Towards Quantifying Stress in Patients with a History of Myocardial Infarction: Validating ECG-Derived Patch Features

Patients with prior myocardial infarction (MI) have an increased risk of experiencing a secondary event which is exacerbated by mental stress. Our team has developed a miniaturized patch with the capability to capture electrocardiogram (ECG), seismocardiogram (SCG) and photoplethysmogram (PPG) signals which may provide multimodal information to characterize stress responses within the post-MI population in ambulatory settings. As ECG-derived features have been shown to be informative in assessing the risk of MI, a critical first step is to ensure that the patch ECG features agree with gold-standard devices, such as the Biopac. However, this is yet to be done in this population. We, thus, performed a comparative analysis between ECG-derived features (heart rate (HR) and heart rate variability (HRV)) of the patch and Biopac in the context of stress. Our dataset contained post-MI and healthy control subjects who participated in a public speaking challenge. Regression analyses for patch and Biopac HR and HRV features (RMSSD, pNN50, SD1/SD2, and LF/HF) were all significant (p<0.001) and had strong positive correlations (r>0.9). Additionally, Bland-Altman analyses for most features showed tight limits of agreement: 0.999 bpm (HR), 11.341 ms (RMSSD), 0.07% (pNN50), 0.146 ratio difference (SD1/SD2), 0.750 ratio difference (LF/HF).Clinical relevance- This work demonstrates that ECG-derived features obtained from the patch and Biopac are in agreement, suggesting the clinical utility of the patch in deriving quantitative metrics of physiology during stress in post-MI patients. This has the potential to improve post-MI patients' outcomes, but needs to be further evaluated.

A Pilot Study of Neurobiological Mechanisms of Stress and Cardiovascular Risk

Objective

Coronary heart disease is a leading cause of death and disability. Although psychological stress has been identified as an important potential contributor, mechanisms by which stress increases risk of heart disease and mortality are not fully understood. The purpose of this study was to assess mechanisms by which stress acts through the brain and heart to confer increased CHD risk.

Methods

Coronary Heart Disease patients (N=10) underwent cardiac imaging with [Tc-99m] sestamibi single photon emission tomography at rest and during a public speaking mental stress task. Patients returned for a second day and underwent positron emission tomography imaging of the brain, heart, bone marrow, aorta (indicating inflammation) and subcutaneous adipose tissue, after injection of [18F]2-fluoro-2-deoxyglucose for assessment of glucose uptake followed mental stress. Patients with (N=4) and without (N=6) mental stress-induced myocardial ischemia were compared for glucose uptake in brain, heart, adipose tissue and aorta with mental stress.

Results

Patients with mental stress-induced ischemia showed a pattern of increased uptake in the heart, medial prefrontal cortex, and adipose tissue with stress. In the heart disease group as a whole, activity increase with stress in the medial prefrontal brain and amygdala correlated with stress-induced increases in spleen (r=0.69, p=0.038; and r=0.69, p=0.04 respectfully). Stress-induced frontal lobe increased uptake correlated with stress-induced aorta uptake (r=0.71, p=0.016). Activity in insula and medial prefrontal cortex was correlated with post-stress activity in bone marrow and adipose tissue. Activity in other brain areas not implicated in stress did not show similar correlations. Increases in medial prefrontal activity with stress correlated with increased cardiac glucose uptake with stress, suggestive of myocardial ischemia (r=0.85, p=0.004).

Conclusions

These findings suggest a link between brain response to stress in key areas mediating emotion and peripheral organs involved in inflammation and hematopoietic activity, as well as myocardial ischemia, in Coronary Heart Disease patients.

POS0373 WHO ARE IN AND WHO ARE NOT? CHARACTERISTICS OF PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES ACCEPTING AN ONLINE SYSTEM FOR REMOTELY ENTERING PATIENT REPORTED OUTCOMES. EXPERIENCE FROM THE DANISH DANBIO REGISTRY

Background

Digital solutions for online monitoring of chronic diseases are increasingly implemented in health care, but not all patients might have access, skills, or interest in using them. Fueled by the COVID-19 pandemic and the urgent need for remote consultations, an online website to enter patient-reported outcomes (PROs) from home (DANBIO-from-home, https://danbio.dk) was implemented on May 15th 2020 for patients with inflammatory rheumatic diseases (IRD) followed in the Danish nationwide DANBIO registry.

Objectives

To explore the use of DANBIO-from-home during the first 1½ year after launching, with focus on a) characteristics of patients who did versus who did not access the webpage, and b) impact of patient age on time to first entry.

Methods

DANBIO-from-home allows PROs to be entered remotely by computer, tablet, or smartphone after secure log-on. All patients followed in DANBIO were informed about this option by invitations sent through eBoks, a national infrastructure for electronic communication, available to 80-90% of Danish citizens. Patients were encouraged to access DANBIO-from-home before planned rheumatology consultations, or when participating in the voluntary questionnaire survey ‘You and your rheumatic disease during times with corona-virus’ (on three occasions: May 2020, Nov 2020, June 2021) (ref). Follow-up ended Dec 1st 2021.

Characteristics of patients who did/did not access DANBIO-from-home during follow-up are explored by multivariable logistic regression analyses adjusted by clinical factors (gender/age-group/diagnosis/disease duration/use of biologics/HAQ/PASS). Time to first entry of PRO using DANBIO-from-home is presented as cumulative incidence curves by age group.

Results

Among 33,776 patients with inflammatory rheumatic diseases followed in DANBIO, 68% used DANBIO-from-home at least once during follow-up (Table 1). Patients who used the system were less frequently below 40 years or above 80 years old, more frequently biologically treated and had lower HAQ-score than patients who did not use it.

