POS0910 EVALUATION OF THE NONSTEROIDAL ANTI-INFLAMMATORY DRUG-SPARING EFFECT OF SECUKINUMAB IN PATIENTS WITH ANKYLOSING SPONDYLITIS: RESULTS OF THE MULTICENTER, RANDOMISED, DOUBLE-BLIND, PHASE IV ASTRUM-TRIAL

Background:

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat inflammatory back pain in patients (pts) with ankylosing spondylitis (AS). However, an increased risk of side effects associated with NSAIDs and their dosage has been reported1. Therefore, lower doses and a dose reduction is desirable.

Objectives:

To evaluate the short-term NSAID sparing effect of secukinumab (SEC) in AS pts with NSAID intake.

Methods:

In a prospective controlled trial, 211 adult pts with active AS (BASDAI ≥4) and an inadequate response (IR) to at least 2 NSAIDs at the highest recommended/tolerated dose and pts with an IR, or those who were naïve/intolerant to a maximum of 2 tumour necrosis factor inhibitors (TNFi) were enrolled. NSAID intake was evaluated using the ASAS-NSAID score. To be eligible, pts had to take at least 50% of the highest recommended/tolerated NSAID dose regularly. Pts were randomised (1:1:1) to receive SEC 150 mg s.c. from Week (Wk) 0 (group [gp] 1), Wk 4 (gp 2) and Wk 16 (gp 3). All groups received SEC 150 mg from Wk 16. NSAID tapering was allowed in all groups from Wk 4 onwards. The primary endpoint (PE) was an ASAS20 response of pooled gp 1 and gp 2 vs. gp 3 at Wk 12.

Results:

There were 71 pts in gp 1, 70 in gp 2 and 70 in gp 3. Baseline (BL) characteristics were comparable across groups; mean age (SD) was 45.2 (12.3) years (yrs), time since diagnosis was 7.4 (9.8) yrs, 57.8% male, 79.0% HLA-B27 positive, 48.6% pts had an elevated CRP 40.8% were current/ever smoker and 72.0% were TNFi-naïve. The ASAS-NSAID (SD) scores at BL were: gp 1 vs. gp 2 vs. gp 3: 82.9 (37.7) vs. 79.9 (45.3) vs.82.3 (39.1). BASDAI and ASDAS-CRP scores were similar between groups: 6.0 (1.4) vs. 6.2 (1.5) vs. 6.2 (1.3), and 3.4 (0.7) vs. 3.3 (0.8) vs. 3.4 (0.7), respectively. The ASAS20 response at Wk 12 of pooled gp 1 and 2 vs. gp 3 was 51.1% vs. 44.3% but PE was not met (p=0.35). A higher proportion of pts in gp 1 and 2 achieved ASAS40 and BASDAI50 and other secondary outcomes at Wk 16 (Table 1). More pts in gp 1 and 2 reduced their NSAID intake from BL through Wk 16 vs. gp 3 (Table 1 and Figure 1).

Conclusion:

In this population of pts with AS, SEC provided clinical improvements in conventional clinical outcomes and a short-term NSAID sparing effect.

References:

[1]Burmester G, et al. Ann Rheum Dis 2011;70:818-822.

Table 1.

Effect of SEC 150 mg s.c. in AS pts (Intention-to-Treat population) at Wk 16

(%), unless otherwise specifiedGroup 1 (N=71)(SEC 150 mg from BL until Wk 20)Group 2 (N=70)(PBO from BL until Wk 4; SEC 150 mg from Wk 4)Group 3 (N=70)(PBO from BL until Wk 16; SEC 150 mg from Wk 16)ASAS20*56.350.041.4ASAS40*43.7§32.921.4ASAS5/6*39.4‡32.921.4ASAS-PR*8.520.0‡5.7ASAS20 TNF-IR^*60.0‡‡26.345.0 TNF-naïve^^*54.958.8‡40.0ASAS40 TNF-IR^*45.015.825.0 TNF-naïve^^*43.1‡39.2‡20.0ASDAS-CRP change (mean±SD)**-1.2±0.9§-1.0±0.9‡-0.7±0.8BASDAI change (mean±SD)***-2.3±1.9‡-2.0±2.0-1.7±2.0BASDAI50+32.428.622.9ASAS-NSAID score change (mean±SD)++-51.5±46.2‡-42.5±68.6-33.7±38.8ASAS-NSAID score decrease ≥50%*64.8‡58.642.9 <10*52.1§45.7‡28.6 =0*32.4‡38.6§17.1

AS, ankylosing spondylitis; ASAS, Assessment of SpondyloArthritis International Society; ASDAS, AS Disease Activity score; BASDAI, Bath AS Disease Activity Index; BL, baseline; CRP, C-reactive protein; IR, inadequate responder; NSAID, nonsteroidal anti-inflammatory drug; N, total number of subjects in each treatment gp; PBO, placebo; PR, partial remission; pts, patients; SEC, secukinumab; TNFi, tumour necrosis factor inhibitor; Wk, week.

†p<0.001; §p<0.01 and ‡p<0.05 vs. gp 3; ‡‡p<0.05 vs. gp 2

*p-values are from a logistic regression model with treatment, TNFi status (IR / naïve) and CRP status (>/ ≤ central lab ULN) as factors.

+p-values are from MMRM with treatment, TNFi status (IR / naïve), CRP status (>/ ≤ central lab ULN) and visit as factors, BL value as continuous covariate.

*+Missing values were imputed as non-response.

Observed data (pts) for gp 1, 2, 3, respectively:

**67, 66, 62

***67, 66, 63

++67, 67, 65

^20, 19, 20

^^51, 51, 50

Disclosure of Interests:

Uta Kiltz Speakers bureau: AbbVie, Biocad, Chugai, Eli Lilly, Grünenthal, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: AbbVie, Biocad, Chugai, Eli Lilly, Grünenthal, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: Abbvie, Amgen, Biogen, Fresenius, GSK, Novartis and Pfizer, Xenofon Baraliakos Consultant of: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Jan Brandt-Juergens Speakers bureau: Abbvie, Pfizer, Roche, Sanofi-Aventis, Novartis, Lilly, MSD, UCB, BMS, Janssen, Medac, Consultant of: Abbvie, Pfizer, Roche, Sanofi-Aventis, Novartis, Lilly, MSD, UCB, BMS, Janssen, Medac, Ulf Wagner Speakers bureau: Pfizer, Novartis and Roche, Consultant of: Pfizer, Novartis and Roche, Grant/research support from: Roche, Novartis, BMS, Pfizer, Sebastian Lieb Employee of: Novartis, Christian Sieder Employee of: Novartis, Christian Mann Employee of: Novartis, Juergen Braun Speakers bureau: Abbvie, Amgen, Celltrion, Chugai, Medac, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: Abbvie, Amgen, Celltrion, Chugai, Medac, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: Abbvie, Amgen, Celltrion, Chugai, Medac, MSD, Novartis, Pfizer, Roche, and UCB

POS0033 IN RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS, BRIDGING SYNDESMOPHYTES INCREASE RISK OF FACET JOINT ANKYLOSIS ON THE SAME VERTEBRAL LEVEL WHILE FACET JOINT ANKYLOSIS DOES NOT INCREASE RISK OF SAME LEVEL SYNDESMOPHYTES

Background:

In radiographic axial spondyloarthritis (r-axSpA), spinal damage manifests as syndesmophytes and facet joint ankylosis (FJA).

Objectives:

Explore whether syndesmophytes and FJA seem to have a preferential order of development.

