Intensive training programme for ultrasound-guided minimally invasive synovial tissue biopsy on knees and wrists in different phases of inflammation

OBJECTIVES

To develop an intensive training programme for ultrasound (US)-guided synovial tissue (ST) biopsy on knees and wrists in inflammatory arthritis and to assess the learning curve, patient tolerability, sample quality and trainees' expectations.

METHODS

Active or remission rheumatoid arthritis patients were enrolled. Nine trainees joined the 4-month programme in a centre experienced in performing US-guided ST biopsies consisting of four sequential phases: (1) observation, (2) performance of guided step-by-step phases, (3) execution of the whole procedure on paired joints (knees or wrists) of the same patient in parallel with the trainer and (4) performance of the procedure autonomously. Sample representativity was assessed by histology, and procedure-related adverse events were recorded. Before and after the programme, trainees' expectations and perceptions were collected.

RESULTS

328 ST biopsy procedures were included. The rate of trainees' informative samples was: (1) comparable to the trainers in active and remission knees, but lower in active wrists (70% for trainees vs 100% for trainers, p=0.06) in phase 3; (2) excellent on active knees and wrists (91.9% and 90.9% respectively) but lower (77.6%, p=0.0089) on remission knees in phase 4. Procedures performed by trainees did not affect patient tolerability. Trainees' expectations about procedure-related invasiveness and pain infliction decreased while the difficulty of procedure execution on active wrists and remission knees remained perceived as moderately difficult.

CONCLUSIONS

This intensive training programme develops advanced skills in the performance of US-guided ST biopsy on knees and wrists, yielding high-quality specimens available for basic and translational studies on inflammatory joint diseases.

Cystoisospora spp. infection at a dog breeding facility in the Madrid region: Infection rate and clinical management based on toltrazuril metaphylaxis

Canine coccidiosis caused by Cystoisospora canis and Cystoisospora ohioensis-complex is common in kennels. While often underestimated, coccidiosis may cause severe clinical signs in puppies and sometimes even lead to death, so preventative measures are important. This study examines Cystoisospora spp. infection at a Labrador retriever breeding facility in Madrid, Spain. To identify environmental factors associated with infection, dams were examined throughout a reproductive cycle (from oestrus to 60 days postpartum) and their puppies during their first 60 days of life. Also assessed was the efficacy of combined treatment with emodepside (0.9 mg/ml) and toltrazuril (18 mg/ml) at a dose of 0.5 ml/kg of weight, equivalent to 0.45 mg/kg and 9 mg/kg, respectively, in puppies on day 35 of life. Oocyst shedding was detected in 4.6-18.6% of 45 dams examined and in 2.2-9.1% of their litters (315 puppies). In both cases, peak opg elimination was recorded on day 30 postpartum/of life. The species of Cystoisospora detected were C. canis (91.3%) and C. ohioensis-complex (8.7%). While in both dams and puppies opg counts were higher in autumn when rainfall was at its highest, correlation between opg and rainfall emerged as significant only in puppies (p = 0.031). The treatment of 35 day-old puppies with toltrazuril was 100% effective in controlling this infection in the kennel. Our findings therefore suggest the need for a strict hygiene regime and the use of toltrazuril as blanket treatment to reduce Cystoisospora transmission in dog breeding facilities.

The assessment of the drug retention rate of secukinumab in patients with psoriatic arthritis in a real-life multicentre cohort

OBJECTIVES

We aimed to evaluate the drug retention rate (DRR) of secukinumab, an anti-IL-17A monoclonal antibody, in patients with psoriatic arthritis (PsA) in a real-life cohort, and to assess the impact of comorbidities and patient clinical characteristics on the DRR of secukinumab.

METHODS

A retrospective study of prospective followed-up patients was performed to evaluate the DRR of secukinumab on patients with PsA attending the recruiting centres between January 2016 and June 2022.

RESULTS

In 207 patients with PsA, a 60-month DRR of secukinumab of 57.0% was estimated (mean time of administration of 21.5±17.1 months). Male gender, age ≥65 years, disease duration ≥5 years and ≥10 years did not influence the DRR of secukinumab. The presence of comorbidities, considering any concomitant disorder, did not affect the DRR of secukinumab. In patients with cardiometabolic multimorbidity, a trend toward a better DRR of secukinumab was recorded. In fact, patients with high blood pressure, dyslipidaemia, and type 2 diabetes showed a trend toward an improved DRR of secukinumab. Furthermore, the presence of obesity did not influence the DRR of secukinumab. Different dosages, previous bDMARDs, and concomitant therapy with csDMARDs did not influence the DRR of secukinumab.

CONCLUSIONS

A cumulative 60-month DRR of secukinumab of 57.0% in patients with PsA was retrieved. The presence of cardiometabolic multimorbidity could be associated with an improved DRR of secukinumab, whereas obesity did not affect this feature in our cohort. Previous bDMARDs, concomitant csDMARDs, and different drug dosages could not influence the DRR of secukinumab over time.

Determining the PASS cut-off points for the FIQR, FASmod and PSD in patients with fibromyalgia: a registry-based study

OBJECTIVES

To determine the cut-off values of Patient Acceptable Symptom State (PASS) for the revised Fibromyalgia Impact Questionnaire (FIQR), the modified Fibromyalgia Assessment Scale (FASmod), and the Polysymptomatic Distress scale (PSD) and to determine the predictors of PASS in patients with fibromyalgia (FM).

METHODS

FM patients belonging to the Italian Fibromyalgia Registry (IFR) completed the FIQR, the FASmod and the PSD. The PASS was assessed using a dichotomous answer. The cut-off values were obtained through the receiver operating characteristic curve (ROC) analyses. A multivariate logistic regression analysis was performed to determine predictors of achieving the PASS.

RESULTS

5545 women (93.7%) and 369 males (6.3%) were included in the study. The 27.8% of patients reported an acceptable symptom state. Patients in PASS differed in all patient-reported outcome measures (p <0.001). The FIQR PASS threshold was ≤58 (area under the ROC curve [AUC] = 0.819). The FASmod PASS threshold was ≤23 (AUC = 0.805) and the PSD PASS threshold was ≤16 (AUC = 0.773). In the pairwise AUC comparison, the discriminatory power of the FIQR PASS outperforms both FASmod PASS (p = 0.0124) and PSD PASS (p <0.0001). Multivariate logistic analysis showed that FIQR items related to memory and pain were the only predictors of PASS.

CONCLUSIONS

The FIQR, FASmod, and PSD PASS cut-off points for FM patients have never been determined before. This study provides additional information to facilitate interpretation of the severity assessment scales in daily practice and clinical research related to FM patients.

Carboplatin and paclitaxel plus avelumab compared with carboplatin and paclitaxel in advanced or recurrent endometrial cancer (MITO END-3): a multicentre, open-label, randomised, controlled, phase 2 trial

BACKGROUND

Adding immunotherapy to first-line chemotherapy might improve outcomes for patients with advanced or recurrent endometrial cancer. We aimed to compare carboplatin and paclitaxel versus avelumab plus carboplatin and paclitaxel as first-line treatment with avelumab given concurrent to chemotherapy and as maintenance after the end of chemotherapy.

METHODS

MITO END-3 is an open-label, randomised, controlled, phase 2 trial conducted at 31 cancer institutes, hospitals, and universities in Italy. Eligible patients were aged 18 years or older with histologically confirmed advanced (FIGO stage III-IV) or recurrent endometrial cancer, an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1, and no previous systemic anticancer therapy as primary treatment for advanced or metastatic disease. Participants were randomly assigned (1:1) using a computerised minimisation procedure stratified by centre, histology, and stage at study entry, to either receive carboplatin (area under the curve [AUC] 5 mg/mL × min) and paclitaxel (175 mg/m²; standard group) intravenously every 3 weeks for six to eight cycles or avelumab (10 mg/kg intravenously) added to carboplatin and paclitaxel (experimental group) every 3 weeks and then every 2 weeks as a single maintenance treatment after the end of chemotherapy until disease progression or unacceptable toxicity. Patients, treating clinicians, and those assessing radiological examinations were not masked to study treatment. The primary endpoint was investigator-assessed progression-free survival, measured in the intention-to-treat (ITT) population. Patients who received at least one dose of study drug were included in the safety analysis. Experimental group superiority was tested with 80% power and one-tailed α 0·20. This trial is registered with ClinicalTrials.gov (NCT03503786) and EudraCT (2016-004403-31).

FINDINGS

From April 9, 2018, to May 13, 2021, 166 women were assessed for eligibility and 39 were excluded. 125 eligible patients were randomly assigned to receive carboplatin and paclitaxel (n=62) or avelumab plus carboplatin and paclitaxel (n=63) and included in the ITT population. The median follow-up was 23·3 months (IQR 13·2-29·6) and was similar between the two groups. 91 progression-free survival events were reported, with 49 events in 62 patients in the standard group and 42 events in 63 patients in the experimental group. The median progression-free survival was 9·9 months (95% CI 6·7-12·1) in the standard group and 9·6 months (7·2-17·7) in the experimental group (HR of progression or death 0·78 [60% CI 0·65-0·93]; one-tailed p=0·085). Serious adverse events were reported more frequently in the experimental group (24 vs seven events in the standard group); neutrophil count decrease was the most frequent grade 3-4 adverse event (19 [31%] of 61 patients in the experimental group vs 26 [43%] of 61 patients in the standard group). Two deaths occurred in the experimental group during treatment (one respiratory failure following severe myositis [possibly related to treatment] and one cardiac arrest [not related to treatment]).

