OP0178 COVID-19 BREAKTHROUGH INFECTIONS IN VACCINATED PATIENTS WITH IMMUNE-MEDIATED INFLAMMATORY DISEASES AND CONTROLS – DATA FROM TWO PROSPECTIVE COHORT STUDIES

Background

Concerns have been raised regarding risks of COVID-19 breakthrough infections in vaccinated patients with immune-mediated inflammatory diseases (IMIDs) treated with immunosuppressants, but data on COVID-19 breakthrough infections in these patients are still scarce.

Objectives

The primary objective was to compare the incidence and severity of COVID-19 breakthrough infections with the SARS-CoV-2 delta variant between fully vaccinated IMID patients with immunosuppressants, and controls (IMID patients without immunosuppressants and healthy controls). The secondary objective was to explore determinants of breakthrough infections.

Methods

In this study we pooled data collected from two large ongoing prospective multi-center cohort studies (Target to-B! [T2B!] study and ARC study). Clinical data were collected between February and December 2021, using digital questionnaires, standardized electronic case record forms and medical files. Post-vaccination serum samples were analyzed for anti-RBD antibodies (T2B! study only) and anti-nucleocapsid antibodies to identify asymptomatic breakthrough infections (ARC study only). Logistic regression analyses were used to assess associations with the incidence of breakthrough infections. Multivariable models were adjusted for age, sex, cardiovascular disease, chronic pulmonary disease, obesity and vaccine type.

Results

We included 3207 IMID patients with immunosuppressants and 1810 controls (985 IMID patients without immunosuppressants and 825 healthy controls). The incidence of COVID-19 breakthrough infections was comparable between patients with immunosuppressants (5%) and controls (5%). The absence of SARS-CoV-2 IgG antibodies after COVID-19 vaccination was independently associated with an increased incidence of breakthrough infections (P 0.044). The proportion of asymptomatic COVID-19 breakthrough cases that were additionally identified serologically in the ARC cohort was comparable between IMID patients with immunosuppressants and controls; 66 (10%) of 695 patients vs. 64 (10%) of 647 controls. Hospitalization was required in 8 (5%) of 149 IMID patients with immunosuppressants and 5 (6%) of 86 controls with a COVID-19 breakthrough infection. Hospitalized cases were generally older, and had more comorbidities compared with non-hospitalized cases (Table 1). Hospitalization rates were significantly higher among IMID patients treated with anti-CD20 therapy compared to IMID patients using any other immunosuppressant (3 [23%] of 13 patients vs. 5 [4%] of 128 patients, P 0.041; Table 1).

Table 1.

Determinants of the severity of COVID-19 breakthrough infections.

Ambulatory care (n = 222)Hospitalized (n = 13)Group - no. (%)IMID patients with immunosuppressants141(64)8(62)IMID patients without immunosuppressants49(22)3(23)Healthy controls32(14)2(15)Patient characteristicsAge, years – mean (SD)51(14)60(11)Female sex – no. (%)143(64)4(31)Comorbidities – no. (%)Cardiovascular disease17(8)5(39)Chronic pulmonary disease17(8)4(31)Diabetes15(7)3(23)Obesity34(15)5(39)Immunosuppressants– no. (%)Methotrexate36(16)2(15)TNF inhibitor48(22)2(15)Anti-CD20 therapy13(6)3(23)Mycophenolate mofetil3(1)0(0)S1P modulator5(2)0(0)Other immunosuppressants70(32)3(23)

Conclusion

The incidence of COVID-19 breakthrough infections in IMID patients with immunosuppressants was comparable to controls, and infections were mostly mild. Anti-CD20 therapy might increase patients’ susceptibility to severe COVID-19 breakthrough infections, but traditional risk factors also continue to have a critical contribution to the disease course of COVID-19. Therefore, we argue that most patients with IMIDs should not necessarily be seen as a risk group for severe COVID-19, and that integrating other risk factors should become standard practice when discussing treatment options, COVID-19 vaccination, and adherence to infection prevention measures with patients.

Disclosure of Interests

None declared

POS1256 RISK FACTORS FOR SHORT-TERM ADVERSE EVENT IN PATIENTS WITH IMMUNE-MEDIATED INFLAMMATORY DISEASES

Background

Many countries are promoting booster SARS-CoV-2 vaccination campaigns as the COVID-19 pandemic continues. Incremental short-term adverse events after two SARS-CoV-2 vaccinations have been reported in healthy individuals.1,2 However, data on incremental short-term adverse events in patients with various immune-mediated inflammatory diseases (IMIDs) after repeated SARS-CoV-2 vaccination is scarce.

