Comparative study of the dental health of 4-year-old children in north-eastern France between 2001 and 2018

PURPOSE

To analyse the evolution of the oral health of 4-year-old children in nursery school between 2001 and 2018 as well as the early predictor and associated risk factors, in different school areas.

METHODS

We compared (1) the prevalence of ECC (4 ≥ dmft ≥ 1) and S-ECC (dmft ≥ 5) of 4-year-old children and (2) data obtained by a structured questionnaire completed by their parents from two studies performed in 2001 and 2018. Data were analysed using the Chi2 test and odds ratio (OR).

RESULTS

A total of 322 children and of 425 children randomly selected among Moselle's public nursery schools in north-eastern France were, respectively, included in the study in 2001 and 2018. The prevalence of ECC was respectively 40.70% and 21.65% in 2001 and 2018 (p < 0.001; OR = 2.48; 95% CI = 1.78-3.47). We also observed a decrease of S-ECC prevalence (10.56% in 2001 vs 5.90% in 2018, p < 0.05, OR = 1.89; 95% CI = 1.07-3.38). The intake of cariogenic food (sweet drink, biscuits, candies, milk, baby bottle) decreased but the knowledge of parents concerning cariogenic food did not improve. The proportion of parents helping their child has not changed in 17 years (82.33% vs 86.52%, p > 0.1) but tooth brushing was initiated earlier in 2018 than in 2001 (p < 0.01). Prescription of systemic fluoride decreased (39.14% vs 3.62%; p < 0.001).

CONCLUSION

The identification of the food consumption habits and the knowledge of parents concerning oral health should enable strengthening of preventive measures and the initiation of an oral health education programme for children and their family.

Latiné immigrant heterogeneity: Striking health differences among Cuban refugee/migration waves to the United States

Latiné people differ markedly in our lived experiences in ways that are underappreciated. Meanwhile, variations in social experiences are known to be associated with differential health outcomes. We test whether immigration history is associated with health differences among U.S.-based Cuban refugees. Cubans from the circum-1980 Mariel Boatlift migration wave reported significantly higher instances of disability than Early Cuban Exiles, Freedom Flight refugees, and Special Period refugees. We also interviewed Miami-based Cubans. Participants described heightened discrimination in 1980s Cuba and U.S., which we hypothesize contributed to higher instances of disability refugees of that era. By understanding how differential social experiences shape health, we aim to provide a nuanced understanding of the social determinants of health and the ways adverse experiences can be combated.

A Pilot Study Exploring Caregivers' Experiences Related to the Use of a Smart Toothbrush by Children with Autism Spectrum Disorder

BACKGROUND

Research on caregivers for children with intellectual disabilities, particularly those with autism spectrum disorder (ASD), has highlighted several obstacles to achieving better oral health. These include challenges with tolerating oral care, sensory processing differences, uncooperative behaviors, and communication impairments. There is limited understanding of what caregivers would consider "successful assistance" in improving oral health for these children.

OBJECTIVES

This pilot study aimed to examine caregivers' and user's experiences with a Kids Smart Electric Toothbrush used by children with ASD.

METHODS

It involved open-ended interviews and questionnaires with caregivers prior to utilization of the toothbrush and after 4 weeks of product use by the child.

RESULTS

Seventeen children with ASD, aged 5-12, participated. A total of 58.8% of caregivers said their child brushed more often, and all reported brushing at least twice a day by week 4. Caregivers reported that children became more independent while brushing their teeth and achieved better quality brushing. Caregivers' frustration with the brushing process, satisfaction with the device, and need to assist the child with brushing were improved. Caregivers did encounter some technical difficulties with the app.

CONCLUSION

This study will assist in exploring "smart" toothbrush technologies for oral hygiene in children with ASD.

