AB0524 RELATIONSHIP BETWEEN SERUM URIC ACID, CARDIOVASCULAR RISK AND INFLAMMATORY STATUS IN PRIMARY SJÖGREN’S SYNDROME

Background

An unhealthy diet, with or without impaired renal urate excretion, is the most frequent cause of hyperuricemia. Despite its pivotal role in the pathogenesis of gout, the clinical relevance of serum uric acid (SUA) levels goes well beyond the simple association with gout and/or nephrolithiasis. Several studies pointed to hyperuricemia as cardiovascular (CV) risk factor in the general population therefore, the 2018 guidelines of the European Society of Cardiology and the European Society of Hypertension included the assessment of uricemia among the screening tests to be performed in hypertensive patients. Furthermore, in view of the association between hyperuricemia and mortality (both CV and all-cause) and CV events, it is conceivable that cardiovascular damage begins with much lower levels of uricemia. In this context, the first results of the URRAH (Uric Acid Right for Heart Health) study identified a uricemia threshold value of 4.7 mg/dL for all-cause mortality and 5.6 mg/dL for CV mortality1.

Objectives

Since patients with primary Sjögren’s syndrome (pSS) have a higher risk of CV events compared to the general population, we aimed to explore how uricemia correlates with other CV risk factors and previous CV events in patients with pSS and without gout.

Methods

A cross sectional study was conducted recruiting consecutive patients with pSS without history of gout. SUA was measured upon recruitment alongside the assessment of disease activity (EULAR Sjögren’s syndrome disease activity index, ESSDAI and ClinESSDAI), patient reported symptoms (EULAR Sjögren’s syndrome patient reported symptoms, ESSPRI), CV risk factors including hypertension and diabetes among others, and previous CV events. Dietary habits were also explored with various food frequency questionnaires.

Results

One hundred and three patients with pSS were enrolled. SUA levels ranged between 2.9 and 6.8 mg/dl and, according to the cut-off values of the URRAH study, 16 (16%) patients had SUA levels >4.7 mg/dL while 5 (5%) had SUA levels >5.6 mg/dL. Patients with SUA levels >4.7 mg/dL were more likely males (20% vs 3%) with a higher number of CV risk factors compared to patients with SUA levels <4.7mg/dL. No differences were observed regarding dietary habits across groups. Disease activity assessed with both ESSDAI and ClinESSDAI was significantly higher in patients with SUA levels >4.7 mg/dL compared to patients with SUA levels <4.7 (9.3 vs 6.3 p= 0.04 and 9.0 vs 6.0 p=0.03). Conversely, patient reported symptoms (total ESSPRI and individual VAS scales for total dryness, xerostomia, xerophtalmia, pain and fatigue) did not differ across groups. Logistic regression analysis confirmed the association of SUA values >4.7 mg/dL and a higher number of CV risk factors (OR 2.8; 95% CI=1.2-6.5; p=0.016).

Conclusion

Accumulating evidence highlights the emerging role of hyperuricemia as an independent CV risk factor, but no data are available in pSS patients. This is the first study demonstrating that SUA levels >4.7 mg/dL correlate with both a higher number of CV risk factors and a higher disease activity in pSS patients. Large interventional studies are needed to clarify the possible benefits of urate-lowering treatments in pSS patients.

References

[1]Virdis A et al. Identification of the Uric Acid Thresholds Predicting an Increased Total and Cardiovascular Mortality Over 20 Years. Hypertension 2020;75(2):302-308

Disclosure of Interests

None declared

POS0723 DIETARY HABITS AND THE IMPACT ON CLINICAL FEATURES IN PRIMARY SJOGREN’S SYNDROME

Background

In recent years, increasing evidence on the role of diet on chronic conditions, including cardiovascular diseases (CV) and rheumatic and musculoskeletal diseases (RMDs) has accrued. Most studies exploring the possible role of nutrients and dietary patterns on both the risk to develop RMDs in the general population and the natural history of the disease in patients with established RMDs pertain to rheumatoid arthritis. Data in patients with established primary Sjogren’s syndrome (pSS) is lacking.

Objectives

To explore dietary habits and their relationship with metabolic and inflammatory features in a cohort of patients with established pSS.

Methods

Consecutive patients with pSS were recruited and dietary habits over the previous 12 months were explored. Adherence to the Mediterranean Diet was assessed with the 14-item PREvencion con DIeta MEDiterranea’ (PREDIMED) tool and the 28-item Mediterranean Lifestyle (MEDLIFE) index. Adherence to the Dietary Approaches to Stop Hypertension (DASH) was estimated using a score based on 8 food items. Tea/herbal tea and coffee intake were also explored and clinical/serological records were retrospectively collected.

Results

We enrolled 105 patients with pSS (95% females) with a mean age of 59 years. According to the PREDIMED score 32 (31%) patients had a good adherence to the Mediterranean Diet, 64 (61%) a medium adherence and only 9 (8%) a poor adherence. According to the DASH score, 74 (71%) patients had low adherence and 31 (29%) had high adherence. When dividing patients according to the extent of adherence to either of the dietary patterns and correlating the diet adherence scores to disease specific variables some associations emerged. The PREDIMED score was inversely correlated with disease activity, as measured by the EULAR Sjögren’s syndrome disease activity index (ESSDAI) (Spearman’s rho=-0.27, p= 0.009) and ClinESSDAI (Spearman’s rho=-0.26, p=0.01) revealing that a higher adherence to the Mediterranean Diet was associated with lower disease activity. With regard to the MEDLIFE, the total of blocks 1 and 2, that are related to Mediterranean foods and dietary habits, did not correlate with the total of block 3 (related to other healthy habits such as physical activity), meaning that the patients adhering the most to the Mediterranean Diet not necessarily had an overall healthy lifestyle. Adherence to DASH was not associated with disease activity. With regard to individual nutrients, fish consumption was associated with a lower prevalence of hypertension as observed in the general population. Higher intake of red meat was associated with higher values of self-reported pain (Spearman’s rho=-0.3; p=0.01) while high wholegrain intake was associated with a lower number of coexisting CV risk factors (OR=0.7; 95% CI=0.52-0.97; p=0.03).

Conclusion

Adherence to the Mediterranean Diet, with particular attention to high intake of fish and wholegrains and low intake of red meat, may be beneficial on various domains in pSS, such as the CV system and the inflammatory environment, and as such should be recommended to patients with this disease.

Disclosure of Interests

None declared

AB0364 THE EFFECT OF BIOLOGIC AND TARGETED SYNTHETIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS ON WORK PARTICIPATION IN LONGSTANDING RHEUMATOID ARTHRITIS: RESULTS FROM A SYSTEMATIC LITERATURE REVIEW

Background

Work participation (WP) is a top priority for people with RA and a determinant of patients’ quality of life. Therefore, assessing the effect of interventions on WP outcomes is important.

Objectives

To review the effect of b/tsDMARDs on employment status (ES), sick leave (SL) and presenteeism in patients with longstanding RA.

Methods

A systematic literature review up to October 2021 was conducted using the PICOT framework (Figure 1). Two researchers independently screened abstracts, then full texts were reviewed to determine eligibility. Data from eligible articles were extracted. Heterogeneity and insufficient reporting of data precluded meta-analysis.

Results

We included 42 studies:16 randomized controlled trials (RCT) and 26 longitudinal observational studies (OBS). All studies were conducted with background therapy with csDMARDs; 33 (78%) in csDMARD-IR patients. RCTs provided short-term data only (≤24 weeks (w)) which have limited relevance for WP outcome domains such as ES1. OBS reported long-term data (≤ 5 years), albeit imposing challenges due to lack of random allocation to interventions and often lack of a comparator. Regarding ES, 6 RCTs and 4 OBS did not report significant differences in bDMARD-treated patients vs background csDMARDs. For SL (19 studies), 1 RCT showed that etanercept significantly reduced RA-related SL up to 12-16w; however, one OBS showed no such effect on the long-term. Conflicting results were obtained by 2 RCTs on baricitinib. Most compounds assessed in the 12 OBS without comparator reported improvement in SL up to 104w. For presenteeism (11 studies; Table 1), 4 RCTs showed that etanercept, golimumab, certolizumab pegol, baricitinib and peficitinib were superior to PBO+csDMARDs up to 12w. Two H2H studies assessing sarilumab and baricitinib vs adalimumab observed comparable presenteeism in all treatment arms at 12-16w.

Table 1.

