AB1265 GENDER DISTRIBUTION AND GENDER-RELATED ISSUES AMONG YOUNG RHEUMATOLOGISTS AND ACADEMIC POSITIONS IN RHEUMATOLOGY: A SNAPSHOT OF THE CURRENT SITUATION IN ITALY

Background:

The Italian Society for Rheumatology (SIR) comprises committees for Rheumatologists under the age of 40 (SIRyoung) and for Women in Rheumatology (Reumatologhe Donne – ReDO). As female representation is increasing in rheumatology worldwide [1], there has been interest in assessing gender-related issues.

Objectives:

To describe the gender distribution among young members of SIR and academic positions in Rheumatology in Italy. To assess the expectations and needs of young rheumatologists with regard to their career.

Methods:

SIRyoung members developed a web-based survey which was distributed among SIR members under the age of 40 during the spring of 2019. Responses were collected and analysed anonymously. ReDO retrieved and analysed the data regarding academic positions in Italy in September 2019 from official data by “Ministry of Education, University and Research” (www.miur.it).

Results:

Out of 478 SIR members under 40 (66.5% F), 113 (23.7%) completed the SIRyoung survey (62.1% F). Regarding career plans, male and female members responded: hospital physician (36.9% vs 37.8%), outpatient clinic physician (18.5% vs 28.3%), academic career (23.9% vs 22.8%), private practice (16.3% vs 9.4%), and industry (4.3 vs 1.6%), respectively. When asked about their interest in doing a fellowship in another national center or abroad, 60.8% of male and 72.8% of female respondents were interested but thought they could not afford it. Reasons reported by males and females were: working reasons, namely barriers to temporarily leave the workplace (61.3% vs 50.7%), family reasons (16.1% vs 25.4%), financial reasons (22.6% vs 16.5%), respectively. As for academic rheumatology in Italy, 113 positions were retrieved. Men held 64 positions (57%) and women 49 (43%). Full professors were mostly men (92%), while assistant professors were women in 65% of the cases (58% of those with a permanent position; 72% of those with a temporary position) (Figure) [2].

Conclusion:

Our study explored for the first time gender distribution and related issues in Rheumatology in Italy. Female representation accounts for two thirds of SIR members under 40. This could reflect the general trend of medical school being chosen more often by women than men. No differences were observed in the career expectations of male and female rheumatologists. Interestingly, nearly one fourth of female respondents were interested in academic career, confirming the trend toward female predominance observed for assistant professors. Therefore, it is likely that the next generation of full professors will have a balanced gender distribution, as it is already for associate professors. The choice of a fellowship is still hampered by several problems, but it seems that reasons for not pursuing such opportunities are similarly distributed in males and females. Although family reasons tend to be more frequent in female rheumatologists, this is not significant as compared to men. This could indicate that family affects career choices of both male and female rheumatologists. It is important that national societies promote surveys for the assessment of gender specific issues among their members, in order to identify unmet needs and design interventions for career support regardless of gender.

References:

[1]Andreoli L, et al. Joint, Bone, Spine: Revue du Rhumatisme. 2019;86(6):669-672.

[2]Bosello SL, et al. Reumatismo 2020; in press.

Acknowledgments:

SIRyoung and ReDO wish to thank the Steering Committee of SIR

Disclosure of Interests:

Laura Andreoli: None declared, Stefano Alivernini: None declared, Alessia Alunno: None declared, Silvia Laura Bosello: None declared, Cecilia Chighizola: None declared, Paola Conigliaro: None declared, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB, Cristina Iannuccelli: None declared, Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, Marta Vadacca: None declared, Maria Sole Chimenti: None declared

AB1177 METHODOLOGICAL ASPECTS OF DESIGN, ANALYSES AND REPORTING OF STUDIES WITH WORK PARTICIPATION AS OUTCOME DOMAIN IN PATIENTS WITH INFLAMMATORY ARTHRITIS: RESULTS OF TWO SYSTEMATIC LITERATURE REVIEWS INFORMING EULAR POINTS TO CONSIDER

Background:

Inflammatory arthritis (IA) has substantial impact on work participation (WP). However, methodological issues hamper interpretation, comparison and meta-analyses of studies with WP as outcome domain. Sources of heterogeneity and methodological choices should be assessed in order to improve the quality of future studies.

Objectives:

To summarize methodological choices in studies with WP as outcome domain in IA and other chronic diseases.

Methods:

A EULAR task force on ‘points to consider (PtC) when designing, analysing and reporting studies with WP as outcome domain among patients with IA’ outlined the scope of the systematic literature review (SLR) and identified 6 areas of potential concern (Table 1). Two searches were conducted (Figure 1): Search 1 (S1): original studies in IA (RCTs and longitudinal prospective observational studies); S2: systematic reviews in other chronic diseases. Two reviewers independently identified eligible studies and extracted data for the pre-defined methodological areas.

Table 1.

Methodological issues across the 6 pre-defined areas (search 1, n=62)

AreaMethodological issues*1. Study design- 16/62 (26%) and 8/62 (13%) studies aligned the target population and sample size with the study’s work outcome.- 9/39 (24%) of the interventional studies aimed to assess changes of work status (employment/disability) over a very short follow-up time (≤6 months).2. Work outcome domains- 7/33 (21%) of studiesdefined work status.- 30/30 (100%), 38/38 (100%) and 7/7 (100%)defined absenteeism, presenteeism and unpaid work, respectively.3. Work outcome measurement instruments- 22/62 (35%) studies usednon-validated instruments(e.g. self-reported days of sick leave/impact of disease on productivity, n=16/62, 26%).4. Contextual factors- 54/62 (87%) studies neglected work-related contextual factors.5. Data analysesOf the studies measuring absenteeism and/or presenteeism:- 10/38 (26%) accounted forskewnessof the work outcome.- 30/38 (79%) tookinterdependencebetween outcomes as part of work productivity and activity impairment questionnaire into account.6. Reporting- 62/62 (100%) studies reported the size and characteristics of the (sub)groups in which the analyses were performed.- 1/62 (2%) reported loss to follow-up and work-related reasons for drop-out.- 42/62 (68%) studies presentedaggregatedresults; 11/62 (18%) presented results aspercentages according to meaningful thresholds; 9/62 (14%): both forms.- 21/24 (88%) studies reportingproductivity costs,provided data on natural volumes (days/hours) used to calculate costs.