Corticosterone effects on postnatal cerebellar development in mice

Glucocorticoids administered early in infancy can affect the architectonic organization of brain structures, particularly those with a postnatal development and resulting in long-term deficits of neuromotor function and cognition. The present study was undertaken to study the effects of daily corticosterone (CORT) injections at a pharmacological dose from postnatal days 8-15 on cerebellar and hippocampal development in mouse pups. Gene expression status for trophic factors involved in synaptic development and function as well as measures of layer thickness associated with cytochrome oxidase labelling were analyzed in the hippocampus, hypothalamus, and specific cerebellar lobules involved in motor control. Repeated CORT injections dysregulated the HPA axis with increased Crh and Nr3c1 mRNA levels in the hypothalamus and a resulting higher serum corticosterone level. The CORT treatment altered the morphology of the hippocampus and down-regulated gene transcription for corticotropin-releasing hormone (Crh) and its type-1 receptor (Crhr1), glucocorticoid receptor (Nr3c1), and brain-derived neurotrophic factor Bdnf and its receptor Ntrk2 (neurotrophic receptor tyrosine kinase 2). Similar mRNA expression decreases were found in the cerebellum for Crhr1, Crhr2, Nr3c1, and Grid2 (glutamatergic δ2 receptor). Morphological alterations and metabolic activity variations were observed in specific cerebellar lobules involved in motor control. The paramedian lobule, normally characterized by mitotic activity in the external germinative layer during the second postnatal week, was atrophic but metabolically hyperactive in its granule cell and molecular layers. On the contrary, lobules with an earlier cell proliferation displayed neurogenesis but a hypoactivated granule cell layer, suggesting a developmental delay in synaptogenesis. The results indicate that glucocorticoid, administered daily during the second postnatal week modulated the developmental programming of the hippocampus and cerebellum. These growth and metabolic alterations may lead possibly to morphological and functional changes later in life.

Frameless Fractionated Linear Accelerator-Based Stereotactic Radiotherapy for Brain Metastases: Results of a Single-Arm Phase II Multi-Institutional Clinical Trial

PURPOSE/OBJECTIVE(S)

Stereotactic radiotherapy (SRT) yields high rates of local control for brain metastases while minimizing neurocognitive side effects. While advanced SRT platforms are widely available in urban centers, rural/suburban patients face geographic and socioeconomic barriers to access SRS. For this reason, we conducted a multi-institutional Phase 2 clinical trial to test the safety and efficacy of 3-5 fraction frameless fractionated stereotactic radiotherapy (FFSRT) for brain metastases in an integrated academic satellite network MATERIALS/METHODS: This IRB-approved Phase 2 trial was conducted for patients ≥18-years-old with 1-4 brain metastases. Brain metastases involving the optic pathway or brainstem were excluded. Gross tumor volume (GTV) was delineated with a volumetric brain MRI and planning target volume (PTV) was GTV + 2 mm margin. Radiation dose was based on GTV size: < 3.0 cm, 27 Gy in 3 fractions, and 3.0-3.9 cm, 30 Gy in 5 fractions. Toxicity was evaluated using the Common Terminology Criteria for Adverse Events (CTCAE) version 4.

RESULTS

Of 76 evaluable patients, the median age was 67 years, 56.6% were female, 82.9% were white/Caucasian and 89.6% had an Eastern Cooperative Oncology Group performance status ≤ 2. Most brain metastases were from lung cancer (51.3%) and breast cancer (15.7%). With median follow-up of 10 months, local control was 93%, median survival was 1.8 years (95% confidence interval (CI): 1.5-2.4 years), 1-year OS was 73.8% (95% CI: 0.59-0.84), and 2-year OS was 31% (95% CI: 0.12-0.52). There were no CTCAE Grade ≥ 3 protocol-related adverse events.

CONCLUSION

Outcomes of this trial compare favorably with contemporary SRT trials for brain metastases. FFSRT may provide opportunities to expand SRS access for underserved populations across the MDACC enterprise and in future clinical trials for brain metastases.

Perinatal outcomes in lesbian couples employing shared motherhood IVF compared with those performing artificial insemination with donor sperm

STUDY QUESTION

In lesbian couples, is shared motherhood IVF (SMI) associated with an increase in perinatal complications compared with artificial insemination with donor sperm (AID)?

SUMMARY ANSWER

Singleton pregnancies in SMI and AID had very similar outcomes, except for a non-significant increase in the rate of preeclampsia/hypertension (PE/HT) in SMI (recipient's age-adjusted odds ratio (OR) = 1.9, 95% CI = 0.7-5.2; P = 0.19), but twin SMI pregnancies had a much higher frequency of PE/HT than AID twins (recipient's age-adjusted OR = 21.7, 95% CI = 2.8-289.4; P = 0.01).

