Irena Butrimiene

Evaluation of vaginal introital sampling as an alternative approach for the detection of genital Chlamydia trachomatis infection in women

BACKGROUND Genital Chlamydia trachomatis infections in women are traditionally detected by testing cervical and urethral samples. This sampling approach is not acceptable in some, e.g. screening situations. We evaluate an alternative approach, i.e. use of vaginal self-collected specimen for testing by polymerase chain reaction. METHODS The sensitivity of self-collected vaginal (introital) samples to diagnose genital infections by Chlamydia trachomatis using Roche AMPLICOR CT/NG PCR was compared with the cervical- and first-voided urine samples from women consulting with- (Group 1; n=123) and without (Group 0; n=160) genital symptoms. Women were interviewed regarding genital hygiene. Genital symptoms and signs were noted. RESULTS C. trachomatis DNA was detected in 13.0% of women from Group 1 and in 5.0% of women from Group 0, i.e. in urine of 6.5% vs. 1.9%, in the cervical swab in 9.8% vs. 5.0% and in vaginal swab in 11.4% vs. 3.8% of women, respectively. The vaginal sample was the most sensitive specimen for detecting C. trachomatis in the Group 1 women. It had sensitivity of 87.5% vs. 75% for cervical- and 50% for urine specimens. In Group 0, the cervical sample was 100% sensitive, while the vaginal introital sample and urine had a sensitivity of 75% and 37.5%, respectively. C. trachomatis was less often detected in urine of women who routinely practised genital washing. CONCLUSIONS Vaginal sampling performed by the woman herself is a sensitive approach and might serve as an important stimulus for screening for C. trachomatis infections in young women at risk.

Influence of Immunogenicity on the Efficacy of Long-Term Treatment with TNF α Blockers in Rheumatoid Arthritis and Spondyloarthritis Patients

Objective. To analyze the clinical relevance of the levels of TNFα blockers and anti-drug antibodies (anti-drug Ab) in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) treated with adalimumab (ADA), etanercept (ETA), or infliximab (INF) for a prolonged period of time. Methods. Clinical characteristics (disease activity, and adverse events), serum TNFα blockers, and anti-drug Ab levels were evaluated in 62 RA and 81 SpA patients treated with TNFα blockers for a median of 28 months. Results. Anti-ADA Ab were detected in 1 (4.0%) and anti-INF Ab in 14 out of 57 (24.6%) RA and SpA patients. Patient with anti-ADA Ab and 57.1% patients with anti-INF Ab were considered nonresponders to treatment. Anti-ETA Ab were not found in any of 61 ETA treated patients. Anti-ADA and anti-INF Ab levels differ between responders and nonresponders (P > 0.05). Three (5.3%) patients with high serum anti-INF Ab levels developed infusion related reactions. Patients with anti-INF Ab more often required changing to another biologic drug (OR 11.43 (95% CI 1.08–120.93)) and treatment discontinuation (OR 9.28 (95% CI 1.64–52.52)). Conclusion. Patients not responding to treatment had higher serum anti-ADA and anti-INF Ab concentrations. Anti-INF Ab formation is related to increased risk of infusion related reactions, changing to another biologic drug, and treatment discontinuation.

European multicentre pilot survey to assess vitamin D status in rheumatoid arthritis patients and early development of a new Patient Reported Outcome questionnaire (D-PRO)

OBJECTIVE To collect data on vitamin D (25(OH)D) serum levels in a large number of rheumatoid arthritis (RA) patients from different European countries, to investigate their relation with disease activity, disability, quality of life, and possibly to construct a new Patient Reported Outcome (PRO) questionnaire in order to self-estimate if they are at risk for vitamin D insufficiency/deficiency-related clinical implications (D-PRO). METHODS This was a European League Against Rheumatism (EULAR) supported cross-sectional study (project No CLI064) which involved 625 RA patients (mean age 55±11years, mean disease duration 11±9years), 276 age and sex matched healthy subjects, and rheumatologists working in academic institutions or hospital centres, as well as PARE organizations (patient representatives) from 13 European countries. Serum samples for 25(OH)D level measurement were collected during winter time and analyzed in a central laboratory using chemiluminescence immunoassay (DiaSorin). Patient past medical history was recorded. RA patients were provided with three questionnaires: the Rheumatoid Arthritis Impact Diseases score (RAID), the Health Assessment Questionnaire (HAQ), and the new D-PRO questionnaire at the time of 25(OH)D serum sampling. D-PRO questionnaire consisted of three domains, Symptom Risk Score (SRS), Habitus Risk Score (HRS) and Global Risk Score (SRS+HRS=GRS), constructed with items possibly related to vitamin D deficiency. D-PRO was correlated with both clinical and PRO scores. DAS28-CRP was also evaluated. Statistical analysis was performed by non parametric tests. RESULTS Mean serum concentration of 25(OH)D in RA patients (17.62±9.76ng/ml) was found significantly lower if compared to the levels obtained in matched controls (18.95±9.45ng/ml) (p=0.01), with statistically significant differences among several European countries. Negative correlations were found between 25(OH)D serum levels and DAS28-CRP (p<0.001), RAID (p=0.05) and HAQ (p=0.04) scores in the RA patients group. Negative correlations were also found in the cohort of enrolled RA patients between 25(OH)D serum concentrations and SRS (p=0.04), HRS (p=0.02) and GRS (p=0.02) domains of the D-PRO questionnaire. CONCLUSIONS This first multicentre European survey add new evidences that vitamin D insufficiency/deficiency is frequent in RA patients with statistically significant differences among several countries. Vitamin D serum concentrations seem to correlate negatively and significantly with the D-PRO Global Risk Score, clinimetric indexes for quality of life, disease activity and disability in present cohort of RA European patients.