Objectives

We report risk factors for short-term adverse events in IMID patients after SARS-CoV-2 vaccination.

Methods

Self-reported daily questionnaires on adverse events in the first seven days after SARS-CoV-2 vaccination were obtained from individuals participating in an ongoing prospective multi-arm multicenter cohort study on SARS-CoV-2 vaccination in patients with various IMIDs in the Netherlands (T2B! immunity after SARS-CoV-2). Clinically relevant adverse events were defined as systemic adverse advents lasting longer than two days or hindering daily activities. Adjusted relative risks for developing clinically relevant adverse events were calculated using a logistic mixed-effects model.

Results

Data of 2081 patients and 178 healthy controls were obtained. Inflammatory bowel disease (N:480), Multiple sclerosis (N:343) and Rheumatoid arthritis (N:266) were the largest disease groups. Adjusted relative risks for relevant adverse events are presented in Figure 1. Third vaccination was not associated with increased risk on adverse events when compared to a second vaccination (aRR: 0.93 95% CI: 0.84-1.02). Patients with IMIDs were at increased risk for developing adverse events after vaccination when compared to controls (aRR: 1.16 95% CI: 1.01-1.34). Female sex (aRR 1.43 95% CI: 1.32-1.56), age below 50 (aRR 1.14 95% CI: 1.06-1.23) and a preceding SARS-CoV-2 infection (aRR: 1.14 95% CI: 1.01-1.29) were also associated with increased risk of adverse events following vaccination. Allergic reactions and hospital admission were uncommon (0.67% and 0.19% respectively); 7.4% and 6.8% of patients reported adverse events impacting daily life on day seven after second and third vaccination, respectively. Data on increase in disease activity of the IMID following vaccination are currently being investigated.

Figure 1.

Risk factors for adverse events after SARS-CoV-2 vaccination in patients with immune-mediated inflammatory disease

Conclusion

A third SARS-CoV-2 vaccination was not associated with an increased risk on short-term clinically relevant adverse events when compared to a second vaccination. Although patients with IMIDs may be slightly more at risk to develop adverse events after SARS-CoV-2 vaccination, most adverse events were transient and disappeared within seven days. This message should reassure IMID patients who are hesitant on booster vaccination. Data on potential IMID flare-ups after vaccination will follow.

References

[1]Polack FP, Thomas SJ, Kitchin N, et al. Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. N Engl J Med. 2020;383(27):2603-2615. doi:10.1056/NEJMoa2034577

[2]Baden LR, El Sahly HM, Essink B, et al. Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine. N Engl J Med. 2021;384(5):403-416. doi:10.1056/NEJMoa2035389

Acknowledgements

We would like to thank ZonMw (The Netherlands Organization for Health Research and Development, grant 10430072010007) for the funding of the study and the T2B partners, including the patient groups and Health Holland for the support in this study. Also, we would like to thank E.P. Moll van Charante, J.A Bogaards and R.A. Scholten for their guidance in the data safety monitoring board.

Disclosure of Interests

Laura Kummer: None declared, Luuk Wieske: None declared, Eileen Stalman: None declared, Koos van Dam: None declared, Laura Boekel: None declared, Gertjan Wolbink Grant/research support from: GW reported a grant from ZonMW (Netherlands Organization for Healthcare research and Innovation) for COVID research in patients with auto-immune diseases., Adriaan Volkers: None declared, Maurice Steenhuis: None declared, Niels Verstegen: None declared, Theo Rispens: None declared, Anja ten Brinke: None declared, Zoé van Kempen: None declared, Sander Tas: None declared, Marieke van Ham: None declared, Taco Kuijpers Grant/research support from: TW reported a grant from ZonMW (Netherlands Organization for Healthcare research and Innovation) for COVID research in patients with auto-immune diseases., Filip Eftimov Grant/research support from: FE reported a grant from ZonMW (Netherlands Organization for Healthcare research and Innovation) for COVID research in patients with auto-immune diseases.