Methods:

Data were used from the Sensitive Imaging in Ankylosing Spondylitis cohort from Leiden and Herne. Patients underwent low-dose Computed Tomography (ldCT) at baseline and two-years. LdCT images were scored independently by two trained readers. Vertebrae were scored according to the Computed Tomography Syndesmophyte Score (CTSS) for presence and size of syndesmophytes; facet joints were scored as not-ankylosed and ankylosed. Analyses were performed on the vertebral unit (VU) level and using individual-reader data (Figure 1). Two hypotheses were tested: 1) presence of bridging syndesmophyte(s) is associated with FJA on the same VU two years later, and 2) presence of FJA is associated with syndesmophyte(s) on the same VU two years later. Generalized Estimating Equations (GEE) models were used to take into account the correlations between VUs from the same patient and adjusting for reader to account for individual reader scores. Two models were tested per hypothesis using different outcomes. Model 1 uses the presence of syndesmophytes or FJA as outcome adjusting for the outcome at baseline. Model 2 uses development of new syndesmophytes or FJA at two years plus an increase in the number of syndesmophytes or FJA.

Results:

In total, 50 patients were included (mean age 49, 84% male, 82% HLA-B27+). At baseline, there was a higher percentage of bridging syndesmophytes (range: 10-60%) than FJA (range: 8-36%) considering all VUs and both readers (Figure 1). In both models, presence of bridging syndesmophytes was associated with development of FJA two years later (OR (95%CI) Model 1: 3.35 (2.18-5.14); Model 2: 2.23 (1.19-4.16)) while presence of FJA at baseline did not have a statistically significant association with development of syndesmophytes two years later (Table 1).

Conclusion:

The data showed a higher occurrence of bridging syndesmophytes than FJA at baseline and showed significantly increased odds to develop FJA when bridging syndesmophyte(s) are present on the same VU two years prior. This mechanism did not hold true for the other direction. These results cautiously imply that bridging syndesmophytes precede FJA, rather than FJA preceding syndesmophytes.

Figure 1.

Percentage of occurrence of syndesmophytes and facet joint ankylosis per vertebral unit and per reader at baseline.

Figure 1 displaying percentages of patients with a bridging syndesmophyte and with facet joint ankylosis at baseline, per reader. The image on the left illustrates the vertebral unit level (VU) at which analyses were performed. Seven VUs are illustrated in dashed boxes as example. Synd, syndesmophyte; FJA, facet joint ankylosis; BL, baseline.

Table 1.

Associations between facet joint ankylosis and syndesmophytes

Model 1: development of new FJA/syndesmophytes at FUOR (95% CI)Model 2: development and/or increase FJA/syndesmophytes at FUOR (95% CI)Hypothesis 1Presence bridging syndesmophytes at BL on development of FJA at FU3.35 (2.18-5.14)2.23 (1.19-4.16)Hypothesis 2Presence FJA at BL on development of syndesmophytes at FU1.60 (0.88-2.91)1.12 (0.76-1.66)

Disclosure of Interests:

None declared.

POS0245 PERFORMANCE OF STANDARDIZED SCORES FOR DISEASE ASSESSMENT AND PAIN IN PATIENTS WITH SPONDYLOARTHRITIS AND FIBROMYALGIA

Background:

The pathogenesis of spondyloarthritis (SpA) including axial SpA (axSpA) and psoriatic arthritis (PsA) differs from fibromyalgia (FM). However, symptoms partially overlap and both patient groups suffer from pain and stiffness. In addition, SpA patients may also develop a secondary form of FM. Classification criteria for SpA and diagnostic criteria for FM are used to differentiate between these subsets. Patient reported outcomes (PRO) often generated by questionnaires are used to assess severity and other disease features.

Objectives:

To study whether PROs developed for axSpA, PsA, and related physician-based information behave in a similar way in patients diagnosed with FM without an additional chronic inflammatory rheumatic disease (CIRD) as in patients with a primary diagnosis of SpA without or with secondary FM.

Methods:

Patients were consecutively recruited. The main inclusion criterion was a clinical diagnosis of FM (without CIRD), axSpA or PsA (without or with secondary FM) and the indication for a treatment adaptation (escalation or change within the same class) for any reason, based on the judgement of experienced rheumatologists. Standardized assessment tools and lab parameters (BASDAI, ASDAS-CRP, DAPSA, patient´s and global assessment (NRS), CRP, BASFI, Fibromyalgia Impact questionnaire (FIQ), Leeds Enthesitis Index (LEI), Maastricht Ankylosing Spondylitis (MASES) and SpA Research Consortium of Canada (SPARCC) Enthesitis Score were assessed and compared between subgroups.

Results:

The baseline demographics of 300 recruited patients (100 FM. 100 axSpA and 100 PsA) are shown in Table 1. All patients with FM (primary or secondary to SpA) showed the highest scores in almost all assessments, and this was independent of the main diagnosis (Table 2). In comparison, patients with axSpA or PsA without secondary FM showed significantly lower scores in all PROs as compared to those with primary and secondary FM, with exception of (i) scores of ASDAS-CRP and (ii) duration of morning stiffness (Question 6 of BASDAI), which were not affected by the presence of secondary FM (Table 2).

Conclusion:

Secondary FM is leading to significantly higher levels of SpA-specific scores. ASDAS-CRP was the only score that was not influenced by the presence of secondary FM in patients with axSpA even though it was also increased in patients with primary FM, while similar results were found for the duration but not the level of morning stiffness. On the other hand, FM-specific questionnaires also showed high scores in patients with axSpA and PsA with concomitant FM but not in those without.

Table 1.

Baseline characteristics of all diagnosis subtypes and comparison (p-values) to primary FM diagnosis. ‘+’: diagnosis with concomitant FM, ‘-‘: diagnosis without concomitant FM

Table 2.

Mean values (±standard deviation) of the assessed diseasespecific indices and comparison (p-values) to primary FM diagnosis.

Disclosure of Interests:

None declared

POS0038 THE INFLUENCE OF AGE ON THE PREVALENCE OF INFLAMMATORY AND POST-INFLAMMATORY MRI LESIONS IN THE SACROILIAC JOINTS OF PATIENTS WITH AND WITHOUT AXIAL SPONDYLOARTHRITIS

Background:

Axial spondyloarthritis (axSpA) is clinically characterized by chronic inflammatory back pain and by inflammatory and structural changes in the sacroiliac joint (SIJ) as assessed by magnetic resonance imaging (MRI). Several studies have reported high rates of bone marrow edema (BME) suggestive of inflammatory SIJ changes in up to 20% of individuals in the general population <45 years. An update of the definition of a positive MRI of the SIJ in axSpA for classification purposes, based on the number of slices or quadrants showing BME or structural changes such as erosions or fat lesions (FL), was recently published by ASAS.

Objectives:

To compare the influence of age on the prevalence of inflammatory and structural MRI changes in the SIJ of patients with chronic low back pain diagnosed with axSpA or non-SpA.

Methods:

MRIs of the SIJ of patients referred for differential diagnosis of back pain who were finally diagnosed with axSpA or not by experienced rheumatologists, were evaluated using semi-coronal STIR and T1-weighted MRI sequences. All images were scored blinded to, age, sex and diagnosis for the occurrence of BME, FL, erosions and ankylosis on the level of SIJ-quadrants (SIJ-Q). Patient groups were built based on decade of age (until 29, 30-39, 40-49 and ≥50 years).

Results:

A total of 309 patients (175 axSpA and 134 non-SpA) with complete MRI sets were included in the analysis. The mean age was 38.5±11.4 and 43.4±13.8, 66.9% and 35.8% were male, the mean CRP was 1.6±2.4 and 1.1±2.1mg/dl and the median back pain symptom duration was 48 and 60 months, respectively. The number of SIJ-Q with BME and erosions was significantly higher in axSpA vs. non-SpA independent of the age group (Table 1). In comparison, with exception of the patients in the oldest population (≥50 years), the number of SIJ-Q with FL and the number of patients with at least one FL was not different between subgroups, while the number of erosions and FL but not BME was higher in both groups with increasing age. In the univariate analysis, only female sex was significantly associated with higher occurrence of FL.

Conclusion:

Despite a relatively high prevalence in non-SpA patients, BME and erosions were significantly more frequent in axSpA independent of age, while the presence of FL was not different between groups. FL and erosions are increasingly found in older age groups independent of diagnosis. These data are relevant for the interpretation of MRI findings in the SIJ of patients suspicious of axSpA.