INTERPRETATION

Adding avelumab to first-line chemotherapy deserves further testing in patients with advanced or recurrent endometrial cancer, although consideration of mismatch repair status is warranted.

FUNDING

Pfizer.

Mothers and fathers of pre-school children: a study on parenting stress and child's emotional-behavioral difficulties

The present study aimed to analyze the differences between maternal and paternal parenting stress and children's behavioral functioning, as determined by teacher and parent reports. In addition, it sought to evaluate the presence of clusters based on parenting stress and to determine whether perceptions of children's behavioral functioning varied across these clusters. The sample was composed of the parents and teachers of N = 201 children. Parents completed a self-report questionnaire on parenting stress and parents and teachers filled out report-form questionnaires assessing children's emotional and behavioral functioning. The results showed that mothers had higher levels of parenting stress than fathers, and both parents reported more prosocial behavior in children than did teachers. Furthermore, middle stressed parents had children who expressed more prosocial behavior than did parents in other clusters. The findings also showed that parenting stress influenced partners' perceptions of children's behavioral functioning. The multiplicity of child observers facilitated a better understanding of how parenting stress, linked to parent-child interactions, may play an important role in shaping parents' perceptions of their children.

AB0936 Neuropathic pain in Psoriatic Arthritis: analysis of populations treated with anti TNF and anti IL17

Background

Psoriatic arthritis (PsA) is a disease characterized by chronic pain and it is often associated with the presence of fibromyalgia (FMS) with an estimated prevalence of 18%. Several studies demonstrated the central role of neuropathic pain in FMS. However, patients with inflammatory diseases such as PsA frequently complain of complex pain symptoms, with neuropathic characteristics. Therefore, in PsA we can recognize both an inflammatory pain and a neuropathic pain that can be exacerbated both by the concomitant fibromyalgia or depending only on the PsA itself. In fact, In the context of PsA, the presence of neuropathic pain features has been documented in 28% of patients. This could be a reason why the low remission rate in these patients. Finally, Studies on murin models revealed a possible role of IL17, key cytokine of PsA pathogenesis, in mechanism of neuropathic pain.

Objectives

To evaluate the role of anti-TNF and antiIL-17 in neuropathic pain in PsA patients treated with the first biological drug (bDMARDS).

Methods

A cross-sectional evaluation was conducted on 38 PsA patients classified by Classification criteria for Psoriatic Arthritis (CASPAR), referred to the PsA outpatient clinic of “University of Campania Luigi Vanvitelli”. Thirty patients were treated with anti-TNF (mean age 53 years, 17F, 13M), 8 were treated with anti-IL17 (mean age 50 years, 5F, 3M), for almost 6 months. For each patient, an assessment of disease activity using DAPSA and physical function was carried out. The presence of comorbid fibromyalgia syndrome (FMS) was evaluated according to ACR 2016 criteria. We investigated neuropathic pain features through the PainDETECT Questionnaire (PDQ).

Results

Nine patients treated with anti TNF were in DAPSA remission; 18 patients had low disease activity, 3 had High disease activity, FMS was detected in 11 of 30 patients, no one in DAPSA remission for PsA. Characteristics of neuropathic pain (PDQ ≥ 19) were found in 13 (43.3%) patients overall; unlikely neuropathic pain (PDQ < 12) in 16 (53.3%) patients. In the first group 7 patients had FMS, in the second group 3 had FMS. So, our analysis revealed the presence of neuropathic pain in 6 patients (54,5%) with PsA treated with antiTNF with no FMS; all of them were in low disease activity. The same analysis was conducted on anti IL17 treated population: 4 patients were in DAPSA remission, 2 patients in low disease activity, 2 patients in high, disease activity. FMS was diagnosed in 3 patients, 1 of them was in DAPSA remission for PsA. PDQ>19 was found only in 1 patient, who had FMS in comorbidity; the others had no neuropathic pain. So, we had no PsA patient treated with antiIL17, that manifested symptoms of neuropathic pain.

Conclusion

The contribute of IL-17 in developing of neuropathic pain suggests the possible role of anti IL17 as therapy; our results support this tesis suggesting a possible role of anti IL17 in treatment of neuropathic pain. A limit to our work is given by the low sample size for which further studies are necessary to confirm this data.

References

[1]Ramjeeawon A, Neuropathic-like pain in psoriatic arthritis: evidence of abnormal pain processing. Clin Rheumatol. 2019;

[2]Sun C, IL-17 contributed to the neuropathic pain following peripheral nerve injury by promoting astrocyte proliferation and secretion of proinflammatory cytokines. Mol Med Rep. 2017

[3]Martinez-Lavin M: Fibromyalgia is a neuropathic pain syndrome. J Rheumatol 2006;

Disclosure of Interests

None declared

AB1198 PREVALENCE AND PSYCHOPATHOLOGICAL CHARACTERISTICS OF ANXIETY AND DEPRESSIVE SYMPTOMS IN FIBROMYALGIA PATIENTS

Background

Several studies reported higher depression and anxiety rates in fibromyalgia (FM) patients compared to the general population. Furthermore, dysfunctional coping strategies

have been pointed to as intrinsic parts of the pathogenesis of FM.

Objectives

Our study aimed to verify the prevalence of anxiety and depressive symptoms and explore their correlation with physical symptoms as fatigue, sleep, and widespread pain in a cohort of patients diagnosed with FM. We also aimed to determine whether dysfunctional coping strategies might increase the depression and anxiety burden, besides worsening the core symptoms of FM.

Methods

We analyzed a cohort of 105 patients (median age of 53 years 6 M, 99 F) with a diagnosis of FM according to the ACR 2016 criteria. The participants were consecutively recruited from the Fibromyalgia clinic of the University of Campania “Luigi Vanvitelli”. All patients underwent a psychiatric evaluation. We assessed widespread pain by the Widespread Pain Index (WPI) and the presence of fatigue by the Symptom Severity score (SS). Sleep disorders were investigated through Pittsburgh Sleep Quality Index (PSQI). We analyzed mental alterations by Hamilton Depression and Anxiety Rating Scales (HAM-D, HAM-A), and coping strategies by Coping Orientation to Problems Experienced (COPE) Inventory.

The Statistical Package for Social Sciences (SPSS) 22.0 was used; the level of significance was set at p < 0.05.

Results

All patients showed fatigue and widespread pain (100%); sleep disturbances were found in 90.5% of patients and overlapped with all sleep phases. The prevalence of anxiety associated with depression was 75.2%. We found isolated anxiety in 14.3% and isolated depression in 4.8% of patients. We further evidenced a different degree of depression: mild (50.7%), moderate (24.3%), and severe (6.5%). All patients showed depressed mood only if questioned (low tendency to spontaneous verbalization). COPE analysis showed no significant differences in the use of the three coping strategies (Problem-focused, emotion-focused, avoidance-focused). Pearson’s correlation analysis highlighted a negative relationship between problem-focused strategies and the severity of anxiety (r = -0.31, p = .001) and depression (r = -0.32, p = .001). Our analysis also highlighted a positive correlation between fatigue, sleep disturbances, widespread pain, and both anxiety and depression. The analysis of the characteristics of anxiety and depressive symptoms showed a scarce tendency to spontaneous verbalization of depressed mood and ideas of guilt, mostly limited to family relationships, and a sense of ineffectiveness conditioned by the physical symptoms of the disease. Most patients showed psychomotor agitation, psychic and somatic anxiety, poor insight. The analysis of coping strategies adopted showed a negative correlation between problem-focused strategies and anxiety-depressive symptoms, suggesting that such strategies are less frequent in FM patients with comorbid anxiety and depressive symptoms.

Conclusion

Our study confirms the high prevalence of anxiety and depressive symptoms in FM patients. A positive correlation between the pivotal symptoms and anxiety and depressive symptoms may suggest, without implying a cause-and-effect relationship, that psychiatric intervention should be considered along with rheumatologic treatment, to improve both physical symptoms and quality of life. Potentiating problem-focused coping strategies may represent a target to improve anxiety and depressive symptoms.

References

[1]Wolfe et al Revisions to the 2010/2011 FM diagnostic criteria. Semin Arth. Rheum. 2016

Table 1.