Overview of presenteeism from RCTs and OBS with a comparator in csDMARD-IR patients

AuthorYearInstrumentRecall periodIntervention (I)¶Comparator (C)¶N employed/N totalEffect sizeFrom the articleComputed SMD (95% CI)Bae2013WPAI-GH7 dI: ETNC: csDMARDNR/197NR/103% improvement49.623.6-0.24 (-0.5; -0)Bingham2014Self-composed single item4 wI: GOLC: PBONR/395NR/197Mean Δ (SD)–2.4 (2.8)–0.7 (4.5)-Emery2017WPAI-RA7 dI: BARI 2mgI: BARI 4mgC: PBO88/22976/22790/228LSM Δ from BL (95% CI)−14 (−20 to −8)−16 (−22 to −11)−8 (−13 to −2)-Keystone 2017WPAI-RA7 dI: BARIC: PBO199/487206/488LSM Δ from BL (95% CI)-18 (-22, -15)-10 (-13, -6)-Kavanaugh 2009WPS-RA1 mI: CZP 200 mgI: CZP 400 mgC: PBO132/393139/39069/199NR-0.09 (-0.3; 0.1)-0.17 (-0.3; -0)Kavanaugh 2009WPS-RA1 mI: CZP 200 mgI: CZP 400 mgC: PBO101/24695/24649/127NR-0.11 (-0.3; 0.1)-0.11 (-0.3; 0.1)Strand2018WPS-RA1 mI: SARIC: ADA78/184185LSM Δ from BL (SE)-3.74 (0.5)-3.50 (0.5)-Kaeley2018WPAI-RA7 dI: ADA + MTX 7.5mgC: ADA + MTX 20mgNR/154NR/155NR0.20 (-0.03-0.4)Tanaka2021†WPAI7 dI: PEF100mg ± csDMARDsI: PEF150mg ± csDMARDsC: PBO60/10453/10250/102Mean Δ−12.2−18.73.6-Tanaka2021WPAI7 dI: PEF100mg ± MTXI. PEF150mg ± MTXC: PBO ± MTX83/174101/17499/170Mean Δ−11.6−16.9−2.7-Tanaka2018 & 2020*WPAI 7 daysI: TCZC: csDMARDs167/377160/347Mean Δ-17.7-17.2-

*OBS WPAI, work productivity and activity index; WPS, work productivity survey; GH, global health; NR, not reported; LSM, least mean square; BL, baseline; CI, confidence interval; SE, standard error; SMD, standardized mean difference; d, days; w, weeks; m, month. ¶Added to background therapy with csDMARDs unless otherwise stated.

Conclusion

Short-term data from RCTs with background therapy with csDMARDs showed adding b/tsDMARDs was more effective than PBO in improving presenteeism. However, data on SL are conflicting and the positive results come from OBS without comparator. Future studies should consider existing guidance on the assessment of WP outcome domains to allow pooling and meta-analysis1.

References

[1]Boonen A, et al. Ann Rheum Dis. 2021;80:1116-23.

Disclosure of Interests

Alessia Alunno: None declared, Mary Lucy Marques: None declared, Louise Falzon: None declared, Sofia Ramiro: None declared, Annelies Boonen Speakers bureau: Abbvie, Galapagos, Consultant of: Galapagos, Grant/research support from: Abbvie

POS0525 ARE BIOLOGIC AND TARGETED SYNTHETIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS ASSOCIATED WITH WORK PARTICIPATION IMPROVEMENT IN EARLY RHEUMATOID ARTHRITIS? A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

In early RA, the benefit of treatment with b-/tsDMARDs on work participation (WP), a top-three social role in RA, has seldom been studied.

Objectives

To review the effect of treatment with b-/tsDMARDs on employment status (ES), presenteeism and sick leave (SL), in patients with early RA.

Methods

A systematic literature review (SLR) was conducted in key electronic databases up to October 2021, to include RCTs assessing the effect of treatment with b-/tsDMARDs vs any comparator on ES, presenteeism and SL in patients with RA (≤ 3y). Two reviewers independently identified eligible studies and extracted data. Random-effects meta-analysis was only performed if ≥3 studies were conducted in comparable populations, assessing WP outcome similarly. Statistical heterogeneity was assessed with I2.

Results

From 7129 records (65 full-text articles screened), 11 RCTs were included in the SLR (7 in csDMARD naïve patients; 2 in inadequate responder to csDMARDs; 1 bDMARD tapering after initial combination with MTX, and 1 strategy study). Large heterogeneity was found across WP outcomes, measurement instruments, interventions and comparators (Table 1), which together with insufficient data reporting hampered meta-analysis of most outcomes. For ES, to allow meta-analysis, all outcomes were converted to employment loss, for which individual study Odds ratios (OR) were computed. The pooled OR of 4 studies with 779 patients treated with adalimumab, infliximab or baricitinib (Figure 1) showed a lower likelihood of employment loss at weeks 56 to 104 in those treated with MTX+b/tsDMARDs compared to MTX+PBO (OR: 0.65; 95% CI:0.43-0.99). For presenteeism and SL, 33/40 (83%) between-group comparisons showed improvement in favour of b-/tsDMARDs, but an effect size was reported or possible to compute for only 12 comparisons, of which 8 (67%) were statistically significant.

Table 1.

Overview of between-group results

Author, year Study nameIntervention (I) Comparator (C)AssessedOutcomeInstrumentFollow-up(weeks)Favours intervention(+ yes; - no) $csDMARD naïveSmolen 2006ASPIREIFX+MTXESSCMI‡54+*PBO+MTXSL+*Bejarano 2008ADA+MTXESWeekly diaries‡56+*PBO+MTXSL+*Anis 2009COMETETN+MTXSLSCMI‡52+*MTXvan den Hout 2009BeStI: IFX+MTXSLSCSI‡10456w: + I vs C1/2C1: seq. monotherapyPresVAS (0-100)104w: + I vs C1 | +* I vsC2: step-up comb. Therapy + IFXC3C3: initial comb. Therapy + IFXvan Vollenhoven 2010PREMIERI1: ADA+MTXESSCMI‡104+* I1 vs C | + I2 vs CI2: ADA+PBOPres+* I1 vs C | + I2 vs CC: PBO+MTXSL+** I1 vs C | +** I2 vs CEmery 2016OPTIMAPROWDADA+MTXESWPAI-RA24-26OPTIMA & PROWD +PBO+MTXPresOPTIMA +*SLOPTIMA -Wiland 2016PRIZEI: ETN25/MTXPresWPAI-RA11739W & 65 W: + I vs C1/239W & 65 W: + I vs C1/2C1: PBO+MTXSLC2: PBO+PBOSchiff 2017RA-BEGIN¶I1: BARI+MTXPresWPAI-RA5224w: + I1/2 vs CI2: BARI+PBOSL52w: + I2 vs CC: PBO+MTX24w: + I1/2 vs C52w: + I2 vs CStrand 2021SELECT-EARLY¶I1: UPA 30Overall work impairmentWPAI-RA12+ I1/2 vs CI2: UPA 15C: MTXcsDMARD Inadequate respondersEriksson 2015SwefotIFX + MTXSLRegistry7 y+csDMARD + MTXFleischmann 2016AMPLE¶ABA+MTXPresWPAI-RA10424, 56 & 104w: +ADA+MTXSL24 & 104w: +

SCMI – self composed multiple items; SCSI – self composed single item; WPAI – Work Productivity Activity Impairment questionnaire; *p ≤ 0.05 **p ≤ 0.001 vs C; ‡ non-validated instrument; $ when > 1 I/C or time-point, between-group comparisons and time-points are presented if I vs C differences were observed; ¶ insufficient data reporting to compute effect sizes.

Conclusion

A protective effect against employment loss was observed in patients with early RA treated with MTX+b-/tsDMARDs compared to MTX monotherapy. The methodological heterogeneity and insufficient reporting hampers clear conclusions regarding the beneficial effects of b-/tsDMARDs on presenteeism and SL. Efforts to uniformize future studies with WP as outcome by following recently developed points to consider are crucial1.

References

[1]Boonen A, et al. Ann Rheum Dis. 2021; 80:1116-1123.

Disclosure of Interests

Mary Lucy Marques: None declared, Alessia Alunno: None declared, Louise Falzon: None declared, Annelies Boonen Speakers bureau: Abbvie /Galapagos, Consultant of: Galapagos, Grant/research support from: Abbvie, Sofia Ramiro: None declared.

POS0888 NON-SURGICAL LOCAL TREATMENTS FOR DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Digital ulcers(DUs) in systemic sclerosis(SSc) represent a major clinical challenge. There are no recommendations for the local management of SSc-DUs. Systemic therapy is considered the standard of care. However, there is a strong rationale for local approaches to DU by avoiding side effects from systemic therapies. The World Scleroderma Foundation DU Working Group intends to develop evidence-based recommendations for DU management including local, non-surgical treatment(ln-sT).

Objectives

To summarise the literature on the safety and efficacy of ln-sT for SSc-DUs.

Methods

A systematic literature review(SLR) of papers describing the use of ln-sT for DU in SSc was performed up to May 2021 according to the PICO framework. References were independently screened by two reviewers who independently assessed the full text of eligible articles and extracted data.

Results

Among 790 retrieved references, 12 were included. Median(range) number of patients per study was 9(7–84), mean age ranging from 37 to 62.5 years. In 5(41%) studies a control group was included. Background systemic therapies are summarized in Table 1. The most studied treatment was botulin toxin A(BTA). It was used as hand injection in 3 studies (median dose ranging from 90 to 150 U) and as 50 U single finger injection in 1 study. Healing rate after a median time of 8-49 weeks ranged from 71% to 100%. In 2 studies a reduction in VAS pain was observed from 20% to 100%. Transient muscle weakness was the most common side effect in 10% of patients. Amniotic(Am) and hydrocolloid membranes(HyM) were used in 1 study each. They were associated with a good healing rate, statistically significant for the HyM. Tadalafil 2% cream was studied in 1 study and was associated with a reduction in the median DU number from 1.6 to 1 per patient after a median time of 4 weeks and a reduction by 1.4 point in the 10-mm VAS scale. Vitamin E gel was shown to be associated with a statistically significant reduction in the healing time compared to SoC alone in 1 RCT(13.2 ± 2.7 versus 20.9 ± 3.6 weeks, P=<0.001). Low-level light therapy, hydrodissection and corticosteroid injection and extracorporeal shock wave(ESW) were evaluated in 1 study each. They were all associated with positive outcomes which was statistically significant only for the ESW. The only negative trial examined dimethyl sulfoxide and was associated with local toxicity.