POS1311 SCLERODERMA PATTERN IN NAILFOLD CAPILLARIES OF (CHILDHOOD-ONSET) SYSTEMIC LUPUS ERYTHEMATOSUS: LESSONS FROM LONGITUDINAL FOLLOW-UP

Background:

It has been suggested that a capillary scleroderma pattern in patients with systemic lupus erythematosus (SLE)-patients predisposes for clinical signs of systemic sclerosis (SSc) or overlap disease (1). However, this was previously shown not to be the case in a cross-sectional study in childhood-onset SLE (cSLE) (2).

Objectives:

To assess if nailfold capillary patterns in cSLE change over time and if a capillary scleroderma pattern is associated with prospective development of clinical SSc-features, higher SLE disease activity or –damage.

Methods:

Prospective clinical and capillaroscopy data were used from a longitudinal cohort of cSLE patients. Patients with a disease onset before the age of 18 years and diagnosis according to SLICC 2012 criteria were included. Disease activity was defined by SLEDAI score and disease damage by the SLICC damage index. Nailfold images from eight fingers (excluding thumbs) were obtained by videocapillaroscopy. A scleroderma pattern was defined according to the ‘fast track algorithm’ (3). An abnormal capillary pattern that did not match the criteria for a scleroderma pattern was defined as ‘microangiopathy’.

Results:

Our longitudinal study cohort consisted of n=53 cSLE patients with a median disease onset of 14 years (IQR 12.5-15.5 years) and a median SLEDAI score at diagnosis of 11 (IQR 8-15.5). Clinical follow-up data were available from 0.5-16 years after disease onset. Median disease duration at first capillaroscopy was 17 months (IQR 5.5-51.5 months) and 17/53 (32.1%) of patients had Raynaud’s phenomenon. In total, n=9 (17%) showed a scleroderma pattern (at some point in time), n=37 (70%) had microangiopathy and n=7 (13%) showed a normal capillary pattern. N=27 patients had follow up with capillaroscopy (1-7 times over 1-5 years). In most patients (23/27) we did not observe any change in capillary pattern during follow-up. Two patients showed changes from microangiopathy to a scleroderma pattern, one patient from a scleroderma pattern to microangiopathy and one patient from microangiopathy to a normal pattern. Raynaud’s phenomenon was equally distributed among patients with different capillaroscopy patterns (p=0.487), as was median SLEDAI score at diagnosis (p=0.285). Follow-up patients with a capillary scleroderma pattern did not show any clinical features for SSc over time (follow-up over 1-5 years, Table 1 below. Patients with a capillary scleroderma pattern showed significantly more disease damage (Chi-square, p=0.008), also indicated by a survival analysis for disease damage (Figure 1, p=0.042).

Conclusion:

Our study indicates that a capillary scleroderma pattern in cSLE correlates with disease damage but not with clinical SSc features during follow-up period.

References:

[1]S. Pavlov-Dolijanovic et al. Is there a difference in systemic lupus erythematosus with and without Raynaud’s phenomenon? Rheum Int 2013;33: 859–865

[2]D. Schonenberg-Meinema et al. Nailfold capillary abnormalities in childhood-onset systemic lupus erythematosus. Revised manuscript after review re-submitted to Lupus in January 2021

[3]V. Smith et al. Fast track algorithm. Autoimm Rev 2019 Nov;18(11): 102394

Table 1.

Clinical characteristics of cSLE-patients (n=9/53) with a nailfold capillary scleroderma pattern

Butterfly rashPhotosensitive rashLupus nephritisAutoimmune cytopeniaPositive CoombsLow C3/C4SerositisDamageType of auto-antibodiesFollow-up in years1++-+++-+ANA, Anti-ds-DNA, anti-Sm, anti-RNP, anti-Ro52, anti-SS-A52++-+++-+ANA, Anti-ds-DNA, anti-Sm, anti-RNP, anti-SS-A53-+++++++ANA, Anti-ds-DNA, anti-Sm, anti-RNP, anti-SS-A104-++-++++ANA, Anti-ds-DNA, anti-Sm, anti-RNP, anti-Ro52, anti-SS-A95-+--+-+-ANA1 (lost)6-++++++-ANA, Anti-ds-DNA, anti-c1q37---+----ANA, Anti-ds-DNA, anti-Sm, anti-RNP18++-+----ANA99-+++++++ANA, Anti-ds-DNA, anti-RNP, anti-SS-A8Figure 1.

Occurrence of disease damage (with survival as ‘no damage’) in cSLE patients with microangiopathy (blue) and a capillary scleroderma pattern (red)

Disclosure of Interests:

None declared

Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline

CLINICAL QUESTION

What are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)? This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice.