Correlation analysis between coping strategies and HAM-D and HAM-A total scores

HAM-DHAM- AProblem-focused Coping- 0,32**- 0,31**Avoidant Coping0,800,92Emotion Coping0,140,13

**p<0.01

Disclosure of Interests

None declared

Feline thelaziosis (Thelazia callipaeda) in Spain: state-of-the-art and first prophylactic trial in cats

OBJECTIVES

Thelaziosis caused by the nematode Thelazia callipaeda (Spirurida, Thelaziidae) affects the eyes of domestic and wild carnivores, lagomorphs and even humans. The role of cats in spreading thelaziosis remains unclear. The present study assesses the current status of feline T callipaeda infection in Spain and presents the results of the first prophylactic trial conducted in this species.

METHODS

We retrospectively analysed the occurrence of feline thelaziosis (study 1), examined its prevalence based on cross-sectional sampling of endemic areas (study 2), and assessed the therapeutic/prophylactic benefits of a spot-on (moxidectin) and therapeutic efficacy of an eye drop (ivermectin) formulation (study 3).

RESULTS

In study 1, 69 Thelazia-infected cats were examined. Autochthonous cases were detected in 18/26 municipalities surveyed in Spain, which corresponds to 88.4% (n = 61/69) of the total number of cases. In study 2, 74 cats (20 from La Vera region and 54 from Orense province) were examined from 2011 to 2013. Ten of these cats (13.5%) were infected with T callipaeda. The infection prevalence was 40% (n = 8/20) in La Vera and 3.7% (n = 2/54) in Orense. The therapeutic efficacy of ivermectin was assessed over a summer (2011) in 12 cats, while that of moxidectin was examined over a 17-month period in seven cats. Four of these seven cats were subsequently included in an all-year-round prophylaxis trial. Treatment efficacy ranged from 91.7% (ivermectin) on day 28 after treatment to 100% (moxidectin) on day 14. Moxidectin prevented reinfections in cats.

CONCLUSIONS AND RELEVANCE

Our data confirm the endemic status of T callipaeda infection in Spain, revealing its high prevalence in cats living in known endemic areas. Moxidectin was effective in treating and preventing infection. We strongly recommend the inclusion of thelaziosis in the differential diagnosis of pets and humans presenting with ocular manifestations, along with adequate preventive measures.

Antibodies elicited by the CaniLeish® vaccine: long-term clinical follow-up study of dogs in Spain

The prevention of canine leishmaniosis in healthy dogs requires a multimodal approach combining repellents with an effective vaccine. A vaccine that modulates the cell-mediated immune response against the protozoan has been available in Europe since 2012 (CaniLeish®, Virbac, France). The aim of the present study was to monitor dogs vaccinated with CaniLeish® to examine the kinetics of the antibody response and the safety and tolerance of CaniLeish®. Dogs vaccinated with CaniLeish® were monitored for 12 months. In follow-up visits at baseline (primovaccination or annual booster) (Visit 1, V1), and 1 (V2), 4 (V3), 8 (V4) and 12 (V5) months later, we examined antibody response kinetics using two serology techniques (IFAT and Speed Leish K™). Tolerance to CaniLeish® and its safety were also monitored. Anti-L. infantum IgG antibodies were determined in 242 dogs (125 dogs after primovaccination (Group P) and 117 dogs after booster vaccination (Group B). In addition, 46, 22 and 19 dogs were followed for 2, 3 and 4 years, respectively. At baseline, 100% of dogs in Group P returned negative IFAT and Speed Leish K™ test results while 9.4% (11/117) in Group B tested IFAT positive though Speed Leish K™ negative. In subsequent visits, seropositivity was detected by IFAT in 31.2% (Group P) and 41% (Group B) of the dogs in V2; 16.8% (Group P) and 10.2% (Group B) in V3; 6.4% (Group P) and 8.5% (Group B) in V4; and 3.2% (Group P) and 5.9% (Group B) in V5. All dogs tested Speed Leish K™ negative except two, in which it was later confirmed by molecular testing that they were not infected. Adverse events that could be associated with the vaccine were detected in 20 out of 314 dogs (6.4%). The good clinical status of all dogs was confirmed in an exhaustive clinical exam and haemato-biochemical profile. The Canileish® vaccine was well-tolerated with exceptions that did not appear to be related to age, sex, race or size of vaccinated dogs. Anti-L. infantum antibodies were detected by IFAT in 31.9-40.3% of the dogs 1 month after vaccination, and these antibodies could still be detected in 3.2% of the dogs 1 year later. This means that veterinarians need to use other tools (eg. PCR) to correctly diagnose seropositive dogs.

Update on the treatment and prevention of ocular thelaziosis (Thelazia callipaeda) in naturally infected dogs from Spain

This study examines the therapeutic and year-round prophylactic efficacy of different formulations used in dogs in three Spanish areas where canine thelaziosis is endemic. The study was conducted as a Good Clinical Practice, multicentre, randomised field study in privately owned outdoor dogs naturally infected with Thelazia callipaeda. The active pharmaceutical ingredients tested were: an oral formulation of milbemycin oxime 12.5 mg combined with praziquantel 125 mg (A), a subcutaneous sustained-release formulation of moxidectin 10 g (B), a moxidectin 2.5% weight/volume (w/v) spot-on formulation combined with imidacloprid 10% w/v (C), and an eye drop formulation (6 µg) of ivermectin 10 mg/ml diluted 10% in propylene glycol (D). Infected dogs were randomly allocated to treatment Groups A, B, C and D. Dogs testing negative for T. callipaeda inspection in two visits (Day 7/Day 14 and D30) were enrolled in the prophylaxis trial and reallocated to the corresponding study group (A, B, C or D). Treatment efficacy ranged from 70.4% recorded in Group A 1 week after treatment, to 100% recorded in Group C on Day 30 and in Group B on Day 60. Treatment was more efficacious in Group D (85.7% 1 week after treatment) than A, but was never 100% efficacious as in Groups B and C. Year-round prophylactic efficacy was 83.3% in Group A, 100% in Group B, 93.5% in Group C and 87.5% in Group D. In conclusion, products containing moxidectin were highly efficacious both in treating and preventing canine thelaziosis. Milbemycin also emerged as a good option. However, the off-label use of topical or subcutaneous ivermectin should be avoided due to possible adverse reactions such as pruritus, irritation or redness. In endemic areas, monthly prophylaxis to limit the spread of T. callipaeda to new areas across Europe and reduce zoonotic risks is essential.

Psychological effects of the COVID-2019 pandemic: Perceived stress and coping strategies among healthcare professionals

Starting from China, the coronavirus disease (COVID-19) contagion spread unexpectedly and quickly all over the world, particularly affecting Italy. In the early stages of the epidemic, healthcare professionals have been in the front-line to manage the infection. The current study aimed to analyse the impact of COVID-19 outbreak on healthcare professionals and to detect some risk and protective factors of their distress levels, with regard to socio-demographic variables, direct exposure to COVID-19 and the coping strategies used to deal with stress. The data were collected during the peak of the infection. A total of 595 healthcare professionals enrolled in the study and completed the measures of socio-demographical and professional data, perceived stress (PSS) and coping strategies (COPE- NVI-25). Overall, we found that a positive attitude towards the stressful situation was the main protective factor, while female gender, seeking social support, avoidance strategies and working with COVID-19 patients were risk factors. Economic status, problem solving ability and turning to religion were not associated with stress levels. This study, one of the first on this topic, highlighted the main coping strategies used by healthcare professionals in facing the highly stressful situation caused by the pandemic.

The red fox (Vulpes vulpes) as a potential natural reservoir of human cryptosporidiosis by Cryptosporidium hominis in Northwest Spain

Giardia duodenalis and Cryptosporidium spp. are ubiquitous intestinal protozoa that parasitize domestic and wild animals, as well as human beings. Due to their zoonotic potential, the objective of the present study was to determine the presence of these pathogens in the fox population (Vulpes vulpes) located in Northwest Spain. A total of 197 faecal samples from legally hunted foxes were collected in the autonomous region of Galicia. The presence of G. duodenalis and Cryptosporidium spp. was investigated by PCR-based methods amplifying the small subunit ribosomal RNA (ssu rRNA) gene of the parasites. Attempts to genotype obtained positive samples were subsequently conducted at the glutamate dehydrogenase (gdh) and β-giardin (bg) genes of G. duodenalis, and the 60 kDa glycoprotein (gp60) gene of Cryptosporidium. Giardia duodenalis and Cryptosporidium spp. were identified in 19 (9.6%) and 12 (6.1%) of the investigated samples, respectively. However, five Cryptosporidium species were detected at the ssu rRNA locus: C. hominis (33.4%, 4/12), C. canis (25.0%, 3/12), C. parvum (16.7%, 2/12), C. ubiquitum (8.3%, 1/12) and C. suis (8.3%, 1/12). An additional Cryptosporidium-positive sample was identified at the genus level only. Typing and subtyping of Giardia- and Cryptosporidium-positive samples were unsuccessful. The detection of C. hominis in wild foxes indicates the probable overlapping of sylvatic and domestic cycles of this parasite in rural settings. Besides, this finding raises the question of whether red foxes may act as natural reservoirs of C. hominis. The detection of C. parvum and C. suis is suggestive of active transmission events between farm and wild animals, opening up the possibility of transmission to human beings.