Table 1.

Comparison of MRI findings between axSpA and non-SpA patients at different age groups

Disclosure of Interests:

None declared.

POS0301 NO MAJOR DIFFERENCES BETWEEN PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATIC DISEASE WHO UNDERWENT MONO- OR MULTISWITCHING OF BIOSIMILARS IN ROUTINE CARE (PERCEPTION STUDY)

Background:

The increasing availability of biosimilars (bsDMARDs) has created a financial incentive to encourage switching to cheaper products (“non-medical switch”) leading to different switching scenarios. While the clinical efficacy and safety of multiswitching seems to be established (1), limited data on patients’ knowledge about bsDMARDs and satisfaction with care are available.

Objectives:

The aim of our study was to learn more about the outcome of mono- and multiswitching scenarios in routine care with respect to patients’ attitudes towards bsDMARDs in chronic inflammatory rheumatic diseases (CIRD) such as rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA).

Methods:

Consecutive patients with CIRD who were planned to switch treatment of one adalimumab biosimilar (ADA-bsDMARD) to another ADA-bsDMARD were recruited. The number of previous ADA-bsDMARD categorized the patients into: monoswitch = 1 and multiswitch = >1. Demographics and standard assessments using validated outcome parameters for disease activity, physical function, and patient satisfaction with care (Leeds Satisfaction Questionnaire (LSQ) were documented. LSQ contains items on five subscales (provision of information; empathy with the patient; attitude to the patient; access to and continuity with the care giver; and technical competence) and a general satisfaction scale. Knowledge about bsDMARDs was recorded using a structured questionnaire.

Results:

Out of 90 patients in total, there were 42 with a monoswitch and 48 with a multiswitch scenario (Table 1). Patients were satisfied with care irrespective of the switching scenario. However, the knowledge about bsDMARDs was generally rather low (Figure 1). Less than one third of patients was able to identify correct answers about manufacturing, efficacy/safety issues, approval status and costs of bsDMARDs. However, when comparing the two switch scenarios, no differences in disease characteristics nor in satisfaction with care were found. Also the number of switches had not increased the knowledge about bsDMARDs.

Table 1.

Patients and disease characteristics stratified by switch scenario

Variables*Monoswitch (n=42)Multiswitch (n=48)P-WertSex, male, n (%)23 (54.7)26 (54.2)Age, years44 (14)51 (11)Rheumatoid Arthritis, n (%)14 (33.3)7 (14.6)Axial Spondyloarthritis, n (%)23 (54.8)31 (64.6)Psoriatic arthritis, n (%)5 (11.9)10 (20.8)Disease duration, years9.2 (2.5)10.6 (6.7)0.48DAS282.2 (1.2)2.9 (0.7)0.13HAQ1.2 (0.6)1.2 (0.5)0.91ASDAS2.1 (1.2)1.6 (1)0.70BASFI4.6 (2.9)3.7 (2.9)0.87Patient satisfactionLSQ-General (1-5) #3.7 (0.7)3.9 (0.6)0.58LSQ-Information (1-5)3.7 (0.6)3.6 (0.4)0.20LSQ-Empathy (1-5)3.6 (0.6)3.5 (0.5)0.57LSQ-Technical (1-5)4.1 (0.5)4.1 (0.5)0.51LSQ-Attitude (1-5)3.8 (0.7)3.9 (0.5)0.62LSQ-Access (1-5)3.7 (0.6)3.8 (0.6)0.70

*values in mean (SD)

# values of 1 indicate dissatisfaction

Conclusion:

This study shows that multiswitching did not lead to reduced satisfaction with care in patients on treatment with bsDMARDs. Especially, the number of switches did have no negative impact on patients satisfaction. The observation that patients who underwent multiple switches had no more knowledge about bsDMARDs than patients who just had one switch may just be explained by the positive experience most patients had with switching.

References:

[1]Kiltz U et al. Ann Rheum Dis 2020;79 (supplement 1):1872

Figure 1.

Knowledge about biosimilars bsDMARDs: biosimilar disease-modifying anti-rheumatic drugs

Disclosure of Interests:

None declared

POS0296 DOSING OF BDMARDS IN AXSPA AND PSA IN A REAL WORLD SETTING

Background:

The treatment of patients with axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) has been revolutionised by the introduction of biologic DMARDs targeting TNF, IL17, and IL23 inhibitors (i). In Germany, about 30-50% of axSpA and PsA patients receive treatment with bDMARDs. Although many patients benefit from these drugs, in some patients effectiveness of the standard dose may be insufficient and higher doses are used.

Objectives:

To describe dosing of TNFi and non-TNFi bDMARDs over a 2 year period in a real world cohort of patients with axSpA and PsA managed by rheumatologists.

Methods:

RABBIT-SpA is a prospective longitudinal cohort study including axSpA and PsA patients enrolled at the start of a new conventional treatment (including NSAID) or b/tsDMARD treatment. Description of dosing of TNFi (adalimumab bio-original (bo), adalimumab bio-similar (bs), etanercept bo, etanercept bs, golimumab, certolizumab) in comparison to nonTNFi-bDMARDs (secukinumab, ustekinumab, ixekizumab, guselkumab) in axSpA and PsA. Standard dosing was defined according to the current labels for axSpA and PsA.

Results:

1628 patients (axSpA: n=903, PsA: n=725) were included in this analysis. At inclusion mean age was 44 years in axSpA and 51 years in PsA. 44% of patients with axSpA and 58% of those with PsA were female. The mean disease duration of axSpA was 7.6 years, of PsA 6.4 years.

Standard doses of TNFi were used during a 2 year period in > 90% of patients with axSpA and PsA (Figure 1). In contrast, standard doses of non-TNFi-bDMARDs were only used in 70-80% of patients. The percentage of documented higher doses in patients with axSpA ranged from 20-30% at different time points. In PsA, this percentage increased from 27% at baseline to 44% at 2 years. On the other hand, TNFi were used in lower doses than the label in up to 9% and 7 % of patients with axSpA and PsA, respectively, after 2 years.

Figure 1.

Percentages of patients with axSpA or PsA who received less than, equal to, or more than the approved doses of bDMARDs at baseline and at 5 follow-up visits.

Conclusion:

While TNFi are used in licensed doses in most patients, non-TNFi-bDMARDs were often used in higher doses, which corresponds to higher doses approved in other indications like psoriasis. The effectiveness of this treatment strategy in axSpA and PsA needs to be analysed further.

Acknowledgements:

RABBIT-SpA is supported by a joint, unconditional grant from AbbVie, Amgen, Biogen, Hexal, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, UCB, and Viatris.

We thank all participating patients and rheumatologists.

Disclosure of Interests:

Anne Regierer Grant/research support from: AbbVie, Amgen, Biogen, Hexal, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, UCB, and Viatris., Anja Weiß Grant/research support from: AbbVie, Amgen, Biogen, Hexal, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, UCB, and Viatris., Denis Poddubnyy: None declared, Herbert Kellner: None declared, Frank Behrens: None declared, Georg Schett: None declared, Juergen Braun: None declared, Joachim Sieper: None declared, Anja Strangfeld Grant/research support from: AbbVie, Amgen, Biogen, Hexal, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, UCB, and Viatris

OP0250 MRI VERTEBRAL CORNER INFLAMMATION AND FAT DEPOSITION ARE ASSOCIATED WITH WHOLE SPINE LOW DOSE CT DETECTED SYNDESMOPHYTES: A MULTILEVEL ANALYSIS

Background:

A few studies have shown an association between vertebral corner inflammation (VCI) and vertebral corner fat deposition (VCFD) on MRI and syndesmophyte formation on cervical and lumbar conventional radiography.

Objectives:

To investigate whether magnetic resonance imaging (MRI) patterns of VCI, VCFD and a combination of both are associated with the development of new or grown syndesmophytes as detected by whole spine low dose computed tomography (ldCT), thereby studying these associations also in the thoracic spine.

Methods:

Patients in the Sensitive Imaging in Ankylosing Spondylitis cohort underwent MRI at baseline, 1 year and 2 years, and ldCT at baseline and 2 years. MRI lesions were scored by 3 central readers, using the SPARCC method for VCI and the CanDen method for VCFD, and coded as absent or present per timepoint and per reader. MRI patterns over time (Table) were based on patterns studied by Machado et al.1 and deemed present if seen by ≥2 out of 3 readers. The patterns reflect hypothetical associations between presence and absence of VCI and VCFD, independently and combined, on ldCT detected new or grown syndesmophytes. Individual reader change scores were used for ldCT images, scored by 2 central readers with the Computed Tomography Syndesmophyte Score. New (CTSS 0 to 1, 2 or 3) and grown (CTSS 1 to 2 or 3; 2 to 3) syndesmophytes were grouped together to represent bone formation. Corners not at risk for the outcome due to presence of a bridged syndesmophyte at baseline were excluded. Multilevel generalized estimated equations were used, with separate models per MRI pattern, accounting for correlations within patients and between ldCT readers.

Table 1.

Effect of vertebral corner inflammation and vertebral corner fat deposition on syndesmophyte formation

Patterns of lesions over time on MRICorners with VCI/VCFD patternN(%)OR (95% CI)1. VCI at any TP, irrespective of VCFD691 (15.0%)2.37 (1.49-3.78)2. VCFD at any TP, irrespective of VCI1080 (23.5%)2.58 (1.97-3.39)3. VCI on ≥1 TP and absence of VCFD on all TPs372 (8.1%)1.90 (1.15-3.13)4. VCFD on ≥1 TP and absence of VCI on all TPs754 (16.4%)1.87 (1.41-2.48)5. VCI precedes VCFD43 (0.9%)2.20 (0.83-5.86)6. VCI precedes or coincides with VCFD. VCFD does not precede VCI198 (4.3%)2.33 (1.47-3.69)7. Absence of VCI and VCFD on all TPs3108 (67.6%)0.35 (0.25-0.49)

VCI, vertebral corner inflammation; VCFD, vertebral corner fat deposition; TP, timepoint.

Results:

50 patients were included, contributing a total of 4600 vertebral corners. Their mean age was 49.3 years (SD 9.8), 86% were male and 78% were HLA-B27+. Presence of VCI and VCFD patterns ranged from 43 (0.9%) to 3108 (67.6%) corners (Table), with the lowest frequency being for VCI preceding VCFD. Protection against syndesmophyte development was seen in case of absence of both VCI and VCFD (OR 0.35) and positive associations with ORs ranging from 1.87-2.58 were observed for various VCI/VCFD patterns. Nevertheless, out of all corners with a new or grown syndesmophyte, 47.3% of corners according to reader 1 and 43.9% according to reader 2 had neither VCI nor VCFD preceding the bone formation.

Conclusion:

Presence of VCI or VCFD and combinations of the two, measured yearly on MRI, increased odds of bone formation 2 years later, whereas absence of both VCI and VCFD decreased the odds, showing that VCI and VCFD have some role in the development of syndesmophytes. However, almost half of all bone formation occurred in corners without VCI or VCFD, suggesting the presence of these lesions in yearly MRIs does not fully explain the development of syndesmophytes. This study confirmed that there is an association between VCI and VCFD and bone formation also for the thoracic spine and on ldCT compared to conventional radiography.

References:

[1]Machado et al ARD 2016

Disclosure of Interests:

Rosalinde Stal: None declared, Xenofon Baraliakos: None declared, Alexandre Sepriano: None declared, Floris A. van Gaalen Grant/research support from: Novartis, Sofia Ramiro: None declared, Rosaline van den Berg: None declared, Monique Reijnierse: None declared, Juergen Braun: None declared, Robert B.M. Landewé: None declared, Désirée van der Heijde: None declared

POS1145 PREVALENCE OF CHONDROCALCINOSIS IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES – FREQUENTLY FOUND IN PATIENTS WITH RHEUMATOID ARTHRITIS AND VICE VERSA

Background:

Calcium pyrophosphate deposition disease (CPPD), also known as pseudogout, is a prominent member of the crystal deposition diseases much like gout where urate crystals are the pathogens. CPPD is differentiated from chondrocalcinosis, a radiographic finding showing joint calcification, which may or may not be relevant for the clinical picture of patients (1).

Objectives:

To determine the prevalence of chondrocalcinosis in different inflammatory rheumatic diseases.

Methods:

In a retrospective cross-sectional study design we reviewed the records of not established new patients presenting to our center between 1.1.2016 and 31.12.2018. Based on the availability of radiographs of hands and feet, 514 patients were identified including 181 patients with CPPD, 273 with rheumatoid arthritis (RA), 143 seropositive (52.4%) and 130 seronegative, 30 with gout and 30 with polymyalgia rheumatica (PMR). Radiographs of hands and feet were available from all patients, of the knee in 376 cases. All images were read by two experienced readers with no access to clinical data.

Results:

Almost all patients had a short disease duration of < 1 year. In patients diagnosed with CPPD all radiographs showed chondrocalcinosis (93%) at some location, mostly in the hands. This was different in seronegative (36.5%) and seropositive (30.3%) RA. Chondrocalcinosis was found less frequently also in gout (18.8%) and PMR (12.5%). More data are shown in the Table 1. Radiographic chondrocalcinosis was present in more than one joint in 36.6% patients with CPPD, in 11.9% in seropositive and in 17.3% in seronegative RA. Patients with CPPD were older and had acute attacks more often than RA patients. While RA patients were more frequently on methotrexate (MTX), patients with CPPD were more often on colchicine.

Table 1.

Radiographic and clinical features of the examined patients

Conclusion:

There were a lot of similarities but also some important differences between patients with CPPD and RA with no major differences between seropositive and seronegative RA. Of interest, radiographic chondrocalcinosis was seen in more than a third of RA patients. Importantly, clinical symmetry of arthritis and involvement of hands did not differentiate between CPPD and RA, mainly the acuteness of attacks did. Co-occurrence of both diseases was frequently observed. There was no major difference between seropositive and seronegative RA.

References:

[1]Rosenthal AM, Ryan LM. N Engl J Med. 2016

Disclosure of Interests:

None declared.

POS0973 CONTEXTUAL FACTORS SHOULD COMPLETE THE ASSESSMENT OF FUNCTIONING IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS (axSpA)

Background:

Functioning of patients (pts.) with axial spondyloarthritis (axSpA) is influenced by a variety of factors. In contrast to clinical factors, the influence of contextual factors on functioning has not been well studied. According to the According to the International Classification of Functioning, Disability and Health (ICF), functioning is a complex interaction between health status and contextual factors such as social support, relationships and attitudes.

Objectives:

The aim of this study is to understand limitations in participation and to investigate barriers and facilitators of contextual factors in pts. with axSpA.

Methods:

Consecutive axSpA pts. underwent a standardized assessment with collection of patient and disease characteristics, patient-reported outcomes (ASDAS, BASFI, BASMI, PHQ-9, ICF Measure of Participation and ACTivities questionnaire (IMPACT-S (0-100%)), ASAS Health Index (ASAS HI and environment factor item set (EFIS) (1). The EFIS contains 9 dichotomous questions addressing ICF categories of products and technologies (e1), support and relationship (e3), attitudes (e4) and health services (e5). Validated cut-offs of ASAS HI were used to categorize global functioning.

Results:

A total of 200 axSpA pts. were included: 69% males, 44.3±12.5 years, symptom duration 17.9±12.6 years, ASDAS 2.5±1.1, BASFI 4.0±2.7, BASMI 3.5±1.8, ASAS HI 7.0±4.1. Pts. reported limitations in the IMPACT-S activity and participation domain (82.3% (15.2) and 83.5% (16.8), respectively. The majority of pts. reported as barrier that treatment of axSpA requires time (e4, 58.5%). A minority of pts. but quite a few reported as barrier the need for support by family members (e3, 43.5%), the need to modify home and work environment (e1, 39.5%) and that they cannot rely on family members for help (e3, 22%). Some pts. (< 20%) reported that they have problems to be understood by health care professionals when experiencing a flare (e5, 18.5%), that pts. at home are not adequately taken care of (e4, 18.5%), disliking friends’ behavior toward them (e4, 13.5%), and that friends are too demanding (e4, 13%). The majority of pts. (e4, 75.9%) identified attitudes of friends as the only and major facilitator. All pts. reporting at least one barrier had significantly worse global functioning (ASAS HI, IMPACT-S), and depression (PHQ-9) compared to patients who reported no barriers in the respective ICF categories (p< 0.01). Similarly, pts. with poor functioning are more likely to report barriers in contextual factors compared to pts. with good functioning (Table 1). Pts. having to ask for more support from their families expressed the feeling that they cannot rely on that.

Conclusion:

Barriers more than facilitators of contextual factors are present in pts. with axSpA. This study shows that barriers in contextual factors are more common in pts. with impairments in self-reported and performed functioning as in those without impairments. This underlines the importance of contextual factors in the management of axSpA pts.

References:

[1]Kiltz et al. Ann Rheum Dis 2013;72(s3):572

Table 1.

Presence of contextual factors, stratified for global functioning categories

ICF categoryEFIS ItemGlobal Functioning (ASAS HI 0-17)Good ≤ 5(n= 69)Moderate <5 to <12(n= 106Poor ≥ 12(n= 25)e3EFIS 1: As a result of my rheumatic disease, the children take more responsibility for household tasks.11 (15.9)55 (51.9)21 (84)e3EFIS 2: I don’t like the way my friends acts around me.0 (0)15 (14,2)12 (48,0)e3EFIS 3: I can’t count on my relatives to help me with my problems11 (15,9)24 (22,6)9 (36)e1EFIS 4: I modify my home and work environments.16 (23,2)47 (44,3)9 (36)e5EFIS 5: I have difficulties getting worsening of my disease acknowledged by a health care professional3 (4,3)21 (19,8)16 (64)e5EFIS 6: Treatment of my rheumatic disease is taking up time22 (31,9)73 (68,9)22 (88)e4,EFIS 7: My friends expect too much of1 (1,4)18 (17,0)7 (28)e4EFIS 8: No one pays much attention to me at home10 (14,5)20 (18,9)7 (28)e4EFIS 9: My friends understand me56 (17,4)83 (78,3)12 (48)

values given as number (%)

Disclosure of Interests:

None declared.

AB0684 LESS THAN 20% OF PATIENTS WITH A CHRONIC INFLAMMATORY RHEUMATIC DISEASE CHANGED THEIR IMMUNOSUPPRESSIVE MEDICATION BECAUSE OF THE COVID 19 PANDEMIC

Background:

The best treatment options of patients with chronic inflammatory rheumatic diseases (CIRD) in the pandemic have not been completely clear, especially in the beginning of the lockdown. Whether and to which degree pandemic-related therapy changes have occurred, has not been studied in detail.

Objectives:

To study the behaviour of patients with CIRD initially facing the COVID 19 pandemic related to their disease status and medication.

Methods:

Patients with CIRD were contacted by telephone to assess their health status and ask for changes in medication. Standardized assessment tools were used to assess disease activity, depression and anxiety. High disease activity was assumed if RADAI-5 ≥ 3.2 and BASDAI ≥ 4. Anxiety (HADS-A) and depression (HADS-D) of patients were assessed using HADS. A score < 8 was taken as indication of no major problem in this regard.

Results:

A total of 886 patients was interviewed between April 15 and June 15 of 2020. Here we report on 550 patients with complete information on standard assessments (62%). About 60% were female, mean age 54.4±13.7, mean disease duration 12.2±10.5 years. Most had spondyloarthritis (SpA, n=287) including axial SpA (axSpA, n=172) and psoriatic arthritis (PsA, n=116), in total 52.2%, while 40.2% had rheumatoid arthritis (RA, n=221), and 7.6% connective tissue diseases (CTD, n=42). Most RA patients were on methotrexate (48.8%), while 43.8% took glucocorticoids. In addition, 61.0% of patients were on bDMARDs, mostly on TNF inhibitors (59.6%). More SpA than RA patients were on bDMARDs: 71.0% vs 49.7% respectively. A recent change in medication was reported by 182 patients (33.1%): 89 with RA (40.2%), 88 with SpA (30.6%) and 5 with CTD (11.9%). Half of those who changed (n=92; 50.5%) admitted that the change was mainly made due to fear of the pandemic (16.7% of all patients). Altogether, significantly more patients changed bDMARDs (68.5%) than csDMARDs (57.3%). The data of patients who changed vs patients who didn’t change is shown in the Table 1, including subgroup analyses. The median HADS scores were < 8.

Table 1.

RA and SpA patients who changed and who did not change their medication

Group (N) / ReasonNActive disease (%)HADS-D≥ 8 (%)HADS-A≥ 8 (%)bDMARD therapy (%)Rheumatoid arthritis221134 (60.6)76 (35.0) [4]94 (43.3) [4]110 (50.9) [5]Spondyloarthritis287130 (45.4)83 (29.5) [6]109 (38.8) [6]204 (72.6) [6]  Pa (RA vs SpA)<0.0010.2280.354<0.001Patients did not change their medication Rheumatoid arthritis (%)132 (59.7)84 (63.6)46 (35.9) [4]58 (45.3) [4]62 (48.4) [4] Spondyloarthritis (%)199 (69.3)88 (44.2)58 (30.1) [6]69 (35.8) [6]137 (71.0) [6]  P (RA vs SpA)0.031<0.0010.3580.101<0.001Patients changed their medication Rheumatoid arthritis89 (40.3)50 (56.2)30 (33.7)36 (40.4)48 (54.5) [1]  P (vs no change)0.3310.8460.5670.457  Reason[9] Pandemic41 (51.3)15 (36.6)11 (26.8)14 (34.1)24 (60.0) [1] Inactive disease23 (28.8)12 (52.2)6 (26.1)10 (43.5)12 (52.2) Active disease b16 (20.0)14 (87.5)6 (37.5)7 (43.8)7 (43.8)  P (reasons)0.0030.6870.6870.526 Spondyloarthritis88 (30.7)42 (47.7)25 (28.4)40 (45.5)67 (76.1)  P (vs no change)0.6730.8890.1570.451  Reason[6] Pandemic50 (61.0)22 (44.0)13 (26.0)22 (44.0)42 (84.0) Inactive disease15 (18.3) 7 (46.7)4 (26.7)7 (46.7)10 (66.7) Active disease b17 (20.7)11 (64.7)6 (35.3)6 (35.3)11 (64.7)  P (reasons)0.3310.7560.7740.156  P (RA vs SpA)0.0310.2940.9500.6030.004

Data are presented as numbers (percentage proportions; across rows except for column N) or medians (interquartile ranges). Missing values are in square brackets.

a P values calculated using χ2 test or Mann-Whitney rank sum test.

b Self-reported claim of disease activity.

Conclusion:

Two thirds of patients did not change medication but one third changed. A relatively high number of patients did so due to fear of the pandemic, mostly those on biologics. There were no major differences between RA and SpA. Anxiety and depression do not seem to play an important role for the decision to change medication (Table 1 below).

Disclosure of Interests:

None declared

POS0900 SECUKINUMAB 150 MG PROVIDES SUSTAINED IMPROVEMENT IN SIGNS AND SYMPTOMS OF NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: 2-YEAR RESULTS FROM THE PREVENT STUDY

Background:

Axial spondyloarthritis (axSpA) is an inflammatory disease characterised by chronic back pain, and it comprises radiographic axSpA and non-radiographic axSpA (nr-axSpA).1 Secukinumab (SEC) 150 mg, with (LD) or without loading (NL), dose significantly improved the signs and symptoms of patients with nr-axSpA in the PREVENT (NCT02696031) study through Week 52.2

Objectives:

To report the long-term clinical efficacy and safety of secukinumab from the PREVENT study through 2 years.

Methods:

A detailed study design, key primary and secondary endpoints have been reported previously.2 In total, 555 patients fulfilling ASAS criteria for axSpA plus abnormal C-reactive protein (CRP) and/or MRI, without evidence of radiographic changes in sacroiliac (SI) joints according to modified New York Criteria for AS were randomised (1:1:1) to receive SEC 150 mg with LD, NL, or placebo (PBO) at baseline. LD patients received SEC 150 mg at Weeks 1, 2, 3, and 4, and then every 4 weeks (q4wk) starting at Week 4. NL patients received SEC 150 mg at baseline and PBO at weeks 1, 2, and 3, and then 150 mg q4wk. 90% patients were anti-tumour necrosis factor (anti-TNF) naïve, 57% had elevated CRP and 73% had evidence of SI joint inflammation on MRI. All images were assessed centrally before inclusion. All patients continued to receive open-label SEC 150 mg treatment after Week 52. Efficacy assessments through Week 104 included ASAS40 in anti-TNF-naïve patients, ASAS40, BASDAI change from baseline, BASDAI50, ASAS partial remission, and ASDAS-CRP inactive disease in the overall population. The safety analyses included all patients who received ≥1 dose of study treatment for the entire treatment period up to Week 104. Data are presented as observed.

Results:

Overall, 438 patients completed 104 weeks of study: 78.9% (146/185; LD), 77.7% (143/184; NL) and 80.1% (149/186; PBO). Efficacy results at Week 52 were sustained through Week 104 and are reported in the Table 1. The safety profile was consistent with the previous reports with no deaths reported during the entire treatment period up to Week 104.2

Conclusion:

Secukinumab 150 mg demonstrated sustained improvement in the signs and symptoms of patients with nr-axSpA through 2 years. Secukinumab was well tolerated with no new or unexpected safety signals.

References:

[1]Strand V, et al. J Clin Rheumatol. 2017; 23(7):383–91.

[2]Deodhar A, et al. Arthritis Rheumatol. 2020. Online ahead of print.

Figure 1.

ASAS40 response was maintained through Week 104 in the overall population

Table 1.

Summary of clinical efficacy (Observed data)

EndpointsWeekSEC 150 mg LD(N=185)SEC 150 mg NL(N=184)PBO-SEC 150 mg(N=186)*ASAS40 in anti-TNF-naïve patients, n/M (%)52a90/137 (65.7)95/145 (65.5)85/151 (56.3)10478/123 (63.4)83/123 (67.5)83/134 (61.9)BASDAI change from baseline, mean±SD52a−3.7±2.8−3.7±2.6−3.3±2.4104−4.1±2.6−3.9±2.6−3.7±2.5BASDAI50, n/M (%)52a90/153 (58.8)92/163 (56.4)90/161 (55.9)10488/137 (64.2)84/136 (61.8)87/142 (61.3)ASAS partial remission,n/M (%)52a46/152 (30.3)56/163 (34.4)46/161 (28.6)10451/137 (37.2)50/135 (37.0)50/142 (35.2)ASDAS CRP inactive disease, n/M (%)52a49/152 (32.2)58/163 (35.6)48/160 (30.0)10450/132 (37.9)53/133 (39.8)53/142 (37.3)

*For anti-TNF-naïve patients, N=164, LD; 166, NL; 171, PBO-SEC.

a total number of evaluable patients including open-label SEC and standard of care (SOC; 2 patients in LD, 1 patient in NL continued on SOC). After Week 52, only patients who continued to receive open-label SEC are presented.

ASAS, Assessment of SpondyloArthritis International Society; ASDAS, Ankylosing Spondylitis Disease Activity Score; BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; M, number of patients with evaluation; N, total randomised patients; n, number of patients who are responders; SD, standard deviation

Disclosure of Interests:

Denis Poddubnyy Speakers bureau: AbbVie, BMS, Eli Lilly, MSD, Novartis, Pfizer, UCB, Consultant of: AbbVie, Biocad, BMS, Eli Lilly, Gilead, MSD, Novartis, Pfizer, Samsung Bioepis, UCB, Grant/research support from: AbbVie, MSD, Novartis, Pfizer, Atul Deodhar Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, GSK, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, and UCB, Xenofon Baraliakos Speakers bureau: AbbVie, BMS, Celgene, Chugai, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, BMS, Celgene, Chugai, Galapagos, Gilead, MSD, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie and Novartis, Ricardo Blanco Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, UCB pharma and MSD and Eli Lilly, Consultant of: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, UCB pharma and MSD, Grant/research support from: AbbVie, MSD, and Roche, Eva Dokoupilova Grant/research support from: AbbVie, Affibody AB, Eli Lilly, Galapagos, Gilead, GSK, Hexal AG, MSD, Novartis, Pfizer, R-Pharm, Sanofi-Aventis, and UCB, Stephen Hall Speakers bureau: Novartis, Merck, Janssen, Pfizer, Eli Lilly, and UCB, Consultant of: Novartis, Merck, Janssen, Pfizer, Eli Lilly, and UCB, Grant/research support from: AbbVie, UCB, Janssen, and Merck, Alan Kivitz Shareholder of: Pfizer, Sanofi, Novartis, Amgen, GlaxoSmithKline, Gilead Sciences, Inc., Speakers bureau: Celgene, GlaxoSmithKline, Eli Lilly, Merck, Novartis, Pfizer, Sanofi, Genzyme, Flexion, AbbVie, UCB, Consultant of: AbbVie, Boehringer Ingelheim, Flexion, Janssen, Pfizer, Sanofi, Regeneron, SUN Pharma Advanced Research, Gilead Sciences, Inc., Marleen G.H. van de Sande Speakers bureau: Novartis, MSD, Consultant of: Abbvie, Novartis, Eli Lily, Grant/research support from: Novartis, Eli Lilly, Janssen, UCB, Anna Stefanska Shareholder of: Novartis, Employee of: Novartis, Patricia Pertel Shareholder of: Novartis, Employee of: Novartis, Hanno Richards Shareholder of: Novartis, Employee of: Novartis, Juergen Braun Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis and UCB pharma, Eli Lilly, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis and UCB, Eli Lilly, Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis and UCB, Eli Lilly

[Quality in acute inpatient rheumatology 2021 : Current aspects of the KOBRA quality label of the Association of Rheumatological Acute Care Clinics]

Mit einer umfassenden gesundheitspolitischen Qualitätsoffensive ab 2021 sollen die Qualität und Transparenz in der Versorgung von Menschen mit Krankheiten in Krankenhäusern in Deutschland verbessert werden. Gesetzliche Vorgaben zu Mindestmengen und die Ausweitung von Qualitätsverträgen zwischen Kostenträgern und Krankenhäusern sowie die Verwendung von planungsrelevanten Qualitätsindikatoren für eine bedarfs- und qualitätsorientierte Weiterentwicklung der stationären Versorgung werden den Wettbewerb in der Versorgungsqualität zwischen den Krankenhäusern verstärken. Dem Thema „Entwicklung und Definition von Qualität in der Medizin“ hat sich auch der Verband der Rheumatologischen Akutkliniken e. V. (VRA) schon früh nach der Gründung im Jahr 1998 umfassend angenommen. Im Zentrum der akutstationären Qualitätssicherung stehen verbindlich festgelegte Strukturkriterien in Verknüpfung mit dem 2003 in der Rheumatologie gestarteten und bis heute kontinuierlich durchgeführten KOBRA-Projekt (Kontinuierliches Outcome Benchmarking in der Rheumatologischen Akutversorgung) mit der Messung von Prozess- und Ergebnisqualität. Auf der Basis dieses Rahmenkonzeptes (Erfüllung der Strukturkriterien und Durchführung des KOBRA-Projektes) können erfolgreich teilnehmende rheumatologische Einrichtungen für jeweils 2 Jahre das KOBRA-Label erwerben, welches von der Projektleitung – dem aQua-Institut – vergeben wird. Die herausragende Stellung des KOBRA-Projektes wird beispielhaft anhand von Datenauswertungen des Projektzyklus 2018 gezeigt mit Auswertungen zum Therapiestrategiewechsel bei aktiver rheumatoider Arthritis, Diagnosesicherung von Kollagenosen und Vaskulitiden während des stationären Aufenthaltes sowie zur partizipativen Entscheidungsfindung bei rheumatoider Arthritis. Auf den gesundheitspolitisch geforderten „Paradigmenwechsel – weg vom Bett, hin zu einer leistungs-, bedarfs- und qualitätsorientierten Planung“ – ist die akutstationäre Rheumatologie mit der Verankerung von Projekten zur Struktur‑, Prozess- und Ergebnisqualität sehr gut vorbereitet. Für die in der vom Gemeinsamen Bundesausschuss (G-BA) erstellten Richtlinie zu „Rheumatologischen Zentren“ geforderten Qualitätssicherung ist das KOBRA-Projekt ebenfalls eine sehr gute Voraussetzung.

Prehospital hypoxemia, measured by pulse oximetry, predicts hospital outcomes during the New York City COVID-19 pandemic

OBJECTIVE

To determine if oxygen saturation (out-of-hospital SpO2), measured by New York City (NYC) 9-1-1 Emergency Medical Services (EMS), was an independent predictor of coronavirus disease 2019 (COVID-19) in-hospital mortality and length of stay, after controlling for the competing risk of death. If so, out-of-hospital SpO2 could be useful for initial triage.

METHODS

A population-based longitudinal study of adult patients transported by EMS to emergency departments (ED) between March 5 and April 30, 2020 (the NYC COVID-19 peak period). Inclusion required EMS prehospital SpO2 measurement while breathing room air, transport to emergency department, and a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription polymerase chain reaction test. Multivariable logistic regression modeled mortality as a function of prehospital SpO2, controlling for covariates (age, sex, race/ethnicity, and comorbidities). A competing risk model also was performed to estimate the absolute risks of out-of-hospital SpO2 on the cumulative incidence of being discharged from the hospital alive.

RESULTS

In 1673 patients, out-of-hospital SpO2 and age were independent predictors of in-hospital mortality and length of stay, after controlling for the competing risk of death. Among patients ≥66 years old, the probability of death was 26% with an out-of-hospital SpO2 >90% versus 54% with an out-of-hospital SpO2 ≤90%. Among patients <66 years old, the probability of death was 11.5% with an out-of-hospital SpO2 >90% versus 31% with an out-of-hospital SpO2 ≤ 90%. An out-of-hospital SpO2 level ≤90% was associated with over 50% decreased likelihood of being discharged alive, regardless of age.

CONCLUSIONS

Out-of-hospital SpO2 and age predicted in-hospital mortality and length of stay: An out-of-hospital SpO2 ≤90% strongly supports a triage decision for immediate hospital admission. For out-of-hospital SpO2 >90%, the decision to admit depends on multiple factors, including age, resource availability (outpatient vs inpatient), and the potential impact of new treatments.

[Standardized documentation of health-related quality of life in patients with psoriatic arthritis : Validation of the German version of the psoriatic arthritis quality of life (PsAQoL) questionnaire]

BACKGROUND

The standardized assessment of health-related quality of life is becoming increasingly more important. The English questionnaire on psoriatic arthritis quality of life (PsAQoL) is a disease-specific instrument for measuring the quality of life of patients with psoriatic arthritis (PsA). The aim of the present study was to translate the PsAQoL into German and to validate the German version in a cohort of PsA patients recruited from routine care.

METHOD

The translation and validation of the PsAQoL questionnaire was carried out in a stepwise procedure involving affected patients with PsA. After translation of the original English questionnaire the German version was evaluated in a field test. The psychometric features of the questionnaire were then examined in a PsA cohort from routine care. In addition to the construct and group validity, the reliability of the questionnaire was tested using test-retest reliability and internal consistency. The physical functioning was measured with the health assessment questionnaire (HAQ) and domains of the quality of life with the Nottingham health profile (NHP).

RESULTS

In a field test with 10 patients the German version of the PsAQoL questionnaire proved to be relevant, easily understandable and feasible (processing time 4.7 ± 2.1 min). A total of 126 patients (37.3% male, age 55.6 ± 11.3 years) were included in the validation cohort. The PsAQoL showed moderate correlation with the HAQ (r = 0.65) and moderate to good correlation with the NHP (subdomains r = 0.58-0.75). The internal consistency was high (Cronbach's α 0.92) and reliability in patients with stable disease course was very good (Spearman correlation coefficient 0.94). The PsAQoL can differentiate between different patient groups.

CONCLUSION

The German translation of the PsAQoL provides a valid disease-specific instrument for the standardized assessment of health-related quality of life in patients with PsA. The psychometric characteristics of this questionnaire are comparable with the original English version. The German PsAQoL can therefore be recommended for clinical and scientific application.

[Future of acute inpatient rheumatology in Germany : Statement of the Boards of the German Society for Rheumatology and the Association of Rheumatological Acute Clinics on hospital planning North-Rhine/Westphalia 2019 for the discipline rheumatology]

Im September 2019 wurde vom Ministerium für Arbeit, Gesundheit und Soziales (MAGS) in NRW ein Gutachten zur Krankenhausplanung veröffentlicht. Hierin wurde eine grundlegende Reform der Krankenhausplanung empfohlen, indem zukünftig eine Bedarfsplanung auf der Grundlage einer detaillierten Ausweisung von Leistungsbereichen und Leistungsgruppen erfolgen soll. Nach Aufforderung durch das MAGS NRW hat auch die Deutsche Gesellschaft für Rheumatologie (DGRh) mit Unterstützung des Verbandes Rheumatologischer Akutkliniken (VRA) hierzu Stellung genommen.

System impacts of the COVID-19 pandemic on New York City's emergency medical services

OBJECTIVES

To describe the impact of the COVID-19 pandemic on New York City's (NYC) 9-1-1 emergency medical services (EMS) system and assess the efficacy of pandemic planning to meet increased demands.

METHODS

Longitudinal analysis of NYC 9-1-1 EMS system call volumes, call-types, and response times during the COVID-19 peak-period (March 16-April 15, 2020) and post-surge period (April 16-May 31, 2020) compared with the same 2019 periods.

RESULTS

EMS system received 30,469 more calls from March 16-April 15, 2020 compared with March 16-April 15, 2019 (161,815 vs 127,962; P < 0.001). On March 30, 2020, call volume increased 60% compared with the same 2019 date. The majority were for respiratory (relative risk [RR] = 2.50; 95% confidence interval [CI] = 2.44-2.56) and cardiovascular (RR = 1.85; 95% CI = 1.82-1.89) call-types. The proportion of high-acuity, life-threatening call-types increased compared with 2019 (42.3% vs 36.4%). Planned interventions to prioritize high-acuity calls resulted in the average response time increasing by 3 minutes compared with an 11-minute increase for low low-acuity calls. Post-surge, EMS system received fewer calls compared with 2019 (154,310 vs 193,786; P < 0.001).

CONCLUSIONS

COVID-19-associated NYC 9-1-1 EMS volume surge was primarily due to respiratory and cardiovascular call-types. As the pandemic stabilized, call volume declined to below pre-pandemic levels. Our results highlight the importance of EMS system-wide pandemic crisis planning.

[Mission statement from rheumatologists in the German Society of Rheumatology (DGRh e. V.) : We live rheumatology. German version]

Systemic disease demands systemic thinkers. In this mission statement we define rheumatology, describe the role of the German Society of Rheumatology and the rheumatologist's spirit to their discipline. Rheumatologists are dedicated to improving the quality of life of their acute, chronic, and rehabilitative patients on the basis of up to date evidence and strong physician-patient relations. We think, act and interact systemically, scientifically, consistently, transparently, reliably, inclusively, innovatively and enthusiastically.

Revealing Hidden Orbital Pseudospin Texture with Time-Reversal Dichroism in Photoelectron Angular Distributions

We performed angle-resolved photoemission spectroscopy (ARPES) of bulk 2H-WSe_{2} for different crystal orientations linked to each other by time-reversal symmetry. We introduce a new observable called time-reversal dichroism in photoelectron angular distributions (TRDAD), which quantifies the modulation of the photoemission intensity upon effective time-reversal operation. We demonstrate that the hidden orbital pseudospin texture leaves its imprint on TRDAD, due to multiple orbital interference effects in photoemission. Our experimental results are in quantitative agreement with both the tight-binding model and state-of-the-art fully relativistic calculations performed using the one-step model of photoemission. While spin-resolved ARPES probes the spin component of entangled spin-orbital texture in multiorbital systems, we unambiguously demonstrate that TRDAD reveals its orbital pseudospin texture counterpart.

The Haemostasis Traffic Light, a user-centred coagulation management tool for acute bleeding situations: a simulation-based randomised dual-centre trial

The Haemostasis Traffic Light is a cognitive aid with a user-centred design to enhance and simplify situation awareness and decision-making during peri-operative bleeding. Its structure helps to prioritise therapeutic interventions according to the pathophysiology and the severity of the bleeding. This investigator-initiated, randomised, prospective, international, dual-centre study aimed to validate the Haemostasis Traffic Light by adapting it to the local coagulation protocols of two university hospitals. Between 9 January and 12 May 2020, we recruited 84 participants at the University Hospital Zurich, Switzerland, and the Italian Hospital of Buenos Aires, Argentina. Each centre included 21 resident and 21 staff anaesthetists. Participants were randomly allocated to either the text-based algorithm or the Haemostasis Traffic Light. All participants managed six bleeding scenarios using the same algorithm. In simulated bleeding scenarios, the design of the Haemostasis Traffic Light algorithm enabled more correctly solved cases, OR (95%CI) 7.23 (3.82-13.68), p < 0.001, and faster therapeutic decisions, HR (95%CI) 1.97 (1.18-3.29, p = 0.010). In addition, the tool improved therapeutic confidence, OR (95%CI) 4.31 (1.67-11.11, p = 0.003), and reduced perceived work-load coefficient (95%CI) -6.1 (-10.98 to -1.22), p = 0.020). This study provides empirical evidence for the importance of user-centred design in the development of haemostatic management protocols.

Long-term follow-up of thoracoscopic ablation for long-standing persistent atrial fibrillation

Background

Catheter ablation in patients with long-standing persistent AF (LSPAF) remains challenging and often requires repeated procedures with variable results. We report long-term outcomes of a bipolar thoracoscopic pulmonary vein and left atrial posterior wall ablation for LSPAF, and compare continuous and interval rhythm monitoring.

Methods

Seventy-seven LSPAF patients who underwent thoracoscopic pulmonary vein and box isolation between 2009–2017 in two Dutch centers were included. Follow-up consisted of continuous rhythm monitoring using an implanted loop recorder or 24-h Holter at 3/6/12/24/60 months.

Results

Mean age was 59±8 years with a median AF duration of 3.8 [1.2–6.3] years. In the total cohort, at 2-year follow-up, 86.0% of patients were in sinus rhythm, 12.3% were in paroxysmal AF and 1.6% in persistent AF. At 5 years, 62.9% of patients were in sinus rhythm, 20.0% in paroxysmal AF, 14.3% in persistent AF and 2.9% was experiencing atrial flutter. Continuous rhythm monitoring was performed in 46% of patients. Comparing continuous and interval rhythm monitoring, freedom from any atrial arrhythmia episode at 2- and 5 years was 60.0% and 49.9% in the continuous group and 93.8% and 51.9% in the interval monitoring group, respectively (p=0.02, Breslow-Wilcoxon test). In patients with continuous rhythm monitoring the mean atrial arrhythmia burden was reduced from 99.1% preoperatively to 0.1% at the end of the blanking period and 7.3% at 2-year follow-up.

Conclusions

Thoracoscopic box ablation is highly effective in restoring sinus rhythm at medium term follow-up. However, it is not a curative treatment as demonstrated by the 50% arrhythmia-free survival at long-term follow-up. Whether this is due to the progressive nature of AF needs further investigation. Continuous rhythm monitoring shows earlier recurrence detection with a potential early treatment adaptation.

Funding Acknowledgement

Type of funding source: None

[Results of the systematic literature search as basis for the "Evidence-based treatment recommendations for familial Mediterranean fever patients with insufficient response or intolerability to colchicine" of the Society for Pediatric and Adolescent Rheumatology and the German Society for Rheumatology]

BACKGROUND

Familial Mediterranean fever (FMF) is a genetic disease of childhood and adulthood which is relatively rare in Germany. It is characterized by recurrent febrile attacks, peritonitis, pleuritis and arthritis. The established treatment with colchicine is effective and well-tolerated by most patients; however, some patients do not adequately respond or do not tolerate this treatment. Biologics can be considered for some of these patients. The Society for Pediatric and Adolescent Rheumatology (GKJR) and the German Society for Rheumatology (DGRh) have agreed to develop joint recommendations for this specific clinical situation.

AIM

Implementation of a systematic literature search (SLR) on the basis of the EULAR recommendations published in 2016 as the foundation for the development of evidence-based treatment recommendations for FMF patients with insufficient response or intolerance to colchicine.

METHODS

The SLR was performed using references from various databases as an update of the SLR carried out by EULAR up to 2014, whereby all articles must have been published between 1 January 2015 and 31 December 2017. The Rayyan abstract tool for the preselection and the classification of the Oxford Centre for Evidence Based Medicine 2009 were used for the preparation of the evidence tables.

RESULTS

The search yielded 360 hits and after duplicate matching 263. A total of 88 publications were included (34%) and 102 excluded (39%), a review of the full publication was necessary for a further 73 (28%) and 43 were discussed more intensively. Finally, 64 publications (24%) remained. A total of 4 case-control studies, 31 cohort studies, 8 case series, 7 controlled studies (including 5 abstracts), 10 reviews, 4 meta-analyses and systematic reviews were accepted.

DISCUSSION

The SLR was carried out in a scientifically accurate and transparent manner according to international standards. The SLR proved to be a good basis for a consensus on the 5 overarching principles and the 10 recommendations, so that the joint activity of the GKJR and DGRh was successfully and even promptly concluded. The recommendations are a solid basis for treating patients of all ages with FMF. The explanations on the problem of colchicine resistance play an important role here.

eV-Scale Sterile Neutrino Search Using Eight Years of Atmospheric Muon Neutrino Data from the IceCube Neutrino Observatory

The results of a 3+1 sterile neutrino search using eight years of data from the IceCube Neutrino Observatory are presented. A total of 305 735 muon neutrino events are analyzed in reconstructed energy-zenith space to test for signatures of a matter-enhanced oscillation that would occur given a sterile neutrino state with a mass-squared differences between 0.01 and 100  eV^{2}. The best-fit point is found to be at sin^{2}(2θ_{24})=0.10 and Δm_{41}^{2}=4.5  eV^{2}, which is consistent with the no sterile neutrino hypothesis with a p value of 8.0%.

Symmetric Nuclear Matter from the Strong Interaction

We study the equation of state of symmetric nuclear matter at zero temperature over a wide range of densities using two complementary theoretical approaches. At low densities, up to twice nuclear saturation density, we compute the energy per particle based on modern nucleon-nucleon and three-nucleon interactions derived within chiral effective field theory. For higher densities, we derive for the first time constraints in a Fierz-complete setting directly based on quantum chromodynamics using functional renormalization group techniques. We find remarkable consistency of the results obtained from both approaches as they come together in density and the natural emergence of a maximum in the speed of sound c_{S} at supranuclear densities. The presence of this maximum appears tightly connected to the formation of a diquark gap. Notably, this maximum is observed to exceed the asymptotic value c_{S}^{2}=1/3 while its exact position in terms of the density cannot yet be determined conclusively.