*The number of studies in denominators vary by methodological issue.

Results:

We included 62 original studies in IA (23 RCTs, 16 interventional and 23 non-interventional observational studies) and 28 SLRs in other chronic diseases. The methodological aspects most often neglected in original studies (Table 1) were: the choice of the study design in relation to the work-related study objective; definitions of the WP outcome domains considered; accounting for skewness of the work outcome; consideration of work-related contextual factors; reporting attrition and its reasons and reporting both aggregated results as well as proportions of individuals based on predefined meaningful thresholds. SLRs on other chronic diseases confirmed high heterogeneity and methodological flaws in all the 6 key methodological areas without identifying new problematic areas.

Conclusion:

High methodological heterogeneity was observed in studies with WP. Consensus around the key methodological aspects is needed to homogenise and improve the quality of future studies. This review informs the EULAR PtC for the conduction and reporting of studies with WP as an outcome domain in IA.

Disclosure of Interests:

Alessia Alunno: None declared, Mary Lucy Marques: None declared, Annelies Boonen Grant/research support from: AbbVie, Consultant of: Galapagos, Lilly (all paid to the department), L. Falzon: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Polina Putrik: None declared

THU0265 THYMIC STROMAL LYMPHOPOIETIN (TSLP) AS A BIOMARKER OF PRIMARY SJÖGREN’S SYNDROME (PSS) AND RELATED LYMPHOMA: VALIDATION IN INDEPENDENT COHORTS

Background:

Thymic stromal lymphopoietin (TSLP) has been implicated in primary Sjögren’s syndrome (pSS) and related B-cell lymphoproliferation/lymphoma (NHL) by tissue studies on salivary glands (SG) (1). It resulted significantly higher in the serum of pSS patients compared to non-pSS sicca and to healthy subjects, with the highest levels found in NHL.

Objectives:

The purpose of this work was to confirm that serum TSLP is elevated in pSS by the study of independent cohorts.

Methods:

Serum TSLP levels were measured by ELISA in 91 pSS patients (F=86, 94.5%; mean age 57.2 years, 25-80) from the Udine cohort (cohort 1, UD), Italy. One additional multicentre cohort (cohort 2) from the Italian SS Study Group (GRISS) was studied, including 125 pSS patients from the Universities of Roma (RO), L’Aquila (L’AQ), Pisa (PI) and Perugia (PG). pSS patients with active NHL (n=12 in cohort 1; n=1 in cohort 2) were excluded from comparative analyses to avoid bias. Secondly, additional serum samples from pSS-related NHL in stable and complete remission, from both cohort 1 and 2, were analysed in a separate subgroup (n = 12). Thirdly, a preliminary evaluation of serum TSLP was performed in pSS patients from a different geographical area (University of Athens, Greece; cohort 3).

Results:

Cohort 2 included 125 pSS patients (F=114, 91.2%; mean age 58.1 years, 23-84): 124 benign, 1 with NHL. In this cohort, serum TSLP levels were confirmed to be high (mean 30.26 pg/mL, 0.41-95.21) and comparable to cohort 1 (mean 33.81 pg/mL, 0-140.8; p=ns). No difference was found by the separate analysis of pSS from each single Centres (RO n=49, mean 33.21, 1.4-95.21; L’AQ n=34, mean 38.6, 16.31-85.11; PI n=28, mean 20.23, 0.41-56.67; PG n=13, mean 19.39, 1.03-68.38; p=ns), and vs cohort 1 (p=ns). The only patient in cohort 2 with NHL showed serum TSLP of 160.91 pg/mL, comparable to the mean TSLP in the 12 UD pSS-NHL (151.96 pg/mL). Importantly, in pSS-related NHL in stable remission, serum TSLP resulted undetectable (7/13) or detectable at very low levels (6/13) (mean 10.46, 0-38.5), and significantly lower than in benign pSS patients from the two cohorts (n=203, mean 31.48, 0-140.8; p=0.0022). Metachronous samples from one patient, at the stage of NHL activity and then at NHL remission, showed a decrease in TSLP from 128.04 pg/mL to undetectable levels. Finally, TSLP levels were increased also in the Greek cohort (mean 54.9, 26.72-78.95), and significantly higher than the two Italian cohorts (p=0.0085 and p<0.0001, vs cohort 1 and 2, respectively).

Conclusion:

Serum TSLP levels are increased in pSS, as herein confirmed in independent cohorts. TSLP might be important in the disease pathophysiology and mirrors the course of pSS-related B-cell lymphoproliferation itself. It may thus represent a novel important biomarker.

References:

[1]Gandolfo S. et al, Clin Exp Rheumatol. 2019 May-Jun;37 Suppl 118(3):55-64.

