Clinical teaching self-efficacy positively predicts professional fulfillment and negatively predicts burnout amongst Thai physicians: a cross-sectional survey

BACKGROUND

Clinician teachers (physicians who teach in clinical settings) experience considerable psychological challenges in providing both educational training and patient care. This study aimed to determine the prevalence of physician burnout and professional fulfillment, and to identify internal and external factors associated with mental health outcomes among Thai clinician teachers working in non-university teaching hospitals.

METHOD

A one-time online questionnaire was completed by physicians at 37 governmental, non-university teaching hospitals in Thailand, with 227 respondents being assessed in the main analyses. Four outcomes were evaluated including burnout, professional fulfillment, quality of life, and intentions to quit.

RESULTS

The observed prevalence of professional fulfillment was 20%, and burnout was 30.7%. Hierarchical regression analysis showed a significant internal, psychological predictor (clinical teaching self-efficacy) and external, structural predictors (multiple roles at work, teaching support), controlling for the background variables of gender, years of teaching experience, family roles, and active chronic disease, with clinical teaching self-efficacy positively predicting professional fulfillment (b = 0.29, p ≤.001) and negatively predicting burnout (b = - 0.21, p =.003).

CONCLUSIONS

Results highlight the importance of faculty development initiatives to enhance clinical teaching self-efficacy and promote mental health among Thai physicians.

Interplay of Oncoplastic Reconstruction and Adjuvant Radiation Therapy in Breast Cancer

Purpose

Oncoplastic breast surgery (OBS) combines breast cancer tumor removal with the cosmetic benefits of plastic surgery at the time of breast-conserving surgery. Potential advantages of OBS include wider surgical margins around the tumor bed, while the natural shape and appearance of the breast are maintained more than standard lumpectomy procedures. However, limited information is available regarding the potential effect on adjuvant radiation treatment planning.

Materials and Methods

Women with localized breast cancer undergoing lumpectomy with immediate OBS and adjuvant radiation therapy between 2014 and 2019 were reviewed. OBS was performed using volume displacement techniques and patients received whole-breast irradiation with 3-dimensional conformal radiation therapy.

Results

Volume of additional ipsilateral breast tissue removed during OBS ranged from 21 to 2086 cm3 (median, 304 cm3), 29% of patients had >500 cm3 of tissue removed. Surgical margins were positive in 12.5% and were not affected by volume of breast tissue removed (445 vs 439 cm3). Patients with surgical clips more often received a lumpectomy bed boost (75.9% vs 50.0%), boost volumes were on average 157 cm3 with clips versus 205 cm3 without clips. Mean V105 was comparable in patients with >500 cm3 tissue removed and irradiated breast volume >1000 cm3, while higher absolute volumes were found in patients with >26 cm posterior separation (58.0 cm3 vs 102.7 cm3; P = .07). No meaningful difference was observed in Dmax or radiation coverage (95% of the volume receiving 95% of the prescription dose) for patients with >26 cm posterior separation, >500 cm3 of breast tissue removed, or irradiated breast volume >1000 cm3.

Conclusions

Radiation dosimetry plans for patients undergoing oncoplastic surgery were acceptable and no significant radiation or surgical advantage was gained in patients with more tissue removed. Our study stresses the importance of clear communication between surgeons and radiation oncologists about sufficient marking of the lumpectomy cavity, using practices that minimize the need for re-excisions and minimize lumpectomy cavity disruption during rearrangement.

Neoadjuvant Radiotherapy Facility Type Affects Anastomotic Complications After Esophagectomy

BACKGROUND

Esophagectomy is a complex oncologic surgery that results in lower perioperative morbidity and mortality when performed in high-volume hospitals by experienced surgeons; however, limited data exists evaluating the importance of neoadjuvant radiotherapy delivery at high- versus low-volume centers. We sought to compare postoperative toxicity among patients treated with preoperative radiotherapy delivered at an academic medical center (AMC) versus community medical centers (CMC).

METHODS

Consecutive patients undergoing esophagectomy for locally advanced esophageal or gastroesophageal junction (GEJ) cancer at an academic medical center between 2008 and 2018 were reviewed. Associations between patient factors and treatment-related toxicities were calculated in univariate (UVA) and multivariable analyses (MVA).

RESULTS

One hundred forty-seven consecutive patients were identified: 89 CMC and 58 AMC. Median follow-up was 30 months (0.33-124 months). Most patients were male (86%) with adenocarcinoma (90%) located in the distal esophagus or GEJ (95%). Median radiation dose was 50.4 Gy between groups. Radiotherapy at CMCs resulted in higher rates of re-operation after esophagectomy (18% vs 7%, p = 0.055) and increased rates of anastomotic leak (38% vs 17%, p < 0.01). On MVA, radiation at a CMC remained predictive of anastomotic leak (OR 6.13, p < 0.01).

CONCLUSION

Esophageal cancer patients receiving preoperative radiotherapy had higher rates of anastomotic leaks when radiotherapy was completed at a community medical center versus academic medical center. Explanations for these differences are uncertain but further exploratory analyses regarding dosimetry and radiation field size are warranted.

Analysis of the impact of green urban areas in historic fortified cities using Landsat historical series and Normalized Difference Indices

Urban green areas minimize the negative effects of climatic change and improve the sustainability of historic cities. Despite this, green areas have traditionally been considered a threat to heritage buildings because they cause humidity changes, that accelerate degradation processes. Within this context, this study evaluates the trends in the inclusion of green areas in historic cities and the effects it causes on humidity and conservation of earthen fortifications. To achieve this goal, vegetative and humidity information has been obtained since 1985 from Landsat satellite images. The historical series of images has been statistically analysed in Google Earth Engine to obtain maps that show the means, 25th, and 75th percentiles of the variations registered in the last 35 years. The results allow visualizing spatial patterns and plotting the seasonal and monthly variations. In the decision-making process, the proposed method allows to monitor whether the presence of vegetation is an environmental degradation agent in the nearby earthen fortifications.The analysis of the historic fortified cities of Seville and Niebla (Spain) shows a gradual increase in green areas and an interest in locating them near the earthen fortifications. The impact on the fortifications is specific to each type of vegetation and can be positive or negative. In general, the low humidity registered indicates low danger, and the presence of green areas favours drying after heavy rains. This study suggests that increasing green spaces to historic cities does not necessarily endanger the preservation of earthen fortifications. Instead, managing both heritage sites and urban green areas together can encourage outdoor cultural activities, reduce the impacts of climate change, and enhance the sustainability of historic cities.

Climate change, large fires, and cultural landscapes in the mediterranean basin: An analysis in southern Spain

Understanding the factors that influence fire regimes in Mediterranean climates is essential to reduce their risk. This research uses Climate Hazards Group InfraRed Precipitation with Station (CHIRPS) and Moderate-Resolution Imaging Spectroradiometer (MODIS) satellite resources to evaluate recent changes in land surface temperature, precipitation, and vegetation and their effects in the occurrence of large fires in the Mediterranean Basin. The results of the analysis of 335 fire events occurred in southern Spain from 2001 to 2020 show an increase in hazardous meteorological factors linked to droughts and thermal anomalies. The study also examines the potential of preserving traditional landscapes to minimize such risk. In fact, the maintenance and recovering of traditional agro-pastoral activities is an effective option to reduce flammability and increase the resilience of cultural landscapes in hazardous climatic conditions.

PRIMARY CUTANEOUS ADENOID CYSTIC CARCINOMA IN THE TRUNK: CASE REPORT AND LITERATURE REVIEW

Primary cystic adenoid skin carcinoma is a rare and poorly documented neoplasm in literature worldwide, with just over 250 reports. This work describes a 52-year-old male patient, with no comorbidities, who presented this neoplasm in nodular format in the posterior thoracic region, associated with localized pain and erythema - symptoms that led him to seek medical help. The clinical findings, differential diagnosis and treatment particularities were reviewed and correlated with the clinical case. The choice of type of surgical treatment was done considering the characteristics of the primary lesion that are associated with a worse prognosis. Despite its rarity, this neoplasm is easily identified through histological examination, the correct choice of treatment and patient follow-up, essential to increase survival. Thus, this work contributes to diminish the scarcity of literature related to this topic, especially the form of treatment employed.

POS0093 ASSESSMENT OF HISTOLOGICAL FEATURES OF CHRONICITY OF MINOR SALIVARY GLAND BIOPSY IN PATIENTS WITH PRIMARY SJOGREN’S SYNDROME

Background

The origin of the histological chronic inflammation of the salivary gland in patients with primary Sjogren’s Syndrome (pSS) is questionable. It is probably a consequence of both, the evolution of the disease itself and ageing

Objectives

This study aims to evaluate histological data of chronicity of minor salivary gland biopsy with clinical characteristics and time of evolution in a series of patients with pSS.

Methods

A cross-sectional study including 98 subjects fulfilling the ACR-EULAR 2017 classification criteria for pSS. All patients underwent a minor salivary gland biopsy requested as per clinical practice. We collected the age at diagnosis and at biopsy, xeroftalmia and xerostomia evolution time, and stimulated and unstimulated salivary flow as a clinical data. We informed the following features in the minor salivary gland biopsy: the focus score (positive if ≥ 1), atrophy, fibrosis and adiposity all graded in negative, mild, moderate, and severe stages according to pathological criteria.

Results

This study included 98 patients with pSS. the median of all recruited parameters are shown in Table 1. Only 2 patients presented severe fibrosis and adiposity, so we did not consider them for the analysis. Both, the age at diagnosis and at biopsy are significantly higher between none, mild and moderate stages in the three biopsy parameters. The age at biopsy increased in negative, mild, and moderate stages, in median, 10, 9 and 6 years in atrophy, fibrosis and adiposity respectively. Although more evolution time is observed in atrophy and fibrosis regarding classification categories, it does not reach statistical signification. Focus score is associated with atrophy as a high percentage in severe stage shows negative biopsy (78% vs 22%, p = 0.046) while in negative, mild, and moderate atrophy display a positive biopsy (61%, 73% and 64%, respectively). Furthermore, we observe a significant OR of 8.75 [1.7-68] for negative, 6 [1.25-44] in mild and 9.92 [1.8-80] in moderate compared to severe atrophy. Fibrosis and adiposity are not related to focus score. A low unstimulated salivary flow is observed in the atrophy and fibrosis stages, although differences are explained when compared negative with mild and moderate (3.5 vs 2 and 1.4 for atrophy and 3 vs 2 and 1.75 for fibrosis). Regarding adiposity, a lineal statistically significant association is observed for every stage (3.5, 1.65 and 0.7, p< 0.001). No differences in the stimulated salivary flow are shown.

Table 1.

Description of variables included in the study.

CategoriesN(%)Median(IQR)Age at diagnosis(years)55.220 (51.097, 58.407)Age at biopsy (years)57.719 (53.851, 61.333)Xerostomia (months)19.614 (10.480, 35.121)Xeroftalmia (months)21.487 (8.148, 38.735)Focus score (positive)63 (64.3%)USF (ml/15 min)2.000 (1.400, 3.000)SSF (ml/ 5min)4.500 (3.000, 5.000)AtrophyNegative28 (28.7%)Mild37 (38.1%)Moderate23 (23.7%)Severe9 (9.3%)FibrosisNegative29 (30.5%)Mild40 (42.1%)Moderate26 (27.4%)AdiposityNegative39 (41.1%)Mild38 (40%)Moderate18 (18.9%)

USF: Unstimulated salivary flow, SSF: Stimulated salivary flow

Conclusion

An older age both, at diagnosis and at biopsy are associated with a severe stage of atrophy, fibrosis, and adiposity. Patient with severe atrophy shows less positive focus score, which might be noticed for biopsy interpretation

Disclosure of Interests

None declared

Alcohol-induced psychotic disorder: a study of hospitalized patients in Lisbon

Introduction

While alcohol-induced psychotic disorder (AIPD) is a well-recognised clinical disorder, relativery little is known about aspects such as epidemiology, course and treatment of the condition. Current evidence suggests AIPD can be clinically distinguised from alcohol-withdrawal delirium and schizophrenia. AIPD is associated with high comorbidity with other psychiatric disorders, high re-hospitalization and mortality rate, namely suicidal behaviour.

