[Effect of multimodal rheumatologic complex treatment in patients with axial spondylarthritis : A systematic evaluation with standardized outcome parameters, such as the ASAS Health Index]

BACKGROUND

Multimodal rheumatologic complex treatment (MRCT) is based on an acute inpatient treatment concept for patients with clinically relevant functional impairments and exacerbation of pain, which are caused by rheumatic and musculoskeletal diseases. Patients with axial spondylarthritis (axSpA) including ankylosing spondylarthritis (AS) often suffer from such health problems. Regular movement exercises and physical therapy measures are an important pillar of treatment management. The ASAS Health Index (ASAS-HI) can be used to document the global functional ability and health of axSpA patients. The selectivity of the ASAS HI for nonpharmacological treatment changes has so far not yet been proven.

OBJECTIVE

Evaluation of the MRCT and ASAS HI for nonpharmacological treatment measures of patients with axSpA carried out in the Ruhr Area Rheumatism Center. The primary endpoint was an improvement of the ASDAS≥ 1.1. It was assumed that > 25% of the patients would achieve this threshold.

METHODS

Consecutively included patients with active axSpA and relevant functional impairments received inpatient treatment for 14 days during MRCT. On days 1 (V1) and 14 (V2) all patients completed questionnaires on pain (NRS), disease activity (BASDAI, ASDAS) and function (BASFI, ASAS HI). The clinical examination was carried out using BASMI and measurement of C‑reactive protein (CRP) at both times.

RESULTS

The 66 prospectively included patients had an average age of 47.2 years (SD 14.2 years), a duration of symptoms of ca. 20 years, 65.3% were male, 75% were positive for HLA B27 and CRP was elevated in 41.3%. The disease activity at V1 was elevated: BASDAI 5.6 (1.8), ASDAS 3.1 (0.9), whereas functional ability and mobility were reduced: BASFI 3.5 (1.8), BASMI 5.6 (2.1), ASAS-HI 8.4 (3.4). During the course the global patient verdict improved (NRS 0-10) from 6.9 (1.7) at V1 to 4.8 (1.8) at V2 and the pain from 6.9 (1.9) to 4.7 (2.0) (all p < 0.001). The disease activity also decreased at V2: BASDAI 4.1 (1.9), ASDAS 2.4 (1.0), function and mobility were also improved: BASFI 4.3 (2.4), BASMI 2.7 (1.6), ASAS HI 6.5 (3.8) (all p < 0.001).

CONCLUSION

In this study the effectiveness of a 2‑week MRCT according to OPS 8-983.1 with respect to important patient-centered outcomes (PCO) could be proven and the results of previous studies could be confirmed. In this context ASAS-HI was also sensitive to change.

Burnout and its determinants among anaesthesia care providers in Switzerland: a multicentre cross-sectional study

The escalating epidemic of burnout in healthcare professionals affects provider well-being, patient care and sustainability of healthcare systems. The objective of this study was to determine the prevalence of burnout among anaesthesia care providers (consultants, trainees or nurse anaesthetists) in Switzerland and identify risk factors to develop strategies for prevention. This multicentre cross-sectional study was conducted at 22 anaesthesia departments in the German-speaking part of Switzerland, using an online questionnaire. Burnout assessment was performed using the Maslach Burnout Inventory. Additionally, the questionnaire included questions on workplace and personal risk factors. Of 1630 anaesthesia care providers contacted, 688 (42%) completed the survey. Among respondents who specified their work positions (n = 676), 52% (149/287) of nurses and 59% (229/389) of physicians were at high risk of burnout; and 9% (26/287) of nurses and 18% (70/389) of physicians met the criteria for burnout syndrome. Logistic regression analysis found significant associations between burnout and perceived lack of support at work among physicians (odds ratio (95%CI) 2.66 (1.40-5.24), p = 0.004); being a trainee in the 1st and 2nd year of training (2.91 (1.14-7.41), p = 0.024); being a trainee with > 5 years of experience (2.78 (1.08-6.98), p = 0.031); and male gender among nurses (4.13 (1.62-11.2), p = 0.004) and physicians (2.32 (1.22-4.47), p = 0.011). Work-related errors due to high workload or fatigue were reported by 65% (444/688) and consideration of leaving the profession due to working conditions was expressed by 46% (319/688) of respondents. Anaesthetic care providers in German-speaking Switzerland experience a considerable prevalence of burnout, influenced mainly by workplace factors.

A nested spin structure and single molecule magnet behaviour in an Fe8Dy12 heterometallic cyclic coordination cluster

The 20-nuclearity compound [Fe8Dy12(tea)8(teaH)12(NO3)12]·8MeCN (where teaH3 = triethanolamine) was synthesised and characterised through single crystal X-ray diffraction and magnetic measurements. The shape of the magnetic hysteresis in the microSQUID measurements was rationalised using the MAGELLAN program.

An Effectively Uncoupled Gd8 Cluster Formed through Fixation of Atmospheric CO2 Showing Excellent Magnetocaloric Properties

The [Gd8(opch)8(CO3)4(H2O)8]·4H2O·10MeCN coordination cluster (1) crystallises in P1¯. The Gd8 core is held together by four bridging carbonates derived from atmospheric CO2 as well as the carboxyhydrazonyl oxygens of the 2-hydroxy-3-methoxybenzylidenepyrazine-2-carbohydrazide (H2opch) Schiff base ligands. The magnetic measurements show that the GdIII ions are effectively uncoupled as seen from the low Weiss constant of 0.05 K needed to fit the inverse susceptibility to the Curie-Weiss law. Furthermore, the magnetisation data are consistent with the Brillouin function for eight independent GdIII ions. These features lead to a magnetocaloric effect with a high efficiency which is 89% of the theoretical maximum value.

Erectile Dysfunction Pharmacotherapy Utilization after 60Gy in 20 Fractions Volumetric Modulated Arc Therapy to the Prostate

PURPOSE/OBJECTIVE(S)

To determine which factors predict for worsening erectile function after highly conformal, modestly hypofractionated radiotherapy to the prostate.

MATERIALS/METHODS

All patients who received 60Gy in 20 fractions, volumetric modulated arc therapy to the prostate across 4 centers over 9 years were included in this study. The provincial electronic medical record was interrogated to identify any new prescriptions for erectile dysfunction (ED) medication, any change in prescription of ED medication or any permanent discontinuance of ED medication persisting beyond 6 months post completion of any androgen deprivation therapy. The penile bulb, penile crux and penile shaft structures were retrospectively contoured. A Youden receiver-operator-curve analysis, logistic regression, and neural network based interpretable machine learning analysis were then used to determine dependencies between worsening ED and clinical factors including mean doses to these structures.

RESULTS

Two-hundred-twelve patients with median (inter-quartile-range) follow-up of 3.6 (3.2-4.4) years were identified. Median age was 72 (67-76) years. 104 (49%) patients received androgen deprivation therapy. Prior to treatment, 52 (25%) patients were on ED medication: 20 (9%) on sildenafil, 28 (13%) on tadalafil and 4 (8%) on vardenafil. Median PTV volume was 158.9 (129.8-192.1) cc. Median penile bulb, penile crux and penile shaft volumes were 4.7 (3.6-6.2) cc, 6.5 (5.1-8.5) cc and 93.3 (80.6-106.2) cc, respectively. PTV V95 was 99.8 (99.5-99.9)%. Mean doses to penile bulb, penile crux and penile shaft were 2094.8 (1306.2-3036.3) cGy, 2094.8 (1306.2-3036.3) cGy and 444.4 (313.2-650.5), respectively. Fifty-nine (28%) patients had a worsening of ED after treatment: 25 (12%) started a new ED medication, 6 (3%) had a prescription change and 28 (13%) stopped ED medication. On univariate analyses pretreatment use of ED medication predicted for worsening ED: odds ratio (OR) yes vs no: 10.2 (5.0 - 20.8; p<0.001). A trend towards mean dose to penile bulb [OR ≤2343.9 vs >2343.9: 1.7 (0.9-3.2; p = 0.08)] predicting for worsening ED was observed. Mean doses to penile crux [OR <1725.8 vs > 1725.8: 2.6 (1.3-5.2; p = 0.005)] and penile shaft [OR ≤344.9 vs >344.9: 5.2 (2.2-12.2; p<0.001)] predicted for worsening ED. Use of androgen deprivation therapy, and age at time of radiotherapy were not predictive of worsening ED. On multivariate analysis, only mean dose to penile shaft [OR ≤344.9 vs >344.9: 6.3 (1.9-20.3; p = 0.002)] and pretreatment use of ED medication [OR yes vs no: 11.1 (5.3-23.2; p<0.001)] predicted for worsening ED. A neural network analysis suggested that penile shaft mean dose and pre-treatment ED medication use are the most important factors in predicting worsening ED.

CONCLUSION

In this limited analysis, pre-treatment use of ED medication and mean dose to penile shaft predicted for worsening ED after treatment with modestly hypofractionated radiotherapy for prostate cancer.

[Frequency and severity of sarcopenia in patients with inflammatory and noninflammatory musculoskeletal diseases : Results of a monocentric study in a tertiary care center]

INTRODUCTION

Sarcopenia (SP) is defined as the pathological loss of muscle mass and function. This is a clinically relevant problem, especially in geriatric patients, because SP is associated with falls, frailty, loss of function, and increased mortality. People with inflammatory and degenerative rheumatic musculoskeletal disorders (RMD) are also at risk for developing SP; however, there is little research on the prevalence of this health disorder in this patient group using currently available SP criteria.

OBJECTIVE

To investigate the prevalence and severity of SP in patients with RMD.

METHODS

A total of 141 consecutive patients over 65 years of age with rheumatoid arthritis (RA), spondylarthritis (SpA), vasculitis, and noninflammatory musculoskeletal diseases were recruited in a cross-sectional study at a tertiary care center. The European Working Group on Sarcopenia in Older People (EWGSOP 1 and 2) definitions of presarcopenia, SP, and severe SP were used to determine the prevalence. Lean mass as a parameter of muscle mass and bone density were measured by dual X‑ray absorptiometry (DXA). Handgrip strength and the short physical performance battery (SPPB) were performed in a standardized manner. Furthermore, the frequency of falls and the presence of frailty were determined. Student's T-test and the χ2-test were used for statistics.

RESULTS

Of the patients included 73% were female, the mean age was 73 years and 80% had an inflammatory RMD. According to EWGSOP 2, 58.9% of participants probable had SP due to low muscle function. When muscle mass was added for confirmation, the prevalence of SP was 10.6%, 5.6% of whom had severe SP. The prevalence was numerically but not statistically different between inflammatory (11.5%) and noninflammatory RMD (7.1%). The prevalence of SP was highest in patients with RA (9.5%) and vasculitis (24%), and lowest in SpA (4%). Both osteoporosis (40% vs. 18.5%) and falls (15% vs. 8.6%) occurred more frequently in patients with SP than those without SP.

DISCUSSION

This study showed a relatively high prevalence of SP, especially in patients with RA and vasculitis. In patients at risk, measures to detect SP should routinely be performed in a standardized manner in the clinical practice. The high frequency of muscle function deficits in this study population supports the importance of measuring muscle mass in addition to bone density with DXA to confirm SP.

Diverse clonal fates emerge upon drug treatment of homogeneous cancer cells

Even among genetically identical cancer cells, resistance to therapy frequently emerges from a small subset of those cells1-7. Molecular differences in rare individual cells in the initial population enable certain cells to become resistant to therapy7-9; however, comparatively little is known about the variability in the resistance outcomes. Here we develop and apply FateMap, a framework that combines DNA barcoding with single-cell RNA sequencing, to reveal the fates of hundreds of thousands of clones exposed to anti-cancer therapies. We show that resistant clones emerging from single-cell-derived cancer cells adopt molecularly, morphologically and functionally distinct resistant types. These resistant types are largely predetermined by molecular differences between cells before drug addition and not by extrinsic factors. Changes in the dose and type of drug can switch the resistant type of an initial cell, resulting in the generation and elimination of certain resistant types. Samples from patients show evidence for the existence of these resistant types in a clinical context. We observed diversity in resistant types across several single-cell-derived cancer cell lines and cell types treated with a variety of drugs. The diversity of resistant types as a result of the variability in intrinsic cell states may be a generic feature of responses to external cues.

Feasibility of salvage resection following locoregional failure after chemoradiotherapy and consolidation durvalumab for unresectable stage III non-small cell lung cancer

INTRODUCTION

In patients with unresectable stage III non-small cell lung cancer, high-dose chemoradiotherapy (CRT) followed by consolidation durvalumab improves the 5-year overall survival compared to CRT alone. The feasibility and safety of salvage surgery for such patients who subsequently develop locoregional failure (LRF) is unclear. We evaluated our institutional experience with radical-intent salvage surgery in this patient population.

MATERIALS AND METHODS

Details of patients undergoing salvage surgery for locoregional failure after CRT and durvalumab were identified from an institutional surgical database. Each patient's case underwent multidisciplinary discussion at initial disease presentation, and again at time of progression.

RESULTS

Ten patients underwent salvage surgery for LRF after prior concurrent (n = 9) or sequential (n = 1) platinum-based high-dose chemo-radiotherapy followed by durvalumab. Consolidation durvalumab was completed in 4 patients, and discontinued in 6, due to either toxicity or disease progression. Median time between end of radiotherapy to detection of LRF was 19 months (range 6-75). Seven patients underwent a lobectomy, 1 a bilobectomy and 2 patients a pneumonectomy. Postoperative morbidity (Clavien-Dindo grade III-V) and 90-day mortality were 10% and 0%, respectively. Median follow-up after surgery was 7 months (range 1-25) during which 2 patients died (both 9 months post-operatively), one due to distant progression, and one of sepsis/bleeding. Eight patients are alive at 1-23 months post-surgery, with 6 showing no evidence of disease.

CONCLUSIONS

Our results suggest that salvage pulmonary resection can be performed safely in selected patients with LRF following chemoradiotherapy and durvalumab. This radical-intent treatment option merits consideration by multidisciplinary lung tumor boards.