Table 1.

Characteristics of the studies.

TreatmentType of studyPatientsBaseline DUBackground therapy (%) ETA CCB APA PG ARB ACE-I PDE-5i ISFollow-up (weeks)Healing rate(%)*Pain Reduction (VAS/10)ComparatorHydrodissection and corticosteroid injectionP1202334.4Rheumatoid ArthritisTadalafil 2% Vitamin E gelRRCT15131.6(1)3.5±2.30462700130704 241(1)Reduced time to heal**1.4SoCAmHyMRP67310001002800002817033143810090**SoCBTAMedian 90 U per handHigh-concentration hand100 U non-dominant handSingle finger 50 URRPP772010314571140718558551008514201001414718 4981277717510020%100%Untreated CHLow-level light therapyP8102537025378100ESWP9493355661144441**1.31Dimethyl sulfoxideDBRCT84No change, skin toxicity with 70% formulation

*Unless otherwise stated. **Statistically significant. ARB= angiotensin receptor antagonist. ACEi= ACE inhibitors. APA= anti-platelet agents. CCB= calcium channel blockers. CH= contralateral hand. DBRCT= double blind randomized-controlled trial. ETA = endothelin antagonist. IS= immunosuppression. PG= prostaglandins. PDE-5i= Phosphodiesterase type-5 inhibitors. P = prospective. R = retrospective. SoC= standard of care (as per local protocol).

Conclusion

Our SLR supports interest to develop ln-sTs for SSc-DUs. The number of studies is limited and mainly case reports and small single studies are present. Treatments were well tolerated and there was evidence of efficacy for BTA, vitamin E, ESW and HyM in refractory DUs. The evidence is not robust and confounding factors (vasodilators background therapies) could impact on the findings. Future research is indicated to conduct larger, well-designed studies.

Disclosure of Interests

Corrado Campochiaro: None declared, Yossra A. Suliman: None declared, Michael Hughes Speakers bureau: Actelion pharmaceuticals, Eli Lilly, and Pfizer, outside of the submitted work., Jan Schoones: None declared, Dilia Giuggioli: None declared, Pia Moinzadeh Speakers bureau: speaking fees from Actelion pharmaceuticals and Boehringer Ingelheim, Nancy Maltez: None declared, Laura Ross: None declared, Murray Baron: None declared, Lorinda Chung: None declared, Yannick Allanore: None declared, Christopher P Denton: None declared, Oliver Distler Speakers bureau: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Speakers bureau: Janssen and Eicos Sciences, Inc., Thomas Krieg: None declared, Masataka Kuwana Speakers bureau: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

POS0741 REPORT FROM THE APS STUDY GROUP OF THE ITALIAN SOCIETY FOR RHEUMATOLOGY (SIR-APS) ON aPL NEGATIVIZATION

Background

The rate of antiphospholipid antibodies (aPL)negativization in antiphospholipid syndrome (APS) patients is uncertain, but it is estimated to be as high as 8%. aPL disappearance seems to be more frequent in patients positive for one single aPL test and appears to be related with the immunosuppressant/immunomodulatory treatment undertaken by the patient. Currently, a consensus definition of aPL negativization is lacking, as well as international recommendations on how to approach treatment in patients with a persistent aPL negative seroconversion.

Objectives

The aim of our work was to evaluate the clinical approach and the level of consensus among experts from the APS Study Group of the Italian Society for Rheumatology (SIR-APS) in different clinical scenario addressing aPL negativization and its definition.

Methods

Experts of SIR-APS were contacted using a survey methodology.

Results

A structured survey was circulated among 30 experts.Up to 90% of the interviewed experts agreed on defining aPL negativization as the presence of two negative determinations, one year apart (90%).Almost ful lconsensus exist among experts in some clinical settings, including: a) the role of aPL negativitation in the management of a thrombotic event determined by concomitant presence of cardiovascular risk factors, both modifiable and not modifiable (90%): b) approach to young patients with triple aPL positivity who experienced pulmonary arterial thrombotic event and tested negative for aPL detection after five year of vitamin K antagonist (VKA) treatment (90%); c)the use of “extra criteria” aPL antibodies testing before pondering VKA suspension (93%).

Conclusion

Consensus is needed to support the management of patients with APS in areas where controlled data are missing. A substantial agreement exists among expert in defying aPL negativization as the presence of two negative determinations, one year apart. On the contrary, VKA suspension should be embraced with extreme caution when it comes to APS patients, particularly if they experienced arterial thrombotic events and/or tested positive for triple aPL. Nevertheless, VKA cessation might be considered when risk factors are carefully monitored/treated and the presence for “extra criteria” aPL is ruled out.

References

[1]Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, Derksen RHWM, DE, Groot PG, Koike T, Meroni PL, Reber G, Shoenfeld Y, Tincani A, Vlachoyiannopoulos PG, Krilis SA. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006; 4: 295–306.

[2]Coloma Bazán E, Donate López C, Moreno Lozano P, Cervera R, Espinosa G.

Discontinuation of anticoagulation or antiaggregation treatment may be safe in patients with primary antiphospholipid syndrome when antiphospholipid antibodies became persistently negative. Immunol Res Immunol Res; 2013; 56: 358–61.

[3]Radin M, Schreiber K, Sciascia S, Roccatello D, Cecchi I, Aguirre Zamorano MÁ, Cuadrado MJ. Prevalence of Antiphospholipid Antibodies Negativisation in Patients with Antiphospholipid Syndrome: A Long-Term Follow-Up Multicentre Study. Thromb Haemost 2019; 119: 1920–6.

Acknowledgements

Italian Society of Rheumatology

Disclosure of Interests

None declared

POS1457 ANALYSIS OF WORLDWIDE RHEUMATOLOGY POSTGRADUATE TRAINING CURRICULA: A MAPPING EXERCISE TO INFORM THE DEVELOPMENT OF EULAR STANDARDS FOR THE TRAINING OF EUROPEAN RHEUMATOLOGISTS

Background

Previous work has highlighted considerable heterogeneity in the organization of postgraduate rheumatology training programs. EULAR strives to harmonise rheumatology training across Europe with defined standards of key aspects of training including knowledge, skills and professional behaviors.

Objectives

To analyse existing documents on postgraduate training in rheumatology and other related specialties available within Europe and the rest of the world.

Methods

As most documents were unpublished, key documents on specialty training in Rheumatology and 28 related specialties were retrieved by hand-search. We started with the collection of documents developed by UEMS (Europe), ACGME (USA), CanMEDS (Canada) and RACP (Australia). Then we searched for specialty training documents developed by other international Boards and we also sent emails to the boards or associations if no document could be found in their websites. Finally, we retrieved national documents from European Countries with a structured rheumatology training process, translated them into English using DeepL/Google translate and, in case of doubt, liaised with native speakers familiar with the documents. The content of all the above documents (including information about the structure of each document) was extracted into a standardized data extraction sheet.

Results

133 documents were retrieved. UEMS, ACGME, CanMEDS documents were available for all the mapped specialties, while RACP documents were retrieved for only 18 specialties. No American or Canadian specialty board developed additional documents on training, while in Europe non-UEMS boards of 11 specialties did (Table 1). With regard to Rheumatology, 2 separate documents for adult and pediatric rheumatology training were available from UEMS and ACGME while one document on adult rheumatology training was retrieved for CanMEDS and RACP. Upon assessment of the content of these 133 documents, we observed that their organisation could be competence-based (48%), role-based (47%), or problem-based (5%). When focusing on Rheumatology, content was fairly similar across international curricula, but several differences emerged in national curricula. These were mainly related to national regulations (e.g. rheumatology training as part of internal medicine training) and a different definition of mandatory/optional competences. The number of listed competences in the rheumatology documents ranged from 18 to 196.

Table 1.

Documents retrieved and extracted for each specialty. Rheumatology national training documents are not listed.

SpecialtyEuropeUSACanadaAustraliaALLUEMSOther boardACGMEOther boardCanMEDSOther boardRACPOther boardRheumatologyxxxx6*Allergologyxxxxx5Anaesthesiologyxxx03Cardiologyxxxxx5Child and Adolescent Psychiatryxxx03Clinical Geneticsxxxx4Dermatology and Venereologyxxxx4Emergency Medicinexxxx04Endocrinologyxxxxx5Gastroenterologyxxxx4General practicexxxx4Geriatricsxxxx4Gynaecology and Obstetricsxxx03Infectious Diseasesxxxx4Internal Medicinexxxx04Medical Oncologyxxxxx5Nephrologyxxxxx5Neurologyxxxx4Occupational Medicinexxxx4Ophthalmologyxxx03Orthopaedicsxxxx04Otorhinolaryngologyxxx03Paediatricsxxxxx5Physical Medicine and Rehabilitationxxxx4Psychiatryxxx03Public Health Medicinexxxx4Radiation Oncology and Radiotherapyxxxx04Respiratory medicinexxxxx5Sport and exercise medicinexxx03TOTAL3011300300180119

*2 UEMS and 2 ACGME document on adult and pediatric rheumatology

Conclusion

We collected and analysed documents on specialty training in Rheumatology and other related specialties across a broad set of international sources. Most documents followed a competence-based or role-based framework; similarities and differences in the content of Rheumatology documents were detected. This mapping exercise informed the EULAR Task Force on the development of standards for the training of European rheumatologists.