Objectives

The objetive of the study was to examine the correlates, clinical features, psycopathology, and short-term response in an inpatient sample with alcohol-induced psychotic disorder, predominant hallucinations (ICD-10 F10.52) admitted to Centro Hospitalar Psiquiátrico de Lisboa.

Methods

We collected retrospectively data from all admitted patients to our Alcohol Unit between January 2010 and January 2020 with the diagnosis of AIPD. The exclusion criteria were: presence of preexisting psychotic disorder, delirium, or other substance use disorders. We characterized our sample in Demographic categories, Clinical categories, Treatment and Short-term course.

Results

A total of 113 subjects were included in the study. The prevalance of alcoholic hallucinosis was found to be 1.3% of all patients who received inpatient treatment. Most individuals reported auditory hallucinations, that iniciated when they decrease their alcohol intake, and 1 in 4 had past episodes of AIPD.

Conclusions

There are specific challenges in studiyng AIPD, such as the relatively rarity of the disorder, its often transient nature and high levels of comorbidity. A high degree of recurrence and morbidity indicates a need to prevent, and intervene early with an abstinent-oriented management goal.

Disclosure

No significant relationships.

POS0782 ULTRASONOGRAPHIC EVALUATION OF MAJOR SALIVARY GLANDS IN PRIMARY SJOGREN’S SYNDROME: COMPARISON OF THREE SCORING SYSTEMS AND ASSOCIATION WITH BIOPSY RESULTS

Background

Salivary glands ultrasound is an imaging technique useful for primary Sjogren’s syndrome (pSS) diagnosis. Nowadays, the use of ultrasound in diagnostic criteria is not clear. Different scoring systems have been published in recent years.

Objectives

This study aims to compare the reliability between three salivary glands ultrasound (SGUS) scores in a series of patients with pSS. Furthermore, we assessed the association of the three SGUS scores with minor salivary gland biopsy.

Methods

A cross-sectional study including 98 subjects fulfilling the ACR-EULAR 2017 classification criteria for pSS. All patients underwent an ultrasound of the salivary glands and a minor salivary gland biopsy requested as per clinical practice. An experienced Rheumatologist in SGUS evaluated systematically the previously acquired images. This Rheumatologist classified the images using three different scoring systems obtained from the grades of bilateral parotid and submandibular glands: De Vita (0-3), Salaffi (0-4) and Omeract (0-3). These three scores were performed in different days and blinded for the previous scores results. SGUS grade ≥ 2 was considered positive. Positive biopsy was deemed when focus score ≥1. We evaluated the agreement between the three scores and the individual scores with respect to the biopsy.

Results

This study included 98 patients with pSS. The distribution of the different grades according to the score system and the percentage of a positive SGUS are shown in Table 1. The reliability for a positive score for the three evaluated systems was almost perfect, with a Light’s kappa of 0.95 [0.9-1] for the De Vita-Salaffi, 0.87 [0.77-0.97] for De Vita- Omeract and 0.83 [0.71-0.94] for Salaffi-Omeract. We observed a same degree of concordance when the individual parotid and submandibular scores were evaluated. There was only a fair agreement for positivity of SGUS and a positivebiopsy in all scoring systems, specifically De Vita (kappa = 0.27 [0.09-0.45]), Salaffi (kappa = 0.26 [0.06-0.45]) and Omeract (kappa = 0.22 [0.03-0.42]). This associations with a positive biopsy did not change in magnitude when individually evaluated parotid and submandibular glands.

Table 1.

Distribution of the ultrasound grades and the percentage of positive biopsy in the different scoring systems evaluated.

01234Positive scoreVita23312618044(23.5%)(31.6%)(26.5%)(18.4%)(44.9%)Salaffi23291623746(23.5%)(29.6%)(16.3%)(23.5%)(7.1%)(46.69%)Omeract27292316039(28.4%)(30.5%)(24.2%)(16.8%)(41.1%)

Conclusion

The three SGUS scores are reliable for the evaluation of the main salivary glands in pSS. There was only weak agreement for SGUS and biopsy, so these two techniques provides complementary information and currently, SGUS cannot replace the biopsy for diagnosis purposes.

Disclosure of Interests

None declared

POS1381 ULTRASONOGRAPHIC EVALUATION OF ENTHESOPATHY IN IDIOPATHIC DIFFUSED SKELETAL HYPEROSTOSIS. APPLICABILITY OF THE MASEI INDEX

Background

In Diffuse idiopathic Skeletal Hyperostosis (DISH) o Forestier-Rotés disease the enthesis is also the hallmark of extraspinal manifestations. Despite being a characteristic hallmark of the disease, it has been poorly investigated.

Objectives

To assess the usefulness of the Madrid Sonographic Enthesitis Index (MASEI) to classify patients with DISH and to analyse the ultrasound findings in hyperostotic entheses.

Methods

We recruited 35 patients with DISH, according to Resnick classification criteria, who were compared with 33 healthy patients age, sex and body mass index-matched. An ultrasound was performed strictly following the MASEI protocol. The ultrasound examiners, with extensive experience in musculoskeletal ultrasound (ECOCAT group), were blinded to the diagnosis of the patients. The interobserver reliability of MASEI index measured by an ICC was 0.97 (95%, CI 89-99) [1]. Demographic, cardiovascular risk factors, clinical, radiological and MASEI-related variables were collected. We categorized into MASEI- inflammatory (MASEI-I) and MASEI-damage (MASEI-D) as previously published [2]but also into MASEI-DISH, which included the variables of thickness, structure and calcification. In the statistical analysis, patients’ data were depicted by using descriptive statistics and the comparison between groups with the Chi-square test for categorical variables and the T-Student test for numerical variables. The validity of the index was examined using the area under the ROC curve and its corresponding 95% confidence interval (CI). The optimal cut-off point was defined as the one that maximizes sensitivity (S) and specificity. (Spe). The statistical program used was R software.

Results

In the analysis of the elemental lesions, the alterations in structure, thickness and calcification of the distal quadriceps (DQT) and Achilles tendons (AQT) stood out (p <0.05). In the total MASEI, the ultrasound score of ≥ 16.50 (S80%, Spe 85%), obtained with an AUC of 0.877 (95% CI, 0.79 to 0.96), was the best cut-off to differentiate patients from healthy subjects. In the categorized indices, MASEI-I: cut-off 5.50 (S 89%, Spe 76%) and AUC 0.835 (95% CI 0.73 to 0.94); MASEI-D: 7.50 (S 86%, Spe 76%) and AUC 0.850 (95% CI, 0.75 to 0.94) and MASEI-DISH: 16.50 (S 74%, Spe 91%) and AUC (95% CI 0.76 to 0.95). The total MASEI in the DISH group was 27.46 (SD 14.4) compared to 10.30 (SD 6.4) in healthy controls (p<0.001) as well as in those categorized as MASEI-I, MASEI-D or MASEI-DISH (p <0.001).

Conclusion

Entheses lesions of the AQT and the DQT mark the differences between DISH and healthy patients. The optimal cut-off point was 16.50, and we did not observe any advantages in establishing MASEI categorizations that could be useful in clinical practice. Although the MASEI is an index designed to classify patients with spondyloarthritis, our study shows that it also allows differentiating DISH patients from healthy subjects. It would also be interesting to analyse the capacity of the MASEI to distinguish DISH from spondyloarthritis.

References

[1]Moya Alvarado P, et al. Rheumatol Int. 2020.

[2]Eder L et al. J Rheumatol. 2014; 41(3): 466-72.

This study has received a grant from the Catalan Rheumatology Society (2019)

Acknowledgements

Investigation Unit Sociedad Española de Reumatología

Catalan Rheumatology Society (Grant)

Disclosure of Interests

Teresa Clavaguera Speakers bureau: 2021 Jansen, UCB, Novartis, Marta Valls Speakers bureau: 2021 Lilly, Nordic, Maria Buxó: None declared, MANEL PUJOL BUSQUETS Speakers bureau: abbvie, pfizer, lilly, UCB, Janssen, Novartis, Georgina Salvador Alarcon Speakers bureau: Lilly, Novartis, Roche, abbvie, Sanofi, Eulàlia Armengol Speakers bureau: Novartis, Jansen, Xavier González-Giménez: None declared, Mireia Moreno Speakers bureau: Many: Novartis, MSD, Marta Arévalo: None declared, Vicenç Torrente: None declared, Lourdes Mateo: None declared, Susana Holgado: None declared, Xabier Michelena: None declared, Juan José De Agustín De Oro: None declared, Meritxell Sallés Lizarzaburu Speakers bureau: Lilly, Sanofi, Sonia Mínguez: None declared, ANDRES PONCE FERNANDEZ: None declared, Rosa Morlà: None declared, Paula Estrada: None declared, D Reina-Sanz Speakers bureau: Novartis, UCB, Patricia Moya: None declared, Hector Corominas Speakers bureau: Gebro, Abbvie, Fresenius, Judith Font Urgellés: None declared, Patricia Reyner Speakers bureau: Lilly, Sanofi, Nordic

POS0935 HIGHER 5-YEAR SURVIVAL OF CERTOLIZUMAB PEGOL IN YOUNG WOMEN WITH AXIAL SPONDYLOARTHRITIS. BIOBADASER DATA

Background

Certolizumab pegol (CZP) in women of childbearing age with rheumatoid arthritis has a more favorable response, suggesting a possible distinctive effect in this group1,2.

Objectives

To evaluate the retention rate of CZP compared to other anti-TNFs and anti-IL17A in patients affected by axSpA, grouped according to gender and age

Methods

Cross-sectional study within the BIOBADASER registry. Patients older than 17 years old, with axSpA receiving anti-TNFs or anti-IL-17A were selected. Mean and standard deviations of ASDAS-CRP and BASDAI were performed at baseline, 1st and 2nd year of treatment. Patients were classified according to treatment into groups 1) CZP, 2) anti-TNF, and 3) anti-IL17A, and according to sex and age in the following groups: 1) women between 18 and 45 years old (young), 2) women over 45 years old (old), 3) men.

Results

Groups and gender distribution, treatment prescription, ASDAS-CRP and BASDAI values according to therapeutic line and demographical characteristics are shown in Table 1. Overall, young women treated with CZP showed remission or low activity during follow-up, compared to low activity for the rest of the molecules.

Table 1.

Efficacy data (BASDAI and ASDAS-CRP values)

IndexFirst lineSecond or subsequent linesAll linesBaseline1 year2 or moreBaseline1 year2 or moreBaseline1 year2 or moreAnti-TNFFemale <45 n=240BASDAI5.6 (2.3)3.3 (2.1)3.2 (2.0)5.4 (2.5)3.7 (2.3)3.5 (2.2)5.5(2.4)3.5 (2.2)3.3 (2.1)ASDAS-CRP3.7 (1.2)2.0 (0.9)2.1 (0.9)3.2 (2.0)1.9 (1.0)1.9 (1.1)3.4 (1.7)1.9 (1.0)2.0 (1.0)Female >45 n=367BASDAI6.0 (1.9)-4.2 (2.6)5.7 (2.3)--5.8 (2.2)-4.2 (2.6)ASDAS-CRP3.9 (0.9)-1.8 (0.7)3.3 (1.2)--3.6 (1.1)-1.8 (0.7)Male n=1252BASDAI5.4 (2.1)3.1 (2.1)2.9 (1.9)5.2 (2.4)3.8 (2.5)3.3 (2.3)5.3 (2.3)3.4 (2.3)3.1 (2.1)ASDAS-CRP3.3 (1.3)1.9 (0.9)1.8 (0.9)3.0 (1.3)2.0 (1.1)2.2 (1.1)3.2 (1.3)1.9 (1.0)1.9 (1.0)CZPFemale <45 n=35BASDAI5.5 (1.6)3.0 (1.7)1.3 (1.0)5.2 (2.6)3.9 (3.1)2.9 (2.2)5.3 (2.2)3.5 (2.6)2.2 (1.9)ASDAS-CRP3.3 (0.5)1.2 (0.5)1.3 (1.1)2.6 (1.1)2.2 (1.2)1.9 (0.7)2.9 (0.9)1.8 (1.1)1.7 (0.8)Female >45 n=25BASDAI6.7 (1.6)--6.4 (1.8)--6.4 (1.8)-ASDAS-CRP---3.5 (1.1)--3.5 (1.1)-Male n=86BASDAI5.6 (2.3)3.3 (2.0)1.9 (2.0)5.3 (2.4)5.8 (1.8)3.1 (2.7)5.4 (2.3)4.5 (2.3)1.4 (2.3)ASDAS-CRP2.4 (1.4)2.2 (2.0)1.5 (0.6)3.1 (0.8)2.8 (1.4)2.1 (1.8)2.8 (1.1)2.4 (1.8)1.7 (1.2)Anti-IL17AFemale <45 n=36BASDAI6.0 (1.4)4.2 (2.0)3.8 (1.7)6.8 (2.2)4.8 (2.3)4.9 (2.6)6.5 (1.9)4.5 (2.1)4.4 (2.2)ASDAS-CRP3.6 (0.89)1.8 (0.7)1.6 (0.7)3.3 (0.8)2.0 (1.1)1.8 (0.8)3.4 (0.8)1.9 (0.9)1.7 (0.7)Female >45 n=57BASDAI6.2 (1.8)--6.3 (1.8)--6.3 (1.8)ASDAS-CRP3.7 (1.2)--3.8 (2.0)--3.8 (1.8)Male n=205BASDAI5.5 (2.2)2.9 (2.3)3.7 (2.5)5.8 (2.3)4.3 (2.2)3.6 (2.4)5.7 (2.3)3.8 (2.3)3.6 (2.4)ASDAS-CRP3.2 (0.9)1.6 (1.0)1.9 (0.8)3.4 (1.2)2.5 (1.0)2.5 (1.0)3.4 (1.1)2.1 (1.1)2.3 (1.0)