Disclosure of Interests:

Saviana Gandolfo: None declared, Cinzia Fabro: None declared, Serena Colafrancesco: None declared, Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Francesco Ferro: None declared, Elena Bartoloni Bocci: None declared, Efstathia Kapsogeorgou: None declared, Andreas Goules: None declared, Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Roberta Priori: None declared, Alessia Alunno: None declared, Guido Valesini: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer, Roberto Gerli: None declared, Chiara Baldini: None declared, Athanasios Tzioufas: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis

THU0576 EMPOWERING PEOPLE WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES TO BE AT THE HEART OF MEDICAL EDUCATION: A EULAR SCHOOL OF RHEUMATOLOGY INITIATIVE

Background:

The earliest examples of active patient involvement in teaching are interventions in which the patient was teaching students how to conduct physical examinations. Over the last two decades, educators have used the expertise of patients to enrich the education of undergraduate physicians and health professionals (HP) in several ways, mainly asking people to outline their own stories. Early patient involvement also aims to sensitise students to pursue a holistic approach and ultimately to build a trustful physician-patient relationship. Most studies report that high patient involvement brings benefits to both learners and patients. Learners report higher satisfaction. Patients report raised self-esteem and empowerment, new insights into their problems and deeper understanding of the physician-patient relationship.

Objectives:

To develop a novel educational framework within the EULAR School of Rheumatology for people with rheumatic and musculoskeletal diseases (RMDs) who are willing to be involved in teaching undergraduate physicians and HPs (Patient Education Partners, PEPs).

Methods:

A multidisciplinary working group including people with RMDs, 1 Rheumatologist, 1 HP in rheumatology and 1 educationalist was established. The project was developed through a questionnaire launched in May 2019, to patient associations across Europe, 2 face to face meetings and online teleconferences.

Results:

Patient associations from 23 European countries responded to the questionnaire and in 10 of them (43%), there have been programmes running for up to 31 years which involve patients with RMDs in undergraduate education. To some extent, 485 people with RMDs have been trained over the years across Europe. However, there are different country and disease-specific types of training and a lack of standardised training for patients involved in these programs. The patient associations from countries that do not have the programme would be interested in taking part, if such initiative were to be developed. The topics that people would like to cover when teaching medical and other health professions students are: disease specific factors, doctor-patient communication, personal history and physical examination, the importance of education and work to the individual, the importance of disease self-management. A subsequent mapping of European countries was undertaken to identify best practice examples of existing programmes: Germany, Denmark, Belgium, Ireland and the UK were included. From these foundations, we developed a new on-line Course, to equip patients with a basic medical knowledge about their disease and effective communication strategies.

Conclusion:

We established a European framework to train people with RMDs who were willing to be involved in teaching undergraduate physicians and HPs. This will allow them to gain confidence and effective communication skills to share their lived experience and become PEPs. The content of the course is currently being developed and all EULAR pillars are involved. Participation in this training course, particularly by people from countries that do not yet engage patients in undergraduate education, may facilitate the implementation of such initiatives, and ultimately improve the training of physicians and HPs across Europe.

References:

[1]Wykurz G et al. BMJ 2002;325:818

[2]Walters K et al. BMJ 2003;326:740

Disclosure of Interests:

None declared

FRI0565 PREVALENCE AND SIGNIFICANCE OF ANTIBODIES AGAINST CITRULLINATED ALPHA-ENOLASE (ANTI-CEP1) IN CONNECTIVE TISSUE DISEASES

Background:

Anti-cyclic citrullinated peptide (anti-CCP) auto-antibodies represent the current gold standard for the diagnosis of rheumatoid arthritis (RA). However, growing evidence suggests that a variety of other citrullinated self-proteins may act as autoantigens and lead to the production of autoantibodies (1). Furthermore, autoantibodies believed to be RA-specific have been detected also in patients with connective tissue diseases (CTDs). We recently demonstrated that antibodies against citrullinated alpha-enolase (anti-CEP1) are a biomarker of erosive disease and RA-associated interstitial lung disease (2).

Objectives:

The purpose of this study was to investigate the prevalence and possible prognostic value of anti-CEP-1 in patients with CTDs.

Methods:

Two hundred and twelve consecutive patients with CTDs (51 systemic lupus erythematosus (SLE), 85 primary Sjogren’s syndrome (pSS) and 76 systemic sclerosis (SSc)) were studied and compared to 97 sex and age matched normal controls (NC) and 267 patients with RA. Anti-CEP1 IgG were detected in serum samples with a commercial ELISA kit (Euroimmun).

Results:

The overall prevalence of anti-CEP1 in CTDs was 7% (15/212 patients). In detail, these antibodies were detectable in 4 out of 85 pSS (5%), 5 out of 51 SLE (10%) and 6/76 SSc (8%). The prevalence and the titer of anti-CEP1 in CTDs was significantly higher compared to NC and significantly lower compared to RA. Anti-CEP1 positive patients did not display a specific clinical and serological picture. Unlike in RA, anti-CEP1 did not correlate with CTD-associated ILD.

Conclusion:

This is the first study assessing anti-CEP1 in a large cohort of patients with CTDs. We demonstrated that the association of these autoantibodies with ILD is specific for RA since it is not observed in SLE, pSS and SSc. Furthermore, although being significantly more prevalent and at higher titer compared to NC, anti-CEP1 do not allow to discriminate different patient subsets displaying peculiar clinical or serological phenotypes. Based on our results, the application of anti-CEP1 in CTDs is not advisable, however larger studies may possibly identify correlations not evident in our cohort.