CURRENT PRACTICE

Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing.

RECOMMENDATION

The guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old).

HOW THIS GUIDELINE WAS CREATED

A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach.

THE EVIDENCE

The systematic review included 21 trials with 2192 participants. For adults with SCH, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid related symptoms, including depressive symptoms, fatigue, and body mass index (moderate to high quality evidence). Thyroid hormones may have little or no effect on cardiovascular events or mortality (low quality evidence), but harms were measured in only one trial with few events at two years' follow-up.

UNDERSTANDING THE RECOMMENDATION

The panel concluded that almost all adults with SCH would not benefit from treatment with thyroid hormones. Other factors in the strong recommendation include the burden of lifelong management and uncertainty on potential harms. Instead, clinicians should monitor the progression or resolution of the thyroid dysfunction in these adults. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of thyroid hormones in multilayered evidence summaries and decision aids available in MAGIC (https://app.magicapp.org/) to support shared decisions and adaptation of this guideline.

Brief pain re-assessment provided more accurate prognosis than baseline information for low-back or shoulder pain

Background

Research investigating prognosis in musculoskeletal pain conditions has only been moderately successful in predicting which patients are unlikely to recover. Clinical decision making could potentially be improved by combining information taken at baseline and re-consultation.

Methods

Data from four prospective clinical cohorts of adults presenting to UK and Dutch primary care with low-back or shoulder pain was analysed, assessing long-term disability at 6 or 12 months and including baseline and 4–6 week assessments of pain. Baseline versus short-term assessments of pain, and previously validated multivariable prediction models versus repeat assessment, were compared to assess predictive performance of long-term disability outcome. A hypothetical clinical scenario was explored which made efficient use of both baseline and repeated assessment to identify patients likely to have a poor prognosis and decide on further treatment.

Results

Short-term repeat assessment of pain was better than short-term change or baseline score at predicting long-term disability improvement across all cohorts. Short-term repeat assessment of pain was only slightly more predictive of long-term recovery (c-statistics 0.78, 95% CI 0.74 to 0.83 and 0.75, 95% CI 0.69 to 0.82) than a multivariable baseline prognostic model in the two cohorts presenting such a model (c-statistics 0.71, 95% CI 0.67 to 0.76 and 0.72, 95% CI 0.66 to 0.78). Combining optimal prediction at baseline using a multivariable prognostic model with short-term repeat assessment of pain in those with uncertain prognosis in a hypothetical clinical scenario resulted in reduction in the number of patients with an uncertain probability of recovery, thereby reducing the instances where patients may be inappropriately referred or reassured.

Conclusions

Incorporating short-term repeat assessment of pain into prognostic models could potentially optimise the clinical usefulness of prognostic information.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1502-8) contains supplementary material, which is available to authorized users.

Bringing immunoglobulin knowledge up to date: how should we treat today?

Immunoglobulin (Ig) therapy is constantly evolving. Advances in the basic and clinical science of immunoglobulins have provided new perspectives in using polyclonal IgG to treat patients with primary immunodeficiencies. Recent meta-analyses of patient data and outcomes, optimization of IgG administration and better understanding of the IgG receptor variability and clinical effect are new concepts which practising immunologists can use in tailoring their approach to treating patients with primary immunodeficiencies. This manuscript presents the proceedings of a satellite symposium, held in conjunction with the European Society for Immunodeficiencies (ESID) 2010 meeting, to inform attendees about new scientific concepts in IgG therapy, with the goal of empowering expert level evaluation of what optimal IgG therapy is today.

[Guideline 'Diagnosis and treatment of obesity in adults and children']

The multidisciplinary guideline 'Diagnosis and treatment of obesity in adults and children' developed by the Dutch Institute for Healthcare Improvement (CBO) is based on published scientific evidence whenever possible. Diagnosis ofobesity requires a body-mass index (BMI) of 30 kg/m2 or more with additional assessment of waist circumference and comorbidity. For children and adolescents, use ofage-specific BMI thresholds is recommended. Treatment of obesity consists of multiple lifestyle interventions for at least 1 year, followed by long-term management aimed at weight maintenance or any further weight loss. In adults, the goal is to achieve weight loss of at least 5% and a reduction in waist circumference of at least 10% after 1 year. If weight loss after 1 year is less than 5%, the addition of pharmacological interventions to lifestyle interventions can be considered. Bariatric surgery can be considered for patients with a BMI of 40 kg/m2 or more and for those with BMI 35-40 kg/m2 with one or more comorbidities. Pharmacological and surgical interventions are not recommended for children and adolescents.