Observation of high-energy neutrinos from the Galactic plane

The origin of high-energy cosmic rays, atomic nuclei that continuously impact Earth's atmosphere, is unknown. Because of deflection by interstellar magnetic fields, cosmic rays produced within the Milky Way arrive at Earth from random directions. However, cosmic rays interact with matter near their sources and during propagation, which produces high-energy neutrinos. We searched for neutrino emission using machine learning techniques applied to 10 years of data from the IceCube Neutrino Observatory. By comparing diffuse emission models to a background-only hypothesis, we identified neutrino emission from the Galactic plane at the 4.5σ level of significance. The signal is consistent with diffuse emission of neutrinos from the Milky Way but could also arise from a population of unresolved point sources.

Fe-Gd Ferromagnetic Cyclic Coordination Cluster [FeIII4GdIII4(teaH)8(N3)8(H2O)] with Magnetic Anisotropy─Theory and Experiment

The synthesis, structural, and magnetic characterization of [Fe^III₄Ln^III₄(teaH)₈(N₃)₈(H₂O)] (Ln = Gd and Y) and the previously reported isostructural Dy analogue are discussed. The commonly held belief that both Fe^III and Gd^III can be regarded as isotropic ions is shown to be an oversimplification. This conclusion is derived from the magnetic data for the Y^III analogue in terms of the zero-field splitting seen for Fe^III and from the fact that the magnetic data for the new Gd^III analogue can only be fit employing an additional anisotropy term for the Gd^III ions. Furthermore, the Fe₄Gd₄ ring shows slow relaxation of magnetization. Our analysis of the experimental magnetic data employs both density functional theory as well as the finite-temperature Lanczos method which finally enables us to provide an almost perfect fit of magnetocaloric properties.

[Lay version of the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis : Translation into German and linguistic validation in German-speaking countries with people affected]

BACKGROUND

Physical activity and exercise are beneficial for people with rheumatic diseases; however, recommendations for the management of rheumatoid arthritis (RA), spondyloarthritis (SpA) and hip- and knee osteoarthritis (HOA/KOA) are usually unspecific with respect to mode and dose of exercise. This is why the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis were formulated. The recommendations consist of 4 overarching principles and 10 recommendations. These were also published as a lay version in the English language.

AIM

Translation of the lay version into German and its linguistic validation in Austria, Germany and Switzerland.

METHODS

A professional translation was reviewed by the authors, including people with, RA, SpA, HOA/KOA from the three German-speaking countries, which provided a prefinal lay version. Subsequently, eight interviews with people with RA, SpA, HOA/KOA were conducted in each country to evaluate understandability, wording, completeness and feasibility of the prefinal lay version. Finally, the authors, i.e. those with RA, SpA, and osteoarthritis, anonymously rated their agreement to the final lay version on a 0-10 scale.

RESULTS

The professional translation was substantially revised by the authors and based on the interviews. Formulations were adapted to increase readability and understandability and specify statements. Comments that would have changed content or structure were not considered. Average agreement with the particular recommendations was between 10 (SD 0) and 7.6 (SD 1.67).

DISCUSSION

For people with RA/SpA/HOA/KOA the EULAR physical activity recommendations should be available in their mother language. The final German lay version is valid and accepted across all three German-speaking countries. Thus, the physical activity recommendations can be provided to people with rheumatic diseases in an understandable and feasible way.

Impact of the COVID-19 pandemic on surgical care in the Netherlands

BACKGROUND

The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands.

METHODS

A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018-2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates.

RESULTS

Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018-2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001).

CONCLUSION

The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.

Evidence for neutrino emission from the nearby active galaxy NGC 1068

A supermassive black hole, obscured by cosmic dust, powers the nearby active galaxy NGC 1068. Neutrinos, which rarely interact with matter, could provide information on the galaxy’s active core. We searched for neutrino emission from astrophysical objects using data recorded with the IceCube neutrino detector between 2011 and 2020. The positions of 110 known gamma-ray sources were individually searched for neutrino detections above atmospheric and cosmic backgrounds. We found that NGC 1068 has an excess of 79 − 20 + 22 neutrinos at tera–electron volt energies, with a global significance of 4.2σ, which we interpret as associated with the active galaxy. The flux of high-energy neutrinos that we measured from NGC 1068 is more than an order of magnitude higher than the upper limit on emissions of tera–electron volt gamma rays from this source.

[Development of quality standards for patients with rheumatoid arthritis for use in Germany]

Despite a qualitatively and structurally good care of patients with rheumatoid arthritis (RA) in Germany, there are still potentially amendable deficits in the quality of care. For this reason, the German Society for Rheumatology (DGRh) has therefore decided to ask a group of experts including various stakeholders to develop quality standards (QS) for the care of patients with RA in order to improve the quality of care. The QS are used to determine and quantitatively measure the quality of care, subject to relevance and feasibility. The recently published NICE and ASAS standards and a systematic literature search were used as the basis for development. A total of 8 QS, now published for the first time, were approved with the intention to measure and further optimize the quality of care for patients with RA in Germany.

Search for Unstable Sterile Neutrinos with the IceCube Neutrino Observatory

We present a search for an unstable sterile neutrino by looking for a resonant signal in eight years of atmospheric ν_{μ} data collected from 2011 to 2019 at the IceCube Neutrino Observatory. Both the (stable) three-neutrino and the 3+1 sterile neutrino models are disfavored relative to the unstable sterile neutrino model, though with p values of 2.8% and 0.81%, respectively, we do not observe evidence for 3+1 neutrinos with neutrino decay. The best-fit parameters for the sterile neutrino with decay model from this study are Δm_{41}^{2}=6.7_{-2.5}^{+3.9}  eV^{2}, sin^{2}2θ_{24}=0.33_{-0.17}^{+0.20}, and g^{2}=2.5π±1.5π, where g is the decay-mediating coupling. The preferred regions of the 3+1+decay model from short-baseline oscillation searches are excluded at 90% C.L.

Measurement error in echocardiographic assessment of aortic stenosis: an epidemiological consideration of research methodology and clinical practice

Background/Introduction

Current international guidelines on treatment of valvular heart disease contain recommendations for aortic valve replacement based exclusively on abnormal echocardiographic parameters in asymptomatic patients with aortic stenosis (AS). To prevent misclassification and subsequent mistreatment of patients, these recommendations require accurate and unbiased measurements of hemodynamic parameters.

Purpose

To illustrate consideration and impact of measurement error in echocardiographic assessment of aortic stenosis in both the research and clinical setting.

Methods

First, a systematic review was performed to investigate the recognition of and correction for measurement error in clinical studies on the prognostic value of peak aortic jet velocity (Vmax), mean pressure gradient (MPG), and effective orifice area (EOA). Second, all potential erroneous sources in the calculation of those primary parameters were listed stratified to random or systematic measurement error, and subsequently their magnitude was quantified. Third, the impact of various types of measurement error on current thresholds for intervention was graphically illustrated in different clinical scenarios.

Results

The presence of measurement error was acknowledged in 44% of the 36 included studies, while none utilized methods to correct for it. Interobserver variability ranged between 0.9–8.3% for Vmax and MPG but was substantially higher for EOA (range 7.7–12.7%) implying lower reliability (Figure 1). Furthermore, the invalid assumption of a circular left ventricular outflow tract area resulted in a median underestimation in EOA of 22.5% compared to 3D-transesophageal echocardiography (3D-TEE), computed tomography (CT), and cardiovascular magnetic resonance (CMR) planimetry. Figure 2 illustrates the impact of this discrepancy on the classification of AS using one-sided t-tests to determine the areas under the curve; the proportion of patients with non-severe AS in a hypothetical cohort (based on values from the PARTNER 3 trial [1[) increased by 42%.

Conclusion(s)

Measurement error is underrecognized in studies of echocardiographic assessment of aortic stenosis. This review demonstrates that random and systematic measurement errors affect echocardiographic assessment, leading to potential misdiagnosis and subsequent mistreatment. Clinicians and scientists should be aware of the implications of measurement errors to enhance rightful clinical decision-making and assure research validity.

Funding Acknowledgement

Type of funding sources: None.

Artificial intelligence-based body composition predicts postoperative complications and mortality in advanced heart failure patients receiving long-term mechanical circulatory support

Background

Obesity is an independent cardiovascular risk factor and is associated with higher postoperative infection rates in patients after cardiac surgery. However, in heart failure, obesity has been described as beneficial in terms of survival (“obesity paradox”); whereas sarcopenia is associated with poor prognosis. An increasing number of advanced heart failure patients requires surgical treatment in terms of left ventricular assist device (LVAD) implantation. The postoperative in-hospital survival has improved in recent years but is still relatively high (11.1%). The impact of body composition on outcome in this population remains unclear.

Purpose

The aim of this investigation was to examine the preoperative computed tomography (CT) body composition based on artificial intelligence (AI) analysis as a predictor of the postoperative outcome in advanced heart failure patients, who underwent LVAD implantation.

Methods

Preoperative CT scans of 137 patients who received LVAD implantations between 2015 and 2020 were retrospectively analyzed using an AI-powered automated software tool based on a convolutional neural network, U-net, developed for image segmentation (Visage version 7.1., Visage Imaging GmbH, Berlin, Germany; Figure 1). Assessment of body composition included visceral and subcutaneous adipose tissue areas (VAT, SAT), psoas and total abdominal muscle areas (PMA, TAMA) and sarcopenia (defined as lumbal skeletal muscle index ≤38.5 cm2/m2 in women and ≤54.4 cm2/m2 in men). The body composition parameters were correlated with postoperative major complication rates and survival.

Results

The mean age of patients was 58.21±11.9 years; 122 (89.1%) were male. Most patients had severe heart failure requiring inotropes (INTERMACS profile I-III, 71.9%) secondary to coronary artery diseases or dilated cardiomyopathy (96.4%). 44 (32.1%) patients were obese (BMI ≥30 kg/m2), 96 (70.1%) were sarcopene and 19 (13.9%) were sarcopene obese. Adipose tissue was associated with a significantly higher risk of overall postoperative complications (SAT 158.22 cm2 [63.09, 256.78 cm2] vs. 124.04 cm2 [42.86, 187.68 cm2], p=0.049) and in-hospital mortality (VAT 168.11 cm2 [134.19, 285.27 cm2] vs. 135.42 cm2 [49.44, 227.91 cm2], p=0.033; SAT 227.28 cm2 [139.38, 304.35 cm2] vs. 173.81 cm2 [97.65, 254.16 cm2], p=0.009). Sarcopenia did not influence the postoperative outcome and survival within 1 year post LVAD implantation.

Conclusions

Preoperative AI-based CT body composition identifies patients with poor prognosis after LVAD implantation. Adipose tissue areas predict in-hospital mortality, thus, obesity as a perioperative risk factor outweighs the protective effect known in heart failure patients when undergoing LVAD implantation.

Funding Acknowledgement

Type of funding sources: None.

Microengineered devices enable long-term imaging of the ventral nerve cord in behaving adult Drosophila

The dynamics and connectivity of neural circuits continuously change on timescales ranging from milliseconds to an animal's lifetime. Therefore, to understand biological networks, minimally invasive methods are required to repeatedly record them in behaving animals. Here we describe a suite of devices that enable long-term optical recordings of the adult Drosophila melanogaster ventral nerve cord (VNC). These consist of transparent, numbered windows to replace thoracic exoskeleton, compliant implants to displace internal organs, a precision arm to assist implantation, and a hinged stage to repeatedly tether flies. To validate and illustrate our toolkit we (i) show minimal impact on animal behavior and survival, (ii) follow the degradation of chordotonal organ mechanosensory nerve terminals over weeks after leg amputation, and (iii) uncover waves of neural activity caffeine ingestion. Thus, our long-term imaging toolkit opens up the investigation of premotor and motor circuit adaptations in response to injury, drug ingestion, aging, learning, and disease.

Strong Constraints on Neutrino Nonstandard Interactions from TeV-Scale ν_{μ} Disappearance at IceCube

We report a search for nonstandard neutrino interactions (NSI) using eight years of TeV-scale atmospheric muon neutrino data from the IceCube Neutrino Observatory. By reconstructing incident energies and zenith angles for atmospheric neutrino events, this analysis presents unified confidence intervals for the NSI parameter ε_{μτ}. The best-fit value is consistent with no NSI at a p value of 25.2%. With a 90% confidence interval of -0.0041≤ε_{μτ}≤0.0031 along the real axis and similar strength in the complex plane, this result is the strongest constraint on any NSI parameter from any oscillation channel to date.

AB1190 SOURCES OF INFORMATION ABOUT SARS-CoV-2 USED BY PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATIC DISEASES (CIRD)

Background

Patients with chronic inflammatory rheumatic diseases (CIRD) may be at increased risk of Corona Virus Disease 2019 (COVID-19).1 The quality of information obtained plays a crucial role for patients’ decision to be vaccinated. Knowing patients’ needs for information and which sources are used is important for the management of CIRD patients by rheumatologists and other physicians.

Objectives

To identify main sources of information on SARS-CoV-2 used by patients with CIRD and to analyze their influence on opinions and willingness to be vaccinated.

Methods

CIRD patients presenting to our tertiary rheumatology hospital were, after informed consent, consecutively included in the study once the vaccination campaign in Germany had started, to fill out a questionnaire. Next to sociodemographic and disease-specific data, vaccination willingness and knowledge regarding SARS-CoV-2 were assessed. Furthermore, patients’ sources of information and their concerns about accuracy of information were evaluated. A numerical rating scale (NRS) ranging from 0 (completely disagree) to 10 (completely agree) was used. Values between ≥7 were taken as positive answer. Nonparametric tests and multivariate linear regression analyses were performed.

Results

In early 2021, a total of 514 patients were interviewed (Table 1). The majority (63.9 %) reported to be well-informed (NRS ≥7), whereas 18% had doubts regarding information on SARS-CoV-2. The most often used source of information was television, and only 8.6% reported to have been informed by a rheumatologist (Figure 1). About 20% of patients were no longer interested in receiving any information on SARS-CoV-2 through media. Information from rheumatologists, general practitioners, public health authorities or health related web sites did not reach 30.5% of patients. Of interest, 16% of subjectively well-informed patients were hesitant towards vaccination. As many as 43.6% of patients with doubts regarding information about SARS-CoV-2 indicated that they were not willing to be vaccinated. No source of information showed a strong correlation with SARS-CoV-2 vaccination willingness or with knowledge on SARS-CoV-2. Weak positive correlations were found between age and education level on the one hand and information sources about SARS-CoV-2 on the other hand. A weak negative correlation was found between doubts about information and health authorities, whereas positive correlations were found with social networks, friends and family.