WHAT IS KNOWN ALREADY

Oocyte donation (OD) pregnancies are associated with an increase in perinatal complications, in particular, preterm delivery and low birth weight, and PE/HT. However, it is unclear to what extent these complications are due to OD process or to the conditions why OD was performed, such as advanced age and underlying health conditions. Unfortunately, the literature concerning perinatal outcomes in SMI is scarce.

STUDY DESIGN, SIZE, DURATION

Retrospective study involving 660 SMI cycles (299 pregnancies) and 4349 AID cycles (949 pregnancies) assisted over a 10-year period.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All cycles fulfilling the inclusion criteria performed in lesbian couples seeking fertility treatment in 17 Spanish clinics of the same group. Pregnancy rates of SMI and AID cycles were compared. Perinatal outcomes were compared: gestational length, newborn weight, preterm and low birth rates, PE/HT rates, cesarean section rates, perinatal mortality, and newborn malformations.

MAIN RESULTS AND THE ROLE OF CHANCE

Pregnancy rates were higher in SMI than in AID (45.3% versus 21.8%, P < 0.001). There was a non-significant trend to higher multiple rate in AID (4.7% versus 8.5%, P = 0.08). In single pregnancies, there were no differences between SMI and AID in gestational age (278 days (268-285) versus 279 (272-284), P = 0.24), preterm rate (8.3% versus 7.3%, P = 0.80), preterm <28 weeks (0.6% versus 0.4%, P = 1.00), newborn weight (3195 g (2915-3620) versus 3270 g (2980-3600), P = 0.296), low birth rate (6.4% versus 6.4%, P = 1.00), extremely low birth weight (0.6% versus 0.5%, P = 1.00), and the distribution of newborns by weight groups. Cesarean section rate, newborn malformation rate, and perinatal mortality were also similar in SMI and AID. Additionally, there was non-significant trend in hypertensive disorders to an increase in PE/HT among SMI (recipient's age-adjusted OR = 1.9, 95% CI = 0.7-5.2). Overall, perinatal data are consistent with what is reported in the general population. In twin pregnancies, the aforementioned perinatal parameters were also very similar in SMI and AID. However, SMI twin pregnancies had a very high risk of PE/HT when compared with AID (recipient's age-adjusted OR = 21.7, 95% CI = 2.8-289.4, P = 0.01).

LIMITATIONS, REASONS FOR CAUTION

Our data regarding the pregnancy course were obtained from information registered in the delivery report as well as from what was reported by the patients themselves, so a certain degree of inaccuracy cannot be ruled out. Additionally, in some parameters, there was up to 10% of data missing. However, since the methodology of reporting was the same in SMI and AID groups, one should not expect a differential reporting bias. It cannot be ruled out that the risk of PE/HT in simple gestations would be significant in a larger study. Additionally, in the SMI group allocation to the transfer of 2 embryos was not randomized so some bias is possible.

WIDER IMPLICATIONS OF THE FINDINGS

SMI, if single embryo transfer is performed, seems to be is a safe procedure. Double embryo transfer should not be performed in SMI. Our data suggest that the majority of complications in OD could be related more with recipient status than with OD itself, since with SMI (performed in women without fertility problems) the perinatal complications were much lower than usually described in OD.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was received. The authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Regulatory Mechanisms of Muscle Mass: The Critical Role of Resistance Training in Children and Adolescent

Muscle mass and strength are subjected to several regulations. We found endocrine signals such as growth hormone, insulin-like growth factor 1, testosterone, thyroid hormones, and glucocorticoids among them. Neural inputs also influence muscle development, modulating mass and strength. Among the external stimuli that modulate these muscular features is physical training such as resistance and endurance training. Specifically, resistance training can mediate an increase in muscle mass by hypertrophy in adults, but the effects in children and adolescents are full of myths for most of the population. However, the evidence shows that the impact of resistance training on children and adolescents is clear and provides a wide range of benefits. However, qualified professionals must be available since exercise prescription and subsequent supervision must follow this population's abilities, needs, and interests.