A greater survival of CZP compared to other treatment groups was observed in young women. This difference was observed since the first year of treatment (71,4 (64.2-77.4) all antiTNF, 84.4 (66.4-93.2) CZP, 72.2 (53.2-84.5) antiIL17) and the magnitude was maintained during the first 5 years of follow-up (Figure 1). In older women, a higher retention rate was observed for both CZP and anti-IL17A compared to anti-TNFs (71.6 (65.4-76.8) in all antiTNF, 78.1 (54.9-90.3) in CZP, 75.3 (61.3-84.9) in antiIL17). In males there were no long-term differences (79.2(76.3-81.8) all antiTNF, 73.0 (62.0-81.4) CZP, 64.6 (57.3-71.0) antiIL17)

Figure 1.

Five years retention rate (first line treatment)

Focussed on first line treatment, the differences were greater in young women. The second and subsequent lines showed the same trends with a lesser extend. Globally, we do not observe these differences in men.

Conclusion

These data suggest a possible specific effect of Certolizumab Pegol in women with axial spondyloarthritis, especially in young women and when used as first line treatment.

References

[1]Favalli E, et al. FRI0114. ARD 2018.

[2]Favalli EG, et al. FRI0042. ARD 2019

Acknowledgements

We would like to thank all members who participated in the BIOBADASER project.

Disclosure of Interests

None declared

POS1398 ASSOCIATION OF FUNCTIONAL SALIVARY TESTS WITH SALIVARY GLAND ULTRASOUND AND BIOPSY IN PATIENTS WITH PRIMARY SJOGREN’S SYNDROME

Background

Salivary gland ultrasonography is useful to assess salivary gland involvement in primary Sjögren Syndrome. Different publications have describes the association between decreases salivary flow and the degree of involvement with ultrasound.

Objectives

This study aims to assess the association of functional salivary tests evaluated by stimulated and unstimulated salivary flow (SSF and USF) with salivary major gland ultrasound scores (SGUS) and a positive focus score in a minor salivary gland biopsy.

Methods

A cross-sectional study including 98 subjects fulfilling the ACR-EULAR 2017 classification criteria for pSS. All patients underwent salivary functional tests, an ultrasound of salivary glands and a minor salivary gland biopsy requested as per clinical practice. The ultrasound images were graded using three different scoring systems: De Vita (0-3), Salaffi (0-4) and Omeract (0-3), obtained as the highest score achieved in the four evaluated glands, left and right parotid and submandibular. Positive biopsy was considered if focus score ≥1

Results

This study included 98 patients with pSS. We evaluated the different ultrasound scoring systems and each score individually assessed in parotid and submandibular gland with the salivary functional tests. USF is associated with all SGUS independently of the measurement, with a 2.5 ml/15min higher in negative compared to positive SGUS. Similar results were shown for SSF, with a 3 ml/5 min higher in negative compared to positive SGUS (Table 1). We observed no association between USF or SSF and a positive focus score in the minor salivary gland biopsy.

Table 1.

Association between salivary flows and ultrasound scoring systems.

Unstimulated Salivary FlowStimulated Salivary FlowUltrasound scoreGroupN(%)Means[95%CI]p-valN(%)Means[95%CI]p-valVitaN54 (55.1%)4.076[3.056, 5.096]0.00454 (55.1%)6.745[5.042, 8.447]0.011P44 (44.9%)1.839 [0.709, 2.969]44 (44.9%)3.436[1.550, 5.322]Vita ParotidN60 (61.2%)3.886[2.912, 4.861]0.00860 (61.2%)6.575 [4.961, 8.190]0.011P38 (38.8%)1.784[0.560, 3.008]38 (38.8%)3.182 [1.153, 5.210]Vita SubmandibularN55 (56.1%)4.002[2.986, 5.017]0.00755 (56.1%)6.668[4.977, 8.358]0.014P43 (43.9%)1.881[0.733, 3.030]43 (43.9%)3.458[1.546, 5.370]SalaffiN52 (53.1%)4.050 [3.005, 5.095]0.00752 (53.1%)6.754[5.015, 8.493]0.014P46 (46.9%)1.965 [0.854, 3.076]46 (46.9%)3.570[1.721, 5.419]Salaffi ParotidN58 (59.2%)3.857[2.861, 4.853]0.01658 (59.2%)6.578[4.931, 8.225]0.014P40 (40.8%)1.932 [0.733, 3.132]40 (40.8%)3.347[1.365, 5.330]Salaffi SubmandibularN54 (55.1%)4.011[2.985, 5.037]0.00754 (55.1%)6.689[4.982, 8.396]0.014P44 (44.9%)1.918[0.782, 3.054]44 (44.9%)3.505[1.614, 5.395]OmeractN56 (58.9%)3.727[2.727, 4.726]0.0156 (58.9%)6.313 [4.612, 8.014]0.043P39 (41.1%)1.854[0.656, 3.051]39 (41.1%)3.574[1.536, 5.613]Omeract ParotidN61(64.2%)3.562 [2.598, 4.526]0.04061 (64.2%)6.227[4.599, 7.854]0.036P34 (35.8%)1.874 [0.582, 3.165]34 (35.8%)3.326[1.147, 5.506]Omeract SubmandibularN57 (60.0%)3.661[2.667, 4.656]0.02857 (60.0%)6.246[4.557, 7.935]0.052P38 (40.0%)1.903[0.685, 3.120]38 (40.0%)3.603[1.534, 5.671]

N: Negative, P: Positive

Conclusion

USF and SSF are associated with SGUS system independently of the salivary gland evaluated but not with positivity in the biopsy, pointing to salivary ultrasound as a good technique to evaluate functionality. Neither USF nor SSF are associated with positivity in the biopsy indicating no link between histology and functionality.

Disclosure of Interests

None declared

Sick leave request following anti-COVID-19 vaccine administration is low among healthcare workers: results from a retrospective cross-sectional monocentric study

OBJECTIVE

Anti-COVID-19 vaccines were mainly associated with non-serious adverse events (AEs), whose prevalence was reported to be up to 70% in healthcare workers (HCWs). This may lead to sick leave requests, but this impact has never been quantified. This study aimed to investigate the absence from work among HCWs following anti-COVID-19 vaccination. Its association with age and previous COVID-19 infection was also assessed.

PATIENTS AND METHODS

This is a retrospective observational cross-sectional study on administrative data about sick leave requests after anti-COVID-19 vaccination. All the HCWs employed at the Niguarda Hospital (Milan, Italy) who received the vaccine from December 27, 2020 to February 28, 2021 were included.

RESULTS

In total, 4,088 HCWs received the first dose of the vaccine and 4,043 completed the vaccination cycle. After the first injection, 1.6% of HCWs requested sick leave, while after the second injection, the number of requests significantly increased (+6.1%, p<0.001). A significant increase in sick leave was detected for those who have had SARS-CoV-2 infection after the first injection (+2.3%, p<0.001). After the second dose, a significant increase in sick leave was observed in the 20-30-year-old group compared to >30 years (+3.6%, p=0.017), if HCWs without a history of SARS-CoV-2 infection were considered.

CONCLUSIONS

The requests for sick leave among HCWs following the anti-COVID-19 vaccine were limited and higher after the second injection. This may help the management of the human resources when the large-scale administration of the anti-COVID-19 vaccines will involve other categories of workers.

Host factors and history of SARS-CoV-2 infection impact the reactogenicity of BNT162b2 mRNA vaccine: results from a cross-sectional survey on 7,014 workers in healthcare

OBJECTIVE

This study aimed to improve the post-marketing surveillance on mRNA anti-SARS-CoV-2 vaccines, characterizing the adverse events (AEs) after the first dose of mRNA BNT162b vaccine. The associations between the AEs and individuals' characteristics were explored.

PATIENTS AND METHODS

All adult healthcare workers at Niguarda Hospital (Milan, Italy) who were referred for the first dose of vaccine were offered to participate in a cross-sectional survey during the second-dose administration, between 18 January and 7 February 2021. All participants completed a questionnaire about age, gender, weight, height, medical history, concurrent therapies, employment status, previous diagnosis/testing for SARS-CoV-2 infection, and a list of 24 AEs (solicited AEs). The development of at least one solicited AEs was the main outcome. AEs were stratified by the presence of injection-site symptoms, systemic symptoms or both, and the differences between strata were assessed as a secondary outcome. Biometric data and reports of a previous diagnosis of SARS-CoV-2 infection were also explored, as predictors of the main outcome.

RESULTS

7,014 healthcare workers were included. An incidence of 3 per 10.000 persons for serious AEs following the first administration of the mRNA BNT162b vaccine was found. An association between the development of non-serious AEs with young age, female gender, low body mass index, and previous history of SARS-CoV-2 was described.

CONCLUSIONS

This real-life study supported data on the safety profile of the BNT162b2 mRNA vaccine. Our findings on the associations between the development of non-serious AEs with some individual characteristics may help physicians and patients make educated and informed medical decisions towards anti-COVID-19 vaccination.

Microseismicity Appears to Outline Highly Coupled Regions on the Central Chile Megathrust

We compiled a novel microseismicity catalog for the Central Chile megathrust (29°-35°S), comprising 8,750 earthquakes between April 2014 and December 2018. These events describe a pattern of three trenchward open half-ellipses, consisting of a continuous, coast-parallel seismicity band at 30-45 km depth, and narrow elongated seismicity clusters that protrude to the shallow megathrust and separate largely aseismic regions along strike. To test whether these shapes could outline highly coupled regions ("asperities") on the megathrust, we invert GPS displacement data for interplate locking. The best-fit locking model does not show good correspondence to seismicity, possibly due to lacking resolution. When we prescribe high locking inside the half-ellipses, however, we obtain models with similar data fits that are preferred according to the Bayesian Information Criterion (BIC). We thus propose that seismicity on the Central Chile megathrust may outline three adjacent highly coupled regions, two of them located between the rupture areas of the 2010 Maule and the 2015 Illapel earthquakes, a segment of the Chilean margin that may be in a late interseismic stage of the seismic cycle.

Healthcare organization and management barriers and facilitators for health promotion in primary care

Background

There are challenges in translating evidence-based interventions into practice, and the need for health care organization, management, and policy changes to align with health promotion activities within the health and social care system is well-documented. This study aims to elucidate the role of these factors as barriers/facilitators influencing the implementation of an evidence-based health promotion intervention in primary care centers in the Basque Country, Spain.