References:

[1] Bonifacio AF, Alunno A, La Paglia GMC, Valentini E, Leone MC, Bartoloni E, Gerli R. Novel autoantibodies in rheumatoid arthritis. Reumatismo 2019;71(1):1-12

[2] Alunno A, Bistoni O, Pratesi F, La Paglia GMC, Puxeddu I, Migliorini P, Gerli R. Anti-citrullinated alpha enolase antibodies, interstitial lung disease and bone erosion in rheumatoid arthritis. Rheumatology (Oxford). 2018;57(5):850-855

Disclosure of Interests:

Alessia Alunno: None declared, Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Onelia Bistoni: None declared, Matteo Antonucci: None declared, Elena Bartoloni Bocci: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer, Roberto Gerli: None declared

AB1083 CURRENT PRACTICE AND OPINIONS ON IMAGING-GUIDED INTERVENTIONAL PROCEDURES IN RHEUMATIC AND MUSCULOSKELETAL DISEASES: INTERIM RESULTS OF A MULTINATIONAL MULTIDISCIPLINARY SURVEY TO INFORM EULAR POINTS TO CONSIDER

Background:

maging is widely used for diagnostic purposes in patients with rheumatic and musculoskeletal diseases (RMDs). In recent years, it is increasingly used also to guide interventional procedures. However, the extent of imaging application for this purpose as well as the different technical standards employed across Europe are not known.

Objectives:

To learn how much imaging is used for interventional procedures in RMDs. To explore the technical standards employed in different settings and how important they are rated by users.

Methods:

As part of the work of a multidisciplinary EULAR Task Force to develop recommendations for the use of imaging to guide interventional procedures in patients with RMDs, a survey was developed. The survey explored aspects of different interventional procedures (e.g. joint aspiration/injection) such as the use of imaging guide and the technical standards. Respondents provided also a 0-10 rating of how important they considered the same conditions/items with regard to each procedure. The survey was distributed to: rheumatologists across Europe, USA, Central America, South America, Asia and Pacific Area, HPs across Europe, European and American associations of other specialities (e.g. radiology, anaesthesiology). The survey was launched in December 2019. Interim results after 4 weeks are presented.

Results:

200 responses from 36 countries were collected. The respondents were mainly rheumatologists (90%) (Figure 1). 90% of respondents performed interventional procedures related to RMDs and of these, 76% use imaging guide. Ultrasonography (US) is the most commonly used technique (96%) followed by X-ray/fluoroscopy (13%). Among respondents using imaging guide, 60% received training on both imaging and imaging-guided procedures, 20% only on imaging and 16% no training. 49% of respondents perform the whole procedure using direct image guidance, 21% use imaging to find the appropriate anatomical landmark and then perform the procedure blindly. Air and contrast agent to control needle placement are rarely used (≤20%). Respondents provided also a rating (0-10) of how important they considered different technical conditions/items for each procedure and an estimate on a Likert scale of how often they used them for each of the procedures (Figure 1 shows an example). In most cases respondents use always/most of the times the conditions/items that they considered important. Discrepancies were mainly due to barriers at their own center.

Conclusion:

Imaging, mainly US, is widely used to guide interventional procedures. However, training is not homogeneous and the use of imaging guide as well as technical conditions are based on the operator’s opinion/experience. This survey will inform the EULAR points to consider for the use of imaging to guide interventional procedures in patients with RMDs.

Table 1.

Characteristics of respondents (n=200) N

N%Age≤ 30381931 –35562836 – 39502540 - 493316.5≥ 502311.5GenderFemale8944.5Male11155.5Specialty/PositionRheumatology18090Radiology115Physical medicine and rehabilitation31.5Pediatrics42Non-clinical researcher31.5Health professionals31.5Other31.5

Disclosure of Interests:

Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Philipp Bosch: None declared, 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, Carlo Alberto Scirè: None declared, Alessia Alunno: None declared, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Christian Dejaco: None declared

AB0369 EFFICACY AND SAFETY OF RITUXIMAB ORIGINATOR AND BIOSIMILAR IN PRIMARY SJÖGREN’S SYNDROME IN A REAL-LIFE SETTING

Background:

Over the last 2 decades rituximab (RTX) has been widely used, albeit off-label, in primary Sjögren’s syndrome (pSS). Several studies reported that B-lymphocyte depletion with RTX is effective in this disease not only by reducing disease activity but also by affecting the inflammation and the lymphoid organization that occur in target tissues. With the recent release of several RTX biosimilars (bRTX) on the market, the demonstration of their interchangeability with RTX originator (oRTX) is required.

Objectives:

To compare efficacy and safety of oRTX and bRTX in pSS patients in a real-life setting.

Methods:

Clinical records of pSS patients referring to a tertiary rheumatology clinic were retrospectively evaluated. Patients having received at least 2 courses of either oRTX or bRTX (1000 mg IV infusion, repeated after 2 weeks -1 course- and the course repeated after 24 weeks) with complete data at baseline and after 3, 6, 9 and 12 months of treatment were enrolled. Disease activity was assessed with the EULAR SS disease activity index (ESSDAI) and its clinical version without the biological domain (ClinESSDAI). Patient-reported symptoms were assessed with the EULAR SS Patient Reported Index (ESSPRI).

Results:

Seven patients that received oRTX and 7 patients that received bRTX were enrolled. Baseline clinical features, including ESSDAI and ESSPRI were similar in the 2 treatment groups. Both compounds significantly reduced ESSDAI and ESSPRI as early as 3 months and no difference between the groups was observed at any time point (Figure 1). Of interest, ESSDAI slowly decreased until month 6 when the most pronounced reduction was observed. Conversely, ESSPRI dropped to its lowest values already at month 3. With regard to safety, at 12 months of follow-up no adverse event was observed in any of the treatment groups.

Conclusion:

At 12 months of follow-up, oRTX and bRTX display similar efficacy and safety profiles. The improvement of patient reported outcomes is faster than the improvement of disease activity with both compounds. Our data support interchangeability of oRTX and bRTX in pSS.