Latest trends in L. infantum infection in dogs in Spain, Part II: current clinical management and control according to a national survey of veterinary practitioners

Background

Canine leishmaniosis (CanL) is a parasitic zoonotic disease, endemic in the Mediterranean basin including Spain. While knowledge about CanL, its management, treatment, prevention and control mounts, it remains unclear whether all clinical veterinarians follow the same international recommendations, such as those of the LeishVet group. This study was thus designed to assess recent trends in the clinical management of CanL in veterinary clinics across Spain through a questionnaire-based survey. Results were compared with those of a prior national multicenter questionnaire administered by our research team in 2005.

Methods

A questionnaire consisting of 28 questions about CanL was developed using Google Forms and distributed by email to 1428 veterinary clinics in Spain. Questions were designed to obtain data on common clinical signs, techniques and complementary exams used to diagnose the disease, and on its monitoring, treatment and control measures. Data were collected in a database for statistical analysis.

Results

Completed questionnaires were returned by 295 clinics. Compared to the situation in 2005, responses indicate that clinical signs of CanL have not changed significantly, cutaneous lesions being still the most prevalent sign observed by practitioners. Quantitative serological techniques are considered an adequate approach to diagnosis, provided their results are supported by the findings of a thorough physical exam, as well as complementary tests (complete blood count, biochemical profile, plasma protein electrophoretogram and complete urinalysis). Treatment protocols and check-ups follow international recommendations. Finally, a multimodal approach is being endorsed to adequately control CanL including preventive measures such as annual serological check-ups and the combination of repellents and vaccines. Additionally, owners are being better informed about CanL by veterinarians, which translates to the improved control of this zoonosis.

Conclusions

The clinical management of CanL has recently undergone significant changes owing to improvements in clinical knowledge of the disease, more unified international criteria, improved diagnostic techniques and their adequate interpretation, as well as a greater awareness of the disease transmitted to owners.

Latest trends in Leishmania infantum infection in dogs in Spain, Part I: mapped seroprevalence and sand fly distributions

Background

This report describes L. infantum infection seroprevalence in dogs in Spain through data obtained from peer-reviewed literature and a cross-sectional serological survey assessing epidemiological and habitat variables as risk factors for infection. The study also provides preliminary sand fly species distribution data and indicates factors affecting their distribution and density.

Methods

Three different studies were conducted in Spain: (i) a peer-reviewed literature seroprevalence survey (1985–2019); (ii) a cross-sectional serological survey (2011–2016); and (iii) a preliminary entomological survey (2013–2014). In the cross-sectional serological survey, 1739 dogs from 74 different locations including 25 Spanish provinces were tested for L. infantum by indirect immunofluorescence antibody test (IFAT) (antibody titre ≥ 1:100). Seroprevalence of L. infantum infection was analysed by province and bioclimatic zone. Statistics were used to analyse relationships between several dog- and environment-related variables and L. infantum seroprevalence. In parallel, during 2013–2014, sand flies were collected across the Iberian Peninsula and the Balearic Islands using CDC light traps to examine relationships between habitat-related factors and sand fly species densities (number of sand flies per trap per hour).

Results

The literature review revealed that the provinces showing the highest seroprevalence were Balearic Islands (57.1%), Ourense (35.6%), Málaga (34.6%) and Cáceres (34.2%), and those showing the lowest seroprevalence were Vizcaya (0%), Cantabria (2.0%) and Álava (3.3%). In our survey, anti-Leishmania IgG antibodies were detected in 176 of the 1739 dogs rendering a seroprevalence of 10.12%. Percentage seroprevalence distributions significantly varied among bioclimatic belts. Seropositivity for L. infantum was related to size (large breed dogs versus small) and were significantly higher in younger dogs (≤ 1 years-old). In the entomological survey, 676 sand flies of five species were captured: 562 (83.13%) Phlebotomus perniciosus; 64 (9.47%) Sergentomyia minuta; 38 (5.62%) P. ariasi: 6 (0.89%) P. sergenti; and 6 (0.89%) P. papatasi. Phlebotomus perniciosus showed a greater density in the thermo-Mediterranean than in the meso-Mediterranean zone. Densities of S. minuta and P. ariasi were significantly higher in rural habitats.

Conclusions

This updated seroprevalence map of L. infantum infection in dogs in Spain defines non-endemic, hypoendemic, endemic and hyperendemic areas, and confirms P. perniciosus as the most abundant sand fly vector in Spain.

New age-related hearing loss candidate genes in humans: an ongoing challenge

Age-related hearing loss (ARHL) is the most frequent sensory disorder in the elderly, affecting approximately one-third of people aged more than 65 years. Despite a large number of people affected, ARHL is still an area of unmet clinical needs, and only a few ARHL susceptibility genes have been detected so far. In order to further investigate the genetics of ARHL, we analyzed a series of 46 ARHL candidate genes, selected according to previous Genome Wide Association Studies (GWAS) data, literature updates and animal models, in a large cohort of 464 Italian ARHL patients. We have filtered the variants according to a) pathogenicity prediction, b) allele frequency in public databases, c) allele frequency in an internal cohort of 113 healthy matched controls, and 81 healthy semi-supercentenarians. After data analysis, all the variants of interest have been tested by functional "in silico" or "in vitro" experiments (i.e., molecular dynamics simulations and protein translation analysis) to assess their pathogenic role, and the expression of the mutated genes have been checked in mouse or zebrafish inner ear. This multi-step approach led to the characterization of a series of ultra-rare likely pathogenic variants in DCLK1, SLC28A3, CEP104, and PCDH20 genes, contributing to describe the first association of these genes with ARHL in humans. These results provide essential insights on the understanding of the molecular bases of such a complex, heterogeneous and frequent disorder, unveiling new possible targets for the future development of innovative therapeutic and preventive approaches that could improve the quality of life of the millions of people affected worldwide.

Temperature is a common climatic descriptor of lachryphagous activity period in Phortica variegata (Diptera: Drosophilidae) from multiple geographical locations

Background

The drosophilid Phortica variegata is known as vector of Thelazia callipaeda, the oriental eyeworm native to Asia that has become an emergent zoonotic agent in several European regions. Unlike almost all other arthropod vectors of pathogens, only P. variegata males feed of lachrymal secretions of animals, ingesting first-stage larvae (L1) of the worm living in the orbital cavities of the host, and allowing with the same behaviour the introduction of infective L3. Despite the increased detection of T. callipaeda in many European countries, information about the length of the lachryphagous activity period of P. variegata and a deep knowledge of the environmental and climatic variables involved are still limited.

Methods

We herein present the results of a multicentre study involving five sites from four different countries (Italy, Spain, UK and USA) where canine thelaziosis is endemic and/or where it has already been ascertained the presence of P. variegata. Field data have been obtained on a fortnightly basis from mid-April to the end of November 2018 from a contemporary standardized sampling (same sampling effort and time of collection in all sites) of lachryphagous flies collected around the eyes of a human bait using an entomological net. These data have been associated to data collection of local climatic variables (day length, temperature, wind speed, barometric pressure and relative humidity).

Results

Overall, a total of 4862 P. variegata flies (4637 males and 224 females) were collected, with high differences in densities among the different sampling sites. Significant positive correlations were found between P. variegata male density and temperature and wind speed, while negative correlations were observed for barometric pressure and relative humidity. However, the above significant differences are confirmed in each sampling site separately only for the temperature.

Conclusions

This multicentre study highlights that temperature is the major common environmental driver in describing the lachryphagous activity of P. variegata in Europe and USA and, therefore, the transmission risk of thelaziosis.

The role of healthy dog carriers of Babesia microti-like piroplasms

BACKGROUND

While in Europe Babesia canis has been traditionally held responsible for canine piroplasmosis, Babesia microti-like piroplasm (Bml) infection is being ever more observed in dogs, with the first clinical cases reported in northwestern Spain. This study examines the epidemiological role of healthy dogs living in endemic areas of Bml infection in Spain. The data obtained were used to describe the clinical status and map the geographical distribution of Bml infection in healthy dogs in northwestern Spain.

RESULTS

Blood samples and ticks were taken from 756 healthy dogs representatively across the whole Galicia region (northwestern Spain): stray (n = 211), hunting dogs (n = 333) and pets (n = 212). Blood samples were tested by microscopy parasite observation, nested PCR-RFLP and sequencing. Piroplasm infection prevalences in healthy dogs from northwestern Spain were 17.1% (129/756) by PCR and 3.4% (26/756) by microscopy observation. The species found by PCR were: 2.2% (17/756) for B. canis and 15.1% (114/756) for Bml. Co-infection with B. canis and Bml was noted in 2 dogs. The higher prevalences detected were Bml in hunting dogs (25.5%; 85/333) and B. canis in stray dogs (6.6%; 14/211). In fox-hunting dogs from any area and dogs from the A Coruña Province, significantly higher prevalences of Bml infection were detected (P < 0.001). Upon physical examination, tick infestation was observed: 130 ticks in 18 hunting and three pet dogs. These were subsequently identified as Rhipicephalus sanguineus (s.l.) (49.2%), Ixodes hexagonus (38.5%), Ixodes ricinus (6.9%) and Dermacentor reticulatus (5.4%). Among the more prevalent ticks infesting healthy carrier dogs were I. hexagonus, followed by D. reticulatus and I. ricinus.