Teledentistry and management protocol in a pediatric dental department during the first COVID-19 lockdown

BACKGROUND

During the first COVID-19 lockdown, from March 12 to May 15, 2020, private dental practices in France and in many other countries remained closed. Dental emergencies were therefore partly redirected to hospital dental departments. The aim of this article is to describe the modalities of remote management of emergencies during this period, by the pediatric dentistry department of Nancy University Hospital (France), via an oral telemedicine protocol.

PATIENTS AND METHODS

All parents of children in difficulty were invited to contact the department by phone. Initial triage was managed by externs, interns, or dental practitioners following a management protocol specifically adapted to pediatric dentistry for this context. Depending on the situation (type of complaint, geographical location of the patients, possibility of travel, availability of digital equipment, etc.), an oral telemedicine solution was proposed using the Covotem® software (Maincare Society, Canejan, France) via the Pulsy platform (public interest grouping validated by the Grand Est Regional Agency for Health) and possibly using an intraoral photographic protocol suggested by the team.

RESULTS

During this period, 176 patients used the pediatric dental department, 40 of whom were managed via oral telemedicine. Of these children, 57% (23/40) required an appointment in the department during the lockdown, 30% (12/40) did not require follow-up, and 13% (5/40) required a post-lockdown appointment. This teledentistry protocol resulted in a diagnosis in most cases (93%).

CONCLUSION

Patient management through oral telemedicine appears to be an effective tool for planning and organizing oral healthcare. It should be more widely considered in dentistry in the current context of pressure in medical emergencies, significant medical needs, and medical desertification.

Ep-CAM (MOC-31) expression in tooth germ and ameloblastoma

BACKGROUND

Ep-CAM, a transmembrane glycoprotein expressed in most epithelium in normal conditions, has diverse roles in these tissues, including in cell adhesion, proliferation, differentiation, cell cycle regulation, migration and intracellular signaling. It is also over-expressed in most malignant neoplasia, participating in the initiation, progression, and metastatic dissemination of the tumor. The expression and roles of this protein in oral neoplasia, particularly in odontogenic tumors, remain unestablished. The objective of this study consisted in analyzing the expression of this protein in ameloblastoma and tooth germ.

MATERIAL AND METHODS

Ep-CAM (MOC-31) expression was evaluated by immunohistochemistry in tooth germs (TG) (n = 16) ameloblastomas (AM) (n = 60) and 2 ameloblastic carcinomas. Sections were visualized in their totality with an optical microscope, and positivity observed in cell membrane and cytoplasm was graded according to the following semi-quantitative scale: Neg, "essentially unstained", for negative sections or staining <5% of cells; + for staining of 5-50% of cells; ++ for staining >50% of cells.

RESULTS

Most tooth germs expressed MOC-31 (81.3%), strong staining was observed both in the inner epithelium of the enamel organ and in the adjacent stellate reticulum. 16.7% of the AM cases showed MOC-31 expression, the immunoexpression expression was diffuse at the cytoplasmic and membrane level. The only two cases of ameloblastic carcinoma included were strong positive to MOC-31. No correlation was observed between protein expression and gender, age, clinical variants, or histological subtypes.

CONCLUSIONS

Overexpression was found in TG and ameloblastic carcinoma compared to AM; further studies with different experimental strategies are suggested to clarify the biological significance of this finding.

Oleanolic acid protection against experimental autoimmune myocarditis modulates the microbiota and the intestinal barrier integrity

Background

Autoimmune myocarditis is a cause of dilated cardiomyopathy and heart failure. Recent studies have indicated that leaky gut may allow environmental factors to enter the body and trigger the initiation/development of autoimmune disease. Moreover, there is a growing literature supporting that, beside myocardial fibrosis, a leaky intestinal barrier and gut dysbiosis are pathogenic factors linked to heart failure. The natural triterpene oleanolic acid (OA) has been shown to beneficially influence the severity of the experimental autoimmune myocarditis (EAM), a preclinical model of human myocarditis, via anti-oxidant and immunomodulatory mechanisms. Herein, we investigate gastrointestinal (GI) disturbances and the gut microbiota composition associated with EAM as potential therapeutic target of OA.