References:

[1]Carubbi F et al. Arthritis Res Ther. 2013;15(5):R172

[2]Carubbi F et al. Lupus. 2014;23(13):1337-49

Figure 1 ESSDAI and ESSPRI values at every time point in the 2 treatment groups. Asterisks indicate p values <0.05 compared to the other treatment group at the same time point

Disclosure of Interests:

Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Alessia Alunno: None declared, Paola Cipriani Grant/research support from: Actelion, Pfizer, Speakers bureau: Actelion, Pfizer, Viktoriya Pavlych: None declared, claudia di muzio: None declared, Roberto Gerli: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer

FRI0158 CLINICAL AND IMAGING FEATURES OF ARTICULAR MANIFESTATIONS IN PRIMARY SJÖGREN’S SYNDROME: SIMILARITIES AND DIFFERENCES ACCORDING TO THE TIME OF ONSET

Background:

Articular manifestations (AMs) are observed in a large proportion of patients with primary Sjögren’s syndrome (pSS) and can occur at the time of pSS diagnosis or during the disease course. Although in the majority of cases AMs are mild and self-limiting, some patients may experience chronic polyarthritis requiring treatment with DMARDs. However to date no specific discriminating biomarkers have been identified. Magnetic resonance imaging (MRI) can help assessing the extent of articular involvement and guide the treatment.

Objectives:

To describe clinical and serological features of patients with pSS developing articular involvement along with the MRI findings of affected joints.

Methods:

Clinical records were retrospectively evaluated and MRI was performed to evaluate AMs. Disease activity was assessed with the EULAR SS disease activity index (ESSDAI) and its clinical version without the biological domain (ClinESSDAI). Patient-reported symptoms were assessed with the EULAR SS Patient Reported Index (ESSPRI). MRI features were described according to the OMERACT rheumatoid arthritis (RA) MRI scoring system. Values are displayed as mean ± standard error of the mean or number and percentages. Patients were tested for autoantibodies such as anti-cyclic citrullinated peptide, anti-citrullinated α enolase and anti-carbamylated proteins with commercially available ELISA kits.

Results:

45 pSS patients were included. 29 patients (64%) displayed AMs at pSS onset while 15 (36%) at a later stage (6.7±1 years after pSS diagnosis). Besides AMs, at the time of pSS diagnosis the two cohorts were comparable with regard to other ESSDAI domains. Interestingly, all patients with anti-SSA and anti-/SSB had AMs at the time of pSS diagnosis (p=0.05) while those developing AMs in the disease course were more likely single positive for anti-SSA (p=0.04). When comparing the clinical and serological features of both groups of patients at the time of overt AMs (Tables 1-2), patients that displayed AMs in the course of the disease have a significantly higher ESSPRI compared to patients that display AMs at pSS onset. With regard to MRI, 80% of patients with AM displayed signs of synovitis, 59% bone erosions, 59% joint space narrowing and 50% bone marrow oedema. To note, 60% of patients displaying AMs at pSS onset show bone marrow oedema while this is present in only 27% of patients developing AMs at a later stage (p<0.05). Anti-cyclic citrullinated peptide, anti-citrullinated α enolase, anti-carbamylated proteins were undetectable in all patients.

Conclusion:

Our results confirm the relevance of AMs in pSS, particularly because of the high prevalence of RA-like MRI features. MRI assessment in patients with pSS is advisable to identify more severe AMs in the spectrum of pSS disease and guide the therapeutic approach.

Table 1.

Clinical and serological features at the time of overt AMs. Categoric variables

All AMs (N=44)AMs at pSS onset (n=29)AMs in the course of disease (N=15)N%N%N%p valueESSDAI domainsConstitutional37310000.54Lymphadenopathy15347248530.09Glandular9205174270.46Articular441002910015100naCutaneous614274270.15Pulmonary614517170.65Renal000000naMuscular000000naPNS6144142131CNS1200170.34Hematological10238282130.45Biological511134270.04Morning stiffness441002910015100naSmall joints2966175912800.31Large joints3727171Both122710342130.17Table 2.

Clinical and serological features at the time of overt AMs. Continuous variables

All AMs (N=44)AMs at pSS onset (n=29)AMs in the course of disease (N=15)p valueMEAN±SEMMEAN±SEMMEAN±SEMYears from pSS diagnosis2.3±0.606.7±1naVAS pain8.4±0.37.7±0.49.7±0.150.001VAS dryness7±0.45.6±0.57.5±0.60.02VAS fatigue6.3±0.46.3±0.58.5±0.70.02ESSPRI7.2±0.36.5±0.48.6±0.40.001ESSDAI18±1.616.8±1.820.2±30.32ClinESSDAI17.5±1.616.4±1.819.6±30.35N of involved joints5.5±46.3±0.84±0.50.06

Disclosure of Interests:

Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Alessia Alunno: None declared, Paola Cipriani Grant/research support from: Actelion, Pfizer, Speakers bureau: Actelion, Pfizer, Elena Bartoloni Bocci: None declared, Alessandro Conforti: None declared, Ilenia Di Cola: None declared, Roberto Gerli: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer

THU0580 EULAR TASK FORCE ON GENDER EQUITY IN ACADEMIC RHEUMATOLOGY: PRELIMINARY SURVEY FINDINGS

Background:

Women represent an increasing proportion of the overall rheumatology workforce, but are underrepresented in academic rheumatology, especially in leadership roles [1].

Objectives:

The EULAR Task Force on Gender Equity in Academic Rheumatology has been convened to establish the extent of the unmet need for support of female rheumatologists, health professionals and non-clinical scientists in academic rheumatology and develop a framework to address this through EULAR and EMEUNET.