Methods

Seven focus groups were conducted with 49 health professionals from 6 primary care centers participating in the Prescribing Healthy Life (PVS) program. Text was analyzed using the Consolidated Framework for Implementation Research (CFIR) focusing on those constructs related to health care organization, management, and policy.

Results

The health promotion intervention was found to be compatible with the values of primary care professionals. However, professionals at all centers reported barriers to implementation related to: (1) external policy and incentives, (2) compatibility with existing workflow, and (3) available resources to carry out the program. Specific barriers related to high caseloads, contracting issues, short consultation times, and lack of appointment times for lifestyle counselling. Other barriers/facilitators were related to CFIR constructs networks and communication, culture, relative priority, and leadership engagement. A set of nine specific barriers-facilitators emerged.

Conclusions

In some centers, certain facilitators addressed barriers identified in other centers influencing implementation of a health promotion intervention in primary care. Proactive identification and modification of barriers by healthcare managers and policy makers can help to ensure effective integration of health promotion into primary care.

Key messages

Implementation science methods for program evaluation can help identify barriers and facilitators to health promotion implementation in primary care. Policy and incentives, compatibility, available resources, networks and communication, culture, relative priority, and leadership engagement influenced successful health promotion implementation.

Quantification of Bone Marrow Edema by MRI of the Sacroiliac Joints in Patients Diagnosed with Axial Spondyloarthritis: Results from the ESPeranza Cohort

Objective: To evaluate whether the quantification of bone marrow edema (BMO) of the sacroiliac (SI) joints by magnetic resonance imaging (MRI) improves capacity for axial spondyloarthritis (axSpA) classification in comparison with the assessment of sacroiliitis by Assessment of SpondyloArthritis international Society (ASAS) classification criteria.Method: This prospective study from the ESPeranza cohort involved 66 subjects with an available MRI of the SI joints at baseline. This subgroup includes patients with axSpA (n = 28), peripheral spondyloarthritis (n = 10), and other diagnoses that were not spondyloarthritis (n = 28). Measures of diagnostic usefulness [area under the curve (AUC), sensitivity, specificity, Youden's J statistic, positive and negative likelihood ratios (LR+ and LR-)] were calculated for MRI of the SI joints according to ASAS criteria and for MRI quantified by means of SCAISS (Spanish tool for semi-automatic quantification of sacroiliac inflammation by MRI in spondyloarthritis). This analysis was stratified in patients who were human leucocyte antigen (HLA)-B27 positive and negative.Results: The AUC value with BMO quantification was 0.919 [95% confidence interval (CI) 0.799-1] for HLA-B27-positive patients and 0.884 (95% CI 0.764-1) for HLA-B27-negative patients. A SCAISS cut-off point of 80 units obtained a specificity of 94.4% and LR+ 7.5, while assessment by ASAS criteria showed a specificity value of 90% and LR+ 6.4.Conclusion: For patients with suspected axSpA, quantification of BMO improves the predictive capacity of MRI of the SI joints, for both HLA-B27-positive and HLA-B27-negative patients.Axial spondyloarthritis (axSpA) has a dramatic impact on physical function and quality of life (1). Despite its significant impact, patients with axSpA are normally diagnosed several years after presenting symptoms (2). In this respect, magnetic resonance imaging (MRI) of the sacroiliac (SI) joints has gained significance over the past decade, particularly in the early stages of the disease. Nowadays, imaging tests and human leucocyte antigen (HLA)-B27 testing are among the most important diagnostic procedures for patients with suspected axSpA.

Baseline 18F-FDG PET/CT quantitative parameters as prognostic factors in esophageal squamous cell cancer

AIM

To determine the utility of [¹⁸F]FDG PET/CT quantitative parameters as prognostic factors for the response to neoadjuvant treatment, progression-free survival (PFS) and cancer-specific survival (CSS) in patients with esophageal squamous cell carcinoma (SCC).

MATERIAL AND METHODS

Thirty patients (29 men) diagnosed with SCC were retrospectively evaluated over a 6-year interval. Metabolic parameters were determined: maximum SUV (SUVmax), mean SUV (SUVmed), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) from baseline PET/CT study. After treatment with chemotherapy and/or radiotherapy, response to treatment and patient survival were assessed. The comparison of parameters between groups of responders and non-responders was carried out using a Mann-Whitney U test ROC curves and the Kaplan-Meier method were used for analysis of prognostic factors and survival curves.

RESULTS

The average follow-up was 22.4 months, with 22 recurrence-progressions and 25 deaths. Significant differences were demonstrated between responders and non-responders with respect to tumor size, MTV and TLG. Survival analysis found significant differences for SCE and CSS depending on these three parameters.

CONCLUSION

Metabolic parameters MTV and TLG, and tumor size were prognostic factors for neoadjuvant treatment response, PFS, and CSS in patients diagnosed with SCC. Neither SUVmax nor SUVmed were predictive for any of the evaluation criteria. Results could help to personalize patient treatment.

Thoracoscopic management of congenital esophageal stenosis secondary to tracheobronchial remnant in pediatric patients

INTRODUCTION

Congenital esophageal stenosis (CES) is an extremely rare pathology in children, with an incidence of 1/25,000-50,000 live births. According to its histopathological classification, there are three types of CES: fibromuscular hyperplasia, membranous diaphragm, and tracheobronchial remnants.

CLINICAL CASE

We present the clinical case of a 39-month-old male patient diagnosed with CES secondary to tracheobronchial remnants, with multiple vomit and reflux episodes since he was 4 months old. He was admitted at the emergency department with respiratory distress. An upper GI endoscopy and an esophagogram were initially carried out. Stenosis resection and thoracoscopic esophageal anastomosis were performed.

CONCLUSIONS

Tracheobronchial remnants are the second most common presentation of congenital esophageal stenosis. They can be managed through dilatations or surgery according to etiology.

Baseline 18F-FDG PET/CT quantitative parameters as prognostic factors in esophageal squamous cell cancer

AIM

To determine the utility of 18F-FDG PET/CT quantitative parameters as prognostic factors for the response to neoadjuvant treatment, progression-free survival (PFS) and cancer-specific survival (CSS) in patients with esophageal squamous cell carcinoma (SCC).

MATERIAL AND METHODS

Thirty patients (29 men) diagnosed with SCC were retrospectively evaluated over a 6-year interval. Metabolic parameters were determined: maximum SUV (SUVmax), mean SUV (SUVmed), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) from baseline PET/CT study. After treatment with chemotherapy and/or radiotherapy, response to treatment and patient survival were assessed. The comparison of parameters between groups of responders and non-responders was carried out using a Mann-Whitney U test. ROC curves and the Kaplan-Meier method were used for analysis of prognostic factors and survival curves.

RESULTS

The average follow-up was 22.4months, with 22 recurrence-progressions and 25 deads. Significant differences were demonstrated between responders and non-responders with respect to tumor size, MTV and TLG. Survival analysis found significant differences for SCE and CSS depending on these three parameters.

CONCLUSION

Metabolic parameters MTV and TLG, and tumor size were prognostic factors for neoadjuvant treatment response, PFS, and CSS in patients diagnosed with SCC. Neither SUVmax nor SUVmed were predictive for any of the evaluation criteria. Results could help to personalize patient treatment.

POS0996 SIX-YEAR RESULTS FROM THE ESPERANZA COHORT: EVALUATION OF CLINICAL FEATURES, DISEASE ACTIVITY MEASURES AND TREATMENT ASPECTS IN AXIAL AND PERIPHERAL EARLY SPONDYLOARTHRITIS

Background:

Esperanza was a multicenter national health program developed to facilitate an early diagnosis of patients with Spondyloarthritis (SpA) in Spain.

Objectives:

To compare the clinical evolution of patients with axial SpA (axSpA) and peripheral SpA (pSpA) included in this program.

Methods:

Patients from the Esperanza cohort fulfilling ASAS criteria for axSpA or pSpA and completed the 6-year follow-up were included. Patients were classified according to the predominant symptom. In case of having axSpA and pSpA, they were classified as axSpA. Clinical features, disease activity and treatment aspects at baseline and 6-year visit were evaluated.

Results:

From 775 patients recruited at baseline, 6-year follow-up data from 178 (83.5%) fulfilling ASAS criteria at the final visit were available: 133 (74.7%) for axSpA and 45 for pSpA (25.3%). 118 (66.3%) were males (50.6% with axSpA and 62.2%, pSpA, p=0.4). Patients with axSpA had more frequently positive HLA-B27 (90.5%) vs. (9.5%), p<0.001. Follow-up clinical features are shown in Table 1. At the final visit, both axSpA and pSpA presented an improvement in clinical symptoms, disease activity (CRP, BASDAI, ASDAS and VAS-pt) and quality of life (ASQoL). A worsening of mobility (BASMI) was observed in both groups. The prevalence of uveitis, psoriasis and inflammatory bowel disease (IBD) at baseline was 10.7%, 18% and 5.6%, respectively. At the 6-year visit, the cumulative prevalence (CP) was 14% for uveitis (16.5% in axSpA and 6.7% in pSpA), 22.5% for psoriasis (12.8% in axSpA and 51.1% in pSpA) and 7.9% for IBD (5.3% in axSpA and 15.6% in pSpA). Most of the patients were prescribed NSAIDS at baseline and more patients maintained this treatment at the 6-year visit in axSpA compared with pSpA (96.9% vs 87.5%, p=0.02). At the final visit, a higher percentage with pSpA received csDMARDs in comparison with axSpA (81% vs. 35.7%, p<0.001). Sixty (44.4%) patients received biologic therapy at the final visit and no differences were observed in their prescription: 43% in axSpA and 48.6% in pSpA(p=0.6).

Conclusion:

The early diagnosis of recent-onset SpA achieves a significant improvement in clinical features, disease activity and quality of life in patients with axSpA and pSpA after 6 years of follow-up. Although previous publications revealed a low radiographic progression in this cohort1, the worsening of BASMI must aware clinicians of possible evolutive structural damage.

Reference:

[1]Fernández-Carballido et al. RMD Open. 2020 Sep;6(2):e001345

Acknowledgements:

The Spanish Foundation of Rheumatology received funding from Pfizer (formerly Wyeth) to develop the Esperanza Program. Later, the Program has been supported by restricted grants from the Instituto de Salud Carlos III and Fondos FEDER (FIS PI13/02034 and PI17/01840) and AbbVie.

Disclosure of Interests:

Carolina Tornero: None declared, Victoria Navarro-Compán: None declared, Beatriz Joven-Ibáñez: None declared, RAQUEL ALMODOVAR: None declared, Xavier Juanola-Roura: None declared, Cristina Fernández-Carballido: None declared, Juan Carlos Quevedo-Abeledo: None declared, Jose Rosas: None declared, Azucena Hernández: None declared, Carlos A. Montilla-Morales: None declared, Jose Ramón Maneiro: None declared, A. Juan-Mas: None declared, Jose Antonio Pinto Tasende: None declared, Mireia Moreno: None declared, Jesus Sanz: None declared, Teresa Ruiz Jimeno: None declared, Manuel Moreno: None declared, María Lourdes Ladehesa Pineda: None declared, Eugenio de Miguel Speakers bureau: AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi., Paid instructor for: Janssen, Novartis, Roche, Consultant of: AbbVie, Novartis, Pfizer, Galapagos, Grant/research support from: Abbvie, Novartis, Pfizer.

POS0242 ROLE OF HLA-B27 CARRIERSHIP IN PERIPHERAL SPONDYLOARTHRITIS: DATA FROM ASAS PERSPA STUDY

Background:

HLA-B27 is well known for its role in conferring susceptibility to spondyloarthritis (SpA), and several studies evaluating its association to axial SpA phenotype have been published. However, there is few evidence about its influence in patients affected with peripheral SpA (pSpA). In this sense we find ASAS perSpA registry suitable for this purpose.

Objectives:

To identify phenotypical differences in pSpA patients regarding HLA-B27 status.

Methods:

Data from all patients fulfilling ASAS pSpA criteria with HLA-B27-testing result available included in the ASAS perSpA study were used for this analysis. Socio-demographic and disease characteristics were collected. A descriptive and comparative analysis was performed between HLA-B27 positive and negative patients, using a simple logistic regression for all variables to assess their association to HLA-B27 positivity. Results were considered significant when p <0.05. A multivariate model was also performed including significant (p<0.1) and the most relevant clinical variables in agreement of medical criteria.