CONCLUSIONS

Babesia canis and Bml were the only piroplasm species found infecting healthy dogs in Galicia, the prevalence of Bml being higher than of B. canis. Factors correlated with a higher Bml infection risk were being a hunting dog and living in the A Coruña Province. Healthy dogs travelling to other countries could act as carriers and probably contribute to the spread of Bml infection in dogs and wild carnivores throughout Europe.

Detection of Thelazia callipaeda in Phortica variegata and spread of canine thelaziosis to new areas in Spain

Background

The fruit fly Phortica variegata (Drosophilidae: Steganinae) feeds on the ocular secretions of animals and humans, and has been described as an intermediate host of the eye worm Thelazia callipaeda (Spirurida: Thelaziidae) in Italy. Despite the increased detection of T. callipaeda in many European countries, information about its vector role in natural conditions is still limited. In the Iberian Peninsula, thelaziosis caused by T. callipaeda has been reported in dogs, cats, red foxes, wild rabbits and humans.

Methods

In the last seven years, we have detected increased numbers of cases of canine thelaziosis at three locations in mainland Spain: Site 1, La Vera region (Cáceres Province, central-western Spain; 51 cases); Site 2, El Escorial municipality (Madrid Community, central Spain; 23 cases); and Site 3, Miraflores de la Sierra municipality (Madrid Community, central Spain; 41 cases). Site 1 is considered endemic for T. callipaeda while the other two sites have been recently recognised as risk zones for T. callipaeda infection.

Results

From June 2016 to September 2017, 2162 flies were collected and morphologically identified as Phortica spp. (Site 1, n = 395; Site 2, n = 1544; and Site 3, n = 223). Upon dissection, third-stage T. callipaeda larvae were found in two out of 155 flies examined from Site 1, and both these larvae tested molecularly positive for the eye worm. Of the 395 flies collected from Site 1, 371 were molecularly processed for arthropod species identification and T. callipaeda detection. All 371 flies were identified as P. variegata and 28 (7.5%; 95% CI: 4.8–10%) tested positive for T. callipaeda DNA haplotype 1.

Conclusions

Our findings indicate that T. callipaeda circulates among dogs and P. variegata in Spain, where zoonotic cases have been also reported. The co-existence of canine thelaziosis and Phortica spp. in geographical areas previously considered free of the eye worm indicates a risk of infection for both animals and humans living in this region.

First report of Leishmania infantum infection in the endangered orangutan (Pongo pygmaeus pygmaeus) in Madrid, Spain

Background

Some wild animals have been recognized as potential reservoirs of Leishmania infantum infection (e.g. carnivores, lagomorphs, rodents, etc.). Leishmania infantum was also identified infecting humans and lagomorphs (i.e. hares and rabbits) over the period of 2009–2016, with the latter acting as the main reservoirs involved in the human leishmaniosis outbreak in Madrid.

Results

Two cases of clinical leishmaniosis are reported in orangutans (Pongo pygmaeus pygmaeus) housed at two different centres in Madrid. The first is the case of a 36-year-old male orangutan with severe weight loss and apathy. A complete blood count and biochemical profile revealed anaemia, neutropenia, hypoalbuminaemia and elevated transaminases. Hepato-splenomegaly was also observed. Four months later, due to worsening of clinical signs (mainly bilateral epistaxis), blood and bone marrow samples were collected. Amastigotes of L. infantum were detected in macrophages from a bone marrow aspirate and by specific polymerase chain reaction. The second case was a 34-year-old female orangutan with severe weight loss and apathy and no other apparent clinical signs. A complete blood count and biochemical profile revealed anaemia, pancytopenia and hypoalbuminaemia. Splenomegaly and pericardial effusion were also observed. As leishmaniosis was included in the differential diagnosis, both blood and bone marrow samples were collected. Leishmania infantum infection was confirmed by microscopy, molecular diagnosis and serology (immunofluorescence antibody test). Both animals were treated daily with oral miltefosine for 28 days; allopurinol was also given uninterruptedly in Case 2 for at least 6 months. During follow-up, though good clinical recovery was clear, a lack of parasitological cure was confirmed molecularly in both blood and bone marrow samples from the two orangutans. In both habitats, the presence of the sand fly vector identified as Phlebotomus perniciosus was confirmed.

Conclusions

To our knowledge, this is the first report of L. infantum infection in great apes and in the endangered species P. p. pygmaeus. We are presently looking for L. infantum in other non-human primates living in the same peri-urban areas. If detected, we will examine the impacts of this serious disease on these critically endangered species.

Modelling the current distribution and predicted spread of the flea species Ctenocephalides felis infesting outdoor dogs in Spain

Background

The cat flea, Ctenocephalides felis, is the most prevalent flea species detected on dogs and cats in Europe and other world regions. The status of flea infestation today is an evident public health concern because of their cosmopolitan distribution and the flea-borne diseases transmission. This study determines the spatial distribution of the cat flea C. felis infesting dogs in Spain. Using geospatial tools, models were constructed based on entomological data collected from dogs during the period 2013–2015. Bioclimatic zones, covering broad climate and vegetation ranges, were surveyed in relation to their size.

Results

The models builded were obtained by negative binomial regression of several environmental variables to show impacts on C. felis infestation prevalence: land cover, bioclimatic zone, mean summer and autumn temperature, mean summer rainfall, distance to urban settlement and normalized difference vegetation index. In the face of climate change, we also simulated the future distributions of C. felis for the global climate model (GCM) “GFDL-CM3” and for the representative concentration pathway RCP45, which predicts their spread in the country.

Conclusions

Predictive models for current climate conditions indicated the widespread distribution of C. felis throughout Spain, mainly across the central northernmost zone of the mainland. Under predicted conditions of climate change, the risk of spread was slightly greater, especially in the north and central peninsula, than for the current situation. The data provided will be useful for local veterinarians to design effective strategies against flea infestation and the pathogens transmitted by these arthropods.

Epidemiological role of dogs since the human leishmaniosis outbreak in Madrid

Background

Canine leishmaniosis (CanL) has been in the spotlight since the 2009 outbreak of human leishmaniosis in Madrid. In the framework of the Leishmaniosis Surveillance Programme set up in Madrid, this study examines Leishmania-specific seroprevalences in stray dogs for the outbreak area and rest of the Madrid region over the period spanning from the outbreak to the present (2009–2016). These data are of interest because stray dogs could be sentinels for disease surveillance in endemic areas. Since 2011, we have also been monitoring owned dogs in the outbreak area.

Methods

Over the study period, Leishmania infantum seroprevalence was determined in 2,123 stray dogs from the outbreak and non-outbreak areas. A serological study was also performed for owned dogs in the outbreak area: high-risk dogs such as hunting or farm dogs (n = 1,722) and pets (n = 1372). All dogs were examined and blood was collected. The variables recorded for each animal were: breed, age, sex, and clinical history indicating if the animal was healthy or clinically suspected of having any disease, and if they showed a clinical picture compatible with CanL.

Results

Seroprevalences of L. infantum in stray dogs were similar in the two areas examined: 4.7% (20 out of 346) in the outbreak area and 5.4% (96 out of 1,777) in the remaining Madrid region (χ² = 0.080, P = 0.777). A significant association was found between seroprevalence and age (z = -6.319; P < 0.001). Seroprevalence in owned dogs in the outbreak area was 2.1% in high-risk dogs (37 out of 1,722) and 1.2% in pets (17 out of 1,372) (χ² = 3.561, P = 0.0591).

Conclusions

Both stray and owned dogs do not seem to play an important role in maintaining the transmission cycle of L. infantum in the Madrid outbreak area. The stable seroprevalence of infection observed in sentinel dogs suggests the good clinical management and prevention of CanL by local practitioners in owned dogs.

Efficacy, safety and tolerance of imidocarb dipropionate versus atovaquone or buparvaquone plus azithromycin used to treat sick dogs naturally infected with the Babesia microti-like piroplasm

BACKGROUND

Piroplasmosis caused by the Babesia microti-like piroplasm (Bml) is increasingly being detected in dogs in Europe. Sick dogs show acute disease with severe anaemia associated with thrombocytopenia with a poor response to current available drugs. This study assesses the safety and tolerance of three treatments and compares their efficacy over a full year of follow up in dogs naturally infected with Bml.

