Patient-reported outcomes in large vessel vasculitis: insights from a retrospective analysis of disease activity and associated factors

BACKGROUND

Patient-reported outcomes (PROs) play a crucial role in assessing rheumatic diseases, offering insights into disease evaluation and treatment efficacy. This study focuses on PRO assessment in large vessel vasculitides, including Takayasu Arteritis and Giant Cell Arteritis (GCA).

METHODS

We retrospectively analyzed routine data from patients treated at our rheumatology clinic over a 10-year span. Patient and physician-rated global disease activity scale (G-DAS) scores, measured on a numeric rating scale (0-10 points), were collected at each visit. Clinical variables like age, sex, body mass index (BMI), disease duration, lab values, pain perception, and questionnaire responses were recorded. Linear regression and generalized additive linear regression (GAM analysis) examined associations between PROs and these factors.

RESULTS

The study included 138 patients, primarily diagnosed with GCA (94.4%). Mean follow-up was 2.5 years (0-7.7). Patient and physician G-DAS exhibited a moderate correlation (Pearson R 0.19, CI 0.14-0.24, p < 0.001). Higher patient G-DAS correlated with younger age (CI -3.4 - -1.5, p < 0.001), increased pain (CI 3.5-4, p < 0.001), functional limitations (HAQ, CI 0.5-0.6, p < 0.001), reduced physical (CI 2.3-2.7, p ≤ 0.001) and psychological well-being (CI 2.1-2.5, p < 0.001), and higher BMI (CI 1.3-2.4, p < 0.001). Physician G-DAS correlated with Birmingham Vasculitis Activity Score (V3.0; R 0.42, p 0.046) and were significantly linked to serum CRP elevations (β = 0.04, CI 0.0-0.08, p 0.028).

CONCLUSIONS

These findings underscore the need to integrate PRO measures into vasculitis disease management strategies, enhancing the understanding of disease activity from the patient's perspective.

Accuracy of retrospective pain measurement in patients with chronic pain

The use of pain scales that refer to a past time period is thereby based on the assumption that patients accurately remember their 'average', 'greatest' and 'least' pain. The present study addresses the validity of numerical pain rating scales that refer to a past period of time (herein, the past 7 days). Routine data from 94 patients with chronic pain were retrospectively analysed. Pain questionnaire data on the greatest, least and average pain during the past week and on current pain were compared with the mean value of entries in a pain diary from the corresponding period. The retrospectively assessed average, greatest and least pain values were consistently slightly higher than the corresponding values of daily current pain measured for the studied collective of chronic pain patients. Current pain (at the time of answering the questionnaire) better represents daily currently measured pain [intraclass correlation (ICC)=0.885] than retrospective individual measurements. The greatest correlation with averaged diary data was shown by the combination of questionnaire data on average, least and current pain (ICC=0.911). The high correlations between the questionnaire and diary data support the validity of retrospective pain surveys. However, the current status influences recall. Thus, composite retrospective pain data improve with the addition of current pain.

Auditing Practices of the Medical Service Regarding Hospitalizations of Patients With a Secondary Diagnosis of Obesity

BACKGROUND

It has been observed that the Medical Service (Medizinischer Dienst, an auditing body of the German statutory health insurance system) is more likely to audit the bill for a hospitalization in a psychosomatic clinic if the patient carries a secondary diagnosis of obesity.

METHODS

In an exploratory study, we retrospectively analyzed 771 datasets collected in 2019 as part of the standard documentation of acute psychosomatic hospitalizations.

RESULTS

In 2019, the Medical Service audited bills for psychosomatic hospital - izations much more often in obese than in non-obese patients (odds ratio [OR] 2.499; 95% confidence interval [1.69; 3.69]). This was accounted for by a very high audit rate for patients with a secondary diagnosis of grade 3 obesity (OR = 3.972 [2.30; 6.86]). The audit categories "quality of coding" and "possible incorrect admission" were examined.

CONCLUSION

Treatments of markedly obese inpatients that incurred greater expenses presumably led to a higher hospitalization audit rate as an automatic consequence of the auditing algorithms used. An unintentional statistical discrimination arose from the unjustified linkage of the audit category "quality of coding" of the secondary diagnosis (obesity) with the audit category "possible incorrect admission" with regard to the main diagnosis. Similar effects may be occurring with economically relevant secondary diagnoses in other areas of medicine as well.

Ascertaining minimal clinically meaningful changes in symptoms of depression rated by the 15-item Centre for Epidemiologic Studies Depression Scale

RATIONALE, AIMS AND OBJECTIVES

In clinical practise and in clinical studies on depression it is important to estimate whether changes in symptomatology measured by self-rating instruments are, in fact, clinically relevant. Therefore, the aim of the study was to estimate the clinical relevance of changes on the 15-item version of the Centre for Epidemiologic Studies Depression Scale (CES-D-15) based on the concept of the minimal clinically important difference (MCID).

METHODS

Data was acquired from 4781 patients with depression symptoms from a German psychosomatic hospital who have been assessed using the CES-D-15 before and after treatment. Threshold values representing the MCID were estimated on the basis of mean change scores and sensitivity/specificity analyses. Patients' global impression of change, clinical (therapists') global impression of change and change in impairment severity were used as external anchor criteria.

RESULTS

On average, the MCID was represented by a reduction of approximately 11 points in the CES-D-15, irrespective of age, gender, type of treatment and first or secondary diagnosis. However, higher baseline scores in the CES-D-15 required larger changes of raw values to represent a clinically important difference.

CONCLUSIONS

Anchor-based values are suggested here as an estimation of the clinical relevance of changes in the CES-D-15. Thus, instead of relying solely on effect sizes, the evaluation of treatment outcomes should be supplemented by reporting the percentage of patients who have reached the MCID. Further examinations to verify our results in other patient populations and with other types of anchor criteria will be needed.

AB1415 GENDER EQUITY IN RHEUMATOLOGY IN GERMANY, WHERE DO WE STAND? – PRELIMINARY RESULTS FROM A NATIONWIDE ONLINE SURVEY AMONG RHEUMATOLOGISTS IN GERMANY

Background

Despite the increasing number of female medical students and fellows, women are still underrepresented in higher career and academic positions in rheumatology [1].

Objectives

To assess gender distribution in rheumatology in Germany and to analyze potential hurdles of flexible work opportunities with the overall aim to improve gender equity in future German rheumatology.

Methods

A web-based anonymous survey using QuestionPro was distributed among rheumatologists in Germany via newsletters, social media and personal contacts (12/2021-01/2022). The survey was developed based on a narrative literature review [1] and discussions among the commission members. It was composed of 29 questions, with single or multiple answers and/or free text. Non-demographic questions could be answered with “I do not know”.

Results

Among the total of 170 respondents who fully completed the survey, 72% were female, 28% were male and 1% was third gender. 73% were employed at a rheumatology clinic with 79% working at an academic institution and 20% at a non-academic clinic, 1% did not specify their institution. Of those working at a clinic, 48% were rheumatologists in training, 35% trained rheumatologists and 7% were head of rheumatology departments.

Regarding the gender-ratio in different hierarchical levels, only 17% reported more male than female rheumatologists in training at their workplace, in 32% the gender ratio was balanced. On higher levels, respondents reported more male than female rheumatologist at staff level in 44% (29% balanced) and in leading positions in 74% (12% balanced).

53% of female respondents were responsible for >50% of family and housework, compared to 11% of the male respondents. Most men covered 50% (49% of male respondents) or less than 50% (32% of male respondents) of family work.

There were coworkers in part time in the work environment of 86% of respondents, with only women working part time in 56% of cases, both women and men in part time in 29% and only men in part time in 1%. Most respondents stated that men and women working part time did not have the same opportunities as coworkers working full time. (Table 1)

Table 1.

Opportunities for advancements of part time working employees compared to full time coworkers with similar qualification in percent of all respondents.