Methods:

To investigate gender equity in academic rheumatology, an anonymous web-based survey was targeted at the membership of EULAR and Emerging EULAR Network (EMEUNET) and their wider networks. The survey was developed based on a narrative literature review [1], best practice from The Association of Women in Rheumatology, a survey of task force members and face-to-face task force discussions. Personal experiences were explored and 24 potential interventions to aid career advancement were ranked. Statistics were descriptive with significance testing for male/female responses compared using chi-squared/t-tests. The level of significance was set at p<0.001.

Results:

A total of 301 respondents from 24 countries fully completed the survey. By profession, 290 (86.4%) were rheumatologists, 19 (6.3%) health professionals, and 22 (7.3%) non-clinical scientists. By gender, 217 (72.1%) were women, 83 (27.6%) men, and 1 (0.3%) third gender. By age, 203 (67.5%) were 40 or under. By ethnicity, 30 (10.0%) identified themselves as ethnic minority. A high proportion of respondents reported having experienced gender discrimination (47.2% total: 58.1% for women and 18.1% for men) and sexual harassment (26.2%: 31.8% and 10.8% respectively) (Figure 1). Chi-squared tests on the numbers on which these proportions were based showed statistically significant differences between women and men in having experienced gender discrimination (Χ2=36.959 (df=1), p <0.001) and sexual harassment (Χ2=12.633 (df=1), p <0.001). The highest-ranked interventions for career advancement regardless of respondents’ gender included: leadership skills training; speaking/presentation/communication skills training; information on training/career pathways; effective career planning training; support on grant writing applications; and high-impact scientific writing master-classes (Figure 2). Only 8 of 24 proposed interventions showed a significantly higher ranking (p<0.001) by female respondents and these typically related to promotion of female role models and gender-balance in committees, editorial boards and research funding (Figure 2).

Figure 1.

Perceived gender discrimination and sexual harassment, 301 responses

Figure 2.

Mean perceived utility of potential interventions for career advancement by gender and statistically significant gender differences (p<.001), 300 responses

Conclusion:

The results of the survey will inform the development of task force policy proposals for interventions to support career advancement among EULAR and EMEUNET members. The identified interventions have potential to support career advancement of all rheumatologists, health professionals and non-clinical scientists regardless of gender.

References:

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

Acknowledgments:

We gratefully acknowledge the rheumatologists, health professionals and non-clinical scientists who responded to the survey.

Disclosure of Interests:

Pavel V Ovseiko: None declared, Laure Gossec Grant/research support from: Lilly, Mylan, Pfizer, Sandoz, Consultant of: AbbVie, Amgen, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sandoz, Sanofi-Aventis, UCB, Laura Andreoli: None declared, Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB, Leonieke van Mens: None declared, Neelam Hassan: None declared, Marike van der Leeden: None declared, Heidi J Siddle: None declared, Alessia Alunno: None declared, Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Florence Apparailly: None declared, Caroline Ospelt Consultant of: Consultancy fees from Gilead Sciences., Irene van der Horst-Bruinsma Grant/research support from: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Consultant of: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Elena Nikiphorou: None declared, Katie Druce Speakers bureau: Pfizer and Lilly, Zoltán Szekanecz Grant/research support from: Pfizer, UCB, Consultant of: Sanofi, MSD, Abbvie, Pfizer, Roche, Novertis, Lilly, Gedeon Richter, Amgen, Alexandre Sepriano: None declared, Tadej Avcin: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Anne Maree Keenan: None declared, Laura C Coates: None declared

AB0674 CLINICAL AND IMAGING FEATURES IN SPONDYLOARTHRITIS PATIENTS WITH AND WITHOUT HLA-B27 AND HLA-B51

Background:

Despite being commonly expressed in the general population, the human leucocyte antigen (HLA)-B27 allele strongly increases the susceptibility to develop spondyloarthritis (SpA). Likewise, the association between the HLA-B51 allele and the development of Behçet’s disease is well documented. However, the exact mechanisms responsible for their pathologic role are still a matter of debate. Moreover, anecdotal reports show an association between HLA-B51 and the clinical spectrum of SpA.

Objectives:

To investigate the clinical and imaging findings of SpA patients according to the absence or presence of HLA-B27 or HLA-B51.

Methods:

We retrospectively analyzed 236 patients with axial or peripheral SpA, according to the ASAS criteria, referring to two tertiary Rheumatology Clinics between 2017 and 2019. All patients had been tested for HLA-B alleles. Patients with HLA-B51 haplotype and fulfilling the criteria for Behçet’s disease were excluded.

Results:

Table 1 shows demographic and clinical features of patients, according with the HLA-B haplotype (neither HLA-B27 nor -B51, double negative; positive for HLA-B27 only, positive for HLA-B51 only). Inflammatory low back pain and sacroiliitis, assessed by X-ray or magnetic resonance imaging (MRI), were more prevalent in double negative and HLA-B27 patients, compared to HLA-B51 patients. In this regard, the presence of HLA-B51 was negatively associated with axial manifestations at onset (OR 0.347, 95% CI 0.200-0.604, p<0.0001) and in the course of the disease (low back pain: OR 0.395, 95% CI 0.225-0.689 p<0.0001; sacroiliitis on imaging: OR 0.342 CI 0.189-0.619 p<0.0005). When considering extra-articular manifestation, aphtous lesions were more prevalent in patients with HLA-B51 (p< 0.0001), inflammatory bowel diseases in the double negative group (p=0.0006), and increased C-reactive protein in double negative and HLA-B27 patients (p=0.02).