Table 1.

Sociodemographic and disease characteristics

Age (years)54.7 ± 12.8Women, No.* (%)315 (61.3%)Educational level, No.* (%) < 8 years50 (10.4 %) 8-12 years275 (57.4 %) >12 years154 (32.2 %)Occupation, No.* (%) Full time198 (38.5 %) Pensioner157 (30.5 %) Part-time80 (15.6 %) Housewife/husband37 (7.2 %) Occupational incapacity29 (5.6 %) In training7 (1.4 %) Healthcare5 (1 %)CIRD, No.* (%)Rheumatoid arthritis192 (37.3 %)Axial spondyloarthritis134 (26.1 %)Connective tissue disease and vasculitis106 (22.6 %)Psoriatic arthritis72 (14.0 %)Disease duration, mean (years)Therapy, No.* (%)9.8 ± 8.9 bDMARD316(61.5 %) csDMARD147(28.6 %) tsDMARD33 (6.4 %) no DMARDs18 (3.5 %)

*Number of patients

Figure 1.

Sources of information of CIRD patients about SARS-CoV-2

Conclusion

Most CIRD patients think that they are well-informed about SARS-CoV-2. However, their information rarely comes from expert-based sources and rarely from rheumatologists. Thus, there is an unmet need for CIRD patients to receive appropriate and comprehensive information about SARS-CoV-2, its influence on rheumatic diseases, and about vaccination of patients with CIRD.

References

[1]Strangfeld A et al. Ann Rheum Dis 2021

Disclosure of Interests

None declared

POS0974 LOW DOSE COMPUTED TOMOGRAPHY HOUNSFIELD UNITS: A RELIABLE METHODOLOGY FOR ASSESSING CHANGES IN VERTEBRAL BONE DENSITY IN RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS

Background

Assessing local vertebral bone loss in radiographic axial spondyloarthritis (r-axSpA) poses challenges, namely because Dual-energy X-ray absorptiometry (DXA) only allows assessment of lumbar vertebrae. The measurement of Computed Tomography (CT) vertebral Hounsfield Units (HU) has been shown to correlate with vertebral bone density as measured by DXA in trauma patients. We have recently reported the excellent reliability of low dose CT (ldCT) HU measurements from C3 to L5 in patients with r-axSpA1; however, HU change scores have never been studied.

Objectives

To describe ldCT HU change scores and their inter-reader reliability per vertebra in patients with r-axSpA over 2 years.

Methods

We used spine ldCT scans of r-axSpA patients included in the multicenter 2-year Sensitive Imaging in Ankylosing Spondylitis (SIAS) study. A standardized protocol and automatic exposure control calibration in ldCT imaging acquisition were used. Baseline and 2-year ldCT scans were independently assessed by two trained readers. The HU measurements were performed as described in Figure 1. Mean (standard deviation, SD) for the change-from-baseline scores were provided by reader, together with the respective mean differences (SD). Inter-reader reliability for the change scores was assessed using intraclass correlation coefficients (ICC) absolute agreement, applying two-way random effect models. Agreement was assessed using the smallest detectable change (SDC = 1.96 x SDdifference /(√2*√k); SDdifference is the SD of the differences in change scores between the two readers, and k=2 readers) and Bland-Altman plots. The percentage of vertebrae in which readers agreed on the direction of the change (positive vs negative) and on change scores > |SDC|were also computed.

Results

Whole spine ldCT scans from 49 r-axSpA patients (mean age of 49 (SD 10) years; 88% male and 84% HLA-B27 positive) were included. In total, 1,053 vertebrae were assessed by both readers. The HU mean change values varied from -23 to 28 and -23 to 29 for reader 1 and 2, respectively – Table 1. More vertebrae showed a positive change in the cervical spine compared with the thoracic and lumbar spine. Inter-reader reliability was excellent (ICC: 0.91 to 0.99). SDC varied from 4 to 7, mean and median of 5. Bland-Altman plots showed homoscedasticity throughout the whole spine, with negligible systematic error between the readers. The two readers agreed on the direction of the change score in 88-96% of vertebrae, and agreement on change scores > |SDC| was obtained in 64-96% of the vertebrae.

Table 1.

Change scores for both readers, mean differences and intraclass correlation coefficients (ICC) from C3 to L5

Vertebra§Mean change (SD)Mean Difference (SD)Change > 5 #Change < -5 #Change >|5| #ICCReader 1Reader 2C318 (56)17 (56)0.2 (5.0)5532870.97C418 (53)17 (52)0.3 (5.5)5932910.98C528 (70)29 (70)-0.7 (5.0)6132930.99C623 (62)23 (62)0.4 (5.8)5039890.99C7-3 (60)-2 (59)-0.7 (6.9)4049890.98T1-6 (87)-6 (88)0.6 (5.0)4749960.98T23 (45)3 (45)0.7 (4.0)4145860.97T31 (43)2 (43)0.6 (4.4)2935640.95T4-2 (48)-1 (47)0.2 (5.3)3945840.94T50.02 (48)-0.3 (48)0.3 (5.1)3945840.91T6-3 (44)-3 (45)-0.1 (4.6)3545800.95T7-4 (43)-4 (43)-0.1 (4.5)2951800.99T8-1 (38)-1 (40)0.1 (4.6)3545800.98T9-9 (50)-9 (50)0.02 (5.4)2259810.99T100.2 (59)1 (59)-0.4 (5.2)3339720.96T11-8 (53)-7 (53)-0.6 (4.3)3543780.94T12-23 (59)-23 (60)-0.3 (4.4)3553880.99L1-9 (33)-7 (33)-1.9 (6.3)2741680.97L21 (46)2 (45)-1.1 (4.6)2941700.98L3-4 (35)-2 (34)-1.2 (6.3)2439630.92L4-2 (24)1 (22)-1.5 (5.4)3137680.91L58 (43)9 (43)-1.0 (6.0)4733800.97

§ C3-C7: n=44; T1-L5: n=49

# % of vertebrae in which both readers agreed on a change score > smallest detectable change.

Conclusion

LdCT measurement of HU is a reliable method to assess changes in bone density at each vertebra from C3 to L5. This methodology can aid the study of bone loss in r-axSpA, a disease affecting the whole spine.

References

[1]Marques ML, et al. Arthritis Rheumatol. 2021; 73 (suppl 10).

Acknowledgements

To the Dutch Rheumatism Association for funding SIAS study.

Disclosure of Interests

Mary Lucy Marques: None declared, Nuno Pereira da Silva: None declared, Désirée van der Heijde Consultant of: AbbVie, Gilead, Glaxo-Smith-Kline, Lilly, Novartis, UCB Pharma, Monique Reijnierse: None declared, Juergen Braun: None declared, Xenofon Baraliakos: None declared, Floris A. van Gaalen: None declared, Sofia Ramiro: None declared

POS0954 WHAT DOES IT MEAN – A GOOD RESPONSE TO NSAIDs? A SYSTEMATIC COMPARISON OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS AND CONTROLS WITH CHRONIC BACK PAIN

Background

A fast response to non-steroidal anti-inflammatory drugs (NSAIDs) is an important finding in the evaluation of clinical findings within the items comprising the ASAS classification criteria but also for the treatment decision for escalation to a bDMARD in patients with axial spondyloarthritis (axSpA). However, the differentiation of NSAID responses between patients with axSpA and degenerative or unspecific back pain is still unclear.

Objectives

To study the differences in the velocity and magnitude of NSAID response velocity in patients with established bDMARD naïve axSpA vs. patients with other, non-inflammatory reasons of back pain.

Methods

Patients with axSpA without degenerative reasons for back pain or patients with degenerative or unspecific back pain presenting due to high levels of back pain (NRS≥4/10) were consecutively recruited. Assessments included clinical examination, laboratory tests and MRI of the lumbar spine.

Previous NSAID intake was allowed only if it was taken in low doses without showing a clinical response, otherwise patients were NSAID naïve. Upon study inclusion, patients were treated with the maximum possible dose of an NSAID that they have reported to tolerate in lower doses in the past, independent of whether this was a Cox-2 inhibitor or a non-coxib. Assessment of response was performed using a standardized questionnaire after 2, 6, 12, 24, 36, 48 hours and after 1, 2 and 4 weeks. Any NSAID response was defined as improvement of pain >2/10 points and a good response to NSAIDs as an improvement >50% from the initial status.

Results

A total of 68 patients with axSpA, 107 patients with degenerative back pain and 58 patients with unspecific back pain were included.

The mean age was 42.7±10.7, 51.2±11.3, and 45.8±10.0 years, the main symptom duration 15.1±11.1, 16.1±12.6, and 11.9 ±10.1 years and the proportion of males was 57.4%, 19.6%, and 19.0% respectively. Inflammatory back pain was reported by 42 (75%), 48 (57.8%), and 29 (60.4%) patients, respectively and the mean pain score was 6.2±2.3,6.7±1.8, and 6.2±1.8, respectively.

In axSpA, the mean BASDAI and BASFI scores were 5.5±1.8 and 4.5±2.5, respectively.

There was no difference in the cumulative response to NSAIDs between all three diagnoses, with an overall proportion of 27%-30% of patients showing improvement. However, better but not faster responses were found for the subgroups of patients with nr-axSpA (Figure 1) and for the male patients in the entire axSpA group, while axSpA patients with systemic inflammatory activity defined by increased CRP showed lower rates of response as compared to non-inflammatory reasons of back pain diagnoses. All other subanalyses did not reveal any differences between axSpA patients and other non-inflammatory reasons of back pain.

Figure 1.

Conclusion

In this prospective evaluation, the generally proposed better response of axSpA patients to treatment with high doses of NSAIDs as compared with non-inflammatory back pain was not confirmed, although the overall rate of responders was similar to previously reported rates. On the other hand, better responses were found in patients treated in the early (nr-axSpA) stage and in male patients. axSpA patients with increased CRP values showed lower rates of response.

Disclosure of Interests

None declared

POS0976 IMPACT OF PATIENT AND DISEASE CHARACTERISTICS ON GLOBAL FUNCTIONING AND HEALTH IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: A BAYESIAN NETWORK ANALYSIS OF DATA FROM AN EARLY axSpA COHORT

Background

Current knowledge on the health status of patients (pts.) with axial spondyloarthritis (axSpA) mainly focusses on physical function and disease activity. Using a generic measure for physical- or mental health (SF36), a hierarchical relationship between disease activity, spinal damage, spinal mobility, physical function and overall health has been demonstrated in pts. with radiographic axSpA (r-axSpA) 1. Disease-specific global functioning and health can be assessed in pts. with axSpA using the ASAS Health Index (ASAS HI), which encompasses physical function, as well as aspects of emotional and social functioning and aspects of activity and participation.

Objectives

To build a structural model that visualizes interrelationships of different patient- and disease characteristics with global functioning and health in pts. with early axSpA.

Methods

Data of pts. with axSpA from the DESIR cohort was analyzed, which included information on socio-demographics (age, BMI), disease activity (ASDAS), physical function (BASFI), spinal mobility (BASMI), structural damage (mSASSS), disease-specific global functioning (ASAS HI), and comorbidity count. Information on patient- and disease characteristics was retrieved from the visit performed 72 months after inclusion, which was the first time point of ASAS HI collection. A Bayesian network (BN) was used to obtain insight of the underlying structural model. BNs are probabilistic graphical models consisting of “nodes” (representing specific variables) joined by “edges” (lines representing directions of effects). They are capable of capturing complex relationships between variables and allow the incorporation of existing (prior) knowledge from previous studies.

Results

The DESIR cohort contained data from 582 pts. at month 72, of whom 398 had data for ASAS HI. Descriptive information of these pts. is shown in Table 1. The mean ASAS HI was 5.7 (range: 0 - 16). Applying existing cut-offs for ASAS HI, 51% had ‘good’ global functioning (ASAS HI ≥5), 40% had ‘moderate’ global functioning (5< ASAS HI <12) and 9% had ‘bad’ global functioning (ASAS HI ≥12). The structural model that was constructed from combining data and prior expert knowledge is visualized in Figure 1. It suggests that ASDAS and BASFI have a direct impact on ASAS HI and that ASDAS has an indirect impact via BASFI. The model also suggests that ASDAS has an impact on the number of co-morbidities via BMI and that BASFI determines BASMI, which is in turn also influenced by age and mSASSS. In addition, it suggests a direct effect of age, BMI and ASAS HI on the comorbidity count. The model denies a relationship between BASMI or mSASSS and ASAS HI.

Table 1.

Patient and disease characteristics at month 72

N = 398Gender (male), N (%)181 (45%)Age (years)40.7 (8.7)Symptom duration (years)7.5 (0.9)BMI (kg/m2)25.0 (4.6)ASDAS2.0 (1.0)BASFI (0–10)2.3 (2.1)BASMI (0–10)2.5 (1.0)mSASSS (0-72)1.0 (3.6)ASAS HI (0-17)5.7 (3.9)good global functioning: ASAS HI ≤5, N (%)201 (51%)moderate global functioning: 5< ASAS HI <12, N (%)160 (40%)bad global functioning: ASAS HI ≥12, N (%)37 (9%)Comorbidity count1.4 (0.7)Figure 1.

Structural model on interrelationships of different patient- and disease characteristics with global functioning and health (ASAS HI) in patients with early axSpA

Conclusion

The BN-analysis approach, that combines prior knowledge and measured data, serves to better understand the construct of global functioning and health in pts. with early axSpA. Our model shows that global functioning (ASAS-HI) is determined both by patient-reported physical function (BASFI) and by disease activity (ASDAS), which confirms the hierarchical model once proposed by Machado et al. The observed directional relationship between ASAS HI and comorbidity count is counterintuitive and requires further investigation.

References

[1]Machado P, ARD 2011.

