Clinical Characteristics of EGPA Patients in Comparison to GPA Subgroup with Increased Blood Eosinophilia from POLVAS Registry

Objective

To characterize the eosinophilic granulomatosis with polyangiitis (EGPA) population from the POLVAS registry depending on ANCA status and diagnosis onset, including their comparison with the granulomatosis with polyangiitis (GPA) subset with elevated blood eosinophilia (min. 400/μl) (GPA HE) to develop a differentiating strategy.

Methods

A retrospective analysis of the POLVAS registry.

Results

The EGPA group comprised 111 patients. The ANCA-positive subset (n = 45 [40.54%]) did not differ from the ANCA-negative one in clinics. Nevertheless, cardiovascular manifestations were more common in ANCA-negative patients than in those with anti-myeloperoxidase (MPO) antibodies (46.97% vs. 26.92%, p = 0.045). Patients diagnosed before 2012 (n = 70 [63.06%]) were younger (median 41 vs. 49 years, p  < 0.01), had higher blood eosinophilia at diagnosis (median 4,946 vs. 3,200/μl, p  < 0.01), and more often ear/nose/throat (ENT) and cardiovascular involvement. GPA HE comprised 42 (13.00%) out of 323 GPA cases with reported blood eosinophil count. Both GPA subsets had a lower prevalence of respiratory, cardiovascular, and neurologic manifestations but more often renal and ocular involvement than EGPA. EGPA also had cutaneous and gastrointestinal signs more often than GPA with normal blood eosinophilia (GPA NE) but not GPA HE. The model differentiating EGPA from GPA HE, using ANCA status and clinical manifestations, had an AUC of 0.92, sensitivity of 96%, and specificity of 95%.

Conclusion

Cardiovascular symptoms were more prevalent in the ANCA-negative subset than in the MPO-ANCA-positive one. Since EGPA and GPE HE share similarities in clinics, diagnostic misleading may result in an inappropriate therapeutic approach. Further studies are needed to optimize their differentiation and tailored therapy, including biologics.

Cervical cancer rates in relation to the Roma population distribution in Slovakia in 2013 – 2020

Background

Globally, more than 300 000 women die due to cervical cancer (CC) each year despite its high preventability and treatability in its early stages. This study aimed to analyse CC rates at the regional level in Slovakia from 2013 to 2020 in relation to the distribution of the Roma population.

Methods

An ecological study was conducted using data obtained from the relevant national and regional authorities in Slovakia. Mortality, incidence, precancerous lesions incidence and the number of colposcopy and oncocytology examinations per 100 000 females 15 years and older were calculated. Linear regression models were performed in the R Project to assess associations between the rates and the estimated percentage of the Roma population at the regional level after adjusting for the unemployment, at-risk-of-poverty rate, and average disposable household income per month.

Results

CC mortality in Slovakia declined from 10.0 in 2013 to 7.1/100 000 in 2020 (p &lt; 0.05). Average mortality ranged from 5.9 in the Presov region to 10.7 in Kosice. Incidence varied from 108 in 2019 to 160/100 000 in 2017, with the highest average rates in Bratislava and the lowest in Banska Bystrica (194 and 89/100 000). Precancerous lesions incidence rates significantly differed between the regions (400 in Kosice, 984/100 000 in Trnava). The average colposcopy and oncocytology examinations rates were found to be lower in Presov (177 and 226) and Kosice (166 and 223) compared to the other regions (318 and 283/100 000 on average). After adjusting for the selected factors, CC mortality (p &lt; 0.05), incidence (p &lt; 0.05) and both preventive examination rates (p &lt; 0.01) were statistically significantly associated with the percentage of the Roma population.

Conclusions

Substantial differences in CC rates and preventive examinations were identified at the regional level in Slovakia. To eliminate CC in line with the WHO Global Strategy, suitable approaches to reaching those at the highest risk should be implemented.

Key messages

• Substantial regional differences in preventive examination and cervical cancer incidence and mortality rates were identified in Slovakia in relation to the distribution of the Roma population.

• Strategies to eliminate cervical cancer should be adjusted to the regional differences and seek alternative approaches for implementing screening in hard-to-reach communities at the highest risk.

Associations of pre-existing comorbidities and COVID-19 in-hospital mortality: an unCoVer analyses

Background

Accumulated evidence on risk factors for adverse COVID-19 outcomes revealed that old age and male sex are main associates, next to pre-existing comorbidities, as analysed from scattered single cohorts of hospitalised COVID-19 patients of accessible electronic medical records. Hence, evidence from federated analyses is called for to provide a more comprehensive and robust analyses of risk factors.

Methods

Using the unCoVer network, i.e., a research platform of 29 partners for the expert use of patient data as routinely gathered in real-world healthcare settings, present analyses restricted to available data of four hospitals from Spain, Slovakia, Romania and Bosnia and Herzegovina covering 8,287 hospitalised COVID-19 patients. In-hospital death after COVID-19 diagnosis was examined in relation to common pre-existing comorbidities using virtual pooling of logistic regression models adjusted for age and sex.

Results

Patients were on average 60.1 (± 20.9) years, 50.7% were male, almost half (43.3%) had at least one pre-existing comorbidity (17.4% having obesity, 21.9% hypertension, 18.0% diabetes and 13.7% cardiovascular diseases (CVD)), and 12.6% died during hospitalisation. Patients with comorbidities had a higher risk of mortality that was increasing with the number of comorbidities: from a virtual pooled odds ratio of 1.16 (95%CI: 0.96, 1.40) for one vs none to 1.30 (1.04, 1.64) and 2.14 (1.64, 2.79) for two and three or more comorbidities, respectively. Of the comorbidities, highest risk was seen for CVD (1.68; 1.40, 2.01), followed by hypertension (1.40; 1.19, 1.64) and diabetes (1.27; 1.07, 1.50), and the lowest for obesity (1.13; 0.94, 1.37).

Conclusions

By federated analyses, this study confirmed that the number of comorbidities was a strong risk factor for in-hospital death after COVID-19, in particular CVD. The unCoVer platform pursues using scattered data sources by innovative computational resources and integrated information for enhanced impact.

Key messages

Reporting guidelines for burden of disease studies: why and how?

Background

The Disability Adjusted Life Year (DALY) is a frequently used metric to assess burden of disease (BoD). Many independent BoD studies have been performed across Europe, showing wide variations and inconsistencies in the application and reporting of DALY specific methods. The European Burden of Disease Network (burden-eu) aims to develop guidelines for reporting DALY calculation studies which may enhance transparency and comparability of BoD estimates across Europe and beyond.

Methods

A burden-eu working group of experts generated a list of potential reporting items based on existing literature, guidance for developing guidelines and consultations with BoD experts. To pilot the drafted product, we asked BoD experts and non-experts to apply it to existing BoD studies. We received feedback and we revised the guidelines accordingly.

Results

The guide for DALY calculation studies comprises about 25 items that should be reported in BoD studies. We included information about the study setting, data input sources including methods for data corrections, DALY-specific methods (e.g., YLL life table, YLD approach, disability weights etc), data analyses, and data limitations. We also included information on how users can compare their new estimates with previously available BoD estimates.

Conclusions

We introduced a reporting instrument for DALY calculations that can be used to document input data and methodological design choices in BoD studies. The application of such guidelines will enhance usability of BoD estimates for decision-makers as well as global, regional, and national health experts.

Key messages

Disruptions of cytological screening procedures due to the COVID-19 pandemic in Slovakia

Background

During the COVID-19 pandemic, most settings experienced healthcare service disruptions. The majority of cytological screening procedures were postponed to focus on assisting patients infected with COVID-19. In this study, we aimed to analyse the impact of the impact of the COVID-19 pandemic on the uptake of cervical cancer screening in Slovakia.

Methods

Data on cytological screening procedures were obtained from two of the three health insurance companies in Slovakia for the years 2019 and 2020, covering the population of women aged 15 and older. All data were calculated stratified for age groups. Rates of cytological screenings were calculated as the number of procedures per women registered in the insurance company in the same age group and rate ratios were calculated as ratios of the rates for the years 2020 and 2019 for the same age group. Incidence rates were calculated as the number of newly diagnosed cervical cancer cases per women registered in the insurance company in the respective year.

Results

Rate ratios of cytological screening procedures revealed that in both examined health insurance companies, the rate of cytological exams was lower in 2020 compared to 2019 (0.95 and 0.89). This was observed across all age groups. The results showed a clear and statistically significant age gradient, indicating that the level of disruption increased with age. The age group 60-69 years had the highest incidence rate of cervical cancer in 2019, at 54.3 per 100 000. In 2020, the highest rate was 48.3 in the age group 50-59 years. The lowest rates were in children and young adults (&lt;20 years).

Conclusions

This study confirms the significant impact of the pandemic on cervical cancer screening uptake in Slovakia, which may have delayed the diagnosis of cervical cancer into later stages of the disease with a worse prognosis. This may lead to increased mortality and years lived with disability due to this disease in Slovakia.

Key messages

• Disruptions in cervical cancer screenings were observed in Slovakia during the COVID-19 pandemic which may result in an increase in cervical cancer incidence and mortality.

• Strategies should be implemented to maintain cancer screening programs during health emergencies to avoid excessive mortality and morbidity.

Serum Calprotectin – a NET Product – as a Biomarker of Disease Activity in Patients with Systemic Lupus Erythematosus: A Single-Center Case-Control Study from Poland

Background

Calprotectin (S100A8/A9 or myeloid-related protein 8/14) is a heterodimeric S100 complex expressed in leukocytes. Calprotectin participates in development of the inflammatory response by binding to receptors for advanced glycation end-products (RAGE) and Toll-like receptors (TLR). The clinical activity of systemic lupus erythematosus (SLE) is evaluated using the Systemic Lupus International Collaborating Clinics (SLICC) criteria and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). This Polish single-center case-control study aimed to evaluate serum levels of calprotectin as a rapid diagnostic biomarker of SLE (59 patients with SLE were compared with 52 healthy controls).

Material/Methods

Calprotectin concentration was measured with the use of enzyme-linked immunosorbent assay (ELISA). The SLE activity of the patients was assessed by the SLEDAI scale. Statistical analysis of the results was carried out using MedCalc 15.8 software. P<0.05 was considered statistically significant.

Results

A significantly higher concentration of calprotectin was found in the study group compared to the control group (medians: 3.11 vs 2.45 ng/ml; P=0.0013). We found that calprotectin has high sensitivity (89.83%) and specificity (53.85%) in differentiating between SLE patients and healthy volunteers. We found that calprotectin has very high sensitivity (100%) and specificity (82.46%) in detection of patients with moderate and severe SLE assessed using SLEDAI.

Conclusions

Consistent with previous studies, serum calprotectin level was revealed to have potential as a rapid diagnostic biomarker of disease activity in patients with SLE.

POS0253 PERSONALIZED RISK EVALUATION FOR OUTCOME PREDICTION IN ANCA ASSOCIATED VASCULITIS (AAV) USING LATENT CLASS ANALYSIS AND MACHINE LEARNING

Background

ANCA associated vasculitides (AAV) are a heterogeneous group of rare diseases with unknown etiology. In the most severe cases AAV can lead to end stage kidney disease or death. Since etiology and detailed pathogenesis of AAV is not known, the prediction of disease outcome at the time of diagnosis is challenging. Thus, there is an unmet need for tools to identify patients with the highest risk of organ dysfunction and death and apply effective personalized therapy.

Objectives

The aim of this work was to search for tools allowing outcome prediction at the time of AAV diagnosis. Early identification of patients, who are likely to develop severe organ dysfunction and death is crucial for appropriate disease management. Induction therapy in AAV relays on immunosuppressive drugs characterized by a high risk of severe side effects. Thus, their administration in high doses should be limited only to individual patients with an especially high risk of poor outcome.

Methods

We applied here two methods of identification of AAV patients at risk to develop severe organ dysfunction and death. First method (latent class analysis [LCA] followed by logistic regression) was meant to subcategorize patients and identify a subgroup at subjects at risk to develop chronic renal replacement therapy (CRRT) and death [1]. Second, served to assess individual poor outcome risk and was based on two machine learning (ML) classifiers, which by analyzing clinical information allow assigning computed risk for CRRT and death in an individual patient allowing to identify subjects with high risk of chronic replacement therapy (CRRT) and death. We have evaluated a number of different approaches to build the ML models (including logistic regression, support vector machines, random forests), and obtained the best results for the gradient boosting algorithm implementation called LightGBM [2]. It works as a sequential ensemble of so-called weak learners (decision trees) finally combined in a one prediction model. Both analyses were based on retrospective data from Polish national AAV registry (POLVAS) [3] including presently 565 GPA and 135 MPA patients. The parameters used were: demographic data and laboratory parameters, specific organ involvement, ANCA specificity and time between selected stages of the disease.

Results

LCA used on our AAV cohort identified four subphenotypes – three already previously proposed - and revealing a fourth clinically relevant subphenotype. This new subphenotype includes only GPA patients, usually diagnosed at a younger age as compared to other groups, and characterized by multiorgan involvement, high relapse rate, relatively high risk of death, but no end-stage kidney disease. Logistic regression analysis revealed significant differences in the risk of CRRT and death between those subphenotypes – the worst prognosis was found for severe MPO AAV. On the other hand, using ML approach we obtained an individual prediction model with potentially relevant clinical performance (ROC AUC of 0.85 for CRRT and 0.82 for death).

Conclusion

We consider results obtained encouraging. They may offer a new insight into AAV course based on data available at diagnosis, and create a solid foundation for potential clinical decision support system.

References

[1]Wójcik K et al. Subphenotypes of ANCA-associated vasculitis identified by latent class analysis. Clin Exp Rheumatol. 2021 Mar-Apr;39 Suppl 129(2):62-68.

[2]Ke G, at al. Light GBM: A Highly Efficient Gradient Boosting Decision Tree. Advances in Neural Information Processing Systems 30 (NIPS 2017), pp. 3149-3157.

[3]Wójcik K et al. Clinical characteristics of Polish patients with ANCA-associated vasculitides-retrospective analysis of POLVAS registry. Clin Rheumatol. 2019 Sep;38(9):2553-2563.

Acknowledgements

This work was supported by a grant from Polish National Science Center UMO-2018/31/B/NZ6/03898

Disclosure of Interests

None declared

AB0504 DOES THE PRESENCE OF ANTIPHOSPHOLIPID ANTIBODIES AFFECT THE PROGRESSION OF RENAL FAILURE IN PATIENTS WITH LUPUS NEPHROPATHY? LONG-TERM OBSERVATION

Background

Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder with various clinical manifestations and diverse courses. Lupus nephropathy (LN) is observed in 30-50% of patients with SLE. 10% of patients with LN will develop renal failure (RF). Antiphospholipid antibodies (aPLs) are known for their pro-thrombotic action. According to the literature data, the presence of aPLs can lead to the development of thrombotic microangiopathy and may influence the progression of RF among patients with LN.

Objectives

The study aims to assess the influence of the presence of aPLs on the course and the progression of LN in long-term observation.

Methods

We conducted a retrospective analysis of the medical history of 34 patients (pts) with SLE and confirmed lupus nephropathy who are under the constant, long-term care of a rheumatology center. The kidney function (creatinine, estimated glomerular filtration rate; eGFR) was assessed at the beginning of the observation and after approximately 7-10 years.

The presence of antiphospholipid antibodies (anticardiolipin antibodies IgG or IgM, anti-beta-2-glycoprotein-I antibodies IgG or IgM, lupus anticoagulants) was taken into consideration. The progression of RF was compared between the pts groups with positive and negative aPLs test results.

Results

A total of 34 patients (median age at the end of follow-up was 50 years; range 24-82) were included. The majority of patients were female (88.2%). Of these patients, 8 (23.5%) had a positive tests for aPLs many times in their medical history. Considering the progression of RF among patients with positive aPLs, significant statistical differences were observed (p <0,01). Moreover, a statistically significant effect of aCL (p <0.03) and antibodies directed against anti-beta2 glycoprotein I (p <0.04) on the reduction of eGFR in the course of the disease was observed.

Conclusion

The presence of aPLs is associated with the risk of the deterioration of kidney function in patients with LN. It affects the decrease of eGFR and an increase of the concentration of creatinine in the blood.

References

[1]Morales E., Galindo M. Et al. Update on Lupus Nephritis: looking for a new vision. Nephron 2021;145:1:1h

[2]Zhang J., Zhang Ji., et al. Association of antiphospholipid antibodies with clinical activity and renal pathological activity in patients with lupus nephritis. Lupus. 2021;30(7):1140-1145.

[3]K. Talari, U. Anandh, A. Patric. Lupus Nephritis with Coexistent Antiphospholipid Antibodies Associated Nephropathy: A Case Report and Literature Review. Indian J Nephrol. 2018; 28(2): 164–166.

Disclosure of Interests

Ewa Łyś: None declared, Dorota Suszek: None declared, Maria Majdan Speakers bureau: Medac, Novartis, Sandoz, Consultant of: Sandoz, AstraZeneca

Plasma micro-RNA-22 is associated with disease activity in well-established rheumatoid arthritis

OBJECTIVES

Micro-RNAs (miRNAs) are an endogenous small, single-stranded, non-coding RNAs with a 18-25 nucleotide long and have been reported as potential extracellular biomarkers of various diseases. They mainly decrease the gene expression by inhibiting the translation or cause mRNA destabilisation. The aim of our study was to identify miRNAs whose concentration may be associated with severity of rheumatoid arthritis (RA).

METHODS

A total of 74 unrelated individuals, 50 with RA and 24 in a control group were enrolled to the study. Real-time PCR was used to evaluate the plasma concentration levels of 8 miRNAs: miR-26a, miR-125b, miR-20b, miR-22, miR-221, miR-17, miR-93, miR-106b.

RESULTS

The logistic regression results showed that miR-22 (p=0.0003) and miR-26a (p=0.049) may be the most important molecules distinguishing RA patients and healthy controls. Moreover, the quantity of miR-22 was different between rheumatoid factor (RF)-positive and RF-negative patients (p=0.04).

CONCLUSIONS

In this study we demonstrated for the first time that plasma concentration of miR-22 may be considered as a potential molecular marker associated with disease activity.

Biological impact of iberdomide in patients with active systemic lupus erythematosus

OBJECTIVES

Iberdomide is a high-affinity cereblon ligand that promotes proteasomal degradation of transcription factors Ikaros (IKZF1) and Aiolos (IKZF3). Pharmacodynamics and pharmacokinetics of oral iberdomide were evaluated in a phase 2b study of patients with active systemic lupus erythematosus (SLE).

METHODS

Adults with autoantibody-positive SLE were randomised to placebo (n=83) or once daily iberdomide 0.15 mg (n=42), 0.3 mg (n=82) or 0.45 mg (n=81). Pharmacodynamic changes in whole blood leucocytes were measured by flow cytometry, regulatory T cells (Tregs) by epigenetic assay, plasma cytokines by ultrasensitive cytokine assay and gene expression by Modular Immune Profiling.

RESULTS

Iberdomide exhibited linear pharmacokinetics and dose-dependently modulated leucocytes and cytokines. Compared with placebo at week 24, iberdomide 0.45 mg significantly (p<0.001) reduced B cells, including those expressing CD268 (TNFRSF13C) (-58.3%), and plasmacytoid dendritic cells (-73.9%), and increased Tregs (+104.9%) and interleukin 2 (IL-2) (+144.1%). Clinical efficacy was previously reported in patients with high IKZF3 expression and high type I interferon (IFN) signature at baseline and confirmed here in those with an especially high IFN signature. Iberdomide decreased the type I IFN gene signature only in patients with high expression at baseline (-81.5%; p<0.001) but decreased other gene signatures in all patients.

CONCLUSION

Iberdomide significantly reduced activity of type I IFN and B cell pathways, and increased IL-2 and Tregs, suggesting a selective rebalancing of immune abnormalities in SLE. Clinical efficacy corresponded to reduction of the type I IFN gene signature.

TRIAL REGISTRATION NUMBER

NCT03161483.

Phase 2 Trial of Iberdomide in Systemic Lupus Erythematosus

BACKGROUND

Iberdomide, a cereblon modulator promoting degradation of the transcription factors Ikaros and Aiolos, which affect leukocyte development and autoimmunity, is being evaluated for the treatment of systemic lupus erythematosus (SLE).

METHODS

In this phase 2 trial, we randomly assigned patients in a 2:2:1:2 ratio to receive oral iberdomide (at a dose of 0.45, 0.30, or 0.15 mg) or placebo once daily for 24 weeks, in addition to standard medications. The primary end point at week 24 was a response on the SLE Responder Index (SRI-4), which was defined as a reduction of at least 4 points in the Systemic Lupus Erythematosus Disease Activity Index 2000 score (a 24-item weighted score of lupus activity that ranges from 0 to 105, with higher scores indicating greater disease activity), no new disease activity as measured on the British Isles Lupus Assessment Group 2004 index, and no increase of 0.3 points or more in the Physician's Global Assessment score (on a visual-analogue scale ranging from 0 [no disease activity] to 3 [maximal disease]).

RESULTS

A total of 288 patients received the assigned intervention: 81 received iberdomide at a dose of 0.45 mg, 82 received iberdomide at a dose of 0.30 mg, 42 received iberdomide at a dose of 0.15 mg, and 83 received placebo. At week 24, the percentages of patients with an SRI-4 response were 54% in the iberdomide 0.45-mg group, 40% in the iberdomide 0.30-mg group, 48% in the iberdomide 0.15-mg group, and 35% in the placebo group (adjusted difference between the iberdomide 0.45-mg group and the placebo group, 19.4 percentage points; 95% confidence interval, 4.1 to 33.4; P = 0.01), with no significant differences between the groups that received the lower doses of iberdomide and the group that received placebo. Iberdomide-associated adverse events included urinary tract and upper respiratory tract infections and neutropenia.

CONCLUSIONS

In this 24-week, phase 2 trial involving patients with SLE, iberdomide at a dose of 0.45 mg resulted in a higher percentage of patients with an SRI-4 response than did placebo. Data from larger, longer trials are needed to determine the efficacy and safety of iberdomide in SLE. (Funded by Bristol Myers Squibb; ClinicalTrials.gov number, NCT03161483; EudraCT number, 2016-004574-17.).

AB0820 INFLUENCE OF ANCA ANTIBODIES ON DEMOGRAPHIC AND CLINICAL CHARACTERISTIC OF AAV

Background:

ANCA associated vasculitides (AAV) are a heterogeneous group of rare diseases with unknown etiology and the broad clinical spectrum ranging from life-threatening systemic disease, through single organ involvement to minor isolated skin changes. Unfortunately the clinical classification, ANCA specificity or genetic characteristics alone is not able to categorize AAV patients in a satisfactory manner. As a consequence advanced statistical techniques were used to identify and stratify AAV subphenotypes [1, 2]. Here we have analyzed influence of the ANCA type on clinical manifestations and demographic characteristics in various types of AAV, based on data from the POLVAS registry

Objectives:

We decided to retrospectively analyze a large cohort of Polish AAV patients deriving from several referral centers – members of the Scientific Consortium of the Polish Vasculitis Registry (POLVAS) – and concentrate on demographic and clinical characteristics of anti-PR3 and anti-MPO positive patients regardless of their clinical diagnosis.

Methods:

We conducted a systematic multicenter retrospective study of adult patients diagnosed with AAV between Jan 1990 and Dec 2016. Patients were enrolled by 9 referral centers. We analyzed dichotomous variables: gender; ANCA status – anti-PR3+ or anti-MPO+, ANCA negative; organ involvement - skin, eye, ENT, respiratory, heart, GI, renal, urinary, CNS, peripheral nerves and polytomous variable (number of relapses), supported by quantitative covariates (e.g., age at diagnosis, CRP at diagnosis, maximal serum creatinine concentration ever)[3].

Results:

MPO-positive patients (both GPA and EGPA phenotype) were older at the time of diagnosis with a substantial percentage diagnosed > 65 years of age, and with high rate of renal involvement. Interestingly, while in the whole group of patients diagnosed with EGPA male to female ratio was 1:2, the MPO+ EGPA patients showed M:F ratio of 1:1.

The analysis of ANCA negative AAV reveled significant differences in GPA, ANCA negative group is characterized with significantly lower frequency of renal involvement compared to rest GPA (11,5% vs 63,7%) p<0,05 what should be emphasized ANCA negative AAV never lead to ESRD (end stage renal disease) or even transient dialysis.

Conclusion:

ANCA specificity is indispensable as a separate variable in any clinically relevant analysis of AAV subcategories. MPO+ group is characterized by older age at time of diagnosis, male to female ration 1:1, kidney involvement, and shows more homogenous clinical phenotype than PR3+ AAV patients. In our group ANCA negative AAV never lead to ESRD (end stage renal disease) or even transient dialysis.

References:

[1]Mahr A, Specks U, Jayne D. Subclassifying ANCA-associated vasculitis: a unifying view of disease spectrum. Rheumatol Oxf Engl 2019;58:1707–9. https://doi.org/10.1093/rheumatology/kez148.

[2]Wójcik K, Biedroń G, Wawrzycka-Adamczyk K, Bazan-Socha S, Ćmiel A, Zdrojewski Z et al. Subphenotypes of ANCA-associated vasculitis identified by latent class analysis. Clin Exp Rheumatol. 2020 Sep 1. Epub PMID: 32896241.

[3]Wójcik K, Wawrzycka-Adamczyk K, Włudarczyk A, Sznajd J, Zdrojewski Z, Masiak A, et al. Clinical characteristics of Polish patients with ANCA-associated vasculitides—retrospective analysis of POLVAS registry. Clinical Rheumatology. 1 wrzesień 2019;38(9):2553–63.

Disclosure of Interests:

None declared

AB0800 HEMATOLOGICAL MARKERS OF SYSTEMIC INFLAMMATION IN PATIENTS RHEUMATOID ARTHRITIS (RA) AND SPONDYLOARTHRITIS (SPA)

Background:

An appropriate assessment of disease activity is essential in the management of patients with chronic inflammatory joint diseases, rheumatoid arthritis (RA) and spondyloarthritis (SpA). Hematological parameters [Neutrophil-To-Lymphocyte (NLR), Platelet-To-Lymphocyte (PLR) and Monocyte-To- Lymphocyte (MLR) ratios] have been demonstrated to be good, promising indicators of systemic inflammation status in different diseases, additionally to conventional inflammatory markers [erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)]. However results remain conflicting in rheumatic patients.

Objectives:

The goal of the study was to determine the role of NLR, PLR, MLR in assessing inflammatory disease activity and to compare the biomarkers in RA and SpA patients.

Methods:

An observational study was conducted in patients with RA and SpA (ankylosing spondylitis and psoriatic arthritis) treated in the Department of Rheumatology and Connective Tissue Diseases, Medical University of Lublin, Poland. Demographic and clinical information was obtained through structured interview, review of medical records and laboratory tests. The following disease activity and functional scores were registered: CRP and ESR levels, swollen and tender joints counts (SJC, TJC), DAS28 (ESR), HAQ, BASDAI, BASFI, patient global assessment (PtGA) and physician global assessment (PGA) rated on a visual analogue scale (VAS).

The study group consisted of 95 patients (58 women, 37 men), with the mean (SD) age 45.4 (9.9), disease duration 10.0 (8.4) years. There were 58 (61.1%) patients with RA (44 women, 14 men) and 37 (38.9%) patients with SpA. The mean age and disease duration were statistically not different in both patients’ groups. The mean (SD) DAS28 was 4.21 (1.8) in RA patients; in SpA patients BASDAI 4.9 (2.6) and BASFI 5.0 (2.8).

Results:

In the whole group (95 patients) and in the SpA group, we found positive correlations between the PLR value and the following parameters CRP, ESR; between NLR and CRP, ESR; between MLR and CRP. In the RA group positive correlations were observed between PLR and CRP, ESR; NLR and CRP; MLR did not correlate with CRP and ESR.

In RA patients, there were statistically significant correlations between values of PLR and DAS28 (r=0.356, p=0.006), TJC (r=0.308, p=0.02), SJC (r=0.318, p=0.016), PtGA (r=0.372, p=0.008). No significant correlation was found between NLR, MLR and other disease activity scores.

In SpA patients, we found a significant correlation between NLR and PtGA (r=0.488, p=0.04). No significant correlations were found between NLR, PLR, MLR and BASDAI, BASFI.

The group of RA patients as compared with SpA, was characterized by significantly higher value of PLR [respectively 207.8 (94.0) vs 169.9 (77.7), p=0.04]. In turn, SpA patients compared with RA, were characterized by unfavorable metabolic parameters: higher atherogenic index [respectively 4.03 (0.8) vs 3.57 (1.1), p=0.03], lower HDL-cholesterol [47.4 (10.7) vs 56.1 (16.4) mg/dl (p=0.006); higher serum uric acid [5.6 (1.2) vs 4.5 (1.4) mg/dl (p=0.0001)], higher waist measurement [96.1 (14.2) vs 85.9 (11.5) cm (p=0.0003).

Conclusion:

In our study we found, that in patients with RA, PLR was associated with both clinical and inflammatory markers of disease activity; in SpA patients NLR, PLR and MLR were associated with conventional inflammatory markers (CRP, ESR). Hematological inflammatory biomarkers may reflect disease activity and could represent potential parameters to evaluate disease activity not only in RA, but also in SpA.

Disclosure of Interests:

Bozena Targonska-Stepniak Speakers bureau: Berlin-Chemie/Menarini, KRKA, Medac, Santen, Krzysztof Grzechnik: None declared, Maria Majdan Speakers bureau: Roche, Medac

POS0191 THE VALUE OF MIR-20B, MIR-22, MIR-26A, MIR-125B AND MIR-221 IN RHEUMATOID ARTHRITIS

Background:

Micro-RNAs (miRNAs) are an endogenous small, single-stranded, non-coding RNAs with a 18-25 nucleotide long and have been reported as a potential extracellular biomarkers of various diseases. They mainly decrease the gene expression by inhibiting the translation or cause mRNA destabilization.

Objectives:

The aim of the study was to identify miRNAs whose plasma expression level is associated with RA prevalence and/or activity.

Methods:

A total of 74 unrelated individuals, 50 with RA and 24 in a control group were enrolled to the study. Real-time PCR was used to evaluate the plasma expression levels of 5 miRNAs: miR-20b, miR-22 miR-26a, miR-125b, miR-221.

Results:

We found the differences in four out of five evaluated miRs between RA and HC group – miR-26a, p<0.0001; miR-125b, p <0.0001; miR-20b p<0.0001; miR-22, p=0.005. Graphical presentation of the results is shown in Figure 1. The logistic regression results showed that miR-22 (p=0.0003) and miR-26a (p=0.049) are the most important molecules distinguishing RA patients and healthy controls in the study. MiR-22 was positively correlated with ESR (rs=0.41), CRP (rs=0.49) and DAS28 (rs=0.33) and miR-26a was positively correlated with ESR (rs=0.49), CRP (rs=0.41), number of swelling joints (rs=0.43), number of painful joints (rs=0.74) and DAS28 (rs=0.63). Moreover, miR-22 expression was different between rheumatoid factor (RF) positive and RF negative patients (p=0.04).

Conclusion:

The results showed that miR-22 (p=0.0003) and miR-26a (p=0.049) may be the most useful in evaluated panel of miRs distinguishing RA patients and HCs. In this study we demonstrated for the first time that plasma concentration of miR-22 may be considered as a potential molecular marker of RA exacerbation.

References:

[1]Ouboussad, L., Hunt, L., Hensor, E.M.A. et al. Profiling microRNAs in individuals at risk of progression to rheumatoid arthritis. Arthritis Res Ther 2017 19, 288.

[2]Churov AV, Oleinik EK, Knip M. MicroRNAs in rheumatoid arthritis: altered expression and diagnostic potential. Autoimmun Rev. 2015 14(11):1029-37.

Figure 1.

Diagrams from A to D show the expression levels of miR-22, miR-26a, miR-125b and miR-20b, respectively. The median values of expression have been connected by a line.

Table 1.

Spearman’s rank correlation between micro-RNA-22 and micro-RNA-26 and the clinical variables.

miRs \ clinical variableAgeDisease durationESRCRPSJCTJCDAS-28ACPARFmiR-220.09-0.270.410.490.260.210.330.240.16miR-26a0.20.140.490.410.430.740.630.260.16

The significant correlations were bolded and indicated by red. Abbreviations: ACPA, anti-citrullinated protein antibodies; CRP, C-reactive protein; SJC, swollen joint count; TJC, tender joint count; DAS-28, disease activity score 28; ESR, erythrocyte sedimentation rate; RF, rheumatoid factor.

Disclosure of Interests:

None declared

The prevalence and significance of anti-PM/Scl antibodies in systemic sclerosis

INTRODUCTION

Anti-PM/Scl (a-PM/Scl) antibodies are found in different systemic autoimmune diseases such as polymyositis, dermatomyositis, systemic sclerosis (SSc) and overlap syndromes. According to literature, they are detected in approx. 2% of SSc patients, but their presence is more common in SSc with myositis overlap.

OBJECTIVE

The aim of the study was to assess the prevalence of a-PM/Scl in patients with SSc and to identify differences in the clinical profile of the disease in patients with the presence of a-PM/Scl.

MATERIAL AND METHODS

The study was performed on 126 European Caucasian SSc patients (98 females and 28 males) hospitalized consecutively in the Department of Rheumatology and Connective Tissue Diseases. The study group was analyzed for the potential presence of a-PM/Scl using a commercial test - EUROLINE Systemic Sclerosis Profile. The detection and interpretation were carried out electronically using the specific Euroimmun - EUROLineScan programme. The subtype of SSc, incidence of internal organ involvement and serological profile were determined in the entire group. Due to the presence of a-PM/Scl, patients were divided into two groups: a-PM/Scl (+) SSc - 22 patients and a-PM/Scl (-) SSc - 104 patients.

RESULTS

A-PM/Scl was detected in 22/126 patients with SSc (17.5%). A strong correlation was found between a-PM/Scl and myalgia or myositis (p = 0.0379), hand joints contractures (p = 0.0002) and the prevalence of overlap syndrome (p = 0.0142). There were no relationships between the presence of a-PM/Scl and subtypes of SSc, other organ involvement, digital ulcers or calcinosis.

CONCLUSIONS

Anti-PM/Scl antibodies are fairly common in patients with systemic sclerosis. In SSc, anti-PM/Scl antibodies are frequently associated with myalgia or myositis, hand joint contractures and an overlap syndrome.

Systemic Inflammatory Parameters in Patients with Elderly-Onset Rheumatoid Arthritis (EORA) and Young-Onset Rheumatoid Arthritis (YORA)-An Observational Study

BACKGROUND

Rheumatoid arthritis (RA) occurs more often in elderly individuals. Elderly onset RA (EORA) (onset > 60 years) encompasses a specific subset of patients if compared with young onset RA (YORA) (onset at a younger age). There is a need to define reliable, simple markers to properly assess the inflammatory activity of RA. Hematological markers of systemic inflammation (Platelet-To-Lymphocyte (PLR) and Neutrophil-To-Lymphocyte (NLR) ratios) are novel measures of the inflammatory response. The goal of the study was to analyze the course of EORA vs. YORA patients and to assess associations between systemic and clinical disease activity markers, including PLR and NLR, in different subsets of patients. PLR and NLR have not previously been assessed in EORA and YORA.

METHODS

The study group consisted of 113 consecutive patients (63 EORA and 50 YORA). The following assessments were performed: joint counts, Disease Activity Score (DAS28), complete blood cell counts, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).

RESULTS

EORA was characterized by significantly higher disease activity markers (conventional inflammatory and clinical), a lower rate of remission or low disease activity, and less frequent use of biological drugs and glucocorticoids. The NLR and PLR were positively correlated with disease activity markers. The PLR was significantly lower in EORA compared with in YORA.

CONCLUSION

EORA and YORA patients differed significantly. In EORA, conventional disease activity markers were higher, the PLR was significantly lower.

The value of anti-CarP and anti-PAD4 as markers of rheumatoid arthritis in ACPA/RF negative rheumatoid arthritis patients

Background:

Anti-citrullinated protein antibodies (ACPAs) and rheumatoid factor (RF) are key factors in the American College of Rheumatology/European League Against Rheumatism rheumatoid arthritis (RA) classification criteria markers. However, about 30% of patients diagnosed with RA are seronegative, rationalizing the need for new serologic markers for RA. Antibodies against carbamylated proteins (anti-CarP) and against peptidyl-arginine deiminase type 4 (anti-PAD4) have been postulated to be useful RA markers. The purpose of this study is to evaluate the value of anti-CarP and anti-PAD4 in a well-characterized population of RA patients and healthy controls (HCs).

Methods:

A total of 122 RA patients and 30 HCs were enrolled in the study. Serum levels of ACPA, anti-PAD4, anti-CarP and RF were determined by enzyme-linked immunosorbent immunoassays (ELISAs). Synthetic carbamylated peptides were used in the ELISA assay to determine the protein targets of the anti-CarP antibodies.

Results:

Rates of ACPA, RF, anti-PAD4 and anti-CarP positivity were 85.2%, 67.2%, 55.7% and 46.7% in RA, and 0%, 0%, 6.7% and 6.7% in HC respectively. In the RA population, 25.4% of patients had all four types of antibodies positive, while 6.6% had no antibodies. There was a significant correlation between anti-PAD4 and ACPAs (r_s = 0.39), RF and ACPAs, (r_s = 0.3) and RF and anti-CarP, (r_s = 0.3). There was no correlation between ACPAs and anti-CarP. Anti-CarP positivity was noted in 49 (47.1%) and 45 (54.9%) of ACPAs and RF positive patients respectively. In addition, five anti-CarP+ patients did not have ACPA nor RF.

Conclusion:

Anti-CarP but not anti-PAD4 may be a useful biomarker in identifying ACPA/RF negative RA patients. This antibody may identify an additional RA population who may benefit from early implementation of aggressive therapy.

The presence of particular criteria and noncriteria antiphospholipid antibodies in patients with uterine malignancies

INTRODUCTION

Currently, there have been limited data on the presence of antiphospholipid antibodies (aPLs) in patients with uterine malignancies (UMs).

OBJECTIVES

We aimed to determine whether criteria and noncriteria aPLs are present in patients with UMs and associated with the thrombotic risk, as compared with patients with noncancerous gynecological diseases (NCGDs).

PATIENTS AND METHODS

The study involved 151 women scheduled for gynecological surgery. The patients were divided into the UM group (n = 70) and the NCGD group (n = 81). The Antiphospholipid 10 Dot assay was used to detect criteria and noncriteria aPLs before surgery. The study patients were considered positive for thrombosis if they exhibited signs of thrombosis within the 2‑year follow‑up period after surgery.

RESULTS

Positive results for aPLs were obtained in 17/70 patients with UMs (24.3%) and in 6/81 patients with NCGDs (7.4%) (P = 0.008). Particular noncriteria aPLs (antiphosphatidic acid, antiphosphatidylserine, anti-annexin V, and antiprothrombin antibodies) yet no criteria aPLs (anticardiolipin and anti-β2‑glycoprotein I antibodies) were more frequently found in patients with UMs than in those with NCGDs. Thrombosis was diagnosed in 9/70 patients (12.9%) in the UM group and in 3/81 patients (3.7%) in the NCGD group (P = 0.03).

CONCLUSIONS

Antiphospholipid antibodies were present at significant levels in patients with UMs. Noncriteria aPLs yet no criteria aPLs were more frequently found in patients with UMs than in those with NCGDs. The incidence of thrombosis was significantly higher in patients with UMs.

Unscattering the burden of disease landscape: supporting interaction between existing burden of disease efforts

The burden of disease landscape in Europe is currently scattered with experts from diverse professional backgrounds, ranging from experts in infectious diseases, non-communicable diseases, injuries and risk factors, to experts in more comprehensive national, regional and global burden of disease studies. Currently there is little interaction between these experts and existing burden of disease efforts. The European burden of disease network (burden-eu) COST Action aims to bring together expertise across different domains and professional backgrounds. During the course of the burden-eu COST Action, several steps will be taken to facilitate interaction between existing burden of disease efforts. First, a survey has been sent around to all members of the EU burden of disease network to map burden of disease studies that have been carried out in their country. Apart from general details about the year of the study and cause of disease categories, items of the survey included data sources, methodological approach and collaborations with institutes of other countries. In the first month, the survey has been completed for over 70 studies that have been carried out in twelve countries. Second, comparison of existing burden of disease initiatives allows for the identification of the various domains for which burden of disease has been assessed, highlight methodological differences as well as similarities, and

facilitate improvements and harmonization of methods and approaches. Furthermore, the data collected from the survey will be included in a continuously updated burden of disease database that lists all past and current burden of disease activities. Lastly, burden-eu will facilitate regular meetings and workshops. Each of these steps will make it possible to move beyond the currently scattered burden of disease landscape and increase interaction between professionals and burden of disease efforts.

The Relationship between Hematological Markers of Systemic Inflammation (Neutrophil-To-Lymphocyte, Platelet-To-Lymphocyte, Lymphocyte-To-Monocyte Ratios) and Ultrasound Disease Activity Parameters in Patients with Rheumatoid Arthritis

Background: An accurate measurement of disease activity is essential for the appropriate management of a patient with rheumatoid arthritis (RA). Hematological markers of systemic inflammation (Neutrophil-to-Lymphocyte (NLR), Platelet-to-Lymphocyte (PLR) and Lymphocyte-to-Monocyte (LMR) ratios) are reported to be novel, sensitive measures of inflammatory response, in addition to conventional markers (erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Disease Activity Score (DAS28)). The goal of the study was to assess the relationship of NLR, PLR, and LMR with ultrasonography (US) parameters of disease activity in RA patients. Methods: The study group consisted of 126 consecutive RA patients (100 women, 26 men). The following assessments were performed: joint counts, DAS28, complete blood cell counts, ESR, CRP, and US of 24 small joints. Results: NLR and PLR were significantly positively correlated with all US parameters of disease activity (Grey Scale US, Power Doppler US, and Global scores). The mean values of NLR and PLR were significantly higher in patients with poor prognostic factors: moderate/high vs. low disease activity (NLR: p < 0.001; PLR: p = 0.007), anti-CCP positive vs. anti-CCP negative (NLR: p = 0.01; PLR: p = 0.006). In multiple regression tests, significant correlations were confirmed for: NLR and DAS28 (p = 0.04), and CRP (p = 0.001); PLR and Power Doppler US (p = 0.04), and ESR (p = 0.02). No correlation was found for LMR. Conclusion: NLR and PLR are associated with US disease activity parameters and may serve as reliable, inexpensive markers, with prognostic significance in RA.

Differential approach to peripheral blood cell ratios in patients with systemic lupus erythematosus and various manifestations

New markers of systemic lupus erythematosus (SLE) activity are under investigation. In recent years, the researchers have been focusing increased attention on the role of haematological indicators in assessing the disease activity. Specifically, neutrophil-, basophil-, eosinophil-, monocyte- and platelet-to-lymphocyte ratios (NLR, BLR, ELR, MLR and PLR) have been considered. The specific objective of this study was to determine the suitability of the haematological markers for the assessment of SLE activity and SLE-related organ damage. This study is a retrospective analysis of 136 patients with SLE (124 women and 12 men) who received chloroquine/hydroxychloroquine (HQ/HCQ) monotherapy or HQ/HCQ therapy combined with low/medium doses of glucocorticoid. All patients were assessed for disease activity using the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) scale. In addition, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) inflammatory parameters were determined in each patient. NLR, BLR, ELR, MLR and PLR were evaluated and correlated with the SLE activity parameters and inflammatory markers. The mean values of the haematological indicators were compared in particular manifestations of SLE-induced organ damage. For numerical variables, descriptive statistics were calculated: median, standard deviation, minimum and maximum values. The Mann–Whitney U test was used for the comparison of continuous variables in the two groups. The Spearman rank correlation test was used to search for any relationships between variables. A p value < 0.05 was considered to be statistically significant. We have found a positive correlation between ELR, MLR and the SLEDAI scale (r = 0.22 and r = 0.27, respectively). NLR, MLR and PLR ratios were significantly correlated with ESR and CRP. Considerably higher NLR values were found in patients with cutaneous and/or mucosal symptoms and with kidney involvement compared to patients without such involvement (4.26 ± 4.2 vs 3.27 ± 2.7; p = 0.05 and 5.45 ± 5.6 vs 3.05 ± 2.0; p < 0.001 respectively). BLR and MLR were significantly higher in patients manifesting symptoms of vasculitis (0.09 ± 0.1 vs 0.02 ± 0.01; p < 0.001 and 3.1 ± 4.2 vs 0.3 ± 0.1; p < 0.001 respectively), arthritis and/or myositis (0.04 ± 0.09 vs 0.02 ± 0.01; p = 0.01 and 1.02 ± 2.6 vs 0.35 ± 0.4; p = 0.01 respectively), whereas elevated ELR ratios were observed in patients with vasculitis (0.4 ± 0.5 vs 0.08 ± 0.06; p < 0.001) compared to patients without such organ involvement. The PLR marker was substantially higher in patients exhibiting haematological disorders in the course of SLE (276.6 ± 226.4 vs 192.6 ± 133.5; p = 0.01). The results indicate that ELR and MLR are effective markers of SLE activity. The haematological indicators may predict SLE-dependent organ damage, particularly cutaneous, mucosal, arthritic, myositic, haematological and kidney involvement.

Peptidyl Arginine Deiminase Type 4 Gene Promoter Hypo-Methylation in Rheumatoid Arthritis

Protein citrullination is carried out by peptidylarginine deiminase type 4 (PAD4) enzyme. As a consequence of this process, post-translationally modified proteins are formed that become antigens for anti-citrullinated protein antibodies (ACPA). The study aimed at identifying whether the PADI4 gene is subject to epigenetic regulation through methylation of its promoter region, whether the degree of methylation differs in healthy individuals vs. rheumatoid arthritis (RA) patients and changes in correlation with ACPA, anti-PAD4 and disease activity. A total of 125 RA patients and 30 healthy controls were enrolled. Quantitative real-time methylation-specific PCR was used to analyze the methylation status. ACPA and anti-PAD4 antibodies were determined in serum by enzyme-linked immunosorbent immunoassay. The differences were observed in the degree of PADI4 gene promoter methylation between RA patients and HC, along with an upward trend for the methylation in RA, which was inversely proportional to the disease activity. A weak or modest negative correlation between the degree of PADI4 gene methylation and anti-PAD4, disease activity score (DAS28) and ACPA level has been found. The elevated methylation is associated with lower disease activity, lower levels of ACPA and aPAD4. The methylation degree in this area is growing up during effective treatment and might play a role in the RA pathophysiology and therefore could be a future therapeutic target.

Hypermethylation of the miR-155 gene in the whole blood and decreased plasma level of miR-155 in rheumatoid arthritis

Objectives

miR-155 plays a critical role in the inflammatory process and in diseases such as rheumatoid arthritis (RA). miR155 gene expression is regulated by its gene promoter region CpG island methylation. Previous studies have shown inconsistent changes in circulating levels of mir-155 in RA patients. The aims of our study were to evaluate miR-155 levels in plasma, to investigate its gene methylation level, and to correlate these levels with RA disease activity.

Methods

One hundred and twenty-five patients with RA, and 30 age and sex-matched healthy controls (HC) were enrolled. Whole blood and plasma samples were collected and stored at -80°C until analysis. DAS28 score at the time of the blood draw was used to assess RA disease activity. The methylation status of miR-155 host gene was determined in whole blood by quantitative real-time methylation-specific PCR (qPCR). miR-155 expression levels were evaluated by quantitative reverse transcription PCR.

Results

We found significantly lower circulating miR155 levels in RA patients compared to HC. Interestingly, the miR-155 gene methylation level was significantly higher in RA patients than in HC. miR-155 levels did not correlate with ACPA or RF positivity or disease activity.

Conclusions

We show here higher miR-155 methylation in whole blood and lower plasma miR155 expression in RA patients in comparison to HC. The evaluation of miR-155 host gene methylation status or miR155 plasma level might be a potentially useful marker in RA determination.

AB0096 FCER1G GENE METHYLATION AND MIR-106/MIR-17 AS A NEW POTENTIAL EPIGENETIC MARKERS IN RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory disease that leads to joints destruction. One of the most important cytokine responsible for this process is interleukin 6 (IL-6). Fc receptor gamma chain (FcRγ), encoded byFCER1Ggene, is responsible for neutrophils activation, phagocytosis, cell surface signaling pathway as well as IL-4, IL-6, IL-10 and tumor necrosis factor production. Epigenetic factors, including DNA methylation and micro-RNAs (miRs) expression regulate the genes expression on transcriptional and post-transcriptional mechanisms. There are miRs responsible for cytokines production, for example GU rich miRs, miR-106b and miR-155 were reported as associated with IL-6 overproduction.

Objectives:

The aim of our study was to evaluateFCER1Ggene methylation and miR-17 family members as epigenetic markers associated with RA, disease activity and IL-6 expression.

Methods:

Bioinformatics analysis were applied to select the miRs with a possible target sites in a promoter region ofFCER1Ggene. The MiR-17 family members, including miR-17, miR-93 and miR-106b were selected for investigation.

A total of 74 individuals, 50 RA patients, 84% female, aged 53,7±12,3 years (mean±SD) and 24 healthy controls (HC), 87,5% female, aged 53±8,49 years were enrolled. RA patients were selected based on DAS-28 scoring. RA patients with high disease activity (DAS28 >5,1; 58%) and remission (≤2,6; 42%) were included in the analysis. DNA was extracted from a whole blood and miRs were extracted from plasma. Quantitative real-time PCR was use for analyze both methylation and expression levels. In a randomly selected samples (16 from high disease activity group; 9 from remission and 19 from HC) the level of IL-6 in serum was evaluated.

Results:

Patients with RA in comparison to HC have had a lowerFCER1Gmethylation (0.98 [0.73-1.46] vs 1.96 [1.44-3], p<0.00001; median [interquartile range]) and miR-106b (0.79 [0.49-1.68] vs 1.54 [0.88-2.51], p=0.008) and miR-17 (1.26 [0.41-2.04] vs 2.44 [2.09-3.47], p=0.0001) expressions. No difference in methylation between high and remission RA groups was found. MiR-106b and miR-17 expressions were different between RA patients with high disease activity and remission (p=0.009 and p=0.003, respectively), however a high disease activity group was not different to HC (p=0.82 and p=0.12, respectively). Detailed results are presented in Table 1. A strong correlation between IL-6 levels andFCER1Gmethylation (rs= -0.46) was found.

Table 1.

Methylation and expression between patients divided by disease activity in compare to controls.

High disease activity, n=29Remission, n=21HC, n=24FCER1Gmethylation1.11 [0.83-1.52]0.96 [0.61-1.18]1.96 [1.44-3]miR-106b expression1.36 [0.63-1.76]0.54 [0.19-1.19]1.54 [0.88-2.51]miR-93 expression0.63 [0.49-1.21]0.59 [0.15-1.5]1.03 [0.65-1.38]miR-17 expression1.46 [1.05-2.54]0.34 [0.11-1.26]2.44 [2.09-3.47]

Data are given by median [interquartile range]. FCER1G, Fc receptor gamma chain gene; HC, healthy controls; miR, micro-RNA; RA, rheumatoid arthritis patients.

Conclusion:

FCER1Gmethylation was found as a new epigenetic marker of RA, which is independent of disease activity and may be associated with IL-6 production. Plasma miR-17 and miR-106b can be considered as a novel molecular biomarkers of disease severity in RA.

FcRγ may plays a significant role in RA pathogenesis andFCER1Ggene methylation was found as a new, epigenetic and promising marker of RA.

References:

[1]Németh T, Futosi K, Szabó M, Aradi P, Saito T, Mócsai A, Jakus Z. Importance of Fc Receptor γ-Chain ITAM Tyrosines in Neutrophil Activation and in vivo Autoimmune Arthritis. Front Immunol. 2019 Feb 25;10:252.

[2]Cunningham F et al. Ensembl 2019. Nucleic Acids Res. 2019 Jan 8;47(D1):D745-D751.

[3]Salvi V, Gianello V, Tiberio L, Sozzani S, Bosisio D. Cytokine Targeting by miRNAs in Autoimmune Diseases. Front Immunol. 2019 Jan 29;10:15.

Disclosure of Interests:

Marek Ciesla: None declared, Bogdan Kolarz: None declared, Magdalena Dryglewska: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen

SAT0218 SINGLE NUCLEOTIDE POLYMORPHISMS LOCATED IN REGULATORY REGIONS OF GENES INVOLVED IN SYSTEMIC INFLAMMATION (MAMDC1, ITGAM, AND CRP) CORRELATION WITH THE CLINICAL PICTURE OF DISEASE AND ACTIVITY PARAMETERS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

The exact pathogenesis of systemic lupus erythematosus (SLE) is poorly understood. It is an autoimmune disease that leads to a chronic inflammatory process involving numerous tissues and organs (skin, kidneys, joints, central nervous system, cardiovascular, respiratory, digestive and hematopoietic systems). However, despite the advancement of SLE molecular biology and the wide availability of tests and diagnostic tools, the knowledge about factors predicting the clinical disease activity as well as related changes in the laboratory results is insufficient.

Objectives:

The goal of the study was to assess the relationship between selected single nucleotide polymorphisms (SNPs) and the clinical picture of diseaseand some activity parametersin patients with SLE.

Methods:

We conducted a study of adult patients with SLE diagnosed and treated in the Rheumatology Department of Medical University of Lublin between 2016-2019. We enrolled 80 patients with SLE (71 women, 9 men), with the median (range) age 36 (19-72) and disease duration 6 (1-37) years. To objectively assess disease activity, standardized SLE activity scale - SLEDAI (Systemic Lupus Erythematosus Disease Activity Index) was used. Using the Real-Time PCR method and specific TaqMan probes SNPs of 3 genes:MAMDC1(rs910875; c.-1687G> C),CRP(rs3091244; c.-390C> A), andITGAM(rs7193943; c.-323G> A) were analyzed and then their relationship with specific clinical picture of disease, activity and laboratory results were assessed.

Results:

Carriers of the CC genotype compared to the remaining polymorphic variants (CG and GG) of theMAMDC1gene had an approximately 4-fold higher risk of skin disease compared to other clinical pictures of disease (renal, articular, neuro-psychiatric, hematological) (OR = 4.04; p = 0.0110)). Carriers of this genotype also had a higher risk of hematuria (OR = 4.57; p = 0.0082), sterile leukocyturia (OR = 53.91; p = 0.0071), the presence of anti-Sm / RNP antinuclear antibodies (OR = 4.15, p = 0.0074), reduced values of the C3 complement component (OR = 6.11; p = 0.0071) and the need for oral glucocorticosteroids (OR = 7.01; p = 0.0028). In addition, significantly higher values of SLEDAI disease activity scale were observed in carriers of the CC genotype of theMAMDC1gene (medians: 6 vs 4; p = 0.0220). Moreover, we observed a trend towards a higher risk of hepatomegaly in GG genotype carriers of theITGAMgene (OR=18.50; p=0.0525). In addition, the AA genotype of theCRPgene was associated with a higher risk of proteinuria (OR = 84; p <0.0001), Anti-SSA / Ro autoantibodies (OR = 3.29; p = 0.0484), and aCL IgM (OR = 3.42; p = 0.0332) occurrence. Carriers of AA genotype of the above gene were also at higher risk of earlier occurrence of first disease symptoms as well as disease diagnosis at a younger age (respectively: 24 vs 31 years; p=0.0225, 23 vs 29 years; 0.0442).

Conclusion:

The results suggest the relationship between SNPs in genes involved in systemic inflammation (MAMDC1, ITGAM, CRP) and disease activity as well as the occurrence of some specific clinical pictures of disease in patients with SLE.The genetic dispositions described above may serve as attractive markers in SLE, potentially useful in clinical practice.

Disclosure of Interests:

Aleksandra Majdan: None declared, Radosław Mlak: None declared, Marcin Mazurek: None declared, Dominika Pigon: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen, Teresa Malecka Massalska: None declared

FRI0223 SUBPHENOTYPES OF ANCA ASSOCIATED VASCULITIS IDENTIFIED BY LATENT CLASS ANALYSIS

Background:

ANCA associated vasculitides (AAV) are a heterogeneous group of rare diseases with unknown etiology and the clinical spectrum ranging from life-threatening systemic disease, through single organ involvement to minor isolated skin changes. Thus there is an unmet need for phenotype identification especially among patients with granulomatosis with polyangiitis GPA, patients with microscopic polyangiitis MPA group seems to be more uniform. Recently, based on previous clustering analysis and clinical, histopathological, serological and prognostic aspects three subcategories of AAV have been proposed and named as: non-severe AAV, severe PR3-AAV and severe MPO-AAV [1].

Objectives:

In line with these attempts to subcategorize AAV we decided to use latent class analysis (LCA) on a large multicenter cohort of polish AAV patients from POLVAS [2] registry to identify potential new subphenotypes or confirm already proposed ones.

Methods:

Latent Class Analysis (LCA) approach was used as a model based clustering method of objects described by dichotomous (e.g., gender; ANCA status – cANCA, pANCA; organ involvement - skin, eye, ENT, respiratory, heart, GI, renal, urinary, CNS, peripheral nerves) and polytomous (number of relapses) variables supported by quantitative covariates (e.g., age at diagnosis, CRP at diagnosis, maximal serum creatinine concentration ever).

Results:

Results of LCA on our AAV group returned four class model of AAV subphenotypes, confirming existence of the previously proposed by Mahr at al. [1] and revealed fourth – previously not described clinically relevant subphenotype. To this fourth class - belong patients only with GPA, diagnosed at young age, with multiorgan involvement, high relapse rate and relatively high risk of death.

Table 1.

AAV subcategorization – summary of clinical characteristics and ANCA specificity

LCA Class 1LCA Class 2LCA Class 3LCA Class 4No of patients13019410297AAV typeMainly GPAMainly GPAmainly MPAOnly GPAAge at diagnosisMiddle ageMiddle ageOldYoungMale/female ratio1:22:11:11:1Main organ involvementENT, respiratory, eyeRenal, respiratory, ENTRenal, respiratory, skinMultiorgan involvementRelapse rateintermediateintermediatelowhighModified class description (based on ref. [1])Non severe AAVSevere PR3 AAVSevere MPO AAVSevere non-renalPR3 AAV

Conclusion:

Based on multiple clinical and serological variables LCA methodology identified 4-class subphenotypes model of AAV. Fourth-class is a new clinically important subphenotype including exclusively PR3-positive young AAV patients with multiorgan involvement, high risk of relapse and distinct mortality.

References:

[1]Mahr A, Specks U, Jayne D. Subclassifying ANCA-associated vasculitis: a unifying view of disease spectrum. Rheumatol Oxf Engl 2019;58:1707–9.https://doi.org/10.1093/rheumatology/kez148.

[2]Wójcik K, Wawrzycka-Adamczyk K, Włudarczyk A, Sznajd J, Zdrojewski Z, Masiak A, i in. Clinical characteristics of Polish patients with ANCA-associated vasculitides—retrospective analysis of POLVAS registry. Clinical Rheumatology. 1 wrzesień 2019;38(9):2553–63.

Disclosure of Interests:

Krzysztof Wójcik: None declared, Adam Ćmiel: None declared, Anna Masiak: None declared, Zbigniew Zdrojewski: None declared, Radoslaw Jeleniewicz: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen, Iwona Brzosko: None declared, Marek Brzosko: None declared, Piotr Głuszko: None declared, Małgorzata Stasiek: None declared, Małgorzata Wisłowska: None declared, Joanna Kur-Zalewska: None declared, Marta Madej: None declared, Anna Hawrot-Kawecka: None declared, Hanna Storoniak: None declared, Barbara Bułło-Piontecka: None declared, Alicja Dębska-Ślizień: None declared, Eugeniusz Kucharz: None declared, Katarzyna Jakuszko: None declared, Jacek Musiał: None declared

FRI0210 ORBITAL PSEUDOTUMOR AMONG PATIENTS WITH GRANULOMATOSIS WITH POLYANGIITIS – DATA FROM THE POLISH REGISTRY POLVAS

Background:

Orbital inflammatory masses have been described as the common manifestation of granulomatosis with polyangiitis (GPA) occuring in 7- 45% of patients.

Objectives:

Identification and characterization of patients with orbital pseudotumor among Polish patients based on the national vasculitis registry, POLVAS.

Methods:

Clinical presentation and management of all GPA patients fulfilling ACR criteria or Chapel Hill Consensus Conference definition included to the Polish registry POLVAS who developed orbital masses in the course of GPA were evaluated.

Results:

Ocular involvement was found in 114 (27%) of 417 GPA patients registered in POLVAS, 34 (8%) developed orbital masses. Mean patients’ age was 47.8 (range from 19-75) yrs., 23 (67%) were women. Forty four per cent of the patients developed tumor at the beginning of the disease, 56% during relapse. Patients’ characteristics on diagnosis of orbital mass: 24 cANCA, 2 pANCA, and 8 ANCA negative, 9% active smokers and 31% past smokers, 29% had localized disease, 21% early systemic and 50% systemic with organ involvement, 29% had other type of ophthalmological involvement before pseudotumor occurred, 88% had active paranasal sinus involvement, 41% lungs, 15% CNS, 15% skin and 6% heart manifestations. Thirty seven per cent of patients had positive nasal swabs cultures, 50% of which were positive for Staphylococcus aureus. In 65%, tumor occurred during steroid therapy (46% had prednisone more than 5mg/d) and 45% on immunosuppressive treatment (19% when treated with AZA, 16% MTX, 6,5% MMF and 3,5% CYC). Due to orbital mass 86.5% were treated with CYC and 13.5% with RTX. Twenty one per cent had complete remission of the pseudotumor, 76% partial remission and in 3% patients there was no response to the treatment; 43% developed visual impairment, 20% suffered from blindness.

Conclusion:

Orbital inflammatory mass was not common manifestation of GPA among our patients. The mass developed at the beginning or in the course of the disease, even during immunosuppressive treatment. Orbital masses have been resistant to therapeutic interventions and were accompanied by high risk of visual impairment.

Disclosure of Interests:

Anna Masiak: None declared, Marcin Ziętkiewicz: None declared, Krzysztof Wójcik: None declared, Katarzyna Wawrzycka-Adamczyk: None declared, Radoslaw Jeleniewicz: None declared, Marta Madej: None declared, Joanna Kur-Zalewska: None declared, Katarzyna Jakuszko: None declared, Małgorzata Wisłowska: None declared, Hanna Storoniak: None declared, Michał Komorniczak: None declared, Barbara Bułło-Piontecka: None declared, Iwona Brzosko: None declared, Małgorzata Stasiek: None declared, Eugeniusz Kucharz: None declared, Alicja Dębska-Ślizień: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen, Jacek Musiał: None declared, Zbigniew Zdrojewski: None declared

FRI0080 CLINICAL CHARACTERISTICS OF PATIENTS WITH ELDERLY-ONSET RHEUMATOID ARTHRITIS (EORA)

Background:

The onset of rheumatoid arthritis (RA) occurs usually between 35-50 years of age. Since the general population is ageing, beginning of RA in older age is more common. The termelderly onset of rheumatoid arthritis(EORA) describes the disease with onset at age over 60. The termyounger-onset rheumatoid arthritis(YORA) refers to the disease with typical, earlier onset. Observational studies indicate, that substantial differences do occur between the two RA subtypes (EORA and YORA).

Objectives:

The goal of the study was to analyze the course of disease and treatment in EORA in comparison to YORA patients.

Methods:

The study was conducted in consecutive RA patients, treated in the Department of Rheumatology and Connective Tissue Diseases, Medical University of Lublin, Poland. The study group consisted of 113 patients (93 women, 20 men), with the mean (SD) age 59.4 (19.0), disease duration 12.9 (10.3) years.

The cut off between EORA and YORA was set at 60 years of age. There were 63 (55.8%) EORA and 50 (44.2%) YORA patients. Demographic and clinical information was obtained through structured interview, review of medical records and laboratory tests. Disease activity was assessed based on joint counts and Disease Activity Score of 28 joints (DAS28).

Results:

In patients with EORA vs YORA, the mean (SD) age was 73.64 (6,6) vs 41.5 (13.7) (p<0.001), the age of RA diagnosis 65.0 (4.2) vs 23.3 (4.8) (p<0.001), RA duration 8.6 (5.4) vs 18.3 (12.3) years (p<0.001).

The group of patients with EORA compared with YORA, was characterized by: significantly higher number of men [respectively 16 (25.4%) vs 4 (8.0%)], unfavorable metabolic parameters [higher body mass index (BMI): 26.0 (5.8) vs 23.4 (4.1) kg/m2(p=0.04); serum uric acid: 5.7 (1.5) vs 4.4 (1.6) mg/dl (p=0.001)], as well as unfavorable parameters of RA activity [higher DAS28: 4.4 (1.5) vs 3.2 (1.6) (p<0.001); higher tender joints count (TJC): 6.1 (6.2) vs 3.2 (3.7) (p=0.01); higher erythrocyte sedimentation rate (ESR) 45.9 (30.3) vs 24.1 (25.6) (p<0.001) and white blood cell count (WBC): 8.3 (2.7) vs 7.0 (2.4)x103/ml (p=0.01)]. At the time of assessment, remission or low disease activity was achieved in significantly fewer EORA vs YORA patients [15 (23.8%) vs 25 (50%) (p=0.007)].

In EORA patients methotrexate was used as the first disease modifying drug (DMARD) more often [54 (85.7%) vs 26 (52%) (p<0.001)], the use of biological DMARDs was less common [5 (7.9%) vs 23 (46.0%) (p<0.001)], as well as glucocorticoids (GC) [49 (77.8%) vs 47 (94.0%) (p=0.04)]. Significantly more patients with EORA than YORA, were affected by concomitant diseases [62 (98.4%) vs 41 (82%) (p=0.007)].

The prevalence of joint erosions, extra-articular manifestations and antibodies typical for RA (rheumatoid factor, RF-IgM and/or anti-citrullinated peptide, ACPA) did not differ significantly between the groups.

Conclusion:

In our study group, EORA patients were characterized by higher proportion of men, higher inflammatory parameters and higher disease activity, in comparison with YORA. In patients with EORA we also found unfavorable metabolic parameters and higher incidence of concomitant diseases, which could affect the method of treatment (less common use of GC and biological DMARDs).

Disclosure of Interests:

Bozena Targonska-Stepniak Consultant of: Berlin-Chemie Mennarini, Sandoz, Speakers bureau: KRKA, Sandoz, Krzysztof Grzechnik: None declared, Katarzyna Kolarz: None declared, Danuta Gagol: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen

Clinical and serological parameters of progression and prognosis in patients with systemic sclerosis - a state of the art review

OBJECTIVE

Systemic sclerosis (SSc) is a multi-organ connective tissue disease that leads to the dysfunction and the impaired morphology of blood vessels due to non-specific inflammation and progressive fibrosis. Due to the diversity of SSc and even though the factors predisposing to the severe course of SSc are known, it is not always possible to predict the disease progression and to determine the prognosis. Ideally, the group of patients with faster progression of organ lesions and a worse course of the disease should be identified and the early intensive treatment should be instituted. The aim of the article, is an attempt to identify the factors that worsen the prognosis in the course of SSc. The analysis of numerous studies demonstrated that patients with short-lasting SSc, with the presence of anti-RNA polymerase III antibodies, with a generalized type of SSc with quickly progressing skin lesions and males should be most strictly monitored. Moreover, vascular complications, tendon ruptures and fast capillaries loss observed in nailfold capillaroscopy are the factors deteriorating the prognosis in SSc.

CONCLUSION

In conclusion, despite the known, the factors that worsen the prognosis, it is difficult to predict the course of systemic sclerosis. Due to its incompletely elucidated etiopathology as well as the diverse and unpredictable nature of the disease, reliable markers to determine the prognosis in SSc have not been found.

Seasonal patterns of traumatic brain injury deaths due to traffic-related incidents in the Slovak Republic

Objective: Traumatic Brain Injuries (TBIs) are an important type of injury in terms of both morbidity and mortality. Road Traffic Incidents are one of the most frequent causes of TBI. This analysis seeks to quantify the number of such injuries occurring in the Slovak Republic, and examine patterns of TBI according to mode of transport and seasonality.Methods: Data concerning total numbers of TBIs occurring from the years 1996-2015 were obtained from the Statistical Office of the Slovak Republic. The events caused by road incidents were examined separately according the external cause stated on death certification. Events were classified into seasons according to the month of death. Summary statistics were produced concerning numbers of deaths according to sex, mode of transport and season. Analyses were performed to examine trends in TBI by season and type of road user.Results: During a period of 20 years from 1996, there were 17,047 recorded deaths involving TBI in the Slovak Republic. Of these, 5,370 were caused by road traffic incidents (RTIs). Age standardized rates tended to decrease from 8.3/100,000/year (1996) to 2.5/100,000/year (2015). Males made up approximately 79% of road traffic-caused TBIs. Summer and autumn showed significantly more events than any other season, with motorcyclists and cyclists in particular being more frequently injured at this time of year.Conclusions: The results show that Slovakia, like many countries, suffers a considerable burden of TBI and that RTIs are a major contributor to this, especially among young adults. Rates of TBI vary by season in Slovakia, and users of different modes of transport appear more or less likely to suffer such injury during different seasons. Considerable variability in rates of injury exists between road users and times of year. Improved understanding of the timing and sufferers of injuries may allow better planning of response and care services. Further research into transport modes and policies aimed at safer driving should be explored.

Factors associated with quality of life in systemic sclerosis: a cross-sectional study

INTRODUCTION

Systemic sclerosis (SSc) is a connective tissue disease characterized by progressive fibrosis of the skin and internal organs, leading to their failure and disturbances in the morphology and function of blood vessels. The disease affects people in different ways, and identifying how the difficulties and limitations are related to quality of life may contribute to designing helpful interventions. The aim of this study was to identify factors associated with quality of life in people with SSc.

METHODS

This was a cross-sectional study conducted in 11 rheumatic centres in Poland. Patients diagnosed with SSc were included. Quality of life was measured using the SSc Quality of Life Questionnaire (SScQoL). The following candidate factors were entered in preliminary multivariable analysis: age, place of residence, marital status, occupational status, disease type, disease duration, pain, fatigue, intestinal problems, breathing problems, Raynaud's symptoms, finger ulcerations, disease severity, functional disability, anxiety and depression. Factors that achieved statistical significance at the 10% level were then entered into a final multivariable model. Factors achieving statistical significance at the 5% level in the final model were considered to be associated with quality of life in SSc.

RESULTS

In total, 231 participants were included. Mean age (SD) was 55.82 (12.55) years, disease duration 8.39 (8.18) years and 198 (85.7%) were women. Factors associated with quality of life in SSc were functional disability (β = 2.854, p < 0.001) and anxiety (β = 0.404, p < 0.001). This model with two factors (functional disability and anxiety) explained 56.7% of the variance in patients with diffuse SSc and 73.2% in those with localized SSc.

CONCLUSIONS

Functional disability and anxiety are significantly associated with quality of life in SSc. Interventions aimed at improving either of these factors may contribute towards improving the quality of life of people with SSc.

Monitoring the activity of anca-associated vasculitis: some questionnaires and laboratory parameters

Systemic vasculitis is a group of diseases manifested by symptoms from many organs. ANCA-associated vasculitis (AAV) require chronic and often aggressive immunosuppressive treatment. This treatment should be adapted to the disease activity. Assessment of AAV is based on various disease activity questionnaires which contain clinical symptoms of the disease and lab results. The most useful questionnaire is BVAS version 3 (Birmingham Vasculitis Activity Score). In every patients, distinction between activity of AAV and irreversible damage is needed. ANCA antibodies are a predictor of poor prognosis in some patients. Using of these antibodies in monitoring of AAV activity has got minor importance.

Urticarial rash, fever, and arthritis: A case of refractory Adult-onset Still's disease with good response to tocilizumab

Adult-onset Still's disease (AOSD) is a rare, systemic inflammatory disorder of not completely understood etiology. Aberrant activation of the innate immune system and overproduction of several pro-inflammatory mediators are considered a critical component in disease pathogenesis. AOSD still poses a challenge due to the broad range of differential diagnoses and no specific biomarkers. Four cardinal symptoms are quotidian spiking fever, joint involvement, evanescent salmon pink-rash rash, and leukocytosis with neutrophilia. We present a case of a 61-year-old female with a recurrent urticarial rash accompanied by attacks of high fever, tender joints, sore throat, enlarged liver, elevated inflammatory reactants, and hyperferritinemia. After an extensive workup, the patient fulfilled the criteria of AOSD. She was refractory to the glucocorticosteroids and disease-modifying anti-rheumatic drugs (DMARDs). Finally, after several unsuccessful attempts to achieve disease control with traditional DMAR's administration of Tocilizumab (TCZ), a humanized anti-IL-6 receptor antagonist resulted in substantial disease improvement. Since skin manifestations are a common feature of AOSD, it should be among differential diagnoses in patients with skin lesions and constitutional symptoms. Biologic agents represent a significant therapeutic advance in patients with AOSD refractory to conventional therapy.

IRF5 promoter methylation as a new potential marker of rheumatoid arthritis

Introduction: The interferon regulatory factor 5 (IRF5) gene is implicated in the toll‑like receptor signaling pathway and has proinflammatory and chemotactic effects, but its role in the pathogenesis of rheumatoid arthritis (RA) remains unclear. Since the pathobiology of RA shares some similarities with other autoimmune diseases, we tested the hypothesis that RA may be associated with IRF5‑related pathways, as has been reported for systemic lupus erythematosus and Sjögren syndrome. Objectives: The aim of the study was to investigate the association between the presence of methylation in the IRF5 promoter and the morbidity and severity of RA as well as with levels of inflammatory markers. Patients and methods: A total of 146 unrelated individuals, 122 patients with RA and 24 healthy controls, were enrolled in the study. All RA patients were genotyped with regard to the following polymorphisms in the IRF5 gene: rs10488631, T>C and rs4728142 G>A. The methylation analysis included 52 patients with RA and 24 healthy controls. A quantitative real‑time methylation‑specific polymerase chain reaction was used to evaluate methylation status. Results: We found differences between patients with RA and healthy controls in the methylation pattern of the promoter region. The methylation level was 43.6% lower in RA patients than in controls (median [interquartile range], 0.79 [0.6-1.13] vs 1.4 [1.16-1.66]; P = 0.0001). Variant rs4728142 G>A was more common in seronegative patients with RA. Conclusions: The methylation profile of the IRF5 promoter may be used as a new potential marker of RA, which is independent of current criteria of disease activity.

Head trauma in sports - clinical characteristics, epidemiology and biomarkers

Traumatic brain injury (TBI) is clinically divided into a spectrum of severities, with mild TBI being the least severe form and a frequent occurrence in contact sports, such as ice hockey, American football, rugby, horse riding and boxing. Mild TBI is caused by blunt nonpenetrating head trauma that causes movement of the brain and stretching and tearing of axons, with diffuse axonal injury being a central pathogenic mechanism. Mild TBI is in principle synonymous with concussion; both have similar criteria in which the most important elements are acute alteration or loss of consciousness and/or post-traumatic amnesia following head trauma and no apparent brain changes on standard neuroimaging. Symptoms in mild TBI are highly variable and there are no validated imaging or fluid biomarkers to determine whether or not a patient with a normal computerized tomography scan of the brain has neuronal damage. Mild TBI typically resolves within a few weeks but 10-15% of concussion patients develop postconcussive syndrome. Repetitive mild TBI, which is frequent in contact sports, is a risk factor for a complicated recovery process. This overview paper discusses the relationships between repetitive head impacts in contact sports, mild TBI and chronic neurological symptoms. What are these conditions, how common are they, how are they linked and can they be objectified using imaging or fluid-based biomarkers? It gives an update on the current state of research on these questions with a specific focus on clinical characteristics, epidemiology and biomarkers.

[Late-onset sjögren's syndrom]

Sjögren's syndrome is a systemic autoimmune disease characterized by exocrine glands damage, resulting in the development of dry eyes and dry mouth, as well as extraglandular manifestation. It usually starts between the ages of 30 and 50. Late-onset Sjögren's syndrome should be considered as a disease that appears after age 65, but the literature also reports of the age 50, 60, or even 70. The prevalence of late-onset Sjögren's syndrome is estimated about 20%. The course of late-onset Sjögren's syndrome may differ when compared with patients with a younger onset. Lack of sicca symptoms and marker antibodies may be associated with a delay in Sjögren's syndrome diagnosis. Particularly in the elderly, the occurrence of sicca symptoms may be considered as age-related and medication-related.

[Uwarunkowania opóźnienia rozpoznań osiowych spondyloartropatii zapalnych]

OBJECTIVE

Wstęp: Prawdopodobieństwo rozwoju osiowej postaci spondyloartropatii zapalnej (axSpA) wynosi ponad 90% u chorych z przewlekłym bólem kręgosłupa, obecnym antygenem HLA B27 i dodatnim wywiadem rodzinnym w kierunku zesztywniającego zapalenia stawów kręgosłupa (ZZSK), łuszczycy, reaktywnego zapalenia stawów, chorób zapalnych jelit lub zapalenia błony naczyniowej oka. Aktywność choroby w postaci nieradiologicznej axSpA i ZZSK podobnie wpływa na jakość życia a z praktycznego punktu widzenia podejście do leczenia jest jednakowe. Cel pracy: Próba identyfikacji przyczyn spóźnionych rozpoznań ZZSK wśród chorych hospitalizowanych w Klinice Reumatologii i Układowych Chorób Tkanki Łącznej w Lublinie oraz sugestie dotyczące poprawy ścieżki diagnostycznej, zwłaszcza wśród lekarzy innych specjalności niż reumatolodzy.

PATIENTS AND METHODS

Materiał i metody: Retrospektywnej analizie poddano historie chorób 82 pacjentów z ustalonym rozpoznaniem ZZSK hospitalizowanych w Klinice Reumatologii i Układowych Chorób Tkanki Łącznej w Lublinie w latach 2000-2019, którzy ukończyli 45. rok życia.

RESULTS

Wyniki: Spośród 82 chorych (28 kobiet i 54 mężczyzn) rozpoznanie ZZSK po 45. roku życia postawiono u 25 chorych (10 kobiet i 15 mężczyzn) - grupa t (30,4%), u pozostałych 57 chorych (grupa n) rozpoznanie ustalono przed 45. rokiem życia. Średni wiek w chwili rozpoznania w całej grupie (t+n) wynosił 40,7±10,2 (18-76) roku, wiek, w którym pojawił się zapalny ból kręgosłupa (wiek objawów osiowych) wynosił 30,9±8,5 (13-51) roku a opóźnienie rozpoznania (okres od pojawienia się objawów osiowych do ustalenia rozpoznania) 9,7±9,5 (0-46) roku. Nie stwierdzono istotnych statystycznie zależności między płcią a wiekiem w chwili rozpoznania, wiekiem pojawienia się objawów osiowych i opóźnieniem rozpoznania. Nie zaobserwowano istotnych zależności między częstością występowania zapalenia przyczepów ścięgnistych, błony naczyniowej oka, stawów obwodowych, chorób z kręgu spondyloartropatii zapalnych w rodzinie oraz stężenia CRP między grupą t i n. Antygen HLA B27 częściej obecny był w grupie t.

CONCLUSION

Wnioski: Mimo postępu w diagnostyce i większego upowszechniania wiedzy na temat spondyloartropatii zapalnych, opóźnienia w rozpoznaniu tych chorób są wieloletnie, ponieważ pacjenci bardzo często poszukują pomocy u innych specjalistów, którzy mogą być niezaznajomieni z kryteriami bólu zapalnego kręgosłupa. W chwili obecnej jedynymi biomarkerami wykorzystywanymi w diagnostyce i monitorowaniu aktywności spondyloartropatii zapalnych jest odpowiednio obecność antygenu HLA B27 i stężenie CRP a jedynym "biomarkerem obrazowym" jest rezonans magnetyczny. Występowanie objawów pozaosiowych nie poprawia czułości diagnostycznej.

Reasons for diagnostic delays of axial spondyloarthritis

OBJECTIVE

Introduction: The probability of development of axial spondyloarthritis (axSpA) is estimated to be above 90% among patients with chronic back pain, presence of HLA B27 antigen and positive family history of ankylosing spondylitis (AS), psoriasis, reactive arthritis, inflammatory bowel disease or uveitis. The nonradiographic axSpA and ankylosing spondylitis diseases' activity has a comparable impact on the patients' quality of life and from the practical point of view the approach to treatment of each of them is the same. The aim: The attempt to identify the reasons of diagnostic delays of AS among patients hospitalized in the Rheumatology and Connective Tissue Diseases Department in Lublin and to suggest the ways of improving the accuracy of diagnostic track among other healthcare providers than rheumatologists.

PATIENTS AND METHODS

Material and methods: We performed a retrospective analysis of the records of 82 patients' with the established diagnosis of AS, hospitalized in the Rheumatology and Connective Tissue Diseases Department in Lublin in 2000-2019, and of 45 years of age and older.

RESULTS

Results: From among 82 patients (28 women and 54 men) the diagnosis of AS after 45 years of age was established in 25 patients (10 women and 15 men) - group t, and in the other 57 patients (group n) the diagnosis was established before 45 years of age. On average the age at the time of diagnosis in the whole group (t+n) was 40,7±10,2 (18-76) years, the age at the beginning of inflammatory back pain (age of axial symptoms) was 30,9±8,5 (13-51) years and the diagnostic delay (period between first axial symptoms and diagnosis establishment) was 9,75±9,5 (0-46) years. We did not find any statistically significant associations between sex and age at the moment of diagnosis, age of the beginning of axial symptoms and the time of diagnostic delay. There was no significant difference of incidence of enthesitis, uveitis, arthritis, prevalence of family history of spondyloarthritis and CRP level between group t and n. Antigen HLA B27 was more frequently present in group t.

CONCLUSION

Conclusions: Instead of the recognition progress and worldwide popularization of knowledge about axSpA, the diagnostic delays in this field are still estimated to last many years, the patients are looking for other specialists' help, and they can be not knowledgeable of the inflammatory back pain criteria. Currently, HLA B27 antigen and C-reactive protein are the two most commonly used biomarkers for diagnostic and disease activity monitoring purposes of axSpA and magnetic resonance is the only "imaging biomarker". The presence of extra-axial symptoms does not improve the diagnostic sensitivity.

Diastolic dysfunction in rheumatoid arthritis patients with low disease activity

INTRODUCTION/OBJECTIVES

Patients with rheumatoid arthritis (RA) are at increased risk for congestive heart failure (CHF) and left ventricular diastolic dysfunction (LVDD), as compared to the general population. High disease activity is to be associated with higher incidence of cardiovascular disease (CVD), CHF, and mortality in RA patients. LVDD is not anticipated in RA patients without CVD symptoms and may be underdiagnosed especially in those with low disease activity.

METHOD

The study group consisted of 70 RA patients (54 women, 16 men) with no CVD and 33 healthy controls, of comparable age. All RA patients had low disease activity (DAS28 ≤ 3.2) from 2 to 7 years. Laboratory and imaging assessments included metabolic, RA-related, and cardiovascular parameters. Echocardiographic and Doppler studies were conducted in patients and controls with assessment of ejection fraction (EF) and diastolic dysfunction (assessed as E/A ratio).

RESULTS

The mean E/A ratio did not differ significantly between RA patients and healthy controls (1.08 (0.28) vs 0.99 (0.21), NS); comparable numbers of patients and controls had abnormal E/A (< 1.0) (26 (37.1%) vs 10 (30.3%), NS). Patients with decreased E/A were significantly older and had higher disease duration, activity, and presence of bone erosions than their RA counterparts with normal E/A. The mean EF was not significantly different in patients and controls.

CONCLUSIONS

The prevalence of DD as expressed by E/A ratio in RA patients with continued low disease activity was not different from that of controls. Higher disease duration and severity may predispose to DD occurrence in patients with preserved EF.

Anti-CCP antibodies and rheumatoid factor in systemic sclerosis: Prevalence and relationships with joint manifestations

BACKGROUND

It is known that anti-citrullinated protein (a-CCP) antibodies and rheumatoid factor (RF) can be present in systemic sclerosis (SSc) patients, particularly with joint involvement.

OBJECTIVES

The aim of the study was to assess the prevalence of a-CCP antibodies and immunoglobulin M class (IgM) RF, and the relationships between their presence and joint manifestations in patients with SSc.

MATERIAL AND METHODS

The study included 100 European Caucasian SSc patients hospitalized consecutively in the Department of Rheumatology and Connective Tissue Diseases (Lublin, Poland). Anti-citrullinated protein antibodies and IgM RF were determined using a commercial enzyme-linked immunosorbent assay (ELISA) test.

RESULTS

Anti-citrullinated protein antibodies were found in 10 out of 100 (10%) SSc patients and IgM RF in 71 out of 100 (71%) SSc patients. In the study, 90/100 (90%) SSc patients had joint manifestations (arthralgia or arthritis), 34/100 (34%) had arthritis and 6/100 (6%) had a systemic sclerosis-rheumatoid arthritis (SSc-RA) overlap syndrome. Significantly higher a-CCP antibody levels (p = 0.012), erythrocyte sedimentation rate (ESR) (p = 0.029) and C-reactive protein (CRP) levels (p = 0.020) were observed in the SSc group with arthritis. A significant correlation was found between the group with arthritis and the presence of a-CCP antibodies, and between the arthralgia group and the presence of IgM RF.

CONCLUSIONS

The prevalence of RF and a-CCP antibodies is relatively high in SSc, and joint involvement occurs frequently. There was a significantly higher prevalence of IgM RF in the group with joint manifestations. About 1/3 of SSc patients had symptoms of arthritis. Arthritis is connected with the presence of a-CCP antibodies, while arthralgia is connected with the presence of IgM RF.

Tofacitinib in the treatment of patients with rheumatoid arthritis: position statement of experts of the Polish Society for Rheumatology

Tofacitinib is a newly approved small-molecule targeted synthetic disease-modifying antirheumatic drug. The drug was designed as a selective and specific inhibitor of pro-inflammatory receptor signalling. Tofacitinib inhibits the process of intracellular signalling from the receptor to the cellular nucleus and inhibits the inflammation process via a new pathway (inhibition of the Janus kinases), which is unavailable to biological medicines. Tofacitinib has been approved for use in the treatment of patients with moderate to severe active RA. The drug may be used in combination with methotrexate or another conventional synthetic disease-modifying antirheumatic drug or in monotherapy. The efficacy of tofacitinib has been confirmed in several clinical trials. The drug inhibits radiographic progression of the disease. The innovative mechanism of action of tofacitinib is a noteworthy feature because it offers hope of effective treatment for patients who fail to respond to other drugs. The presented article discusses the mechanism of action and the clinical application of tofacitinib. Tofacitinib represents a new group of disease-modifying antirheumatic drugs that can be placed on an equal footing with biological drugs already available.

Prospective assessment of cardiovascular risk parameters in patients with rheumatoid arthritis

Background

The study presents a prospective follow-up assessment of cardiovascular (CV) risk parameters in patients with rheumatoid arthritis (RA) in comparison with control subjects.

Methods

The study group consisted of 41 RA patients. The following parameters were assessed at subsequent visits [initial (T0), follow-up after 6 years (T6)]: traditional CV risk factors, carotid intima media thickness (cIMT), QTc duration, serum concentration of amino-terminal pro-brain natriuretic peptide (NT-proBNP). A comparative cIMT assessment was performed on 23 healthy controls of comparable age.

Results

The mean (SD) cIMT value in RA patients was significantly higher at T6 than at T0 [0.87 (0.21) vs 0.76 (0.15) mm, p < 0.001], the increase in patients with atherosclerotic plaques was noted. Patients with plaques were significantly older, had higher inflammatory parameters. The mean cIMT was significantly higher in RA patients than in controls at both T6, T0 visits. Certain traditional CV risk factors exacerbated during follow up. Unfavorable metabolic parameters and significantly higher cIMT were found in male patients than in female patients at T6. During follow-up, no significant differences in NT-proBNP, QTc were found. There were no significant relationships between cIMT, NT-proBNP, QTc and parameters of disease activity at T6.

Conclusions

During the 6-year course of established RA, significant exacerbation of atherosclerosis was found, revealed by higher cIMT. A careful monitoring should be applied to patients with atherosclerotic plaques and of male gender due to higher burden of CV risk. In long-standing disease, traditional CV risk factors seem to play a key role, beyond the inflammatory activity.