Could the complement component C4 or its fragment C4d be a marker of the more severe conditions in patients with primary Sjögren’s syndrome?

Our aim is to evaluate the complement component C4 (C4) and its fragment C4d (C4d) levels, focusing on their associations with other markers of B cells’ activity in patients with primary Sjögren’s syndrome (pSS). Humoral factors C4, C4d, B cell-activating factor (BAFF), κ and λ free light chains (FLCs) and IgG (by immunoassay) were investigated in 58 patients with pSS and in 28 healthy controls. We observed significantly higher levels of BAFF, κ and λ FLC and IgG, and significantly lower level of C4 in pSS patients, while the level of C4d was similar in the both groups. Significantly higher levels of BAFF, κ and λ FLCs, IgG, and significantly lower C4 level were found in anti-SSA/SSB antibodies (Abs) seropositive pSS patients’ group comparing with healthy controls. Level of C4d was significantly lower in anti-SSA/SSB Abs seropositive pSS patients comparing with seronegative pSS patients and healthy controls. C4d correlated with C4, anti-SSB Abs level and κ/λ ratio. Significantly higher κ FLC and IgG levels were found in anti-SSA/SSB Abs seronegative pSS patients comparing with healthy controls. Anti-SSA/SSB seropositivity in pSS patients is associated with the decreased level of C4d. These results show that C4d can be an appropriate marker of antibody response and complement activation in pSS patients with Abs, and possibly may show the more severe condition—exhaustion of C4. Further studies are required to determine whether C4d assessment could be a relevant biomarker for the more severe condition and the worse prognosis of pSS.

Are cytotoxic effector cells changes in peripheral blood of patients with Sjögren’s syndrome related to persistent virus infection: Suggestions and conundrums

Etiology of Sjögrens syndrome (SS) is still unknown, but there is strong evidence that certain pathogens of bacterial or viral origin can incite autoimmune response. The aim of this study was to quantitatively evaluate changes of the main cell populations (dendritic cells, natural killer, natural killer T and cytotoxic T lymphocytes) presumably participating in virus clearance in peripheral blood of patients with primary SS (pSS). In analyzing cytotoxic T lymphocytes (CTL) populations we observed alterations in the frequency of highly cytotoxic effector CD8high/57+/27-/45RA+, less cytotoxic CD8high/57-/27-/45RA+ effector cells and cytotoxic memory CD8high/57+/27+/45RA- effector cells. We found a decrease of conventional dendritic cells (cDC) population in peripheral blood of pSS patients. It is possible that, a decrease of effector CTL and cDC, accompanied by increase of transitory phenotype memory CTL in peripheral blood of pSS patients may be associated with viral etiopathogenesis of Sjögrens syndrome.

SAT0604 Detection of TNFα Blockers and Anti-Drug's Antibodies Levels: A Comparison of Two Commercially Available Assays

Background Formation of antibodies (Ab) to TNFα blockers (adalimumab (ADA), etanercept (ETA) and infliximab (INF)) inversely correlates with functional drug levels and clinical outcome. Comparison of drug levels and anti-drug antibody (anti-drug Ab) monitoring is hampered by lack of standardization. Objectives To determine the correlation and agreement between two different assays for measuring levels of TNFα blockers and anti-drug Ab. Methods Serum samples of 145 patients with autoimmune rheumatic diseases were evaluated in two different assays developed by Sanquin (Amsterdam, Netherlands (Assay A), and a commercially available kit from Progenica Biopharma (Derio, Spain) (Assay B) performed in the Centre of Laboratory Medicine at Vilnius University Hospital Santariskiu clinics. Results Assay A found detectable levels of ADA in 26 (96.3%), ETA – in 56 (88.9%), INF –in 35 (63.6%) patients, whereas Assay B these results were 26 (96.3%), 59 (93.7%) and 39 (70.9%), respectively. The good correlation was obtained when comparing Assay A vs. B in detecting drug levels (Spearmans rank correlation coefficient r=0.960, p<0.0001 for INF; r=0.932, p<0.0001 for ETA and r=0.765, p=0.001 for ADA). High agreement between two assays was found only in INF (ICC=0.925; 95% CI 0.875–0.956; p<0.0001)), but not in ADA (ICC=0.732; 95% CI 0.387–0.898; p<0.0001) and ETA assays (ICC=0.427; 95% CI 0.195–0.613; p<0.001). The Bland–Altman and Mountain plots of ADA, INF and ETA show good agreement of two assays, used to analyze concentrations of all TNFα blockers (the best agreement found in INF group). Passing – Bablock regression revealed no systematic differences between the two assay methods in ADA, ETA and INF testing, although both methods has proportional differences. Assay A detected anti-ADA Ab in 4 (14.8%), anti-INF Ab – in 17 (30.9%) patients. Assay B detected anti-ADA Ab in 1 (3.7%), anti-INF Ab – in 14 (25.4%) patients. Anti-ETA Ab were not detected by both assays. Conclusions We found good correlation of TNFα blockers level measurements between the both commercially available assays. Nevertheless, the agreement between two assays could be calculated only for detection of TNFα blockers levels, but not for anti-drug Ab as the both assays report different outcome measures. The existing assays to measure levels of TNFα blockers and anti-drug Ab need to be standardized. References Vincent FB, Morand EF, Murphy K, et al. Antidrug antibodies (ADAb) to tumour necrosis factor (TNF)-specific neutralising agents in chronic inflammatory diseases: a real issue, a clinical perspective. Ann Rheum Dis. 2013; 72:165-178. Ruiz-Arguello B, Ruiz del AquaA, Torres N, et al. Comparison study of two commercially available methods for the determination of infliximab, adalimumab and anti-drug antibody levels. Clin Chem Lab Med. 2013; 51(12):e287-e289. Garces S, Antunes M, Benito-Garcia E, et al. A preliminary algorithm introducing immunogenicity assessment in the management of patients with RA receiving tumor necrosis factor inhibitor therapies. Ann Rheum Dis. 2014; 73:1138-1143. Disclosure of Interest None declared

SAT0084 Incidence of Infectious Complications in Rheumatic Patients Treated with BIOLOGICS in Vilnius University, Rheumatology Centre

Background Biologics offer effective ways to treat autoimmune arthritis avoiding radiological progression. Yet, it has its own risks and hazards, most common - infectious complications. Objectives To evaluate the incidence of infectious complications in patients with autoimmune arthritis (AA) treated with biological therapy (BT). Methods Patients with AA (rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), juvenile idiopathic arthritis (JIA)), treated with BT agents (Infliximab (INX), Adalimumab (ADA), Etanercept (ETA) or Rituximab (RTX)) were tested for any infectious events at the start of treatment, after 12, 24 and then every 24 weeks during treatment with BT. The data was collected from 01 Dec 2007 to 01 Jan 2013. Statistical analysis was performed with SPSS 17.0 and Microsoft Excel programs. The study was approved by Lithuanian Bioethics committee. Results 269 patients treated with BT were evaluated for adverse events (AE). From all (289) AE reported, half (n=145; 52.35%) of them were from infections (female – 89; 61.38%, male – 56; 38.62%). Infections mostly were reported in RA patients (n=82; 56.55%), less so in PsA patients (n=27; 18.62%), AS (n=24; 16.55%) and JIA (n=12; 8.28%). Most of infections were upper respiratory tract (n=44; 30.34%) and urogenital system infections (n=32; 22.07%) for INX, ADA, ETA, RTX users were 60.81, 98.78, 93.96, 30.55; and, 30.40, 89.80, 57.82, 76.37, respectively (per 1000 patient years). Less common were ear-nose-throat infections (n=24; 16.55%) (33.78, 35.92, 65.05 and 15.27), cutaneous infections (n=16; 11.03%) (30.40, 26.94, 28.91 and 0 respectively). There were 11 cases of tuberculosis (TB) (7.59%) (10.13, 53.88, 14.46 and 0 per 1000 patient years respectively for INX, ADA, ETA and RTX), and 3 cases of sepsis (2.07%) (6.76, 8.98, 0 and 0 per 1000 patient years). Two cases of active TB was diagnosed in INX patients, the remaining 9 cases were latent TB, all treated prophylactically before resuming BT. Nearly half of infections were mild (n=68; 46.9%), severe infections were seen in 9 patients (6.21%) and for one patient (0.69%) was the cause of death. The onset of infectious AE on average were seen after 19,6 [95% CI: 16,68-22,54] months after the start of BT and lasted approximately 22,47 days [95% CI: 13,64-31,3]. Infections were most common among patients treated with ADA - 332.26 per 1000 patient years; least common - with RTX - 152.74; INF - 202.69 and ETA - 274.67, respectively. No correlation between infection severity and patients age, gender, diagnosis, BT drug, time of AE occurrence, duration and outcomes were found (p<0,05). Conclusions Half of AE in patients with AA treated with BT were infections (n=145; 50.23%). Highest rate of infectious complications were seen in patients with RA. Upper respiratory tract and urogenital system infections were most common. They were most often seen in patients treated with ADA and the least - in patients with RTX. Half of infections were mild. Average onset of infections were after 19,6 months after initiation of BT and lasted an average of 22,47 days. References E.D. Dommasch, K. Abuabara et al. J Am Acad Dermatol 2011;64(6):1035-50. J.B. Galloway, K.L. Hyrich et al. Rheumatology 2011;50:124-31. S.A.A. van Dartel, J. Fransen et al. Ann Rheum Dis 2013;72:895-900. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1791