Disclosure of Interests

Imke Redeker: None declared, Robert B.M. Landewé Speakers bureau: AbbVie, BMS, GSK Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB, Consultant of: AbbVie, BMS, GSK Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB, Désirée van der Heijde Speakers bureau: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, UCB Pharma, Sofia Ramiro Speakers bureau: Eli Lilly, MSD, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, UCB, Sanofi, Grant/research support from: AbbVie, Galapagos, Novartis, Pfizer, UCB, Annelies Boonen Speakers bureau: Abbvie / Galapagos, Consultant of: Galapagos, Grant/research support from: Abbvie, Maxime Dougados: None declared, Juergen Braun Speakers bureau: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB, Consultant of: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB, Grant/research support from: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB, Uta Kiltz Speakers bureau: AbbVie, Biocad, Biogen, Chugai, Eli Lilly, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: AbbVie, Biocad, Biogen, Chugai, Eli Lilly, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Grant/research support from: AbbVie, Biogen, Fresenius, Amgen, Hexal, Novartis, Pfizer

OP0155 DO FATTY LESIONS EXPLAIN THE ASSOCIATION BETWEEN INFLAMMATION AND NEW SYNDESMOPHYTES IN PATIENTS WITH RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS?

Background

Presence of vertebral corner inflammation (VCI) increases the likelihood of a new syndesmophyte in the same vertebral corner (VC) in patients with r-axSpA. It was suggested that subsequent vertebral corner fat deposition (VCFD) partially explains this effect. However, this has not been formally tested.

Objectives

To determine how much of the effect of VCI on the development of new syndesmophytes is explained by new VCFD.

Methods

Two datasets (SIAS cohort, ASSERT clinical trial) were analyzed. Patients with r-axSpA were assessed at baseline (T0), an intermediate visit (T1) (SIAS: 1 year; ASSERT: 24 weeks) and the end of follow-up (T2) (SIAS: 2 years; ASSERT: 102 weeks). Syndesmophytes were assessed on whole spine low dose CT (SIAS) or spinal radiographs (ASSERT) at T0 and T2 and considered present if seen by 2 of 2 readers. VCI (T0) and VCFD (T0 and T1) on spinal MRI were present if seen by ≥2 of 3 readers (SIAS) or 2 of 2 readers (ASSERT). VCs with VCFD or a syndesmophyte at baseline were excluded. We used the counterfactual approach1 to decompose the total effect of VCI at T0 (binary exposure) on the formation of a new syndesmophyte in the same VC at T2 (binary outcome) into the effect that is explained (natural indirect effect, NIE) and the effect that is not explained (natural direct effect, NDE) by new VCFD (binary mediator) at T1. Because there was no interaction between the exposure and mediator (p=0.88 for SIAS; p=0.82 for ASSERT), the average NIE (aNIE) and average NDE (aNDE) are reported. The aNIE, aNDE and total effect, expressed as absolute increase in risk, were estimated in R using the ‘mediation’ package, which takes into account the 2-level structure of the data (VCs nested within patients).

Results

In total, 49 patients (2,667 corners) in SIAS and 168 patients (2,918 corners) in ASSERT were included. A new syndesmophyte occurred at T2 in 124/2,667 (5%) corners in SIAS and 91/2,918 (3%) corners in ASSERT (Table 1). New VCFD at T1 was also uncommon (SIAS: 4%; ASSERT: 2%), but occurred more often in corners with (SIAS: 12%; ASSERT: 18%) than without VCI at T0 (SIAS: 3%; ASSERT: 1%). Applying the mediation formula, in SIAS, the presence of VCI at T0 increased the probability of a new syndesmophyte in the same VC at T2 by 9.3% [total effect (95% CI)=9.3% (4.5; 15.0)]. There was only a 0.2% increase in this probability that was mediated by the formation of new VCFDs at T1 [aNIE=0.2% (-0.4; 1.0)]. In contrast, 9.1% of the increase in probability remained unexplained [aNDE=9.1 (4.3; 15.0)]. This means that only 2% (0.2/9.3) of the total effect of VCI on the formation of new syndesmophytes was explained by new VCFD [% mediated=2.0% (-4.1; 13)]. In ASSERT, the total effect was somewhat lower than in SIAS [total effect=7.3% (2.0; 16.0)], and again the aNIE was small [aNIE=0.8% (-0.2; 3.0)], and the aNDE composed most of the total effect [aNDE=6.5% (1.3; 14.0)]. The proportion of the total effect explained by VCFD (0.8/7.3=10% (-3.1;44)) was larger than in SIAS but still non-significant.

Table 1.

Marginal and conditional probabilities

SIASVCI T0New VCFD T1New SYND T2nP (SYND|VCI, VCFD)P(VCFD|VCI)0002302P (SYND|0,0) =90/2392= 0.038P(VCFD|0) = 74/2466=0.0300019001070P (SYND|0,1) =4/74 = 0.0540114100152P (SYND|1,0) = 25/177 = 0.141P(VCFD|1) = 24/201 =0.1191012511019P (SYND|1,1) = 5/24 = 0.2081115ASSERTVCI T0New VCFD T1New SYND T2nP (SYND|VCI, VCFD)P(VCFD|VCI)0002660P (SYND|0,0) = 76/2736= 0.028P(VCFD|0) = 35/2771 =0.0130017601034P (SYND|0,1) =1/35= 0.0290111100112P (SYND|1,0) = 9/121= 0.074P(VCFD|1) = 26/147 =0.177101911021P (SYND|1,1) = 5/26 = 0.1921115

VCI, vertebral corner inflammation; VCFD, vertebral corner fat deposition; Synd, syndesmophytes; T0, baseline; T1, intermediate visit; T2, end of follow-up; n, number of vertebral corners; P, probability

Conclusion

In these two datasets we see that VCI only infrequently leads to syndesmophyte formation via visible VCFD.

References

[1]Pearl, The mediation formula, 2011

Figure 1.

The pathways under study. VCI, vertebral corner inflammation; VCFD, vertebral corner fat deposition

Disclosure of Interests

Rosalinde Stal: None declared, Alexandre Sepriano Speakers bureau: Novartis, Consultant of: UCB, Sofia Ramiro Speakers bureau: Eli Lilly, MSD, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: AbbVi, Galapagos, MSD, Novartis, Pfizer, UCB, Floris A. van Gaalen Consultant of: Novartis, MSD, AbbVie, Bristol Myers Squibb, Eli Lilly, Grant/research support from: Stichting vrienden van Sole Mio, Stichting ASAS, Jacobus Stichting, Novartis, UCB, Pedro Machado Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, Xenofon Baraliakos: None declared, Rosaline van den Berg: None declared, Monique Reijnierse Grant/research support from: reader for ASAS CLASSIC study, Juergen Braun: None declared, Robert B.M. Landewé Consultant of: AbbVie, Amgen, BMS, GSK, Janssen, Eli Lilly, Novartis, Pfizer, UCB, Désirée van der Heijde Consultant of: AbbVie, Gilead, Glaxo-Smith-Kline, Lilly, Novartis, UCB Pharma, Grant/research support from: Dutch Rheumatism Association

AB0587 THE RISK OF PATIENTS WITH POLYMYALGIA RHEUMATICA AND GIANT CELL ARTERITIS TO DEVELOP DIABETES AND OSTEOPOROSIS ON FOLLOW UP

Background

Patients with polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are commonly treated with glucocorticoids (GC) in different dosages. Therefore, the most common comorbidities that may develop are osteoporosis (OPO) and diabetes mellitus (DM).

Objectives

To study the development of these comorbidities in the management of PMR and GCA in a real-life setting.

Methods

In a retrospective study design, longitudinal data of patients with a clinical diagnosis of PMR and GCA treated in a tertiary center were studied. Patients and disease characteristics were documented according to clinical routine in patients in whom ≥ 2 documented visits ≥ 3 months apart had been documented.

Results

A total of 550 patients (382 PMR, 168 GCA) was analysed (Table 1). The time period of follow up (FU) ranged between 3 months and 13.6 years (mean 1.4 (0.3) years). The majority of patients received a diagnosis of PMR or GCA in our center while 29.5% of patients came for a second opinion. Their mean age was around 70 years, and most patients were female (Table 1). Eight GCA patients were already blind (4.8%) at first presentation, and 77 and 80 patients had a diagnosis of DM (15.5%) and OPO (16.0), respectively, already at baseline. During FU 56 PMR (16.0%) and 7 GCA patients (4.2%) were diagnosed with another autoimmune disease, mainly with rheumatoid arthritis (n=50 (69.4%)). The mean dose of GC differed substantially between groups (Table 1). On FU, 9 (2.4%) and 5 (3.0%) of PMR and GCA patients developed DM and 17 (4.5%) and 14 (8.4%) OPO, respectively. Thus, about 20% and 25% of patients with PMR or GCA finally had DM and OPO, respectively. Almost all patients received vitamin D and antiresorptive agents.

Table 1.

Patients and disease characteristics

PMR patients (n=382)GCA patients (n=168)SignificanceAge (years)68,2 (9.3)71.1 (8,6)0.9BMI (kg/m2)27.0 (4.9)26.0 (5,3)0.44Female sex, n (%)216 (56.6)121 (72,0)<0.001Time to rheumatologist (months)2.1 (9,7)1.4 (5,4)0,33CRP at baseline (mg/dl)3,8 (4,6)4,5 (5,5)0,07Prednisolone at baseline (mg/d)25.1 (20,2)52.0 (69,7)<0.001Comorbidities at baseline-Number of comorbidities (mean)1.45 (1.12)1.51 (1.12)0.26-Diabetes, n (%)61 (16.0)24 (14.3)0.36-Osteoporosis, n (%)64 (16.8)30 (17.9)0.7-Ischemic heart disease, n (%)38 (9.9)19 (11.4)0.46Organ manifestation and comorbidities at FU-Blindness n (%)6 (1.6)8 (4.8)0.048-Aneurysm n (%)1 (0.3)9 (5.4)<0.001-Diabetes, n (%)70 (18.4)29 (17.3)0.89-Osteoporosis, n (%)81 (21.4)44 (26.3)0.003-Vascular stenosis4,610,10,048

values given as mean (SD)

Conclusion

In this large real-life cohort, patients with PMR and GCA aged around 70 years were seen by rheumatologists about 1-2 months after their first symptom but 8 GCA patients were already blind at first visit. DM and OPO were frequent comorbidities in both, PMR and GCA patients, already at baseline and during follow-up more patients developed these comorbidities despite prophylactic and therapeutic medication. OPO and DM should be a routine concern in the care of PMR and GCA patients - already when glucocorticoids are started.

Disclosure of Interests

None declared

POS0299 EFFECT OF SECUKINUMAB ON RADIOGRAPHIC PROGRESSION AND INFLAMMATION IN SACROILIAC JOINTS AND SPINE IN PATIENTS WITH NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: 2-YEAR IMAGING OUTCOMES FROM A PHASE III RANDOMISED TRIAL

Background

Axial spondyloarthritis (axSpA) is characterised by inflammation of the sacroiliac joints (SIJ) and the spine. Secukinumab (SEC) treatment was clinically efficacious and reduced SIJ bone marrow oedema as detected by magnetic resonance imaging (MRI) in patients (pts) with non-radiographic (nr)-axSpA through 52 weeks in the PREVENT (NCT02696031) study.1

Objectives

To report radiographic progression and the course of inflammation as assessed by X-ray and MRI of SIJ and spine over 2 years in the PREVENT study.

Methods

Study design and key endpoints have been reported earlier.1 In total, 555 pts were randomised (1:1:1) to receive SEC 150 mg, with (LD) or without loading (NL) doses, or placebo (PBO). Switch to open-label (OL) SEC or standard of care (SoC) was permitted after Week (Wk) 20. All pts (except those who switched to SoC) received OL SEC from Wk 52. Radiographs of the spine and SIJ were collected at baseline (BL) and Wk 104; MR images of the spine and SIJ were collected at BL, Wk 16, 52, and 104. Spinal radiographs were scored using the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) and SIJ radiographs according to modified New York criteria (mNYC). Pts whose screening SI joint radiographs fulfilled mNY criteria during the eligibility reading session were excluded from the study. Spinal MR images were assessed for signs of inflammation with the Berlin score. SIJ bone marrow oedema was assessed according to the Berlin Active Inflammatory Lesions Scoring. All images were evaluated in blinded fashion independently by 2 central readers. All data are reported from the Wk 104 reading session and are presented as observed.

Results

The vast majority (98%) of pts treated with SEC 150 mg (pooled LD and NL) showed no structural progression, defined as change in total mSASSS score ≤ smallest detectable change (SDC) of 0.76 (80% agreement level) over 2 years. At BL, 62 pts (43 in SEC, 19 in PBO) presented with ≥1 syndesmophyte (≥1 vertebral unit scored by ≥1 reader). Among these pts, 9 in SEC (20.9%) and 7 in PBO (36.8%) groups had developed ≥1 new syndesmophyte by Wk 104. Among 237 SEC and 117 PBO pts without syndesmophytes at BL, only 4 pts on SEC (1.7%) and 4 pts on PBO (3.4%) developed ≥1 new syndesmophyte by Wk 104. SIJ radiographs showed that 88% of pts on SEC and 86% on PBO had no progression in SIJ (defined as change ≤ SDC (0.46) in total mNYC score) by Wk 104. No patient had an increase in total mNYC score of 2 or more. When screening radiographs of eligible pts were scored alongside post-BL images in the final reading campaign, approximately 25% of pts (68/277 and 34/139 pts in the SEC and PBO groups, respectively) were evaluated as mNY-positive at screening (pts were considered mNY-positive if ≥1 reader evaluated them as mNY-positive). Of these, 11/68 pts in the SEC (16.2%) and 5/34 in the PBO (14.7%) groups were evaluated as mNY-negative at Wk 104. In the SEC and PBO groups, 202 (96.7%) and 102 (97.1%) pts who were mNY-negative at screening stayed negative through Wk 104, respectively. Only 7 pts in the SEC (3.3%) and 3 in the PBO (2.9%) groups who were mNY-negative at BL were scored as mNY-positive at Wk 104. In both groups, fewer pts progressed from mNY-negative to mNY-positive than had a change in the opposite direction (from positive to negative), resulting in an overall negative net progression. Spinal inflammation on MRI (Berlin score) was low at BL with a mean of 0.82 in SEC and 1.07 in PBO groups with no meaningful change up to Wk 104 (mean of 0.56, SEC). SEC reduced SIJ bone marrow oedema score versus PBO at Wk 16 and Wk 52 with sustained reduction through Wk 104 in the overall patient population, with greater reduction in pts with BL score >2 (Figure 1).

Conclusion

Most pts initially randomised to SEC or PBO showed no radiographic progression through 2 years. There was some discrepancy between SIJ eligibility and efficacy reads. SEC reduced SIJ inflammation (bone marrow oedema) on MRI in pts with active nr-axSpA.

References

[1]Deodhar A, et al. Arthritis Rheumatol. 2021;73:110–20.

Disclosure of Interests

Juergen Braun Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Medac, MSD (Schering-Plough), Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, UCB pharma, Eli Lilly, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, UCB, Eli Lilly, Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, UCB, Eli Lilly, Ricardo Blanco Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, UCB pharma, MSD, Eli Lilly, Consultant of: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, UCB pharma, MSD, Grant/research support from: AbbVie, MSD, Roche, Helena Marzo-Ortega Speakers bureau: AbbVie, Celgene, Janssen, Eli Lilly and Company, Novartis, Pfizer, Takeda, UCB, Consultant of: AbbVie, Celgene, Janssen, Eli Lilly and Company, Novartis, Pfizer, Takeda, UCB, Grant/research support from: Janssen, Novartis, UCB, Lianne S. Gensler Consultant of: Gilead, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Grant/research support from: UCB, Pfizer, Filip van den Bosch Speakers bureau: AbbVie, BMS, Celgene, Galapagos, Janssen, Eli Lilly, Merck, Novartis, Pfizer, UCB, Consultant of: AbbVie, BMS, Celgene, Galapagos, Janssen, Eli Lilly, Merck, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, BMS, Celgene, Galapagos, Janssen, Eli Lilly, Merck, Novartis, Pfizer, UCB, Stephen Hall Speakers bureau: Novartis, Merck, Janssen, Pfizer, Eli Lilly, UCB, Consultant of: Novartis, Merck, Janssen, Pfizer, Eli Lilly, UCB, Grant/research support from: AbbVie, UCB, Janssen, Merck, Hideto Kameda Speakers bureau: Abbvie, Asahi-Kasei, Astellas, BMS, Chugai, Eisai, Eli Lilly, Gilead Sciences, Janssen, Mitsubishi-Tanabe, Novartis, Pfizer, Consultant of: Abbvie, Astellas, Boehringer, Eli Lilly, Gilead Sciences, Janssen, Novartis, Sanofi, UCB, Grant/research support from: Abbvie, Asahi-Kasei, Boehringer, Chugai, Eisai, Mitsubishi-Tanabe, Denis Poddubnyy Speakers bureau: AbbVie, BMS, Lilly, MSD, Novartis, Pfizer, UCB, Consultant of: AbbVie, Biocad, BMS, Eli Lilly, Gilead, MSD, Novartis, Pfizer, Samsung Bioepis, UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, Marleen G.H. van de Sande Speakers bureau: Novartis, MSD, Consultant of: Abbvie, Novartis, Eli Lily, Grant/research support from: Novartis, Eli Lilly, Janssen, UCB, Désirée van der Heijde Paid instructor for: Novartis, AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Pfizer, UCB Pharma, and Director of Imaging Rheumatology BV, Tingting Zhuang Shareholder of: Novartis, Employee of: Novartis, Anna Stefanska Shareholder of: Novartis, Employee of: Novartis, Aimee Readie Shareholder of: Novartis, Employee of: Novartis, Hanno Richards Shareholder of: Novartis, Employee of: Novartis, Atul Deodhar Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB

AB1400 ARE COMORBIDITIES IN PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATIC DISEASES ASSOCIATED WITH TREATMENT NON-ADHERENCE TO BIOSIMILARS IN A NON-MEDICAL SWITCH SCENARIO?

Background

The availability of biosimilars has created a financial incentive to encourage non-medical switching if cheaper products are on the market. In patients with chronic inflammatory rheumatic diseases (CIRD), we have previously reported a relatively high retention rate after switching from originator etanercept to its biosimilar. However, this has been different in other studies and the reasons for non-adherence are poorly understood. Comorbidity has recently gained much attention in patients with CIRD and might be a reason for non-adherence.

Objectives

The aim of this study was to analyse the effectiveness and safety of systematic non-medical switching from originator adalimumab (ADA) to ADA ABP501 biosimilar (ABP) over 6 months in patients with CIRD and to investigate the influence of comorbidities on retention rates.

Methods

Patients with CIRD on originator ADA who switched to ABP subsequently from October 2018 onwards were identified from a large routine database and then followed for 6 months. The presence of comorbidities and disease characteristics as well as measures of disease activity, physical function and changes in treatment were documented at baseline (the time of switching from originator ADA to ABP), and at months 3 and 6. Longitudinal data including information on the clinical efficacy and safety of ABP, and the reasons for discontinuation were documented.

Results

A total of 111 CIRD patients on treatment with originator ADA were switched to the biosimilar ABP (Table 1). More than half of the patients (62%) had a Charlson comorbidity score of 0, though there were differences between disease subtypes. RA patients were comparatively older (mean age 65 years) and had the highest mean Charlson score (1.8). Treatment retention varied only slightly between patients with a Charlson score of 0 and those with ≥0 (Figure 1). In both groups, the majority of patients (90% vs 95%) continued therapy with ABP, while only a small proportion either switched back to originator ADA (6% vs 5%), switched to a different biologic (3% vs 0%), or dropped out (1% vs 0%). The main reason for back switch was the occurrence of adverse events, mostly subjective complaints, most frequently pain. Patients with a Charlson comorbidity score > 0 tended to have poorer scores in trajectories of scores for disease activity and physical function stratified by disease subtype.

Figure 1.

Treatment retention after 6 months stratified by the Charlson comorbidity score

Table 1.

Patients and disease characteristics

RAaxSpAPsAOtherN=23N=68N=15N=5Age (years), mean (SD)65.1 (12.0)47.3 (13.1)51.1 (11.2)41.8 (14.2)Women60.9% (14)32.4% (22)53.3% (8)40.0% (2)Disease duration (years), median (IQR)4.0 (3.0-8.0)5.0 (2.0-8.0)4.0 (2.0-13.0)7.0 (4.0-7.0)Duration originator ADA therapy (month), mean (SD)43.8 (28.6)39.4 (26.9)34.7 (29.0)60.9 (27.7)Charlson score, mean (SD)1.8 (2.1)0.6 (1.1)0.7 (1.2)0.2 (0.4)Gastroenterological comorbidities26.1% (6)22.1% (15)6.7% (1)0Hepatic comorbidities17.4% (4)2.9% (2)13.3% (2)0Hematological conditions8.7% (2)2.9% (2)13.3% (2)0Cardiovascular comorbidities60.9% (14)32.4% (22)33.3% (5)60.0% (3)Neurological and psychological comorbidities8.7% (2)17.6% (12)33.3% (5)0Metabolic comorbidities21.7% (5)7.4% (5)26.7% (4)40.0% (2)Osteoporosis43.5% (10)11.9% (8)6.7% (1)20.0% (1)Lung diseases21.7% (5)8.8% (6)040.0% (2)Skin diseases26.1% (6)26.5% (18)80.0% (12)20.0% (1)Eye diseases8.7% (2)23.5% (16)6.7% (1)60.0% (3)Kidney diseases13.0% (3)10.3% (7)040.0% (2)

Conclusion

Comorbidity had no influence on the biosimilar retention rate after 6 months in this study but the majority of patients did not have Charlson scores > 0. However, disease activity and physical function tended to be worse among CIRD patients with comorbidity. Cardiovascular disease and osteoporosis were more often present in RA patients than in axSpA or PsA patients, while neurological and psychological comorbidities were more often observed in the latter.

Disclosure of Interests

Imke Redeker: None declared, Stefan Moustakis: None declared, Styliani Tsiami: None declared, Xenofon Baraliakos Speakers bureau: Abbvie, Pfizer, MSD, UCB, Novartis, Lilly, Galapagos, Hexal, Paid instructor for: Abbvie, Pfizer, MSD, UCB, Novartis, Lilly, Galapagos, Hexal, Consultant of: Abbvie, Pfizer, MSD, UCB, Novartis, Lilly, Galapagos, Hexal, Grant/research support from: Abbvie, Pfizer, MSD, UCB, Novartis, Lilly, Galapagos, Hexal, Ioana Andreica Speakers bureau: UCB, MSD, Novartis, Abbvie, Lilly, Janssen, SOBI, Consultant of: Lilly, Novartis, Galapagos, Amgen, Takkeda, SOBI, Grant/research support from: Lilly, Bjoern Buehring Speakers bureau: UCB, Amgen, Gilad/Galapagos, Biogen, Sanofi/Genzyme, Consultant of: UCB, Theramex, Gilead/Galapagos, Amgen, Abbvie, Juergen Braun Speakers bureau: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB, Consultant of: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB, Grant/research support from: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB, Uta Kiltz Speakers bureau: AbbVie, Biocad, Biogen, Chugai, Eli Lilly, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: AbbVie, Biocad, Biogen, Chugai, Eli Lilly, Fresenius, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Grant/research support from: AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, Pfizer.

AB1114 VACCINATION OF PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATIC DISEASES: AN ANALYSIS OF BARRIERS AND FACILITATORS IN A PROSPECTIVE COHORT

Background

Patients (pts.) with chronic inflammatory rheumatic diseases (CIRD) are often not adequately protected against infectious diseases. As shown in an earlier study, less than 50% of CIRD pts. were vaccinated against pneumococci and influenza before the SARS-CoV2 pandemic started 1. High vaccination rates are critical to achieve herd immunity. Knowledge on barriers and facilitators of vaccine uptake in CIRD pts. is limited.

Objectives

The aim of this study was to characterize barriers and facilitators towards vaccines in general and specifically against pneumococci, influenza and SARS-CoV-2 in adult CIRD pts.

Methods

In early 2021, consecutive CIRD pts. completed a structured questionnaire including knowledge on vaccination, attitudes, and perceived barriers and facilitators towards vaccination. A total of 12 facilitators and 11 barriers towards vaccination was assessed in general, and specifically for vaccination against pneumococci, influenza and SARS-CoV2. The Likert scales had 4 response options, ranging from 1 (completely disagree) to 4 (completely agree). Patient and disease characteristics, their vaccination history and attitudes towards vaccination against SARS-CoV-2 were assessed.

Results

Of 514 prospectively recruited pts., 441 responded (85.8%) to the questionnaire (table 1). Self-reported vaccine uptake was 48.8% against pneumococci and 66.2% against seasonal influenza. The majority (82.2%) was willing to be vaccinated against SARS-CoV-2. The majority (≥70%) had decent knowledge about vaccination, and only <10% doubted its effectiveness. The level of knowledge did not differ between the studied 3 vaccinations. Pts. were more likely to rate statements about facilitators favorably compared to statements about barriers. Facilitators for SARS-CoV-2 vaccination did not different from vaccination in general (Figure 1). Societal and organizational facilitators such as public vaccine campaigns or protection for high-risk pts. were more commonly named compared to inter- or intrapersonal facilitators. Protection of high-risk pts. was by far the most frequently cited facilitator. Most pts. indicated that they were likely to receive a vaccine if their health care professional would recommend it – without preference for GP or rheumatologist. The frequency of barriers was much lower compared to facilitators and more barriers towards SARS-CoV-2 vaccination were reported in comparison to vaccination in general or pneumococci and influenza, respectively. However, pts. frequently cited intrapersonal issues as barriers against vaccination. Importantly, the major barrier was an inadequate risk perception between the severity of COVID-19 and the potential adverse events of the vaccine.

Table 1.

Patient and disease characteristics

Age, y54.1 (12.6)Women, No. (%)272 (61.7)Rheumatoid Arthritis, No. (%)156 (35.4)Axial Spondyloarthritis, No. (%)120 (27.2)Psoriatic Arthritis, No. (%)61 (13.8)Other diagnoses, No. (%)104 (23.6))Treatment, csDMARD, No. (%)121 (27.4)Treatment, bDMARD, No. (%)280 (63.5)Treatment, tsDMARD, No. (%)24 (5.4)CDAI, n=19411.1 (9.0)CRP, mg/L, n=4400.4 (0.7)HAQ score, n=3171.1 (0.7)BASDAI, n=1183.8 (2.2)BASFI, n=1183.8 (2.3)Patient global, NRS 0-104.1 (2.5)HADS-A, n=4366.6 (4.0)HADS-D, n=4365.8 (4.3)

variables as mean (SD)

Figure 1.

Facilitators of vaccine uptake in general and for SARS-CoV-2

Conclusion

A relatively high number of pts. was vaccinated against pneumococci and influenza, – a probable campaign success during the last years. In addition, more than 80% of pts. were willing to be vaccinated against SARS-CoV2. Facilitators were of greater significance than barriers in this scenario. The high number of societal and organizational facilitators enables the implementation of effective strategies to increase future vaccination rates.

References

[1]Kiltz et al. RMD Open 2021

Disclosure of Interests

Ioana Andreica Speakers bureau: UCB, MSD, Novartis, Abbvie, Lilly, Janssen, Sobi, Consultant of: Novartis, Lilly, Sobi, Galapagos, Amgen, Takeda, Grant/research support from: Lilly, Iulia Roman: None declared, Xenofon Baraliakos Speakers bureau: Abbvie, Lilly, Pfizer, UCB, MSD, Novartis, Galapagos, Hexal, Paid instructor for: Abbvie, Lilly, Pfizer, UCB, MSD, Novartis, Galapagos, Hexal, Consultant of: Abbvie, Lilly, Pfizer, UCB, MSD, Novartis, Galapagos, Hexal, Grant/research support from: Abbvie, MSD; Novartis, Lilly, Juergen Braun Speakers bureau: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, FResenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Pfizer, UCB, Novartis, Consultant of: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, FResenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Pfizer, UCB, Novartis, Grant/research support from: Abbvie, Amgen, Biogen, Fresenius, Hexal, Janssen, Lilly, MSD, Pfizer, UCB, Novartis, Uta Kiltz Consultant of: AbbVie, Chugai, Eli Lilly, Fresenius, Hexal, Janssen, MSD, Novartis, onkowissen.de, Pfizer, Roche and UCB, Grant/research support from: Abbvie, Amgen, Hexal, Fresenius, Novartis und Pfizer.