Employees working part time have similar opportunities for advancements as employees of the same gender working full time.YesNoI do not knowWomen23%65%12%Men21%54%25%

Many respondents perceived a preference of either gender despite equal performance regarding different aspects with men more often perceived as preferred in terms of opportunities for advancements and staffing of positions. (Figure 1)

Figure 1.

Perceived preference of employees in rheumatology with regards to opportunities for advancements, staffing of positions, allocation of research projects and salary according to gender by female and male survey-respondents. Perceived discrimination was not assessed.

66% of respondents agreed that activities to improve gender equity are necessary. The highest need was seen in the improvement of compatibility of care and work with adequate part time models, childcare options at work, and the higher acceptancy of part time working men and women by employers and persons in higher positions (freetext).

Conclusion

Gender misbalance is prevalent in rheumatology in Germany with lower numbers of women at higher hierarchical levels. Traditional role allocation is still common with a higher frequency of part time working females. Part time employment is perceived to decrease chances of advancement. The focus should be on promoting flexible job-sharing models, part time work among men and gender equity not only at work but also in private life (“care work”). Preference for one gender over the other is perceived differently between women and men.

References

[1]Andreoli L et al. Gender equity in clinical practice, research and training: Where do we stand in rheumatology? Joint, Bone, Spine: Revue du Rhumatisme. 2019;86(6):669-672.

Disclosure of Interests

None declared

Conservative In-Patient Treatment of Specific Back Pain Before and During the Coronavirus Disease Pandemic

BACKGROUND

The measures taken in the coronavirus disease pandemic have had major structural and financial effects on orthopaedics and trauma surgery as many surgeries in this field. Experience Appropriate reports from non-surgical orthopaedics are not yet available.

AIMS OF THE STUDY

The study aimed to provide information on the changes that occurred in a group of patients with spinal diseases undergoing conservative in-patient treatment during the coronavirus disease pandemic, with regard to the number of cases, patient structure and course of treatment.

MATERIALS AND METHODS

Data from a total of 954 patients from an acute department for conservative treatment of back pain from the years 2019 and 2020 were retrospectively compared, thus allowing conclusions to be drawn about the course of in-patient conservative spinal treatment. In addition to sociodemographic data, numerical pain rating scales, scales for impairment by pain and physical function at the beginning and at the end of treatment were analysed using descriptive statistics and differentiation tests.

RESULTS

The study showed a 21% reduction in the number of cases in 2020 compared with those in 2019. The patient structure has changed in terms of diagnosis groups and physical function. The values of the assessments on discharge and their pre-post differences show an almost identical pattern of treatment outcomes before and after the start of the pandemic.

CONCLUSIONS

The relatively small decline in the number of in-patient admissions for the non-surgical treatment of specific spinal disorders indicates that this treatment option was also necessary in the pandemic-related crisis. With minor changes in the patient structure, comparable treatment results could be achieved.

AB0341 SLE PREGNANCIES AT HIGH RISK FOR PRE-ECLAMPSIA BENEFIT MOST FROM COMBINATION OF LOW DOSE ASPIRIN AND HYDROXYCHLOROQUINE

Background:

Women with SLE face a high risk of preeclampsia (PE). Low dose Aspirin (LDA) is known to protect against PE in non-autoimmune patients and is recommended for SLE patients1. Besides, a beneficial effect of hydroxychloroquine (HCQ) on the occurrence of PE has recently been discussed2.

Objectives:

To investigate the influence of LDA and HCQ on the occurrence of PE in SLE patients.

Methods:

Pregnancies of women with SLE from an outpatient pregnancy clinic were prospectively evaluated. Clinical characteristics, medication use and pregnancy outcomes were analysed. Association of LDA use (latest from gestational week 16 on) and HCQ use (from 1st trimester on) with PE were analysed using a multiple logistic regression model (adjustment for age, BMI, hypertension, disease activity in 1st trimester, lupus nephritis, nulliparity, history of PE and high-risk aPL profile3).

Results:

We enrolled 190 lupus pregnancies (148 women, 1995-2019). Additional risk factors for PE were present in 83.7%: 55.8% showed a high-risk profile (HRP) for PE according to ACOG4 (history of PE, hypertension, lupus nephritis or aPL), another 27.9% had at least one moderate risk factor (nulliparous, BMI>30 or age>35) (see table 1).

Each 20.5% of pregnancies received HCQ only or LDA only, while 22.6% were prescribed both drugs. 36.3% took neither HCQ nor LDA. Women with HRP were more likely to take LDA alone or in combination with HCQ (28.3% and 35.8%, respectively).

PE occurred in 13.2% of pregnancies (7.7% in HCQ only, 15.4% in LDA only, 14.0% in HCQ and LDA, 14.5% in no HCQ or LDA). Most pregnancies affected by PE carried a HRP (88.0%).

Use of LDA was significantly associated with a lower risk for PE [aOR 0.21 (95%-CI 0.05-0.99), p<0.05]. HCQ use also had a moderating effect on the incidence of PE, but this effect did not reach significance [aOR 0.47 (95%-CI 0.15-1.52), p=0.21]. If only pregnancies with HRP were considered, the effect size increased for HCQ (LDA [aOR 0.18 (95%-CI 0.04-0.96), p<0.05], HCQ [aOR 0.28 (95%-CI 0.07-1.14), p=0.075]).

Conclusion:

In this prospective real-life cohort, timely LDA medication was associated with a lower risk of PE in SLE pregnancies. In a multiple regression model taking LDA and HCQ into account, the favourable effect on the occurrence of PE was partially explained by HCQ. In particular, SLE patients at high risk for PE seem to benefit from HCQ during pregnancy. Future research may reveal mechanisms by which HCQ might lower the incidence of PE.

References:

[1]doi: 10.1136/annrheumdis-2016-209770

[2]doi: 10.1111/bcp.14131

[3]doi: 10.1136/annrheumdis-2019-215213

[4]doi: 10.1097/AOG.0000000000002708

Table 1.

Patient characteristics and risk profile

HCQ only (n=39)LDA only (n=39)HCQ + LDA (n=43)no HCQor LDA(n=69)Patient characteriticsAge (years), median (IQR)29 (25-33)32 (30-33)30 (28.5-33.5)31 (28-35)BMI, median (IQR)23.5 (22-25)23 (22-24)22 (22-24)23 (22-24)Chronic Hypertension, n (%)7 (17.9%)9 (23.1%)6 (14.0%)9 (13.0%)Preconception counselling, n (%)23 (59.0%)28 (71.8%)35 (81.4%)41 (59.4 %)Obstetrical historyNulliparous, n (%)20 (51.3%)26 (66.7%)33 (76.7%)36 (52.2%)Previous fetal loss, n (%)1 (2.6%)10 (25.6%)14 (32.6%)10 (14.5%)Previous PE, n (%)2 (5.1%)4 (10.3%)4 (9.3%)5 (7.2%)SLE characteristicsand therapyDisease duration (years), median (IQR)7.0 (2.0-11.0)7.5 (3.0-11.5)6.7 (3.4-10.0)6.0 (3.0-9.2)SLEDAI, median (IQR)2.0 (1.0-4.3)2.0 (0-2.5)4.0 (2.0-4.0)2.0 (0-4.0)Lupus nephritis, n (%)9 (23.1%)13 (33.3%)18 (41.9%)14 (20.3%)Anti-dsDNA antibodies, n (%)22 (56.4%)15 (38.5%)36 (83.7%)33 (47.8%)Prednisolone therapy, n (%)26 (66.7%)15 (38.5%)25 (58.1%)29 (42.0%)Prednisolone (mg/d), median (IQR)5.0 (5.0-8.0)5.0 (5.0-7.5)5.0 (4.0-5.0)5.0 (5.0-8.0)aPL statusAPS, n (%)-12 (30.8%)14 (32.6%)2 (2.9%)Any positive aPL, n (%)-20 (51.3%)19 (44.2%)5 (7.2%)LAC, n (%)-15 (38.5%)13 (30.2%)3 (4.3%)ACL, n (%)-14 (35.9%)13 (30.2%)4 (5.8%)β2-GP1, n (%)-12 (30.8%)12 (27.9%)2 (2.9%)

LAC = Lupus anticoagulant, ACL = Anticardiolipin antibody, β2-GP1 = β2-Glycoprotein I antibody

Disclosure of Interests:

None declared

POS1458-HPR DIGITAL RHEUMATOLOGY IN THE ERA OF COVID-19: RESULTS OF A NATIONAL PATIENT AND PHYSICIAN SURVEY

Background:

Digital health applications (DHAs) are gaining influence and promise great potential for the monitoring and management of rheumatic and musculoskeletal diseases (RMDs).

Objectives:

To analyse the impact of the COVID-19 pandemic on RMD patients’ and rheumatologists’ usage, preferences, and perception of digital health applications (DHAs) in Germany.

Methods:

A web-based national survey was developed by the Working Group Young Rheumatology of the German Society for Rheumatology and the German League against Rheumatism. The prospective survey was distributed via social media, QR-code, and email. Descriptive statistics were calculated, and regression analyses were performed to show correlations.

Results:

We analysed the responses of 299 patients and 129 rheumatologists. Most patients (74%) and rheumatologists (76%) believed that DHAs are useful in the management of RMDs and felt confident in their own usage thereof (90%; 86%). 38% of patients and 71% of rheumatologists reported that their attitude had changed positively towards DHAs and that their usage had increased due to COVID-19 (29%; 48%).

Usage and recommendation of DHAs for both groups are shown in Figure 1:

Figure 1.

Usage or recommendation of digital health applications. Patients and rheumatologists were asked to indicate the specific digital health applications (DHAs) they used or were recommended.

The majority in both groups agreed on implementing virtual visits for follow-up appointments in stable disease conditions. The most reported advantages of DHAs were usage independent of time and place (76.6%; 77.5%). The main barriers were a lack of information on suitable, available DHAs (58.5%; 41.9%), poor usability (42.1% of patients) and a lack of evidence supporting the effectiveness of DHAs (23.2% of rheumatologists) (Table 1).

Table 1.

Advantages and Barriers of DHA, n (%).

AdvantagesBarriersPatientsRheumatologistsPatientsRheumatologistsLocation-Independence229 (76.6)100 (77.5)Too little information175 (58.5)54 (41.9)Time-independence223 (74.6)94 (72.9)Too little evidence of benefits36 (12.0)30 (23.3)Detailed documentation97 (32.4)47 (36.4)Poor quality of current apps47 (15.7)29 (22.5)Cost saving95 (31.8)37 (28.7)Concernsabout data protection52 (17.4)25 (19.4)More information88 (29.4)38 (29.5)Lack of usability126 (42.1)17 (13.2)Independenceof doctors+36 (12.0)-Lack of accessibility4 (1.3)-More flexibility107 (36.8)77 (59.7)High costs4 (1.3)23 (17.8)Preparationfor discussion+46 (15.4)-No suitable equipment17 (5.7)11 (8.5)No advantages at all18 (6.0)1 (0.8)Lack of user competenceNo Need9 (3.0)39 (13.0)-12 (9.3)

Patients and rheumatologists were asked about the advantages and barriers of DHAs. Multiple answers were allowed. Patients had two additional potential advantages and potential barriers to choose from*.

Only a minority (<10% in both groups) believed that digitalisation has a negative impact on the patient-doctor relationship.

Conclusion:

The COVID-19 pandemic instigated an increase in patients’ and rheumatologists’ acceptance and usage of DHAs, possibly introducing a permanent paradigm shift in the management of RMDs.

Acknowledgements:

The authors thank the following persons and societies for their great effort, distributing the online survey: P.Aries, A.Hueber, E.Feist, C.Fiehn, P.Korsten, I.Kötter, F.Mühlensiepen, A.Pfeil, M.Rudwaleit, M.Welcker, S.Zinke, Deutsche Vereinigung Morbus Bechterew e.V., Deutsche Rheuma-Liga Bundesverband e. V., Sklerodermie Selbsthilfe e.V.

Disclosure of Interests:

Anna Kernder: None declared, Harriet Morf: None declared, Philipp Klemm: None declared, Diana Vossen Speakers bureau: Novartis, Abbvie, Amgen, Consultant of: Abbvie Deutschland GmbH & Co. KG, Bristol-Myer Squibb, Celgene GmbH, Gilead Sciences Inc., Lilly Deutschland GmbH, Medac GmbH, Novartis Pharma GmbH, Pfizer Deutschland GmbH, UCB Pharma GmbH, Grant/research support from: Pfizer, Abbvie, Marco Meyer Consultant of: Medac, Isabell Haase Speakers bureau: Medac, Consultant of: Medac, Grant/research support from: UCB, Abbvie, BMS, Johanna Mucke Speakers bureau: AbbVie Deutschland GmbH & Co. KG, Amgen, Bristol-Myers Squibb, Chugai Pharma Germany GmbH, Celgene GmbH, Gilead Sciences Inc., GlaxoSmithKline, Janssen-Cilag GmbH, Lilly Deutschland GmbH, Novartis Pharma GmbH, Pfizer Deutschland GmbH and UCB Pharma GmbH., Consultant of: AbbVie Deutschland GmbH & Co. KG, Amgen, Bristol-Myers Squibb, Chugai Pharma Germany GmbH, Celgene GmbH, Gilead Sciences Inc., GlaxoSmithKline, Janssen-Cilag GmbH, Lilly Deutschland GmbH, Novartis Pharma GmbH, Pfizer Deutschland GmbH and UCB Pharma GmbH., Arnd Kleyer Shareholder of: yes, Speakers bureau: Lilly, Novartis, Consultant of: Abbvie, Lilly, Novartis BMS, Gilead,Janssen, Grant/research support from: Lilly, Novartis, Gilead,, Philipp Sewerin Consultant of: AbbVie, Amgen, Axiom Health, Biogen, Bristol-Myers Squibb, Celgene, Chugai Pharma Marketing Ltd./Chugai Europe, Deutscher Psoriasis-Bund, Fresenius Kabi, Gilead Sciences, Hexal Pharma, Janssen-Cilag, Johnson & Johnson, Lilly, Medi-login, Mediri GmbH, Novartis Pharma, Onkowissen GmbH, Pfizer, Roche Pharma, Rheumazentrum Rhein-Ruhr, Sanofi-Genzyme, Swedish Orphan Biovitrum, and UCB, Grant/research support from: AbbVie, Amgen, Biogen, Bristol-Myers Squibb, Bundesministerium fuer Bildung und Forschung (BMBF), Deutsche Forschungsgesellschaft (DFG), Deutscher Psoriasis-Bund, Fresenius Kabi, Gilead Sciences, Hexal Pharma, Janssen-Cilag, Lilly, Novartis Pharma, Pfizer, Rheumazentrum Rhein-Ruhr, Roche Pharma, Sanofi-Genzyme, and UCB, Gerlinde Bendzuck: None declared, Sabine Eis: None declared, Johannes Knitza Consultant of: Abbvie, Novartis, Lilly, Medac, BMS, Sanofi, Amgen, Gilead, UCB, ABATON, GSK, Grant/research support from: Novartis, UCB, Thermofisher, Sanofi, Martin Krusche Speakers bureau: Lilly, Medac, Novartis, Roche/Chugai, Consultant of: Abbvie, Lilly, Gilead, Medac, Novartis, Sobi, BMS, Amgen, GSK, Grant/research support from: Sanofi

Clinical Relevance of Changes in Pain Intensity in Patients with Specific Back Pain

BACKGROUND

Pain intensity is frequently measured on the 11-point numerical pain rating scale (NRS-PI), ranging from 0 (no pain) to 10 points (worst imaginable pain). However, it is difficult to interpret the clinical importance of changes from baseline to endpoint on this instrument.

OBJECTIVES

To estimate the minimal detectable change (MDC) and the minimal clinically important difference (MCID) for average pain intensity in patients with specific back pain.

MATERIALS AND METHODS

Data on 1232 subjects with specific back pain from a German hospital were included in this study. A score combining the patient's (PGIC) and the physician's global impression of change (CGIC) over the in-patient length of stay was used as an external criterion. A priori, we considered the score value "slightly improved" as the MCID. MDC was calculated using the standard error of measurement (SEM) and the standard deviation (SD) of the sample. MCID was estimated by the mean value of PI-NRS change in patients who self-assess as "slightly improved", and by sensitivity/specificity analyses, computed by the receiver operating characteristic method (ROC).

RESULTS

MDC was 1.77. The MCS and ROC methods consistently showed an MCID of 2 for the total sample. Both methods showed the dependence of the MCID on the initial pain: 1 for mild to moderate pain at baseline (1 - 4 NRS points), 2 for moderate to severe pain (5 - 7) and 3 - 4 for very severe to extreme pain (8 - 10). For patients with lumbosacral intervertebral disc disorders and patients in the acute phase (duration of pain < 6 weeks), the ROC method resulted in a higher limit than the MCS method.

CONCLUSIONS

In order to facilitate the interpretation of changes and to take into account the patient's perspective, the global assessment of the success of treatment should be used as an anchor criterion. In addition to dealing with pain measurement, function-related and psychosocial aspects of pain symptoms should be kept in mind.

AB0375 SAFETY AND BENEFICIAL EFFECTS OF HYDROXYCHLOROQUINE ON PREGNANCY OUTCOMES IN WOMEN WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

The use of hydroxychloroquine (HCQ) has long been established in Systemic Lupus Erythematosus (SLE) and especially as applicable drug during pregnancy. Recently, beneficial effects and safety of HCQ have been re-discussed in the light of a change in the summary of product characteristics in some countries. More current studies are required to provide patients with evidence-based advice regarding this essential drug when counselling for pregnancy.

Objectives:

To examine the impact of HCQ on pregnancy outcomes of SLE women.

Methods:

Pregnancies of women with SLE from an outpatient pregnancy clinic were prospectively evaluated before and throughout gestation. Maternal and fetal outcomes in women without HCQ therapy (group A) were compared to pregnancies under HCQ treatment from 1sttrimester on (group B). A multiple logistic regression was performed with adjustment for confounding factors.

Results:

We enrolled 184 live births from singleton pregnancies in 145 women (n=77 with HCQ and n=107 w/o HCQ). One neonatal death (group B) occurred after severe preeclampsia at 24 weeks of gestation (w/g) linked to noncompliance in a woman with high-risk aPL profile. One child (group B) was born with mycophenolate mofetil embryopathy.

Women in the HCQ group had a significantly lower rate of preterm births [aOR 0.31 (95%-CI: 0.15-0.64), p = 0.026]. Regarding preeclampsia, we found a tendency towards less incidence with the use of HCQ [aOR 0.49 (95%-CI: 0.23-1.03), p = 0.24]. These improved outcomes are opposed by a higher frequency of risk factors in group B (lupus nephritis, high-risk aPL profile, slightly more hypertension) and a tendency towards more severe SLE (expressed in terms of increased use of Azathioprine) (Table 1). Nevertheless, women with HCQ therapy experienced significantly less flares during pregnancy [aOR 0.18 (95%-CI: 0.09-0.38), p = 0.013].

Table 1.

Patient characteristics

All pregnancies (n=184)No HCQ in pregnancy (n=107)HCQ during pregnancy (n=77)Age (years), median (IQR)31.0 (28.0-34.0)31.0 (29.0-34.0)30.0 (27.0-33.0)Hypertension, n (%)29 (15.8%)16 (15.0%)13 (16.9%)Preconception counselling, n (%)122 (66.3%)69 (64.5%)53 (68.8%)SLE disease & therapy characteristicsDisease duration (years), median (IQR)6.7 (2.9-10.3)7.0 (3.0-10.0)6.7 (2.1-11.0)Lupus nephritis*1, n (%)51 (27.7%)25 (23.4%)26 (33.8%)High-risk aPL profile*2, n (%)39 (21.3%)21 (19.8%)18 (23.4%)SLEDAI*1, median (IQR)2.0 (0-4.0)2.0 (0.0-4.0)2.0 (2.0-4.0)Anti-dsDNA, n (%)102 (55.7%)47 (44.3%)55 (71.4%)Anti-SSA/Ro and/or Anti-SSB/La, n (%)91 (49.7%)55 (51.9%)36 (46.8%)Azathioprine*1, n (%)38 (20.7%)18 (16.8%)20 (26.0%)Low dose Aspirin*3, n (%)74 (41.1%)34 (32.7%)40 (52.6%)Obstetrical historyNulliparous, n (%)113 (61.4%)63 (58.9%)50 (64.9%)Previous fetal loss, n (%)39 (21.2%)22 (20.6%)17 (22.1%)Previous (pre-)eclampsia or HELLP, n (%)14 (7.6%)8 (7.5%)6 (7.8%)Previous congenital heart block, n (%)1 (0.54%)-1 (1.3%)Pregnancy outcome(mild-moderate) flare*4, n (%)44 (29.5%)30 (34.9%)14 (22.2%)Preterm birth*5, n (%)46 (25%)30 (28.0%)16 (20.8%)Preeclampsia, n (%)24 (13%)15 (14.0%)9 (11.7%)Intrauterine growth restriction, n (%)3 (1.7%)1 (1.0%)2 (2.6%)Congenital heart block, n (%)1 (0.54%)-1 (1.3%)

*1last visit before pregnancy, *2according to the 2019 EULAR recommendations,*3until 16 w/g,*4increase in SLEPDAI ≥ 4 or increase in prednisolone ≥ 5mg/d,*5< 37 w/g

Conclusion:

In our cohort, SLE women with additional risk factors achieved a favourable pregnancy outcome. This encouraging result is in part attributable to pregnancy counselling with the advice to continue HCQ throughout gestation.

Disclosure of Interests:

Isabell Haase Grant/research support from: Abbvie, Medac, Hexal, Pfizer, Ralph Brinks: None declared, Matthias Schneider Grant/research support from: GSK, UCB, Abbvie, Consultant of: Abbvie, Alexion, Astra Zeneca, BMS, Boehringer Ingelheim, Gilead, Lilly, Sanofi, UCB, Speakers bureau: Abbvie, Astra Zeneca, BMS, Chugai, GSK, Lilly, Pfizer, Sanofi, Rebecca Fischer-Betz Consultant of: UCB, Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celgene, Chugai, GSK, Janssen, Lilly, Medac, MSD, Novartis, Roche, UCB, Pfizer.

[Pregnancy with lupus erythematosus-an update]

Current research in the field of systemic lupus erythematosus (SLE) and pregnancy focuses on predictors of adverse pregnancy outcomes, the safety and efficacy of hydroxychloroquine (HCQ) in pregnancy and the importance of preconception counselling. In particular, the prospective predictors of pregnancy outcome: biomarkers in antiphospholipid antibody syndrome and SLE (PROMISSE) study adds to the understanding of risk factors for adverse outcomes. There is increasing evidence of the numerous benefits associated with continuing HCQ treatment in pregnancy and for the use of low-dose acetylsalicylic acid in the prevention of preeclampsia. The European League Against Rheumatism (EULAR) has published evidence-based recommendations for the treatment of women with SLE and/or antiphospholipid syndrome before, during and after pregnancy. Rheumatologists caring for women with SLE should be familiar with the current state of knowledge in order to help optimize the management and thus the outcome of pregnancy in their patients.

Evaluation einer stationären nicht operativen Behandlung von akuten, subakuten und chronischen Rückenschmerzen

Hintergrund Rückenschmerzen zählen in Deutschland zu den Volkskrankheiten. Spezielle Verfahren zur Behandlung stehen zur Verfügung. Im Rahmen einer evaluativen Studie sollte die Wirksamkeit eines akutstationären konservativen Behandlungsangebots hinsichtlich Schmerzstärke, Beeinträchtigung, körperlicher Funktionsfähigkeit und Lebensqualität untersucht werden.

Patienten und Methoden Es wurden im Rahmen einer prospektiven beobachtenden Studie alle im Verlauf von 2 Jahren wegen Rückenschmerzen akutstationär aufgenommenen Patienten bei Aufnahme, bei Entlassung sowie 3, 6 und 12 Monate nach Entlassung schriftlich befragt. Der Fragebogen beinhaltete etablierte Messinstrumente wie Numerische Rating-Skalen (NRS) zur Messung von Schmerzintensität und Beeinträchtigung, den Funktionsfragebogen Hannover (FFbH – R) und den EQ-5D (Lebensqualität). Im Zentrum der Auswertung stand die Verlaufsbeobachtung hinsichtlich der genannten Zielparameter.

Ergebnisse 1010 Patienten bilden die Basis der Untersuchung. Es zeigten sich kurz-, mittel- und langfristig positive Verläufe hinsichtlich Schmerzintensität, Beeinträchtigung und Lebensqualität (r = 0,51 – 0,85) und überwiegend mittlere Effekte bei der körperlichen Funktionsfähigkeit (r = 0,45 – 0,62). Die Zahl derjenigen, die Arbeitsunfähigkeit wegen Rückenbeschwerden angegeben haben, sank entsprechend von 19% nach 3 Monaten auf 6% nach 6 Monaten und 4% nach 1 Jahr. Innerhalb der ersten 3 Monate nach Entlassung mussten sich 7% wegen der Wirbelsäulenerkrankung einer Operation unterziehen (leicht ansteigend auf 10% nach 6 Monaten und 12% nach 1 Jahr).

Schlussfolgerung Die bei allen Zielgrößen beobachteten Verläufe sprechen dafür, dass die konservative Behandlung von Rückenschmerzen effektiv ist. Letztlich geht es aber nicht um die Alternative „entweder Operation oder konservative Behandlung“, sondern vielmehr um ein „Sowohl-als-auch“ in einem sinnvollen Algorithmus.

Epidermal Rac1 regulates the DNA damage response and protects from UV-light-induced keratinocyte apoptosis and skin carcinogenesis

Non-melanoma skin cancer (NMSC) is the most common type of cancer. Increased expression and activity of Rac1, a small Rho GTPase, has been shown previously in NMSC and other human cancers; suggesting that Rac1 may function as an oncogene in skin. DMBA/TPA skin carcinogenesis studies in mice have shown that Rac1 is required for chemically induced skin papilloma formation. However, UVB radiation by the sun, which causes DNA damage, is the most relevant cause for NMSC. A potential role of Rac1 in UV-light-induced skin carcinogenesis has not been investigated so far. To investigate this, we irradiated mice with epidermal Rac1 deficiency (Rac1-EKO) and their controls using a well-established protocol for long-term UV-irradiation. Most of the Rac1-EKO mice developed severe skin erosions upon long-term UV-irradiation, unlike their controls. These skin erosions in Rac1-EKO mice healed subsequently. Surprisingly, we observed development of squamous cell carcinomas (SCCs) within the UV-irradiation fields. This shows that the presence of Rac1 in the epidermis protects from UV-light-induced skin carcinogenesis. Short-term UV-irradiation experiments revealed increased UV-light-induced apoptosis of Rac1-deficient epidermal keratinocytes in vitro as well as in vivo. Further investigations using cyclobutane pyrimidine dimer photolyase transgenic mice revealed that the observed increase in UV-light-induced keratinocyte apoptosis in Rac1-EKO mice is DNA damage dependent and correlates with caspase-8 activation. Furthermore, Rac1-deficient keratinocytes showed reduced levels of p53, γ-H2AX and p-Chk1 suggesting an attenuated DNA damage response upon UV-irradiation. Taken together, our data provide direct evidence for a protective role of Rac1 in UV-light-induced skin carcinogenesis and keratinocyte apoptosis probably through regulating mechanisms of the DNA damage response and repair pathways.

[Anchor-based ascertaining of meaningful changes in depressive symptoms using the example of the German short form of the CES-D]

BACKGROUND AND OBJECTIVES

Depression is frequently measured on the 15 item version of the Center for Epidemiological Studies Depression Scale (CES-D-15). Up to now, there are no data based estimates for minimal clinically important differences (MCID) in depression scales.

METHODS

Data on 5241 subjects with depressive symptoms from a German psychosomatic hospital were used. The changes in the CES-D-15 from admission to discharge were compared to the clinically global impression of change (CGIC), i. e., the therapists' perception. Categories of "slightly improved" and "much improved" were used as indicators of a clinically important difference. The relation between these ratings and the CES-D-15 was explored using mean change scores and sensitivity/specificity analyses.

RESULTS

On average, a reduction of approximately nine points or 30 percent in the CES-D-15 or an individual effect size of 0.9 represented a minimal clinically important difference. A consistent relationship between the changes in the CES-D-15 and the CGIC was demonstrated irrespective of age, gender, education level, type of treatment, or first diagnosis. However, higher baseline scores in CES-D-15 required larger changes of raw values to represent a clinically important difference.

CONCLUSIONS

Our results show anchor-based values for change in CES-D-15 that best represent a minimal clinically important difference. Reporting the percentage of patients who have reached the MCID improves the evaluation of therapeutical processes. The estimated MCID could also be used as an indicator for relevant changes in clinical practice. A further examination in other patient populations will be needed.

[Anchor-based ascertaining of meaningful changes in depressive symptoms using the example of the German short form of the CES-D]

BACKGROUND AND OBJECTIVES

Depression is frequently measured on the 15 item version of the Center for Epidemiological Studies Depression Scale (CES-D-15). Up to now, there are no data based estimates for minimal clinically important differences (MCID) in depression scales.

METHODS

Data on 5241 subjects with depressive symptoms from a German psychosomatic hospital were used. The changes in the CES-D-15 from admission to discharge were compared to the clinically global impression of change (CGIC), i. e., the therapists' perception. Categories of "slightly improved" and "much improved" were used as indicators of a clinically important difference. The relation between these ratings and the CES-D-15 was explored using mean change scores and sensitivity/specificity analyses.

RESULTS

On average, a reduction of approximately nine points or 30 percent in the CES-D-15 or an individual effect size of 0.9 represented a minimal clinically important difference. A consistent relationship between the changes in the CES-D-15 and the CGIC was demonstrated irrespective of age, gender, education level, type of treatment, or first diagnosis. However, higher baseline scores in CES-D-15 required larger changes of raw values to represent a clinically important difference.

CONCLUSIONS

Our results show anchor-based values for change in CES-D-15 that best represent a minimal clinically important difference. Reporting the percentage of patients who have reached the MCID improves the evaluation of therapeutical processes. The estimated MCID could also be used as an indicator for relevant changes in clinical practice. A further examination in other patient populations will be needed.

[Anchor-based ascertaining of meaningful changes in depressive symptoms using the example of the German short form of the CES-D]

BACKGROUND AND OBJECTIVES

Depression is frequently measured on the 15 item version of the Center for Epidemiological Studies Depression Scale (CES-D-15). Up to now, there are no data based estimates for minimal clinically important differences (MCID) in depression scales.

METHODS

Data on 5241 subjects with depressive symptoms from a German psychosomatic hospital were used. The changes in the CES-D-15 from admission to discharge were compared to the clinically global impression of change (CGIC), i. e., the therapists' perception. Categories of "slightly improved" and "much improved" were used as indicators of a clinically important difference. The relation between these ratings and the CES-D-15 was explored using mean change scores and sensitivity/specificity analyses.

RESULTS

On average, a reduction of approximately nine points or 30 percent in the CES-D-15 or an individual effect size of 0.9 represented a minimal clinically important difference. A consistent relationship between the changes in the CES-D-15 and the CGIC was demonstrated irrespective of age, gender, education level, type of treatment, or first diagnosis. However, higher baseline scores in CES-D-15 required larger changes of raw values to represent a clinically important difference.

CONCLUSIONS

Our results show anchor-based values for change in CES-D-15 that best represent a minimal clinically important difference. Reporting the percentage of patients who have reached the MCID improves the evaluation of therapeutical processes. The estimated MCID could also be used as an indicator for relevant changes in clinical practice. A further examination in other patient populations will be needed.

Using ICT to Support Individual Guidance in Health Promotion Programs for Increased Physical Activity

INTRODUCTION

We report on experiences in implementing a system to support the individual guidance of training in health promotion programs aiming to increase participants' regular level of physical activity.

METHODS

We used an iterative development approach considering data privacy and security aspects, followed by a phase of field testing and continuous further development.

RESULTS

Our preliminary results comprise identified clinically relevant parameters, suitable data collection methods, experienced privacy and security challenges and a glance on our developed prototype system.

DISCUSSION

We consider our results to be of interest for others doing related research. The most important requirements for a simple supporting system can be fulfilled with established solutions in the short run. A more adaptable and flexible system with an increased level of support in analysing the data, which we aim to achieve, leads to currently open research challenges.

Genetically Modified Mice as a Tool to Study Inflammatory Skin Diseases

Although mice have a long tradition as models for human skin diseases, they have recently received increasingly more attention. This is because of the rapid advancement of genetic engineering methods which made it possible to create mice with precisely defined genetic changes. Many of these mice develop impressive and sometimes unexpected, puzzling phenotypes. Their interpretation is a major challenge to the basic researcher and can often be ameliorated by the input of an experienced dermatologist. Together with recent examples of genetically modified mouse models of inflammatory skin diseases we give a short overview of the methods used to generate such mice, describe possible ways to analyse them, and discuss problems that arise in the interpretation of the findings.

Tumor necrosis factor receptor signaling in keratinocytes triggers interleukin-24-dependent psoriasis-like skin inflammation in mice

Psoriasis is a common chronic inflammatory skin disease with a prevalence of about 2% in the Caucasian population. Tumor necrosis factor (TNF) plays an essential role in the pathogenesis of psoriasis, but its mechanism of action remains poorly understood. Here we report that the development of psoriasis-like skin inflammation in mice with epidermis-specific inhibition of the transcription factor NF-κB was triggered by TNF receptor 1 (TNFR1)-dependent upregulation of interleukin-24 (IL-24) and activation of signal transducer and activator of transcription 3 (STAT3) signaling in keratinocytes. IL-24 was strongly expressed in human psoriatic epidermis, and pharmacological inhibition of NF-κB increased IL-24 expression in TNF-stimulated human primary keratinocytes, suggesting that this mechanism is relevant for human psoriasis. Therefore, our results expand current views on psoriasis pathogenesis by revealing a new keratinocyte-intrinsic mechanism that links TNFR1, NF-κB, ERK, IL-24, IL-22R1, and STAT3 signaling to disease initiation.

A function for Rac1 in the terminal differentiation and pigmentation of hair

The small GTPase Rac1 is ubiquitously expressed in proliferating and differentiating layers of the epidermis and hair follicles. Previously, Rac1 was shown to regulate stem cell behaviour in these compartments. We have asked whether Rac1 has, in addition, a specific, stem-cell-independent function in the regulation of terminal hair follicle differentiation. To address this, we have expressed a constitutively active mutant of Rac1, L61Rac1, only in the basal epidermal layer and outer root sheath of mice possessing an epidermis-specific deletion of endogenous Rac1, which experience severe hair loss. The resulting 'rescue' mice exhibited a hair coat throughout their lives. Therefore, expression of Rac1 activity in the keratin-14-positive compartment of the skin is sufficient for the formation of hair follicles and hair in normal quantities. The quality of hair formed in rescue mice was, however, not normal. Rescue mice showed a grey, dull hair coat, whereas that of wild-type and L61Rac1-transgenic mice was black and shiny. Hair analysis in rescue mice revealed altered structures of the hair shaft and the cuticle and disturbed organization of medulla cells and pigment distribution. Disorganization of medulla cells correlates with the absence of cortical, keratin-filled spikes that normally protrude from the cortex into the medulla. The desmosomal cadherin Dsc2, which normally decorates these protrusions, was found to be reduced or absent in the hair of rescue mice. Our study demonstrates regulatory functions for Rac1 in the formation of hair structure and pigmentation and thereby identifies, for the first time, a role for Rac1 in terminal differentiation.

The adaptor protein FADD protects epidermal keratinocytes from necroptosis in vivo and prevents skin inflammation

Epidermal keratinocytes provide an essential structural and immunological barrier forming the first line of defense against potentially pathogenic microorganisms. Mechanisms regulating barrier integrity and innate immune responses in the epidermis are important for the maintenance of skin immune homeostasis and the pathogenesis of inflammatory skin diseases. Here, we show that epidermal keratinocyte-restricted deficiency of the adaptor protein FADD (FADD(E-KO)) induced severe inflammatory skin lesions in mice. The development of skin inflammation in FADD(E-KO) mice was triggered by RIP kinase 3 (RIP3)-mediated programmed necrosis (termed necroptosis) of FADD-deficient keratinocytes, which was partly dependent on the deubiquitinating enzyme CYLD and tumor necrosis factor (TNF)-TNF receptor 1 signaling. Collectively, our findings provide an in vivo experimental paradigm that regulation of necroptosis in keratinocytes is important for the maintenance of immune homeostasis and the prevention of chronic inflammation in the skin.

Enhanced contact allergen- and UVB-induced keratinocyte apoptosis in the absence of CD95/Fas/Apo-1

FAS/CD95/Apo-1 is a ubiquitously expressed cell-surface receptor involved in the initiation of programmed cell death. Its function in epidermal keratinocytes has been incompletely defined. Available evidence from in vitro studies points to important roles of Fas in the pathogenesis of contact dermatitis and in keratinocyte apoptosis induced by ultraviolet light. To define functions of Fas in the epidermis in vivo, we have generated mice with epidermis-specific deletion of the fas gene and tested its requirement for 2,4-dinitrofluorobenzene-induced contact dermatitis and for ultraviolet light B (UVB)-induced keratinocyte apoptosis. We report here our unexpected finding that keratinocyte apoptosis induced by both a contact allergen and UVB irradiation was significantly enhanced in Fas-negative epidermis. Expression of Fas by epidermal keratinocytes was neither necessary for the normal development of contact hypersensitivity of the skin, nor required for keratinocyte apoptosis following UVB irradiation. Our study results thus show that in the epidermis in vivo Fas exerts antiapoptotic effects that outweigh its proapoptotic role in contact hypersensitivity responses of the skin and in the tissue response of the epidermis to UVB irradiation.

Establishment of spontaneously immortalized keratinocyte lines from wild-type and mutant mice

A considerable number of transgenic or knockout mice in which epidermal keratinocytes have been targeted die shortly after birth due to barrier defects. In this case, recovery and cultivation of keratinocytes from these animals provide an opportunity for in vitro studies. Working with isolated keratinocytes is also interesting for certain experiments which cannot be performed in live animals. Primary human keratinocytes can be kept in culture for a variable number of passages and then senescence. Immortalization can be achieved by transduction with constructs encoding viral genes. Murine keratinocytes can be kept in culture as primary cells. Naturally the numbers of cells obtained by direct isolation from mouse epidermis is restricted and sometimes not sufficient for certain biochemical analyses. To overcome this restriction some permanent murine keratinocyte lines have been generated by transfection with SV40T or HPV E6E7 genes. This is, however, not suitable if established or hypothetical biochemical links exist between these genes and the pathways or processes to be analysed in the respective experiment. We describe an easy and reproducible method of establishing permanent keratinocyte lines from spontaneously immortalized primary murine keratinocytes. This method employs co-cultivation of keratinocytes with 3T3-J2 fibroblast feeder cells for several passages during which immortalization occurs. The resulting keratinocyte lines do not only grow infinitely but, in many cases, individual lines from the same genetic background also exhibit similar growth characteristics, hence they are especially valuable for comparative studies.

ALX4 dysfunction disrupts craniofacial and epidermal development

Genetic control of craniofacial morphogenesis requires a complex interaction of numerous genes encoding factors essential for patterning and differentiation. We present two Turkish families with a new autosomal recessive frontofacial dysostosis syndrome characterized by total alopecia, a large skull defect, coronal craniosynostosis, hypertelorism, severely depressed nasal bridge and ridge, bifid nasal tip, hypogonadism, callosal body agenesis and mental retardation. Using homozygosity mapping, we mapped the entity to chromosome 11p11.2-q12.3 and subsequently identified a homozygous c.793C-->T nonsense mutation in the human ortholog of the mouse aristaless-like homeobox 4 (ALX4) gene. This mutation is predicted to result in a premature stop codon (p.R265X) of ALX4 truncating 146 amino acids of the protein including a part of the highly conserved homeodomain and the C-terminal paired tail domain. Although the RNA is stable and not degraded by nonsense-mediated RNA decay, the mutant protein is likely to be non-functional. In a skin biopsy of an affected individual, we observed a hypomorphic interfollicular epidermis with reduced suprabasal layers associated with impaired interfollicular epidermal differentiation. Hair follicle-like structures were present but showed altered differentiation. Our data indicate that ALX4 plays a critical role both in craniofacial development as in skin and hair follicle development in human.

A comparison of mycophenolate mofetil with ciclosporine for the treatment of chronic plaque-type psoriasis

AIMS

To compare the efficacy of ciclosporine (CsA) versus mycophenolate mofetil (MMF) in psoriasis, a randomized trial was conducted.

METHODS

A prospective multicenter randomized open-label clinical trial was performed to compare two parallel groups of patients with chronic plaque psoriasis undergoing different treatments. Therefore, a total of 54 patients with psoriasis were randomly assigned to treatment with either CsA (2.5 mg/kg body weight) or MMF (2 g daily) for 12 weeks, and the drug doses were adjusted according to response. The psoriasis area and severity index (PASI) was used to assess the clinical severity of psoriasis. The primary outcome of this trial was the time to disease relapse. Safety, PASI scores and psoriasis disability index (PDI) were assessed as secondary outcome.

RESULTS

There was no difference in time to disease relapse between the two groups. After 12 weeks of treatment, the mean PASI score (+/-SD) decreased from 24.6 +/- 11.1 to 6.6 +/- 7.3 in the CsA group (n = 27) and from 22.4 +/- 9.2 to 10.6 +/- 6.7 in the MMF group (n = 27; p = 0.02). The side effects, time to remission and PDI were similar in both groups.

CONCLUSIONS

After 12 weeks, CsA demonstrated a significantly superior efficacy in psoriasis compared to MMF.

The human papillomavirus type 8 E2 protein induces skin tumors in transgenic mice

Transgenic mice expressing early genes of the cutaneous human papillomavirus 8 (HPV8) spontaneously develop skin papillomas, epidermal dysplasia, and squamous cell carcinoma (6%). As the HPV8 protein E2 revealed transforming capacity in vitro, we generated three epidermal specific HPV8-E2-transgenic FVB/N mouse lines to dissect its role in tumor development. The rate of tumor formation in the three lines correlated with the different E2-mRNA levels. More than 60% of heterozygous line 2 mice, but none of the HPV8-negative littermates, spontaneously developed ulcerous lesions of the skin over an observation period of up to 144 weeks, beginning on average 74+/-22 weeks after birth. Most lesions presented infundibular hyperplasia and acanthosis combined with low-grade dysplasia. Severe dysplasia of the epidermis occurred in 6%. Two carcinomas revealed a sharply demarcated spindle-cell component. Only 3 weeks after a single UV irradiation, 87% of heterozygous line 2 and 36% of line 35 mice developed skin tumors. A rapidly growing invasive tumor composed of spindle cells arose 10 weeks after irradiation of a line-35 animal. The histology of skin cancers in HPV8-E2 mice is reminiscent of a subset of highly aggressive squamous cell carcinoma in immunosuppressed transplant recipients with a massive spindle-cell component.

In vitro differentiation of murine embryonic stem cells into keratinocyte-like cells

Embryonic stem (ES) cells are omnipotent; they can differentiate into every cell type of the body. The development of culture conditions that allow their differentiation has made it conceivable to produce large numbers of cells with lineage-specific characteristics in vitro. Here, we describe a method by which murine ES cells can be differentiated into cells with characteristics of epidermal keratinocytes. Keratinocyte-like cells were isolated from embryoid bodies and grown in culture. Potential applications of this method are the in vitro differentiation of cells of interest from ES cells of mice with lethal phenotypes during embryonic development and the production of genetically modified epidermal keratinocytes that could be used as temporary wound dressing or as carriers of genes of interest in gene therapeutic treatments.

Crosstalk between keratinocytes and adaptive immune cells in an IkappaBalpha protein-mediated inflammatory disease of the skin

Inflammatory diseases at epithelial borders develop from aberrant interactions between resident cells of the tissue and invading immunocytes. Here, we unraveled basic functions of epithelial cells and immune cells and the sequence of their interactions in an inflammatory skin disease. Ubiquitous deficiency of the IkappaBalpha protein (Ikba(Delta)(/Delta)) as well as concomitant deletion of Ikba specifically in keratinocytes and T cells (Ikba(K5Delta/K5Delta lckDelta/lckDelta)) resulted in an inflammatory skin phenotype that involved the epithelial compartment and depended on the presence of lymphocytes as well as tumor necrosis factor and lymphotoxin signaling. In contrast, mice with selective ablation of Ikba in keratinocytes or lymphocytes showed inflammation limited to the dermal compartment or a normal skin phenotype, respectively. Targeted deletion of RelA from epidermal keratinocytes completely rescued the inflammatory skin phenotype of Ikba(Delta)(/Delta) mice. This finding emphasizes the important role of aberrant NF-kappaB activation in both keratinocytes and lymphocytes in the development of the observed inflammatory skin changes.

Use of geographic and genotyping tools to characterise tuberculosis transmission in Montreal

SETTING

In Canada, tuberculosis (TB) is increasingly an urban health problem. Montreal is Canada's second-largest city and the second most frequent destination for new immigrants and refugees.

OBJECTIVES

To detect spatial aggregation of cases, areas of excess incidence and local 'hot spots' of transmission in Montreal.

DESIGN

We used residential addresses to geocode active TB cases reported on the Island of Montreal in 1996-2000. After a hot spot analysis suggested two areas of overconcentration, we conducted a spatial scan, with census tracts (population 2500-8000) as the primary unit of analysis and stratification by birthplace. We linked these analyses with genotyping of all available Mycobacterium tuberculosis isolates, using IS6110-RFLP and spoligotyping.

RESULTS

We identified four areas of excess incidence among the foreign-born (incidence rate ratios 1.3-4.1, relative to the entire Island) and one such area among the Canadian-born (incidence rate ratio 2.3). There was partial overlap with the two hot spots. Genotyping indicated ongoing transmission among the foreign-born within the largest high-incidence zone. While this zone overlapped the area of high incidence among Canadian-born, genotyping largely excluded transmission between the two groups.

CONCLUSIONS

In a city with low overall incidence, spatial and molecular analyses highlighted ongoing local transmission.

Impaired epidermal wound healing in vivo upon inhibition or deletion of Rac1

To address the functions of Rac1 in keratinocytes of the basal epidermal layer and in the outer root sheath of hair follicles, we generated transgenic mice expressing a dominant inhibitory mutant of Rac, N17Rac1, under the control of the keratin 14 promoter. These mice do not exhibit an overt skin phenotype but show protracted skin wound re-epithelialization. Investigation into the underlying mechanisms revealed that in vivo both proliferation of wound-edge keratinocytes and centripetal migration of the neo-epidermis were impaired. Similar results were obtained in mice with an epidermis-specific deletion of Rac1. Primary epidermal keratinocytes that expressed the N17Rac1 transgene were less proliferative than control cells and showed reduced ERK1/2 phosphorylation upon growth factor stimulation. Adhesion, spreading, random migration and closure of scratch wounds in vitro were significantly inhibited on collagen I and, to a lesser extent, on fibronectin. Stroboscopic analysis of cell dynamics (SACED) of N17Rac1 transgenic and control keratinocytes identified decreased lamella-protrusion persistence in connection with increased ruffle frequency as a probable mechanism for the observed impairment of keratinocyte adhesion and migration. We conclude that Rac1 is functionally required for normal epidermal wound healing and, in this context, exerts a dual function - namely the regulation of keratinocyte proliferation and migration.

Normal epidermal differentiation but impaired skin-barrier formation upon keratinocyte-restricted IKK1 ablation

The kinase IKK1 (also known as IKKalpha) was previously reported to regulate epidermal development and skeletal morphogenesis by acting in keratinocytes to induce their differentiation in an NF-kappaB independent manner. Here, we show that mice with epidermal keratinocyte-specific IKK1 ablation (hereafter referred to as IKK1(EKO)) develop a normally differentiated stratified epidermis, demonstrating that the function of IKK1 in inducing epidermal differentiation is not keratinocyte-autonomous. Despite normal epidermal stratification, the IKK1(EKO) mice display impaired epidermal-barrier function and increased transepidermal water loss, due to defects in stratum corneum lipid composition and in epidermal tight junctions. These defects are caused by the deregulation of retinoic acid target genes, encoding key lipid modifying enzymes and tight junction proteins, in the IKK1-deficient epidermis. Furthermore, we show that IKK1-deficient cells display impaired retinoic acid-induced gene transcription, and that IKK1 is recruited to the promoters of retinoic acid-regulated genes, suggesting that one mechanism by which IKK1 controls epidermal-barrier formation is by regulating the expression of retinoic acid receptor target genes in keratinocytes.

Factors contributing to patient satisfaction with medical rehabilitation in German hospitals

The objective of this study was to quantify overall patient satisfaction, through the identification of the particular aspects of patient satisfaction that were most likely to cause patients to recommend the rehabilitation hospital to others. The research entailed analysing secondary data from a quality improvement programme for medical rehabilitation, conducted from 1997 until 2004, in seven rehabilitation hospitals in Germany. Overall patient satisfaction and several potential predictors were examined in relation to 120,825 patients who had received inpatient medical rehabilitation. Recommending the rehabilitation hospital to others is a measure of overall patient satisfaction with the rehabilitation. Logistic regression was used to identify the factors that predicted patient satisfaction or dissatisfaction at discharge from the rehabilitation hospital. Overall satisfaction was mainly determined by the general atmosphere in the hospital, successful rehabilitation and the medical care. The general atmosphere was strongly associated with admission procedures, accommodation, catering, service, organisation and nursing care. In conclusion, the results suggest that in order to increase the rate of recommendation, rehabilitation hospitals should aim for not only high quality in medical care, but also the creation of a pleasant atmosphere.

Role of aPKC isoforms and their binding partners Par3 and Par6 in epidermal barrier formation

The skin water barrier, essential for terrestrial life, is formed by a multilayered stratifying epithelium, which shows a polarized distribution of both differentiation and intercellular junction markers. Recently, several reports showed the crucial importance of tight junctions for the in vivo water barrier function of the skin. In simple epithelial cells, intercellular junction formation is closely coupled to the establishment of polarity. However, if and how polarity proteins contribute to epidermal differentiation and junction formation is not yet known. Here, we have characterized the localization and isoform expression of the polarity protein atypical PKC (aPKC) and its binding partners Par3 and Par6 in epidermis and primary keratinocytes of mice. Their distribution is only partially overlapping in the granular layer, the site of functional tight junctions, suggesting that next to a common Par3/Par6/aPKC function they also may have functions independent of each other. Both aPKCzeta and aPKCiota/lambda, are expressed in the epidermis but only aPKCiota/lambda showed a strong enrichment in the junctions, suggesting that this aPKC isoform is important for epidermal tight junction function. Indeed, inhibition of aPKC function showed that endogenous aPKC is crucial for in vitro barrier function and this required the presence of both the Par3 and Par6 binding sites.

Rac1 is crucial for hair follicle integrity but is not essential for maintenance of the epidermis

Rac1 is a small GTPase that regulates the actin cytoskeleton but also other cellular processes. To investigate the function of Rac1 in skin, we generated mice with a keratinocyte-restricted deletion of the rac1 gene. Rac1-deficient mice lost nearly all of their hair within a few weeks after birth. The nonpermanent part of mutant hair follicles developed constrictions; lost expression of hair follicle-specific keratins, E-cadherin, and alpha6 integrin; and was eventually removed by macrophages. The permanent part of hair follicles and the sebaceous glands were maintained, but no regrowth of full-length hair follicles was observed. In the skin of mutant mice, epidermal keratinocytes showed normal differentiation, proliferation, cell-cell contacts, and basement membrane deposition, demonstrating no obvious defects of Rac1-deficient epidermis in vivo. In vitro, Rac1-null keratinocytes displayed a strong spreading defect and slightly impaired adhesion. These data show that Rac1 plays an important role in sustaining the integrity of the lower part of hair follicles but not in maintenance of the epidermis.

Pathogenic role for skin macrophages in a mouse model of keratinocyte-induced psoriasis-like skin inflammation

Psoriasis is a common skin disease, the pathogenesis of which has not yet been resolved. In mice, epidermis-specific deletion of inhibitor of NF-kappaB (IkappaB) kinase 2 (IKK2) results in a skin phenotype that mimics human psoriasis in several aspects. Like psoriasis, this skin disease shows pronounced improvement when mice are treated with a TNF-neutralizing agent. We have found previously that this phenotype does not depend on the presence of alphabeta T lymphocytes. In order to evaluate contributions of other immune cell populations to the skin disease, we selectively eliminated macrophages and granulocytes from the skin of mice with epidermis-specific deletion of IKK2 (K14-Cre-IKK2fl/fl mice). Elimination of skin macrophages by subcutaneous injection of clodronate liposomes was accompanied by inhibition of granulocyte migration into the skin and resulted in a dramatic attenuation of psoriasis-like skin changes. The hyperproliferative, inflammatory skin disease in K14-Cre-IKK2fl/fl mice was a direct consequence of the presence of macrophages in the skin, as targeted deletion of CD18, which prevented accumulation of granulocytes but not macrophages, did not lead to major changes in the phenotype. Targeted deletion of the receptor for IFN-gamma revealed that the pathogenesis of the skin disease does not depend on classical IFN-gamma-mediated macrophage activation. Our results demonstrate that in mice epidermal keratinocytes can initiate a hyperproliferative, inflammatory, IFN-gamma-independent, psoriasis-like skin disease whose development requires essential contributions from skin macrophages but not from granulocytes or alphabeta T lymphocytes.