Table 1.All (236 patients)Double-negative (101 patients)HLA-B27 (53 patients)HLA-B51 (82 patients)p valueFemale (%)167 (71)73 (72)28 (53)66 (60)0.0024 (cumulative)Age, years (mean±SD)53.7±13.356.4±12.7#48.2±14.4$54±12.7#<0.01 vs HLA-B27$< 0.05 vs HLA-B51Age at diagnosis, years (mean±SD)48±14.550.3±13*40.8±15.5§50.2±14.3*<0.001 vs HLA-B27§<0.001 vs HLA-B51Time from symptoms to diagnosis, years (mean±SD)3.8±5.73.6±4.83.2±3.74.4±7.5nsType of onset:0.0031 (cumulative)-Axial (%)129 (55)67 (66)31 (59)31 (38)-Peripheral (%)63 (27)19 (19)12 (23)32 (39)-Axial and peripheral (%)44 (19)15 (15)10 (19)19 (23)

Conclusion:

The presence of HLA-B51 identifies a subgroup of SpA patients with peculiar features compared to double-negative or HLA-B27 SpA patients. HLA-B51-related SpA may be an additional condition to be included in the SpA spectrum.

References:

[1]Bodis G, et al. Role of Human Leukocyte Antigens (HLA) in Autoimmune Diseases. Rheumatol Ther 2018;5:5–20.

[2]Rudwaleit M, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis 2009;68:777–83.

[3]Rudwaleit M, et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis 2011;70:25–31.

[4]Maksymowych WP, et al. MRI lesions in the sacroiliac joints of patients with spondyloarthritis: an update of definitions and validation by the ASAS MRI working group. Ann Rheum Dis. 2019;78:1550-1558.

Disclosure of Interests:

Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Alessia Alunno: None declared, Alessandro Conforti: None declared, Angelo Francesco Bonifacio: None declared, Paola Cipriani Grant/research support from: Actelion, Pfizer, Speakers bureau: Actelion, Pfizer, Roberto Gerli: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer

THU0583 STRATEGIES FOR ASSESSMENT OF COMPETENCES DURING RHEUMATOLOGY TRAINING ACROSS EUROPE: RESULTS OF A QUALITATIVE STUDY

Background:

In order to become a rheumatologist, trainees must successfully complete a rheumatology training program. Both the content and the assessments within these programs are regulated by national authorities, and therefore a wide heterogeneity between countries is expected.

Objectives:

To gain insight into current methods and practices for the assessment of competences during rheumatology training, and to explore the underlying priorities and rationales for competence assessment across EULAR countries.

Methods:

We used a qualitative approach through online focus groups of rheumatology trainers and trainees, separately. The study included five countries - Denmark, The Netherlands, Slovenia, Spain and United Kingdom. A summary of current practices of assessment of competences was developed, modified and validated during the focus groups. A prioritising method (9 diamond technique) was then used to identify key assessment priorities.

Results:

Overall, 26 participants (12 trainers, 14 trainees), participated in 9 online focus groups (2 per country, except Slovenia), totalling 12 hours of online discussion. Strong nationally (Netherlands, UK) or institutionally (Spain, Slovenia, Denmark) standardised approaches were described. Current practices were described as follows: two countries only provide national summative assessments (Slovenia, UK), while all were providing formative assessments regularly at varying frequencies. All groups identified providing frequent formative feedback to trainees for developmental purposes as the highest priority (figure 1). Most discussions identified a need for improvement, particularly in developing streamlined approaches to portfolios that remain close to clinical practice, protecting time for quality observation and feedback, and adopting systematic approaches to incorporating teamwork and professionalism into assessment systems.

Figure 1.

Priorities on assessment of competences for all participants and stratified by trainees and trainers.

Conclusion:

This paper presents a clearer picture of the current practice on the assessment of competences in rheumatology in key countries and the underlying rationale of trainers’ and trainees’ priorities. This work informed the EULAR Points-to-Consider for the assessment of competences in rheumatology training across Europe.

Acknowledgments:

This work was funded by EULAR (EDU043)

Disclosure of Interests:

Aurelie Najm: None declared, Alessia Alunno: None declared, Francisca Sivera: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Catherine Haines: None declared

Novel autoantibodies in rheumatoid arthritis

Rheumatoid factor and antibodies against cyclic citrullinated peptides represent a diagnostic hallmark in rheumatoid arthritis (RA). However, over the last decades many other autoantibodies have been identified. Several proteins can trigger an aberrant autoimmune response in their native form while others acquire this feature after post-translational modifications such as citrullination, carbamylation or acetylation. It is of interest that also the enzymes catalyzing such post-translational modifications (e.g. the protein arginine deiminases) can transform themselves into autoantibodies in RA. The purpose of this review article is to provide an overview of relevant literature published over the last years regarding novel autoantibodies and their possible diagnostic and prognostic significance in RA.

Extra-articular rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease that mainly affects the joints, though a consistent proportion of patients may also display extra articular manifestations (EAMs). From rheumatoid nodules to interstitial lung disease, from cardiovascular events to vasculitis, the spectrum of EAMs encompasses various conditions with different prognoses. EAMs may also occur as first RA manifestation, therefore the coordination with other health professionals, including general practitioners, is needed. The aim of this article is to provide an overview on EAMs in RA with particular focus on the recognised risk factors and the available recommendations for managing them, as well as comorbidities in RA patients.

Histopathology of salivary glands

Salivary gland (SG) biopsy is a technique broadly applied for the diagnosis of primary Sjögren's syndrome (pSS), lymphoma accompanying SS, sarcoidosis, amyloidosis, and IgG4-related disease The most peculiar feature of pSS on biopsy is focal lymphocytic sialadenitis. In the past, several histological scores have been reported in the literature to describe glandular involvement during pSS. However, the variability among centres in reporting glandular scores is one of the rationales behind the development of standardised consensus guidance. SGs as well as lacrimal glands are involved in up to 50% of patients with IgG4-related disease with 3 histopathological hallmarks such as dense lymphoplasmacytic infiltration, storiform fibrosis and obliterative phlebitis. SGs can be also affected by amyloidosis with MSG biopsy being more sensitive than that of rectal mucosa or subcutaneous fat. SG involvement is a rare manifestation during sarcoidosis, and the presence of non-caseating granulomas needs to be differentiated from granulomas of other etiology. This review article provides an overview of normal and pathological SGs in the context of rheumatic diseases, identifying key elements in the tissue as diagnostic and prognostic biomarkers, useful in the current clinical practice.

Association between anti-citrullinated alpha enolase antibodies and clinical features in a cohort of patients with rheumatoid arthritis: a pilot study

In recent years several antibodies against citrullinated peptides (ACPAs) have been identified in patients with rheumatoid arthritis (RA) and their pathogenic, diagnostic and prognostic significance is under intense investigation. Among ACPAs, those targeting citrullinated alpha enolase (anti-CEP1) have been identified in RA but data about their ability to predict the development of erosive disease are conflicting. Furthermore, no data are currently available concerning their possible association with extra-articular manifestations (EAMs) in RA. The aim of this study was to investigate the prevalence and significance of anti-CEP1 from a prognostic point of view. In this pilot study we confirmed that anti-CEP1 Abs are associated with higher prevalence of bone erosions, but we also provided the first evidence of an association between anti-CEP1 Abs and RA interstitial lung disease (ILD). These results provide the basis to investigate the association between anti-CEP1 Abs and EAMs in larger cohorts of RA patients to possibly confirm its role as biomarker for RA-ILD.

The clinical spectrum of primary Sjögren's syndrome: beyond exocrine glands

Although primary Sjögren's syndrome (pSS) is a mild indolent chronic disease mainly characterized by mucosal dryness in the majority of cases, a consistent subgroup of patients display extra-glandular manifestations. Virtually any organs and systems can be affected, leading to a more serious disease prognosis. Therefore, the prompt identification of patients at higher risk of extra-glandular manifestations is necessary to start a thorough follow up and an aggressive treatment. The aim of this review article is to provide an overview of epidemiological, clinical and serological features of extra-glandular manifestations in pSS as well as current knowledge about putative biomarkers useful in clinical practice.

Role of Inflammatory Diseases in Hypertension

Chronic inflammatory diseases (CID) are characterized by an increased risk of cardiovascular (CV) morbidity and mortality. Several mechanisms, including early acceleration of subclinical atherosclerotic damage, inflammatory markers and immune system deregulation factors, have been demonstrated to strictly interplay for development and progression of atherosclerosis. Moreover, traditional CV risk factors are likely to explain at least some of the excess of CV risk in these patients. Among traditional CV risk factors, compelling evidence suggests a higher incidence and prevalence of hypertension in patients with CID in comparison to the general population. Moreover, hypertension represents an important predictor of CV events in these patients. Pathogenic mechanisms underlying the rise of blood pressure in CID are multifactorial and still poorly investigated. Indeed, multiple disease-related factors may affect blood pressure control in these patients and hypertension may affect disease prognosis and increase CV risk. Better knowledge of the complex interplay between hypertension and CID will be important to elucidate pathogenic mechanisms and to improve CV outcome in these patients. Aim of this review is to highlight available evidence on the relationship between hypertension and CID and to elucidate the multiple factors that may affect blood pressure control in these disorders.

The onset site of rheumatoid arthritis: the joints or the lung?

The etiopathogenesis of rheumatoid arthritis (RA) is not yet fully elucidated and the site of inflammation onset is still a matter of debate. The presence of autoantibodies as well as clinical manifestations, such as interstitial lung disease, before the onset of arthritis seems to be in favour of the hypothesis that initial pathogenic events take place in tissues other than the joint. In this review article we summarize the most recent literature on extra-synovial autoimmunity triggers eventually leading to RA, with particular focus on the role of the lung. To date, anti-cyclic citrullinated peptide antibodies (ACPAs) are considered central players in RA pathogenesis and represent the gold-standard for disease diagnosis. Lungs and mucosae are exposed to environmental stimuli such as dusts and smoke which have been shown to foster citrullination of peptides in lungs thereby triggering the production of ACPA. In addition, other mechanisms of disease pathogenesis independent of citrullination play an important role. Deeper knowledge of these processes could represent a huge step forward in the management of RA, with dramatic impact on diagnosis, prevention, prognostic stratification and treatment of the disease.

Interleukin (IL)-17-producing pathogenic T lymphocytes co-express CD20 and are depleted by rituximab in primary Sjögren's syndrome: a pilot study

Compelling evidence suggests that interleukin (IL)-17 and IL-17-producing cells play a pivotal role in the pathogenesis of primary Sjögren's syndrome (pSS). We investigated phenotypical and functional effects of the anti-CD20 antibody rituximab (RTX) on circulating and glandular IL-17-producing T cells in pSS. RTX is able to deplete glandular IL-17(+) CD3(+) CD4(-) CD8(-) double-negative (DN) and CD4(+) Th17 cells as well as circulating IL-17(+) DN T cells. A fraction of glandular and circulating IL-17(+) DN cells and CD4(+) T helper type 17 (Th17) cells co-expresses CD20 on the cell surface explaining, at least in part, such depletive capacity of RTX. The exposure to RTX does not rescue the in-vitro corticosteroid resistance of IL-17(+) DN T cells. Our results support further the therapeutic role in pSS of RTX that, despite its B cell specificity, appears able to also hamper IL-17-producing T cells in this disease.