Course and prognosis of shoulder symptoms in general practice

OBJECTIVES

To investigate the course and prognosis of shoulder pain in the first 6 months after presentation to the general practitioner. We separately studied patients with acute, subacute and chronic shoulder pain, as duration of symptoms at presentation has been shown to be the strongest predictor of outcome.

METHODS

A prospective cohort study with 6 months follow-up was carried out in The Netherlands, including 587 patients with a new episode of shoulder pain. Patients were categorized as having acute (symptoms <6 weeks), subacute (6-12 weeks) or chronic (>3 months) shoulder pain. The course of shoulder pain, functional disability and quality of life was analysed over 6 months. Patient and disease characteristics, including physical and psychosocial factors, were investigated as possible predictors of outcome using multivariable regression analyses.

RESULTS

Acute shoulder symptoms showed the most favourable course over 6 months follow-up, with larger pain reduction and improvement of functional disability. Patients with chronic shoulder symptoms showed the poorest results. The multivariable regression analysis showed that predictors of a better outcome at 6 months for acute shoulder pain were lower baseline disability scores and higher baseline pain intensity (explained variance 46%). Predictors of a better outcome for chronic shoulder pain were lower scores on pain catastrophizing and higher baseline pain intensity (explained variance 21%).

CONCLUSIONS

The results indicate that, besides a different course of symptoms in patients presenting with acute or chronic shoulder pain, predictors of outcome may also differ with psychosocial factors being more important in chronic shoulder pain.

The involvement of Fc gamma receptor gene polymorphisms in Kawasaki disease

Kawasaki disease is an acute febrile syndrome in infancy, characterized by vasculitis of medium-sized arteries. Without treatment the disease can lead to coronary artery lesions (CAL) in approximately 25% of the children. Therapy consists of intravenous immunoglobulins (IVIG), leading to a decrease of complications to 5-16%. Little is known about the working mechanisms of IVIG. In this study we evaluated the involvement of Fcgamma receptors (FcgammaRs) in Kawasaki disease by the determination of the frequency of known single nucleotide polymorphisms (SNPs) in the genes coding for the FcgammaRs and compared this with frequencies in a cohort of healthy controls. There was no difference in the distribution of the functionally relevant genotypes for FcgammaRIIa-131H/R, FcgammaRIIb-232I/T, FcgammaRIIIa-158 V/F and FcgammaRIIIb-NA1/NA2 between the patient group and the healthy controls. Furthermore, there were no polymorphisms linked to the disease severity as indicated by the absence or development of CAL during the disease. Altered transcription or expression of FcgammaR on specific cell types of the immune system may still play a role in susceptibility and treatment success, but at a level different from the functional SNPs in FcgammaR genes tested in this study.

Primary autoimmune neutropenia in children: a study of neutrophil antibodies and clinical course

BACKGROUND AND OBJECTIVES

Primary autoimmune neutropenia (AIN) in children is characterized by severe neutropenia, but mild bacterial infections and a spontaneous resolution. Neutrophil autoantibodies are involved in the disease. The precise relationship between the specificity and level of reactivity of the antibodies with the absolute neutrophil count and frequency of infections is not known. To obtain a better insight into this relationship, we performed a follow-up study in 15 patients with primary AIN. In addition, we performed two different neutrophil antibody tests to evaluate their sensitivity and specificity.

MATERIALS AND METHODS

Blood samples from 15 children were tested for neutrophil antibodies, at different time-points during the disease, by using the indirect granulocyte immunofluorescence test (GIFT) and the monoclonal antibody-specific immobilization of granulocyte antigens (MAIGA) assay. Clinical data related to the occurrence of bacterial infections and treatment, and neutrophil counts were collected.

RESULTS

Early in the disease, antibodies with pan-FcRIIIb specificity were detected, and HNA-1a or HNA-1b specificity of the antibodies developed over time. The sensitivity and specificity of neutrophil antibody detection tests were higher in the GIFT than in the MAIGA assay. Variables predicting time of recovery from neutropenia were not found. Prophylactic antibiotics led to the almost complete disappearance of infections.

CONCLUSIONS

In patients with primary neutropenia, neutrophil antibody specificity changes over time. Prophylactic antibiotics do benefit the patients.