POS0964 IS LOW VERTEBRAL BONE DENSITY ASSOCIATED WITH SUBSEQUENT BONE FORMATION AT THE SAME VERTEBRA IN AXIAL SPONDYLOARTHRITIS? – A MULTILEVEL ANALYSIS FROM THE SIAS COHORT

Background

In radiographic axial spondyloarthritis (r-axSpA) it has been hypothesized that inflammation-driven bone loss triggers bone repair at anatomically distinct sites of the same vertebra: bone loss occurring in the trabecular bone and ectopic bone formation in the periosteum1.

Objectives

To investigate whether inflammation is associated with lower bone density (surrogate of bone loss) and subsequently, if lower bone density is associated with 2-year bone formation in r-axSpA at the same vertebra.

Methods

Data from the Sensitive Imaging in Ankylosing Spondylitis (SIAS), a multicentre 2-year cohort, was used. Baseline vertebral bone density was assessed by Hounsfield Units (HU) on low dose Computed Tomography (ldCT) by two independent readers (Figure 1). Baseline magnetic resonance imaging (MRI) bone marrow edema (BME) status scores, and 2-year ldCT syndesmophyte formation or growth change scores were assessed by three and two readers respectively. Inter-reader reliability was assessed for each imaging scoring by vertebra. Average of readers´ continuous scores (bone density HU) or readers´ agreement in binary scores (MRI-BME and bone formation) were used at the same vertebra (1-present in ≥1 quadrant/0-absent in all quadrants). The hypothesised associations were tested in multilevel generalised estimating equations models adjusted for confounders, the unit of analysis being the vertebra.

Results

We analysed 1,100 vertebrae in 50 patients with r-axSpA. Intraclass correlation coefficients for HU measurements varied from 0.89 to 0.97, Fleiss Kappa values for MRI-BME were between 0.41-0.78 and Cohen´s kappa for syndesmophyte formation/growth change scores varied from 0.36 to 0.74. Bone density HU decreased from cranial to caudal vertebrae. Baseline MRI-BME was present in 300/985 (30%) and syndesmophytes in 588/910 (65%) vertebrae, both most prevalent at the thoracolumbar region. Syndesmophyte formation or growth was observed in 18% of at-risk vertebrae (124/691). A significant association was found between inflammation (MRI-BME) and lower bone density (regression coefficient=-51; 95% CI:-63;-39) (Table 1A). Bone density was not associated with 2-year syndesmophyte formation or growth (adjOR 1.00; 95% CI:0.99;1.00) (Table 1B).

Table 1.

Relationships between (A) baseline MRI detected spinal inflammation (MRI-BME) and bone density, and (B) baseline bone density and ldCT bone formation after two years, at the same vertebra.

A.Independent variablesBone density (Hounsfield Units)Univariable analysisMultivariable analysisReg coeff. (95% CI)Adj Reg coeff. (95% CI)N = 910 to 985N = 985MRI-BME (presence)-51 (-63 to -39)-51 (-63 to -39)Age (years)-1 (-2 to 1)-1 (-2 to 1)Gender (male)21 (-20 to 63)16 (-24 to 57)TNFi treatment (yes)26 (-7 to 59)27 (-6 to 61)Baseline syndesmophytes (presence)*-42 (-54 to -30)-B.Independent variablesSyndesmophyte formation or growth§Univariable analysisMultivariable analysisOR (95% CI)AdjOR (95% CI)N = 672 to 691N = 672Bone density (HU)1.00 (0.99 to 1.00)1.00 (0.99 to 1.00)Age (years)1.02 (0.99 to 1.06)1.02 (0.98 to 1.05)Gender (male)0.44 (0.13 to 1.52)0.56 (0.15 to 2.06)Smoking (current)0.89 (0.40 to 1.97)1.02 (0.42 to 2.44)Treatment with TNFi (yes)1.34 (0.56 to 3.21)1.30 (0.43 to 3.90)MRI-BME (presence)2.03 (1.23 to 3.71)1.73 (1.06 to 3.34)Baseline syndesmophytes (presence)*2.84 (1.83 to 4.41)-

*Multicollinearity with MRI-BME. § Absolute agreement of readers.

adjOR - adjusted odds ratio; CI-confidence interval; BME - bone marrow edema; HU - Hounsfield units; ldCT - low dose computed tomography; MRI - magnetic resonance imaging; TNFi – Tumour necrosis factor inhibitors. Statistical significance highlighted in bold.

Conclusion

While in r-axSpA vertebral inflammation associates with low vertebral bone density, lower vertebral bone density itself does not increase the risk for ectopic bone formation at the same vertebra.

References

[1]Lories RJ. Best Pract Res Clin Rheumatol. 2018 Jun;32(3):331–41.

Acknowledgements

To the Dutch Rheumatism Association for funding SIAS study.

Disclosure of Interests

Mary Lucy Marques: None declared, Nuno Pereira da Silva: None declared, Désirée van der Heijde Consultant of: AbbVie, Gilead, Glaxo-Smith-Kline, Lilly, Novartis, UCB Pharma, Rosalinde Stal: None declared, Xenofon Baraliakos: None declared, Juergen Braun: None declared, Monique Reijnierse: None declared, Caroline Bastiaenen: None declared, Floris A. van Gaalen: None declared, Sofia Ramiro: None declared

AB1068 HIGH FREQUENCY OF STRUCTURAL DAMAGE IN THE LOWER SPINE OF PATIENTS WITH CHONDROCALCINOSIS

Background

Calcium pyrophosphate dihydrate crystal deposition disease (CPPD, chondrocalcinosis) is known to affect fibrocartilaginous tissue in the large and smaller peripheral joints. The affection of similar structures in the axial skeleton is unclear.

Objectives

To assess the frequency and severity of structural changes in the lower spine in patients with established CPPD in comparison to degenerative disc disease (DDD).

Methods

In a retrospective study, patients with CPPD or DDD as a main diagnosis with available spinal conventional radiographs (CR) performed during 2014 – 2020 were included. Definite other inflammatory conditions affecting the spine were excluded. The CR segments T7/8-L5/S1 were evaluated for the occurrence of disc calcification, intradiscal vacuum phenomenon, disc height (normal, narrowing, complete loss), endplate erosion, osteophytes and spondylolisthesis. When lumbar spine MRIs of the same time point were available, discovertebral units were evaluated for the occurrence of vacuum phenomena, endplate erosion, Modic changes and disc dehydration (Pfirrmann). Follow up CR were assessed if available. All available images were evaluated by 2 independent readers and discrepancies were solved by consensus.

Results

CR of 140 patients (1.171 discovertebral units) with CPPD and 99 DDD (803 discovertebral units) were evaluated (mean age 74.4±9.9 and 71±6.2, 20% vs. 20.2% males, respectively). MRIs of the spine were available from 48 CPPD and 44 DDD patients. Vacuum phenomena, disc calcification, osteophytes and erosion were significantly more frequently seen in patients with CPPD compared to DDD (Table 1) with no differences between the thoracic and the lumbar spine. Follow-up CR were available for 29 patients with CPPD and 46 DDD. Both groups presented statistically significant progression of endplate erosions and osteophytes (p 0.001 - 0.02 for both groups). Notably, even though CR follow-up times in the CPPD group were, compared to DDD (median (IQR) 1.9 (2.4) vs 3.0 (3.1) years, p=0.033, respectively), shorter, radiographic progression was noted more frequently in CPPD vs. DDD for erosive changes (6.8% vs. 0.6%, p=0.018) and disc calcification (5.8% vs. 0.6%, p=0.007), respectively. When comparing MRIs, a higher number of discovertebral units was affected by vacuum phenomena (34 vs 13, p=0.04) and endplate erosions (L4/5 (45.5% vs 24.4%, p=0.04), L5/S1(40.4% vs 19.5%, p=0.03) in patients with CPPD vs. DDD, respectively.

Table 1.

Frequency of affected discovertebral units on conventional radiographs

CPPDDDDpVacuum phenomenon156 (13.3%)44 (5.5%)<0.001Disc calcification193 (16.5%)42 (5.2%)<0.001Endplate erosion159 (13.6%)26 (3.2%)<0.001Osteophytes861 (73.5%)480 (59.8%)<0.001Spondylolisthesis126 (10.8%)69 (8.6%)0.264

CPPD: calcium pyrophosphate dihydrate crystal deposition disease DDD: degenerative disc disease

Conclusion

Patients with chondrocalcinosis showed more severe and progressive degenerative findings in the lower spine as assessed by both, CR and MRI, even more in comparison to established DDD. This data shows that disease manifestations of CPPD in the axial skeleton are clinically relevant.

Disclosure of Interests

None declared

AB1419 PERFORMANCE OF AN EARLY TRIAGE SYSTEM FOR IDENTIFICATION OF PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES

Background

The preselection of patients with suspicion of an inflammatory rheumatic disease is not easy for general practitioners and orthopedists. In countries with a limited number of practicing rheumatologists waiting lists are often long, since a full rheumatologic examination often needs a long consultation time.

Objectives

To test the performance of an early triage strategy for early identification of patients with inflammatory rheumatic diseases.

Methods

Prior to the SARS-CoV 2 pandemic, physicians caring for patients contacting a tertiary rheumatologic cente were first contacted by a health-care professional (HPR) who offered an appointment the timing of which was based on the symptoms reported (Step 1). Patients were then seen by a rheumatologist who, within a 10-minute consultation (Step 2), shortly examined the patient to determine the urgency of a planned full work up. The main outcome of the study was the comparison between the initial assessment and the final expert diagnosis (Step 3).

Results

Within 9 months, physicians caring for 1.180 patients contacted the hospital, 972 of whom kept their appointment (82.4%). Most patients were transferred by GPs (73.1%) and orthopedists (22.1%). The mean time between Step 1 and Step 2 was 10.4 days, while 6.2% of patients were seen within 4 days, 24.4% within 7 days and 69.3% within 12 weeks. Only 36 patients (3.7%) of patients had an already established rheumatic disease. Complaints lasting between 0-4 weeks were reported by 69 (7.1%), of > 4-12 weeks by 100 (10.3%), and of > 12 weeks by 973 (82.6%) patients. Almost 90% of patients reported a pain intensity >4/10 (NRS) for < 2 weeks. An elevated CRP was found in 207 patients (24.5%). Prior treatment with glucocorticoids was reported in 163 (16.8%) and with NSAIDs in 730 (75.1% of) patients. The confirmed diagnosis at Step 3 was rheumatoid arthritis in 127 (13.1%), spondyloarthritis including psoriatic arthritis in 72 (7.4%), systemic diseases including connective tissue diseases in 112 (11.5%), vasculitides in 41 (4.2%), and crystal arthropathy in 38 (3.9%) patients, while 38 (3.9%) had an infection, a malignancy or a differential diagnosis such as Raynaud’s phenomenon or sicca syndrome. Degenerative joint diseases (n=254; 26.1%) and non-inflammatory soft tissue syndromes such as fibromyalgia (n=369; 38%) accounted for more than half of the patients.

Conclusion

This study describes the performance of a standardized triage system hereby confirming the need for an early identification and preselection of patients with rheumatic musculoskeletal symptoms, including involvement of HPRs in the initial phase of contact. Based on the results, three patients with musculoskeletal complaints had to be examined in order to identify one patient with an inflammatory rheumatic disease.

Disclosure of Interests

None declared

POS1451 DISCRIMINATORY CAPACITY OF THE ASAS HEALTH INDEX IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS TREATED IN A TIGHT CONTROL SETTING VERSUS STANDARD OF CARE

Background

Improvement in functioning and health as assessed by the ASAS Health Index (HI) is an important outcome of interventions in patients with axial spondyloarthritis (axSpA). ASAS HI thresholds for measuring improvement have been proposed but not yet tested in an independent intervention trial to study its discriminant capacity.

Objectives

To test the discriminant capacity of the ASAS HI using data from a randomized, active-controlled trial.

Methods

In this post-hoc analysis from the tight-controlled, treat-to-target (T2T) trial TICOSPA [1], data of active axSpA patients randomized to either the T2T arm (visits every 4 weeks, prespecified strategy of treatment intensification until achieving low disease activity) or standard of care (SOC; visits every 12 weeks, treatment at the rheumatologist’s discretion) were compared to test whether different thresholds for improvement or achieved state of ASAS HI could discriminate between treatment arms. Week 48 effect sizes (ES) of improvement from baseline were calculated for each treatment arm as Phi Coefficient (higher means better discrimination) and OR (95% CI).

Results

The table shows the ES between treatment arms for all tested improvements and health states achieved in ASAS HI. Overall, absolute improvement outcomes performed better than percentage changes outcome followed by status outcomes. The absolute improvement of ≥2.0, ≥2.5, and ≥3.0 performed best followed by the 20% improvement. As the ASAS HI ≥3.0 is the smallest detectable change for this outcome, this seem to be the most appropriate proposed outcome.

Table 1.

Thresholds by treatment groups.

Non-responder imputation at 48 weeksEffect size measuresTC/T2TUCPhi Coefficient*OR [95% CI]ASAS HI 20% improvement56.9%45.8%0.11 [0-1.0]0.64 [0.33-1.23]ASAS HI 25% improvement51.4%41.7%0.10 [0-1.0]0.68 [0.35-1.30]ASAS HI 30% improvement43.1%34.7%0.09 [0-1.0]0.70 [0.36-1.38]ASAS HI 35% improvement40.3%31.9%0.09 [0-1.0]0.70 [0.35-1.38]ASAS HI 40% improvement37.5%31.9%0.06 [0-1.0]0.78 [0.39-1.56]ASAS HI 50% improvement29.2%22.2%0.08 [0-1.0]0.69 [0.33-1.47]ASAS HI 60% improvement26.4%18.1%0.10 [0-1.0]0.61 [0.28-1.36]ASAS HI 70% improvement16.7%12.5%0.06 [0-1.0]0.71 [0.28-1.82]ASAS HI 80% improvement13.9%11.1%0.01 [0-1.0]0.78 [0.29-2.09]ASAS HI 90% improvement9.7%9.7%0.0[0-1.0]1.0 [0.33-3.01]ASAS HI improvement ≥1.066.7%61.1%0.06[0-1.0]0.79 [0.40-1.55]ASAS HI improvement ≥2.055.6%41.7%0.14 [0.0-1.0]0.57 [0.30-1.11]ASAS HI improvement of ≥2.544.4%31.9%0.13 [0-1.0]0.59 [0.30-1.16]ASAS HI improvement of ≥3.041.7%29.2%0.13 [0-1.0]0.58 [0.29-1.15]ASAS HI improvement of ≥ 3.529.2%22.2%0.08 [0-1.0]0.69 [0.33-1.47]ASAS HI improvement ≥4.029.2%22.2%0.08 [0-1.0]0.69 [0.33-1.47]ASAS HI improvement ≥5.016.7%12.5%0.06 [0-1.0]0.71 [0.28-1.82]ASASHI, end of study, ≤12.087.5%80.6%0.09 [0.0- 1.0]0.59 [0.24, 1.47]ASASHI, end of study, ≤5.037.5%33.3%0.04 [0.0, 1.0]0.83 [0.42, 1.65]

A value of PHI = 0.1 is considered to be a small effect, 0.3 a medium effect, and 0.5 a large effect.

Conclusion

In this active-controlled trial an absolute improvement in the ASAS HI discriminated best between treatment arms. A similar evaluation is needed in a placebo-controlled trial to be able to propose the best outcome for the ASAS HI in a trial.

References

[1]Molto A et al. Ann Rheum Dis 2021

Disclosure of Interests

Uta Kiltz Speakers bureau: AbbVie, Biocad, Biogen, Chugai, Eli Lilly, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: AbbVie, Biocad, Amgen, Chugai, Eli Lilly, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Grant/research support from: AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, Pfizer., Anna Moltó: None declared, Clementina López-Medina: None declared, Maxime Dougados: None declared, Désirée van der Heijde Speakers bureau: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, UCB Pharma, Annelies Boonen Speakers bureau: Abbvie / Galapagos, Consultant of: Galapagos, Grant/research support from: Abbvie, Filip van den Bosch Speakers bureau: Abbvie, Amgen, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB., Consultant of: Abbvie, Amgen, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB., Grant/research support from: Abbvie, Amgen, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB., Juergen Braun Speakers bureau: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB, Consultant of: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB, Grant/research support from: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB

AB0184 IDENTIFYING TRAJECTORIES OF REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED IN A TERTIARY CARE CENTRE

Background

The main goal of treatment for patients (pts) with rheumatoid arthritis (RA) is remission to preserve physical function and prevent radiographic damage. However, less than 50% of pts with early RA have achieved remission in clinical studies and inception cohorts 1. Little is known about the course of disease and the clinical patterns when remission is tried to be achieved in pts with RA.

Objectives

To identify subgroups with distinct trajectories of DAS28-CRP in pts with RA.

Methods

Longitudinal data from adult RA pts presenting to a tertiary centre were used. Socio-demographic data, disease characteristics and standard assessments including established outcome parameters for disease activity (DAS28-CRP) and physical function (FFbH) were retrospectively analysed. Group-based trajectory modelling (GBTM) was used to identify homogeneous classes of DAS28-CRP trajectories, where the number of classes was selected using Nagin’s Bayesian information criterion (BIC). Differences between the identified classes and clinical variables were studied.

Results

Data of 134 pts with 849 DAS28-CRP values were analysed. Retrospective chart data were available for a follow-up of 33.7 (SD 18.0) months. One third of pts already had erosions and severe limitations in physical functioning. About half of the pts were on bDMARDS and <20% on steroids. Five distinct classes of DAS28-CRP trajectories were identified (Figure 1). These groups were subsequently categorized as 1) high-increasing, 2) high-stable, 3) low-increasing, 4) low-decreasing disease activity, and 5) remission. Pts.’ characteristics at baseline in each trajectory group are shown in Table 1. Group 4 had a shorter disease duration but more erosions, a better function and a higher educational level than seen in other groups. The increase of disease activity in group 3 was modest.

Table 1.

Patients demographics and disease characteristics at baseline in trajectory groups

Class 1(N=10)Class 2(N=36)Class 3(N=56)Class 4(N=23)Class 5(N=9)Age, years65.8 (12.7)60.6 (10.6)56.7 (16.0)50.5 (15.4)56.8 (12.0)Gender, female80.0% (N=8)77.8% (N=28)82.1% (N=46)52.2% (N=12)66.7% (N=6)Education level university0.0% (N=0)11.1% (N=4)16.1% (N=9)21.7% (N=5)0.0% (N=0)Employment10.0% (N=1)33.3% (N=12)53.6% (N=30)69.6% (N=16)33.3% (N=3)Body mass index30.6 (5.4)27.8 (4.3)27.1 (4.7)25.2 (4.2)29.0 (6.4)Symptom duration, years12.8 (7.3)10.4 (8.3)9.5 (9.6)6.7 (3.6)12.4 (13.2)Anti-CCP49.2 (63.9)101.3 (89.7)98.6 (95.6)94.9 (78.2)114.5 (84.6)CRP1.0 (1.1)0.7 (0.9)0.4 (0.4)0.4 (0.5)1.2 (1.1)Erosions20.0% (N=2)36.1% (N=13)28.6% (N=14)45.5% (N=10)44.4% (N=4)At least one Comorbidity100.0% (N=10)94.4% (N=34)78.6% (N=44)65.2% (N=15)88.9% (N=8)Charlson Comorbidity Index (0-29)1.1 (1.4)1.1 (1.3)0.6 (0.9)0.4 (0.7)1.2 (1.3)No. of patients on steroids0.0% (N=0)0.0% (N=0)2.9% (N=1)15.4% (N=2)0.0% (N=0)No. of patients on bDMARD77.8% (N=7)45.8% (N=11)41.2% (N=14)30.8% (N=4)71.4% (N=5)No. of patients on tsDMARD0.0% (N=0)0.0% (N=0)5.9% (N=2)7.7% (N=1)0.0% (N=0)Pain (NRS 0-10)6.1 (1.8)5.8 (1.8)4.2 (2.0)2.3 (2.6)4.2 (2.0)Patient Global (NRS 0-10)5.8 (2.8)5.3 (1.7)3.7 (2.1)2.8 (3.0)6.3 (2.2)DAS28-CRP5.3 (1.2)3.9 (0.7)2.5 (0.7)2.1 (1.0)4.6 (0.9)FFbH38.5 (29.0)48.8 (21.8)74.2 (18.9)90.4 (8.8)61.1 (19.4)RAID (0-10)6.5 (2.0)5.3 (2.1)3.8 (1.9)1.8 (1.8)4.6 (1.8)Figure 1.

Longitudinal DAS-28-CRP in trajectory groups

Conclusion

Using GBTM five distinct trajectories in pts with RA were identified. Only a small proportion of pts showed a reduction in disease activity over time, whereas the largest proportion of pts showed rather constant high or constant low disease activity. The cohort size may have impacted the modelling and further analyses in larger cohorts are needed. Importantly, even though well established in our hospital it is unclear how consequent the T2T strategy was followed and which intervention was successful to reach remission. The impact of pts global assessment on DAS28 values also needs further study.

References

[1]Nikiphorou Rheumatol 2020

Disclosure of Interests

None declared

POS0998 DEPRESSION IN SPONDYLOARTHRITIS: THE CHOICE OF MEASUREMENT INSTRUMENT MATTERS

Background

The prevalence of depression is increased in spondyloarthritis (SpA). Research on this topic in SpA is challenging for several reasons, one of them being the wide variety of different instruments used to assess depressive symptoms. It is unknown whether these instruments are comparable in measuring the construct ‘depression’ and can be considered interchangeable. If these instruments actually differ in what they measure, this should be taken into account when designing and interpreting studies, and in clinical practice when monitoring patients with SpA.

Objectives

To compare the constructs of several instruments used to assess depressive symptoms in patients with SpA.

Methods

Data from the international ASAS Health Index Validation Study were used. Included patients had a diagnosis of SpA and fulfilled the ASAS classification criteria for axial/peripheral SpA. Data on demographics and disease characteristics were collected. The following instruments that have been used to assess depressive symptoms in SpA were available: the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D), the Short Form 36 (SF-36) and item 5 of the 5-level EuroQoL 5D (EQ-5Di5). The HADS-D ranges 0-21 (best-worst), with scores ≥8 and ≥11 indicating possible (HADS-possible) and probable depression (HADS-probable), respectively. The SF-36 was summarized using all 36 items in a Mental Component Summary (SF-36MCS, score ≤40 indicating depression), or using only 5 items in the Mental Health subscale (SF-36MH, score ≤56 indicating depression). For the EQ-5Di5, a score of at least “moderately” (level ≥3 on 1-5 scale) or “severely” depressed (level ≥4) indicated depression. Spearman correlations between instrument scores, agreement (kappa) between depressed states, and test characteristics (sensitivity [SE], specificity [SP], positive and negative predictive value [PPV, NPV]) were calculated with HADS-D as external standard, as it was specifically designed to detect depression and considered to have highest content validity.

Results

In total, 1548 patients were included, of which 1281 (83%) had axial SpA, mean age was 41.6 (SD 13.5) years, 1005 were male (65%), mean symptom duration 14.5 (11.4) years, mean ASDAS 2.6 (1.2) and BASDAI 4.1 (2.5). The prevalence of depression varied around 1 in 3 patients for the lower thresholds of depression (32% for HADS-possible, 45% for SF-36MH, 33% for SF-36MCS and 24% for EQ-5Di5-moderately) and was lower for the more stringent thresholds of HADS-probable (15%) and EQ-5Di5-severely (6%); 192 patients (24% of those who scored positive for depression on ≥1 instrument) scored positive on all instruments (Figure 1). Correlations between instruments were moderate (rho = 0.59-0.66), except between SF-36MH and MCS (rho = 0.85). Agreement between instruments was moderate for lower thresholds for depression (pairwise kappa = 0.47-0.58 for HADS-possible, SF-36MCS, SF-36MH, EQ-5Di5-moderately) and substantial for higher thresholds (pairwise kappa = 0.75 for HADS-probable/EQ-5Di5-severely). Using HADS-D as external standard, EQ-5Di5 was very specific but less sensitive, while SF-36MCS/MH were more sensitive but less specific (Table 1).

Table 1.

Test characteristics of instruments

External standard: HADS-D≥8 (possible)Definition of ‘depression’SESPPPVNPVEQ-5Di5 ≥3 (moderate)51896980EQ-5Di5 ≥4 (severe)17998572SF-36MCS ≤4068836685SF-36MH ≤5678715687External standard: HADS-D≥11 (probable)Definition of ‘depression’SESPPPVNPVEQ-5Di5 ≥3 (moderate)67844194EQ-5Di5 ≥4 (severe)30986889SF-36MCS ≤4083753796SF-36MH ≤5688632997

All values are percentages.

Conclusion

Instruments used to assess depression in SpA are not interchangeable. The choice of instrument should be taken into account when interpreting studies on depression in SpA. SF-36MCS and SF-36MH are sensitive and could be considered for screening while EQ-5Di5 is useful when high specificity is required. In situations where assessment of depression is the primary objective, depression-oriented instruments such as the HADS are recommended.

Disclosure of Interests

Casper Webers: None declared, Uta Kiltz: None declared, Juergen Braun: None declared, Désirée van der Heijde Consultant of: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, UCB Pharma, Employee of: Director of Imaging Rheumatology bv., Annelies Boonen Speakers bureau: Abbvie, Galapagos, Consultant of: Galapagos, Grant/research support from: Abbvie

POS0304 THE EFFECT OF ANTI-INFLAMMATORY TREATMENT ON DEPRESSION IN SPONDYLOARTHRITIS: DOES THE TYPE OF DRUG MATTER?

Background

Patients with spondyloarthritis (SpA) are at increased risk of depression compared to the general population. Currently, it is unknown whether this increased risk is only secondary (due to SpA-related symptoms), or also due to a shared inflammatory pathway. From both clinical and pathophysiological perspectives, it is relevant to know whether comorbid depressive symptoms improve with treatment of SpA, and if so, whether such an improvement depends on drug type/mechanism of action.

Objectives

To investigate the effect of pharmacological treatment of SpA on depressive symptoms, and to explore whether this effect differs between drug types.

Methods

Data from the international ASAS Health Index Validation Study were used. Included patients had a diagnosis of SpA and fulfilled the ASAS classification criteria for axial/peripheral SpA. Patients were assessed at baseline, and for those who required a therapeutic change (initiation of NSAID, conventional synthetic (cs)DMARD or TNFi) due to high disease activity, a follow-up assessment was conducted. The current analysis included only those with a therapeutic change. Data on demographics, disease characteristics and disease activity (ASDAS, BASDAI, CRP) were available. Depressive symptoms were assessed with the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D, range 0-21 [best-worst]). HADS-D scores ≥8 and ≥11 indicated possible and probable depression, respectively. Change in depressive symptoms from baseline was compared between treatments (NSAID, csDMARD, TNFi) with ANOVA and linear regression analysis, adjusting for potential confounders.

Results

In total, 1548 patients were assessed at baseline. A therapeutic change was initiated in 304 patients (n=102/45/157 initiated an NSAID/csDMARD/TNFi). Of these, 260 (85%) had axSpA, 190 (63%) were male, mean age was 37.3 (SD 12.6) years and mean ASDAS at baseline 3.3 (1.1). The mean HADS-D was 6.9 (4.2); 126 (42%) were possibly depressed and 66 (22%) probably depressed. At baseline, there were no significant differences in demographics, disease parameters or depressive symptoms between treatment groups. At follow-up, mean HADS-D had improved to 5.1 (change -1.9 (3.8), p<0.01). Improvement in HADS-D was greater for TNFi (-2.4) than NSAIDs (-1.3, p=0.05) or csDMARDs (-1.2, p=0.15). Also, the proportion of patients with possible depression decreased more for TNFi (from 48% at baseline to 29% at follow-up) compared to NSAIDs (from 38% to 32%). In multivariable regression, initiation of TNFi was associated with greater improvement in HADS-D compared to NSAID (B = -1.27, 95%CI -2.23 to -0.32, base model) (Table 1). However, after additional adjustment for change in ASDAS/BASDAI, drug type was no longer associated with HADS-D improvement (Table 1). Adjustment for CRP in addition to BASDAI did not change results, and CRP itself was not associated with depressive symptoms (not shown). Of note, csDMARDs did not differ from NSAIDs in any of the analyses regarding their effect on HADS-D.

Table 1.

Multivariable regression analysis of change in HADS-D from baseline

Base modelASDAS modelBASDAI modelVariableB95%CIB95%CIB95%CIAge, years0.040.00 to 0.070.03-0.01 to 0.070.030.00 to 0.06Male gender0.23-0.67 to 1.140.55-0.39 to 1.490.28-0.54 to 1.10HLA-B27 (vs negative) Positive1.560.46 to 2.671.380.27 to 2.491.170.17 to 2.18 Unknown1.700.19 to 3.222.210.66 to 3.751.410.04 to 2.77Therapy initiated (vs NSAID) csDMARD0.19-1.16 to 1.540.02-1.34 to 1.390.14-1.07 to 1.36 TNFi-1.27-2.23 to -0.32-0.51-1.58 to 0.55-0.23-1.13 to 0.67ASDAS, change1.270.84 to 1.71†BASDAI, change†0.780.60 to 0.96

Associations in bold are statistically significant (p<0.05) †Due to collinearity, ASDAS and BASDAI were tested in separate models

Conclusion

Treatment of active SpA also improves depressive symptoms. TNFi have a larger effect than NSAIDs, which can mainly be explained by a stronger effect on disease activity. This analysis did not find evidence for a direct link between CRP-mediated inflammation and depressive symptoms in SpA.

Disclosure of Interests

Casper Webers: None declared, Uta Kiltz: None declared, Juergen Braun: None declared, Désirée van der Heijde Consultant of: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, UCB Pharma, Employee of: Director of Imaging Rheumatology bv, Annelies Boonen Speakers bureau: Abbvie, Galapagos, Consultant of: Galapagos, Grant/research support from: Abbvie

Estimating muscle activation from EMG using deep learning-based dynamical systems models

OBJECTIVE

To study the neural control of movement, it is often necessary to estimate how muscles are activated across a variety of behavioral conditions. One approach is to try extracting the underlying neural command signal to muscles by applying latent variable modeling methods to electromyographic (EMG) recordings. However, estimating the latent command signal that underlies muscle activation is challenging due to its complex relation with recorded EMG signals. Common approaches estimate each muscle activation independently or require manual tuning of model hyperparameters to preserve behaviorally-relevant features.

APPROACH

Here, we adapted AutoLFADS, a large-scale, unsupervised deep learning approach originally designed to de-noise cortical spiking data, to estimate muscle activation from multi-muscle EMG signals. AutoLFADS uses recurrent neural networks (RNNs) to model the spatial and temporal regularities that underlie multi-muscle activation.

MAIN RESULTS

We first tested AutoLFADS on muscle activity from the rat hindlimb during locomotion and found that it dynamically adjusts its frequency response characteristics across different phases of behavior. The model produced single-trial estimates of muscle activation that improved prediction of joint kinematics as compared to low-pass or Bayesian filtering. We also applied AutoLFADS to monkey forearm muscle activity recorded during an isometric wrist force task. AutoLFADS uncovered previously uncharacterized high-frequency oscillations in the EMG that enhanced the correlation with measured force. The AutoLFADS-inferred estimates of muscle activation were also more closely correlated with simultaneously-recorded motor cortical activity than were other tested approaches.

SIGNIFICANCE

This method leverages dynamical systems modeling and artificial neural networks to provide estimates of muscle activation for multiple muscles. Ultimately, the approach can be used for further studies of multi-muscle coordination and its control by upstream brain areas.

Right ventricular remodelling in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery

Funding Acknowledgements

Type of funding sources: None.

Background

Inconsistent changes in right ventricular (RV) dimensions and function have been observed after tricuspid valve (TV) surgery and their associations with long-term outcomes have not been explored.

Purpose

To evaluate RV remodelling and RV function in patients with significant (moderate or severe) tricuspid regurgitation (TR) undergoing TV surgery and their association with outcome.

Methods

A total of 121 patients (mean age 63 ± 12 years, 47% male) with significant TR treated with TV surgery and who had an echocardiogram between 3 months and 1 year of follow-up, were included for this analysis. Remodelling was assessed by comparing dimensions and function at follow-up to baseline values. The population was stratified by tertiles of percentage reduction of RV end-systolic area (RVESA) and absolute change of RV fractional area change (RVFAC). Five-year mortality rates were compared across the tertiles of RV remodelling and the independent associates of mortality were investigated.

Results

Reduction in RVESA and improvement in RVFAC were significantly associated with better survival after TV surgery, whereas reduction in RV end-diastolic area was not (Figure 1). One third of the patients presented with a reduction in RVESA of at least 17.2% and improvement in RVFAC of at least 2.3%, constituting the third tertiles for comparison. Kaplan-Meier curves for overall survival according to RVESA- and RVFAC-tertiles are shown in Figure 2. Cumulative survival rates were significantly better in patients in the third tertile of RVESA reduction: 49%, 69%, and 90% for tertile 1, tertile 2, and tertile 3, respectively (log-rank chi-square: 12.526; p = 0.002); as well as according to RVFAC improvement: 57%, 65%, and 87% for tertile 1, tertile 2, and tertile 3, respectively (log-rank chi-square: 7.784; p = 0.02). Tertile 3 of RVESA-reduction as well as tertile 3 of RVFAC-change were both independently associated with better survival after TV surgery compared to tertile 1 (hazard ratio: 0.221 [95% CI: 0.074 to 0.658] and 0.327 [95% CI: 0.118 to 0.907], respectively).

Conclusion

The magnitude of RV reverse remodelling (based on reduction in RVESA) and improvement in RVFAC were associated with better survival at 5 years’ follow-up after TV surgery for significant TR. Abstract Figure 1: Spline curves  Abstract Figure 2: KM curves for overal survival

Search for Relativistic Magnetic Monopoles with Eight Years of IceCube Data

We present an all-sky 90% confidence level upper limit on the cosmic flux of relativistic magnetic monopoles using 2886 days of IceCube data. The analysis was optimized for monopole speeds between 0.750c and 0.995c, without any explicit restriction on the monopole mass. We constrain the flux of relativistic cosmic magnetic monopoles to a level below 2.0×10^{-19}  cm^{-2} s^{-1} sr^{-1} over the majority of the targeted speed range. This result constitutes the most strict upper limit to date for magnetic monopoles with β≳0.8 and up to β∼0.995 and fills the gap between existing limits on the cosmic flux of nonrelativistic and ultrarelativistic magnetic monopoles.

[Axial spondyloarthritis : Update on management based on the interdisciplinary S3 guidelines on axial spondyloarthritis including early forms and ankylosing spondylitis]

This review article presents the innovations in the update of the S3 guidelines on axial spondylarthritis. The total of eight new recommendations address the areas of the consideration of differential diagnoses, coordination of comorbidity management, including a vaccination strategy, treatment targets, safety of nonsteroidal anti-inflammatory drugs (NSAID), treatment response to biological disease-modifying antirheumatic drugs (bDMARD) and discontinuation strategies when remission has been achieved. In this article the authors deal particularly with the areas of early diagnosis and referral as well as exercise therapy and drug treatment.

Striking sex differences in magnetic resonance imaging findings in the sacroiliac joints in the population

Background

In patients with axial spondyloarthritis (axSpA), magnetic resonance imaging (MRI) is used to detect bone marrow edema (BME) in sacroiliac joints (SIJ) but SIJ BME are also detected in the population. Not much is known about sex differences in that regard.

Objective

To explore sex-specific differences associated with the extent of BME in the SIJ suggestive of axSpA in a general population cohort study.

Methods

Taking advantage of 793 recently evaluated MRIs of subjects < 45 years taking part in the SHIP cohort, we used negative-binomial (NB) count data regression to analyze factors associated with the extent of SIJ BME. Predictors were explored by model-based boosting (MBB), a machine learning approach.

Results

Estimates of NB regression showed strong effects of sex in interaction with age, BMI, back pain, and particularly HLA-B27. The NB regression model showed incidence rate ratios (IRR) for the main effect of sex (females vs. males): 0.94 [95% CI: 0.63; 1.41], HLA-B27: 4.32 [2.09; 9.8], and for the interaction of sex to HLA-B27: 0.22 [0.06; 0.75]. According to MBB, HLA-B27 positivity, BMI, current smoking, back pain in the last 3 months, the interaction of sex and HLA-B27, and delivery in the last 12 months were of highest importance to explain the extent of SIJ BME.

Conclusions

Different factors were associated with the extent of SIJ BME in females and males. Most importantly, HLA-B27 was relevant only in males but not in females in whom a postpartal state was important. This finding may be relevant for the pathogenesis of axSpA.

Favourable outcome of planned pregnancies in systemic sclerosis patients during stable disease

Objective: Studies evaluating pregnancy outcomes in systemic sclerosis (SSc) are limited. SSc is associated with maternal complications and adverse neonatal outcomes. This study investigated the impact of disease stage (stable vs active) on the maternal and neonatal outcomes of pregnancies of patients followed at an Israeli medical centre.Method: The charts of 354 SSc female patients followed during 2003-2020 were reviewed. Data on clinical and laboratory features, number of pregnancies close to SSc diagnosis, and maternal and neonatal outcomes were analysed. Patients were divided into a stable disease and an active/early disease group.Results: The active/early disease group included 26 patients [19 diffuse SSc (dSSc)], with 38 pregnancies. Median disease duration was 1 year, except for four patients who were first diagnosed during pregnancy. SSc was exacerbated in all patients during pregnancy or shortly after delivery [skin, lung, and heart involvement in dSSc; severe vasculopathy in limited SSc patients]. Six patients had hypertensive disorders of pregnancy; four pregnancies ended with foetal death. Thirty-three children were born, 60% with intrauterine growth retardation (IUGR)/low birthweight (LBW). The stable disease group included 19 patients, including seven with previously active disease, now stabilized (five dSSc), and 32 pregnancies. All pregnancies were planned and monitored closely. Disease remained stable in all patients. Four patients had hypertensive disorders of pregnancy; 12/29 newborns had LBW (41%).Conclusion: Active maternal disease during pregnancy poses an increased risk of SSc aggravation. The maternal and neonatal outcomes in planned pregnancy during stable disease are favourable. IUGR/LBW is common among neonates, even in stable disease.

A nationwide population-based cohort study of surgical care for patients with superior sulcus tumors: Results from the Dutch Lung Cancer Audit for Surgery (DLCA-S)

OBJECTIVES

Data on national patterns of care for patients with superior sulcus tumors (SST) is currently lacking. We investigated the distribution of surgical care and outcome for patients with SST in the Netherlands.

MATERIAL AND METHODS

Data was retrieved from the Dutch Lung Cancer Audit for Surgery (DLCA-S) for all patients undergoing resection for clinical stage IIB-IV SST from 2012 to 2019. Because DLCA-S is not linked to survival data, survival for a separate cohort (2015-2017) was obtained from the Netherlands Cancer Registry (NCR).

RESULTS

In the study period, 181 patients had SST surgery, representing 1.03% (181/17488) of all lung cancer pulmonary resections. For 2015-2017, the SST resection rate was 14.4% (79/549), and patients with stage IIB/III SST treated with trimodality had a 3-year overall survival of 67.4%. 63.5% of patients were male, and median age was 60 years. Almost 3/4 of tumors were right sided. Surgery was performed in 20 hospitals, with average number of annual resections ranging from ≤ 1 (n = 17) to 9 (n = 1). 39.8% of resections were performed in 1 center and 63.5% in the 3 most active centers. 12.7% of resections were extended (e.g. vertebral resection). 85.1% of resections were complete (R0). Morbidity and 30-day mortality were 51.4% and 3.3% respectively. Despite treating patients with a higher ECOG performance score and more extended resections, the highest volume center had rates of morbidity/mortality, and length of hospital stay that were comparable to those of the medium volume (n = 2) and low-volume centers (n = 1).

CONCLUSION

In the Netherlands, surgery for SST accounts for about 1% of all lung cancer pulmonary resections, the number of SST resections/hospital/year varies widely, with most centers performing an average of ≤ 1/year. Morbidity and mortality are acceptable and survival compares favourably with the literature. Although further centralisation is possible, it is unknown whether this will improve outcomes.

[Answering epidemiologic rheumatologic questions by cooperation with the large population-based SHIP cohort-findings with relevance for the diagnosis of axial spondyloarthritis (axSpA)]

This article presents how, based on the availability of new imaging methods and medications, objectives regarding the rheumatic disease axial spondyloarthritis (axSpA) have developed over the course of more than two decades into a rheumatologic research group. During recent years, cooperation with the Study of Health in Pomerania (SHIP) cohort has given rise to new fundamental aspects. This involved intensive cooperation between the Ruhr University Bochum (Rheumazentrum Ruhrgebiet) and the Greifswald University Hospital (Community Medicine research collective). The design of the SHIP cohort was published 10 years ago and the cohort approach presented in the Bundesgesundheitsblatt, which also described central methodologic questions in detail. In 2014, a cooperation project between the Ruhr Rheumatology Center/Ruhr University Bochum and the SHIP Department of Clinical and Epidemiologic Research (Klinisch-Epidemiologische Forschung, KEF; SHIP-KEF) was established, which has already resulted in publication of interesting results in high-ranking journals. In order to stress the potential of such corporations, important contents thereof are presented herein, with a focus on MRI and consideration of historical aspects.