Methods and results

BALB/c mice were α-myosin-inmunized to induce EAM and treated with OA (25 mg/kg/day, i.p). On day 21, heart fibrosis and parameters related to gut damage such as oxidative stress (O2- ions, lipid peroxidation), gut permeability (D-lactate; I-FABP), inflammation and mucins were determined in serum and/or colon. Fecal microbial profiles were identified by 16S rRNA gene sequencing analysis. Firstly, histological analysis of hearts showed presence of fibrosis (Sirius Red stain) in EAM mice, whereas these effects were not detectable in myocardium from healthy or OA-treated EAM mice. In addition, OA preserved the mucin-containing goblet cells along the colon (Alcian Blue/PAS stain). Consistently, serum levels of the epithelial gut damage markers, including D-lactate and iFABP were significantly reduced in OA treated-EAM mice. The beneficial OA effects also included a decrease in the pro-inflammatory mediators sPLA2-IIA and IL-1β and a protection from the oxidative stress response (DHE stain and TBARS) in serum and colonic tissue of EAM-mice. Furthermore, gut microbiota composition showed a lower bacterial diversity and different relative abundance of certain bacterial taxa in EAM-mice compared to control mice. The families of Muribaculaceae, Lachnospiraceae, and Ruminococcaceae were significantly affected in EAM mice, and only Muribaculaceae recovered levels similar to the healthy-control group, after treatment with OA.

Conclusion

Our data show that in addition to the heart, the intestinal barrier and gut microbiota are altered in myocarditis, and that OA treatment could ameliorate this profile. Our data contribute to the idea that gut dysbiosis and GI dysfunction influences myocarditis pathogenesis, and provides new findings regarding the beneficial activity of OA in EAM, suggesting that it may be an interesting candidate to be explored for the treatment of human patients.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): MINECO, ISCIII, CIBERCV-ISCIII

Influence of Calcium Scaling on Corrosion Behavior of Steel and Aluminum Alloys

Calcium scaling is a serious problem encountered in the oil and gas industry because it is common that brines produced alongside oil and gas exhibit high concentrations of calcium ions, among others, which is expensive to remedy. The precipitation of calcium salts on the internal wall of the pipelines may occur because of the physical and chemical changes as fluids are produced from downhole to surface facilities. Although different researchers have address scaling and corrosion in the oil and gas industry, there are few reports in the literature relating the corrosion and scaling phenomena simultaneously. Despite there being indications that scales may produce corrosion problems, affecting the mechanical integrity of the infrastructure, there is minimal research in the literature addressing such relations. Previous studies presented aluminum alloys as excellent and reliable materials for applications in the petroleum industry, such as drilling activities. In this work, we evaluate the corrosion behavior of steel and aluminum alloys under highly scaling environments using supersaturated brines. Our results show that the presence of calcium carbonate and calcium sulfate as a scaling environment increases the corrosion rates for aluminum alloys and carbon steel; however, the same environments do not affect the corrosion behavior of stainless steel.

Randomised clinical trial of a motivational interviewing intervention to improve oral health education amongst older adults in Philadelphia: 12-month evaluation of non-clinical outcomes

OBJECTIVES

We conducted a trial to assess the treatment fidelity of an individual-based oral health education intervention utilising motivational interviewing (MI) techniques and its efficacy when compared to a group-based traditional oral health education intervention (TOHE) and a standard of care group (SC) in a sample from Philadelphia during a 12-month follow-up.

BACKGROUND

There is lack of information on how different types of oral health educational interventions affect older adults on non-clinical outcomes including changes in oral health-related quality of life (OHRQoL), oral health self-efficacy (SE) and oral health knowledge (OHK).

MATERIALS AND METHODS

One hundred and eighty patients were randomly allocated to TOHE, MI and SC groups. Treatment fidelity was measured in 16 non-study patients. The MI intervention was administered by a public health dental hygienist (PHDH). All interviews were audio-recorded and coded by an expert using the Motivational Interviewing Treatment Integrity (MITI) Code. Multivariable longitudinal regression analyses accounting for baseline demographics and correlated errors due to repeated measures via generalised estimating equation were conducted following an intention to treat approach.