Disclosure of Interests

None declared

POS0898 SURGICAL MANAGEMENT OF DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Management of digital ulcers (DUs) in systemic sclerosis (SSc) is a major clinical challenge. To date, systemic therapy is generally considered as the ‘standard of care’ for significant SSc-DUs. However, there is a strong rationale to develop local approaches to DUs, to avoid side effects from systemic therapies. World Scleroderma Foundation DU Working Group intends to develop practical, evidence-based recommendations for DU management including local, Surgical Treatment (L-ST).

Objectives

To summarize the literature on the safety and efficacy of L-ST for SSc-DUs.

Methods

A systematic literature review (SLR) was conducted up to May 2021. According to the PICO framework, eligibility criteria were defined and original research articles about surgical treatment of SSc DUs in adult patients were included. References were independently screened by 2 reviewers who assessed the full text of eligible articles and extracted data.

Results

Thirteen eligible articles out of 790 total publications were identified (Table 1). Due to the paucity of randomized controlled trials of surgical treatments for SSc-DU, we included retrospective studies and case series with at least 4 patients. Autologous fat (adipose tissue AT) grafting was the surgical modality mostly identified (7 studies of which 1 RCT and 6 prospective open label single arm). The healing rate (HR) with autologous fat grafting (4 studies) ranged from 66-100 %. In the RCT, two age and sex matched groups were included, adipose tissue (AT)group (n=25 pts) and sham procedure (SP) group (n=13), DU healing was reported in 23/25 in AT group versus 1/13 in the SP group in 8 wks, (p<0.0001), 12 pts in the SP group, received rescue AT injection, all of them healed after 8 wks. Three studies reported autologous adipose-derived stromal vascular fraction(SVF) grafting and the HR ranged from 32-60%, followed up to 12 months. Transient edema and paresthesia were reported in 2 studies, and amputation in 2 ulcers in 1 study, and no complications were reported in other studies. Surgical sympathectomy was reported in 3 studies, with a median healing rate of 81%. Bone marrow derived cell transplantation in a single study showed 87% healing rate over (4-24 wks). Two surgical studies (of direct microsurgical revascularization N=4, and microsurgical arteriolysis, N=6), showed 100% healing of ulcers, no complications reported.

Table 1.

Characteristics of the extracted studies.

StudydesignPatients (n)Baseline DU (n)Background therapy (%)Follow-upOutcomeHealed ulcers(%) Adipose tissue graftAutologous fat graftp9.15PG, CCB—100ETA 26PDE-5i 138-12 wks66Adipose tissue graftingRCT25 case13- Ctr25-case13- CtrPG- 100CCB 1008 wks92-case7-CtrAdipose tissue implantp1515no therapy7 wks100Adipose tissue graftp129PG,CCB-100ETA6 month88adipose derived SVFp1215PDE-5i, ccb, PG allowed22m6Adipose derived SVFp1215CCB 50ETA166 m63 Adipose derived SVFp1819CCB 50PG 27ETA 5IS 7124 wks32SympathectomySympathectomyR611CCB-10020 m81SympathectomyR1335PGCCBAPA35Sympathectomy, vascular bypass (+vein graftR1726Ccb 35APA 47PDE-i5 589 m100Bone marrow derived cells transplantation)p88PG-6236 m87Direct microsurgical revascularizationR44m100Limited microsurgical arteriolysisR61712 m100

SVF =stromal vascular fraction P = prospective. R = retrospective. RCT= double blind randomized-controlled trial. ETA = endothelin antagonist. CCB= calcium channel blockers. APA= anti-platelet agents. PG= prostaglandins. ARB= angiotensin receptor antagonist. ACEi= ACE inhibitors. PDE-5i= PDE-5 inhibitors. IS= immunosuppression. M=median. SoC= standard of care. HR= healing rate

Conclusion

Our SLR has identified several surgical modalities for SSc-DUs. L-STseemed generally effective and safe for DU healing, thus Significant methodological issues emerged including small numbers of pts, lack of comparator, failure to report confounders such as background therapies and variable follow up. Future research is warranted to rigorously investigate surgical interventions for Dus.

Disclosure of Interests

Yossra A. Suliman: None declared, Corrado Campochiaro: None declared, Michael Hughes Speakers bureau: speaking fees from Actelion pharmaceuticals, Eli Lilly, and Pfizer, outside of the submitted work, Jan Schoones: None declared, Dilia Giuggioli: None declared, Nancy Maltez: None declared, Pia Moinzadeh Speakers bureau:: speaking fees from Actelion pharmaceuticals and Boehringer Ingelheim, Laura Ross: None declared, Lorinda Chung: None declared, Yannick Allanore: None declared, Murray Baron: None declared, Christopher P Denton: None declared, Oliver Distler Shareholder of: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Speakers bureau: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Consultant of: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Grant/research support from: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Speakers bureau: Janssen and Eicos Sciences, Inc., Paid instructor for: Janssen and Eicos Sciences, Inc., Consultant of: Janssen and Eicos Sciences, Inc., Thomas Krieg: None declared, Masataka KUWANA Speakers bureau: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Paid instructor for: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Consultant of: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

AB1181 THE BURDEN OF POST-SARS-COV2 VACCINE COMPLICATIONS AND NEWLY DIAGNOSED IMMUNE-MEDIATED INFLAMMATORY DISEASES

Background

Local and systemic reactions have been observed after all vaccines for SARS-CoV-2 but in the majority of cases, symptoms are mild and self-limiting. However, evidence on more severe clinical scenarios, requiring admission to hospital or referral to outpatient clinics after the administration of SARS-CoV-2 vaccines has accrued. This also includes newly diagnosed diseases, such as cardiovascular and immune-mediated inflammatory diseases (IMID).

Objectives

We aimed at quantifying the burden of post-vaccine hospital admissions/referrals and of newly diagnosed IMID.

Methods

Clinical records of patients referred to our Internal Medicine institution (both inpatients and outpatients) between February and June 2021 were retrospectively assessed. Subjects having received one or more doses of any of the EMA-approved SARS-CoV-2 vaccines within the previous 30 days were included. Subjects with a previous diagnosis of IMID were excluded.

Results

Our cohort included 99 patients, 45 females and 54 males, with a mean age of 64 years and a median of 3 comorbities (range 0-7). Eighty-eight patients (89%) required admission to the Internal Medicine ward while 11 were referred to the outpatient clinic. 68 (69%) of patients received the vaccine BNT162b2, 16 (16%) the ChAdOx1 nCoV-19, 9 (9%) the mRNA-1273 and 6 (6%) the Ad26.COV2.S. Twenty-seven (27%) subjects developed symptoms after the first vaccine dose with a mean latency of 2 days (median=0 indicating symptom onset on the day of the vaccine administration). Twenty-four (24%) subjects developed symptoms after the second dose with a mean latency of 4 days (median 1 day). All the other subjects did not develop symptoms within the week after the vaccine and were admitted for reasons apparently unrelated to vaccine administration. The number of presenting complaints ranged between 1 and 4 with 87% of subjects presenting with 1 or two coexisting complaints. Gastrointestinal manifestations were the most frequent being the presenting complaint in 31 (31%) of patients followed by severe fatigue/appetite loss in 19 (19%) of subjects, fever in 18 (18.2%) and neurological manifestation in 16 (16%) of subjects. A temporal and causal association with the SARS-CoV-2 vaccine was identified since all other known causes for these manifestations were ruled out. No in-hospital deaths were observed and 19 (19%) patients were diagnosed with a new onset IMID (Table 1). The clinical picture of these subjects was not significantly different from that of patients without a confirmed IMID and neither were demographic features. No association with the type of vaccine was observed.

Table 1.

Immune-mediated inflammatory diseases diagnosed after SARS-CoV2 vaccination (N=19)

DiseaseNumber of patientsRheumatoid arthritis5Psoriatic arthritis2IgA vasculitis2Spondyloarthritis1Giant cell arteritis1Polymyalgia rheumatica1Gout1Primary biliary cholangitis1Antiphospholipid syndrome1Graves’ disease1Ulcerative colitis1Autoimmune thrombocytopenia1Leukocytoclastic vasculitis1

Conclusion

Our data show that post-vaccine newly diagnosed IMID may represent a challenge in clinical practice and it seems that no demographic or clinical feature is able to predict their onset. A multidisciplinary cooperation and registry data are needed in order to reliably estimate and define the impact of SARS-CoV-2 vaccinations on new onset IMID.

Disclosure of Interests

None declared

POS0992 CLINICAL AND IMAGING FEATURES IN SPONDYLOARTHRITIS PATIENTS WITH AND WITHOUT HLA-B27 AND HLA-B51: A VALIDATION COHORT

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. In a previous pilot study, we identified similarities and differences in patients with axial or peripheral SpA according to the presence of HLA-B51 only, HLA-B27 only or neither of the two.

Objectives

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

Methods

We retrospectively analyzed patients with axial or peripheral SpA, according to the ASAS criteria, referring to our institution between 2020 and 2021. 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

The independent validation cohort included 185 patients and was comparable to the original cohort of 236 patients with regard to age, gender, age at diagnosis and symptom duration. In line with the findings in the original cohort we observed that aphtous lesions were more prevalent in patients with HLA-B51 (p< 0.001) while inflammatory bowel disease was more prevalent in the double negative group (p=0.0006). Unlike the original cohort, patients of the validation cohort did not show a different prevalence of inflammatory back pain (IBP) at disease onset or in the disease course based on the HLA status. A sub-analysis by gender demonstrated a comparable prevalence of IBP in males and females within the 3 groups. As novel finding, we observed that enthesitis and psoriasis were significantly more prevalent in the double negative group compared to the B27 and B51 groups (p=0.004) and their prevalence did not differ when comparing B27 and B51 groups. With regard to imaging in patients with axial manifestations, in the original cohort we observed that 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 and the latter showed a significant negative association with sacroiliitis on imaging (OR 0.342 CI 0.189-0.619 p<0.0005). In this validation cohort we observed that the prevalence of sacroiliitis on X-ray was similar in the 3 groups while sacroiliitis on MRI scan was significantly more prevalent in the B27 group (81%) compared to the double negative (63%) and the B51 group (51%). A negative association between sacroiliitis on MRI and HLA-B51 but not double negative status was observed in the validation cohort (OR=0.23, 95% CI=0.07-0.8, p=0.02).

Conclusion

Our findings underscore the clinical and radiological heterogeneity of patients with SpA and HLA-B51 alone or neither HLA-B27 nor HLA-B51 compared to those with HLA-B27 only and underline the need to explore further this area by means of registry data with large real-life cohorts.

Disclosure of Interests

None declared

POS0900 SYSTEMIC PHARMACOLOGICAL TREATMENT OF DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Digital ulcers (DU) are common in systemic sclerosis (SSc) and associated with reduced survival, high morbidity and poor quality of life. Recommendations have previously been proposed for DU management yet there remains significant unmet patient need. Therefore the World Scleroderma Foundation DU Working Group intends to develop practical evidence based recommendations for DU management.

Objectives

To summarise data on efficacy and safety of systemic treatments for SSc DU.

Methods

A systematic literature review to May 2021 was performed. PubMed, MEDLINE, Embase, Web of Science, Cochrane Library, Emcare (OVID) and Academic Search Premier databases were searched for original studies on adult patients with SSc DU treated with systemic pharmacological treatment. Based on the PICO framework, eligibility criteria were defined and references were independently screened by two reviewers. Reviewers independently assessed the full text of eligible articles. Owing to interstudy heterogeneity narrative summaries were used to present data.

Results

The search strategy identified 1271 references of which 45 eligible articles were included. Seventeen studies were randomised placebo controlled trials (RCT) pertaining to PDE5 antagonists (PDE5i) (n=3), endothelin receptor antagonists (ERA) (n=3), prostanoids (n=7), antiplatelet agents (n=1) and other (n=3) (Table 1). No head to head RCT was retrieved. All other studies were observational studies (OBS). Studies were highly heterogeneous with application of differing definition of DU, variable study eligibility criteria, clinical endpoints and follow up periods. This limited the calculation of effect size and comparison across studies.

Table 1.

Characteristics of placebo controlled randomised controlled trials

Author YearInterventionnFollow upOutcomeFavours interventionHachulla 2016Sildenafil8312 weeksTime to DU healing-Andrigueti 2017Sildenafil4112 weeksDU healing+Shenoy 2010Tadalafil246 weeksNew DU+Khanna 2016Macitentan55416 weeksNew DU-Matucci-Cerinic 2011Bosentan18832 weeksNew DU Time to healing of DU+-Korn 2004Bosentan12212 weeksNew DU+Kawald 2008IV iloprost5012 monthsDU healing-Wigley 1992IV iloprost3510 weeksDU healing+Wigley 1994IV iloprost739 weeks50% reduction in DU score-Seibold 2017Treprostinil14820 weeksNet DU burden-Vayssairat 1999Beraprost10725 weeks% patients with new DU-Denton 2017Selexipag7412 weeksNumber of new DU DU healing-Lau 1993Cicaprost334 weeksNumber of DU-Abou-Raya 2008Atorvastatin844 monthsNumber of DU+Au 2010Cyclophosphamide15812 monthsNumber of patients with DU-Beckett 1984Dipyridamole / aspirin412 yearsChange in general SSc-Nagaraja 2019Riociguat1732 weeksNet DU burden-

+ significantly superior to comparator

- non significantly different from comparator

DU: digital ulcers IV: intravenous SSc: systemic sclerosis

Several RCT found improved DU healing with treatment: two with PDE5i, one with iloprost and one showed improved DU healing and prevention with atorvastatin. Two RCT demonstrated effective prevention of new DU with bosentan. OBS studies with a total of 621 patients showed variable improvements in the healing of DU with CCB, PDE5i, ERA, statins, N-acetylcysteine, prostanoids and ketanserin and prevention of new DU with ERA.

Regarding safety, all treatments were generally tolerated with few serious adverse events. Treatment was ceased in 6.25-17.5% of patients in RCT due to treatment related side effects.

Conclusion

Despite several studies assessing the efficacy and safety of systemic pharmacological treatment of SSc DU, it is not possible to draw solid conclusions due to study heterogeneity. Small RCT have shown treatment benefit with PDE5i, iloprost and atorvastatin. Large studies demonstrated effective prevention of new DU with bosentan. Our results highlight the urgent need for improved clinical trial design to generate more robust evidence and novel therapies to guide the management SSc DU.

Acknowledgements

This work was supported by the World Scleroderma Foundation.

Disclosure of Interests

Nancy Maltez: None declared, Laura Ross: None declared, Michael Hughes Speakers bureau: Actelion Pharmaceuticals, Eli Lilly and Pfizer outside of the submitted work., Jan Schoones: None declared, Murray Baron: None declared, Lorinda Chung Consultant of: Eicos, Corrado Campochiaro: None declared, Yossra A. Suliman: None declared, Dilia Giuggioli: None declared, Pia Moinzadeh Speakers bureau: Actelion Pharmaceuticals, Boehringer Ingelheim, Yannick Allanore: None declared, Christopher P Denton: None declared, Oliver Distler Speakers bureau: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Grant/research support from: Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143), Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Consultant of: Eicos Sciences Inc, Janssen, Thomas Krieg: None declared, Masataka Kuwana Speakers bureau: Speaker fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and consultancy fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

POS0895 THE ROLE OF SURGERY IN THE ESOPHAGEAL INVOLVEMENT IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Among gastrointestinal (GI) manifestations in Systemic Sclerosis (SSc) one of the predominant and challenging problems is gastroesophageal reflux disease (GERD), which occurs in ~75% of patients. Although proton pump inhibitors are useful, they are ineffective in 40% of cases with chronic use at high doses, against the background of long-term risks (e.g., cardiovascular disease and infections) which have been identified in the general population. Surgery might be an option following failure of medical therapy but currently, there is no consensus regarding the optimal surgical procedure for refractory GERD in SSc.

Objectives

To evaluate, among the surgical approaches to GERD, the feasibility of fundoplication (FP) with regards to its safety, efficacy, indications, and timing.

Methods

Four research questions based on the PICO framework were developed to guide the systematic literature review that was conducted up to 22 December 2021. The search and performed across different databases including PubMed, MEDLINE (OVID), EMBASE, Cochrane Library, Web of Science, Google Scholar, Emcare and Academic Search Premier. References were independently screened by two reviewers (PMC and AA) who also independently assessed the full text of eligible articles, and extracted data. Due to heterogeneity of retrieved studies, narrative summaries are used to present the data.

Results

The search yielded 916 papers of which 30 were eligible for full text review. In these studies, out of 2919 clinically heterogeneous patients, 348 SSc patients were identified (mostly female, mean age 52.7 years). Out of these 348, only 257 underwent anti-reflux surgical procedure and were included in the analysis. Most of the studies were conducted in surgical settings and relevant rheumatological data were largely missing. Refractory GERD symptoms, were the commonest indication for surgery, with post-operative dysphagia being the most frequent complication. In 18 studies, FP was effective, whereas 4 studies had equivocal findings and in 5 a lack of efficacy was reported. The Collis-Nissen FP was the most popular procedure overall as well as in earlier studies, followed by Nissen FP, and Dor FP in relatively more recent studies, reflecting the change in surgical strategy over time. The data extracted shows also an acceptable rate of mortality and morbidity related to surgery, and heterogeneous outcome measures were used hampering any comparison of the studies (Table 1). Due to the heterogeneity of the data, it was not possible to separate the mortality and morbidity rate of SSc patients from the rest of the population.

Table 1.

GERD ASSESSMENT AND SURGICAL OUTCOMES

Domain assessed/outcomeInstrument/MeasurementN° of studiesReflux severityDysphagia: 20Number of antireflux medications: 10High dose PPI: 9pH monitoring (pre-procedure): 11Oesophagitis/Barret 4Reflux improvement (post-procedure)Symptom resolution/reduction 24pH monitoring 12Repeat EGDS 8N° of patientsN° of surgical proceduresTotSSc 257Collis-Nissen FP 54Nissen FP 39Dor FP 37Collis-Belsey FP 20Toupet FP 18RYGB 23Others 30Undefined 36Post-operative surgical complications73 (2,5%)*Mortality (n° deaths)8 (0,27%)*

*rate in total population (2919)

Conclusion

Our SLR has highlighted that the surgical management of GERD in SSc patients is still highly challenging since the available evidence is scarce and of poor quality. Among the surgical approaches to the problem of GERD, overall FP seems a safe and effective procedure in SSc. Transient post-operative dysphagia was noted in many studies, particularly related with the posterior FP. In the future, it will be necessary to develop minimal requirement to conduct surgical studies in SSc as well as to design studies aimed at defining the clinical criteria for referral to surgery. Indeed, the right timing for surgery and the best surgical procedure in SSc still remains an unmet need.

Disclosure of Interests

None declared

OP0074 A FRAMEWORK OF POTENTIAL INTERVENTIONS TO ACCELERATE GENDER-EQUITABLE CAREER ADVANCEMENT IN ACADEMIC RHEUMATOLOGY

Background:

A growing number of professional societies in clinical and medically related disciplines investigate evidence, make recommendations, and take action to advance gender equity. Evidence on women’s advancement and leadership in the context of the European Alliance of Associations for Rheumatology, EULAR, is limited [1].

Objectives:

The objective of the EULAR Task Force on Gender Equity in Academic Rheumatology was 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 Emerging EULAR Network (EMEUNET).

Methods:

Potential interventions to accelerate gender-equitable career advancement in academic rheumatology were gathered from a narrative review of the relevant literature, expert opinion of a multi-disciplinary Task Force (comprised of 23 members from 11 countries), data from the surveys of EULAR scientific member society leaders, EULAR and EMEUNET members, and EULAR Executive Committee members. These interventions were rated by Task Force members, who ranked each according to perceived priority on a five-point numeric scale from 1 = very low to 5 = very high.

Results:

A framework of 29 potential interventions was formulated, which covers six thematic areas, namely, EULAR policies, advocacy and communication, EULAR Congress and associated symposia, training courses, mentoring/peer support, and EULAR funding (Figure 1).

Figure 1.

A framework of potential interventions with the levels of priority, mean and standard deviation (SD)

Conclusion:

The framework provides structured interventions for accelerating gender-equitable career advancement in academic rheumatology.

References:

[1]Andreoli L, Ovseiko PV, Hassan N, et al. Gender equity in clinical practice, research and training: Where do we stand in rheumatology? Joint Bone Spine 2019;86(6):669-72.

Acknowledgements:

The task force is grateful to EULAR for funding this activity under project number EPI 024.

Disclosure of Interests:

None declared

POS1099 EFFICACY OF INTRA-ARTICULAR CORTICOSTEROID INJECTIONS IN KNEE OSTEOARTHRITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Background:

Knee osteoarthritis (OA) is a frequent degenerative disease representing an important health and economic burden. Symptomatic medical treatments available include intra-articular (IA) injections of corticosteroids (GC) but their efficacy is debated. In addition, safety signals regarding cartilage damage with IA GC have been highlighted in a few studies.

Objectives:

To perform a meta-analysis of studies assessing IA GC efficacy and safety in knee OA.

Methods:

A systematic literature review and a meta-analysis of randomized controlled trials (RCTs) assessing the effect of GC IA injections versus other interventions (IA Hyaluronic Acid, IA placebo, IA NSAID, oral NSAID or physiotherapy) in knee OA was performed. The effect of the interventions on pain and function were extracted from the single studies and pooled and are presented as short term (<6weeks), medium term (6-24 weeks) and long term (>24 weeks) follow-up period. Standardized mean differences (SMD) are reported.

Results:

Of 520 studies screened, 23 were included in the SLR and 14 subsequently included in the MA. While IA GC showed a superior effect compared to control on both pain (SMD -0.61 (95% CI -1,25, 0.03)) and function (SMD -1.02 (95% CI -2.14, 0.10)) in short term follow-up; long term follow-up analysis favored controls (IA HA, IA NSAID, physiotherapy) for both pain (SMD 0.68 (95% CI -0.11, 1.47)) and function (SMD 0.88 (95% CI -0.36, 2.12) outcomes (Figure 1). No difference was found between interventions in the medium term. Safety data were reported in 18/23 studies (n= 1936/2314 patients); and side effects were reported as follows: arthralgia (69 IA GC patients, 146 IA HA patients, and 20 saline patients); site injection pain (7 in the IA GC group, 2 in the IA saline group, 14 in the IA HA group); 16 post injection knee swelling without signs of septic arthritis in the IA GC group and 24 in the IA HA group. In one study assessing cartilage effects of GCs, the rate of cartilage loss was greater in the GC group with a reduction of cartilage thickness at 2 year compared to placebo group. No difference was observed in the progression of cartilage denudation or bone marrow lesion. On the contrary, another study showed no effect of injections on the cartilage structure.

Conclusion:

We demonstrate in this work that IA GC injections reduce pain and improve function in the early phase (≤6 weeks) of treatment. In the long term (≥24 weeks), other intervention such as IA HA injections or physiotherapy seem to be more efficient, but this effect was largely driven by single studies with large effect sizes and the comparators were heterogeneous.

Figure 1.

Knee pain outcome at short term (≤6weeks) (A), medium term (>6 & <24 weeks) (B), and long term (≥24 weeks) (C) follow up.

Disclosure of Interests:

None declared.

OP0287 IMMUNOMODULATORY THERAPIES FOR SEVERE FORMS OF COVID-19: A SYSTEMATIC LITERATURE REVIEW TO INFORM EULAR POINTS TO CONSIDER

Background:

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic is a global health problem. Beside the specific pathogenic effect of SARS-CoV-2, a deleterious aberrant non-effective host immune response plays an important role especially in severe forms of COVID-19. There is intense investigation to explore the utility of immunomodulatory drugs commonly used in the Rheumatology arena as agents that may mitigate against COVID-19 to improve disease prognosis. Rheumatologists are used to the utilization of these immune targeted therapies.

Objectives:

To summarize the available information on the use of immunomodulatory agents in severe COVID-19.

Methods:

As part of a EULAR taskforce, a systematic literature search was conducted from January 2019 up to December 11, 2020. Two reviewers independently identified eligible studies according to the PICO framework P (population): patients with SARS-CoV-2 infection; I (intervention): any immunomodulator agent/strategy; C (comparator): any comparator; O (outcome) any clinical outcome including but not limited to mortality, admission to intensive care unit and clinical improvement. Data on efficacy and safety of immunomodulatory agents utilized therapeutically in SARS-CoV-2 infection at any stage were extracted. The risk of bias was assessed using validated tools.

Results:

Of 60372 records, 401 articles were eligible for inclusion. Studies were at variable risk of bias. Randomised controlled trials (RCTs) were available for the following drugs: hydroxychloroquine (N=12), glucocorticoids (N=6), tocilizumab (N= 4), convalescent plasma (N=4), interferon beta (N=2), IVIg (N=2) and N=1 each for anakinra, baricitinib, colchicine, leflunomide, ruxolitinib, interferon kappa, and vilobelimab. For glucocorticoids, dexamethasone reduced mortality only in patients requiring respiratory support; while methylprednisolone reduced mortality in patients aged 60 years or over. Data from RCTs on tocilizumab are conflicting and definite conclusions cannot be drawn at this point in time, but recent studies suggest possible benefit in patients requiring respiratory support. Hydroxychloroquine was not beneficial at any disease stage, one RCT with anakinra was negative, one RCT with baricitinib+remdesivir was positive, and individual trials testing some other compounds provided interesting, albeit preliminary, results.

Conclusion:

Although there is emerging evidence about immunomodulatory therapies for the management of COVID-19, conclusive data is scarce with some conflicting data. Since glucocorticoids seem to improve survival in some subsets of patients, RCTs comparing glucocorticoids alone versus glucocorticoids plus anti-cytokine/immunomodulatory treatment are warranted. This SLR informed the initiative to formulate EULAR points to consider on pathophysiology and use of immunomodulatory therapies in COVID-19.

Figure 1.

Forest plots showing the risk ratio (RR) and 95% confidence interval for mortality in randomized controlled trials divided by intervention. The latest follow-up available is reported in the timing column.

Disclosure of Interests:

None declared

AB0652 FERRITIN IS ASSOCIATED WITH THE SEVERITY OF LUNG INVOLVEMENT BUT NOT WITH WORSE PROGNOSIS IN PATIENTS WITH COVID-19: DATA FROM TWO ITALIAN COVID-19 UNITS

Background:

The coronavirus 2019 disease (COVID-19) is characterised by a heterogeneous clinical presentation and a wide range of imaging findings, depending on disease severity and time course. The pathophysiology is complex, involving immune and hematologic systems, epithelial cells and vascular system and to date reliable biomarkers aimed at stratifying patients and predicting worse outcomes have not been identified

Objectives:

The aim of this study was to describe clinical, serological and CT imaging features of a cohort of patients with COVID-19 pneumonia and identify possible relationships between the variables and disease outcomes (admission to intensive care unit (ICU) and/or death).

Methods:

We evaluated hospitalized patients with proven SARS-CoV-2 infection, clinical signs of COVID-19 and computed tomography (CT) scan-proven pulmonary involvement. Clinical and serological records of patients admitted to two COVID-19 Units in Italy with proven SARS-CoV-2 pulmonary involvement investigated with CT scan, assessed at the time of admission to the hospital, were retrospectively collected.

Results:

Sixty-one patients (22 females and 39 males) of median age 65 years were enrolled. Fifty-six patients were discharged while death occurred in 5 patients. None of the lung abnormalities detected by CT was different between discharged and deceased patients. No differences were observed in the features and extent of pulmonary involvement according to age and gender. Logistic regression analysis with age and gender as covariates demonstrated that ferritin levels over the 25th percentile were associated with the involvement of all 5 pulmonary lobes (OR=14.5, 95% CI=2.3-90.9, p=0.004), the presence of septal thickening (OR=8.2, 95% CI=1.6-40.9, p=0.011) and the presence of mediastinal lymph node enlargement (OR=12.0, 95% CI=1.1-127.5, p=0.039) independently of age and gender.

Conclusion:

We demonstrated that ferritin levels over the 25th percentile are associated with a more severe pulmonary involvement, independently of age and gender, but not with disease outcomes (admission to ICU/death). The identification of reliable biomarkers in patients with COVID-19 may help guiding clinical decision, tailoring therapeutic approaches and ultimately improving the care and prognosis of patients with this disease.

Disclosure of Interests:

None declared.

OP0077 THE EMERGING EULAR NETWORK (EMEUNET): AN INTERNATIONAL SURVEY REFLECTING ON A TEN-YEAR JOURNEY

Background:

The Emerging EULAR NETwork (EMEUNET), founded in 2009, aims to promote education, foster research collaborations and facilitate the integration of young researchers and rheumatologists within EULAR.

Objectives:

After 10 years, we aimed to interview our members to assess how EMEUNET is fulfilling its goals, understand if there are unmet needs and explore new ideas.

Methods:

In July 2019 a survey was circulated for 3 months among EMEUNET members via its social media channels. The survey contained 18 closed and 2 open items, in addition to general questions on age, job and country of origin and work.

Results:

Out of 124 total respondents, most completed all items (120/124) and only a minority had some missing items (4/124). A little over half of the respondents were female (n=69, 54.8%) and median age was 33y (range 25y-42y). Most respondents were born (n=109, 88.6%) and/or worked in Europe (n=114, 92.7%) (fig. 1), although there was also a representation from extra-European countries, which is in line with the general EMEUNET membership (https://emeunet.eular.org/map.cfm).

Figure 1.

Country of origin and where respondents work at the time of completing the EMEUNET VISE questionnaire.

11 (9.1%) had been EMEUNET members for less than 2 years, 81 (66.9%) for 2-5years and 29 (24.0%) for more than 5 years.

Figure 2 shows a clear link between the respondents’ perception of EMEUNET aim(s) and the actual aims of EMEUNET set out in our mission statement (https://emeunet.eular.org/mission_statement.cfm).

Figure 2.

The links between what participants would like to see as EMEUNET aims and the aims of EMEUNET as they are now

Most of the respondents got to know about EMEUNET through a friend/colleague in Rheumatology (n=67, 54.0%), at EULAR/ACR annual conferences (n=32, 25.8%), via social media (n=9, 7.3%), other international meeting (n=6, 4.8%), national Rheumatology meeting (n=6, 4.8%) or via the EMEUNETs country liaisons (n=4, 3.2%).

29 respondents (24%) were part of the EMEUNET working group (WG), 43% (n=53) applied before to be part of the WG, 24% (n=29) never applied and 15% (n=19) did not know what the WG was. Most of the respondents who never applied to the WG thought it to be too time consuming. Only 21 (16.9%) felt there was a subgroup in the WG missing and most of those (n=8, 38.1%) found this should fully focus on research collaborations, which is actually part of the general aims of EMEUNET and a focus of all Working Groups.

Only a relatively small portion of EMEUNET of respondents (<5%) stated to have approached EMEUNET with their ideas. Although 90.2% (n=110) felt that the opportunity to submit new ideas is a good initiative, only 52.5% (n=..) knew that such possibilities exists. This suggests that EMEUNET could do more to make members aware of this possibility. Additionally, while the main reasons for not contacting EMEUNET with an idea were ‘not having one’ (41.9%) or having ‘no time’ (34.9%), 20.9% feels their ideas would not be received well, which is another aspect offering room for improvement.

Twice a year, EMEUNET organises networking events (NE) for their members to discuss their work in an informal setting. We found that 56/120 (46.7%) of the respondents prefer a low-budget (<€20) event, including an activity and the possibility to network, accompanied by drinks and bites. This is much in line with EMEUNETs past NE. In addition, past NEs were often mentioned as an example of ideal events.

Conclusion:

Awareness on EMEUNET often comes from colleagues and international conferences in rheumatology, which coincides with one of the focuses of EMEUNET to increase visibility in the last 10 years. Expectations about NE are in line with the previously organised NE.

Areas for improvement are dissemination of information on the EMEUNET WG, the possibility to submit ideas -which is open to all members- and the increased focus on research collaboration, an aspect on which we are actively working as EMEUNET is fully engaged with the newly launched EULAR Virtual Research Centre.

Disclosure of Interests:

None declared

POS0755 PREVALENCE AND RELEVANCE OF ANTIBODIES AGAINST CITRULLINATED ALPHA ENOLASE (ANTI-CEP1) IN CONNECTIVE TISSUE DISEASES

Background:

Anti-citrullinated alpha enolase antibodies have been investigated in rheumatoid arthritis and associated with bone erosion and interstitial lung disease but little is known about their prevalence and role in connective tissue diseases (CTDs).

Objectives:

The aim of this study was to investigate the prevalence and relevance of anti-CEP1 antibodies in CTDs.

Methods:

Serum samples from five independent patient cohorts were assessed: 1) established (est) primary Sjogren’s syndrome (pSS) N=78, 2) est-systemic lupus erythematosus (SLE) N=52, 3) est-systemic sclerosis (SSc) N=71, 4) pSS at disease onset N=30, 5) SLE at disease onset N=46 (cohorts 4 and 5 had at least 3 years of follow-up). Samples from ninety sex and age matched healthy donors (HD) and 200 patients with est-RA (disease controls) were also tested. Anti-CEP1 IgG antibodies were measured with a commercially available ELISA kit (Euroimmun, Luebeck, Germany).

Results:

Anti-CEP1 titer was significantly higher in est-pSS, est-SLE and est-SSc compared to HD, significantly lower in est-pSS and est-SSc compared to est-RA and comparable in est-SLE versus est-RA. We divided patients in every CTD group based on whether their anti-CEP1 titer was below or above the 25th, 50th and 75th percentile. In est-SLE anti-CEP1 values over the 25th percentile were associated with articular involvement (odds ratio, OR (95% confidence interval, CI)=11.5; 1.9-70.6, p=0.008). In est-pSS, no relationship between anti-CEP1>25th percentile and articular involvement was found but rather an association with rheumatoid factor positivity (OR (95% CI)=4.8, 1.6-14.1, p=0.004) and salivary gland swelling (OR (95% CI)=6.2, 1.3-29.1, p=0.021). In est-SSc no difference could be detected across the 3 groups. Anti-CEP-1 titers in pSS and SLE at onset did not differ from each other, were comparable also to those of HD and significantly lower than those of est-pSS, est-SLE and est-RA patients (all p<0.0001).). Of interest, we could retrieve a serum sample collected at the time of diagnosis for 5 patients from the cohort of established pSS and we observed that anti-CEP1 titers were significantly lower at pSS onset than during follow up (at least 12 months after the diagnosis, p=0.0024). No difference was observed in the clinical presentation at disease onset according to different anti-CEP1 titer and they did not predict the development of new clinical manifestations during follow-up.

Conclusion:

Anti-CEP-1 antibodies can be detected in CTDs at different title during the disease course and may increase overtime, at least in pSS. Although anti-CEP1 antibodies are associated with specific clinical manifestation in est-CTDs, such as articular involvement in est-SLE, they seem to lack a predictive value for future manifestations when measured at disease onset.

References:

[1]Alunno A, Bistoni O, Pratesi F et al Rheumatology (Oxford) 2018.

[2]Manca ML, Alunno A, D’Amato C et al. Joint Bone Spine 2018.

Disclosure of Interests:

None declared

POS0052 PATHOPHYSIOLOGY OF ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 INFECTION: A SYSTEMATIC LITERATURE REVIEW TO INFORM EULAR POINTS TO CONSIDER

Background:

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a global health problem. Beside the specific pathogenic effect of SARS-CoV-2, incompletely understood deleterious and aberrant host immune responses play critical roles in severe disease. Rheumatologists have the best experience of studying and treating these complicated hyperinflammatory processes.

Objectives:

To summarize the available information on pathophysiology of COVID-19.

Methods:

As part of a EULAR taskforce, two systematic literature reviews were performed one on pathophysiology and one on immunomodulatory therapies. Two reviewers independently identified eligible studies according to the following PICO framework: P (population): patients with SARS-CoV-2 infection; I (intervention): any intervention/no intervention; C (comparator): any comparator; O (outcome) any clinical or serological outcome including but not limited to immune cell phenotype and function and serum cytokine concentration. The results pertaining to pathophysiology of COVID-19 are presented here.

Results:

Of the 55496 records yielded, 85 articles were eligible for inclusion. Included studies were at variable risk of bias and exploring various aspects of disease pathogenesis from immune to non-immune cells (Table 1). Pro-inflammatory cytokines’ expression including IL-6, was increased, especially in severe COVID-19, although not as high as other states with severe systemic inflammation. Innate and adaptative immune cell compartments were differentially affected by SARS-CoV-2 infection: neutrophils displayed an immature differentiation state and also increased neutrophil extracellular traps (NETs) formation. Dendritic cell number was reduced and classical monocytes was increased although displaying a reduced expression of HLA-DR. The lymphoid compartment was also affected: lymphopenia was present with a reduced number of CD4+ and CD8+ T lymphocytes and more frequent PD1+CD8+ T cells corresponding to an exhausted phenotype. Antibody response to SARS-CoV-2 infection showed a high variability across individuals and disease spectrum. Multiparametric algorithms showed variable diagnostic performances in predicting survival, hospitalization, disease progression or severity, and mortality. Differences in SARS-CoV-2 manifestations in adults and children were highlighted.

Conclusion:

Overall, SARS-CoV-2 infection affects both innate and adaptative immune responses in a variable way, according to both disease severity and individual parameters. This SLR informs the EULAR points to consider on pathophysiology and use of immunomodulatory therapies in COVID-19.

Table 1.

Studies on SARS-CoV-2 infection pathogenesis

Research questionNCytokines profile7Immune profile18Algorithm17Children3Comorbidities1Endothelial dysfunction and platelets8Gut and microbiota3Genetics and variants8Histology7Antibodies profiles8Viral load and immune response4Interferon3Immunosenecsnce3Total90*

*Some manuscripts were including in several research questions. Total number of studies included n=85.

Disclosure of Interests:

Aurelie Najm Speakers bureau: BMS, Consultant of: BMS, Alessia Alunno: None declared, Xavier Mariette Speakers bureau: BMS, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Novartis, Pfizer, Servier and UCB, Consultant of: BMS, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Novartis, Pfizer, Servier and UCB, Benjamin Terrier Speakers bureau: Roche, Chugai, Vifor Pharma, GSK, AstraZeneca, Terumo BCT, LFB and Grifols, Consultant of: Roche, Chugai, Vifor Pharma, GSK, AstraZeneca, Terumo BCT, LFB and Grifols, Gabriele De Marco: None declared, Laura Mason: None declared, Jenny Emmel: None declared, Dennis McGonagle Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Pedro M Machado Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB.

The role of self-expanding vascular stent in superior vena cava syndrome for advanced tumours

INTRODUCTION

Superior vena cava (SVC) syndrome (SVCS) is a life-threatening occurrence that necessitates prompt treatment. At present, endovascular stenting is proposed as a first-line treatment to relieve symptoms. We assessed the effectiveness, safety and outcome of SVC stent positioning in patients affected with advanced cancer.

METHODS

Forty-two patients undergoing stent positioning in the SVC for neoplasms from January 2002 to December 2018 form the basis of this retrospective study. Demographic data, risk factors, associated diseases, symptoms at presentation according to the score proposed by Kishi and the type of SVCS according to Sanford and Doty were collected. Minor and major complications were recorded. Suspected stent occlusion was confirmed by means of recurrence of symptoms followed by a confirmatory computed tomography (CT).

RESULTS

Thirty-four (81%) patients had a nonresectable lung tumour invading or compressing the SVC. Five (12%) patients had a non-Hodgkin's lymphoma, and three (7%) had metastatic lymphadenopathies. Nitinol stents (Memotherm^®) were employed in 19 (45%) patients, and steel stents (Wallstent™) in the remaining 23 (55%) patients. Thirty-five (85%) patients died during follow up for disease progression and the overall survival rate at 24 months was 11% (standard error (SE)=0.058). Thirteen patients (32%) had a recurrence of SVCS because of stent thrombosis in three (23%) and extrinsic compression from uncontrolled cancer progression in ten (77%). The overall symptom-free interval at 24 months was 57% (SE=0.095).

CONCLUSIONS

We recommend the use of the endovascular procedure as a first-line treatment in locally advanced or metastatic tumour in the presence of SVCS.

FRI0562 THE PERSPECTIVE OF YOUNG PEOPLE WITH INFLAMMATORY ARTHRITIS ON PATIENT REPORTED OUTCOME MEASURES: RESULTS OF A EUROPE-WIDE SURVEY

Background:

Although patient-reported outcome measures (PROMs) are widely used in clinical practice and research, it is unclear if these instruments adequately cover the perspective of young people (18-35 years) with inflammatory arthritis (IA). We recently performed focus groups on PROMs with 53 young IA patients from 4 European countries, but the perspective of these patients has never been explored on a large scale.

Objectives:

To explore personal experience, opinions and beliefs of young people with IA across Europe concerning PROMs content, characteristics and ways of administration in order to inform EULAR points to consider (PtC) for including the perspective of young patients with IA into PROMs.

Methods:

Based on the results of our previous qualitative study, a task force including patients, rheumatologists and health professionals developed an online survey. The survey covered personal experience, preferences and opinions concerning PROMs. After being pilot tested and revised accordingly, the survey was distributed through the EULAR people with arthritis and rheumatism in Europe (PARE), Young PARE networks and the Emerging EULAR Network (EMEUNET).

Results:

547 people (88% females) from 29 countries aged 18-35 years with a diagnosis of juvenile idiopathic arthritis, rheumatoid arthritis, Still’s disease, psoriatic arthritis or spondyloarthritis completed the survey (Figure 1). Thirty-seven percent of respondents reported they never filled a PROM. A North-South and West-East Europe gradient was observed (30.4% vs 56.3% and 25.5% vs 58.8% respectively). Figure 2 outlines key findings of our survey. Among respondents having filled PROMs (n=313), two thirds perceived their access to PROM results useful for self-management of their health. Discomfort while filling PROMs was an issue for nearly half of the respondents, as questions were perceived as scaring or not relevant. This discomfort, the fear of judgement, or inadequate assessed time frames were major reasons for difficulties in translating the health experience into a rating scale. Still 75% use their own experience in the past as reference. Among several reasons, people scored differently from what they felt to emphasize how much better or worse they felt from previous assessment. Concerning preferences of numerical rating scales (NRS) or visual analogue scales (VAS) explored in all respondents regardless having ever filled in PROMs, those in favour of VAS mainly reasoned this by having more possibilities to select and those favouring NRS by better readability and interpretation. Maintaining a sitting position, preparing food, doing physical activity, intimacy and sleep problems were the items selected most frequently in the survey as in the qualitative study to be included in PROMs. The implementation of discussion on self-management, education/work and support possibilities at regular clinic visits was considered important by over 60% of responders. Overall, electronic capturing of PROMs was preferred over paper-based questionnaires (57% vs 13%).

Conclusion:

Our survey explored for the first time the personal experience and opinions of young people with IA concerning PROMs on a large scale and confirmed the results obtained in the qualitative study. This survey informed the EULAR PtC for including the perspective of young patients with IA into PROMs.

References:

[1] Mosor E et al. Arthritis Rheumatol. 2019; 71 (suppl 10)

Disclosure of Interests:

Alessia Alunno: None declared, Erika Mosor: None declared, Tanja Stamm Grant/research support from: AbbVie, Roche, Consultant of: AbbVie, Sanofi Genzyme, Speakers bureau: AbbVie, Roche, Sanofi, Paul Studenic Grant/research support from: Abbvie

THU0586 ESTABLISHING THE KEY COMPONENTS OF A EULAR PORTFOLIO FOR TRAINING IN RHEUMATOLOGY: A EULAR SCHOOL OF RHEUMATOLOGY INITIATIVE

Background:

In clinical training, a portfolio is expected to stimulate learning and encourage critical reflection. Some, but not all, European countries use a portfolio in rheumatology training, and their scope varies widely. A EULAR portfolio for Rheumatology trainees could contribute to improve overall training, raise educational standards, foster the setting of common goals and harmonize rheumatology training across countries.

Objectives:

Develop key components that should be included in a EULAR portfolio of Rheumatology.

Methods:

A working group (WG) composed of 9 rheumatologists and 1 educationalist was established. A systematic literature review (SLR) was conducted in November 2018, according to the PIM structure: Population: trainees; Instrument of interest: portfolio; Measurement of properties of interest: content portfolio. A survey was disseminated among the WG group and WG members of the EMerging EUlar NETwork (EMEUNET), inquiring about the content and structure of existing national portfolios. Portfolio materials of selected countries were reviewed. Last, the WG elected the key components of the portfolio.

Results:

13/2,034 articles were included in the SLR (12 high/1 moderate risk of bias). Information on direct observation of procedural skills (DOPS) (9/13), personal reflections (8/13), learning goals (5/13) and multisource feedback (5/13) were most often included in the portfolio. Twenty-five respondents filled out the survey (response rate ≈ 50%). Reflective writing (n=7), learning goals (n=4) and feedback (n=4) were considered the most useful components of a portfolio. About half indicated that a portfolio was a bureaucratic burden; 4 respondents mentioned lack of feedback by supervisors as a barrier. Portfolio materials of 7 European countries were reviewed. Several portfolios (Germany, Italy, Greece and Spain) were logbooks, i.e. a record of clinical activities. Other portfolios (UK, Denmark, The Netherlands) also included information on workplace-based assessments, learning goals, and personal reflections. The proposed key components of the portfolio are included in Table 1.

Table 1.

Key components of the EULAR portfolio of Rheumatology.

Key componentContentCurriculum vitaePersonal record of achievements, experiences, knowledge and skillsPersonal Development PlanLearning goals and action planClinical workInformation on managing patients (e.g. rheumatoid arthritis)Skills (e.g. joint aspiration)Assessments (summative and formative)Personal reflectionsProfessional behaviourMultisource feedbackPersonal reflectionsEducationContinuing professional development, list of formal and non-formal learning activitiesAssessments (e.g. teaching assessment, evidence based medicine assignment)Personal reflectionsResearchList of abstracts, published articlesInformation on research funding, scholarships, bursaries, academic posts

Conclusion:

This initiative resulted in the establishment of a list of key components to be included in a EULAR portfolio of Rheumatology. Assessment forms for each key portfolio component are currently being developed. Portfolio implementation, particularly in countries that do not use it yet, may contribute significantly to promote a higher standard of patient care across Europe.

Disclosure of Interests:

Marloes van Onna: 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, M. Holland-Fischer: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Jean Dudler: None declared, Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB,

Alessia Alunno: None declared, Elena Nikiphorou: None declared, L. Falzon: None declared, Francisca Sivera: None declared

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.