METHODS

Fifty-nine dogs naturally infected with Bml were randomly assigned to a treatment group: imidocarb dipropionate (5 mg/kg SC, 2 doses 14 d apart) (IMI); atovaquone (13.3 mg/kg PO q 8 h, 10 d)/azithromycin (10 mg/kg PO q 24 h, 10 d) (ATO); or buparvaquone (5 mg/kg IM, 2 d apart)/azithromycin (same dosage) (BUP). Before and after treatment (days 15, 45, 90 and 360), all dogs underwent a physical exam, blood tests and parasite detection (blood cytology and PCR). Clinical efficacy was assessed by grading 24 clinical and 8 clinicopathological signs from low to high severity.

RESULTS

Before treatment, most dogs had severe regenerative anaemia (88.13%) and thrombocytopenia (71.4%). On treatment Day 45, clinical signs were mostly reduced in all dogs, and by Day 90, practically all dogs under the ATO or BUP regimen were clinically healthy (76.4 and 88%, respectively). Highest percentage reductions in laboratory abnormalities (82.04%) were detected in animals treated with ATO. Over the year, clinical relapse of Bml was observed in 8 dogs (8/17) treated with IMI. However, on Day 360, these animals had recovered clinically, though clinicopathological abnormalities were still present in some of them. Parasitaemia was PCR-confirmed on Days 90 and 360 in 47.05 and 50% of dogs treated with ATO, 68 and 60.08% with BUP, and 94.1 and 73.3% with IMI, respectively. Even after 360 days, 13.3% of the dogs treated with IMI returned a positive blood cytology result.

CONCLUSIONS

IMI showed the worse clinical and parasitological, efficacy such that its use to treat Bml infection in dogs is not recommended. The treatments ATO and BUP showed better efficacy, though they were still incapable to completely eliminate PCR-proven infection at the recommended dose. All three treatments showed good tolerance and safety with scarce adverse events observed.

Flea species infesting dogs in Spain: updated spatial and seasonal distribution patterns

This entomological survey examines the spatial and seasonal distribution patterns of flea species infesting dogs in Spain. Bioclimatic zones covering broad climate and vegetation ranges were surveyed according to size. In a cross-sectional spatial survey carried out from late May 2013 to mid-July 2015, 1084 dogs from 42 different locations were examined. A total of 3032 fleas were collected and identified as belonging to the following species: Ctenocephalides felis (Siphonaptera: Pulicidae) (81.7%, 2476 fleas); Ctenocephalides canis (11.4%, 347 fleas); Pulex irritans (Siphonaptera: Pulicidae) (6.9%, 208 fleas), and Echidnophaga gallinacea (Siphonaptera: Pulicidae) (0.03%, one flea). Variables observed to have effects on flea abundance were animal weight, sex, length of hair and habitat. In the seasonal survey conducted from June 2014 to June 2015, 1014 fleas were collected from 239 dogs at 30 veterinary practices across Spain. Peaks in C. felis abundance were observed in early summer and late autumn, whereas high numbers of P. irritans and C. canis were recorded in autumn. Numbers of fleas detected in winter were low overall. Based on these findings, the present study updates the spatial and seasonal distributions of flea species in Spain and assesses the impacts of host and habitat variables on flea infestation.

Risk of infections using anti-TNF agents in rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis: a systematic review and meta-analysis

INTRODUCTION

Five anti-tumor necrosis factor (anti-TNF) agents have received regulatory approval for use in rheumatology: adalimumab, golimumab, infliximab, certolizumab, and etanercept. Apart from their well-documented therapeutic value, it is still uncertain to what extent they are associated with an increased risk of infectious adverse events. Areas covered: We conducted a systematic review and meta-analysis of published randomized studies to determine the effect of anti-TNF drugs on the occurrence of infectious adverse events (serious infections; tuberculosis; opportunistic infections; any infection). We searched Medline, Embase, and the Cochrane Library up to May 2014 to identify eligible studies in adult patients with rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis that evaluated anti-TNF drugs compared with placebo or no treatment. Expert opinion: Our study encompassed data from 71 randomized controlled trials involving 22,760 participants (range of follow-up: 1-36 months) and seven open label extension studies with 2,236 participants (range of follow-up: 6-48 months). Quantitative synthesis of the available data found statistically significant increases in the occurrence of any infections (20%), serious infections (40%), and tuberculosis (250%) associated with anti-TNF drug use, while the data for opportunistic infections were scarce. The quality of synthesized evidence was judged as moderate. Further evidence from registries and long-term epidemiological studies are needed to better define the relationship between anti-TNF agents and infection complications.

Cardiovascular outcomes and tumour necrosis factor antagonists in chronic inflammatory rheumatic disease: a focus on rheumatoid arthritis

INTRODUCTION

Many chronic rheumatic diseases have an inflammatory etiology, leading to accelerated atherosclerosis and increased occurrence of vascular diseases. In rheumatoid arthritis (RA), a reduction in cardiovascular (CV) events has been reported under treatments reducing systemic inflammation. Areas covered: Given the central role of tumour necrosis factor alpha (TNFα) in chronic inflammatory conditions and in atherosclerosis, it has been suggested that TNFα-antagonists may reduce CV risk and mortality. Although there are no randomized controlled or head-to-head trials investigating the effect of specific anti-TNF-agents on CV outcomes, observational cohort studies, national registry data, and meta-analyses in RA have reported improved CV outcomes with anti-TNF therapy. Expert opinion: It is unclear whether this is due to reduced systemic inflammation or a specific anti-TNF effect at the atherosclerotic plaque level. Observed CV benefits appear to correlate with anti-TNF response. Conversely, although inconsistently, anti-TNF agents have also been linked with increased incidence/worsening of heart failure. Additional CV adverse events with anti-TNFs include vasculitis and venous thromboembolic events. We provide an overview of the likely effects of anti-TNF therapy on CV risk and adverse events, and evaluated differences in CV outcomes among different anti-TNF-agents.

Anti-TNF treatment response in rheumatoid arthritis patients with moderate disease activity: a prospective observational multicentre study (MODERATE)

OBJECTIVES

Rheumatoid arthritis (RA) patients with moderate disease activity show progression of joint damage and have impaired quality of life, physical function, work and daily activities. Little is known about management of patients with moderate RA. The aim of the study was to assess the 1-year response to anti-TNF in biologic-naïve RA patients with moderate (3.2 <DAS28 ≤5.1) disease activity despite DMARD treatment, in the Italian clinical practice.

METHODS

The MODERATE study is a multicentre prospective, cohort non-interventional study, conducted in 19 Italian rheumatology sites. Patients with moderate RA, diagnosed according to the 2010 American College of Rheumatology (ACR)/EULAR criteria, were enrolled if they also were aged ≥18 years, had disease onset after 16 years old, moderate disease at baseline (DAS28 score >3.2 and ≤5.1), and were naïve to anti-TNF treatment.

RESULTS

Among 157 RA patients, 93 (59%) underwent etanercept, 43 (22%) adalimumab, 26 (17%) certolizumab, 10 golimumab and 2 infliximab; 80% of patients were still in treatment after 12-month observation. One-year clinical remission was achieved by 27 RA patients (21%), reduction of DAS28 score greater than 1.2 was observed in 75 (58%) patients. Moderate and good response according to EULAR criteria was observed in 59 (46%) and 45 (35%) patients, respectively.

CONCLUSIONS

Results confirm the efficacy of anti-TNF alpha also in moderate RA patients, who may achieve a substantial decrease of disease activity, and improve their quality of life. The low rate of patients achieving remission may suggest that therapeutic strategies should be more timely and aggressive.

The protection of individuals affected with Specific Learning Disorders in the Italian Legislation

Specific Learning Disorders (SLDs) affect specific abilities in individuals with an otherwise normal academic development. Among Italian School population, their reported prevalence is between 2.5% and 3.5%. Dysfunctions at the base of these disorders interfere with the normal acquisition process of reading, writing and/or mathematical abilities, leading to various degrees of adjustment difficulties in the affected individuals. The aim of this study was to assess the support that Italian Government offers to its citizens affected with SLDs, with a particular focus on assistance during the school-age years, particularly through the introduction of the Law 170/2010 and successive guidelines, supplementing the existing regulations to offer more efficient means and legal instruments aimed at achieving earlier diagnoses.

Sleep disorders and driving licence: the current Italian legislation and medico-legal issues

Road traffic accidents (RTA) are a serious issue in all industrialized countries and have dramatic social and healthcare-related implications. Fatigue (sleepiness) is the principal identifiable and preventable cause of road traffic accidents. Obstructive sleep apnoea syndrome (OSAS) and narcolepsy are two of the leading causes of excessive daytime sleepiness. In this article, the authors analyze the current Italian legislation regarding driving licence issuance and fitness to drive, in order to evaluate the potential implications of sleep disorders, particularly OSAS and narcolepsy. In European Legislation and in Italy, OSAS and narcolepsy are not included among the illnesses or invalidating conditions that limit the fitness to drive for driving licence issuance purposes. In fact, they are not included in the Annex III of the European Council Directive 91/439/EEC of the 29th of July 1991 on driving licences. Some Countries of the European Union (Belgium, France, Finland, Great Britain, the Netherlands, Spain and Sweden) had implemented the 91/439/EEC Directive with national restrictions on driving licence issuance policies in case of OSAS and narcolepsy. Given the well-established scientific evidence available, in Italy, the lack of legislation regulating the assessment of the psychophysical requisites for the issuance and renewal of driving licences of individuals affected by sleep disorders seems extremely worrying. Furthermore, the current lack of legal obligation in Italy for healthcare facilities to disclose such diagnoses to the organs responsible for issuing driving licences (such as the Motorizzazione Civile - the Department of motor vehicles) remains the subject of heated debate.

First detection of Onchocerca lupi infection in dogs in southern Spain

Background

Onchocerca lupi causes ocular pathology of varying severity in dogs from south-western United States, western Europe and northern Asia. This filarioid has also been recognized as a zoonotic agent in Tunisia, Turkey, Iran and the USA, though the information about the biology and epidemiology of this infection is largely unknown. In Europe, O. lupi has been reported in dogs from Germany, Greece, Hungary, Portugal and Romania and in a cat from Portugal. The present study was designed to establish the occurrence of O. lupi in dogs in southwestern Spain.

In the present study a total of 104 dogs of different breed, sex, and age living in a shelter in Huelva (SW Spain) were examined. Skin snip samples were collected using a disposable scalpel in the forehead and inter-scapular regions and stored as aliquots in saline solution (0.5 ml) before light microscopy observation of individual sediments (20 μl) and molecular examination.

Results

Of the 104 dogs examined, 5 (4.8 %) were skin snip-positive for O. lupi: two by microscopy and three by PCR. One of the O. lupi infected dogs showed neurological signs but ocular ultrasonography and/or MRI detected no abnormalities.

Conclusions

This first report of O. lupi infection in dogs in southern Spain expands the range of geographical distribution of this parasite and sounds an alarm bell for practitioners and physicians working in that area.

Antiatherogenic effects of ellagic acid and urolithins in vitro

Atherosclerosis, one of the leading causes of death worldwide, is characterized by impaired endothelial function and lipid metabolism, among other factors. Ellagitannins are a class of phenolic compounds that may play a role in cardiovascular health. This work aimed to study the potential atheroprotective effects of urolithins, ellagitannin-derived gut microbiota metabolites, on different key factors in atherosclerosis development: the ability of monocytes to adhere to endothelial cells and the uptake and efflux of cholesterol by macrophages. The biotransformations urolithins undergo in peripheral cells were also evaluated. Results indicated that some urolithins and ellagic acid were able to reduce the adhesion of THP-1 monocytes to human umbilical vein endothelial cells (HUVECs) and the secretion of a cellular adhesion molecule (sVCAM-1) and pro-inflammatory cytokine (IL-6). Urolithin C, a combination of urolithins A and B, and ellagic acid also decreased the accumulation of cholesterol in THP-1-derived macrophages, but they were not able to promote cholesterol efflux. The analysis of cell media by UHPLC-ESI-MS(n) indicated urolithins and ellagic underwent extensive metabolism, with sulfate and methyl conjugation. This evidence indicates that atherosclerotic processes may be attenuated by urolithins, but future human intervention trials are required to establish if is translated in vivo.

Drug outcome survey to evaluate anti-TNF treatment in rheumatoid arthritis: an Italian observational study (the DOSE study)

OBJECTIVES

The aim of this paper is to analyse the use of anti-TNF drugs in current Italian practice, evaluate clinical responses to treatment, and identify possible predictors of negative response in patients with rheumatoid arthritis (RA).

METHODS

DOSE is a non-interventional, prospective study of patients with active RA treated for the first time with anti-TNF agents in 21 Italian hospitals. Demographic and clinical characteristics of patients, treatments and outcome measures were assessed. Outcome measures used were EULAR response, DAS28 remission and HAQ remission at 12 months. A stepwise logistic regression model was used to study the predictors of non-response.

RESULTS

Of 299 RA patients (mean 53.8 ± 12.8 years, 76.1% female), DAS28 was >5.1 in 60.5% of patients and HAQ was >1 in 65.9%. Etanercept was the most prescribed anti-TNF. DMARDs were used in 77.6% of patients (methotrexate in 59.2%). Significant improvements in clinical and laboratory parameters were observed at 12 months. The proportion of patients classed as non-responders remained high, and varied according to assessment criteria. The main predictors independently and significantly associated with a high risk of non-response were: age and female gender for all outcome criteria; high DAS28 value for disease remission; and HAQ >1 for disability remission.

CONCLUSIONS

In Italian anti-TNF treatment for RA, age, gender, and high values of both disease activity and disability were predictors of non-response to first-line therapy with anti-TNF drugs. Future studies should consider optimal second-line therapies for RA patients who do not achieve remission to their first anti-TNF treatment.

Caffeic acid phenethyl ester abrogates bone resorption in a murine calvarial model of polyethylene particle-induced osteolysis

Particle-induced bone loss by osteoclasts is a common cause of aseptic loosening around implants. This study investigates whether caffeic acid phenethyl ester (CAPE), a potent and specific inhibitor of nuclear factor of activated T cells, cytoplasmic, calcineurin-dependent 1 and nuclear factor kappa B, at a low dose reduces bone resorption in a murine calvarial model of polyethylene (PE) particle-induced osteolysis. The effects of particles and CAPE treatment on gastrointestinal tract (GIT) histopathology were also evaluated. Mice were scanned using in vivo animal micro-computed tomography (μCT) as a baseline measurement. PE particles (2.82 × 10(9) particles/mL) were implanted over the calvariae on day 0. CAPE was administered subcutaneously (1 mg/kg/day) at days 0, 4, 7 and 10. Mice were killed at day 14 and serum was analysed for Type-1 carboxyterminal collagen crosslinks (CTX)-1 and osteoclast-associated receptor (OSCAR) levels. Ex vivo μCT scans were conducted to assess bone volume (BV) change and percentage area of calvarial surface resorbed. Calvarial and GIT tissue was processed for histopathology. By day 14, PE particles significantly induced calvarial bone loss compared with control animals as evidenced by resorption areas adjacent to the implanted PE in three-dimensional μCT images, an increase in percentage of resorbed area (p = 0.0022), reduction in BV (p = 0.0012) and increased Tartrate-resistant acid phosphatase positive cells. Serum CTX-1 (p = 0.0495) and OSCAR levels (p = 0.0006) significantly increased in the PE implant group. CAPE significantly inhibited PE particle-induced calvarial osteolysis, as evidenced by a significant reduction in surface bone resorption (p = 0.0012) and volumetric change (p = 0.0154) compared with PE only, but had no effect on systemic CTX-1. Neither particles nor CAPE had an effect on GIT histopathology.

Quantifying not only bone loss, but also soft tissue swelling, in a murine inflammatory arthritis model using micro-computed tomography

In rodent models of inflammatory arthritis, bone erosion has been non-invasively assessed by micro-computed tomography (micro-CT). However, non-invasive assessments of paw swelling (oedema) are still based on clinical grading by visual evaluation, or measurements by callipers, not always reliable for the tiny mouse paws. The aim of this work was to demonstrate a novel straightforward 3D micro-CT analysis protocol capable of quantifying not only joint bone erosion, but also soft tissue swelling, from the same scans, in a rodent inflammatory arthritis model. Balb/c mice were divided into two groups: collagen antibody-induced arthritis (CAIA) and CAIA treated with prednisolone, the latter reflecting an established treatment in human rheumatoid arthritis. Clinical paw scores were recorded. On day 10, front paws were assessed by micro-CT and histology. Micro-CT measurements included paw volume (bone and soft tissue together) and bone volume at the radiocarpal joint, and bone volume from the radiocarpal to the metacarpophalangeal joint. Micro-CT analysis revealed significantly lower paw volume (−36%, P < 0.01) and higher bone volume (+17%, P < 0.05) in prednisolone-treated CAIA mice compared with untreated CAIA mice. Paw volume and bone volume assessed by micro-CT correlated significantly with clinical and histological scores (|r| > 0.5, P < 0.01). Untreated CAIA mice showed significantly higher clinical scores, higher inflammation levels histologically, cartilage and bone degradation, and pannus formation, compared with treated mice (P < 0.01). The presented novel micro-CT analysis protocol enables 3D-quantification of paw swelling at the micrometre level, along with the typically assessed bone erosion, using the same images/scans, without altering the scanning procedure or using contrast agents.

Etanercept reduces symptoms and severity of psoriasis after cessation of cyclosporine therapy: results of the SCORE study

Cyclosporine is an established therapy for psoriasis that provides rapid relief of symptoms but has long-term toxic side effects. The objective of this study was to demonstrate the efficacy of etanercept as replacement therapy for cyclosporine in patients with moderate-to-severe plaque psoriasis. Patients with plaque psoriasis were given cyclosporine 5 mg/kg/day until achievement of PASI50 at which point cyclosporine was tapered to 0 over 6 weeks. At week 6, patients were randomised (1:1) to receive etanercept (50 mg/week) or placebo for an additional 24 weeks. Patients in the etanercept group (n = 58) experienced a reduction of -1.1 in mean PASI score (p = 0.233 vs. cyclosporine) at week 30; patients in the placebo group (n = 62) had mean PASI increase of 3.7 (p < 0.001 vs. cyclosporine). The incidence of patients reporting any adverse events was not significant between groups (77% etanercept, 74% placebo; p = 0.675). Etanercept demonstrated higher efficacy and good tolerability as replacement therapy for cyclosporine in plaque psoriasis.

Pruritus and quality of life in moderate-to-severe plaque psoriasis: post hoc explorative analysis from the PRISTINE study

BACKGROUND

Pruritus is a clinically important symptom of psoriasis that has a major impact on quality of life (QoL).

OBJECTIVE

The objective of this study was to examine pruritus and QoL in patients with moderate-to-severe psoriasis treated with etanercept (ETN) in the PRISTINE clinical trial.

METHODS

Patients were randomized (1 : 1, double-blind) to ETN 50 mg QW or 50 mg BIW for 12 weeks, followed by 50 mg QW for 12 weeks. Pruritus was reported as 0 (no itching) to 5 (severe itching). Associations were examined between pruritus and Psoriasis Area and Severity Index, Dermatology Life Quality Index (DLQI), Hospital Anxiety and Depression Screening (HADS), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue), Euro-Qol 5D (EQ-5D) and Medical Outcomes Study (MOS) Sleep Index II.

RESULTS

At baseline, patients (n = 270) had a mean pruritus level of 3.6. Itching (level ≥1) was reported by 96% of patients, 62% of whom had severe itching (level ≥4) and 26% had the highest level of itching. DLQI, HADS-Anxiety, HADS-Depression, FACIT-Fatigue, EQ-5D visual analog scale, and MOS Sleep Index II were significantly associated with itch. At week 12, mean pruritus improvement in the ETN BIW/QW group was greater than in the QW/QW group (2.4 vs. 1.6, P < 0.001), but not at week 24 (2.2 vs. 2.0, P = 0.180). Patients with the most severe itching at baseline (score of 5) had a mean score of 1.7 at week 24. Overall, patients with clinically meaningful pruritus improvement at week 24 reported greater improvement in QoL measures than other patients.

CONCLUSION

Most patients with moderate-to-severe psoriasis in this study (96%) reported pruritus. Pruritus improved significantly with ETN therapy and was strongly associated with improvements in QoL. These data support the clinical relevance of pruritus as an important symptom of patients with moderate/severe psoriasis.

Surface scratch assessment of titanium implant abutments and cementum following instrumentation with metal curettes

OBJECTIVES

This study was conducted to compare the surface scratch resistance of titanium implant abutments and cementum to evaluate the impact of scaling with metal curettes on both surfaces.

MATERIALS AND METHODS

A standard in vitro force of 14 N was used to assess the scratch width and depth created by curettes on extracted human tooth roots and titanium implant abutments. Scratch width and depth were analysed using a stereomicroscope and non-contact surface profilometry.

RESULTS

The mean force applied during test scaling procedures by experienced volunteer operators was 14 N. Mechanical scaling using this force in vitro of cementum produced a mean scratch width of 59.4 ± 1.9 μm, N = 20, and scratch depth of 0.86 ± 0.03 μm, N = 20, compared to the titanium abutments' mean scratch width of 30.8 ± 1.9 μm, N = 6, and scratch depth of 0.34 ± 0.02 μm, N = 6. These differences were statistically significant (P < 0.05).

CONCLUSIONS

Although there a number of factors in the clinical situation which are not easily reproducible in vitro, this proof-of-principle in vitro study is the first to confirm quantitatively that titanium abutments had a significantly greater scratch resistance than cementum when metal curettes were used on these surfaces. This information should be considered, especially if there is a preferred choice of metal instruments for effective dental prophylactic procedures for the maintenance of titanium dental implants.

CLINICAL RELEVANCE

Clinical dogma suggests that titanium implant abutment surfaces should not be instrumented with metal instruments due to scratching of the surface. However, since cementum is softer than titanium, the logic of this tenet seems flawed. This study demonstrated for the first time that titanium abutments undergo less scratch damage during scaling with metal curettes than does cementum. Metal curettes may be used on titanium abutments with as much confidence as for root planing on natural teeth.

Current status of L. infantum infection in stray cats in the Madrid region (Spain): implications for the recent outbreak of human leishmaniosis?

Background

Since 2009, the incidence of human leishmaniosis in the SW of the Madrid region has been unusually high. Although dogs are the main reservoir for this disease, a role played by dogs in this outbreak has been ruled out and investigators are now considering other hosts (eg. cats, rabbits, hares) as possible alternative reservoirs.

This study was designed to examine the Leishmania infantum status of stray cats in Madrid to assess its possible implications in the human leishmaniosis outbreak.

Methods

346 captured stray cats were tested for antibodies against L. infantum by the indirect fluorescent antibody technique (IFAT) and nested-PCR methods were used to detect Leishmania DNA in blood samples of cats testing seropositive for L. infantum and/or retroviruses infection. Cats were also tested for Toxoplasma gondii using the direct agglutination test (DAT) and feline leukemia virus (FeLV) antigen and feline immunodeficiency virus (FIV) antibodies (PetChek* FIV/FeLV). The presence of intestinal parasites was determined using a routine coprological method.

Results

The seroprevalence of L. infantum infection (cut off ≥ 1/100) was 3.2% (11/346). However, it was not possible to amplify Leishmania DNA in any of the blood samples. Seropositivity was not associated with sex, age, capture site, clinical status, retrovirus infection or T. gondii seropositivity. Of the 11 cats seropositive for L. infantum, 3 also tested positive for FIV, none for FeLV and 6 for T. gondii. It should be mentioned that the prevalence of FeLV p27 antigen was 4% and of FIV antibody was 9.2%. Although the seroprevalence of T. gondii was quite high at 53.5%, no T. gondii oocysts were found in any of the faeces samples analysed (n = 287). In contrast, intestinal parasites were detected in 76 (26.5%) samples, Toxocara cati being the most prevalent.

Conclusions

Our results suggest a stable L. infantum infection situation among the stray cats of the Madrid area; the disease is uncommon and no clinical cases have been reported to date. The detection of other zoonotic parasites such as T. gondii and T. cati in stray cats indicates a need to adopt strict control measures in this population.

GABA heteroreceptors modulate noradrenaline release in human dental pulp

γ-aminobutyric-acid-containing neurons and GABA(B) receptors have been identified in human dental pulp; however, their significance in pulpal physiology is unclear. The purpose of this study was to determine whether pre-synaptic GABAergic heteroreceptors influence the release of noradrenaline (NA). Segments of vital pulp were incubated in [(3)H]NA (0.6 μM) and superfused with Krebs solution. GABA, a GABA(B) receptor agonist (baclofen), GABA(A and B) receptor antagonists [bicuculline and (+)-(S)-5, 5-dimethylmorpholinyl-2-acetic acid (Sch 50911), respectively], and a GABA(A) receptor-mediated Cl(-) channel inhibitor (picrotoxin) were added to the superfusion medium at least 10 min prior to the second period of stimulation (S2). Sympathetic nerves were stimulated electrically after 70 (S1) and 115 (S2) min. We determined the effects of agonists/antagonists by comparing the overflow of [(3)H]NA at S2 with that at S1 in the presence and absence of the compound. Baclofen (3 µM) inhibited the release of [(3)H]NA (IC50 = 2 µM), an action reversed by Sch 50911 (10 µM). GABA (100 µM) inhibited the release of [(3)H]NA (IC50 = 75 µM), an effect reversed by Sch 50911 (10 µM) but not by bicuculline (10 µM). However, picrotoxin (100 µM) prevented the inhibitory action of GABA. GABA(B) and GABA(A) heteroceptors mediate the release of NA from sympathetic nerves in human dental pulp in vitro.

Mesenchymal stem cells from iPS cells facilitate periodontal regeneration

Mesenchymal stem cells (MSC) have been considered as a potential therapy for the treatment of periodontal defects arising from periodontitis. However, issues surrounding their accessibility and proliferation in culture significantly limit their ability to be used as a mainstream treatment approach. It is therefore important that alternative, easily accessible, and safe populations of stem cells be identified. Controlled induction of induced pluripotent stem cells (iPSC) into MSC-like cells is emerging as an attractive source for obtaining large populations of stem cells for regenerative medicine. We have successfully induced iPSC to differentiate into MSC-like cells. The MSC-like cells generated satisfied the International Society of Cellular Therapy's minimal criteria for defining multipotent MSC, since they had plastic adherent properties, expressed key MSC-associated markers, and had the capacity to undergo tri-lineage differentiation. Importantly, the resulting iPSC-MSC-like cells also had the capacity, when implanted into periodontal defects, to significantly increase the amount of regeneration and newly formed mineralized tissue present. Our results demonstrate, for the first time, that MSC derived from iPSC have the capacity to aid periodontal regeneration and are a promising source of readily accessible stem cells for use in the clinical treatment of periodontitis.