RESULTS

Over the 1-year follow-up, SE and OHRQoL scores significantly improved amongst the MI group whereas both outcomes worsened amongst the SC group. During the same period, SE and OHRQoL did not change in the TOHE group.

CONCLUSION

Findings from the study support the fidelity of this intervention and the improvement of all non-clinical outcomes after 12 months amongst the MI group.

OP0078 MAPPING FROM THE ANKYLOSING SPONDYLITIS DISEASE ACTIVITY SCORE (ASDAS) TO EQ5D IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

Clinical studies often omit outcomes that allow the direct estimation of Quality Adjusted Life Years (QALYs) for use in cost effectiveness analyses crucial for informing policy decisions. This means analysts often have to estimate the relationship, “map”, between included outcomes and preference based ones like the EuroQoL EQ5D. In ankylosing spondylitis (AS), the relationship between BASDAI/BASFI and EQ5D has been established but the emergence and growing use of the Ankylosing Spondylitis Disease Activity Score (ASDAS), a new composite index used to assess clinical disease activity, means new mapping tools are required. Furthermore mapping has never been done for the entire axial spondyloarthritis (axSpA) spectrum of patients i.e. including not only patients with AS but also those with non-radiographic axSpA.

Objectives:

To estimate a robust mapping between ASDAS and EQ5D (3 level version) and to test its performance out of sample (external validation) in patients with axSpA.

Methods:

Data from an electronic, prospective, nationwide Rheumatic Disease Portuguese Register (Reuma.pt) provided data pertaining to 1140 patients (5483 observations) with a confirmed diagnosis of axSpA was used to develop a model to predict EQ5D from the ASDAS score. We compared a range of different statistical models developed to deal with the complex distributional features of health utility data. A range of criteria examining model fit across the spectrum of disease severity were used to select preferred models. A smaller dataset for out of sample validation from the SPondyloArthritis Caught Early (SPACE) cohort was used, providing data from 317 patients (1225 observations) at five European centres.

Results:

Characteristics of patients from the Reuma.pt and SPACE are presented in the table. There is a non-linear relationship between ASDAS and EQ5D. We found that a four component mixture model based on a bespoke distribution, with one component constrained to reflect the mass of observations at full health, was the best fitting of the ASDAS models estimated (figure). ASDAS squared and age squared featured as within component variables. The model demonstrated close fit to the observed data where ASDAS was less than 4 but diverged from the mean of the data where ASDAS was higher. There is a very limited data at this more severe level of disease activity. In the out of sample testing, the model continued to perform well overall and exhibited the same divergence from the observed data only where data was sparse.

Conclusion:

There is a clear relationship between ASDAS and EQ5D that we were able to model reliably using bespoke mixture model based methods. There is more uncertainty regarding model fit at very high levels of disease activity owing to the relative paucity of data from patients in such disease activity state. Future analyses may wish to focus on these severely affected patients in order to improve the robustness of model estimates.

Table.

Characteristics of patients from the Reuma.pt and SPACE datasets

REUMA (n = 1140)SPACE (n = 317)NMeansdminmaxNmeansdminmaxAge at visit (yrs)548346.5811.9917.7082.70122531.447.7816.1450.46Number of visits54834.815.261.0039.0012254.051.601.008.00ASDAS total score48862.020.970.606.3011812.100.960.645.44BASDAI total score53832.972.260.0010.0012113.272.200.009.80BASFI total score52582.842.410.009.8812051.922.090.009.30EQ-5D-3L54830.700.26-0.591.0012250.690.25-0.591.00Proportion Male54830.5612250.50Figure.

 Mean observed versus fitted values for the preferred model mapping EQ5D-3L from ASDAS (Reuma.Pt dataset)

Acknowledgments:

We would like to that all the contributors to the Reuma.Pt and SPACE datasets.

Disclosure of Interests:

Monica Hernandez: None declared, Allan Wailoo: None declared, Georgios Chrysanthou: None declared, Pedro Carvalho: None declared, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Maria Jose Santos Speakers bureau: Novartis and Pfizer, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB