Outbreak of SARS-CoV-2 in a geriatric acute-care ward during summer 2023: current aspects of infection control in the postpandemic period

Aim

Management of a SARS-CoV-2 outbreak in geriatric patients, taking into account the transition to the post-pandemic period.

Methods

PCR tests were conducted to identify the scale of infection during the outbreak; no new patients were admitted to the ward until the availability of the PCR results. Based on the results and individual risk assessment, three cohorts were formed and treated as recommended by the RKI. After terminating the admissions stop, new admissions received PCR screening. Contact patients were retested on days 3 and 5. Employees carried out self-monitoring, and if symptoms developed, an antigen test was performed.

Results

Nine of the 11 PCR-positive patients (6m, 5f), median age 85 years, were immunized. Eight patients were symptomatic, ten received antiviral therapy and two required intensive care. Three symptomatic employees had a positive antigen test. Patients without direct contact to the positive cases who initially tested negative and the 16 new admissions with a negative PCR test did not contract COVID-19. Outbreak management ended after 15 days without deaths from COVID-19.

Conclusion

During the outbreak, PCR screening, the temporary stop in new admission until the availability of PCR results, and the risk-adapted cohorting of patients supplemented by consistent PCR tests of new admissions formed the basis for successful outbreak management. Treatment can be made possible despite high vulnerability. Close symptom monitoring and rapid implementation of measures reduce the risk. Repeated PCRs of direct-contact patients on day 3 can warrant pre-emptive antiviral therapy despite being asymptomatic; testing on day 5 makes it possible to shorten preventive isolation measures. The use of protective masks and self-monitoring by employees are fundamental to preventing further infections.

[Anticoagulation in older patients]

Prescribing oral anticoagulation in older patients for e.g. stroke prophylaxis has proven to be beneficial, but some special risks have to be considered. Renal function may be substantial impaired and dose reduction in at least some of the substances is recommended. Therefore, a closer monitoring of renal function is essential. Further as bleeding risk also increases with age usual scoring lists do less help this therapeutic dilemma than in younger patients. Adequate blood pressure control is essential in preventing intracerebral hemorrhage. Fall risk has to be assessed to initiate early compensation for this risk. Only high and unimprovable fall incidence may outweigh the benefits of oral anticoagulation therapy (>1 hospital admission per month due to a fall incident). Comprehensive geriatric assessment is crucial for early detection of specific adherence problems in older patients and is also helpful for discussion of individual deprescribing options in an end of live situation.

First Search for Exclusive Diphoton Production at High Mass with Tagged Protons in Proton-Proton Collisions at sqrt[s]=13 TeV

A search for exclusive two-photon production via photon exchange in proton-proton collisions, pp→pγγp with intact protons, is presented. The data correspond to an integrated luminosity of 9.4  fb^{-1} collected in 2016 using the CMS and TOTEM detectors at a center-of-mass energy of 13 TeV at the LHC. Events are selected with a diphoton invariant mass above 350 GeV and with both protons intact in the final state, to reduce backgrounds from strong interactions. The events of interest are those where the invariant mass and rapidity calculated from the momentum losses of the forward-moving protons match the mass and rapidity of the central, two-photon system. No events are found that satisfy this condition. Interpreting this result in an effective dimension-8 extension of the standard model, the first limits are set on the two anomalous four-photon coupling parameters. If the other parameter is constrained to its standard model value, the limits at 95% confidence level are |ζ_{1}|<2.9×10^{-13}  GeV^{-4} and |ζ_{2}|<6.0×10^{-13}  GeV^{-4}.

POS0079 DOES METHOTREXATE IMPACT USTEKINUMAB IMMUNOGENICITY IN PATIENTS WITH ACTIVE PSORIATIC ARTHRITIS? A POST HOC ANALYSIS OF SAMPLES FROM A RANDOMIZED, PLACEBO-CONTROLLED TRIAL

Background

The formation of antidrug-antibodies (ADA) may reduce treatment efficacy or provoke discontinuation due to adverse reactions. Subsequent alterations in the drugs’ pharmacodynamics, pharmacokinetics, safety, and efficacy are often unpredictable and can impede clinical discourse. Recent studies gave us some insights regarding the role of ADA formation against the monoclonal IL-12/-23 antibody ustekinumab (UST) and the impact of concomitant MTX treatment on immunogenicity in psoriatic arthritis (PsA) patients [1,2]. Valid measurement of ADA, particularly of neutralizing ADA (nADA) is essential to understand UST-associated immunogenicity and may help to predict clinical outcomes.

Objectives

To examine the impact of concomitant MTX on UST-immunogenicity in patients with active psoriatic arthritis (PsA).

Methods

Plasma samples were collected from a randomized controlled trial in patients with active PsA, treated with open UST and placebo-controlled methotrexate over a 52 weeks. We compared samples of 112 patients treated with either UST and MTX (n=58) or UST and placebo (n=54). Plasma samples were obtained shortly before UST injection at weeks 0, 4, 16, 40, and 52.

Immunogenicity testing was performed as described by our group elsewhere [3], in a multitiered manner with ELISA and surface plasmon resonance analysis for the detection and quantification of ADA and UST, respectively. Neutralizing capacity was characterized in a cell-based assay. For statistical analysis, a two-way ANOVA with Sidak correction for multiple comparisons was used.

Results

Over the 52 weeks treatment period, 10 (18 %) of patients in the placebo cohort developed UST-specific ADA with one patient having non-neutralizing ADA, whereas 15 (27 %) subjects in the MTX cohort generated UST-specific ADA with 2 patients having non-neutralizing ADA. The ADA rates and concentrations at the different time points (Figure 1A, B) did not differ significantly between MTX and non-MTX users (p< 0.05). Furthermore, the presence of UST-specific ADA was not associated with decreased UST levels (Figure 1C).

Figure 1.

(A) ADA prevalence (%), (B) mean concentration (µg/ml) of confirmed ADA with 95%confidence interval and (C) mean UST concentration (µg/ml) with 95%confidence intervall in the MTX cohort (UST/MTX; n=58) and placebo cohort (UST/pbo; n=54) overall and with confirmed ADA (ADA+), respectively, at week (w) 0, 4, 16, 40, and 52.

Conclusion

The presented data yielded no statistically significant difference in ADA detection between the two analyzed groups. Our findings suggest that concomitant MTX had no impact on UST immunogenicity in PsA patients.

References

[1]McInnes, I. B. et al. Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled PSUMMIT 1 trial. Lancet. 2013;382(9894):780-9.

[2]Leonardi, C.L. et al. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 1). Lancet, 371 (2008), pp. 1665-1674.

[3]Mojtahed Poor, S. et al. Immunogenicity assay development and validation for biological therapy as exemplified by ustekinumab. Clin Exp Immunol. 2019;196(2):259-275.

Acknowledgements

Sorwe Mojtahed Poor received research support from the German Society of Rheumatology (DGRh e.V.)

Disclosure of Interests

Sorwe Mojtahed Poor: None declared, Marina Henke: None declared, Thomas Ulshoefer: None declared, Frank Behrens Grant/research support from: Janssen, Michaela Köhm Grant/research support from: Janssen, Harald Burkhardt: None declared, Susanne Schiffmann: None declared

POS1059 EFFICACY OF UST IN ACTIVE PsA IS INDEPENDENT FROM CONCOMITANT MTX USE, EVEN IN PATIENTS WITH MORE SEVERE SKIN PSORIASIS: SUBGROUP ANALYSIS FROM A RANDOMIZED PLACEBO-CONTROLLED INVESTIGATOR INITIATED CLINICAL TRIAL

Background

The use of bDMARDs treatments in patients with psoriatic arthritis (PsA) usually requires treatment failure or intolerance of csDMARD/MTX before initiation. The value of MTX in combination with bDMARDs is still unclear. We designed an investigator-initiated, randomized, placebo-controlled trial (IIT) in active PsA to examine if outcomes of treatment with ustekinumab (UST) in combination with MTX (either newly initiated or ongoing) were different from UST only (+Placebo; PBO). With known efficacy of MTX on skin psoriasis outcomes may differ in patients with or without significant skin involvement of their psoriatic disease.

Objectives

To compare efficacy outcomes in UST+PBO vs UST+MTX in dependency of skin involvement (Body Surface Area [BSA]) at baseline.

Methods

A total of 186 patients with active PsA (defined as TJC≥4, SJC≥4 [68/66 joint count] and DAS28≥3.2) were screened for eligibility. 173 patients were randomized to UST+MTX (new or ongoing) or UST+PBO.

With this post hoc subgroup analysis outcome parameters were compared between patients with or without skin psoriasis > 3 % BSA. Demographic data and disease activity status of arthritis (joint count [TJC/SJC], DAPSA, DAS28), skin (PASI, BSA), HR-QoL (EQ5D, DLQI) and physical function (HAQ) were compared between groups.

Results

BL data were well-balanced between main treatment groups (UST+MTX, n=86; UST+PBO, n=74) including gender (42.5% vs 40.5% female) and mean values for age (49.2 vs 47.2 years), BMI (29.4 vs 28.9 kg/m2), SJC (8 vs 8), TJC (12 vs 12), DAS28-CRP (4.6 vs 4.4), DAPSA (36.7 vs 34.9) and PASI (2.8 vs 2.4. Disease activity remained well-balanced even after dividing groups according to skin involvement ((a) BSA ≤3% and (b) BSA >3%) with a trend of more severe joint involvement (SJC, TJC) in BSA >3% for UST+MTX compared to UST+PBO. At week 24, relative changes in TJC (-62% vs -62%), change in DAS28 and DAPSA were equal in all treatment groups independent from skin involvement (Table 1). Differences between the groups according to skin involvement were seen for relative changes in SJC (BSA >3%: -74.8% UST+MTX vs -84.3% UST+PBO), subject global assessment (SGA), physician global assessment (PGA), DLQI and EQ5D. Highest levels for changes were detected in the UST+PBO group with high skin involvement (BSA >3%).

Table 1.

Outcomes at Week 24 (LOCF)

UST+MTXUST+PBOBSA ≤3%BSA >3%BSA ≤3%BSA >3%n=46n=40n=51n=23TJC68 change from BL-7.83 (SD 10.3)-9.5 (SD 10.3)-8.9 (SD 9.5)-7.3 (SD 7.4)SJC66 change from BL-6.0 (SD 5.4)-7.1 (SD 3.5)-6.5 (SD 6.2)-6.4 (SD 3.8)PASI change from BL+-1.3 (SD 1.9)-8.5 (SD 9.6)-1.5 (SD 2.4)-9.0 (SD 10.7)DAS-28 ESR [mm/hr] change from BL-1.6 (SD 1.1)-1.8 (SD 1.2)-1.7 (SD 1.4)-1.8 (SD 1.1)DAS-28 CRP [mg/l] change to BL-1.5 (SD 1.2)-1.5 (SD 1.3)-1.6 (SD 1.2)- 1.7 (SD 1.1)DAPSA change from BL-17.4 (SD 16.8)-20.8 (SD 13.2)-20.5 (SD 16.6)-20.4 (SD 15.3)HAQ change from BL-0.1 (SD 0.4)-0.2 (SD 0.5)-0.3 (SD 0.3)-0.3 (SD 0.5)DLQI change from BL-3.1 (SD 5.5)-5.5 (SD 8.2)-2.3 (SD 3.3)-6.4 (SD 7.9)EQ5D VAS Health State change from BL6.7 (SD 24.7)11.7 (SD 23.6)8.0 (SD 24.2)21.3 (SD 25.3)

Conclusion

IL12/23 inhibition with UST is an effective treatment for active PsA independent of MTX use. Data from this IIT indicate that additional MTX has no positive impact on UST efficacy for arthritis, skin, HR-QoL and physical function. This independency of UST effect from MTX can also be demonstrated in patients with active skin involvement despite known efficacy of MTX for skin psoriasis.

Acknowledgements

We thank Janssen for support of the study with a research grant.

Disclosure of Interests

Michaela Köhm Speakers bureau: Janssen, Consultant of: Janssen, Grant/research support from: Janssen, Tanja Rossmanith Grant/research support from: Janssen, Ann Christina Foldenauer Grant/research support from: Janssen, Herbert Kellner Speakers bureau: Janssen, Consultant of: Janssen, Uta Kiltz Speakers bureau: Abbvie, Fresenius, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: AbbVie, Amgen, Biocad, Biogen, Chugai, Eli Lilly, Hexal, Grünenthal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Grant/research support from: AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, Pfizer, Jürgen Rech Speakers bureau: Abbvie, Biogen, BMS, Chugai, GSK, Lilly, MSD; Novartis, Roche, Sanofi, Sobi, UCB, Consultant of: Biogen, BMS, Chugai, GSK, Lilly, MSD, Novartis, Roche, Sanofi, Sobi, UCB, Grant/research support from: Novartis, Sobi, Gerd Rüdiger Burmester Speakers bureau: Janssen, Consultant of: Janssen, Grant/research support from: Janssen, David M Kofler Speakers bureau: Janssen, Consultant of: Janssen, Grant/research support from: Janssen, Jan Brandt-Juergens Speakers bureau: Janssen, Consultant of: Janssen, Grant/research support from: Janssen, Christin Jonetzko Grant/research support from: Janssen, Harald Burkhardt Speakers bureau: Janssen, Consultant of: Janssen, Grant/research support from: Janssen, Frank Behrens Speakers bureau: Janssen, Consultant of: Janssen, Grant/research support from: Janssen

The Sex-Specific Impact of the FORTA (Fit-fOR-The-Aged) List on Medication Quality and Clinical Endpoints in Older Hospitalized Patients: Secondary Analysis of a Randomized Controlled Trial

Background

Little is known about the sex-specific impact of drug optimization tools such as the Fit fOR The Aged (FORTA) list on drug use and relevant clinical endpoints in older people.

Objective

We aimed to detect gender differences of interventional effects on medication quality and related clinical effects in the VALFORTA trial.

Patients and methods

A sex-specific analysis of data from 409 patients (147 men and 262 women, mean age 79.4 and 82.7 years, respectively) in acute geriatric care comparing the control and FORTA intervention groups was performed. Changes of the FORTA score (sum of over- and undertreatment errors per patient), the incidence of adverse drug events (ADEs) during hospitalization, and several clinically relevant endpoints [e.g., the Barthel index (BI)] were tested for equivalence at a 20% margin. “Success” or “failure” for the development of these clinical endpoints was defined and their frequencies compared by a risk reduction analysis.

Results

Sex differences were insignificant for the reduction of the FORTA score, the improvement of BI, or over- and undertreatment errors (p > 0.05). In women only, the FORTA intervention significantly increased the number of patients without an ADE (p = 0.010). Statistical sex equivalence was found for the improvement of the FORTA scores, BI, and the number of prevented events (e.g., falls, confusion, or renal failure) (p < 0.05), but not for the improvement of specific mistreatments or over- and undertreatment scores under altered inclusion criteria (p > 0.05).

Conclusions

Both sexes benefit equally from the FORTA intervention regarding the amelioration of the quality of drug treatment as well as several clinically relevant outcomes. In addition, the positive impact of the FORTA intervention on the number of adverse drug events appears to be greater in women.

Trial Registration Number

DRKS00000531.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-022-00292-9.

Odderon Exchange from Elastic Scattering Differences between pp and pp[over ¯] Data at 1.96 TeV and from pp Forward Scattering Measurements

We describe an analysis comparing the pp[over ¯] elastic cross section as measured by the D0 Collaboration at a center-of-mass energy of 1.96 TeV to that in pp collisions as measured by the TOTEM Collaboration at 2.76, 7, 8, and 13 TeV using a model-independent approach. The TOTEM cross sections, extrapolated to a center-of-mass energy of sqrt[s]=1.96  TeV, are compared with the D0 measurement in the region of the diffractive minimum and the second maximum of the pp cross section. The two data sets disagree at the 3.4σ level and thus provide evidence for the t-channel exchange of a colorless, C-odd gluonic compound, also known as the odderon. We combine these results with a TOTEM analysis of the same C-odd exchange based on the total cross section and the ratio of the real to imaginary parts of the forward elastic strong interaction scattering amplitude in pp scattering for which the significance is between 3.4σ and 4.6σ. The combined significance is larger than 5σ and is interpreted as the first observation of the exchange of a colorless, C-odd gluonic compound.

POS0591 SARILUMAB ATTENUATES DISEASE ACTIVITY IN SERONEGATIVE RA PATIENTS – PRELIMINARY DATA FROM A NON-INTERVENTIONAL STUDY IN REGULAR CARE IN GERMANY

Background:

Although seronegative RA patients often present with substantial disease burden [1], patients are underrepresented in research cohorts or clinical trials. Consequently, less knowledge about this subgroup has been accumulated.

Objectives:

To describe outcome of seronegative vs. seropositive RA patients treated with sarilumab in regular care in Germany.

Methods:

The prospective, observational, 24-month single-arm PROSARA study (SARILL08661) is currently running in Germany at 96 sites, aiming to enroll up to 750 RA patients treated with sarilumab. RA patients are prospectively selected at physician’s discretion according to label, and medical history is documented before treatment. This interim analysis included patients with data available up to 24 months. Here we focus on sustained treatment response after 6 and 12 months, respectively. Patients were stratified according to serostatus (RF- AND ACPA- as seronegative or RF+ AND/OR ACPA+ as seropositive). All analyses are descriptive only.

Results:

To date 473 patients were included in the study, of which 22.2% (n=105) were seronegative and 59.0% (n=279) were seropositive (Table 1). For 89 patients (18.8%) serostatus was not specified.

Table 1.

Baseline data regarding patient characteristics, prior treatment and disease activity

seronegativeseropositivepatients [n] (%)105(22.2)279(59.0)patient characteristicsSex female [n] (%)81(77.1)207(74.2)Age mean [years] (SD)56.6(12.5)59.6(10.9)BMI mean (SD) [kg/m2]29.2(6.7)28(6.0)Smoking history current/former [%]22.1/11.525.5/20.4Time since diagnosis of RA mean [years] (SD)7.9(7.6)11.5(9.9)prior RA treatmentcsDMARD [n] (%)102(97.1)273(97.8)bDMARD (TNFi) [n] (%)54(51.4)167(59.9)bDMARD (non-TNFi) [n] (%)32(30.5)83(29.7)tsDMARD (JAKi) [n] (%)25(23.8)57(20.4)disease activityCRP [mg/l] (SD)12.9(30.9)14.2(31.0)ESR [mm/h] (SD)23.7(20.5)25.3(22.4)SJC mean (SD)5.3(5.5)4.6(4.8)TJC mean (SD)10.2(8.2)7.2(6.6)HAQ-DI mean (SD)1.4(0.7)1.2(0.7)DAS28-ESR mean (SD)5.0(1.5)4.6(1.5)CDAI mean (SD)27.7(14.7)23.0(12.9)Fatigue [VAS] (SD)64.0(25.5)51.1(28.1)

The mean time since diagnosis of RA was shorter in seronegative than in seropositive patients (7.9±7.6 years vs. 11.5±9.9 years) (Table 1).

At baseline, CDAI score was 27.7±14.7 (n=104) and 23.0±12.9 (n=272) in seronegative and seropositive patients, respectively. After 12 months of sarilumab treatment, CDAI improved to 15.6±12.3 (n=38) and 9.1±8.7 (n=101) in seronegative and seropositive, respectively, for patients with post-baseline data available. At that time, remission/low disease activity according to CDAI was reached by 5.3% (n=2/38) / 39.5% (n=15/38) of seronegative patients, respectively and by 26.7% (n=27/101) / 68.3% (n=69/101) of seropositive patients, respectively (Fig. 1A, B).

Figure 1.

CDAI (A, B) and HAQ-DI (C) outcomes in seronegative and seropositive patients

Physical function, assessed by HAQ-DI, was slightly more impaired in seronegative patients (1.4±0.7) than in seropositive patients (1.2±0.7) at baseline. HAQ-DI improved over 12 months to 0.9±0.7 in seropositive patients (n=90) but showed no change in seronegative patients (1.4±0.7; n=37) (Fig. 1C).

Safety was consistent with the anticipated profile of IL-6-R-inhibition and no new safety signals occurred. Adverse events and serious adverse events were described in 61.7% and 12.8% of seronegative patients, respectively and in 55.2% and 13.7% of seropositive patients, respectively.

Conclusion:

Sarilumab treatment ameliorated CDAI in both seronegative (ΔCDAI -17.0±16.5) and seropositive (ΔCDAI -15.4±14.3) patients to the same extent over the course of 12 months, with a higher remission rate in seropositive patients. Functional capacity improved meaningfully in the seropositive cohort but had no significant impact in seronegative patients. The safety profile was consistent with data reported from controlled clinical trials.

References:

[1]Choi S-T et al. (2018) PLoS ONE 13(4): e0195550.

Acknowledgements:

We thank Cornelia Kühne (Haldensleben) for substantial contribution to patient recruitment in PROSARA.

Disclosure of Interests:

Harald Burkhardt Speakers bureau: Sanofi, Pfizer, Roche, Abb- vie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scribb, Janssen, and Novartis, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Grant/research support from: Pfizer, Roche, Abbvie, Hans-Peter Tony Consultant of: AbbVie, Astra-Zeneca, BMS, Chugai, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, Peer-Malte Aries Speakers bureau: Abbvie, Biogen, Berlin Chemie, Celgene, GSK, Hexal, Mylan, Novartis, Pfizer, UCB, Consultant of: Abbvie, Celgene, Hexal, Janssen, Medac, Novartis, Pfizer, Sanofi, UCB, Silke Zinke: None declared, Klaus Krueger Speakers bureau: Sanofi, Jonas Ahlers Employee of: Sanofi, Rolf Hecker Employee of: Sanofi, Inka Albrecht Employee of: Sanofi, Stefanie Kalus Consultant of: Sanofi, Oliver Bley Employee of: Sanofi, Patrizia Sternad: None declared, Ann-Dörthe Holst: None declared, Niklas Thomas Baerlecken: None declared, Thilo Klopsch: None declared, Martin Welcker Speakers bureau: Abbvie, Aescu, Amgen, Biogen, Berlin Chemie, Celgene, GSK, Hexal, Mylan, Novartis, Pfizer, UCB, Consultant of: Abbvie, Actelion, Aescu, Amgen, Cel- gene, Hexal, Janssen, Medac, Novartis, Pfizer, Sanofi, UCB, Grant/research support from: Abbvie, Novartis, UCB, Hexal, BMS, Lilly, Roche, Celgene, Sanofi, Eugen Feist Speakers bureau: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, Consultant of: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi

[Evaluation of the fluid balance in geriatric patients-What contribution can abdominal ultrasound make?]

The assessment of the fluid balance as well as the identification of hyperhydration and dehydration often represent a diagnostic challenge, especially in older patients. In principle, various diagnostic procedures and approaches are suitable for assessment of the various facets, by which such a disorder can be recognized. The contribution of abdominal ultrasound is described and evaluated in the context of the different diagnostic procedures. An overview of the current situation with respect to assessment of the vena cava is provided. In many respects there is no strict consensus concerning the thresholds of the individual measurements and the value of the different measurements. Currently, an orthograde diameter of the inferior vena cava > 2 cm is accepted as being a good indicator for hyperhydration. Less certain are analogously derived thresholds as indicators for dehydration.

[How to manage polypharmacia?]

Polypharmacia is a frequent challenge in modern medicine due to increasing complexity of both patients' aspects in an ageing society - multimorbidity - and progress of therapeutic approaches. Although risks are clearly increasing with number of simultaneously prescribed drugs, neither analysis of the polypharmacia-problem solely by number nor focusing on deprescribing strategies by number alone is sufficient. The optimum of an overall risk-benefit ratio in the multimorbidity situation has to be described and put into practice by an individualized approach. Pattern analysis may help this, by identifying both the most vulnerable patients and polypharmacia-pattern with pronounced risk burden. Patient vulnerability depends significantly on functional abilities and prioritizing therapeutic goals in a comprehensive deprescribing process needs to implement stage of life and disease.

Measurement of single-diffractive dijet production in proton-proton collisions at s = 8 Te with the CMS and TOTEM experiments

Measurements are presented of the single-diffractive dijet cross section and the diffractive cross section as a function of the proton fractional momentum loss ξ and the four-momentum transfer squared t. Both processesp p → p X andp p → X p , i.e. with the proton scattering to either side of the interaction point, are measured, whereX includes at least two jets; the results of the two processes are averaged. The analyses are based on data collected simultaneously with the CMS and TOTEM detectors at the LHC in proton-proton collisions ats = 8 Te during a dedicated run withβ ∗ = 90 m at low instantaneous luminosity and correspond to an integrated luminosity of 37.5 nb - 1 . The single-diffractive dijet cross section σ jj p X , in the kinematic region ξ < 0.1 ,0.03 < | t | < 1 Ge 2 , with at least two jets with transverse momentump T > 40 Ge , and pseudorapidity | η | < 4.4 , is 21.7 ± 0.9 (stat) - 3.3 + 3.0 (syst) ± 0.9 (lumi) nb . The ratio of the single-diffractive to inclusive dijet yields, normalised per unit of ξ , is presented as a function of x, the longitudinal momentum fraction of the proton carried by the struck parton. The ratio in the kinematic region defined above, for x values in the range - 2.9 ≤ log 10 x ≤ - 1.6 , is R = ( σ jj p X / Δ ξ ) / σ jj = 0.025 ± 0.001 (stat) ± 0.003 (syst) , where σ jj p X and σ jj are the single-diffractive and inclusive dijet cross sections, respectively. The results are compared with predictions from models of diffractive and nondiffractive interactions. Monte Carlo predictions based on the HERA diffractive parton distribution functions agree well with the data when corrected for the effect of soft rescattering between the spectator partons.

Measurement of single-diffractive dijet production in proton-proton collisions at s = 8 Te with the CMS and TOTEM experiments

Measurements are presented of the single-diffractive dijet cross section and the diffractive cross section as a function of the proton fractional momentum loss ξ and the four-momentum transfer squared t. Both processes p p → p X and p p → X p , i.e. with the proton scattering to either side of the interaction point, are measured, where X includes at least two jets; the results of the two processes are averaged. The analyses are based on data collected simultaneously with the CMS and TOTEM detectors at the LHC in proton-proton collisions at s = 8 Te during a dedicated run with β ∗ = 90 m at low instantaneous luminosity and correspond to an integrated luminosity of 37.5 nb - 1 . The single-diffractive dijet cross section σ jj p X , in the kinematic region ξ < 0.1 , 0.03 < | t | < 1 Ge 2 , with at least two jets with transverse momentum p T > 40 Ge , and pseudorapidity | η | < 4.4 , is 21.7 ± 0.9 (stat) - 3.3 + 3.0 (syst) ± 0.9 (lumi) nb . The ratio of the single-diffractive to inclusive dijet yields, normalised per unit of ξ , is presented as a function of x, the longitudinal momentum fraction of the proton carried by the struck parton. The ratio in the kinematic region defined above, for x values in the range - 2.9 ≤ log 10 x ≤ - 1.6 , is R = ( σ jj p X / Δ ξ ) / σ jj = 0.025 ± 0.001 (stat) ± 0.003 (syst) , where σ jj p X and σ jj are the single-diffractive and inclusive dijet cross sections, respectively. The results are compared with predictions from models of diffractive and nondiffractive interactions. Monte Carlo predictions based on the HERA diffractive parton distribution functions agree well with the data when corrected for the effect of soft rescattering between the spectator partons.

Shared Decision-Making in Oncology: Preferences in Older versus Younger Patients of an Oncology Clinic - A Conjoint Analysis

BACKGROUND

Data concerning older patients' preferences with regard to physician-patient interaction and the concept of shared decision-making (SDM) in oncology are still sparse although significantly influencing treatment planning.

METHODS

Patients were recruited as a convenience sample from an outpatient oncology department. To test for patients' attitudes toward participating in clinical decisions, the PEF-FB-9 questionnaire (the German version of SDM-Q9) and the autonomy preference index (API) instrument were applied. A conjoint analysis was performed by a full set of vignettes exposing three different clinical attributes: clinical experience in oncology of the responsible physician, type of hospital, and type of physician-patient interaction in decision-making. Two independent cohorts were retrieved: patients aged <65 years and patients aged >70 years.

RESULTS

A total of 71 patients were included. Younger subjects rated higher (44 vs. 10, p < 0.001) on the API scale. In both cohorts, physician-patient interaction received the highest preference values compared with type of hospital and physician experience. Analysis for age differences on preference values showed significantly higher values among the older patients concerning physician-patient interaction and lower values concerning type of hospital. Further analysis of the preferred type of physician-patient interaction revealed the highest preference in both cohorts for SDM.

CONCLUSIONS

The high significance of physician-patient interaction could be proved. As a SDM approach is preferred in older and younger patients, an age-related different approach does not seem appropriate.

FRI0360 IMPACT OF METHOTREXATE ON DISEASE PATTERN IN ACTIVE PSORIATIC ARTHRITIS PATIENTS ELIGIBLE FOR A RANDOMIZED CLINICAL TRIAL WITH USTEKINUMAB: COMPARATIVE BASELINE DATA FROM MULTICENTRE INVESTIGATOR-INITIATED MUST TRIAL

Background:

Methotrexate (MTX) is a csDMARD treatment that is initiated as first-line therapy (after NSAID) in active psoriatic arthritis (PsA). Randomized clinical trials mostly require treatment failure or intolerance of csDMARD/MTX therapy before initiation of a biological treatment. We designed an investigator-initiated (IIT) randomised blinded study comparing PsA patients starting open label Ustekinumab (UST) combined with blinded MTX or placebo (PLC). Patients are stratified regarding their previous MTX therapy (continuation or discontinuation of MTX (MTX-pre-treated patients –group A) or newly initiate MTX or continue without MTX (MTX-naïve patients – group B).

Objectives:

To determine disease characteristics of patients with active psoriatic arthritis regarding their skin and musculoskeletal manifestations in dependence of their MTX treatment status.

Methods:

A total of 186 patients with active PsA (defined as TJC ≥4, SJC ≥4 (68/66 joint count) and DAS28 ≥ 3,2) were screened for eligibility. At baseline (BL) 173 patients starting open label UST were randomised to receive either MTX or PLC. At Screening (SCR) and BL, demographic data, PsA and PsO disease activity (joint count (TJC/SJC), enthesitis (LEI), dactylitis (number of digits), PASI, BSA, mtNAPSI), previous medication as well as quality of life (QoL) and function (documented as PRO using DLQI, HAQ and subjects assessment of pain as visual analogue scale (VAS) was documented.

Results:

Our preliminary blinded data export comprised all documented and released data for SCR and BL until Mid-January 2020 - in total 154 randomized patients. Thereof, 78 patients were randomized in group A and 76 in group B. BL characteristics were well balanced between groups (mean age A: 50,7 years vs. 46,4 in B, BMI 29 vs. 29,6 in B). More male were included in B (72% vs. 50 %). In median, patients in A had a disease duration of 2,9 y whereas duration in B was in median 0,3 y. More patients in A had failed previous biological therapy (17 to 6 in B), discontinued due to intolerability or ineffectiveness as allowed for study inclusion. Mean DAS28 was 4,5 (moderate disease activity) for both groups and mean values for SGA, PGA were comparable (SGA: 59,1 vs 54,9 PGA: 61,4 vs. 55.6) reflecting comparable disease activity in peripheral arthritis. Mean LEI was comparable in both groups (A: 1,3 vs B: 1,1). Mean number of digits with dactylitis were slightly higher in B (0,8) than in A (0,2). Overall HAQ showed no differences (1.0 in B vs. 0.8 in A – missing data 45 and 29 resp.) and pain VAS did not differ between groups (A: 54,9 mm vs. 56,6 mm in B). PASI and NAPSI were higher in B at BL than in group A (PASI: 7,2 vs. 3,3, mtNAPSI 5,0 vs. 3,0) and PRO showed a higher skin disease burden experienced by MTX-naïve patients prior randomization: in DLQI more patients on MTX experience “no effect” of their skin disease on QoL (22% vs. 7%) whereas more MTX naïve patients see a “moderate” “large” to “extreme large effect” of their disease on QoL (16%, 11%, 5% in B vs. 10%, 8%, 3% in A).

Conclusion:

Our results give important information about comparability of patient population on MTX or without MTX therapy eligible for biological trials. Despite a comparable disease activity in peripheral arthritis scores, skin disease activity was increased in patients without MTX compared to MTX treated patients. Number of affected digits in dactylitis was lower with MTX, whereas its impact on enthesitis seems to be neglectable.

Disclosure of Interests:

Tanja Rossmanith Grant/research support from: Janssen, BMS, LEO, Pfizer, Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis, 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, Jürgen Rech Consultant of: BMS, Celgene, Novartis, Roche, Chugai, Speakers bureau: AbbVie, Biogen, BMS, Celgene, MSD, Novartis, Roche, Chugai, Pfizer, Lilly, Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Herbert Kellner: None declared, Anita Bulczak-Schadendorf Grant/research support from: Janssen, Ann Christina Foldenauer: None declared, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai

AB1237 Diagnostic value of proteasomal and autophagic markers in muscular diseases

Background:

Deficient cellular degradation pathways such as autophagy and the ubiquitin proteasome system (UPS) show a correlation with the onset of neurodegenerative diseases. Especially immune-mediated inflammatory myopathies often show therapy-resistant phenotypes with medical need for further understanding of pathogenesis und possible treatment.

Objectives:

The aim of this work was to study an association of these two degradation pathways in a large group of different muscle entities and to examine a possible influence in the pathogenesis of the investigated muscle diseases. Furthermore, a potential benefit in diagnostics was studied using factors such as ubiquitin, p62, NBR1 and LC3 and their role as adapter molecules.

Methods:

We examined ubiquitin, p62, NBR1 and LC3 on muscle biopsies from patients with the diagnosis of s-IBM, dermato- and polymyositis, muscular dystrophy, neurogenic atrophy, myotonic dystrophy type II (PROMM) and metabolic myopathies such as Pompe and McArdle disease. Immunohistochemical single and double stainings as well as immunofluorescence stainings were performed on cryosections. Furthermore, Western blot analysis was performed. The use of a histological score, defined as the product of the frequency of positive fibres and staining intensity, was used to investigate possible differences between the diseases in the expression of the investigated factors.

Results:

Especially in s-IBM, myofibrillar myopathies and Pompe disease, proteasomal and autophagic markers were detected. On the other hand, neurogenic atrophy, McArdle disease and the majority of the myotonic dystrophies type II showed no positive signals, except for p62, which was detected especially in internalized nuclei and regenerative fibres. Overall, in all entities in regenerative and necrotic as well as in atrophic fibres, a positive staining for ubiquitin, p62, NBR1 and LC3 could be shown. Dermatomyositis showed a moderate immunoreactivity for p62 and NBR1 in the area of the perifascicular atrophy. Polymyositis showed a strong endomysial reaction in the area of the attacked muscle fibres, especially in the area of the lymphocytic infiltrates. The histological score showed that ubiquitin was significantly higher in s-IBM than in polymyositis. NBR1 was significantly higher in s-IBM than in dermatomyositis and muscular dystrophies. LC3 and p62 showed a significantly higher level in s-IBM as compared to dermatomyositis and polymyositis. Except for NBR1, a positive correlation of autophagic and proteasomal markers was shown in dermatomyositis. There was also a positive correlation between LC3 and ubiquitin in polymyositis. Using multivariate analysis and recursive partitioning, we could show a predictability of the diagnosis of s-IBM with a LC3 score above 3. On the other hand, a value below 3 excluded the diagnosis of s-IBM.

Conclusion:

In particular, s-IBM, myofibrillar myopathies and Pompe disease showed a possible involvement disturbed proteasomal and autophagic degradation pathways in their pathogenesis. In addition, p62 and NBR1 seemed to have an important role in the immune response. Furthermore, the altered autophagic and proteasomal degradation pathways may be involved in ageing processes, sarcopenia and disease. In particular, LC3 seems to be suitable as a screening marker to recognize an idiopathic inflammatory myopathy. The other markers, such as p62, LC3, and NBR1, would be able to distinguish between the subgroups of idiopathic inflammatory myopathies. Therefore, LC3 could be included as a marker in the routine of neuropathological diagnostics. Further studies are needed to fully understand the role of proteasomal and autophagic factors in possible immune suppressive and immune modulatory therapies and to assess possible side effects.

Disclosure of Interests:

Ulrich Drott: None declared, Patrick Harter: None declared, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Michel Mittelbronn: None declared

AB1099 EVALUATION OF DIFFERENT FLUORESCENCE-OPTICAL IMAGING (FOI) ASSESSMENT METHODS TO DIFFERENTIATE CLINICAL PSORIATIC ARTHRITIS FROM PSORIASIS

Background:

Psoriasis (Pso) is one of the most common chronic inflammatory skin diseases in Europe. Psoriatic arthritis (PsA) is closely associated to Pso whereas the skin manifestation appears usually years before PsA-related symptoms emerge. Up to 30% of Pso patients develop PsA, but there is no clear correlation between disease duration of Pso and PsA development. In early PsA, changes in synovial vascularisation combined with increased expression of proangiogenic factors appear first. Therefore, imaging biomarkers for detection of changes in vascularisation might be useful for early detection of musculoskeletal disease. Fluorescence-optical imaging (FOI) is an indocyanine green (ICG) tailored method to detect microvascular changes in the hands using ICG kinetics over 360 sec. Different methods for assessment of FOI are available. It has not yet been demonstrated to what extent these methods can be used to differentiate psoriasis from psoriasis arthritis.

Objectives:

To evaluate different reader dependent assessment methods to evaluate FOI in psoriasis and psoriatic arthritis.

Methods:

FOI data (clinical PsA n=137, PsO without PsA n=202) from an observational prospective multicentre trial in Germany was used for manual assessment of the films using two different published assessment methods:(1) FOI activity score (FOIAS) and (2) individual characteristics of ICG kinetics. For (1) FOIAS, the levels of signal enhancement were scored using a scoring system from 0 to 3 (0=no enhancement, 3=strong enhancement) per joint as well as an assessment of the summation picture. (2) Kinetics were determined by joint-related signal enhancements as well as by ICG related flow-on and flow-off behaviour. Time to the first appearance of the signal, the time to the maximum enhancement and the time to the end of the signal were determined.

Results:

By use of (1) FOIAS, the maximum score (overall signals of all joints assessed by FOIAS) showed a significant difference (p=0.0075) between PsA (mean 4.76) and PsO (mean 3.84). (2) Time to global maximum showed no significant difference (PsA mean 91.1 sec vs PsO 92.6 sec). Moreover, the mean time to maximum and clearance of ICG did not differ between the two diseases. The duration of the 3 phases of kinetic (phase 1: flow-in, phase 2: stable, phase 3: clearance) was 52.4 sec, 180.2 sec and 119.8 sec for PsA and 57.6 sec, 186.0 sec and 130.5 sec for PsO with an earlier phase 2 and 3 for PsA by trend. The most frequently affected joints in PsA (affected > 10%): PIP 3 right and PIP 5 right.

Conclusion:

FOI is a sensitive method to detect changes in microvascularisation in the hands. The use of the manual FOIAS is able to differentiate significantly between PsA and PsO patients by comparison of the sum of scores over all joints (maximum score). The assessment of ICG kinetics is limited to discriminate between musculoskeletal and joint disease, differentiation of diseases is only seen by trend. Both methods characterize disease states differently. A combination of both methods might be useful to increase the potential of manual assessment of FOI signals.

Figure 1.

Maximum sum score of FOIAS in PsO and PsA patients (p=0.0075 in two-sided t-test).

Disclosure of Interests:

Luis Haan: None declared, Ulf Henkemeier: None declared, Ann Christina Foldenauer: None declared, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai, Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis

SAT0325 STELLATE BLOCKADE COMBINED TO ILOPROST AS SUPPORTIVE TREATMENT OPTION IMPROVES PAIN AND ISCHAEMIC SYMPTOMS IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Peripheral ischaemia is a common symptom in systemic sclerosis (SSc) patients with risk of development of digital ulcers (DU). For its treatment, intravenous iloprost is the most effective option. Accompanying pain symptoms worsen the ischaemic symptoms, so a combination with anaesthetic procedures may improve ischaemic status and the subjective sensation of raynaud and pain. The aim of this study was to observe the impact of a combined treatment of iloprost with stellate blockade (ILOST) in improvement of ischaemic symptoms compared to iloprost treatment only (ILO).

Objectives:

To evaluate efficacy of the ILOST treatment on changes in vascularisation and sensation of patients with SSc and indication for vasodilatative treatment with Iloprost.

Methods:

Twenty SSc-patients with indication for ILO-treatment (prophylactic or due to digital ulcerations (DU)) will be included in a prospective observational study. Patients will be offered to combine ILO with stellate blockade (ILOST). Beside documentation of disease activity characteristics (mRSS, number of DU, capillary microscopy at baseline, after ILO-treatment and at week 12), patients are assessed using fluorescence-optical imaging (FOI) as innovative method for illustration of changes in microvascularisation and patient reported outcomes (DASH, VAS) at week 12.

Results:

This interims analysis includes the result of the first 11 patients treated. Mean baseline characteristics (age and gender) are well balanced. Iloprost treatment was initiated due to prophylactic treatment to avoid DU in all patients. 100% of the patients in the ILOST-group were diagnosed as limited SSc compared to 60% in the ILO-group (diffuse type with 40%). All patients showed abnormalities in capillary microscopy (ILOST group: 83,3% late pattern 16.7% active pattern; ILO group: 80% late pattern, 20% early pattern). MRSS was low in both groups with 1.8, the disease duration in mean 15.3 years in the ILOST-group compared to 13.2 in the ILO-group, respectively. In both groups, no new DU occurred in the 12-week follow-up. Improvement in VAS pain was reported in 83% of the patients in the ILOST group compared to 60% in the ILO group. DASH improved with a mean of 5.5 points in the ILOST group compared to 3 points in the ILO group. FOI was compared individual at both arms in the ILOST group only. The arm with stellatum blockade showed a pronounced increase of FOI signals of 5% in mean whereas the opposite site showed a decrease of the signal shortly after ILO treatment indicating a pronounced increase of vascularisation in the ILOST treated body site.

Conclusion:

A new treatment approach to improve acute ischaemic symptoms was tested by combining stellate blockade to iloprost treatment. No new DU occurred up to 12 weeks after treatment in all patients of both groups indicating the relevance of iloprost as effective vascular dilatative therapy in SSc. The additional intervention was well tolerated and asked to repeat. Subjective sensation on pain of the hands as well as DASH was improved in the combined group. FOI showed a relevant increase in vascularisation in the blockade arm compared to the opposite site in which signals decreased indicating a stronger effect of the combined treatment for improvement of vascularisation.

Disclosure of Interests:

Franziska Höcketstaller Grant/research support from: Rheumazentrum Rhein-Main, Ulf Henkemeier: None declared, Michael Zimmermann: None declared, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai, Ulrich Drott: None declared, Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis

AB1138 ASSESSMENT OF FLUORESCENCE-OPTICAL IMAGING TECHNIQUE OF THE HANDS IN PSORIASIS AND PSORIATIC PATIENTS USING AN INNOVATIVE OBJECTIVE METHOD

Background:

Psoriasis (Pso) is one of the most common chronic inflammatory skin diseases in Europe. Psoriatic arthritis (PsA) is closely associated to Pso whereas the skin manifestation appears usually years before PsA-related symptoms emerge. Up to 30% of Pso patients develop PsA, biomarkers for its early detection are of major importance. In early PsA, changes in synovial vascularisation appear first. Imaging biomarkers for detection of changes in vascularisation might be useful for early detection of musculoskeletal disease. Fluorescence-optical imaging (FOI) is a new method to detect changes in microvascularisation of the hands. Each collected data set of the FOI system contains 360 images representing a time progression of the indocyanine green (ICG) distribution.

Objectives:

To evaluate a reader-independent assessment method for evaluation of FOI in patients with PsO and PsA.