Results:

Among the 4465 patients included in the registry, 555 fulfilled ASAS pSpA criteria and of them 286 had the HLA-B27 typing available. HLA-B27 was positive in 118 (41.3%) and negative in 168 (58.7%). Results are listed in Table 1. No differences were observed for gender distribution (males 55.1% in HLA-B27 positive vs 49.4% in HLA-B27 negatives). HLA-B27 positive patients were significantly younger, presented a younger disease onset, had significantly higher prior axial involvement, radiographic sacroiliitis and higher root joint involvement. On the other hand, HLA-B27 negative patients showed longer disease duration with a higher diagnosis delay. Around half of the patients in both groups showed a mono or oligoarticular pattern without differences regarding HLA-B27 status, however, psoriatic arthritis (PsA) and peripheral joint damage was significantly higher in HLA-B27 negative patients. Also psoriasis and inflammatory bowel disease (IBD) were more frequent in HLA-B27 negative patients compared to positive ones, and acute anterior uveitis (AAU) was significantly more frequent in HLA-B27 positive patients without differences in number of AAU episodes lifelong. Finally, obesity and concomitant fibromyalgia were both more common in HLA-B27 negatives. No significant differences were found for the rest of variables evaluated.

Table 1.HLA-B27+ (N = 118)HLA-B27- (N = 168)N/mean%/SDN/mean%/SDpObesity (BMI >30)1411,9%4426,3%0,003Men6555,1%8349,4%0,344Family history4437,3%5231,0%0,265Axial involvement6252,5%4225,0%<0.001Radiographic sacroilitis3028,3%2516,8%0,029Psoriathic arthritis2319,5%11272,6%<0.001Reactive arthritis54,2%31,8%0,229IBD arthritis10,9%84,8%0,098Mono/oligoarticular pattern5954,6%7651,0%0,566Root joint involvement5244,1%5432,1%0,04Tarsitis2218,6%169,5%0,028Enthesitis6252,5%6941,1%0,056Dactylitis3126,3%5130,4%0,452Peripheral structural damage97,6%4124,4%<0.001Psoriasis2117,8%12574,4%<0.001AAU2117,8%74,2%<0.001IBD21,7%137,7%0,039Fibromyalgia1513,2%4326,7%0,008Age (y)42,714,852,213,4<0.001Age onset (y)33,913,738,314,50,013Dx delay (m)4,78,27,79,80,009Disease duration (y)9,0610,214,211,6<0.001BASDAI3,92,24,42,40,06CRP16,925,11227,30,148ASDAS-CRP2,71,22,71,10,876AAU number of episodes6,88,42,11,70,265

In the multivariate analysis, age at disease onset (OR 0.96, CI95% 0.94-0.98), disease duration (OR 0.96, CI95% 0.92-0.99), PsA (OR 0.28, CI95% 0.09-0.85), presence of psoriasis (OR 0.22, CI95% 0.07-0.64), IBD related arthritis (OR 0.03, CI95% 0.01-0.19), AAU (OR 3.63, CI95% 1.22-11.9) and tarsitis (OR 2.61, CI95% 1.01-6.98) were the most important variables independently associated to HLA-B27 status.

Conclusion:

Presence of HLA-B27 in pSpA patients was associated to a higher axial and root joint involvement, an earlier disease onset and presence of AAU, but not to PsA, psoriasis and IBD that were higher in HLA-B27 negative patients.

Disclosure of Interests:

Marta Arévalo Speakers bureau: Abbvie, Nordic Pharma, Clementina López-Medina: None declared, Victoria Navarro-Compán: None declared, Mireia Moreno Speakers bureau: Abbvie, Novartis, UCB, Bristol and AMGEN, María LLop Vilaltella Speakers bureau: Novartis, Joan Calvet: None declared, Jordi Gratacos-Masmitja Speakers bureau: During the course of the year, I have received funding for courses and conferences or as an advisor and speaker from MSD, Pfizer, AbbVie, Janssen Cilag, Novartis, Celgene, and Lilly., Maxime Dougados: None declared

OP0123 SAFETY PROFILE OF JAK-INHIBITORS VERSUS TNF-INHIBITORS IN REAL-WORLD CLINICAL PRACTICE: DATA FROM A MULTICENTER REGISTER

Background:

JAK-inhibitors (JAKi) are small molecules emerging as a promising treatment for immune mediated diseases. Data from clinical trials are very promising. But long-term observational studies, with patients with diverse clinical backgrounds are required to confirm safety profile.

Objectives:

To compare the safety profile of JAKi versus TNF antagonists (anti-TNF) in a multicenter real world dataset.

Methods:

Data of patients enrolled in BIOBADASER 3.0 up to November 2020 with the start of anti-TNF or JAKi were analysed. Adverse events (AE) were classified according to Meddra dictionary (v19.0). For each group, demographic, clinical variables and ncidence rate ratios of AE per 1000 patients-year (PYs) and 95% confidence interval were estimated.

Results:

A total of 3,729 patients on anti-TNF (5,306) or JAKi (493) were analyzed. Patients on JAKi were older and with a mean disease duration of 10 years. JAKi were prescribed as first line treatment only in 24% of patients. The main reason of stopping treatment was ineffectiveness (53-59%) followed by adverse events (25-34%) in both groups. Survival during first year was similar between groups.

Table 1.

Patient characteristics and adverse events by treatment group

Anti-TNFJAKiMean age start of treatment (SD), yrs50.8 (12.6)57.6 (11.9)Female, n (%)3122 (58.8)392 (79.5)Disease duration, median (IQR)7.0 (2.7-13.7)9.9 (4.9-16.8)First line biologic, n (%)2614 (49.3)117 (23.7)Rheumatoid Arthritis1385 (41.1)339 (95.2)Ankylsosing Spondylitis1031 (30.6)1 (0.3)Psoriatic Arthritis957 (28.4)16 (4.5)DAS28-ESR4.3 (1.4)4.7 (1.4)Survival first year (IC 95%)73.3 (71.9-74.6)69.7 (66.0-73.0)Charlson Index, mean (SD)1.9 (1.3)2.3 (1.6)Reason to stop therapy (n)*: Lack of efficacy1534 (53.2)57 (58.8) Adverse event723 (25.1)33 (34.0)Adverse events (AE)*Serious infections14.2 (12.4-16.2)33.2 (19.3-57.3)Herpes zoster5.7 (4.6-7.1)12.8 (5.3-30.7)Tuberculosis0.7 (0.4-1.3)0.0 (0.0-0.0)Malignancy/Neoplasia10.2 (8.7-11.9)15.3 (6.9-34.2)Cardiac events13.9 (12.2-16.0)30.7 (17.4-54.0)GI perforation1.2 (0.8-1.9)10.2 (3.8-27.3)Vascular events9.8 (8.3-11.5)25.6 (13.8-47.5)

*Data show the incidence rate ratio per 1000 patient-years (PYs; 95% CI)

Conclusion:

Serious infections and herpes zoster tend to be more frequent in patients on JAKi. However patients on JAKi were older, presented higher comorbidity and have a longer disease duration.

Disclosure of Interests:

None declared

An uncommon case of vulvar cancer metastatic to breast

Vulvar carcinoma corresponds to the fourth gynecological malignancy in incidence, with more than forty thousand new cases being estimated worldwide in 2020. It is a disease characterized by locoregional spread presenting high recurrence rates although distant metastases are an uncommon event. The purpose of this work is to describe the diagnosis, treatment, and clinical course of vulvar carcinoma in a patient who presented regional recurrences and late metastasis to the mammary gland. Vulvar cancer is a disease with a well-defined natural history; but with the advancement of therapeutic possibilities in recent years, it has been possible to improve the prognosis, reducing the chance of locoregional recurrence. Thus, the possibility of distance recurrence must be remembered in inpatient follow-up with locally advanced vulvar carcinoma, even if atypically, as in the case reported.

Key Role of Deep Orbitals in the dx2-y2-d3z2-r2 Gap in Tetragonal Complexes and 10Dq

Using first-principles calculations, we show that the origin of the intrinsic a_1g(∼3z² – r²)–b_1g(∼x² – y²) splitting, Δ_int, in tetragonal transition-metal complexes and the variations of the cubic field splitting, 10Dq, with the metal–ligand distance, R, are much more subtle than commonly thought. As a main novelty, the key role played by covalent bonding with deep valence ligand levels and thus the inadequacy of too simple models often used for the present goal is stressed. Taking as a guide the isolated D_4h CuF₆^4– complex, it is proved that Δ_int essentially arises from bonding with deep 2s(F) orbitals despite them lying ∼23 eV below 2p(F) orbitals. This conclusion, although surprising, is also supported by results on octahedral fluoride complexes where the contribution to 10Dq splitting from bonding with 2s(F) orbitals is behind its strong R dependence, stressing that explanations based on the crystal-field approach are simply meaningless.

Dietary tryptophan depletion alters the faecal bacterial community structure of compulsive drinker rats in schedule-induced polydipsia

RATIONALE

Compulsive behaviour, present in different psychiatric disorders such as obsessive-compulsive disorder, schizophrenia and drug abuse, is associated with altered levels of serotonin (5-hydroxytryptamine, 5-HT). The gut microbiota regulates tryptophan (TRP) metabolism and may affect global 5-H synthesis in the enteric and central nervous systems, suggesting a possible involvement of gut microbiota in compulsive spectrum disorders.

OBJECTIVES

The present study investigated whether chronic TRP depletion by diet alters the faecal bacterial community profiles of compulsive versus non-compulsive rats in schedule-induced polydipsia (SIP). Peripheral plasma 5-HT and brain-derived neurotrophic factor (BDNF) levels were evaluated.

METHODS

Wistar rats were selected as High Drinkers (HD) or Low Drinkers (LD) according to their SIP behaviour and were fed for 14 days with either a TRP-free diet (T-) or a TRP-supplemented diet (T+). The faecal bacterial community structure was investigated with 16S rRNA gene-targeted denaturing gradient gel electrophoresis (DGGE) fingerprinting analysis.

RESULTS

Compulsive HD rats showed a lower bacterial diversity than LD rats, irrespectively of the diet. The TRP-depleted HD rats, the only group increasing compulsive licking in SIP, showed a reduction of bacterial evenness and a highly functionally organized community compared with the other groups, indicating that this bacterial community is more fragile to external changes due to the dominance of a low number of species. The chronic TRP depletion by diet effectively reduced peripheral plasma 5-HT levels in both HD and LD rats, while plasma BDNF levels were not altered.

CONCLUSIONS

These results highlight the possible implication of reduced microbial diversity in compulsive behaviour and the involvement of the serotonergic system in modulating the gut brain-axis in compulsive spectrum disorders.

18F-FDG PET/CT quantitative parameters as prognostic factor in localized and inoperable lung cancer

AIM

To assess the utility of ¹⁸F-FDG PET/CT quantitative parameters as prognostic factor in patients diagnosed with localized and inoperable lung cancer treated by stereotactic body radiotherapy (SBRT).

MATERIAL AND METHODS

Fifty patients (42 men) diagnosed in the last 7years with early-stage lung cancer and treated with SBRT alone were assessed by a prospective study. After PET/CT study, metabolic parameters maximum SUV (SUVmax), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were determined at different thresholds. The prognostic factors for overall survival (OS), cause-specific survival (CS) and disease-free survival (DFS) were analysed by Cox proportional hazards model and the survival analysis by Kaplan-Meier method.

RESULTS

The average follow-up was 39.6months, with 21 recurrences and 24 dead. Univariate analysis determined MTV₃₀ and MTV₄₀ as predictors for OS; MTV₃₀, MTV₄₀, TLG₃₀ and TLG₄₀ for CS, and MTV₂, MTV₃₀, MTV₄₀, TLG₂, TLG₃₀ and TLG₄₀ for DFS. Survival analysis found statistically significant differences for CS and DFS depending on tumor size and for DFS considering the cut-off values of MTV₂ and TLG₂ (threshold SUVmax=2). SUVmax, age and sex were not shown to be significant factors.

CONCLUSION

Pre-treatment quantitative assessment using metabolic parameters MTV₂ and TLG₂ as well as tumor size proved to be prognostic factors in patients diagnosed with localized and inoperable lung cancer treated by SBRT. Results could help to personalize treatment.

AB0700 RADIOGRAPHIC PROGRESSION IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS UNDER TREATMENT WITH TNF INHIBITORS. DATA FROM REGISPONSERBIO (SPANISH REGISTER OF BIOLOGICAL THERAPY IN SPONDYLOARTHRITIDES)

Background:

Clinical efficacy of TNF inhibitors (TNFi) in axial spondyloarthritis (axSpA) has been widely probed in randomized control trials. In clinical practice, some studies suggested that long-term (more than 4 years) treatment with TNFi could slow down radiographic progression in axSpA; however, whether this treatment inhibits structural damage remains unclear.

Objectives:

To evaluate radiographic progression in axSpA patients receiving long-term TNFi (over 4 years) in comparison with patients starting TNFi.

Methods:

A total of 204 patients with axSpA were included in the Spanish Register of Biological Therapy in Spondyloarthritides (REGISPONSERBIO). Out of these, 80 patients (31 starting TNFi and 49 under long-term TNFi) were included in this study based on the availability of spinal radiographs (cervical and lumbar lateral views), at two time points. Radiographs in patients starting TNFi were available: i) at baseline (before TNFi) and ii) after 3 to 5 years of TNFi therapy (mean follow-up 3.7±0.8), while in long-term TNFi patients, these were available: i) at one follow-up visit at least 4 years later since TNFi was started and ii) after 3 to 5 years of this visit (mean follow-up 3.5±1.1). Two trained readers, not blinded for chronological order, independently scored lateral cervical and lumbar spine images according to the mSASSS system (0-72). Following definitions for progression were used: change of the absolute scores, change of ≥2 units, development of new syndesmophytes, and development of new syndesmophytes or growth of the existing syndesmophytes.

Results:

Reliability of both readers was excellent with intraclass correlation coefficients (ICCs) of 0.98 (0.98-0.99) at inclusion and 0.98 (0.97-0.99) at follow-up. Most patients (82.5%) were classified as radiographic axSpA. Mean BASDAI at first visit (i) was of 5.0±2.4 for starting TNFi patients and of 3.2±1.9 for long-term TNFi patients. The table depicted the results for radiographic scores and progression. Mean mSASSS score at first visit (i) was 15.8±21.5 and 15.1±18.4 units for starting TNFi and long-term TNFi patients, respectively. The change score between both visits was 2.3±4.2 and 2.3±4.1, respectively. Similarly, no differences were found for change of ≥2 points (32.3% in starting TNFi and 35% in long-term TNFi patients). However, development of new syndesmophytes or growth of the existing syndesmophytes were found to be more frequently (but not significant) in starting TNFi patients compare to long-term TNFi patients.

Conclusion:

In patients with axSpA treated with TNFi in clinical practice radiographic progression is observed, independently of the time under this therapy. Nevertheless, the development and growth of syndesmophytes seem to be lower in long-term treated patients.

Table.Starting TNFi patientsLong-term TNFi patients*p-valuePresence of syndesmophytes at first visit, % (n)45.2% (14)53.1% (26)NSPresence of syndesmophytes at follow up, %51.6% (16)55.1% (27)NSMean change score, mean ± SD2.32 ± 4.192.26 ± 4.09NSChange of ≥ 2 units in the score % (n)32.3% (10)34.7% (17)NSDevelopment of new syndesmophytes, % (n)29% (9)18.4% (9)0.3Progression or development of new syndesmopyhtes % (n)29% (9)22.4% (11)0.5

* Patients with more than 4 years under TNFi treatment

Disclosure of Interests:

María LLop Vilaltella Speakers bureau: Janssen and Pfizer, Mireia Moreno: None declared, Jordi Gratacos-Masmitja Grant/research support from: a grant from Pfizzer to study implementation of multidisciplinary units to manage PSA in SPAIN, Consultant of: Pfizzer, MSD, ABBVIE, Janssen, Amgen, BMS, Novartis, Lilly, Speakers bureau: Pfizzer, MSD, ABBVIE, Janssen, Amgen, BMS, Novartis, Lilly, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB, Eugenio de Miguel Grant/research support from: Yes (Abbvie, Novartis, Pfizer), Consultant of: Yes (Abbvie, Novartis, Pfizer), Paid instructor for: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Speakers bureau: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Font Ugalde Pilar: None declared, Teresa Clavaguera Speakers bureau: novartis, BMS, Faes, Luis F. Linares Ferrando: None declared, Beatriz Joven-Ibáñez Speakers bureau: Abbvie, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Xavier Juanola-Roura: None declared

SAT0075 ABATACEPT IN COMBINATION WITH METOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS ASSOCIATED TO INTERSTITIAL LUNG DISEASE: NATIONAL MULTICENTER STUDY OF 263 PATIENTS

Background:

Interstitial Lung Disease (ILD) is an extra-articular complication of rheumatoid arthritis (RA) that is associated with increased morbidity and mortality. Conventional disease-modifying drugs (DMARDs) such as methotrexate (MTX) have been implicated in the development and exacerbation of a pre-existing ILD.

Objectives:

The aim of our study was to check the influence of combined MTX treatment in patients with RA-ILD treated with abatacept (ABA).

Methods:

National multicentre retrospective registry of 263 patients with RA-ILD treated with ABA. RA was diagnosed according to the ACR classification criteria of 1987 or by the EULAR/ACR criteria of 2010. ILD was diagnosed by high resolution computed tomography (HRCT). In this study we have done a subanalysis of the 46 patients treated with ABA in combination with MTX (ABA+MTX) vs. 217 patients treated with ABA in monotherapy or in combination with other synthetic DMARDs. Efficacy was evaluated according to the following parameters: a) Dyspnoea (MMRC) considering variations ≥ 1; b) Lung function test (LFT) considering variations ≥ 10% in FVC and a variation of DLCO ≥ 10%; c) Imaging test (HRCT) d) DAS28 score e) prednisone dose. Variables were collected at the beginning of the study and at months 3, 6, 12 and then every 12 months until a maximum of 60 months.

Results:

263 patients with ILD associated with RA were included in the study with mean age 64.64±10 years. RF or CCPA were positive in 235 (89.4%) and 233 (88.6%) cases, respectively, with a mean follow-up of 22.7±19.7 months. Baseline characteristics of both groups are shown in table 1, while data obtained during evolution of this complication are presented in Figure 1.

Conclusion:

Despite the baseline differences of both groups, the good evolution in the ABA+MTX subgroup suggests that this therapeutic strategy can be a safe combination for patients with RA-ILD.

ABA with MTX (n=46)ABA w/t MTX (n=217)PSex (F/M)28/18122/950.625Age (years)65.11±10.216.2±9.80.202RF/CCPA + (%)91.3/91.389.8/90.10.810Smoking or past smoking (%)47.855.10.417Follow-up (months)22.73±18.0022.3±20.850.916DAS28 at baseline4.08±1.514.61±1.470.056DAS28 at last visit3.00±1.463.13±1.310.642Prednisone at baseline, median (IQR) (mg)5 (5-7.5)7.75 (5-15)0.008*Prednisone at the end of study, median (IQR) (mg)5 (1-5)5 (5-7.5)0.032*DLCO at baseline (%)66.85±19.0465.43±18.210.823DLCO at the end of study (%)66.05±20.9565.17±19.720.831FVC at baseline (%)90.06±17.7785.40±21.560.164FVC at the end of study (%)90.58±15,4584.21±21.490.038*

Disclosure of Interests:

Carlos Fernández-Díaz Speakers bureau: Brystol Meyers Squibb, Santos Castañeda: None declared, Rafael Melero: None declared, J. Loricera: None declared, Francisco Ortiz-Sanjuán: None declared, A. Juan-Mas: None declared, Carmen Carrasco-Cubero Speakers bureau: Janssen, MSD, AbbVie, Novartis, Bristol Myers Squibb, and Celgene, S, Rodriguéz-Muguruza: None declared, S. Rodrigez -Garcia: None declared, R. Castellanos-Moreira: None declared, RAQUEL ALMODOVAR Speakers bureau: Abbvie, Celgene, Janssen, Lilly, Novartis, Pfizer.

, CLARA AGUILERA CROS: None declared, Ignacio Villa-Blanco Consultant of: UCB, Speakers bureau: Novartis, MSD, Lilly, Sergi Ordoñez: None declared, Susana Romero-Yuste: None declared, C. Ojeda-Garcia: None declared, Manuel Moreno: None declared, Gemma Bonilla: None declared, I. Hernández-Rodriguez: None declared, Mireia Lopez Corbeto: None declared, José Luis Andréu Sánchez: None declared, Trinidad Pérez Sandoval: None declared, Alejandra López Robles: None declared, Patricia Carreira Grant/research support from: Actelion, Roche, MSD, Consultant of: GlaxoSmithKline, VivaCell Biotechnology, Emerald Health Pharmaceuticals, Boehringer Ingelheim, Roche, Speakers bureau: Actelion, GlaxoSmithKline, Roche, Natalia Mena-Vázquez: None declared, C. Peralta-Ginés: None declared, ANA URRUTICOECHEA-ARANA: None declared, Luis Marcelino Arboleya Rodríguez: None declared, J. Narváez: None declared, DESEADA PALMA SANCHEZ: None declared, Olga Maiz-Alonso: None declared, J. Fernández-Leroy: None declared, I. Cabezas-Rodriguez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, A. Ruibal-Escribano: None declared, JR De Dios-Jiménez Aberásturi: None declared, Paloma Vela-Casasempere: None declared, C. González-Montagut Gómez: None declared, J M Blanco: None declared, Noelia Alvarez-Rivas: None declared, N. Del-Val: None declared, M. Rodíguez-Gómez: None declared, Eva Salgado-Pérez: None declared, Carlos Fernández-López: None declared, E.C. Cervantes Pérez: None declared, A. Devicente-DelMas: None declared, Blanca Garcia-Magallon Consultant of: MSD, Speakers bureau: Pfizer, Amgen, Celgene, MSD, Cristina Hidalgo: None declared, Sabela Fernández: None declared, Edilia García-Fernández: None declared, R. López-Sánchez: None declared, S. Castro: None declared, P. Morales-Garrido: None declared, Andrea García-Valle: None declared, Rosa Expósito: None declared, L. Exposito-Perez: None declared, Lorena Pérez Albaladejo: None declared, Ángel García-Aparicio: None declared, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD

SAT0387 ROLE OF HLA-B27 IN THE COMORBIDITIES OBSERVED IN AXIAL SPONDYLOARTHRITIS: DATA FROM COMOSPA

Background:

Comorbidities have merged as an important field in Spondyloarthritis, however there is few data about its relationship to genetic factors such as HLA-B27.

Objectives:

To analyze the potential association between the presence of HLA-B27 and the different comorbidities observed in axSpA patients.

Methods:

A comparative cross-sectional study including axSpA patients from COMOSPA registry. COMOSPA is a worldwide registry that includes a wide set of anthropometric and clinical variables from 3984 patients with spondyloarthritis. The registry also includes the most frequent comorbidities observed in spondyloarthitis such as obesity, hypertension, diabetes, hyperlipidemia, heart ischemic disease, stroke, renal failure, neoplasms, peptic ulcer, diverticulitis, chronic obstructive pulmonary disease, and the presence of osteoporosis. A descriptive analysis and a multiple logistic regression model was performed including all variables assessed.

Results:

2370 patients fulfilled ASAS criteria of axSpA patients and were included in the study. 1858 (78.4%) of them were HLA-B27 positive. HLA-B27 positive axSpA patients presented significantly higher percentage of male sex, longer disease duration, higher percentage of definite Ankylosing Spondylitis, higher CRP levels, and were also more frequent tobacco consumers and excessive alcohol intakers compared to the negatives. However, disease activity measured by BASDAI, BASFI and ASDAS-CRP were all significantly higher in the HLA-B27 negative patients compared to the positive ones.

The only association observed between any comorbidity and presence of gen HLA-B27 was the presence of osteoporosis. This association was independently significant even after adjusting in the multivariate analysis for all variables assessed.

Conclusion:

The association observed between the gen HLA-B27 and the presence of osteoporosis in axSpA patients could be of great relevance given the impact of osteoporosis in the phenotypical frame of axSpA patients.

Disclosure of Interests:

Marta Arévalo: None declared, Clementina López-Medina: None declared, Mireia Moreno: None declared, Anna Moltó Grant/research support from: Pfizer, UCB, Consultant of: Abbvie, BMS, MSD, Novartis, Pfizer, UCB, Font Ugalde Pilar: None declared, Eduardo Collantes-Estévez Grant/research support from: ROCHE and Pfizer., Speakers bureau: ROCHE, Lilly, Bristol and Celgene., Jordi Gratacos-Masmitja Grant/research support from: a grant from Pfizzer to study implementation of multidisciplinary units to manage PSA in SPAIN, Consultant of: Pfizzer, MSD, ABBVIE, Janssen, Amgen, BMS, Novartis, Lilly, Speakers bureau: Pfizzer, MSD, ABBVIE, Janssen, Amgen, BMS, Novartis, Lilly

AB0655 IMPACT OF BIOLOGIC THERAPY ON WORK IMPAIRMENT IN REAL LIFE IN AXIAL SPONDYLOARTHRITIS PATIENTS: DATA FROM REGISPONSERBIO

Background:

Biologic therapy (BT) has demonstrated its effect in improving work impairment in axial Spondyloarthritis (axSpA) patients in clinical trials, however there is few data of these effects in clinical practice.

Objectives:

-To assess the influence of BT in work status using the WPAI questionnaire in patients with axSpA in real life.

-To compare work status between incident and prevalent cases with BT.

-To evaluate factors related to changes in work status in these patients.

Methods:

REGISPONSERBIO is an observational, prospective and multicentric Spanish registry of SpA patients under biologic treatment recruited between September 2013 and December 2014. The study includes demographic, radiologic and disease data from both incident (starting biological therapy at the inclusion) and prevalent (already under biologic therapy at the inclusion) patients. WPAI (Work Productivity and Activity Impairment) questionnaire was used to assess work status (employment, lost hours, absenteeism and presenteeism) in both groups of patients at six months after study inclusion. Patients more than 65 years old who were not working were excluded from the analysis, as no changes in work impairment are expected in these individuals.

A descriptive study of work status and related factors was performed using mean and standard deviation as appropriate. Work status was compared between both time-points in incidents and between incidents and prevalents. Uni and multivariate analysis for factors related to baseline work status were assessed, and correlation for change at six months.

Results:

The study included 75 incident and 134 prevalent axSpA patients. After start of BT, incident patients presented an increase in the number of patients who affirmed to be actively working and an improvement in absenteeism, lost hours and presenteeism, however statistical significance was only reached in the number of hours lost. Comparing incident and prevalent cases, incident patients showed worse data on work status compared to prevalent ones, but only presenteeism reached statistical significance. Factors related to absenteeism and presenteeism at study inclusion were disease activity variables (PGA, BASDAI, ASDAS-CRP), ASQoL and BASFI. Best correlation with improvement in absenteeism at six months was with change in BASDAI (0.84 p 0.07) and age (-0.56 p 0.11), and with improvement in presenteeism were BASFI (0.59 p 0.002), ASQoL (0.57 p 0.002), BASDAI (0.54 p 0.04), PGA (0.51 p 0.01) and ASDAS-CRP(0.51 p 0.01).

Conclusion:

Biologic therapy is associated to an improvement in work status in axSpA patients. The results suggest that the fast and high improvement in disease activity and disability observed after start of BT is not directly translated to an improvement in work status at short time. Disease activity, disability and quality of life were the main factors influencing both, work status at inclusion and improvement in absenteeism and presenteeism after BT was started.

Disclosure of Interests:

Marta Arévalo: None declared, Mireia Moreno: None declared, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB, Font Ugalde Pilar: None declared, Eugenio de Miguel Grant/research support from: Yes (Abbvie, Novartis, Pfizer), Consultant of: Yes (Abbvie, Novartis, Pfizer), Paid instructor for: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Speakers bureau: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Teresa Clavaguera Speakers bureau: novartis, BMS, Faes, Luis F. Linares Ferrando: None declared, Beatriz Joven-Ibáñez Speakers bureau: Abbvie, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Jordi Gratacos-Masmitja Grant/research support from: a grant from Pfizzer to study implementation of multidisciplinary units to manage PSA in SPAIN, Consultant of: Pfizzer, MSD, ABBVIE, Janssen, Amgen, BMS, Novartis, Lilly, Speakers bureau: Pfizzer, MSD, ABBVIE, Janssen, Amgen, BMS, Novartis, Lilly, Xavier Juanola-Roura: None declared

AB1290-HPR UTILITY OF FRAX IN THE RISK DETECTION OF FRACTURE IN SPONDYLOARTHRITIS

Background:

Axial spondyloarthritis (SpAax) presents an increased risk of vertebral fracture not fully detected by Dual energy X-ray absorptiometry (DXA). The FRAX algorithms give the 10-year probability of hip fracture and of mayor osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture), taking into account 11 clinical risk factors.

Objectives:

To analyze the suitability of FRAX to detect the risk of fracture in patients with SpAax. To assess whether the incorporation of SpAax as a clinical risk factor to conventional FRAX provides additional information.

Methods:

Cross-sectional study in which SpAax patients (ASAS criteria) were included. Clinical-demographic and related to the disease variables were collected. FRIDEX model for Spanish population was used to determine low, intermediate or high risk of mayor fracture by FRAX. These results were compared with those obtained by DXA and trabecular bone score (TBS). In the statistical analysis we used mean and standard deviation (SD) in quantitative variables and frequency in qualitative ones. To compare means among 3 groups, ANOVA test was used.

Results:

The characteristics of the patients are shown in Table 1. According to FRIDEX, no patient had high risk of fracture and 2.4% had intermediate risk. When SpAax was added as a risk factor, no patient had high risk of fracture and 6.1% presented intermediate risk. According to DXA, 7.3% had high risk of fracture and 41.3% intermediate risk. TBS detected high risk of fracture in 18.3% and intermediate risk also in 18.3% of patients.

Table 1.

Sociodemographic, clinical and related characteristics with the disease (BMD: bone mineral density, BMI: index of body mass)

Gender (Male), n (%)61 (74.4)Age, mean ± SD49.48 ± 12.47BMI, mean ± SD27.13 ± 4.42Smoking, n (%)26 (31.7)Diabetes mellitus, n (%)9 (11)Osteoporotic fracture, n (%)1 (1.2)Disease duration (years), mean ± SD11.77 ± 10syndesmophytes, n (%)38 (46.3)ASDAS-PCR, mean ± SD2.55 ± 1.07Lumbar BMD (g / cm2), mean ± SD1.032 ± 0.180BMD femoral neck (g / cm2), mean ± SD0.816 ± 0.140Lumbar TBS, mean ± SD1.383 ± 0.133

Conclusion:

FRAX does not seem an adequate tool to detect the risk of fracture in patients with SpAax since it did not improve the results obtained by DXA meanwhile TBS did. The incorporation of SpAax as a clinical risk factor to conventional FRAX did not provide additional information in most cases

Disclosure of Interests:

None declared

AB0768 TREATMENT WITH TOFACITINIB IN REFRACTORY PSORIATIC ARTHRITIS. MULTICENTER STUDY OF 87 PATIENTS IN CLINICAL PRACTICE

Background:

Tofacitinib (TOFA) is the first JAKi approved for psoriatic arthritis (PsA) in Europe (July 2018). TOFA has shown efficacy in refractory patients to anti-TNF in Randomized Clinical Trials (RCT) (Gladman D. NEJM 2017; 377: 1525-36).

Objectives:

To assess efficacy and safety of TOFA in clinical practice (CP). To compare the profile of CP with RCT

Methods:

Study of 87 patients of CP with PsA treated with TOFA; Results are expressed as percentage, mean±SD or median [IRQ].

Results:

87 patients (28♀/59♂), mean age of 52.8±11.4 years (Table 1). Pattern of joint involvement was: peripheral (n=60), axial (1) and mixed (26). Presented also enthesitis (49.4%), nail involvement (30.2%) and dactylitis (31%).

Prior TOFA, most patients (80%) received oral prednisone, synthetic immunosuppressants (mean 2.3±0.9) and biological therapy (BT) (3.6±1.9): etanercept (n=58), adalimumab (54), infliximab (31), golimumab (37), certolizumab (30), secukinumab (54), ustekinumab (39) and ixekizumab (2). Apremilast was used in 17.

After a mean follow-up of 12.3±9.3 years from PsA diagnosis, TOFA was started (5 mg/12 h). In 48 (55.2%) TOFA was used in combined therapy: methotrexate (30) and leflunomide (15). In the remaining 39, monotherapy was prescribed.

Patients of CP compared with RCT have a longer duration of PsA, worst functional disability (HAQ) and received a higher proportion of corticosteroids and BT (anti-TNF and non-anti-TNF) (Table 1).

Patients improved in activity indexes (PASI, DAS28, DAPSA) and laboratory test (table 2). Minor side effects were reported in 21 patients (gastrointestinal symptoms), and TOFA was discontinued in 29 due to inefficiency mainly.

Conclusion:

Patients of CP had a longer evolution and received a greater number of biologics than those of RCT. TOFA as in RCT seems effective, rapid and relatively safe for refractory PsA.

Table 1.

Baseline features

CLINICAL TRIALGladmanN=131CLINICAL PRACTICEN=87Age, years (mean±SD)49.5±12.352.8±11.4Sex, n (%)67M/64F (51/49)59M/28F (68/32.2)Duration PsA, years (mean±SD)9.6±7.612,3±9.3HAQ-DI1.3±0.71.4±0.7 (n=26)Swollen joint count, mean±SD12.1±10.65.7±5.8Painful joint count, mean±SD20.5±13.08.0±6.6Elevated CRP, n (%)85 (65)55 (63.2)PASI score, median [IQR]7.6 [0.6-32.2]9.0 [4.2-15]Oral glucocorticoid, n (%)37(28)44(50.5)Concomitant synthetic DMARDs, n (%)- Methotrexate98 (75)30 (34.4)- Leflunomide12 (9)15 (17.2)- Sulfasalazine21 (16)6 (6.9)- Others2 (2)N. of previous TNF inhibitors, mean±SD1.7±1.02.4±1.4Previous use of other biological no anti-TNF, n (%)11 (8)68 (78.2)Table 2.

Table 2. Improvement at 1st, 6thand 12thmonth

Baselinen=871st monthn=776th monthn=5212th monthn=20Nail involvement, n (%)17 (19.5)Improvement, n (%)5 (35.7)6 (60)5 (83.3)Enthesitis, n (%)28 (32.2)Improvement, n (%)8 (47.1)10 (58.8)3 (50)Dactylitis, n (%)16 (18.4)Improvement, n (%)9 (69.2)6 (85.7)0 (0)CRP mg/dl, median [IQR]1.9 [0.3-5]0.5 [0.1-2.2]0.5 [0.3-1.2]0.4 [0.4-3.7]p (vs baseline)0.0040.0050.66DAS28, median [IQR]4.8 [4.1-5.403.7 [2.8-4.6]2.8 [2.2-3.8]2.9 [2.2-3.7]p (vs baseline)<0.001<0.001<0.001DAPSA, median [IQR]28 [18.41-34.05]15.5 [10.1-25.7]9 [6.07-15]4.3 [2.4-8]p (vs baseline)<0.001<0.001<0.001PASI, median [IQR]5 [1-14]1.4 [0-7]0 [0-4]0.05 [0-2.7]p (vs baseline)0.1920.1050.300

Disclosure of Interests:

E. Galindez: None declared, D. Prieto-Peña: None declared, José Luis Martín-Varillas Grant/research support from: AbbVie, Pfizer, Janssen and Celgene, Speakers bureau: Pfizer and Lilly, Beatriz Joven-Ibáñez Speakers bureau: Abbvie, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Olga Rusinovich: None declared, RAQUEL ALMODOVAR Speakers bureau: Abbvie, Celgene, Janssen, Lilly, Novartis, Pfizer.

, Juanjo J Alegre-Sancho Consultant of: UCB, Roche, Sanofi, Boehringer, Celltrion, Paid instructor for: GSK, Speakers bureau: MSD, GSK, Lilly, Sanofi, Roche, UCB, Actelion, Pfizer, Abbvie, Novartis, LARA MENDEZ DIAZ: None declared, Agusti Sellas-Fernández Speakers bureau: Abbott, Lilly, Celgene, Pfizer, Schering-Plough, Janssen, Novartis, and Nordic Pharma, À Martínez-Ferrer: None declared, Rosario Garcia de Vicuna Grant/research support from: BMS, Lilly, MSD, Novartis, Roche, Consultant of: Abbvie, Biogen, BMS, Celltrion, Gebro, Lilly, Mylan, Pfizer, Sandoz, Sanofi, Paid instructor for: Lilly, Speakers bureau: BMS, Lilly, Pfizer, Sandoz, Sanofi, Clara Ventín-Rodríguez: None declared, Julio Ramirez: None declared, Manuel Moreno: None declared, Maria jose Moreno: None declared, María del Carmen Castro Villegas: None declared, Antia Crespo Golmar: None declared, Natalia Palmou-Fontana: None declared, FRANCISCO ORTIZ SANJUAN: None declared, Ximena Elizabeth Larco Rojas: None declared, Antonio Juan Mas: None declared, Christian Y Soleto: None declared, Iñigo Gorostiza: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD

SAT0035 RESPONSE TO ABATACEPT OF DIFFERENT PATTERNS OF INTERSTITIAL LUNG DISEASE IN RHEUMATOID ARTHRITIS: NATIONAL MULTICENTER STUDY OF 263 PATIENTS

Background:

Interstitial Lung Disease (ILD) is a severe extraarticular manifestation of rheumatoid arthritis (RA). In this line, several radiological patterns of RA-ILD have been described: i) usual interstitial pneumonia (UIP), ii) nonspecific interstitial pneumonia (NSIP), iii) obliterating bronchiolitis, iv) organized pneumonia and mixed patterns. Abatacept (ABA) could be an effective and safe option for patients with RA-ILD, although the response in the different radiological patterns is not well defined.

Objectives:

Our aim was to assess the response to ABA in different radiological patterns of ILD.

Methods:

Observational retrospective multicenter study of RA-ILD treated with ABA. ILD was diagnosed by HRCT and classified by radiological patterns in 3 different subgroups of RA-ILD: a) UIP, b) NSIP and c) “other”. ABA was used sc. or iv. at standard dose. We assessed: a) Dyspnoea (MMRC scale; significant variation ≥1); b) Respiratory function tests (significant changes ≥10% in FVC and DLCO); c) HRCT imaging; d) DAS28 e)prednisone dose.

Variables were collected at months 0, 3, 6, 12 months and subsequently every 12 months until a maximum of 60 months.

Results:

We included 263 patients: 106 UIP, 84 NSIP and 73 others (150 women / 113 men), mean age 64.64±10 years. Total patients positive for RF or CCPA were 235 (89.4%) and 233 (88.6%), respectively. In 26 out of 263 patients, the development of ILD was closely related to the administration of sDMARDs (MTX n = 11 and LFN n = 1) or bDMARDs (ETN n = 5, ADA n = 4, CZP n = 2 and IFX n = 3). Patient characteristics are shown in table 1. Figure 1 shows the evolution of the cases with available data after a mean follow-up of 22.7±19.7 months. Mean DLCO and FVC remained stable in the 3 groups without statistically significant changes, and all the groups showed a statistically significant reduction in DAS28 and prednisone dose.

Conclusion:

ABA could be a good choice of treatment in patients with RA-ILD independently of the radiological pattern of ILD.

Disclosure of Interests:

Carlos Fernández-Díaz Speakers bureau: Brystol Meyers Squibb, Santos Castañeda: None declared, Rafael Melero: None declared, J. Loricera: None declared, Francisco Ortiz-Sanjuán: None declared, A. Juan-Mas: None declared, Carmen Carrasco-Cubero Speakers bureau: Janssen, MSD, AbbVie, Novartis, Bristol Myers Squibb, and Celgene, S, Rodriguéz-Muguruza: None declared, S. Rodrigez -Garcia: None declared, R. Castellanos-Moreira: None declared, RAQUEL ALMODOVAR Speakers bureau: Abbvie, Celgene, Janssen, Lilly, Novartis, Pfizer.

, CLARA AGUILERA CROS: None declared, Ignacio Villa-Blanco Consultant of: UCB, Speakers bureau: Novartis, MSD, Lilly, Sergi Ordoñez: None declared, Susana Romero-Yuste: None declared, C. Ojeda-Garcia: None declared, Manuel Moreno: None declared, Gemma Bonilla: None declared, I. Hernández-Rodriguez: None declared, Mireia Lopez Corbeto: None declared, José Luis Andréu Sánchez: None declared, Trinidad Pérez Sandoval: None declared, Alejandra López Robles: None declared, Patricia Carreira Grant/research support from: Actelion, Roche, MSD, Consultant of: GlaxoSmithKline, VivaCell Biotechnology, Emerald Health Pharmaceuticals, Boehringer Ingelheim, Roche, Speakers bureau: Actelion, GlaxoSmithKline, Roche, Natalia Mena-Vázquez: None declared, C. Peralta-Ginés: None declared, ANA URRUTICOECHEA-ARANA: None declared, Luis Marcelino Arboleya Rodríguez: None declared, J. Narváez: None declared, DESEADA PALMA SANCHEZ: None declared, Olga Maiz-Alonso: None declared, J. Fernández-Leroy: None declared, I. Cabezas-Rodriguez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, A. Ruibal-Escribano: None declared, JR De Dios-Jiménez Aberásturi: None declared, Paloma Vela-Casasempere: None declared, C. González-Montagut Gómez: None declared, J M Blanco: None declared, Noelia Alvarez-Rivas: None declared, N. Del-Val: None declared, M. Rodíguez-Gómez: None declared, Eva Salgado-Pérez: None declared, Carlos Fernández-López: None declared, E.C. Cervantes Pérez: None declared, A. Devicente-DelMas: None declared, Blanca Garcia-Magallon Consultant of: MSD, Speakers bureau: Pfizer, Amgen, Celgene, MSD, Cristina Hidalgo: None declared, Sabela Fernández: None declared, R. López-Sánchez: None declared, Edilia García-Fernández: None declared, S. Castro: None declared, P. Morales-Garrido: None declared, Andrea García-Valle: None declared, Rosa Expósito: None declared, L. Exposito-Perez: None declared, Lorena Pérez Albaladejo: None declared, Ángel García-Aparicio: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD

OP0212 ABATACEPT IN INTERSTITIAL LUNG DISEASE ASSOCIATED WITH RHEUMATOID ARTHRITIS. NATIONAL MULTICENTER STUDY OF 263 PATIENTS

Background:

Interstitial Lung Disease (ILD) is a severe complication of Rheumatoid Arthritis (RA). Several conventional disease-modifying anti-rheumatic drugs (cDMARDs) and biologic (b) DMARDs may induce or impaired ILD-RA. Abatacept (ABA) may be useful in ILD-RA (1).

Objectives:

To assess the efficacy and safety of ABA in a large series of ILD-RA for a long-term follow-up.

Methods:

Multicenter open-level study of ILD-RA treated with at least 1 dose of ABA. ILD was diagnosed by high-resolution computed tomography (HRTC). We study these outcomes: a) 1-point change Modied Medical Research Council (MMRC); b) forced vital capacity (FVC) and/or DLCO improvement or decline ≥10%; c) change in HRCT, d) change in DAS28. e) Prednisone dose. Values were collected at 0, 3, 6, 12 and then every 12 months.

Results:

We studied 263 patients (150 women/113 men) (mean age;64.6±10 years), with ILD-RA. At ABA-onset they were smokers or exsmoker (53.8%), positive APCC (88.6%), median [IQR] duration of ILD of 12 [3-41.25] months, mean DLCO (65.7±18.3) and FVC (85.9±21.8).

The ILD-pattern were usual interstitial pneumonia (UIP) (40.3%), non-specific interstitial pneumonia (NSIP) (31.9%) and others (27.8%).

ABA was prescribed at standard subcutaneous (125 mg/w) in 196 (74.5%) or intravenously (10 mg/kg/4 w) in 67 (25.5%); in monotherapy (n=111) or combined with cDMARDs (n=152); especially leflunomide (n=55), MTX (n=46), or antimarials (n=21).

After a mean follow-up of 22.7±19.7 months most outcomes remain stable (Figure). Moreover, DAS28 improved from 4.5±1.5 to 3.1±1.3; prednisone dose reduced from a median 7.5 [5-10] to 5 mg [5-7.5] and retention rate was 76.4%. The main adverse effects were serious infections (n=28), neoplasia (n=3), serious infusion reaction (n=1) and myocardial infarction (n=1).

Conclusion:

ABA seems effective and relatively safe in ILD-RA.

References:

[1]Fernández-Díaz C et al. Semin Arthritis Rheum. 2018; 48:22-27

Disclosure of Interests:

Carlos Fernández-Díaz Speakers bureau: Brystol Meyers Squibb, Santos Castañeda: None declared, Rafael Melero: None declared, J. Loricera: None declared, Francisco Ortiz-Sanjuán: None declared, A. Juan-Mas: None declared, Carmen Carrasco-Cubero Speakers bureau: Janssen, MSD, AbbVie, Novartis, Bristol Myers Squibb, and Celgene, S, Rodriguéz-Muguruza: None declared, S. Rodrigez -Garcia: None declared, R. Castellanos-Moreira: None declared, RAQUEL ALMODOVAR Speakers bureau: Abbvie, Celgene, Janssen, Lilly, Novartis, Pfizer.

CLARA AGUILERA CROS: None declared, Ignacio Villa-Blanco Consultant of: UCB, Speakers bureau: Novartis, MSD, Lilly, Sergi Ordoñez: None declared, Susana Romero-Yuste: None declared, C. Ojeda-Garcia: None declared, Manuel Moreno: None declared, Gemma Bonilla: None declared, I. Hernández-Rodriguez: None declared, Mireia Lopez Corbeto: None declared, José Luis Andréu Sánchez: None declared, Trinidad Pérez Sandoval: None declared, Alejandra López Robles: None declared, Patricia Carreira Grant/research support from: Actelion, Roche, MSD, Consultant of: GlaxoSmithKline, VivaCell Biotechnology, Emerald Health Pharmaceuticals, Boehringer Ingelheim, Roche, Speakers bureau: Actelion, GlaxoSmithKline, Roche, Natalia Mena-Vázquez: None declared, C. Peralta-Ginés: None declared, ANA URRUTICOECHEA-ARANA: None declared, Luis Marcelino Arboleya Rodríguez: None declared, J. Narváez: None declared, DESEADA PALMA SANCHEZ: None declared, Olga Maiz-Alonso: None declared, J. Fernández-Leroy: None declared, I. Cabezas-Rodriguez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, A. Ruibal-Escribano: None declared, JR De Dios-Jiménez Aberásturi: None declared, Paloma Vela-Casasempere: None declared, C. González-Montagut Gómez: None declared, J M Blanco: None declared, Noelia Alvarez-Rivas: None declared, N. Del-Val: None declared, M. Rodíguez-Gómez: None declared, Eva Salgado-Pérez: None declared, Carlos Fernández-López: None declared, E.C. Cervantes Pérez: None declared, A. Devicente-DelMas: None declared, Blanca Garcia-Magallon Consultant of: MSD, Speakers bureau: Pfizer, Amgen, Celgene, MSD, Cristina Hidalgo: None declared, Sabela Fernández: None declared, Edilia García-Fernández: None declared, R. López-Sánchez: None declared, S. Castro: None declared, P. Morales-Garrido: None declared, Andrea García-Valle: None declared, Rosa Expósito: None declared, L. Exposito-Perez: None declared, Lorena Pérez Albaladejo: None declared, Ángel García-Aparicio: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD