A randomized placebo-controlled double-blinded study comparing oral and subcutaneous administration of mistletoe extract for the treatment of equine sarcoid disease

BACKGROUND

Equine sarcoids (ES) are the most common cutaneous tumors in equids. Systemic treatment options are sparse. Subcutaneous (SC) injections of Viscum album extract (VAE) demonstrate efficacy as a systemic treatment directed against ES.

OBJECTIVES/AIM

To critically assess the therapeutic efficacy of orally administered VAE.

ANIMALS

Forty-five ES-affected, privately owned, 3-12 year-old horses.

METHODS

A 3-armed randomized placebo-controlled, double-blinded study was conducted in a double-dummy design. Horses were subjected to oral administration and SC injections of either VAE or placebo (VAE oral/placebo SC, VAE SC/placebo oral, placebo oral/placebo SC) over a 7-month treatment period. Primary endpoint was the change of baseline of a composite index of ES number and ES area after 14 months. Second endpoint was the clinical response.

RESULTS

No statistically significant difference in the composite endpoint between the 3 study arms was found. The primary endpoint showed 4 (27%) horses in the VAE oral group with complete ES regression, 3 (21%) in the VAE SC injection group, and 2 (13%) in the placebo group. The clinical response revealed complete or partial regression in 6 horses of the oral VAE group (40%), 4 of the SC injection group (29%), and 4 of the placebo group (25%). Direct comparison of oral VAE and placebo showed an odds ratio, stratified for prognosis of 2.16 (95%-CI: 0.45-10.42) and a P-value of 0.336.

CONCLUSION AND CLINICAL IMPORTANCE

Oral administration of VAE is well tolerated. No statistically significant difference in the effectiveness of systemic VAE versus placebo against ES was found.

[DDB2-associated incidence of squamous cell carcinoma in Haflingers: risk minimization by genotyping]

INTRODUCTION

SCC (squamous cell carinomas) are among the most common eye neoplasms in horses. In recent studies Haflinger horses with a homozygous genotype for a missense variant in the DDB2 gene (damage specific DNA binding protein 2) had a significant increased risk of developing ocular SCC. The aims of this study were to determine the frequency of the SCC-associated risk allele in the DDB2 gene in Swiss and Austrian Haflinger populations and to validate the previously described phenotypic correlation. For this purpose, Haflingers presented at various horse clinics in Switzerland (n = 21, including 11 SCC cases), privately kept Haflingers (n = 52, including 1 SCC case), and Haflingers from a stud farm in the Austrian Tyrol (n = 53) were recruited. The individual DDB2 genotype of the animals was determined using a polymerase chain ceaction (PCR) test using hair follicle or whole blood samples. Of the 12 horses suffering from SCC, nine had ocular SCC and three had non-ocular SCC. Six of the nine Haflingers with ocular SCC and one of the three Haflingers with non-ocular SCC were homozygous for the DDB2 variant. Of the 113 clinically normal animals, 7/113 were homozygous (6 %) and 42/113 were heterozygous (37 %), which corresponds to an allele frequency of 24,8 % in the control cohort. The risk of ocular SCC occurring in Haflingers is significantly increased with the homozygous DDB2 genotype. However, not all animals with SCC carry this gene variant and not all DDB2 homozygous animals develop SCC, which can be explained by the multifactorial genesis of the disease. Due to the high frequency of the undesirable allele, we recommend taking the individual DDB2 genotype of breeding animals into account in order to avoid homozygous offspring with a greatly increased SCC risk by excluding high-risk matings.

[Ocular and non-ocular squamous cell carcinomas in the Haflinger: Eight cases at the Institut Suisse de Médecine Equine (2015-2022)]

INTRODUCTION

This case series describes the clinical course of ocular and non-ocular squamous cell carinoma (SCC) in the Haflinger horse and is intended to raise awareness of the high recurrence rate and tendency to metastasize. Eight Haflingers with histologically confirmed SCC were included, five ocular and three non-ocular, who were presented at the Institut Suisse de Médecine Équine (ISME) Bern between July 2015 and January 2022. The ocular SCC cases were all presented because of an apparent mass, which in most cases was post-treatment recurrence. The occurrence of recurrences was observed between 3 weeks and 16 years after initial therapy. Four of five Haflingers with ocular SCC had an enucleation, three of which were clinically normal at the time of the completion of this study, one case was euthanized due to confirmed metastases and one due to lameness. The result of enucleations for therapy of ocular SCC was good if no metastases occurred. Of the three non-ocular SCC cases, only one case, a penile SCC, had an apparent mass. Therapy was initiated in this case, while the other two cases were euthanized shortly after diagnosis due to the poor prognosis of SCC in the appropriate locations (maxillary sinus, mandible). Metastases occurred three and two years after removal of the primary tumor in ocular SCC in the scapula, liver and lungs and in non-ocular SCC from the penis to the nostrils. Since a postmortem pathological examination was not carried out on all Haflingers, further metastases cannot be ruled out. Haflingers with SCC should be monitored by a veterinarian over the long term, as recurrences and/or metastases can still occur years later.

The potential of three whole blood microRNAs to predict outcome and monitor treatment response in sarcoid-bearing equids

MicroRNAs (miRNAs) have been proposed as biomarkers for equine sarcoid (ES) disease. In this study, the suitability of three whole blood miRNAs to diagnose ES and to predict and monitor the outcome of therapy was explored. Using reverse transcription-quantitative polymerase chain reaction (RT-qPCR), expression levels of eca-miR-127, eca-miR-379, and eca-miR-432 in whole blood of ES-affected equids before and at least one year after therapy were compared to those of unaffected control equids. Associations of age, sex, species, diagnosis, and therapy outcome with miRNA expression levels were examined using general linear models. In total, 48 ES-affected equids and 47 control equids were recruited. From the affected animals, 31 responded favorably to treatment, and 17 demonstrated a failure of therapy. None of the tested miRNAs were influenced by age. Male equids showed increased expression of eca-miR-127 compared to females and horses showed higher expression levels of eca-miR-379 and eca-miR-432 than donkeys. Eca-miR-127 was confirmed as a diagnostic discriminator between ES-affected and control equids. No difference in miRNA profiles before therapy was found when comparing ES-affected equids with success vs. failure of therapy. Eca-miR-379 and eca-miR-432 decreased over time in horses where therapy was successful, but not in those cases where it failed. Biological variables influence equine whole blood miRNA expression, which may complicate biomarker validation. While none of the tested miRNAs could predict the response to therapy in ES-affected equids and eca-miR-127 showed poor diagnostic accuracy for ES, eca-miR-379 and eca-miR-432 miRNAs might allow refinement of monitoring of success of ES therapy.

Characterization of an outbreak of equine coronavirus infection in adult horses in Switzerland

INTRODUCTION

Outbreaks of equine coronavirus (ECoV) infections have been described in different parts of the world including Europe. The aim of this report was to describe clinical signs, diagnostic work-up and outcome of the first documented outbreak of ECoV in Switzerland in order to raise the awareness for the disease and its various clinical presentations. The outbreak occurred on a farm with 26 horses. Of these, seven horses developed clinical disease ranging from mild signs such as fever and anorexia to severe signs of acute colitis. One horse died due to severe endotoxemia and circulatory shock secondary to severe acute necrotizing enteritis and colitis. Out of the 26 horses, five horses tested positive for ECoV, including two ponies without any clinical signs of infection. The low number of positive cases should nevertheless be interpreted with caution as testing was only performed on one occasion, over a month after the onset of clinical signs in the first suspected case. This report highlights the importance of diagnostic testing and early implementation of biosecurity measures on a farm with an ECoV outbreak. It should furthermore raise the awareness for unspecific and mild clinical signs such as fever and anorexia in affected animals that are potentially able to spread the disease.

AB0899 A 24-month Prospective Psoriatic Arthritis Observational Study of Persistence of Treatment (PRO-SPIRIT) - Interim Analysis of Baseline Characteristics

Background

Ixekizumab (ixe), a highly selective interleukin (IL)-17A monoclonal antibody, has been approved for treatment of psoriatic arthritis (PsA). However, there is limited real-world evidence (RWE) available for ixe. PRO-SPIRIT is the first large-sample prospective observational study to provide RWE for ixe in patients (pts) with PsA.

Objectives

PRO-SPIRIT’s primary objective is to describe treatment persistence at 24 months (M) among pts with PsA who initiate or switch to a new biologic Disease Modifying Arthritis Rheumatic Drugs (bDMARDs) or targeted synthetic (tsDMARDs), including ixe. This abstract describes the interim baseline (BL) characteristics.

Methods

PRO-SPIRIT is a prospective observational study, conducted in FR, ES, IT, DE, UK, and CA, enrolling adults with PsA (≥6M) to be initiated or switched to a new b/tsDMARD, locally approved for PsA. Treatment groups include ixe, secukinumab, IL-12/IL-23 inhibitors (i) (ustekinumab) or IL-23i (guselkumab), tumour necrosis factor (TNFi) (adalimumab, etanercept, infliximab or biosimilar), Janus kinase (JAKi) (tofacitinib or upadacitinib). Pt demographic, disease activity and therapy characteristics are collected at BL; clinical and patient-reported outcomes measures are collected at BL and at a routine post-BL visit. BL descriptive statistics are reported.

Results

From December 2019 until this interim data cut (June 2021), a total of 477 pts (305 female; mean age 52) were enrolled. Mean age ranged from 48 (IL-12/23i and IL-23i) to 55 (JAKi), with a majority of female pts in each group (Table 1). Pts in the IL-12/23i and IL-23i and TNFi groups showed the shortest time since PsA diagnosis (5.2±4.5; 6.5±7.9), while pts in the JAKi group showed the longest time (10.6±9.4). The lowest proportion of pts with a prior b/tsDMARDs use was observed in the TNFi group (31%), the highest in the IL-12/23i and IL-23i group (71%). Pts in the ixe and IL-12/23i and IL-23i groups were more likely to be on monotherapy. Tender Joint Count (9.1-11.3) and Swollen Joint Count (3.3-5.8) were comparable across groups, with the highest values in the ixe and JAKi groups, respectively. Pt proportion with enthesitis and dactylitis was higher in the ixe, secukinumab and JAKi groups. Percentage of Body Surface Area affected by psoriasis was higher in the ixe, secukinumab and IL-12/23i and IL-23i groups. Pt proportion with nail psoriasis was higher in the ixe and secukinumab groups. Physician’s Global Assessment Visual Analog Scale (VAS), Patient’s Global Assessment VAS and Patient’s Assessment of Joint Pain VAS reflected a high burden of illness.

Table 1.

Baseline characteristics

bDMARDstsDMARDsIxekizumabSecukinumabIL-12/23 and IL-23 inhibitorsTNF inhibitorsJAK InhibitorsN=137N=46N=24N=211N=40Age52.8±12.252.8±13.147.6±13.450.3±11.755.3±9.9Female, n (%)86 (62.8)31 (67.4)16 (66.7)135 (64.0)25 (62.5)Years since diagnosis8.4±7.57.6±8.05.2±4.56.5±7.910.6±9.4Prior b/tsDMARD, n (%)87 (63.5)27 (58.7)17 (70.8)66 (31.3)26 (65.0)Concomitant csDMARD, n (%)47 (34.3)19 (41.3)5 (20.8)108 (51.2)19 (47.5)Tender Joint Count11.3±10.29.1±10.89.1±9.310.9±10.611.1±8.8Swollen Joint Count5.7±6.63.3±3.83.4±6.44.8±5.65.8±6.6Body Surface Area % affected by psoriasis6.1±10.57.6±14.27.0±9.74.6±11.02.2±3.1Presence of enthesitis, n (%)58 (42.3)16 (34.8)4 (16.7)67 (31.8)16 (40.0)Presence of dactylitis, n (%)33 (24.1)10 (21.7)3 (12.5)26 (12.3)10 (25.0)Presence of nail psoriasis, n (%)57 (41.6)20 (43.5)7 (29.2)71 (33.6)11 (27.5)Physician’s Global assessment VAS62.6±18.159.5±20.555.7±24.661.7±18.063.0±20.5Patient’s Global Assessment VAS60.5±20.456.8±25.156.2±25.757.5±22.955.4±22.5Patient’s Assessment of Joint Pain VAS62.7±21.358.4±27.155.7±28.359.4±22.957.5±24.0

Mean±SD, unless otherwise stated

Conclusion

The reported BL characteristics offer preliminary information about which pts initiate or switch to a b/tsDMARD in a real life-setting. Future disclosures (at 12 and 24M) will provide RWE regarding persistence, effectiveness, and health care resource use of available treatments for PsA, which will help pts and physicians to make better informed treatment decisions.

Disclosure of Interests

Jacques Morel Speakers bureau: Abbvie, Amgen, Biogen, Biogen, Bristol Myer Squib, Fresenius, Galapagos, Eli Lilly and Company, Médac, Novartis, Sandoz, Sanofi, Consultant of: Abbvie, Galapagos, Eli Lilly and Company, Médac, Novartis, Glaxo Smith Kline, Grant/research support from: Bristol Myer Squib, Biogen, Eli Lilly and Company, Novartis, Pfizer, Lorenzo Dagna Speakers bureau: Abbvie, Amgen, BMS, Eli Lilly and Company, Galapagos, GSK, Pfizer, Sobi, Consultant of: Abbvie, Amgen, Astra Zeneca, Biogen, BMS, Celltrion, Eli Lilly and Company, Galapagos, GSK, Janssen, Kiniksa, Pfizer, Roche, Sobi, Sanofi, Beatriz Joven-Ibáñez Speakers bureau: Eli Lilly and Company, Grant/research support from: (institutional grant) Eli Lilly and Company, Thorsten Holzkaemper Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Celine El Baou Consultant of: Eli Lilly and Company, Leonore Unger Speakers bureau: Eli Lilly and Company, Angelo Semeraro: None declared, Nicola Gullick Speakers bureau: AbbVie, Celgene, Janssen, Eli Lilly and Company, Novartis, UCB, Consultant of: AbbVie, Janssen, Eli Lilly and Company, Novartis, UCB, Grant/research support from: (institutional grants) Eli Lilly and Company, AbbVie, Astra Zeneca, Izana, Novartis, Tamas Treuer Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company

AB0622 The Joint Vasculitis Registry in German-speaking countries (GeVas) – subgroup analysis of 113 GPA-patients

Background

Granulomatosis with polyangiitis (GPA) is the second most frequent vasculitis in Germany with an annual incidence of 34 per million and a prevalence of 210 per million [1]. GPA is characterized by its chronic course, frequent relapses, significant overall morbidity and mortality, and substantial socio-economic impact. Multiorgan involvement affecting the respiratory tract, kidney, and other organs is common. Limited variants also occur [2]. So far, prospective long-term observational data on the disease course of GPA are missing in Germany. Therefore, the Joint Vasculitis Registry in German-speaking countries (GeVas) has been established to follow the course of patients recently diagnosed with vasculitis or a change of their treatment due to a relapse (inception cohort). The GeVas registry allows long-term follow-up of a substantial cohort of vasculitis patients in a multicenter setting.

Objectives

To present the first data on the follow-up of newly diagnosed and relapsing GPA enrolled in the GeVas registry.

Methods

GeVas is a prospective, web-based, multicenter, clinician-driven registry for the documentation of organ manifestations, damage, long-term outcomes, and therapy regimens in various types of vasculitis. Recruitment started in June 2019. By January 2022, 17 centers in Germany were initiated and started enrolling patients. Meanwhile, more than 350 patients have been documented in the registry. Sites in Austria and the German-speaking cantons of Switzerland will be integrated soon [3].

Results

By mid-October 2021, the participating centers included 113 patients with GPA. The majority of patients were PR3-ANCA positive and affected by general symptoms, ENT, lung, renal, and neurological involvement. Patients commonly received cyclophosphamide or rituximab in combination with glucocorticoids for the induction of remission. Fewer patients received methotrexate or other immunosuppressants. Patient characteristics and therapy are summarized in Table 1.

Table 1.

Patient characteristics (n = 113). *Unless otherwise specified.

CategoryFeaturen (%)*AgeAge (years); median [range]60 [51 - 70]GenderMale61 (54.0)Female52 (46.0)Reason for inclusion in the registryNewly diagnosed vasculitis57 (51.4)Relapse56 (49.6)ANCA statusPR3-ANCA99 (87.6)MPO-ANCA4 (3.6)ANCA negative9 (7.9)Organ manifestationGeneral symptoms86 (76.1)ENT69 (61.1)Lung/chest66 (58.4)Renal35 (31.0)Cardiovascular7 (6.2)GI3 (2.7)Neurological27 (23.9)TherapyGlucocorticoid102 (90.3)Rituximab56 (49.6)Cyclophosphamide37 (32.7)Methotrexate and other immunosuppressants, respectively26 (23.0) and 19 (16.8), respectively

Conclusion

Here, we present the first interim analysis of the GeVas registry. Clinical manifestations of GPA reported herein show less frequent renal involvement in comparison with a recent report from another European registry (POLVAS) and an UK study [4, 5]. This is potentially related to the predominance of recruiting rheumatology centers thus far. By contrast, respiratory tract involvement is more frequent and PR3-ANCA less common in Japan [5]. Further data are prospectively documented and a follow up analysis is in progress.

References

[1]Hellmich B, et al. New insights into the epidemiology of ANCA-associated vasculitides in Germany: results from a claims data study. Rheumatology 2021;60:4868-73.

[2]Kitching AR, et al. ANCA-associated vasculitis. Nat Rev Dis Primers 2020;6:71.

[3]Iking-Konert C, et al. The Joint Vasculitis Registry in German-speaking countries (GeVas) – a prospective, multicenter registry for the follow-up of long-term outcomes in vasculitis. BMC Rheumatol 2021;5:40.

[4]Wójcik K, et al. Clinical characteristics of Polish patients with ANCA-asscoiated vasculitides – retrospective analysis of POLVAS registry. Clin Rheumatol 2019;38:2553-63.

[5]Furuta S, et al. Comparison of the phenotype and outcome of granulomatosis with polyangiitis between UK and Japanese cohorts. J Rheumatol 2017;44:216-22.

Acknowledgements

GeVas was supported by unrestricted grants by: DGRh, John Grube Foundation, Vifor and Roche Pharma

Disclosure of Interests

Sabrina Arnold: None declared, Pia Wallmeier: None declared, Fabian Schubach: None declared, Gabriele Ihorst: None declared, Peer Aries: None declared, Raoul Bergner Consultant of: VIFOR, Jan Philip Bremer: None declared, Norman Görl: None declared, Bernhard Hellmich: None declared, Jörg Henes: None declared, Bimba Hoyer: None declared, Antje Kangowski: None declared, Ina Kötter: None declared, Claudia Metzler: None declared, Ulf Müller-Ladner: None declared, Matthias Schaier: None declared, Ulf Schönermark: None declared, Jens Thiel: None declared, Leonore Unger: None declared, Nils Venhoff Speakers bureau: Roche and Vifor: speaker honoraries, Consultant of: Roche and Vifor: advisory boards, Grant/research support from: John-Grube Research Award 2021, Julia Weinmann-Menke: None declared, Jana Petersen: None declared, Christof Iking-Konert Speakers bureau: Lecture fees from: Chugai, GSK, Roche, and Vifor, Consultant of: Consulting fees from: Chugai, GSK, Roche, and Vifor, Grant/research support from: Research grants for GeVas: Roche, Vifor, DGRh, John Grube Foundation, Peter Lamprecht Speakers bureau: Chugai, GSK, Roche, and Vifor, Consultant of: Chugai, GSK, Roche, and Vifor, Grant/research support from: DGRh, John Grube Foundation, Roche, and Vifor

POS0800 THE JOINT VASCULITIS REGISTRY IN GERMAN-SPEAKING COUNTRIES (GeVas) – SUBGROUP ANALYSIS OF 131 GCA-PATIENTS REFERENCES:

Background

The most frequent form of vasculitis in elderly people is giant cell arteritis (GCA) with an annual incidence rate less than 10 per 100,000 persons over the age of 50. Like most vasculitides, GCA is characterized by chronicity and relapses, leading to significant overall morbidity and higher mortality in a subset of patients with aortic involvement and dissection. Most studies carried out so far have been retrospective, used monocentric study designs and small patient cohorts. Therefore, the Joint Vasculitis Registry in German-speaking countries (GeVas) has been established to record patients, who have been recently diagnosed with vasculitis or who have changed their treatment due to a relapse (inception cohort). The GeVas-Registry allows a long-term follow-up of a substantial cohort of vasculitis patients in a prospective and multicenter manner.

Objectives

To describe the subgroup of GCA and its characteristics within the GeVas registry.

Methods

GeVas is a prospective, web-based, multicenter, clinician-driven registry for the documentation of organ manifestations, damage, long-term outcomes, and therapy regimens in various types of vasculitis. Recruitment started in June 2019. By January 2022, 17 centers in Germany were initiated and have begun enrolling patients. Meanwhile, more than 350 patients have been documented in the registry. Sites in Austria and the German-speaking cantons of Switzerland will be integrated soon (1).

Results

By mid-October 2021, the participating centers recruited 131 GCA patients into the registry. 21.7% of patients (n=28) were enrolled in the registry due to relapse, and 78.3% (n=101) due to a first-time diagnosis. In accordance with long-standing epidemiology data, the majority of patients (67,2%), were female (n=88), and 32.8% (n=43) were male. Mean age was 74 years (max. 92y, min. 52y). The most frequently recorded organ manifestations in GCA patients addressed cranial and ophthalmic symptoms, and the cardiovascular system. However, vascular lung/chest involvement was also observed in 3% of cases (n=4). Out of the 131 patients, 97.7% (n=128) received immunosuppressive therapy, three refused to take any medication. An equal number of patients were treated with glucocorticoid (GC) therapy. While about two equal parts were treated by stable long term oral GC therapy (47,7%, n=62) or by i.v. pulse therapy followed by tapering (49,2%, n=64), only about 2.3% (n=3) were treated by oral GC therapy with intermittent i.v. pulses. 48.5% (n=63) of patients received tocilizumab as additional immunosuppressive therapy, 19.2% (n=25) methotrexate, and 18.5% (n=24) cyclophosphamide i.v. pulses.

Conclusion

In June 2019, we successfully established the prospective multicenter vasculitis registry GeVAS. It describes the first systematically recorded prospective GCA cohort in German-speaking countries. Its characteristics correspond to those that can be expected from the literature, with some unexpected finding e.g. the high proportion of patients treated with cyclosphosphamid, probably reflecting a sicker patient population with e.g. aortic or central nervous involvement. After 2.5 years of follow-up documentation, the first long-term results will be systematically evaluated and interpreted. The newly acquired data on disease manifestation, diagnostics and therapy regimens will provide important insights into the treatment of GCA patients in Germany and may generate further research goals.

References

Trial registration: German Clinical Trials Register (Deutsches Register Klinischer Studien): DRKS00011866. Registered 10 May 2019. 3

[1]C Iking-Konert; P Wallmeier; S Arnold; S Adler; K de Groot; B Hellmich; B Hoyer; K Holl-Ulrich; Ihorst; M Kaufmann; I Kötter; U Müller-Ladner; T Magnus; J. Rech; H. Schulze-Koops; N. Venhoff; T. Wiech; P. Villiger; F. Schubach; P. Lamprecht. The Joint Vasculitis Registry in German-speaking countries (GeVas) – a prospective, multicenter registry for the follow-up of long-term outcomes in vasculitis. BMC Rheumatol. 2021 Jul 31;5(1):40. doi: 10.1186/s41927-021-00206-2.

Acknowledgements

GeVas was supported by unrestricted grants by: DGRh, John Grube Foundation, Vifor and Roche Pharma

Disclosure of Interests

Pia Wallmeier: None declared, Sabrina Arnold: None declared, Fabian Schubach: None declared, Gabriele Ihorst: None declared, Peer Aries: None declared, Raoul Bergner Consultant of: Advisory Board VIFOR, Grant/research support from: John-Grube Research Award 2021, Jan Philip Bremer: None declared, Norman Görl: None declared, Bernhard Hellmich: None declared, Jörg Henes: None declared, Bimba Hoyer: None declared, Antje Kangowski: None declared, Ina Kötter: None declared, Tim Magnus: None declared, Claudia Metzler: None declared, Ulf Müller-Ladner: None declared, Matthias Schaier: None declared, Ulf Schönermark: None declared, Jens Thiel: None declared, Leonore Unger: None declared, Nils Venhoff Speakers bureau: Roche and Vifor, Consultant of: Roche and Vifor, Grant/research support from: John-Grube Research Award 2021, Julia Weinmann-Menke: None declared, Jana Petersen: None declared, Peter Lamprecht Speakers bureau: Lecture fees from: Chugai, GSK, Roche, Consultant of: Consulting & lecture fees from: Chugai, GSK, Roche, and Vifor., Grant/research support from: Research grants for GeVas: DGRh, John Grube Foundation, Roche, and Vifor, Christof Iking-Konert Speakers bureau: lecture fees from: Chugai, GSK, Roche, and Vifor., Consultant of: Consulting fees from: Chugai, GSK, Roche, and Vifor., Grant/research support from: Research grants for GeVas: DGRh, John Grube Foundation, Roche, and Vifor;

OP0182 SECUKINUMAB IN GIANT CELL ARTERITIS: THE RANDOMISED, PARALLEL-GROUP, DOUBLE-BLIND, PLACEBO-CONTROLLED, MULTICENTRE PHASE 2 TitAIN TRIAL

Background

Little is known about glucocorticoid-sparing agents in giant cell arteritis (GCA) except for IL-6 inhibition. Secukinumab (SEC) has shown significant improvements in the signs and symptoms of IL-17A driven medical conditions such as plaque psoriasis, psoriatic arthritis, and axial spondyloarthritis.1,2 It has a favourable long-term safety profile.1,2

Objectives

TitAIN is the first randomised controlled trial investigating the potential efficacy, safety, and tolerability of SEC in GCA patients (pts).

Methods

This phase 2, randomised, double-blind, placebo (PBO) controlled, multicentre, proof-of-concept trial enrolled pts (aged ≥50 years) with new onset (diagnosed within 6 weeks (wks) of baseline) or relapsing (diagnosed >6 wks from baseline) GCA, naïve to biological therapy. Pts were randomised (1:1) to SEC 300 mg or PBO initially administered wkly (5 doses) and every 4 wks thereafter through Wk 48 (last dose), in combination with a 26-wk prednisolone taper regimen starting from baseline. Proportion of GCA pts in sustained remission until Wk 28 was the primary endpoint assessed by a Bayesian analysis of the posterior distribution with non-responder imputation. Other key endpoints included proportion of GCA pts in sustained remission until Wk 52 (based on study data with non-responder imputation) and time to first GCA flare after baseline.

Results

Out of 52 randomised pts (SEC, n=27; PBO, n=25), 71.2% (n=37) completed study treatment (SEC, 81.5%; PBO, 60.0%). Overall, 42 (80.8%) pts had new onset GCA and 10 (19.2%) pts had relapsing GCA at baseline. Proportion (posterior median with 95% credibility interval) of GCA pts in sustained remission until Wk 28 was higher with SEC, 70.1% (51.6%-84.9%), than with PBO, 20.3% (12.4%-30.0%); odds ratio (posterior median with 95% credibility interval), 9.31 (3.54-26.29) (Table 1). Until Wk 52, proportion (95% confidence interval) of GCA pts in sustained remission were 59.3% (38.8%-77.6%) in SEC group and 8.0% (1.0%-26.0%) in PBO group (Table 1). Median (95% confidence interval) time to first GCA flare after baseline was not reached for GCA pts treated with SEC and was 197.0 (101.0-280.0) days for PBO (Figure 1). Overall, treatment-emergent adverse events (AEs) occurred in 98.1% (SEC vs PBO, 100.0% vs 96.0%) and serious AEs in 32.7% (SEC vs PBO, 22.2% vs 44.0%) pts. Two pts in each SEC and PBO groups had AEs that led to study drug discontinuation and 1 pt in each group had AEs that led to death (not treatment-related). There were no new or unexpected safety signals identified with SEC treatment.

Table 1.

Proportion of GCA patients with sustained remission (Full analysis set) until Week 28 and 52

Proportion of ptsSecukinumab (N=27)Placebo (N=25)Median percentage (95% credibility interval), Wk 2870.1% (51.6%, 84.9%)20.3% (12.4%, 30.0%)Percentage (95% confidence interval), Wk 5259.3% (38.8%, 77.6%)8.0% (1.0%, 26.0%)

The full analysis set comprises all pts to whom study treatment has been assigned by randomisation and who received at least one dose of randomised study treatment (secukinumab or placebo).

GCA, giant cell arteritis; N, number of pts in each treatment group in the full analysis set, pts, patients; Wk, Week

Figure 1.

Kaplan-Meier plot of time to first GCA flare from baseline up to Week 52 (Full analysis set)

Conclusion

SEC demonstrated a higher sustained remission rate and longer time to first GCA flare vs PBO through 52 wks in pts with GCA. This proof-of-concept phase 2 study supports further development of SEC as a potential treatment in combination with 26 wk glucocorticoid taper for pts with GCA.

References

[1]Mease PJ, et al. ACR Open Rheumatol. 2020;2(1):18-25

[2]Baraliakos X, et al. RMD Open. 2019;5:e001005

Disclosure of Interests

Nils Venhoff Speakers bureau: AbbVie, Novartis, Bristol-Myers-Squibb, Chugai, Roche, Vifor, Consultant of: AbbVie, Chugai, Novartis, Vifor, Grant/research support from: Bristol-Myers-Squibb, Novartis, Wolfgang A. Schmidt Speakers bureau: Abbvie, Chugai, Medac, Novartis, Roche, Sanofi, Consultant of: Advisory board member: Abbvie, Chugai, GlaxoSmithKline, Novartis, Roche, Sanofi, Grant/research support from: principle investigator in GCA trials: Abbvie, GlaxoSmithKline, Novartis, Sanofi, Raoul Bergner Speakers bureau: Abbvie, Bristol Myers Squibb, Chugai, Novartis, Roche, Consultant of: Advisory board member: Gilead, GlaxoSmithKline, Vifor, Jürgen Rech Speakers bureau: Abbvie, Biogen, BMS, Chugai, GSK, Janssen, Lilly, MSD; Novartis, Roche, Sanofi, Sobi, UCB, Consultant of: Abbvie, Biogen, BMS, Chugai, GSK, Janssen, Lilly, MSD, Novartis, Roche, Sanofi, Sobi, UCB, Leonore Unger Paid instructor for: Novartis, Hans-Peter Tony Consultant of: Abbvie, BMS, Chugai, Gilead, Lilly, Novartis, Roche, Sanofi, Meryl Mendelson Shareholder of: Novartis Pharmaceuticals Corporation, Employee of: Novartis Pharmaceuticals Corporation, Christian Sieder Employee of: Novartis Pharma GmbH, Meron Maricos Employee of: Novartis Pharma GmbH, Jens Thiel Speakers bureau: Novartis, GSK, Bristol-Myers-Squibb, Roche, AstraZeneca, Vifor, Consultant of: Novartis, Janssen, GSK; research grants: Bristol-Myers-Squibb, Novartis

Outbreak of equine coronavirus disease in adult horses, Switzerland 2021

Coronaviruses are causing severe respiratory and enteric diseases in humans and animals. Here, we report an outbreak of equine coronavirus disease in adult horses, detected by a voluntary syndromic surveillance scheme for equine diseases in Switzerland. This scheme allowed a rapid concerted action to diagnose and contain the disease.

Diagnostic and prognostic potential of eight whole blood microRNAs for equine sarcoid disease

MicroRNAs have been proposed as biomarkers for equine sarcoids, the most prevalent equine skin tumors globally. This study served to validate the diagnostic and prognostic potential of whole blood microRNAs identified in a previous study for long-term equine sarcoid diagnosis and outcome prediction. Based on findings of a clinical examination at the age of 3 years and a follow-up following a further 5–12 years, 32 Franches-Montagnes and 45 Swiss Warmblood horses were assigned to four groups: horses with regression (n = 19), progression (n = 9), new occurrences of sarcoid lesions (n = 19) and tumor-free control horses (n = 30). The expression levels for eight microRNAs (eca-miR-127, eca-miR-432, eca-miR-24, eca-miR-125a-5p, eca-miR-134, eca-miR-379, eca-miR-381, eca-miR-382) were analyzed through reverse transcription quantitative polymerase chain reaction in whole blood samples collected on initial examination. Associations of sex, breed, diagnosis, and prognosis with microRNA expression levels were examined using multivariable analysis of variance. Sex and breed influenced the expression level of five and two microRNAs, respectively. Eca-miR-127 allowed discrimination between sarcoid-affected and tumor-free horses. No variation in microRNA expression was found when comparing horses with sarcoid regression and progression. Expression levels of eca-miR-125a-5p and eca-miR-432 varied in male horses that developed sarcoids throughout the study period in comparison to male control horses. While none of the investigated miRNAs was validated for predicting the prognosis of sarcoid regression / progression within young horses with this condition, two miRNAs demonstrated potential to predict if young male (though not female) tumor-free horse can develop sarcoids within the following years. Sex- and breed- biased miRNAs exist within the equine species and have an impact on biomarker discovery.

Molecular characterization of equine thymidine kinase 1 and preliminary evaluation of its suitability as a serum biomarker for equine lymphoma

Background

Thymidine kinase 1 (TK1) plays a key role in the synthesis of deoxythymidine triphosphate (dTTP) and is thus important for DNA replication and cell proliferation. The expression of TK1 is highest during S-phase, and it is rapidly degraded after mitosis. In cancer cells, TK1 is upregulated, resulting in leakage of excess TK1 into the blood. Consequently, serum TK1 has been used as a diagnostic and prognostic cancer biomarker, mainly in human medicine. The aims of this work were to characterize equine TK1 and to evaluate its suitability as a serum biomarker for equine lymphoma.

Results

Equine TK1 was cloned, expressed in E. coli and affinity purified. The purified recombinant horse TK1 showed broad substrate specificity, phosphorylating pyrimidine deoxyribo- and ribonucleosides and, to some extent, purine deoxynucleosides, including anticancer and antiviral nucleoside analogues. ATP was the preferred phosphate donor. Serum TK1 activity was measured in samples collected from horses with confirmed or suspected lymphoma and control horses with and without concurrent diseases. Serum TK1 activity levels were significantly higher in horses with lymphoma (p <  0.0005) and suspected lymphoma (p <  0.02) and in tumour-free groups with diverse diseases (p <  0.03) than in controls without concurrent diseases. There was a significant difference between the lymphoma group and the tumour-free group with diverse diseases (p <  0.0006). Furthermore, receiver operating characteristic analysis revealed a sensitivity of 0.86, a specificity of 0.95 and an AUC (area under the curve) of 0.92 compared to the controls without concurrent diseases, with a sensitivity of 0.97, a specificity of 0.71 and an AUC of 0.88 when compared with the tumour-free group with diverse diseases.

Conclusion

Equine TK1 showed high specific activity and broader substrate specificity than human TK1. Anticancer and antiviral thymidine analogues were efficiently phosphorylated by horse TK1, suggesting that these analogues might be good candidates for chemotherapy in horses. Serum TK1 activity was significantly higher in horses with lymphoma than in controls. ROC analysis indicated that serum TK1 could serve as a promising cancer biomarker in horses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12860-021-00399-x.

Diagnostic potential of three serum microRNAs as biomarkers for equine sarcoid disease in horses and donkeys

BACKGROUND

MicroRNAs (miRNAs) are potential biomarkers for equine sarcoids (ES).

OBJECTIVES

To assess eca-miR-331, eca-miR-100, and eca-miR-1 as serum biomarkers for ES disease.

ANIMALS

Sixty-eight ES cases (56 horses, 12 donkeys), 69 tumor-free controls (60 horses, 9 donkeys), and 20 horses with other skin tumors.

METHODS

For this case-control study, expression of serum eca-miR-331, eca-miR-100, and eca-miR-1 in ES-affected equids was compared to tumor-free age-, sex-, and breed-matched control horses and donkeys with other skin tumors using reverse transcription quantitative PCR (polymerase chain reaction) for relative miRNA quantification. Biological, preanalytical, and clinical variable influences on miRNA expression were examined. Receiver operator characteristic (ROC) curve analyses were used to determine differences in miRNA expression between groups.

RESULTS

The expression of eca-miR-100 was affected by age (P = .003) and expression of eca-miR-100 and eca-miR-1 were affected by hemolysis (both P < .001). Eca-miR-331 was unaffected by biological variation, hemolysis, ES type, and disease severity. Eca-miR-331 concentrations were higher in ES-affected compared to tumor-free controls (P = .002). The ROC curve analysis indicated an area under the curve of 0.65 (P = .002) with a sensitivity of 60%, specificity of 71%, and positive and negative likelihood ratios of 2.1 and 0.56, respectively, to diagnose ES. Eca-miR-331 expression did not discriminate between horses with ES and other skin tumors. Expression of eca-miR-100 and eca-miR-1 was not different between groups.

CONCLUSIONS AND CLINICAL IMPORTANCE

Serum eca-miR-331 expression is neither sensitive nor specific enough as a single ES biomarker. If combined with other miRNAs, it may be helpful for ES diagnosis.

[Future of rheumatologists: what are the perspectives? : Survey of resident physicians in rheumatology in middle Germany]

BACKGROUND AND OBJECTIVE

The work environment for rheumatologists has significantly changed over the last years. The healthcare of patients with rheumatic diseases is at risk due to the age structure of specialized rheumatologists in middle Germany and the limited availability of training positions for rheumatologists. In this context, it is important to have detailed information on the resident physicians in rheumatology concerning their own visions regarding their future professional career.

MATERIAL AND METHODS

A questionnaire was sent to resident physicians in 25 rheumatology training hospitals in the middle of Germany (Saxony, Saxony-Anhalt and Thuringia). The questionnaire was completed and returned by 27 participants (17 women and 10 men).

RESULTS

Most of the participants (60%) aimed to qualify as a specialist in internal medicine followed by a specialization in rheumatology (altogether training for a minimum of 8 years). After finishing training 44% would prefer to work in an outpatient setting while 30% planned to work in a combined outpatient and clinical setting. Of the participants 48% would prefer to work as part-time rheumatologists and 74% (women 94% and men 40%) were interested in employment in an outpatient medical healthcare center. The compatibility of family and work as well as the work-life balance was considered to be highly relevant for the future professional life.

CONCLUSION

Less than half of the participants intended to work exclusively in an outpatient setting after completing the training in rheumatology. In addition, the participants preferred a part-time employment with compatibility of professional and private life. Consequently, alternative models of employment should be created in rheumatology to be attractive for future physicians. On the other hand, the study revealed that the independent rheumatological practice has a lower priority for the young rheumatologists taking part in this survey.

Differences in miRNA differential expression in whole blood between horses with sarcoid regression and progression

Background

Currently no methods are available to predict the clinical outcome of individual horses with equine sarcoid (ES) disease.

Objective

To investigate if whole blood microRNA (miRNA) profiles can predict the long‐term development of ES tumors.

Animals

Five horses with regression and 5 with progression of ES lesions monitored over 5‐7 years and 5 control horses free of ES for at least 5 years.

Methods

For this cohort study, RNA extracted from whole blood samples from the regression, progression, and control groups was used for high throughput sequencing. Known and novel miRNAs were identified using miRDeep2 and differential expression analysis was carried out by the DESeq2 algorithm. Target gene and pathway prediction as well as enrichment and network analyses were conducted using TarBase, mirPath, and metaCore from GeneGo.

Results

Fourteen miRNAs were differentially expressed between regression and progression groups after accounting for the control condition: 4 miRNAs (28.6%) were upregulated and 10 miRNAs (71.4%) were downregulated with >2‐fold change. Seven of the 10 downregulated miRNAs are encoded in an miRNA cluster on equine chromosome 24, homologous to the well‐known 14q32 cluster in humans. Their target genes show enrichment for pathways involved in viral carcinogenesis.

Conclusions and Clinical Importance

Whole blood miRNA expression profiles are associated with long‐term ES growth in horses and warrant further validation as prognostic biomarkers in a larger study cohort. Deregulation of miRNAs on equine chromosome 24 might represent a trigger for ES development.

Spatio-temporal Analysis of Multichannel Atrial Electrograms Based on a Concept of Active Areas

Atrial tachycardia and atrial flutter are frequent arrhythmia that occur spontaneously and after ablation of atrial fibrillation. Depolarization waves that differ significantly from sinus rhythm propagate across the atria with high frequency (typically 140 to 220 beats per minute). A detailed and personalized analysis of the spread of depolarization is imperative for a successful ablation therapy. Thus, catheters with several electrodes are employed to measure multichannel electrograms inside the atria. Here we propose a new concept for spatio-temporal analysis of multichannel electrograms during atrial tachycardia and atrial flutter. It is based on the calculation of simultaneously active areas. The method allows to identify atrial tachycardia and to automatically distinguish between subtypes of focal activity, micro-reentry and macro-reentry.

Genetic risk for squamous cell carcinoma of the nictitating membrane parallels that of the limbus in Haflinger horses

Squamous cell carcinoma (SCC) is the most common cancer affecting the equine eye, with a higher incidence documented in Haflinger horses. Recently, a missense variant in the gene damage specific DNA binding protein 2 (DDB2, p.Thr338Met) on ECA12 was identified as a risk factor for the development of limbal SCC in Haflinger horses. SCC also occurs on the nictitating membrane; therefore, investigating the role of this missense variant in nictitating membrane SCC is warranted. In this study, a common ancestor was identified among Haflinger horses affected with limbal SCC or with nictitating membrane SCC, thus supporting a recessive risk factor for the development of cancer at both ocular locations. Analysis of genotype data from Haflinger horses with and without nictitating membrane SCC revealed that the same region on ECA12 associated with limbal SCC was also associated with nictitating membrane SCC (P < 2.04 × 10^-5 ). Fine mapping of this locus using 25 cases and 49 controls supported the hypothesis that DDB2:c.1013C>T, p.Thr338Met, is a risk factor for nictitating membrane SCC, as 88% of our cases were homozygous for this variant and no other polymorphism was more strongly associated (P = 4.13 × 10^-14 ). These data indicate that the genetic risk is the same for the development of both limbal and nictitating membrane SCC in Haflinger horses and validates utilization of genetic testing of the DDB2 variant for both clinical management and the guidance of mating decisions.

Regulatory T Cells Promote Natural Killer Cell Education in Mixed Chimeras

Therapeutic administration of regulatory T cells (Tregs) leads to engraftment of conventional doses of allogeneic bone marrow (BM) in nonirradiated recipient mice conditioned with costimulation blockade and mammalian target of rapamycin inhibition. The mode of action responsible for this Treg effect is poorly understood but may encompass the control of costimulation blockade-resistant natural killer (NK) cells. We show that transient NK cell depletion at the time of BM transplantation led to BM engraftment and persistent chimerism without Treg transfer but failed to induce skin graft tolerance. In contrast, the permanent absence of anti-donor NK reactivity in mice grafted with F1 BM was associated with both chimerism and tolerance comparable to Treg therapy, implying that NK cell tolerization is a critical mechanism of Treg therapy. Indeed, NK cells of Treg-treated BM recipients reshaped their receptor repertoire in the presence of donor MHC in a manner suggesting attenuated donor reactivity. These results indicate that adoptively transferred Tregs prevent BM rejection, at least in part, by suppressing NK cells and promote tolerance by regulating the appearance of NK cells expressing activating receptors to donor class I MHC.

The Immunosuppressive Effect of CTLA4 Immunoglobulin Is Dependent on Regulatory T Cells at Low But Not High Doses

B7.1/2-targeted costimulation blockade (CTLA4 immunoglobulin [CTLA4-Ig]) is available for immunosuppression after kidney transplantation, but its potentially detrimental impact on regulatory T cells (Tregs) is of concern. We investigated the effects of CTLA4-Ig monotherapy in a fully mismatched heart transplant model (BALB/c onto C57BL/6). CTLA4-Ig was injected chronically (on days 0, 4, 14, and 28 and every 4 weeks thereafter) in dosing regimens paralleling clinical use, shown per mouse: low dose (LD), 0.25 mg (≈10 mg/kg body weight); high dose (HD), 1.25 mg (≈50 mg/kg body weight); and very high dose (VHD), 6.25 mg (≈250 mg/kg body weight). Chronic CTLA4-Ig therapy showed dose-dependent efficacy, with the LD regimen prolonging graft survival and with the HD and VHD regimens leading to >95% long-term graft survival and preserved histology. CTLA4-Ig's effect was immunosuppressive rather than tolerogenic because treatment cessation after ≈3 mo led to rejection. FoxP3-positive Tregs were reduced in naïve mice to a similar degree, independent of the CTLA4-Ig dose, but recovered to normal values in heart recipients under chronic CTLA4-Ig therapy. Treg depletion (anti-CD25) resulted in an impaired outcome under LD therapy but had no detectable effect under HD therapy. Consequently, the immunosuppressive effect of partially effective LD CTLA4-Ig therapy is impaired when Tregs are removed, whereas CTLA4-Ig monotherapy at higher doses effectively maintains graft survival independent of Tregs.

Optimized methods for extracting circulating small RNAs from long-term stored equine samples

Circulating miRNAs in body fluids, particularly serum, are promising candidates for future routine biomarker profiling in various pathologic conditions in human and veterinary medicine. However, reliable standardized methods for miRNA extraction from equine serum and fresh or archived whole blood are sorely lacking. We systematically compared various miRNA extraction methods from serum and whole blood after short and long-term storage without addition of RNA stabilizing additives prior to freezing. Time of storage at room temperature prior to freezing did not affect miRNA quality in serum. Furthermore, we showed that miRNA of NGS-sufficient quality can be recovered from blood samples after >10 years of storage at −80 °C. This allows retrospective analyses of miRNAs from archived samples.

Interactions between Metopolophium festucae cerealium (Hemiptera: Aphididae) and Barley yellow dwarf virus (BYDV-PAV)

Interactions between an invasive aphid, Metopolophium festucae (Theobald) subsp. cerealium, and Barley yellow dwarf virus (BYDV-PAV) were studied under laboratory conditions. M. festucae cerealium is an economic pest of wheat and barley that has recently been found in high population densities in wheat in the Pacific Northwest of the United States. BYDV-PAV is the most prevalent and injurious species of BYDV worldwide and in the Pacific Northwest. Although M. festucae sensu stricto (Theobald 1917) has been reported previously as a vector of some BYDV isolates, there is no confirmed transmission of BYDV by M. festucae cerealium. Two experiments examined the ability of M. festucae cerealium to transmit BYDV-PAV. The first used single aphids caged to indicator plants of a BYDV-susceptible winter wheat cultivar and the second used multiple aphids on each test plant. M. festucae cerealium did not transmit BYDV-PAV in either experiment, whereas transmission by a known BYDV vector, Rhopalosiphum padi L., was consistently high (≥ 93%). A third experiment compared the intrinsic growth rate, days until first reproduction and daily reproduction by M. festucae cerealium on sham-inoculated and BYDV-PAV-infected wheat, but detected no differences. The findings are reviewed in light published data on M. festucae species, BYDV transmission, and the potential pest status of this new invading aphid.

Lung Sealing with the Sandwich-Technique: A New Surgical Method to Deal with the Emphysematous Lung

The persistent air leak is a common and sometimes difficult to manage complication after major pulmonary resections. Especially in cases with lung emphysema spontaneous sealing of the lung surface under conservative therapy can be prolonged or even fail and a reoperation to close the damaged visceral pleura might be necessary. An ideal surgical solution to deal with this problem is not known, all of the techniques have advantages but also limitations and additional operations should be avoided in this group of frail patients. In this paper a new surgical method to seal the lung surface is presented based on two exemplary cases and our clinical experience. Basically, two stripes of fleece bounded fibrin based sealant are put on the visceral pleura parallel to the wound, which will be then closed by multiple stitches of absorbable suture line inserted through the stripes. Afterwards, a second layer of the same sealant will be placed over it to cover the suture with a narrow overlapping in all directions to the adjacent visceral pleura (Sandwich-Technique). In our experience, this technique can be used to successfully prevent or treat persistent air leaks especially in patients with lung emphysema in whom otherwise treatment options are limited.

ABBREVIATIONS

VATS = video-assisted thoracoscopic surgery POD = postoperative day LVRS = lung volume reduction surgery FEV1 = forced expiratory volume in the first second DLCO = diffusing capacity of the lung for carbon monoxide.

Outcomes for split-thickness skin transplantation in high-risk patients using octenidine

Skin transplantation is a commonly used surgical technique; however, the complication rate, including postoperative infection and delayed wound healing due to inefficient perfusion, is significantly higher in patients suffering from comorbidities. Hence, a subsequent repeat procedure is often necessary. In this report, two case studies are presented in which an octenidine-based antiseptic is used with a tie-over dressing (TOD) instead of povidone iodine (PVP-iodine), following a split-thickness skin graft. The two patients selected were deemed to be at high risk of impaired wound healing due to comorbidities. The first patient, a confirmed smoker with diabetes, presented with a nodular melanoma that was resected and covered with a split-thickness skin graft. After 5 days of negative pressure wound therapy as a TOD, in combination with PVP-iodine, the graft became necrotic. A second split-thickness skin graft was performed and an antiseptic regimen with octenidine in combination with the same TOD resulted in a completely healed transplant. The second patient, also a confirmed smoker with diabetes and receiving oral corticosteroid treatment, was diagnosed with a skin necrosis on her leg. Following the split-thickness skin graft, octenidine and TOD were applied. The patient's skin graft completely healed without any adverse events. These two case studies indicate that the combination of octenidine and TOD following split-thickness skin transplantation is safe, well-tolerated and appears to have positive benefits in the reconstruction of defects in patients with impaired wound healing.

An outbreak of Arthroderma vanbreuseghemii dermatophytosis at a veterinary school associated with an infected horse

We report a case of an outbreak of inflammatory dermatophytoses caused by Arthroderma vanbreuseghemii (formally Trichophyton mentagrophytes pro parte) that involved an infected horse, the owner and at least 20 students, staff and stablemen at a veterinary school in Bern (Switzerland) that presented highly inflammatory dermatitis of the body and the face. Transmission from human to human was also recorded as one patient was the partner of an infected person. Both the phenotypic characteristics and ITS sequence of the dermatophytes isolated from the horse and patients were identical, consistent with the conclusion that the fungus originated from the horse. Three infected persons had not been in direct contact with the horse. Although direct transmission from human to human cannot be ruled out, fomites were most likely the source of infection for these three patients. Inspection of the literature at the end of the nineteenth and beginning of the twentieth century revealed that this dermatophyte was frequently transmitted from horses to humans in contact with horses (stablemen, coachmen, carters and artillery soldiers). The rarity of the present case report at the present time is likely related to the transformation of civilisation from the nineteenth century to nowadays in Europe with the change of horse husbandry. In addition, the inadequate immune response of the horse and the high number of people in contact with it at the equine clinic may explain the exceptional aspect of this case report.

Nodular epitheloid sarcoma of the upper limb. A case report and review of the literature

Epitheloid sarcoma is a rare malignant soft tissue sarcoma. We present a 36-year-old male patient with a primary tumour on his wrist and subcutaneous spread in a sporotrichoid pattern along the upper extremity. Early surgical treatment with micrographic control of all margins provides best long term outcome as long as a solitary lesion is present. In case of cutaneous and internal spread of the disease treatment options are only palliative. Early diagnosis, therefore, is most crucial.

[Leg discoloration]

Many patients present with discolouration of the legs or with non-ulcerating skin lesions, the most frequent causes being chronic venous insufficiency or other chronic or acute states of congestion. Erysipelas (cellulitis) is also a frequent example of a bacterial skin infection. A complex differential diagnosis arises from all types of immune-mediated skin lesions, opening up the broad spectrum of inflammatory systemic disease, such as vasculitis and sarcoidosis. Livedo like lesions and skin involvement in borreliosis are challenging to classify but of considerable clinical importance. The present review focuses on the description of underlying diseases as well as on diagnosis and differential diagnosis. Therapeutic considerations are discussed in less detail.

[Foot lesions]

The foot is the target organ of a variety of internal diseases. Of upmost importance is the diabetic foot syndrome (DFS). Its complex pathophysiology is driven by the diabetic neuropathy, a vastly worsening effect is contributed by infection and ischemia. Seemingly localised lesions have the potential for phlegmone and septicaemia if not diagnosed and drained early. The acral lesions of peripheral artery occlusive disease (PAOD) have unique features as well. However, their life-threatening potential is lower than that of DFS even if the limb is critical. Notably, isolated foot lesions with a mere venous cause may arise from insufficient perforator veins; the accompanying areas of haemosiderosis will lead the diagnostic path. Cholesterol embolization (blue toe syndrome, trash foot) elicits a unique clinical picture and will become more frequent with increasing numbers of catheter-based procedures. Finally, descriptions are given of podagra and of foot mycosis as disease entities not linked to perfusion. The present review focuses on the depiction of disease and its diagnosis, leaving therapeutic considerations untouched.

Clinical outcomes and safety of rituximab treatment for patients with systemic lupus erythematosus (SLE) - results from a nationwide cohort in Germany (GRAID)

OBJECTIVE

The objective of this article is to evaluate the safety and clinical outcome of rituximab treatment in systemic lupus erythematosus (SLE) patients refractory to standard of care therapy in a real-life setting in Germany.

METHODS

The GRAID registry included patients with different autoimmune diseases who were given off-label treatment with rituximab. Data on safety and clinical response were collected retrospectively. In SLE patients, clinical parameters included tender and swollen joint counts, fatigue, myalgia, general wellbeing, Raynaud's and the SLEDAI index. Laboratory tests included dsDNA antibody titres, complement factors, hematologic parameters and proteinuria. Finally, the investigators rated their patients as non-, partial or complete responders based on clinical grounds.

RESULTS

Data from 85 SLE patients were collected, 69 female and 16 male, with a mean disease duration of 9.8 years. The mean follow-up period was 9.6 ± 7.4 months, resulting in 66.8 patient years of observation. A complete response was reported in 37 patients (46.8%), partial response in 27 (34.2%), no response in 15 (19.0%). On average, major clinical as well as laboratory efficacy parameters improved substantially, with the SLEDAI decreasing significantly from 12.2 to 3.3 points. Concerning safety, one infusion reaction leading to discontinuation of treatment occurred. Infections were reported with a rate of 19.5 (including six severe infections) per 100 patient years.

CONCLUSION

With the restrictions of a retrospective data collection, the results of this study confirm data of other registries, which suggest a favourable benefit-risk ratio of rituximab in patients with treatment-refractory SLE.

Hypoglycin A concentrations in seeds of Acer pseudoplatanus trees growing on atypical myopathy-affected and control pastures

Background

Hypoglycin A, found in seeds of Acer negundo, appears to cause seasonal pasture myopathy (SPM) in North America and is implicated in atypical myopathy (AM) in Europe. Acer negundo is uncommon in Europe. Thus, the potential source of hypoglycin A in Europe is unknown.

Hypothesis and Objectives

We hypothesized that seeds of Acer pseudoplatanus were the source of hypoglycin A in Europe. Our objective was to determine the concentration of hypoglycin A in seeds of A. pseudoplatanus trees located in pastures where previous cases of AM had occurred.

Animals

None.

Methods

University of Berne records were searched to retrospectively identify 6 farms with 10 AM cases and 11 suspected AM deaths between 2007 and 2011. During October 2012, A. pseudoplatanus seeds were collected from 2 to 6 trees per pasture on 6 AM farms (7 pastures) from trees in or close to 2 pastures on 2 control farms where AM had not been previously reported. Hypoglycin A in seeds was analyzed by GC–MS.

Results

Acer pseudoplatanus trees were identified on all AM pastures. Hypoglycin A was detected in all A. pseudoplatanus seeds in highly variable concentrations ranging from 0.04 to 2.81 μg/mg (mean 0.69) on AM farms and 0.10 to 9.12 μg/mg (mean 1.59) on control farms.

Conclusion and Clinical Importance

Preventing horses from grazing pastures containing A. pseudoplatanus seeds during late fall and early spring might be the best means to prevent AM.

[Leg pain]

Leg pain is a very common complaint in clinical medicine which deserves thorough investigation. All tissues of the lower leg are able to cause pain, each of them by different pathomechanisms. In the current review, all the different types of tissue, i.e., spine, neural plexus, peripheral nerves, muscles, and vasculature, are systematically covered. The different disease entities are explained in terms of pathophysiology and clinical picture. Diagnostic measures and pathways are sketched, as well as therapeutic approaches in some instances. Diseases of the bone and joint are omitted since they are the subject of orthopedic surgery.

Evaluation of the conjunctival fungal flora and its susceptibility to antifungal agents in healthy horses in Switzerland

OBJECTIVE

To characterize the conjunctival fungal flora and to determine the susceptibility of 2 isolated molds to antifungal drugs in samples of 64 healthy horses from The National Stud in Switzerland.

PROCEDURE

Conjunctival cytobrush samples were collected from both eyes of 64 ophthalmologically normal horses in August 2012 and subsequently cultured on Sabouraud's agar medium. Growing fungi were identified and counted. Etests or broth microdilution tests for Aspergillus fumigatus and Eurotium amstelodami were carried out to determine antifungal drug sensitivity. These species had previously been detected in samples from eyes with keratomycosis in Switzerland. Minimal inhibitory concentrations (MICs) for voriconazole, fluconazole, itraconazole, amphotericin B, and miconazole were recorded.

RESULTS

Fifty-nine of the horses were tested positive for fungal growth from at least one eye (92%). Eleven genera of fungi were identified. The most common fungal genera were Alternaria, Eurotium, Rhizopus, and Cladosporium. Aspergillus spp. and Penicillium spp. were isolated frequently, while no Fusarium spp. was found. In only 2 cases, yeasts were identified as Candida guilliermondii. For certain fungal species, the type of bedding and housing appeared to influence their prevalence. Susceptibility testing of A. fumigatus showed lowest MICs for voriconazole, E. amstelodami for voriconazole and itraconazole. High MICs for fluconazole were detected for all tested fungi while MICs for amphotericin B and miconazole were variable.

CONCLUSIONS

A large range of fungal mold species was identified including A. fumigatus and E. amstelodami, which have been causative agents of keratomycosis in Switzerland. Best in vitro susceptibility results for these two species were obtained for voriconazole.

European outbreaks of atypical myopathy in grazing equids (2006-2009): spatiotemporal distribution, history and clinical features

REASONS FOR PERFORMING STUDY

Improved understanding of the epidemiology of atypical myopathy (AM) will help to define the environmental factors that permit or support the causal agent(s) to exert toxicity.

OBJECTIVES

This European survey of AM aimed to describe spatiotemporal distribution, survival, clinical signs, circumstances in which AM develops and its different expressions between countries and over time.

METHODS

The spatiotemporal distribution, history and clinical features of AM cases reported to the Atypical Myopathy Alert Group from 2006 to 2009 were described. Comparisons of data from the most severely affected countries and from the large outbreaks were made with Fisher's exact and Welch's tests with Bonferroni correction.

RESULTS

Of 600 suspected cases, 354 met the diagnostic criteria for confirmed or highly probable AM. The largest outbreaks occurred during the autumns of 2006 and 2009 in Belgium, France and Germany. For the first time, donkeys, zebras and old horses were affected, and clinical signs such as gastrointestinal impaction, diarrhoea, penile prolapse, buccal ulceration and renal dysfunction were observed. Affected horses spent >6 h/day on pastures that almost always contained or were surrounded by trees. The latency period was estimated at up to 4 days. Overall survival rate was 26%. Although differences between countries in affected breeds, body condition, horse management and pasture characteristics were recognised, the common presenting clinical signs and mortality were similar between countries.

CONCLUSIONS AND POTENTIAL RELEVANCE

This study describes new data on case details, history and clinical course of AM that is of preventive, diagnostic and therapeutic value. However, the true impact of the findings of this study on the development of or severity of AM should be tested with case-control studies.

European outbreaks of atypical myopathy in grazing horses (2006-2009): determination of indicators for risk and prognostic factors

REASONS FOR PERFORMING STUDY

Appropriate management of atypical myopathy (AM) requires the establishment of an accurate diagnosis and prognosis. Furthermore, preventive measures to avoid AM need to be refined.

OBJECTIVES

The aims of the study were as follows: 1) to improve the diagnosis of AM; 2) to identify prognostic predictors; and 3) to refine recommended preventive measures based on indicators of risk factors.

METHODS

An exploratory analysis of cases in Europe between 2006 and 2009 reported to the Atypical Myopathy Alert Group was conducted. Based on clinical data, reported cases were allocated into 2 groups: confirmed or highly probable AM (AM group; further divided into survivors and nonsurvivors); and cases with a low probability of having AM or with another final diagnosis (non-AM group). Using Welch's test and odds ratios corrected for multiple comparisons, the AM vs. non-AM groups were compared to identify indicators for diagnosis and risk factors, and survivors vs. nonsurvivors in the AM group were compared to identify prognostic factors. Sensitivity, specificity and positive and negative predictive values were calculated for specific clinical signs related to final diagnosis and outcome.

RESULTS

From 600 reported cases, 354 AM cases (survival rate of 26%) and 69 non-AM cases were identified, while there were insufficient data to categorise the remainder. Variables valuable for diagnosing AM compared with similar diseases were as follows: presence of dead leaves and wood and/or trees on pastures; sloping pastures; full-time pasture access; no food supplementation; normal body condition; pigmenturia; normothermia; and congested mucous membranes. Nonsurvival was associated with recumbency, sweating, anorexia, dyspnoea, tachypnoea and/or tachycardia. Survival was associated with remaining standing most of the time, normothermia, normal mucous membranes, defaecation and vitamin and antioxidant therapy.

CONCLUSIONS AND POTENTIAL RELEVANCE

This study refines the list of risk factors for AM. Clinical signs valuable for diagnosis and prognosis have been identified, enabling clinicians to improve management of AM cases.