Table 1.Data entry, DANBIO-from-home solution N=33,776YES, 68%NO, 32%Gender, female6436Gender, male7822Age strata, yrs< 40623840-60732761-807228>803961DiagnosisRA6723AxSpA6931PsA7030Biologic treatment, yes*7327PASS, yes7129Age, yrs, median (IQR)62 (52-71)65 (50-77)Time since diagnosis, yrs, median (IQR)9 (5-16)10 (5-17)HAQ, median (IQR)0.5 (0.125-1.0)0.625 (0.125-1.25)

Row percentages unless otherwise shown

* latest visit before March 2020

AxSpA: Axial spondyloarthritis, HAQ: health assessment questionnaire, PASS: patient acceptable symptom scale, PsA: psoriatic arthritis, RA: rheumatoid arthritis

In logistic regression analyses, factors associated with DANBIO-from-home access were: female gender (odds ratio, OR 1.2 (1.1;1.3)), age group 40-60 (1.8 (1.6;2.0)) or 61-80 yrs (1.9 (1.7;2.19) and not age >80 yrs (0.6 (0.5;0.7) with age <40 as the reference), biologic treatment (1.4 (1.3;1.5)), higher HAQ (1.3 (0.3;1.4)), scoring PASS ‘no’ (1.1 (1.02;1.2)) (all p <0.001), whereas disease duration and diagnosis had no impact.

Time to first entry was longest in in patients >80 yrs followed by the <40 yrs group. For all age-groups, and most pronounced for age <40 yrs, the use increased when invitations to questionnaire surveys were sent out. (Figure 1)

Conclusion

A web-based system for secure remote entry of PROs was well-received after a nationwide launch. Patient-related factors had a substantial impact on the use. Lower use in the elderly might indicate lack of technical skills or facilities, whereas low use in younger age groups, which improved over time, is likely driven by other factors. Further analyses are planned to explore if lack of use impacts treatment outcomes.

References

[1]Glintborg et al, Rheumatology. 2021 Oct 9;60:SI3-SI12

Disclosure of Interests

Bente Glintborg Grant/research support from: AbbVie, BMS, Pfizer, Dorte Vendelbo Jensen: None declared, Lene Terslev Speakers bureau: Roche, Novartis, Pfizer, UCB, Janssen, Oliver Hendricks Grant/research support from: AbbVie, Novartis, Pfizer, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Galapagos, Gilead, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Celgene, Merck, Novartis, Simon Horskjær Rasmussen: None declared, Mogens Pfeiffer-Jensen: None declared, Thomas Adelsten: None declared, Ada Colic: None declared, Kamilla Danebod: None declared, Malene Kildemand: None declared, Anne Gitte Loft Speakers bureau: AbbVie, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, and UCB, Heidi Lausten Munk: None declared, Jens Kristian Pedersen: None declared, René Østgård Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Eli-Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi and UCB., Grant/research support from: Abbvie, Christian Møller Sørensen: None declared, Niels Steen Krogh: None declared, Jette Nørgaard Agerbo: None declared, Connie Ziegler: None declared, Merete Lund Hetland Grant/research support from: AbbVie, Biogen, BMS, Celtrion, Eli Lilly Denmark A/S, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopis, Sandoz

POS1197 REMOTE AND PHYSICAL CONSULTATIONS DURING THE FIRST 15 MONTHS OF THE COVID-19 PANDEMIC: USE AND PATIENT-SATISFACTION IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES FOLLOWED IN THE DANBIO REGISTRY

Background

During COVID-19 related lockdowns, physical attendance may be replaced by remote (by telephone, email, video consultations in patients with inflammatory rheumatic diseases (IRD). During re-opening of society, reallocation of health-care resources could potentially cause persistent changes in access to physical consultations.

Objectives

To explore use of remote consultations in patients with IRD followed in the nationwide DANBIO registry at three time points (lockdown from spring 2020 followed by gradual reopening of society) during the COVID-19 pandemic. Furthermore, to explore satisfaction with treatment access, and preferred mode of consultation including potentially associated clinical factors.

Methods

We performed a nationwide survey where three times, an online questionnaire (Q) “You and your arthritis in times of COVID-19” with questions regarding use of and access to remote and physical consultations was sent to all patients in DANBIO (Q1: March-April 2020, Q2: November 2020, Q3: May 2021). (ref)

Patient characteristics were captured in DANBIO (gender/age/diagnosis/biological therapy) and from the questionnaire (work status/comorbidities/EQ-5D). Use of physical and/or remote consultations 0-3 months before surveys and satisfaction with access was identified. Clinical factors associated with a preference for physical consultations at time of Q3 (versus remote contact (telephone/e-mail/video)) were explored with multivariable logistic regression analysis.

Results

Totally, 12,789/14,755/13,921 patients responded to Q1/Q2/Q3, respectively, with 23,311 unique patients participating in at least one survey. Characteristics of patients responding to Q3 are shown in Table 1.

Table 1.

Respondents to questionnaire 3, n=13,921.

GenderFemale63%Median age, IQR, years64 (54-72)DiagnosisRheumatoid arthritis64%Psoriatic arthritis16%Axial spondyloarthritis (AxSpA)12%Other8%Current occupational statusWorking41%No. of self-reported comorbidities≥165%Current biologic useyes27%*EQ-5D, median (IQR)0.8 (0.7-0.9)

EQ-5D: EuroQol quality of life (5-dimension)

*By March 2020

During the preceding 3 months, proportions of patients with physical/remote consultations were 22%/45%, 41%/38%, 40%/39% for Q1, Q2, Q3, respectively. Remote consultations were mainly by telephone, whereas email (<5%) and video (<1%) were rarely used. In all three surveys, only 7% of respondents found that access to counseling with their rheumatologist had deteriorated during the pandemic (Figure 1A) whereas the majority found it to be unchanged or did not know. The preferred contact form was physical consultations (68-74%, Figure 1B, not available for Q1). Factors associated with preference for physical consultation were female gender, higher age (>60 years), biological treatment, low EQ-5D and not having axial spondyloarthritis, whereas work status and comorbidities were without significance (logistic regression analyses, details not shown).

Figure 1.

Conclusion

Despite a widespread use of remote consultations during the pandemic, nationwide questionnaire surveys performed at three time-points during the COVID-19 pandemic showed that most patients were satisfied with access to rheumatic counseling. Nevertheless, in-person contacts were preferred by most patients, mainly women and elderly.

References

[1]Glintborg B, al. RMD Open. 2021;7(1).

Acknowledgements

Patients and Danish departments contributing to the DANBIO registry. Lundbeck foundation for funding

Disclosure of Interests

Bente Glintborg Grant/research support from: AbbVie, BMS, Pfizer, Dorte Vendelbo Jensen: None declared, Lene Terslev Speakers bureau: Roche, Novartis, Pfizer, and UCB, Oliver Hendricks Grant/research support from: AbbVie, Novartis, Pfizer, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Galapagos, Gilead, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Celgene, Merck, Novartis, Simon Horskjær Rasmussen: None declared, Mogens Pfeiffer-Jensen: None declared, Thomas Adelsten: None declared, Ada Colic: None declared, Kamilla Danebod: None declared, Malene Kildemand: None declared, Anne Gitte Loft Speakers bureau: AbbVie, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, and UCB, Heidi Lausten Munk: None declared, Jens Kristian Pedersen: None declared, René Østgård: None declared, Christian Møller Sørensen: None declared, Niels Steen Krogh: None declared, Jette Nørgaard Agerbo: None declared, Connie Ziegler: None declared, Merete Lund Hetland Grant/research support from: AbbVie, Biogen, BMS, Celtrion, Eli Lilly Denmark A/S, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopis, Sandoz

POS1226 CLINICAL FACTORS ASSOCIATED WITH A POSITIVE SARS-CoV-19 TEST AND WITH FREQUENT TESTING DURING THE COVID-19 PANDEMIC IN >10.000 PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES. RESULTS FROM A NATIONWIDE SURVEY FROM THE DANISH DANBIO REGISTRY

Background

Patients with inflammatory rheumatic diseases (IRD) have used self-isolation and social distancing during the pandemic to avoid SARS-CoV-19 infection (reference). In countries with unlimited and free access to SARS-CoV-19 testing, anxiety or other patient related factors might potentially increase test-frequency.

Objectives

In patients with IRD followed in the nationwide DANBIO registry we aimed to explore clinical factors including self-isolation associated with a) a positive SARS-CoV-19 test result (‘infection’), b) higher frequency of SARS-CoV-19 testing during the first 1½ year of the pandemic.

Methods

In May-June 2020, IRD patients followed in the quality registry, DANBIO (n=36,152), were invited to participate in the voluntary online questionnaire survey ‘You and your rheumatic disease during times with corona-virus’. Patient characteristics, treatment and patient reported outcomes were captured in DANBIO and from the questionnaire. Patients were considered as self-isolating if they agreed to the question: I stay at home and avoid others as much as possible.

After written consent, information on dates and SARS-CoV-19 test results (by PCR, polymerase chain reaction) during follow-up (until Nov 2021 and thus before entry of the Omicron variant) was obtained through linkage to the nationwide laboratory system.

Time to first positive PCR and associated characteristics were explored by multivariable Cox regression analyses with hazard ratios, HR, adjusted for: gender/age-group/ diagnosis/biologic therapy/working/ self-isolation/HAQ/EQ-5D. Day 0 was defined as the date of first positive test in cohort (May-07-2020).

Number of SARS-CoV-19 tests (median (IQR)), and characteristics associated with higher test frequency (upper quartile) was explored with multivariable logistic regression analyses (odds ratios, OR, adjustment like above).

Results

In 10,098 included patients, 2.8% were infected during follow-up (Table 1). Age and HAQ seemed lower in infected (Table 1, Figure 1). In multivariable Cox regression analyses, male gender was associated with higher infection risk (HR 1.38 (1.05;1.80) whereas risk was lower in the age-group 61-80 years (0.60 (0.39;0.92) vs. below 40 years). Other factors were statistically insignificant.

Table 1.Total populationSARS-CoV-19 testsNumber of testsPOSITIVE*NEGATIVE<9≥9Patient number10,098282981674062692Patient %1003977426Female, %66543977228Male, %34443977723Age, yrs, median (IQR)61 (51-70)56 (47-55)61 (51-70)55 (47-61)64 (54-72)Age, strata, yrs< 40969496623840-603898496594161-8049842988515>80247199973DiagnosisAxSpA14644966634RA63452987624PsA16893977030Other6004967931Biologic treatment, yes**38313977228HAQ, median**0.50.3750.50.3750.5EQ-5D, median0.80.80.80.80.8Self-isolating, yes84743977426Working46164965842

Row percentage unless otherwise shown

* At least one positive PCR before Nov 2021

**May 2020

AxSpA: Axial spondyloarthritis, EQ-5D: EuroQol quality of life (5D), HAQ: health assessment questionnaire, IQR: interquartile range, PsA: psoriatic arthritis, RA: rheumatoid arthritis

Median number of PCR tests was 4 (IQR 1-9). In patients with <9 tests, 2.6% were infected whereas for patients with ≥9 tests, 3.2% were infected. Patients with ≥9 tests were younger, more frequently female and working in univariate (Table 1) and adjusted analyses, whereas other characteristics were statistically insignificant (details not shown).

Conclusion

Few patients with IRD were infected during the first 1½ years of the pandemic. Gender and age were associated with infection risk and frequency of testing. Self-isolation and a range of other clinical characteristics had no impact, which to some extent may be due to behavioral differences across age-groups.

References

[1]Glintborg B et al, RMD open, 2021

Disclosure of Interests

Bente Glintborg Grant/research support from: AbbVie, BMS, Pfizer, Dorte Vendelbo Jensen: None declared, Lene Terslev Speakers bureau: Roche, Novartis, Pfizer, UCB, Janssen, Oliver Hendricks Grant/research support from: AbbVie, Novartis, Pfizer, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Celgene, Merck, Novartis, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Galapagos, Gilead, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Simon Horskjær Rasmussen: None declared, Mogens Pfeiffer-Jensen: None declared, Thomas Adelsten: None declared, Ada Colic: None declared, Kamilla Danebod: None declared, Malene Kildemand: None declared, Anne Gitte Loft Speakers bureau: AbbVie, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, and UCB, Heidi Lausten Munk: None declared, Jens Kristian Pedersen: None declared, René Østgård Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Eli-Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi and UCB, Grant/research support from: AbbVie, Christian Møller Sørensen: None declared, Niels Steen Krogh: None declared, Jette Nørgaard Agerbo: None declared, Connie Ziegler: None declared, Merete Lund Hetland Grant/research support from: AbbVie, Biogen, BMS, Celtrion, Eli Lilly Denmark A/S, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopis, Sandoz

GPCR kinase knockout cells reveal the impact of individual GRKs on arrestin binding and GPCR regulation

G protein-coupled receptors (GPCRs) activate G proteins and undergo a complex regulation by interaction with GPCR kinases (GRKs) and the formation of receptor-arrestin complexes. However, the impact of individual GRKs on arrestin binding is not clear. We report the creation of eleven combinatorial HEK293 knockout cell clones lacking GRK2/3/5/6, including single, double, triple and the quadruple GRK knockout. Analysis of β-arrestin1/2 interactions for twelve GPCRs in our GRK knockout cells enables the differentiation of two main receptor subsets: GRK2/3-regulated and GRK2/3/5/6-regulated receptors. Furthermore, we identify GPCRs that interact with β-arrestins via the overexpression of specific GRKs even in the absence of agonists. Finally, using GRK knockout cells, PKC inhibitors and β-arrestin mutants, we present evidence for differential receptor-β-arrestin1/2 complex configurations mediated by selective engagement of kinases. We anticipate our GRK knockout platform to facilitate the elucidation of previously unappreciated details of GRK-specific GPCR regulation and β-arrestin complex formation.

POS0056 ANXIETY AND CONCERNS RELATED TO THE WORK SITUATION DURING THE COVID-19 PANDEMIC IN >5,000 PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASE FOLLOWED IN THE DANISH DANBIO REGISTRY, RESULTS FROM A NATIONWIDE QUESTIONNAIRE

Background:

During the COVID-19 pandemic, widespread changes in how we work have been observed. Working from home is not an option for everyone. At work it may be difficult to keep social distance, which may lead to fear and anxiety of being infected with SARS-CoV-19 or of spreading the virus.

Objectives:

To explore frequency of anxiety and concerns related to work in patients with inflammatory rheumatic diseases(IRD) during the COVID-19 pandemic and to identify patient and disease characteristics associated with increased anxiety.

Methods:

Patients in routine care followed in the nationwide Danish DANBIO registry were invited to answer an on-line questionnaire regarding current rheumatic disease activity, behavior and anxiety including current work-status and -concerns. Responses were linked to patient data previously recorded in DANBIO. Clinical factors associated with work-related concerns (completely/mostly agree versus neither/nor, completely/mostly disagree) were explored with multivariable logistic regression.

Results:

Among 14,758 respondents (38% of eligible patients), 5,950 patients (40%) were currently working (60% full time/31% part time/9% self-employed) (61% female, 53% rheumatoid arthritis/19% psoriatic arthritis/20% axial spondyloarthritis/9% other). Although 68% reported that the workplace helped to make necessary interventions, work-related concerns and anxiety were frequent. Thus, 22% found it difficult (completely/mostly agree) to keep physical distance at work and 20% were worried about going to work (Figure 1).

Factors associated with concerns about going to work were female gender, longer education, other chronic conditions, biological therapy, and higher (=poorer) EQ-5D, whereas diagnosis was without significance. Similar patterns were found for other work-related concerns (not shown).

Conclusion:

In this cohort of >5,000 patients with inflammatory rheumatic diseases followed in a nationwide registry, during the COVID-19 pandemic anxiety and concerns related to the work situation were frequent, especially in women and patients treated with biologicals, with other chronic diseases and with poor quality of life.

References:

[1]Glintborg et al, 2021, https://rmdopen.bmj.com/content/rmdopen/7/1/e001505.full.pdf

Table 1.

Factors associated with being worried (agree versus disagree) to go to work (Figure 1, panel F). Multivariable logistic regression analyses

Odds ratio (95% CI)pGenderfemale1male0.45 (0.38;0.54)<0.001Age, years>40140-601.12 (0.87;1.44)0.4>600.89 (0.67;1.20)0.5EducationLong1No/short0.80 (0.69;0.93)0.005Living alone, yes0.97 (0.79;1.20)0.8Other chronic condition, yes1.37 (1.17;1.59)<0.001Biological therapy1.36 (1.17;1.58)<0.001DiagnosisRheumatoid arthritis1Psoriatic arthritis1.21 (0.99;1.48)0.06Axial spondyloarthritis1.03 (0.84;1.28)0.8Other1.17 (0.89;1.54)0.3PASS, yes*1.03 (0.85;1.25)0.7SmokingCurrent1Previous1.17 (0.94;1.47)0.2Never1.10 (0.90;1.35)0.4EQ5D**0.03 (0.02;0.06)<0.001

*patient acceptable symptom state, **European Quality of Life, 5 dimensions

Disclosure of Interests:

Bente Glintborg Grant/research support from: AbbVie, BMS, Pfizer, Dorte Vendelbo Jensen: None declared, Sara Engel: None declared, Lene Terslev Speakers bureau: AbbVie, Janssen, Roche, Novartis, Pfizer, MSD, BMS and GE, Mogens Pfeiffer Jensen: None declared, Oliver Hendricks: None declared, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB., Grant/research support from: Abbvie, BMS, Celgene, Merck, Novartis, Simon Horskjær Rasmussen: None declared, Thomas Adelsten: None declared, Ada Colic: None declared, Kamilla Danebod: None declared, Malene Kildemand: None declared, Anne Gitte Loft Speakers bureau: AbbVie, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, and UCB, Heidi Lausten Munk: None declared, Jens Kristian Pedersen: None declared, René Østgård Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Eli-Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi and UCB., Grant/research support from: Abbvie, Christian Møller Sørensen: None declared, Niels Steen Krogh: None declared, Jette Nørgaard Agerbo: None declared, Connie Ziegler: None declared, Merete L. Hetland Grant/research support from: AbbVie, Biogen, BMS, Celtrion, Eli Lilly Denmark A/S, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopis, Sandoz. MLH chairs the steering committee of the Danish Rheumatology Quality Registry (DANBIO), which receives public funding from the hospital owners and funding from pharmaceutical companies. MLH co-chairs the EuroSpA research collaboration, which generates real-world evidence of treatment of psoriatic arthritis and axial spondylorthritis based on secondary data and is partly funded by Novartis.

POS1170 SELF-PROTECTION STRATEGIES, HEALTH BEHAVIOR AND DISEASE ACTIVITY DURING THE FIRST WAVE, RE-OPENING AND SECOND WAVE OF THE COVID-19 PANDEMIC IN >7000 DANISH PATIENTS WITH INFLAMMATORY ARTHRITIS

Background:

The COVID-19 pandemic has caused lockdown, reduced access to face-to-face consultations, anxiety about taking immunosuppressive agents and self-isolation1 which potentially impact rheumatic disease control negatively. However, changes in behavior including self-protection strategies during the ongoing pandemic and impact on rheumatic disease activity have only been scarcely described.

The first COVID-19 wave hit Denmark in March 2020 followed by a gradual re-opening from mid-April and the second surge began in the late autumn of 2020.

Objectives:

To describe changes over time in self-protection strategies and health behavior during the first 8 months of the COVID-19 pandemic and to explore impact on self-reported disease activity and quality of life (=patient reported outcomes, PROs) in patients with inflammatory rheumatic disease (IRD) in DANBIO.

Methods:

Patients were invited to answer two on-line questionnaires regarding current behavior and disease specific PROs: One in June 2020 (including also questions regarding behavior in March 2020), and one in November 2020. Responses were linked to PROs collected as part of routine care before March 2020 (=Before) in DANBIO. For each PRO, changes (=delta values) between the two timepoints were calculated in individual patients.

Results:

Overall, 7,836 patients (22% of eligible patients) answered both questionnaires and were included (rheumatoid arthritis(RA): 5270(67%), psoriatic arthritis(PsA): 1217(15%), axial spondyloarthritis(AxSpA): 932(12%), other IRD: 417(5%). Patients reported highest levels of anxiety and self-protection in March with an improvement in June that was largely unchanged in November (Figure 1), e.g. proportions staying at home avoiding others as much as possible (completely or mostly agree) were 87%/49%/51% in March/June/November, respectively (Figure 1, Panel C).

Disease activity and proportions of patients reporting acceptable symptom state remained stable at the three time points (Table 1), with all median delta values being close to zero (not shown).

Conclusion:

In this large cohort of patients with inflammatory rheumatic diseases followed in the nationwide DANBIO registry, COVID-19 related self-protection strategies were highest in March 2020, but more than half of the patients also reported self-isolation in June and November. We found no negative impact of the pandemic on patient-reported outcomes, which remained largely unchanged and were similar to before the pandemic. The latter finding probably reflects that few patients reduced or withdrew from treatment due to fear of COVID-19.1

References:

[1]Glintborg et al, 2021, https://rmdopen.bmj.com/content/rmdopen/7/1/e001505.full.pdf

Table 1.

Patient reported outcomes before March, in June and in November 2020 in patients with IRD. N=7,836

Before*June 2020Nov 2020Patient VAS global, mm30 (12-58)28 (10-54)29 (10-55)Patient VAS pain, mm27 (11-51)28 (11-51)29 (11-52)HAQ0.50 (0.13-1.0)0.50 (0.13-1.00)0.50 (0.13-1.00)EQ-5D0.80 (0.72-0.86)0.79 (0.71-0.86)0.80 (0.71-0.86)PASS, yes73%75%76%

Numbers are median (IQR) unless otherwise stated*Latest registration in DANBIO before March 2020Patient characteristics for RA/AxSpA/PsA/Other: female, %: 70/53/44/69. Age, years, median(IQR): 67(59-74)/62(54-69)/56(46-65)/59(50-68)Abbreviations: EQ-5D: Quality of life, 5 dimensions, HAQ: health assessment questionnaire, PASS: patient acceptable symptom state, VAS: visual analogue scale

Disclosure of Interests:

Bente Glintborg Grant/research support from: AbbVie, BMS, Pfizer, Dorte Vendelbo Jensen: None declared, Sara Engel: None declared, Lene Terslev Speakers bureau: AbbVie, Janssen, Roche, Novartis, Pfizer, MSD, BMS and GE, Mogens Pfeiffer Jensen: None declared, Oliver Hendricks Grant/research support from: AbbVie, Novartis, Pfizer, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB., Grant/research support from: Research grants: Abbvie, BMS, Celgene, Merck, Novartis, Simon Horskjær Rasmussen: None declared, Thomas Adelsten: None declared, Kamilla Danebod: None declared, Ada Colic: None declared, Malene Kildemand: None declared, Anne Gitte Loft Speakers bureau: AbbVie, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, and UCB, Heidi Lausten Munk: None declared, Jens Kristian Pedersen: None declared, René Østgård Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Eli-Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi and UCB., Grant/research support from: Research grants: Abbvie, Christian Møller Sørensen: None declared, Niels Steen Krogh: None declared, Jette Nørgaard Agerbo: None declared, Connie Ziegler: None declared, Merete L. Hetland Grant/research support from:: AbbVie, Biogen, BMS, Celtrion, Eli Lilly Denmark A/S, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopis, Sandoz. MLH chairs the steering committee of the Danish Rheumatology Quality Registry (DANBIO), which receives public funding from the hospital owners and funding from pharmaceutical companies. MLH co-chairs the EuroSpA research collaboration, which generates real-world evidence of treatment of psoriatic arthritis and axial spondylorthritis based on secondary data and is partly funded by Novartis.

Attachment style and oxytocin receptor gene variation interact in influencing social anxiety

OBJECTIVES

Social anxiety has been suggested to be promoted by an insecure attachment style. Oxytocin is discussed as a mediator of trust and social bonding as well as a modulator of social anxiety. Applying a gene-environment (G × E) interaction approach, in the present pilot study the main and interactive effects of attachment styles and oxytocin receptor (OXTR) gene variation were probed in a combined risk factor model of social anxiety in healthy probands.

METHODS

Participants (N = 388; 219 females, 169 males; age 24.7 ± 4.7 years) were assessed for anxiety in social situations (Social Phobia and Anxiety Inventory) depending on attachment style (Adult Attachment Scale, AAS) and OXTR rs53576 A/G genotype.

RESULTS

A less secure attachment style was significantly associated with higher social anxiety. This association was partly modulated by OXTR genotype, with a stronger negative influence of a less secure attachment style on social anxiety in A allele carriers as compared to GG homozygotes.

CONCLUSIONS

The present pilot data point to a strong association of less secure attachment and social anxiety as well as to a gene-environment interaction effect of OXTR rs53576 genotype and attachment style on social anxiety possibly constituting a targetable combined risk marker of social anxiety disorder.

Clonal B cells in Waldenström's macroglobulinemia exhibit functional features of chronic active B-cell receptor signaling

Waldenström's macroglobulinemia (WM) is a B-cell non-Hodgkin's lymphoma (B-NHL) characterized by immunoglobulin M (IgM) monoclonal gammopathy and the medullary expansion of clonal lymphoplasmacytic cells. Neoplastic transformation has been partially attributed to hyperactive MYD88 signaling, secondary to the MYD88 L265P mutation, occurring in the majority of WM patients. Nevertheless, the presence of chronic active B-cell receptor (BCR) signaling, a feature of multiple IgM+ B-NHL, remains a subject of speculation in WM. Here, we interrogated the BCR signaling capacity of primary WM cells by utilizing multiparametric phosphoflow cytometry and found heightened basal phosphorylation of BCR-related signaling proteins, and augmented phosphoresponses on surface IgM (sIgM) crosslinking, compared with normal B cells. In support of those findings we observed high sIgM expression and loss of phosphatase activity in WM cells, which could both lead to signaling potentiation in clonal cells. Finally, led by the high-signaling heterogeneity among WM samples, we generated patient-specific phosphosignatures, which subclassified patients into a ‘high' and a ‘healthy-like' signaling group, with the second corresponding to patients with a more indolent clinical phenotype. These findings support the presence of chronic active BCR signaling in WM while providing a link between differential BCR signaling utilization and distinct clinical WM subgroups.

[Surgical treatment of ulnar collateral ligament injuries of the thumb metacarpophalangeal joint]

OBJECTIVE

Reconstruction of the ruptured ulnar collateral ligament of the metacarpophalangeal (MP) joint of the thumb.

INDICATIONS

Ruptured ulnar collateral ligament of the thumb MP joint with instability: joint opening of more than 30° in flexion and more than 20° in extension, Stener lesion, displaced avulsion fractures.

CONTRAINDICATIONS

Abrasions, wound-healing disturbance, skin disease, osteoarthritis.

SURGICAL TECHNIQUE

Curved skin incision dorsoulnar above the thumb MP joint. Protection of the branches of the superficial radial nerve. Incision of the adductor aponeurosis. Exposing the ulnar collateral ligament; opening and examination of the joint. Depending on the injury, primary suture repair, transosseous suture, repair with a bone anchor, osteosynthesis with K-wires or small screws in avulsion fracture, ligament reconstruction in chronic instability or older injury.

POSTOPERATIVE TREATMENT

Cast splint of the MP joint until swelling subsides; cast immobilization for 6 weeks; range-of-motion exercises, avoiding forced radial deviation of the MP joint for 3 months.

RESULTS

Complete joint stability 3 months postoperatively in all 34 patients with rupture of the ulnar collateral ligament.

Lithium-induced Clock Gene Expression in Lymphoblastoid Cells of Bipolar Affective Patients

INTRODUCTION

Disturbances of circadian rhythms occur in all episodes of bipolar disorder (BD). Lithium, as gold-standard in the maintenance treatment of BD, is known to influence circadian processes.

METHODS

In a pilot study lymphoblastoid cell lines (LCLs) were generated from 8 BD patients and 6 healthy controls. The LCLs were treated with lithiumchloride (LiCl) for 3 weeks. Cell cycles were then synchronized and expressional analysis by quantitative Real Time PCR was done.

RESULTS

BD and controls differed in the period length regarding DBP (albumin D-box binding protein) expression and DBP expression was also influenced by lithium treatment. Furthermore, baseline DBP expression was significantly different between non-treated BD and healthy controls. None of the other analyzed circadian genes showed to be influenced by chronic lithium treatment or to be differentially regulated due to the diagnosis.

DISCUSSION

We here show that chronic lithium treatment of LCLs leads to decreased expression of the clock gene DBP, rendering DBP a lithium-regulated gene. We could confirm the role of the circadian clock as well in lithium mode of action as in the pathomechanisms of BD although future studies with a greater number of participants and cell lines are needed.

Highly transparent Bi2MoO6- and Bi2WO6-polymer nanocomposites

A combined method of precipitation, phase transfer into organic solvent, solvothermal treatment and subsequent in situ polymerization was used to integrate nanocrystalline Bi2MoO6- and Bi2WO6-particles into a polymer matrix of poly-laurylacrylate. The presented method offers a new and gentle way to produce highly transparent bulk nanocomposites containing evenly distributed Bi2MoO6- and Bi2WO6-nanoparticles. Characterization results of DLS-, XRD-, REM- and TEM-measurements are presented as well as solid state UV/VIS-measurements of the particles. The transparent nanocomposites were characterized using UV/VIS-spectroscopy and ellipsometry. All composites show a good transmission in the range from 800-400 nm. The particle content of the nanocomposites was measured with TG-measurements.

A CMOS-based microelectrode array for interaction with neuronal cultures

We report on the system integration of a CMOS chip that is capable of bidirectionally communicating (stimulation and recording) with electrogenic cells such as neurons or cardiomyocytes and that is targeted at investigating electrical signal propagation within cellular networks in vitro. The overall system consists of three major subunits: first, the core component is a 6.5 mm x 6.5 mm CMOS chip, on top of which the cells are cultured. It features 128 bidirectional electrodes, each equipped with dedicated analog filters and amplification stages and a stimulation buffer. The electrodes are sampled at 20 kHz with 8-bit resolution. The measured input-referred circuitry noise is 5.9 microV root mean square (10 Hz to 100 kHz), which allows to reliably detect the cell signals ranging from 1 mVpp down to 40 microVpp. Additionally, temperature sensors, a digital-to-analog converter for stimulation, and a digital interface for data transmission are integrated. Second, there is a reconfigurable logic device, which provides chip control, event detection, data buffering and an USB interface, capable of processing the 2.56 million samples per second. The third element includes software that is running on a standard PC performing data capturing, processing, and visualization. Experiments involving the stimulation of neurons with two different spatio-temporal patterns and the recording of the triggered spiking activity have been carried out. The response patterns have been successfully classified (83% correct) with respect to the different stimulation patterns. The advantages over current microelectrode arrays, as has been demonstrated in the experiments, include the capability to stimulate (voltage stimulation, 8 bit, 60 kHz) spatio-temporal patterns on arbitrary sets of electrodes and the fast stimulation reset mechanism that allows to record neuronal signals on a stimulating electrode 5 ms after stimulation (instantaneously on all other electrodes). Other advantages of the overall system include the small number of needed electrical connections due to the digital interface and the short latency time that allows to initiate a stimulation less than 2 ms after the detection of an action potential in closed-loop configurations.

CMOS microelectrode array for the monitoring of electrogenic cells

Signal degradation and an array size dictated by the number of available interconnects are the two main limitations inherent to standalone microelectrode arrays (MEAs). A new biochip consisting of an array of microelectrodes with fully-integrated analog and digital circuitry realized in an industrial CMOS process addresses these issues. The device is capable of on-chip signal filtering for improved signal-to-noise ratio (SNR), on-chip analog and digital conversion, and multiplexing, thereby facilitating simultaneous stimulation and recording of electrogenic cell activity. The designed electrode pitch of 250 microm significantly limits the space available for circuitry: a repeated unit of circuitry associated with each electrode comprises a stimulation buffer and a bandpass filter for readout. The bandpass filter has corner frequencies of 100 Hz and 50 kHz, and a gain of 1000. Stimulation voltages are generated from an 8-bit digital signal and converted to an analog signal at a frequency of 120 kHz. Functionality of the read-out circuitry is demonstrated by the measurement of cardiomyocyte activity. The microelectrode is realized in a shifted design for flexibility and biocompatibility. Several microelectrode materials (platinum, platinum black and titanium nitride) have been electrically characterized. An equivalent circuit model, where each parameter represents a macroscopic physical quantity contributing to the interface impedance, has been successfully fitted to experimental results.

Projection Structure and Oligomeric State of the Osmoregulated Sodium/Glycine Betaine Symporter BetP of Corynebacterium glutamicum

The high-affinity glycine betaine uptake system BetP, an osmosensing and osmoregulated sodium-coupled symporter from Corynebacterium glutamicum, was overexpressed in Escherichia coli with an N-terminal StrepII-tag, solubilized in beta-dodecylmaltoside and purified by streptactin affinity chromatography. Analytical ultracentrifugation indicated that BetP forms trimers in detergent solution. Detergent-solubilized BetP can be reconstituted into proteoliposomes without loss of function, suggesting that BetP is a trimer in the bacterial membrane. Reconstitution with E.coli polar lipids produced 2D crystals with unit cell parameters of 182A x 154A, gamma=90 degrees exhibiting p22(1)2(1) symmetry. Electron cryo-microscopy yielded a projection map at 7.5A. The unit cell contains four non-crystallographic trimers of BetP. Within each monomer, ten to 12 density peaks characteristic of transmembrane alpha-helices surround low-density regions that define potential transport pathways. Small but significant differences between the three monomers indicate that the trimer does not have exact 3-fold symmetry. The observed differences may be due to crystal packing, or they may reflect different functional states of the transporter, related to osmosensing and osmoregulation. The projection map of BetP shows no clear resemblance to other secondary transporters of known structure.

Comparative electron microscopic study on projectin and titin binding to F-actin

Using the system of F-actin paracrystals, we have obtained electron microscopic evidence that projectin from synchronous flight muscles of Locusta migratoria binds to actin filaments in the same fashion as skeletal titin. Control actin paracrystals formed in the presence of Mg(2+) ions have great width and length and blunted ends. The addition of either projectin or titin results in disruption of compact ordered packing of F-actin in paracrystals and leads to the formation of loose filament bundles with smaller diameters and tapered ends. It is also accompanied with the appearance of individual actin filaments in considerable amounts. The effect becomes more pronounced with the increase in concentrations of added projectin or titin. Possible physiological implications of projectin-actin interactions are discussed.

Scanning-force techniques to monitor time-dependent changes in topography and adhesion force of proteins on surfaces

Scanning-force microscopy (SFM) investigations were conducted to probe the influences of the interactions of proteins with surfaces relevant in medicine. These interactions are an important feature in the area of biofilm formation. The adsorption of proteins leads to changes in topography, which was monitored for the build up of protein layers of hen egg-white lysozyme and bovine serum albumin (BSA) on mica in real time in phosphate-buffered aqueous solution over a time period of 10 min. Phase imaging was additionally applied to compare material contrasts and to evaluate this method for further application in this field. The adhesion forces that develop on a time scale below 20 s between a protein-modified SFM tip and titanium surfaces (TiO(2), TiAl6V4 and TiAl6Nb7) were investigated. The influences of the parameters loading force and interaction time between the protein and the surface were monitored as well as the influence of protein structure. The interaction time dependency of the adhesion force could be described with a kinetic model of two consecutive first-order reactions. For the maximal adhesion force a correlation to the ratio of the amino acids cysteine, proline and glycine has been proposed.

Protein adsorption on surfaces: dynamic contact-angle (DCA) and quartz-crystal microbalance (QCM) measurements

Adsorption of the protein bovine serum albumin (BSA) on gold has been tested at various concentrations in aqueous solution by dynamic contact-angle analysis (DCA) and quartz-crystal microbalance (QCM) measurements. With the Wilhelmy plate technique advancing and receding contact angles and the corresponding hysteresis were measured and correlated with the hydrophilicity and the homogeneity of the surface. With electrical admittance measurements of a gold-coated piezoelectrical quartz crystal, layer mass and viscoelastic contributions to the resonator's frequency shift during adsorption could be separated. A correlation was found between the adsorbed mass and the homogeneity and hydrophilicity of the adsorbed film.

Adsorption/desorption phenomena on pure and Teflon AF-coated titania surfaces studied by dynamic contact angle analysis

As a result of inflammatory processes, plaque formation on dental titanium implants often leads to clinically pathogenic situations. This special biofilm formation on (bio)materials in contact with saliva is initiated by ionic and protein interactions. In this interfacial process, albumin becomes a main constituent of dental pellicle. Interfacial reactions change the surface characteristics. They determine the following steps of macromolecular adsorption and bacterial adhesion. This work focuses on the dynamic contact angle analysis (DCA), which is a tool for online measurements of dynamic changes of wettability without disturbing the interface during detection. Repeatability of the DCA method has been assessed according to the Bland and Altman method. The kinetics and equilibrium data of shifts in the wetting tension hysteresis indicate ionic influences at the titanium/bovine serum albumin (BSA) interface: the Ca-mediated increase of the BSA adsorption on titanium and the adsorption maximum at the isoelectric point (IEP) of BSA. Ti was surface modified by Teflon AF polymeric coatings. The result of the assessment gives reason to consider Teflon AF as a reference material for DCA repeatability studies. This surface modification caused drastic changes in the dynamic interfacial reactions. Shifts in the wetting tensions during DCA adsorption-desorption experiments clearly demonstrated the partially irreversible adsorption of BSA on Teflon AF. In contrast, reversible adsorption behavior was detected on pure Ti surfaces. These findings strengthen the hypothesis that the analysis of dynamic changes in wetting tension and wetting tension hysteresis is a sensitive analytical method for the detection of dynamic interfacial changes at biomaterial/biosystem interfaces during the initial steps of biofilm formation.

[Digital volume tomography--an extension to the diagnostic procedures available for application before surgical removal of third molars]

BACKGROUND

Trauma to the inferior alveolaris nerve is one of the worst complications of the surgical removal of wisdom teeth. With digital volume tomography (DVT), a new imaging technique has been introduced to dentistry and oral and maxillofacial surgery, offering the same options for reconstruction as computer tomography (CT). Since mid-2000 we have been performing imaging via DVT in the case of deeply dislocated third molars sited very close to the nerve canal.

METHODS AND RESULTS

In the present study DVT images were made for a total of 81 lower and 11 upper wisdom teeth; the existing orthopantomogram of these teeth had not been sufficiently clear to allow a diagnosis in these cases. Detailed visualization of the wisdom tooth concerned in all planes was possible in each case, and exact reconstruction of the course of the inferior alveolar nerve was successful in 93%.

DISCUSSION

In summary, DVT is an advantageous and practical imaging technique that can be used for to extend the diagnosis in surgery on third molars.

Promotion of neural cell adhesion by electrochemically generated and functionalized polymer films

New strategies for spatially controllable cell adhesion have been developed for brain cells from embryonic chicken. They are based on electrochemically active phenol and pyrrole derivatives, and can be used for the selective coverage of electroconductive substrates. Besides mimicking standard laminin-related adhesion promoting mechanisms by means of an electroactive monomer-linked 18-peptide segment from laminin (SRARKQAASIKVAVSADR), electrochemically generated thin (6-30 nm) polymer films of 3-hydroxybenzyl-hydrazine (3HBH) and 2-(3-hydroxyphenyl)-ethanol (2(3HP)E) with and without mechanically entrapped or covalently linked D-lysine have proved to promote cell adhesion in serum-free medium on indium-doped tin oxide (ITO) substrates during the first 6 culturing days in vitro. The effectiveness of the peptide was strongly density-dependent. Unexpectedly, laminin itself or a combination of laminin and poly-D-lysine (PDL) did not promote cell adhesion and neuron differentiation in serum-free cultures on ITO. However, they worked perfectly well on regular polystyrene substrates in serum-free medium or on ITO when medium with serum was used. This finding might suggest that the adhesion efficiency of laminin does not depend only on the kind of medium supplement but also on the type of substrate. In contrast, the adhesion-promoting properties of "artificial" polymeric films seemed to be based on a more direct cell-film interaction, with the film masking the substrate properties.

The role of mineralocorticoid receptors in the circadian activity of the human hypothalamus-pituitary-adrenal system: effect of age

The purpose of this study was to test the role of the mineralocorticoid receptor (MR) in the circadian activity of the hypothalamus-pituitary-adrenal (HPA) system of elderly healthy subjects. Nine elderly subjects (age: 66.2 +/- 7.7 years) were treated for 8 days with both the MR antagonist spironolactone and a placebo in a randomized, single-blind cross-over order. After treatment, we studied the circadian profiles of ACTH, plasma cortisol and saliva cortisol. No significant change in ACTH concentrations emerged. However, there were significant increases in circadian minimal (52.4 +/- 26.7 versus 33.3 +/- 14.4 nmol/l), mean (166.2 +/- 24.9 versus 133.0 +/- 18.3 nmol/l), and maximal cortisol concentrations (389.7 +/- 57.7 versus 335.4 +/- 45.0 nmol/l). Also, in the diurnal trough, we found an increase in saliva cortisol concentrations. Compared to young healthy controls, spironolactone treatment had stronger effects in the elderly. We therefore conclude that: 1) MR is involved in the human HPA system regulation; 2) the MR participates in the regulation of circadian nadir and peak activity of the HPA system; and 3) the HPA system in the elderly is more vulnerable to dysregulation at the level of the MR.

The relationship between market orientation and performance in the hospital industry: a structural equations modeling approach

There is general consensus in the research literature that market orientation is related to organizational performance. This study examines this relationship in the hospital industry. One unique feature of this study is that both market orientation and performance are conceptualized as being multi-dimensional constructs. Hence the technique of Structural Equations Modeling (SEM) is used to examine the relationship. Analyses were based on market orientation and performance data obtained from 175 hospitals in a five-state region of the United States. The SEM results confirm the multi-dimensional nature of both market orientation and performance, and the strong relationship between the constructs. Interestingly, this relationship is found to be much stronger for smaller hospitals than for larger hospitals. Implications for the hospital industry are discussed.