We observe less CD63 signal in whole-mount stainings of proinflammatory-activated cremaster muscles from TPC2 knockout mice. We find that TPC2 is activated and needed to ensure the transfer of CD63 from endolysosomes via Weibel-Palade bodies to the plasma membrane to retain P-selectin on the cell surface of human primary endothelial cells. Our findings establish TPC2 as a key element to leukocyte interaction with the endothelium and a potential pharmacological target in the control of inflammatory leukocyte recruitment.

Peri-operative tobacco cessation interventions: a systematic review and meta-analysis

Tobacco smoking is associated with a substantially increased risk of postoperative complications. The peri-operative period offers a unique opportunity to support patients to stop tobacco smoking, avoid complications and improve long-term health. This systematic review provides an up-to-date summary of the evidence for tobacco cessation interventions in surgical patients. We conducted a systematic search of randomised controlled trials of tobacco cessation interventions in the peri-operative period. Quantitative synthesis of the abstinence outcomes data was by random-effects meta-analysis. The primary outcome of the meta-analysis was abstinence at the time of surgery, and the secondary outcome was abstinence at 12 months. Thirty-eight studies are included in the review (7310 randomised participants) and 26 studies are included in the meta-analysis (5969 randomised participants). Studies were pooled for subgroup analysis in two ways: by the timing of intervention delivery within the peri-operative period and by the intensity of the intervention protocol. We judged the quality of evidence as moderate, reflecting the degree of heterogeneity and the high risk of bias. Overall, peri-operative tobacco cessation interventions increased successful abstinence both at the time of surgery, risk ratio (95%CI) 1.48 (1.20-1.83), number needed to treat 7; and 12 months after surgery, risk ratio (95%CI) 1.62 (1.29-2.03), number needed to treat 9. More work is needed to inform the design and optimal delivery of interventions that are acceptable to patients and that can be incorporated into contemporary elective and urgent surgical pathways. Future trials should use standardised outcome measures.

Glutamine prevents acute kidney injury by modulating oxidative stress and apoptosis in tubular epithelial cells

Acute kidney injury (AKI) represents a common complication in critically ill patients that is associated with increased morbidity and mortality. In a murine AKI model induced by ischemia/reperfusion injury (IRI), we show that glutamine significantly decreases kidney damage and improves kidney function. We demonstrate that glutamine causes transcriptomic and proteomic reprogramming in murine renal tubular epithelial cells (TECs), resulting in decreased epithelial apoptosis, decreased neutrophil recruitment, and improved mitochondrial functionality and respiration provoked by an ameliorated oxidative phosphorylation. We identify the proteins glutamine gamma glutamyltransferase 2 (Tgm2) and apoptosis signal-regulating kinase (Ask1) as the major targets of glutamine in apoptotic signaling. Furthermore, the direct modulation of the Tgm2-HSP70 signalosome and reduced Ask1 activation resulted in decreased JNK activation, leading to diminished mitochondrial intrinsic apoptosis in TECs. Glutamine administration attenuated kidney damage in vivo during AKI and TEC viability in vitro under inflammatory or hypoxic conditions.

SARS-CoV-2 is associated withabnormal biomarkers of oxidative stress,and endothelial function linked with cardiovascular dysfunction four months after the infection

Introduction

COVID-19 infection has been associated with increase arterial stiffness, endothelialdysfunction, and impairment in coronary and cardiac performance. Inflammation and oxidative stress have beensuggested as possible pathophysiological mechanisms leading to vascular and endothelial deregulation afterCOVID-19 infection.

Purpose

The objective of our study is to evaluate premature alterations in arterial stiffness, endothelial,coronary, and myocardial function markers four months after SARS-CoV-2 infection.

Methods

In a case-control prospective study, we included 70 patients 4 months after COVID-19 infection, 70 age- and sex-matched untreated hypertensive patients (positive control) and 70 healthy individuals. We measured (i) perfused boundary region (PBR) of the sublingual arterial microvessels (increased PBR indicates reduced endothelial glycocalyx thickness), (ii) flow-mediated dilatation (FMD), (iii) coronary flow reserve (CFR) by Doppler echocardiography, (iv) pulse wave velocity (PWV) and central systolic blood pressure (cSBP), (v) global left and right ventricular longitudinal strain (GLS), (vi) malondialdehyde (MDA), an oxidative stress marker, thrombomodulin and von Willebrand factor as endothelial biomarkers.

Results

COVID-19 patients had similar CFR and FMD with hypertensives (2.48±0.41 vs 2.58±0.88, p=0.562, 5.86±2.82% vs 5.80±2.07%, p=0.872 respectively) but lower values than controls (3.42±0.65, p=0.0135, 9.06±2.11%, p=0.002 respectively). Compared to controls, both COVID-19 and hypertensives had greater PBR5–25 (2.07±0.15μm and 2.07±0.26μm p=0.8 vs 1.89±0.17μm, p=0.001), higher PWV, (12.09±2.50 vs 11.92±2.94, p=0.7 vs 10.04±1.80m/sec, p=0.036) increased cSBP (128.43±17.39 vs 135.17±16.83 vs 117.89±18.85) and impaired LV and RV GLS (−19.50±2.56% vs −19.23±2.67%, p=0.864 vs −21.98±1.51%, p=0.020 and −16.99±3.17% vs −18.63±3.20%, p=0.002 vs −20.51±2.28%, p<0.001). MDA and thrombomodulin were higher in COVID-19 patients than both hypertensives and controls (10.67±2.75 vs 1.76±0.30, p=0.003 vs 1.01±0.50nmole/L, p=0.001 and 3716.63±188.36 vs 3114.46±179.18, p=0.017 vs 2590.02±156.51pg/ml, p<0.001). COVID-19 patients displayed similar vWF values with hypertensives but higher compared with healthy controls (4018.03±474.31 vs 3756.65±293.28 vs 2079.33±855.10 ng/ml, p=0.718 and p=0.016 respectively).

Conclusions

SARS-CoV-2 infection is associated with oxidative stress, endothelial and vascular dysfunction, which are linked to impaired longitudinal myocardial deformation 4 months after COVID-19 infection.

Funding Acknowledgement

Type of funding sources: None.

Impaired endothelial glycocalyx, vascular dysfunction and myocardial deformation four months after COVID-19 infection are partially improved at twelve months

Introduction

COVID-19 patients present impaired subclinical markers of cardiovascular and endothelial function. Subclinical myocardial and vascular dysfunction during COVID-19 disease have been associated with worse outcomes and higher mortality risk.

Purpose

We investigated the effect of COVID-19 infection on markers of endothelial, vascular and myocardial function at four and twelve months after the infection

Methods

We recruited 70 patients who were examined in a dedicated post-COVID-19 outpatient clinic during a scheduled follow-up visit at four and twelve months after a confirmed COVID-19 infection and 70 healthy individuals with similar clinical characteristics. At four and twelve months we measured (i) perfused boundary region (PBR) of the sublingual arterial microvessels (increased PBR indicates reduced endothelial glycocalyx thickness), (ii) flow-mediated dilatation (FMD), (iii) coronary flow reserve (CFR) by Doppler echocardiography, (iv) pulse wave velocity (PWV) and central systolic blood pressure (cSBP), (v) global left and right ventricular longitudinal strain (GLS), (vi) myocardial global work index (GWI) global constructive work (GCW), global wasted work (GWW) and the myocardial global work efficiency (GWE) and v) malondialdehyde (MDA), an oxidative stress marker.

Results

At four months, COVID-19 patients displayed higher values of PBR5–25 compared to control group (p<0.001) which increased at twelve months (p<0.001). FMD, PWV and cSBP values were similar between 4 and 12 months (p>0.05 for all the comparisons) and higher than those in controls (p<0.001, p=0.057, p=0.003 respectively). At four months, COVID-19 patients presented impaired CFR and LVGLS values which were improved at twelve months (p=0.002, p=0.069 respectively), though remained impaired compared to controls (p=0.003 for all the comparisons). At four months, COVID-19 patients had impaired RVGLS values which were significantly improved at twelve months (p=0.001,) and showed no statistically significant difference compared to controls (p>0.05). COVID-19 patients at four months display higher myocardial wasted work and decreased myocardial efficiency compared to controls (p=0.01, p=0.006 respectively). There was a modest improvement in GWW and GWE at twelve months,(p=0.043, p=0.001, respectively); however, these markers remained impaired compared to controls (p>0.05). At four months, MDA was higher in COVID-19 patients compared to control group and significantly decreased at twelve months (p<0.001); however, these values remain higher than in controls (p=0.002) (Table 1).

Conclusions

SARS-CoV-2 causes endothelial and cardiovascular dysfunction which are partially restored at twelve months after the infection.

Funding Acknowledgement

Type of funding sources: None.

Remote ischemic preconditioning causes transient cell-cycle arrest and renal protection by a NF-kB-dependent Sema5B pathway

Acute kidney injury increases morbidity and mortality, and previous studies have shown that remote ischemic preconditioning (RIPC) reduces the risk of acute kidney injury after cardiac surgery. RIPC increases urinary high mobility group box protein-1 (HMGB1) levels in patients, and this correlates with kidney protection. Here, we show that RIPC reduces renal ischemia-reperfusion injury and improves kidney function in mice. Mechanistically, RIPC increases HMGB1 levels in the plasma and urine, and HMGB1 binds to TLR4 on renal tubular epithelial cells, inducing transcriptomic modulation of renal tubular epithelial cells and providing renal protection, whereas TLR4 activation on nonrenal cells was shown to contribute to renal injury. This protection is mediated by activation of induction of AMPKα and NF-κB; this induction contributes to the upregulation of Sema5b, which triggers a transient, protective G₁ cell cycle arrest. In cardiac surgery patients at high risk for postoperative acute kidney injury, increased HMGB1 and Sema5b levels after RIPC were associated with renal protection after surgery. The results may help to develop future clinical treatment options for acute kidney injury.

Targeting Procalcitonin Protects Vascular Barrier Integrity

RATIONALE

Capillary leakage frequently occurs during sepsis and after major surgery and is associated with microvascular dysfunction and adverse outcome. Procalcitonin is a well-established biomarker in inflammation without known impact on vascular integrity.

OBJECTIVE

We determined how procalcitonin induces endothelial hyperpermeability and how targeting procalcitonin protects vascular barrier integrity.

METHODS

In a prospective observational clinical study, procalcitonin levels were assessed in 50 cardiac surgery patients and correlated to postoperative fluid and vasopressor requirements along with sublingual microvascular functionality. Effects of the procalcitonin signaling pathway on endothelial barrier and adherens junctional integrity were characterized in vitro and verified in mice. Inhibition of procalcitonin activation by dipeptidyl-peptidase 4 (DPP4) was evaluated in murine polymicrobial sepsis and clinically verified in cardiac surgery patients chronically taking the DPP4 inhibitor sitagliptin.

MEASUREMENTS AND MAIN RESULTS

Elevated postoperative procalcitonin levels identified patients with 2-fold increased fluid requirements (P<0.01), 1.8-fold higher vasopressor demand (P<0.05) and compromised microcirculation (reduction to 63.5±2.8% of perfused vessels, P<0.05). Procalcitonin induced 1.4-fold endothelial and 2.3-fold pulmonary capillary permeability (both P<0.001) by destabilizing VE-cadherin. Procalcitonin effects were dependent on activation by DPP4 and targeting the procalcitonin receptor or DPP4 during sepsis-induced hyperprocalcitonemia reduced capillary leakage by 54±10.1% and 60.4±6.9% (both P<0.01), respectively. Sitagliptin prior to cardiac surgery was associated with augmented microcirculation (74.1±1.7% vs. 68.6±1.9% perfused vessels in sitagliptin non-medicated patients, P<0.05) and 2.3-fold decreased fluid (P<0.05) and 1.8-fold reduced vasopressor demand postoperatively (P<0.05).

CONCLUSION

Targeting procalcitonin's action on the endothelium is a feasible means to preserve vascular integrity during systemic inflammation associated with hyperprocalcitonemia.

POS0832 MORTALITY TRENDS IN ANCA-ASSOCIATED VASCULITIDES (AAVs): DATA FROM A CONTEMPORARY, MULTICENTER ANCA REGISTRY

Background

AAVs are a group of rheumatic diseases with excess morbidity and mortality (~3-fold higher compared to the general population). Long-term studies looking at mortality trends in contemporary patient cohorts are limited.

Objectives

To investigate the overall long-term survival and all-cause mortality in a contemporary AAV patient cohort.

Methods

Multicenter cohort study of patients registered and prospectively followed in the Greek ANCA Registry.

Results

Data for 165 patients (989.38 patient-years of follow up) with a diagnosis of AAV (GPA n=95, 58%, MPA n=54, 33%, EGPA n=16, 9%) were analyzed (January 1, 1998 - January 10, 2022). 53% of patients were female, with a mean age of 65 (±16.4) years; the majority (97%) had generalized disease and were ANCA positive (76%). The mean follow-up since diagnosis was 5.9 (±5.1) years. At the end of follow-up, the overall mortality rate was 20% (33/165), whereas the cumulative mortality rates at 5 and 10 years were 24% and 26% respectively. Overall cumulative survival at 5 years was worse in patients with MPA (57%) compared to GPA (81%) and EGPA (92%), (p<0.001). There was no difference in long-term survival among those treated with different induction regimens including cyclophosphamide (CYC, n of deaths=24/83, 28.9%), rituximab (RTX, n=4/40, 10%) or the CYC+RTX combination (n=3/16, 18.7%). Furthermore, there was no difference in survival between relapsing (≥1 relapses) and non-relapsing (n=76) patients (Figure 1). Cumulative survival was worse in patients who initially presented with lung (66% vs. 90% at 5 years, p=0.007), kidney (56% vs. 96% at 5 years, p<0.001) and simultaneous lung and kidney (39% vs. 93% at 5 years, p<0.001) involvement. Among the 33 registered deaths, the most frequent causes were infections (52%), followed by cardiovascular events (24%), disease flares (14%) and malignancies (10%).

Figure 1.

Conclusion

In a contemporary multi-center AAV cohort, the cumulative mortality rates at 5 and 10 years were 24% and 26% respectively. Overall survival was worse in patients with MPA as well as those with combined lung and kidney involvement at baseline while there were no survival differences according to the initial induction regimen. Infection was the most common cause of death. These findings emphasize the unmet needs for better, less toxic therapies.

Acknowledgements

Supported in part by the Greek Rheumatology Society and Professional Association of Rheumatologists (ERE-EPERE) and the Special Account for Research Grants (S.A.R.G.), National and Kapodistrian University of Athens, Athens, Greece (DV #12085, 12086).

Disclosure of Interests

None declared

Endoscopic surveillance after bariatric surgery: Results from a large, single-institution cohort

Objective

Sleeve gastrectomy (SG) and Roux-en-Y-gastric bypass (RYGB) are associated with long- term abnormalities, including erosive esophagitis (EE), hiatal hernia (HH), gastritis, Barrett`s esophagus and ulcers. The aim of this study is to assess the prevalence of abnormal endoscopic and histologic findings after SG and RYGB in a large cohort.

Methods

This is a retrospective analysis of 720 consecutive patients who underwent esophagogastroduodenoscopy (EGD) after primary SG or RYGB. Patients were invited for a control EGD after two years of follow-up. EGD was also performed in order to evaluate postoperative symptoms, such as nausea, vomiting or reflux. If revisional surgery was planned, an EGD was included in the prerevisional work up.

Results

304 post-SG patients (64.1% female) and 416 post-RYGB patients (85% female) were included. The mean age at the time of operation was 43.9 years (95% confidence intervals (CI) 42.5–43.3 years) for the post-SG group and 40.5 years (95% CI 39.4–41.6 years) for the post-RYGB group (p&lt;0.001). The mean preoperative body mass index (BMI) was 44.2 kg/m2 (95%CI 43.4–44.9) and 41.1 kg/m2 (95%CI 40.7–41.5) for the post-SG and the post-RYGB group respectively (p&lt;0.001). EE, gastritis and HH were more prevalent after SG than RYGB (38.8% vs 8.9%, 62.5% vs 27.6% and 28% vs 2.6% respectively, p&lt;0.001). RYGB was associated with more postoperative ulcers than SG (14.4% vs 0.7%, p&lt;0.001). The incidence of anastomotic strictures requiring anastomotic dilatation after RYGB was 4.6%. No significant difference was found in the prevalence of Barrett`s esophagus (4.3% post SG vs. 4.1 post RYGB, p=1.000) and Helicobacter pylori (3.3% post SG vs. 1.2% post RYGB, p=0.065) between the two groups.

Conclusion

SG is associated with higher rates of EE, gastritis and HH, while the prevalence of ulcers is higher post RYGB. There is a low risk of anastomotic stricture post RYGB. The incidence of Barrett`s oesophagus is low after both procedures. Routine use of EGD after bariatric surgery should be evaluated.

AB0633 Health-Related Quality of Life in ANCA Vasculitides and Rheumatoid Arthritis patients: a cross-sectional comparative study

Background

ANCA associated vasculitides (AAVs) are rare, serious forms of vasculitides. There are limited data regarding the quality of life in patients with AAVs compared to other chronic inflammatory diseases.

Objectives

The purpose of this study was to compare the quality of life between patients with AAV and those with a chronic inflammatory arthritis such as rheumatoid arthritis (RA).

Methods

Multicenter, cross-sectional study of AAV and RA patients followed in three tertiary referral centers. Data from 1007 healthy controls served as historic controls.1 HRQoL was assessed with the Short Form 36 Health Survey (SF-36) which includes physical and mental component summary scores (PCS and MCS). Disease activity were assessed with the Birmingham Vasculitis Activity Score version 3 (BVAS 3, for AAVs) and the DAS28-ESR (for RA) respectively and organ damage/function with the Vasculitis Damage Index (VDI for AAVs) score and Health Assessment Questionnaire (HAQ for RA) scores, respectively.

Results

66 patients with AAVs (GPA 62%, MPA 29% and EGPA 9%, females 56%, mean age 63.4 years, generalized disease 74%, mean disease duration 6.2 years, remission 73%) and 71 with RA (females 56%, mean age 63.3 years, remission 72%) were included. Both AAV and RA patients had significantly lower PCS and MCS scores compared to healthy controls (p < 0.05) while RA patients had lower PCS and MCS scores compared to AAV patients (p < 0.05). According to disease activity status, there was no difference in the SF-36 scores between those with active (BVAS > 1) and inactive (BVAS < 1) AAV, except for the energy-fatigue component (55.0 ± 21.8 vs. 67.2 ± 20.7, p= 0.038) whereas patients with active RA (DAS28-ESR > 3.2) had lower scores for all SF36 components compared to those with low disease activity (DAS28-ESR < 3.2). Additionally, active RA patients had lower both PCS and MCS scores compared to active AAV patients (p < 0.05). AAV patients with increased damage scores (VDI > 3) had lower PCS score compared to those with less organ damage (VDI < 3), (33.9 ± 10.1 vs. 49.1 ± 10.2, p < 0.001) while RA patients with increased damage/poor functionality (HAQ ≥ 0.75) had lower both PCS and MCS scores compared to those with less damage (HAQ ≤ 0.63), (35.0 ± 7.2 vs. 48.4 ± 8.6, p < 0.001) and (40.5 ± 8.6 vs. 48.2 ± 7.6, p < 0.001 respectively). Compared to patients with AAV, RA patients with increased damage had lower score for the pain component compared to AAV patients (37.7 ± 28.6 vs. 61.2 ± 29.5, p= 0.024).

Conclusion

In general, patients with AAV and RA, demonstrate impaired quality of life compared to healthy controls. In the AAV group, quality of life correlated more with organ damage and less with disease activity whereas in RA patients, quality of life correlated both with disease activity and damage. These data emphasize the need for more efficacious therapies for AAV patients that could prevent chronic organ damage and improve quality of life.

References

[1]Pappa, E., Kontodimopoulos, N. & Niakas, D. Validating and norming of the Greek SF-36 Health Survey. Qual Life Res 14, 1433–1438 (2005).

Acknowledgements

Supported in part by the Greek Rheumatology Society and Professional Association of Rheumatologists (ERE-EPERE) and the Special Account for Research Grants (S.A.R.G.), National and Kapodistrian University of Athens, Athens, Greece (DV #12085, 12086).

Disclosure of Interests

None declared

The Pathogenesis of Ischemia-Reperfusion Induced Acute Kidney Injury Depends on Renal Neutrophil Recruitment Whereas Sepsis-Induced AKI Does Not

Acute kidney injury (AKI) may be induced by different causes, including renal ischemia-reperfusion injury and sepsis, which represent the most common reasons for AKI in hospitalized patients. AKI is defined by reduced urine production and/or increased plasma creatinine. However, this definition does not address the molecular mechanisms of different AKI entities, and uncertainties remain regarding distinct pathophysiological events causing kidney injury in the first place. In particular, sepsis-induced AKI is considered not to be associated with leukocyte infiltration into the kidney, but a direct investigation of this process is missing to this date. In this study, we used two murine AKI models induced by either renal ischemia-reperfusion injury (IRI) or cecal ligation and puncture (CLP) to investigate the contribution of neutrophils to tissue injury and kidney function. By using VEC-Y731F mice, in which neutrophil recruitment is impaired, we analyzed the specific contribution of neutrophil recruitment to the pathogenesis of IRI- and CLP-induced AKI. We observed that the degree of renal injury evaluated by plasma creatinine, urinary biomarkers and histological analyses, following IRI-induction was dependent on neutrophil migration into the kidney, whereas the pathogenesis of CLP-induced AKI was independent of neutrophil recruitment. Furthermore, plasma transfer experiments suggest that the pathogenesis of CLP-induced AKI relies on circulating inflammatory mediators. These results extend our knowledge of the AKI pathogenesis and may help in the development of prophylactic and therapeutic treatments for AKI patients.

Treatment outcomes of bladder stones in children with intact bladders in developing countries: A systematic review of >1000 cases on behalf of the European Association of Urology Bladder Stones Guideline panel

INTRODUCTION

Bladder stones (BS) are still endemic in children in developing nations and account for a high volume of paediatric urology workload in these areas. The aim of this systematic review is to comparatively assess the benefits and risks of minimally invasive and open surgical interventions for the treatment of bladder stones in children.

METHODS

This systematic review was conducted in accordance with Cochrane Guidance. Database searches (January 1970- March 2021) were screened, abstracted, and assessed for risk of bias for comparative randomised controlled trials (RCTs) and non-randomised studies (NRSs) with >10 patients per group. Open cystolithotomy (CL), transurethral cystolithotripsy (TUCL), percutaneous cystolithotripsy (PCCL), extracorporeal shock wave lithotripsy (ESWL) and laparoscopic cystolithotomy (LapCL) were evaluated.

RESULTS

In total, 3040 abstracts were screened, and 8 studies were included. There were 7 retrospective non-randomised studies (NRS's) and 1 quasi-RCT with 1034 eligible patients (CL: n=637, TUCL: n=196, PCCL: n=138, ESWL: n=63, LapCL n=0). Stone free rate (SFR) was given in 7 studies and measured 100%, 86.6%-100%, and 100% for CL, TUCL and PCCL respectively. CL was associated with a longer duration of inpatient stay than PCCL and TUCL (p<0.05). One NRS showed that SFR was significantly lower after 1 session with outpatient ESWL (47.6%) compared to TUCL (93.5%) and CL (100%) (p<0.01 and p<0.01 respectively). One RCT compared TUCL with laser versus TUCL with pneumatic lithotripsy and found that procedure duration was shorter with laser for stones <1.5cm (n=25, p=0.04).

CONCLUSION

In conclusion, CL, TUCL and PCCL have comparable SFRs but ESWL is less effective for treating stones in paediatric patients. CL has the longest duration of inpatient stay. Information gathered from this systematic review will enable paediatric urologists to comparatively assess the risks and benefits of all urological modalities when considering surgical intervention for bladder stones.

Association of COVID-19 with impaired endothelial glycocalyx, vascular function and myocardial efficiency four months after infection

Funding Acknowledgements

Type of funding sources: None.

Aims

SARS-CoV-2 infection may lead to endothelial and vascular dysfunction. We

investigated alterations of arterial stiffness, endothelial coronary and myocardial

function markers four months after COVID-19 infection.

Methods

In a case-control prospective study, we included 100 patients four months after COVID-19 infection, 50 age- and sex-matched healthy individuals. We measured a) pulse wave velocity (PWV), b) flow-mediated dilation (FMD) of brachial artery, c) coronary Flow Reserve (CFR) by Doppler echocardiography d) left ventricular (LV) global longitudinal strain (GLS), e) left ventricular myocardial work index, constructive work, wasted work and work efficiency and e) von-Willenbrand factor and thrombomodulin as endothelial biomarkers.

Results

COVID-19 patients had lower CFR and FMD values than controls (2.39 ± 0.39 vs 3.31 ± 0.59, p = 0.0122, 5.12 ± 2.95% vs 8.12 ± 2.23%, p = 0.006 respectively). Compared to controls, COVID-19 patients had higher PWV (PWVc-f 12.32 ± 2.44 vs 10.11 ± 1.85 m/sec, p = 0.033) and impaired LV GLS (-19.11 ± 2.14% vs -20.41 ± 1.61%, p = 0.001). Compared to controls, COVID-19 patients had higher myocardial work index, and wasted work (2067.7 ± 325.9 mmHg% vs 1929.4 ± 312.7 mmHg%, p = 0.026, 104.6 ± 58.9 mmHg% vs 75.1 ± 52.6 mmHg%, p = 0.008, respectively), while myocardial efficiency was lower (94.8 ± 2.5% vs 96.06 ± 2.3%, p = 0.008). and thrombomodulin were higher in COVID-19 patients than controls (3716.63 ± 188.36 vs 2590.02 ± 156.51pg/ml, p &lt; 0.001). MDA was higher in COVID-19 patients than controls (10.55 ± 2.45 vs 1.01 ± 0.50 nmole/L, p = 0.001). Residual cardiovascular symptoms at 4 months were associated with oxidative stress markers. Myocardial work efficiency was related with PWV (F=-0.309, p = 0.016) and vWillenbrand (F=-0.541, p = 0.037). Myocardial wasted work was related with PWV (F = 0.255, p = 0.047) and vWillenbrand (F = 0.610, p = 0.016).

Conclusions

SARS-CoV-2 may cause vascular dysfunction, followed by a waste of cardiac work, in order to compensate for increased arterial stiffness 4 months after infection.

Evaluation of an online toolkit for carers of people with a life-limiting illness at the end-of-life: health professionals' perspectives

Carers of people with a life-limiting illness report unmet information, practical, and emotional support needs, and are often unaware of services available to help improve preparedness, wellbeing, and reduce strain. CarerHelp is the first e-health toolkit that focuses on the information and support needs of carers of people with a life-limiting illness at the end-of-life, using a pathway approach. This study investigated the usefulness of CarerHelp, from the perspective of health professionals who care for these people. Through a 10-min online survey, health professionals provided feedback about their user experience and perceived usefulness of the website. Their expert opinion was sought to ascertain whether CarerHelp could increase carers' preparedness and confidence to support the person for whom they are caring and thereby improve carers' own psychological wellbeing. Health professionals also evaluated whether CarerHelp adequately raised awareness of support services available. CarerHelp was perceived as a useful resource for increasing preparedness for the caring role, including physical tasks and emotional support. Health professionals reported that CarerHelp would increase carers' knowledge of services, confidence to care and ability for self-care. Health professionals endorsed CarerHelp as a useful information source, guide for support, and would promote CarerHelp to clients and their families.

COVID-19 patients present impaired endothelial glycocalyx, vascular dysfunction and myocardial deformation resembling those observed in hypertensives four months after infection

Background/Introduction

COVID-19 infection has been associated with increase arterial stiffness, endothelial dysfunction, and impairment in coronary and cardiac performance. Inflammation and oxidative stress have been suggested as possible pathophysiological mechanisms leading to vascular and endothelial deregulation after COVID-19 infection.

Purpose

The objective of our study is to evaluate premature alterations in arterial stiffness, endothelial, coronary, and myocardial function markers four months after SARS-CoV-2 infection.

Methods

We conducted a case-control prospective study, including 70 patients four months after COVID-19 infection, 70 age- and sex-matched untreated hypertensive patients (positive control) and 70 healthy individuals. We measured a) perfused boundary region (PBR) of the sublingual arterial microvessels (increased PBR indicates reduced endothelial glycocalyx thickness b) flow-mediated dilation (FMD), c) coronary Flow Reserve (CFR) by Doppler echocardiography d) pulse wave velocity (PWV) and central systolic (SBP) e) global LV longitudinal strain (GLS) by speckle tracking imaging and f) malondialdehyde (MDA) as oxidative stress marker.

Results

COVID-19 patients had similar CFR and FMD with hypertensives (2.48±0.41 vs 2.58±0.88, p=0.562, 5.86±2.82% vs 5.80±2.07%, p=0.872 respectively), but lower CFR and FMD than controls (3.42±0.65, p=0.0135 9.06±2.11%, p=0.002 respectively) Both COVID-19 and hypertensive group had greater PBR than controls (PBR5–25: 2.07±0.15 μm and 2.07±0.26 μm p=0.8 vs 1.89±0.17 μm, p=0.001). COVID-19 patients and hypertensives had higher PWV and central SBP than controls (PWVcf 12.09±2.50 and 11.92±2.94, p=0.7 vs 10.04±1.80 m/sec, p=0.036). COVID-19 patients and hypertensives had impaired values of GLS compared to controls (−19.50±2.56% and −19.23±2.67%, p=0.864 vs −21.98±1.51%, p=0.020). Increased PBR5–25 was associated with increased SBP central which in turn was related with impaired GLS (p<0.05). MDA was found increased in COVID-19 patients compared to both hypertensives and controls (10.67±2.75 vs 1.76±0.30, p=0.003 vs 1.01±0.50 nmole/L, p=0.001).

Conclusions

SARS-CoV-2 may cause impaired coronary microcirculatory, endothelial and vascular deregulation which remain four months after initial infection and are associated with reduced cardiac performance. The 10-fold increase of MDA compared to healthy individuals four months after COVID-19 infection indicate oxidative stress as possible pathophysiological mechanism.

FUNDunding Acknowledgement

Type of funding sources: None.

733 Long-Term Outcomes of Outpatient Laser Ablation for Recurrent Non-Muscle Invasive Bladder Cancer: A Retrospective Cohort Study

Aim

Non-muscle-invasive bladder cancer (NMIBC) is the most prevalent form of bladder cancer, predominantly affecting the elderly population. The most common treatment for recurrent NMIBC is transurethral resection of the bladder tumour (TURBT), which carries a risk of perioperative morbidity and mortality in this often-co-morbid population. Outpatient laser ablation of low-grade NMIBC recurrences is a minimally invasive treatment option, but long-term efficacy is poorly reported.

Method

We retrospectively reviewed the case notes of all patients treated with Holmium:YAG laser ablation from 2008-2016. Data regarding patient demographics, original histology, dates of procedures, follow-up time, recurrence, progression, and complications were recorded.

Results

A total of 199 procedures were performed on 97 patients (mean age of 83.56), 73 (75.3%) of which originally had low-grade (G1 or G2) tumours. Overall, 55 (56.7%) patients developed tumour recurrence at long-term follow-up (mean 5.36 years), and only 9 (9.3%) patients had tumour progression to a higher stage or grade, but there was no progression to muscle-invasive disease. The median recurrence-free, progression-free and overall survival times were 1.69 years (95% CI 1.20-2.25), 5.70 years (95% CI 4.10-7.60) and 7.60 years (95% CI 4.90-8.70), respectively. No patients required emergency inpatient admission after laser ablation for any associated complications.

Conclusions

Office-based Holmium: YAG laser ablation is an oncologically-safe method of managing recurrent low-grade non-muscle-invasive bladder cancer in the long-term, with no patients progressing to muscle-invasive disease. Furthermore, the procedure is safe, and no significant complications were seen in this elderly and co-morbid population.

Mental health improvements after elective spine surgery: a Canadian Spine Outcome Research Network (CSORN) study

BACKGROUND CONTEXT

Spine patients have a higher rate of depression then the general population which may be caused in part by levels of pain and disability from their spinal disease.

PURPOSE

Determination whether improvements in health-related quality of life (HRQOL) resulting from successful spine surgery leads to improvements in mental health.

STUDY DESIGN/SETTING

The Canadian Spine Outcome Research Network prospective surgical outcome registry.

OUTCOME MEASURES

Change between preoperative and postoperative SF12 Mental Component Score (MCS). Secondary outcomes include European Quality of Life (EuroQoL) Healthstate, SF-12 Physical Component Score (PCS), Oswestry Disability Index (ODI), Patient Health Questionaire-9 (PHQ9), and pain scales.

METHODS

The Canadian Spine Outcome Research Network registry was queried for all patients receiving surgery for degenerative thoracolumbar spine disease. Exclusion criteria were trauma, tumor, infection, and previous spine surgery. SF12 Mental Component Scores (MCS) were compared between those with and without significant improvement in postoperative disability (ODI) and secondary measures. Multivariate analysis examined factors predictive of MCS improvement.

RESULTS

Eighteen hospitals contributed 3222 eligible patients. Worse ODI, EuroQoL, PCS, back pain and leg pain correlated with worse MCS at all time points. Overall, patients had an improvement in MCS that occurred within 3 months of surgery and was still present 24 months after surgery. Patients exceeding Minimally Clinically Important Differences in ODI had the greatest improvements in MCS. Major depression prevalence decreased up to 48% following surgery, depending on spine diagnosis.

CONCLUSIONS

Large scale, real world, registry data suggests that successful surgery for degenerative lumbar disease is associated with reduction in the prevalence of major depression regardless of the specific underlaying diagnosis. Worse baseline MCS was associated with worse baseline HRQOL and improved postoperatively with coincident improvement in disability, emphasizing that mental wellness is not a static state but may improve with well-planned spine surgery.

Platelets orchestrate the resolution of pulmonary inflammation in mice by T reg cell repositioning and macrophage education

Beyond hemostasis, platelets actively participate in immune cell recruitment and host defense, yet their potential in the resolution of inflammatory processes remains unknown. Here, we demonstrate that platelets are recruited into the lung together with neutrophils during the onset of inflammation and alongside regulatory T (T reg) cells during the resolution phase. This partnering dichotomy is regulated by differential adhesion molecule expression during resolution. Mechanistically, intravascular platelets form aggregates with T reg cells, a prerequisite for their recruitment into the lung. This interaction relies on platelet activation by sCD40L and platelet P-selectin binding to PSGL-1 on T reg cells. Physical platelet–T reg cell interactions are necessary to modulate the transcriptome and instruct T reg cells to release the anti-inflammatory mediators IL-10 and TGFβ. Notably, the presence of platelet–T reg cell aggregates in the lung was also required for macrophage transcriptional reprogramming, polarization toward an anti-inflammatory phenotype, and effective resolution of pulmonary inflammation. Thus, platelets partner with successive immune cell subsets to orchestrate both the initiation and resolution of inflammation.

Randomised controlled trial of oxygen therapy and high-flow nasal therapy in African children with pneumonia

Purpose

The life-saving role of oxygen therapy in African children with severe pneumonia is not yet established.

Methods

The open-label fractional-factorial COAST trial randomised eligible Ugandan and Kenyan children aged > 28 days with severe pneumonia and severe hypoxaemia stratum (SpO₂ < 80%) to high-flow nasal therapy (HFNT) or low-flow oxygen (LFO: standard care) and hypoxaemia stratum (SpO₂ 80–91%) to HFNT or LFO (liberal strategies) or permissive hypoxaemia (ratio 1:1:2). Children with cyanotic heart disease, chronic lung disease or > 3 h receipt of oxygen were excluded. The primary endpoint was 48 h mortality; secondary endpoints included mortality or neurocognitive sequelae at 28 days.

Results

The trial was stopped early after enrolling 1852/4200 children, including 388 in the severe hypoxaemia stratum (median 7 months; median SpO₂ 75%) randomised to HFNT (n = 194) or LFO (n = 194) and 1454 in the hypoxaemia stratum (median 9 months; median SpO₂ 88%) randomised to HFNT (n = 363) vs LFO (n = 364) vs permissive hypoxaemia (n = 727). Per-protocol 15% of patients in the permissive hypoxaemia group received oxygen (when SpO₂ < 80%). In the severe hypoxaemia stratum, 48-h mortality was 9.3% for HFNT vs. 13.4% for LFO groups. In the hypoxaemia stratum, 48-h mortality was 1.1% for HFNT vs. 2.5% LFO and 1.4% for permissive hypoxaemia. In the hypoxaemia stratum, adjusted odds ratio for 48-h mortality in liberal vs permissive comparison was 1.16 (0.49–2.74; p = 0.73); HFNT vs LFO comparison was 0.60 (0.33–1.06; p = 0.08). Strata-specific 28 day mortality rates were, respectively: 18.6, 23.4 and 3.3, 4.1, 3.9%. Neurocognitive sequelae were rare.

Conclusions

Respiratory support with HFNT showing potential benefit should prompt further trials.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06385-3.

Laser therapy is a safe and effective treatment for unwanted hair in adults undergoing male to female sex reassignment

Reduction in unwanted facial and body hair is an important goal in the process of sex reassignment. Laser treatment is a popular, well-established safe and effective method of reducing unwanted hair growth. In the UK a limited number of laser treatment and electrolysis sessions are publically funded for people undergoing sex reassignment. To date, published evidence on efficacy and adverse effects (AEs) has focused on treatment of women and men not undergoing sex reassignment. In the current study, data were collected prospectively from 2015 to 2020 at a UK regional laser centre. Patients were included if they were transgender women aged > 16 years old and seeking laser treatment for unwanted hair at any body site. The study demonstrated significant reductions in hair growth and significant patient satisfaction, with no AEs. Laser treatment is a safe and effective method of managing unwanted hair growth in the transgender transfeminine population.

A neural network to predict the knee adduction moment in patients with osteoarthritis using anatomical landmarks obtainable from 2D video analysis

OBJECTIVE

The knee adduction moment (KAM) can inform treatment of medial knee osteoarthritis; however, measuring the KAM requires an expensive gait analysis laboratory. We evaluated the feasibility of predicting the peak KAM during natural and modified walking patterns using the positions of anatomical landmarks that could be identified from video analysis.

METHOD

Using inverse dynamics, we calculated the KAM for 86 individuals (64 with knee osteoarthritis, 22 without) walking naturally and with foot progression angle modifications. We trained a neural network to predict the peak KAM using the 3-dimensional positions of 13 anatomical landmarks measured with motion capture (3D neural network). We also trained models to predict the peak KAM using 2-dimensional subsets of the dataset to simulate 2-dimensional video analysis (frontal and sagittal plane neural networks). Model performance was evaluated on a held-out, 8-person test set that included steps from all trials.

RESULTS

The 3D neural network predicted the peak KAM for all test steps with r2( Murray et al., 2012) 2 = 0.78. This model predicted individuals' average peak KAM during natural walking with r2( Murray et al., 2012) 2 = 0.86 and classified which 15° foot progression angle modifications reduced the peak KAM with accuracy = 0.85. The frontal plane neural network predicted peak KAM with similar accuracy (r2( Murray et al., 2012) 2 = 0.85) to the 3D neural network, but the sagittal plane neural network did not (r2( Murray et al., 2012) 2 = 0.14).

CONCLUSION

Using the positions of anatomical landmarks from motion capture, a neural network accurately predicted the peak KAM during natural and modified walking. This study demonstrates the feasibility of measuring the peak KAM using positions obtainable from 2D video analysis.

CT diagnosis of ilioinguinal lymph node metastases in melanoma using radiological characteristics beyond size and asymmetry

Background

Diagnosis of lymph node (LN) metastasis in melanoma with non-invasive methods is challenging. The aim of this study was to evaluate the diagnostic accuracy of six LN characteristics on CT in detecting melanoma-positive ilioinguinal LN metastases, and to determine whether inguinal LN characteristics can predict pelvic LN involvement.

Methods

This was a single-centre retrospective study of patients with melanoma LN metastases at a tertiary cancer centre between 2008 and 2016. Patients who had preoperative contrast-enhanced CT assessment and ilioinguinal LN dissection were included. CT scans containing significant artefacts obscuring the pelvis were excluded. CT scans were reanalysed for six LN characteristics (extracapsular spread (ECS), minimum axis (MA), absence of fatty hilum (FH), asymmetrical cortical nodule (CAN), abnormal contrast enhancement (ACE) and rounded morphology (RM)) and compared with postoperative histopathological findings.

Results

A total of 90 patients were included. Median age was 58 (range 23–85) years. Eighty-eight patients (98 per cent) had pathology-positive inguinal disease and, of these, 45 (51 per cent) had concurrent pelvic disease. The most common CT characteristics found in pathology-positive inguinal LNs were MA greater than 10 mm (97 per cent), ACE (80 per cent), ECS (38 per cent) and absence of RM (38 per cent). In multivariable analysis, inguinal LN characteristics on CT indicative of pelvic disease were RM (odds ratio (OR) 3.3, 95 per cent c.i. 1.2 to 8.7) and ECS (OR 4.2, 1.6 to 11.3). Cloquet’s node is known to be a poor predictor of pelvic spread. Pelvic LN disease was present in 50 per cent patients, but only 7 per cent had a pathology-positive Cloquet’s node.

Conclusion

Additional CT radiological characteristics, especially ECS and RM, may improve diagnostic accuracy and aid clinical decisions regarding the need for inguinal or ilioinguinal dissection.

Genome-wide surveillance of transcription errors in response to genotoxic stress

Mutagenic compounds are a potent source of human disease. By inducing genetic instability, they can accelerate the evolution of human cancers or lead to the development of genetically inherited diseases. Here, we show that in addition to genetic mutations, mutagens are also a powerful source of transcription errors. These errors arise in dividing and nondividing cells alike, affect every class of transcripts inside cells, and, in certain cases, greatly exceed the number of mutations that arise in the genome. In addition, we reveal the kinetics of transcription errors in response to mutagen exposure and find that DNA repair is required to mitigate transcriptional mutagenesis after exposure. Together, these observations have far-reaching consequences for our understanding of mutagenesis in human aging and disease, and suggest that the impact of DNA damage on human physiology has been greatly underestimated.

Idiopathic systemic capillary leak syndrome (Clarkson's disease) presenting with recurrent hypovolemic shock

A 49-year old male with a past medical history of myocardial infarction and compartment syndromes requiring fasciotomies presented on five occasions with hypovolemic shock. We describe his admissions and presumptive diagnoses which required large volumes of intravenous fluids, admission to intensive care for vasopressors and renal replacement therapy. The presentations were always precipitated by a prodrome of fatigue and pre-syncopal episodes. On his last admission, a diagnosis of Idiopathic systemic capillary leak syndrome (ISCLS), also known as Clarkson's Disease, was reached. He is currently receiving high dose intravenous immunoglobulins on a monthly basis.

ArhGAP15, a RacGAP, Acts as a Temporal Signaling Regulator of Mac-1 Affinity in Sterile Inflammation

During inflammation, leukocyte recruitment has to be tightly controlled to prevent overwhelming leukocyte infiltration, activation, and, consequently, organ damage. A central regulator of leukocyte recruitment is Rac1. In this study, we analyzed the effects of the RacGAP ArhGAP15 on leukocyte recruitment. Using ArhGAP15-deficient mice, reduced neutrophil adhesion and transmigration in the TNF-α-inflamed cremaster muscle and a prolongation of chemokine-dependent leukocyte adhesion could be observed. In a murine model of sterile kidney injury, reduced neutrophil infiltration, and serum creatinine levels were apparent. Further in vitro and in vivo analyses revealed a defective intravascular crawling capacity, resulting from increased affinity of the β₂-integrin Mac-1 after prolonged chemokine stimulation of neutrophils. LFA-1 activity regulation was not affected. Summarizing, ArhGAP15 specifically regulates Mac-1, but not LFA-1, and affects leukocyte recruitment by controlling postadhesion strengthening and intravascular crawling in a Mac-1-dependent manner. In conclusion, ArhGAP15 is involved in the time-dependent regulation of leukocyte postadhesion in sterile inflammation.

Role of the Thalamus in Basal Forebrain Regulation of Neural Activity in the Primary Auditory Cortex

Many studies have implicated the basal forebrain (BF) as a potent regulator of sensory encoding even at the earliest stages of or cortical processing. The source of this regulation involves the well-documented corticopetal cholinergic projections from BF to primary cortical areas. However, the BF also projects to subcortical structures, including the thalamic reticular nucleus (TRN), which has abundant reciprocal connections with sensory thalamus. Here we present naturalistic auditory stimuli to the anesthetized rat while making simultaneous single-unit recordings from the ventral medial geniculate nucleus (MGN) and primary auditory cortex (A1) during electrical stimulation of the BF. Like primary visual cortex, we find that BF stimulation increases the trial-to-trial reliability of A1 neurons, and we relate these results to change in the response properties of MGN neurons. We discuss several lines of evidence that implicate the BF to thalamus pathway in the manifestation of BF-induced changes to cortical sensory processing and support our conclusions with supplementary TRN recordings, as well as studies in awake animals showing a strong relationship between endogenous BF activity and A1 reliability. Our findings suggest that the BF subcortical projections that modulate MGN play an important role in auditory processing.

FRI0170 THERAPEUTIC ΤARGETS AND QUALITY INDICATORS IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE), DEFINED ACCORDING TO THE 2019 UPDATE OF THE EULAR RECOMMENDATIONS: DATA FROM THE “ATTIKON“ LUPUS COHORT

Background:

Targets of therapy and quality of care are receiving increased attention in the management of SLE, as outlined in the 2019 update of the EULAR recommendations for SLE treatment.

Objectives:

To assess compliance with quality indicators and attainment of treatment targets, according to recent EULAR recommendations, in the SLE cohort of “Attikon” Rheumatology Unit.

Methods:

100 consecutive SLE patients followed for at least one year were. A 30 item Quality Indicator Set (QIS) was developed, according to the 2019 EULAR recommendations for SLE, to include laboratory tests for diagnosis and monitoring, evaluation of disease activity and damage using validated indices, use of patient-reported outcomes, counselling for women’s health and reproduction issues, attainment of targets of therapy [remission or low disease activity state (LLDAS) with low-dose glucocorticoids (GC, ≤7.5mg/day prednizone) and hydroxychloroquine (HCQ dose≤5mg/kg/day)], prevention of disease flares and prevention and management of co-morbidities. Chart review and patient interview was performed to assess the degree of compliance with each item of the QIS and achievement of treatment targets.

Results:

Disease activity was monitored by means of validated indices in 31% and antiphospholipid antibody testing during the first 6 months from diagnosis was performed in 58.8% of patients. Sustained remission (defined as remission of a sustained period of 12 months) or LLDAS was achieved by only 3% and 22% respectively; in contrast, other targets of therapy, such as ≤1 minor flares during last year, were achieved by 85% (43% had complete absence of flares), with 90.2% of patients receiving low-dose GC and 81.8% corrected HCQ dose. Fertility and pregnancy counselling were offered in 40% (12/30 eligible women) and 63.3% (19/30) of patients, respectively, while 65.4% had a Pap Test and only 3 of 32 eligible patients had received the HPV vaccine. Annual lipid status was assessed in 43% and counselling for smoking cessation in 44.6%. Flu vaccination was performed in 77%, while pneumococcal (including both of the pneumococcal vaccines) and herpes-zoster vaccination, were given in 32.7% and 2% (1/44 eligible patients) respectively.

Conclusion:

Our real-life data suggest low vaccination rates (excluding flu) and suboptimal management of cardiovascular risk factors in lupus patients. While the majority of patients received the suggested doses of GC and HCQ, only one quarter of patients achieved remission or LLDAS. There is an unmet need for new therapies in SLE to improve therapy targets.

References:

[1]Arora S, Sequeira W, Yazdany J, Jolly M, “Does Systemic Lupus Erythematosus Care Provided in a Lupus Clinic Result in Higher Quality of Care Than That Provided in a General Rheumatology Clinic?”, Arthritis Care Res. 2018 Dec;70(12):1771-1777. doi: 10.1002/acr.23569. Epub 2018 Nov 10.

Disclosure of Interests:

KATERINA HAVATZA: None declared, KONSTANTINA TOGIA: None declared, Sofia Flouda: None declared, Antigoni Pieta: None declared, Ourania Gioti: None declared, Dionysis Nikolopoulos: None declared, Noemin Kapsala: None declared, Aliki Ntourou: None declared, Panagiota Rapsomaniki: None declared, Thaleia Gerogianni: None declared, Dimitrios Tseronis: None declared, Michail Aggelakos: None declared, Theofanis Karageorgas: None declared, PELAGIA KATSIMPRI: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, Konstantinos Thomas: None declared, DIMITRIOS BOUMPAS Grant/research support from: Unrestricted grant support from various pharmaceutical companies, Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan

AB1201 INCREASING RATES OF INFLUENZA VACCINATION COVERAGE IN RHEUMATOID ARTHRITIS PATIENTS: DATA FROM A MULTICENTER, LONGITUDINAL COHORT STUDY OF 1,406 PATIENTS

Background:

Despite the increased incidence of influenza infection in rheumatoid arthritis (RA) patients, vaccination coverage has been shown to be suboptimal. Prospective data regarding the current rate and predictors of influenza vaccination adherence in RA patients are limited.

Objectives:

To calculate the current rate and predictors of influenza vaccination in a real-life, prospective, longitudinal RA cohort.

Methods:

Data regarding demographics, disease characteristics, treatments and co-morbidities from a multi-center, longitudinal cohort of Greek RA patients were collected at baseline and ~ 3 years later. Disease and patient characteristics were compared between patients with at least one influenza vaccine administration and non-vaccinated ones, during the 3 year follow-up period.

Results:

From a cohort of 1,569 RA patients, 1,406 with available vaccination data at baseline and 3 years later (mean interval: 2.9 years) were included; (women: 80.4%, mean age: 61.8 years, mean disease duration: 9.7 years, RF and/or anti-CCP positive: 50.4%, mean DAS-28 = 3.33, mean HAQ: 0.44, bDMARD use: 44.8%). At baseline, 54.2% of patients reported influenza vaccination in the past (31.8% during the previous season), while during the 3 year follow-up period, 81% had ≥1 influenza vaccinations (p=<0.001). Patients who received ≥1 influenza vaccine were older (63.5 vs. 54.7 years, p<0.001), were more likely to be seropositive (59.2% vs. 45.2%, p<0.001), had higher HAQ (0.46 vs. 0.36, p=0.02) and BMI (27.7 vs. 26.9, p=0.02) at baseline, more likely to be treated with bDMARDs (46.8% vs. 36.4%, p<0.001) and more likely to have chronic lung disease (9.7% vs. 5.3%, p=0.02), dyslipidemia (36.4% vs. 24.2%, p<0.001), hypertension (46.1% vs. 29.2%, p<0.001) and to report vaccination against influenza the previous season before baseline evaluation (34.9% vs. 18.2%, p<0.001). By multivariate analysis, history of influenza vaccination during the last season before baseline (OR=1.87, CI: 1.27-2.74, p=0.001), bDMARD treatment (OR=1.51, CI: 1.07-2.13, p=0.018) and age (OR=1.05, CI: 1.04-1.06, p<0.001) were independent predictors of influenza vaccination.

Conclusion:

In this ongoing, longitudinal, prospective, real-life RA cohort study, a significant increase in the influenza vaccination coverage was noted (from 53% to 81%). Influenza vaccination was independently associated with recent history of influenza vaccination, older age, and bDMARD treatment.

Acknowledgments:

Supported by grants from the Greek Rheumatology Society and Professional Association of Rheumatologists.

Disclosure of Interests:

Konstantinos Thomas: None declared, Argyro Lazarini: None declared, Evripidis Kaltsonoudis: None declared, Alexandros Drosos: None declared, ARGYRO REPA: None declared, Prodromos Sidiropoulos: None declared, Kalliopi Fragkiadaki: None declared, Maria Tektonidou Grant/research support from: AbbVie, MSD, Novartis and Pfizer, Consultant of: AbbVie, MSD, Novartis and Pfizer, Petros Sfikakis Grant/research support from: Grant/research support from Abvie, Novartis, MSD, Actelion, Amgen, Pfizer, Janssen Pharmaceutical, UCB, Panagiota Tsatsani: None declared, Sousana Gazi: None declared, Pelagia Katsimbri: None declared, Dimitrios Boumpas: None declared, Evangelia Argyriou: None declared, Kyriaki Boki: None declared, Gerasimos Evangelatos: None declared, Alexios Iliopoulos: None declared, Konstantina Karagianni: None declared, Lazaros Sakkas: None declared, Konstantinos Melissaropoulos: None declared, Panagiotis Georgiou: None declared, Eleftheria Grika: None declared, PANAYIOTIS VLACHOYIANNOPOULOS: None declared, Theodoros Dimitroulas: None declared, Alexandros Garyfallos Grant/research support from: MSD, Aenorasis SA, Speakers bureau: MSD, Novartis, gsk, Constantinos Georganas: None declared, Periklis Vounotrypidis: None declared, Konstantinos Ntelis: None declared, Maria Areti: None declared, George D Kitas: None declared, Dimitrios Vassilopoulos: None declared

OP0103 DOES GENDER, AGE OR SUBPOPULATION INFLUENCE THE MAINTENANCE OF CLINICAL REMISSION IN AXIAL SPONDYLOARTHRITIS FOLLOWING CERTOLIZUMAB PEGOL DOSE REDUCTION?

Background:

Previous studies have shown that withdrawing tumour necrosis factor inhibitors (TNFi) in patients (pts) with axial spondyloarthritis (axSpA) who have achieved sustained remission often leads to relapse.1However, none have formally tested TNFi dose reduction strategies in a broad axSpA population or evaluated whether relapse following TNFi dose reduction and withdrawal is associated with a specific demographic subgroup.

Objectives:

C-OPTIMISE evaluated the percentage of pts without flare after TNFi dose continuation, reduction or withdrawal in adults with early axSpA treated with the Fc-free, PEGylated TNFi certolizumab pegol (CZP). Here, we analyse whether responses to reduced maintenance dose were comparable in pts stratified by axSpA subpopulation, gender and age.

Methods:

C-OPTIMISE (NCT02505542) was a multicentre, two-part phase 3b study in adults with early (<5 years’ symptom duration) active axSpA (stratified for radiographic [r]- and non-radiographic [nr]- axSpA). Pts received CZP 200 mg every 2 weeks (wks) (Q2W; 400 mg loading dose at Wks 0, 2 and 4) during the open-label induction period. At Wk 48, pts in sustained remission (Ankylosing Spondylitis Disease Activity Score [ASDAS] <1.3 at Wk 32 or 36 [if ASDAS <1.3 at Wk 32, it must be <2.1 at Wk 36, or vice versa] and at Wk 48) were randomised to double-blind full maintenance dose (CZP 200 mg Q2W); reduced maintenance dose (CZP 200 mg every 4 wks [Q4W]) or placebo (PBO) for a further 48 wks (maintenance period). The primary endpoint was the percentage of pts not experiencing a flare (ASDAS ≥2.1 at two consecutive visits or ASDAS >3.5 at any timepoint) during Wks 48–96. Analyses were conducted on subgroups according to axSpA subpopulation, gender and age ≤/> the median age of the randomised set (32 years).

Results:

During the 48-wk induction period, 43.9% of patients (323/736) achieved sustained remission and 313 pts entered the 48-wk maintenance period (r/nr-axSpA: 168/145 pts; males/females: 247/66 pts; age ≤32/>32: 165/148 pts). During the maintenance period, responses in r- and nr-axSpA pts were comparable across all three randomised arms. 83.9% r-axSpA and 83.3% nr-axSpA pts receiving the full CZP maintenance dose did not experience a flare, and in the reduced maintenance dose arm 82.1% r-axSpA and 75.5% nr-axSpA pts did not experience a flare. In the PBO group this was reduced to 17.9% and 22.9%, respectively. Similar responses were seen in pts stratified by gender or age, with substantially higher percentages of pts randomised to CZP full or reduced maintenance dose remaining free of flares compared to PBO in all subgroups (Figure).

Conclusion:

The results of C-OPTIMISE indicate that a reduced maintenance dose is suitable for pts with axSpA who achieve sustained remission following 1 year of CZP treatment, regardless of axSpA subpopulation, gender or age. Complete treatment withdrawal is not recommended due to the high risk of flare.

References:

[1]Landewe R. Lancet 2018;392:134–44.

Acknowledgments:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical

Disclosure of Interests:

Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, 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, Maxime Dougados Grant/research support from: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Speakers bureau: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Karl Gaffney Grant/research support from: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Speakers bureau: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Lars Bauer Employee of: UCB Pharma, Bengt Hoepken Employee of: UCB Pharma, Natasha de Peyrecave Employee of: UCB Pharma, Karen Thomas Employee of: UCB Pharma, Lianne S. Gensler Grant/research support from: Pfizer, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, GSK, Novartis, UCB

FRI0147 PREVALENCE OF COMORBIDITIES IN ANTIPHOSPHOLIPID SYNDROME VERSUS RHEUMATOID ARTHRITIS: A MULTICENTRE, AGE- AND SEX-MATCHED STUDY

Background:

Comorbidities in rheumatic diseases (RDs) have been associated with increased morbidity and mortality. Evidence on prevalence of comorbidities in antiphospholipid syndrome (APS) and its difference from high comorbidity burden RDs is limited.

Objectives:

To compare the prevalence of common comorbidities between APS [primary (PAPS) and Systemic lupus erythematosus (SLE)-APS] and Rheumatoid arthritis (RA) patients.

Methods:

326 APS patients from the Greek registry (237 women, mean age 48.7±13.4 years, 161 PAPS) were matched 1:2 for age and sex with 652 RA patients from Greek RA Registry. Prevalence of cardiovascular (CV) risk factors, stroke, coronary artery disease (CAD), osteoporosis, diabetes mellitus (DM), Chronic obstructive pulmonary disease (COPD), depression and neoplasms were compared between APS and RA using logistic regression analysis.

Results:

Regarding CV burden, hyperlipidemia and obesity (ΒMI≥30) were comparable while hypertension, smoking, CAD and stroke were more prevalent in APS compared to RA patients (Table 1). Osteoporosis and depression were more frequent in APS while DM, COPD and neoplasms were comparable between two groups. Comparison of APS subgroups to 1:2 matched RA patients revealed that smoking and stroke were more prevalent in PAPS and SLE-APS vs RA. Hypertension, CAD and osteoporosis were more prevalent only in SLE-APS vs. RA while DM was less prevalent in PAPS vs. RA patients.

Table 1.

Comparison of comorbidities between Antiphospholipid syndrome (APS) vs. matched Rheumatoid Arthritis (RA) patients and between primary APS (PAPS) or Systemic Lupus Erythematosus-APS (SLE-APS) vs matched RA patients

APSRAOR*PAPSRAORSLE-APSRAORn (%)326652161322165330Hypertension97 (29.8)136 (21)1.61 (1.19-2.18)40 (25)75 (23.3)1.09 (0.70-1.69)57 (34.6)61 (18.5)2.33 (1.52-3.56)Smoking175 (53.7)264 (40.5)1.70 (1.30-2.22)87 (54)142 (44)1.49 (1.02-2.18)88 (53.3)122 (37)1.95 (1.33-2.85)Hyperlipidemia79 (24.2)135 (20.7)1.23 (0.89-1.68)40 (24.8)62 (19.3)1.39 (0.88-2.18)39 (23.6)73 (22)1.09 (0.70-1.70)Obesity48 (20.5)105 (19.5)1.06 (0.73-1.56)20 (17)51 (19)0.86 (0.49-1.52)28 (24)54 (19.7)1.28 (0.76-2.15)Stroke±66 (20.3)9 (1.4)13.8 (6.5-29.1)36 (22.4)4 (1.2)19.9 (6.6-59.9)30 (18.2)5 (1.5)7.8 (2.7-22.6)Coronary disease±16 (4.9)13 (2)3.14 (1.17-8.45)2 (1.2)7 (2.2)0.46 (0.04-4.77)14 (8.5)6 (1.8)10.9 (2.7-44.3)Osteoporosis×66 (20.3)92 (14)1.45 (1.01-2.06)19 (11.8)42 (13)0.96 (0.54-1.73)47 (28.5)50 (15)1.91 (1.20-3.05)Diabetes×18 (5.5)58 (9)0.58 (0.33-1.01)5 (3)29 (9)0.34 (0.13-0.89)13 (8)29 (9)0.88 (0.44-1.79)COPD≠11 (3.4)14 (2.2)1.26 (0.56-2.84)3 (1.9)6 (2)0.96 (0.23-4.0)8 (5)8 (2.4)1.28 (0.44-3.72)Depression#53 (16.3)66 (10)1.70 (1.15-2.53)23 (14)30 (9.3)1.69 (0.93-3.05)30 (18.2)36 (10.9)1.65 (0.96-2.84)Neoplasms˅14 (4.3)27 (4.1)1.05 (0.54-2.06)5 (3)12 (3.7)0.84 (0.28-2.52)9 (5.5)15 (4.6)1.31 (0.55-3.1)

*OR: Odds ratio, crude or adjusted for:

 ± age, sex, smoking, hypertension, hyperlipidemia, BMI, corticosteroid (Cs) duration

 × Cs duration

 ≠ smoking, Cs duration

 #sex, disease duration, Cs duration

 ˅ age, disease duration

Conclusion:

Comorbidity burden in APS (PAPS and SLE-APS) is comparable or even higher to that in RA, entailing a high level of diligence for CV risk prevention, awareness for depression and corticosteroid exposure minimization.

Disclosure of Interests:

Stylianos Panopoulos: None declared, Konstantinos Thomas: None declared, Georgios Georgiopoulos: None declared, Dimitrios Boumpas Grant/research support from: Unrestricted grant support from various pharmaceutical companies, Christina Katsiari: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, Alexandros Drosos: None declared, Kyriaki Boki: None declared, Theodoros Dimitroulas: None declared, Alexandros Garyfallos Grant/research support from: MSD, Aenorasis SA, Speakers bureau: MSD, Novartis, gsk, Charalambos Papagoras: None declared, PELAGIA KATSIMPRI: None declared, Apostolos Tziortziotis: None declared, Christina Adamichou: None declared, Evripidis Kaltsonoudis: None declared, Evangelia Argyriou: None declared, GEORGIOS VOSVOTEKAS Grant/research support from: MSD, Janssen, Consultant of: MSD, Novartis, Roche, UCB pharma, Bristol-Myers Squibb, AbbVie, Speakers bureau: UCB pharma, Menarini, Bristol-Myers Squibb, MSD, Petros Sfikakis Grant/research support from: Grant/research support from Abvie, Novartis, MSD, Actelion, Amgen, Pfizer, Janssen Pharmaceutical, UCB, Dimitrios Vassilopoulos: None declared, Maria Tektonidou Grant/research support from: AbbVie, MSD, Novartis and Pfizer, Consultant of: AbbVie, MSD, Novartis and Pfizer

AB1216 INTERSTITIAL PNEUMONIA WITH AUTOIMMUNE FEATURES (IPAF): A SINGLE CENTER, PROSPECTIVE STUDY

Background:

Interstitial pneumonia with autoimmune features (IPAF)1describes a group of patients with interstitial lung disease and autoimmune features who do not meet the classification criteria for a specific connective tissue disease. Limited data regarding IPAF are available so far.

Objectives:

To identify the epidemiological and clinical characteristics of patients with IPAF and to observe disease progression, response to treatment and frequency of infections in 1-year follow-up period.

Methods:

Thirty-nine patients from ‘Attikon’ University Hospital of Athens fulfilling the IPAF criteria were enrolled. Clinical and laboratory findings, comorbidities, medications, pulmonary outcomes assessed with repeated pulmonary function tests (PFTs) and chest HRCT and complications in a 1-year follow-up period were documented for each patient. Univariate models were performed in order to identify determinants of infection and clinically significant difference in PFTs (defined as change of ≥ 10% in FVC and/or ≥ 15% in DLCO).

Results:

The mean age at the time of IPAF diagnosis was 63.2 (±11) years and 62% of the patients were female. The most common clinical features included in the IPAF criteria were arthritis (82%) and Raynaud’s phenomenon (26%). A morbilliform and/or polymorphic rash of the face, neck and extremities (not included in the IPAF criteria) was noted in 54% of patients. ANA (59%) and anti–Ro (21%) were the most common auto-antibodies. Non-specific Interstitial Pneumonia (NSIP) was the most prevalent radiological pattern (61.5%) as shown in table 1. Treatment comprised corticosteroids and immunosuppressants including hydroxychloroquine, methotrexate, azathioprine, mycophenolate and cyclophosphamide. PFTs following treatment at 6 and 12 months from baseline showed a trend of improvement (Table 2, p> 0.05). At 1 year from baseline, 20.5% of patients showed a clinically significant deterioration while 25% had a clinically significant improvement. Infections were observed in 23.1% of patients during the first semester and in 12.8% during the second semester of the follow-up period. All were respiratory tract infections and two patients (5.1%) required hospitalization. All infections occurred in patients with non-UIP pattern (p=0.02) which might be attributed to higher doses of corticosteroids used in these patients (mean initial prednisolone dose = 27 (±18) mg/d in patients with non-UIP pattern versus 17 (±16) mg/d in patients with UIP pattern, p=0.4).

Table 1.

Prevalence of HRCT patterns in 39 patients.

Radiological patternNo (%)NSIP24 (61,5%)OP2 (5,1%)NSIP with OP overlap2 (5,1%)LIP1 (2,6%)UIP7 (18%)NSIP and UIP3 (7,7%)

NSIP: Non-specific Interstitial Pneumonia, OP: Organizing Pneumonia, LIP: Lymphocytic Interstitial Pneumonia, UIP: Usual Interstitial Pneumonia.

Table 2.

PFTs at baseline, 6 and 12 months.

PFTs (% of predicted value ± SD)Baseline6 months12 monthsP valueFVC79% (±19%)82% (±18%)84% (±17%)nsDLCO49% (±16%)52% (±17%)53% (±17%)ns

Conclusion:

Rash is a common feature in IPAF and may be considered for inclusion into IPAF criteria. A trend of improvement in PFTs and a significant risk of respiratory tract infections mainly in the first semester of treatment and in patients with non-UIP radiological pattern were observed. Larger prospective studies are warranted in order to elucidate IPAF’s prognosis and to identify effective management approaches.

References:

[1]Fischer A, et al. An official European Respiratory Society/American Thoracic Society research statement: interstitial pneumonia with autoimmune features. Eur Respir J 2015; 46: 976-987.

Disclosure of Interests:

Maria Karampeli: None declared, Konstantinos Thomas: None declared, Dimitrios Tseronis: None declared, Michail Aggelakos: None declared, Dimitra Kassara: None declared, Katerina Havatza: None declared, Sofia Flouda: None declared, Dionysis Nikolopoulos: None declared, Antigoni Pieta: None declared, Vasiliki Tzavara: None declared, Pelagia Katsimbri: None declared, Dimitrios Boumpas Grant/research support from: Unrestricted grant support from various pharmaceutical companies, Theofanis Karageorgas: None declared

Treatment modalities and drug survival in a systemic sclerosis real-life patient cohort

BACKGROUND

European data indicate that systemic sclerosis (SSc)-related death rates are increasing, thus raising concerns about SSc's optimal management. Herein, we describe current treatment modalities and drug survival in a real-life SSc cohort.

METHODS

Details on immunosuppressive/antiproliferative (methotrexate, mycophenolate, cyclophosphamide, azathioprine, rituximab, tocilizumab) and vasoactive agent [(endothelin receptor antagonists (ERAs), sildenafil, iloprost, and calcium channel blockers (CCB)] administration during the disease course (11.8 ± 8.4 years, mean + SD) of 497 consecutive patients examined between 2016 and 2018 were retrospectively recorded. Drug survival was assessed by Kaplan-Meier analysis.

RESULTS

Methotrexate was the most frequently administered immunosuppressive/antiproliferative agent (53% of patients), followed by cyclophosphamide (26%), mycophenolate (12%), and azathioprine (11%). Regarding vasoactive agents, CCB had been ever administered in 68%, ERAs in 38%, iloprost in 7%, and sildenafil in 7% of patients; 23% of patients with pulmonary fibrosis had never received immunosuppressive/antiproliferative agents, 33% of those with digital ulcers had never received ERAs, iloprost, or sildenafil, whereas 19% of all patients had never received either immunosuppressive/antiproliferative or other than CCB vasoactive agents. Survival rates of methotrexate, cyclophosphamide, and mycophenolate differed significantly, being 84/75%, 59/43%, and 74/63% at 12/24 months, respectively, with inefficacy being the most frequent discontinuation cause. Conversely, CCB, ERAs, and sildenafil had high and comparable retention rates of 97/91%, 88/86%, and 80/80%, respectively.

CONCLUSIONS

Existing therapeutic limitations indicate that more evidence-based treatment is warranted for successful management of SSc. Vasculopathy seems to be managed more rigorously, but the low retention rates of immunosuppressive/antiproliferative drugs suggest that effective and targeted disease-modifying agents are warranted.

Development of a Novel mcr-6 to mcr-9 Multiplex PCR and Assessment of mcr-1 to mcr-9 Occurrence in Colistin-Resistant Salmonella enterica Isolates From Environment, Feed, Animals and Food (2011-2018) in Germany

The polymyxin antibiotic colistin has been used in decades for treatment and prevention of infectious diseases in livestock. Nowadays, it is even considered as last-line treatment option for severe human infections caused by multidrug- and carbapenem-resistant Gram-negative bacteria. Therefore, the discovery of plasmid-mediated mobile colistin resistance (mcr) genes raised major public health concern. The aim of our study was to analyze colistin-resistant Salmonella enterica strains from animals, food, feed and the environment collected at the National Reference Laboratory for Salmonella in Germany on the presence of mcr-1 to mcr-9 genes. Altogether 407 colistin-resistant (MIC >2 mg/L) Salmonella isolates received between 2011 and 2018 were selected and screened by PCR using a published mcr-1 to mcr-5 as well as a newly developed mcr-6 to mcr-9 multiplex PCR protocol. 254 of 407 (62.4%) isolates harbored either mcr-1 (n = 175), mcr-4 (n = 53), mcr-5 (n = 18) or mcr-1 and mcr-9 (n = 8). The number of mcr-positive isolates ranged from 19 (2017) to 64 (2012) per year. WGS revealed that none of our isolates harbored the mcr-9.1 gene. Instead, two novel mcr-9 variants were observed, which both were affected by frameshift mutations and are probably non-functional. The mcr-harboring isolates were mainly derived from animals (77.2%) or food (20.1%) and could be assigned to ten different Salmonella serovars. Many of the isolates were multidrug-resistant. Co-occurrence of mcr-1 and AmpC or ESBL genes was observed in eight isolates. Our findings suggest that mcr genes are widely spread among colistin-resistant Salmonella isolates from livestock and food in Germany. Potential transfer of mcr-harboring isolates along the food chain has to be considered critically.