Methods:

A prospective study including patients with dermatological confirmed skin PsO was performed. 411 patients were included from German dermatology units without PsA diagnosis but potential risk for its development. Clinical examination (CE) was performed by a qualified rheumatologist. For a reader independent evaluation of the FOI images an objective joint-based scoring method was developed. For this method, the joint areas are defined by image segmentation and scored based on generated heatmaps. To calculate a heatmap indicating conspicuous joints from a data set containing 360 images, each pixel is converted to a time series containing 360 values. From this time series, three independent values (features) are extracted: amplitude, average value and maximal slope. Thus, each pixel is reduced to three different feature values. After the three features are determined for each pixel, k-means clustering is performed on each feature. The numbers of centroids (k) are set to 3, 5, 7 and 9. 12 heatmaps (3 features à 4 ks) are calculated, which results in 12 scores for each joint as well. The clusters are then sorted dependent on their centroid value and coloured accordingly to a predefined heatmap colour palette. To finally score each joint, the pixels in the segmented joint area and their assigned cluster are summed and normalized by the area’s amount of pixels and k.

Results:

271 of the patients were investigated by the newly developed method and compared with the CE scoring. 6426 joints were labeled as healthy whereas 1162 joints were either labeled as swollen, tender or both. The result over all investigated patients for k = 9 is summed in table 1. It is observable that every average and median healthy value is lower than the corresponding affected value.

Table 1.

Resulting scores for k = 9 for all 271 patients.

Feature Statistic valueAmplitudeMeanSlopeHealthyAffectedHealthyAffectedHealthyAffectedAverage0.5030.5280.4860.5090.3950.414Median0.4960.5320.4820.5050.3890.415

Conclusion:

FOI is an innovative method that detects early changes in vascularization of the hands. So, this method can be useful in early detection of arthritis especially in risk populations such as PsO patients. The results of the objective scoring method show that a clear distinction between healthy and affected joints is possible with the average scores as well as the median values. However, if the range of the scores is considered, the overlap between healthy and affected is not neglectable. Thus, the current scoring system can be used as an indicator but not as a single classification marker. Nevertheless, the research at hand has shown the expected outcome and motivates further development on the heatmap approach.

Disclosure of Interests:

Lukas Zerweck: None declared, Ulf Henkemeier: None declared, Phuong-Ha Nguyen: None declared, Tanja Rossmanith Grant/research support from: Janssen, BMS, LEO, Pfizer, Andreas Pippow: None declared, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai, Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis

SAT0032 INCIDENCE OF RHEUMATOID ARTHRITIS IN PATIENTS WITH NEW ONSET OF MUSCULOSKELETAL SYMPTOMS AND ANTI-CPP POSITIVITY COMPARED TO ANTI-CPP NEGATIVE PATIENTS

Background:

Rheumatoid Arthritis (RA) is a chronic inflammatory joint disease. Strategies for its early detection and diagnosis are of high importance as prompt treatment improves clinical and structural outcome. Autoantibodies against cyclic citrullinated proteins (anti-CCP) have been associated with RA-development. Non-specific musculoskeletal (nsMSK) symptoms are often described prior to RA development. Majority of patients with nsMSK symptoms present to their general practice (GP) first. Studies of early arthritis cohorts have shown that many early arthritis patients cannot be accurately diagnosed at their first visit and are often referred as undifferentiated arthritis patients.

Objectives:

To evaluate the incidence of anti-CCP positivity in patients with new onset of nsMSK symptoms and the incidence of RA in these patients over a 3-year follow-up period compared to anti-CPP negative patients.

Methods:

In this prospective study (PANORA), 978 patients with new onset of nsMSK symptoms were included in 77 GP sites in Germany. Patients with a positive anti-CCP rapid-test (CCPoint®) were referred to Rheumatology Department (RD) for rheumatological assessment, RA-evaluation and an anti-CCP validation test (ELISA). ELISA anti-CCP positive patients without RA were monitored every 6 months for a total follow-up of 36 months or until RA-diagnosis. Patients with a negative anti-CPP result (CCPoint® or ELISA) are followed up with a questionnaire after 1 and 3 y.

Results:

From 978 included patients, 105 (10.7%) were CCPoint® positive. 96 were tested with ELISA and 27 (28.1%) were confirmed anti-CCP positive. 9 (33.3%) were diagnosed with RA at the first RD visit (study visit 2); 4 further patients were diagnosed with RA during the follow-up (FU) period so far. Overall, 48.1% of ELISA-positive (ELISA+) patients were diagnosed with RA up to now; 11 ELISA+ patients are still in the FU period of the study. Of the 868 CCPoint® negative patients, currently, 282 have filled out a 1-year FU questionnaire; 3.5% of those reported a RA diagnosis (Table 1). As expected, clinical parameters at V2 (e.g. CRP, swollen and tender joint count) were worse in the ELISA+/RA+ group compared to the ELISA-/RA- group, but no obvious differences were detected between ELISA+ patients who were diagnosed with RA during the FU period (after V2) and ELISA-/RA- patients

Table 1.

Number and percentage of patients with a RA diagnosis

Anti-CCP statusVisit 2Follow-up*TotalPoint-of-Care Test --3.5% (10 of 282)#3.5% (10 of 282)#Point-of-Care Test + / ELISA -2.9% (2 of 69)0% (0 of 34)#2.9% (2 of 69)Point-of-Care Test + / ELISA +33.3% (9 of 27)14.8% (4 of 27)48.1% (13 of 27)$

* 1 year-questionnaire for Point-of-Care Test and ELISA negative patients or every 6 months follow-up for ELISA positive patients;#Patient-reported;$11 patients are still in the follow-up phase of the study

Conclusion:

Currently, 48.1% of anti-CCP+ (ELISA) patients have received a RA diagnosis, whereas 3.5% of the anti-CCP- (CCPoint®) received a RA diagnosis (patient reported), which underlines, that anti-CCP can be used as a marker to identify high-risk patients in GP setting. While clinical parameters are correlated with the diagnosis of RA, they are not suited for predicting future RA development alone. Anti-CCP, possibly in combination with additional parameters imaging, might increase the likelihood to early diagnose or predict RA development.

Figure 1.

Study overview: Patient distribution depending on anti-CCP results and RA diagnosis.

Disclosure of Interests:

Stephanie Dauth Grant/research support from: BMS, Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis, Timm Oberwahrenbrock Grant/research support from: BMS, Ulf Henkemeier: None declared, Tanja Rossmanith Grant/research support from: Janssen, BMS, LEO, Pfizer, Karola Mergenthal Grant/research support from: BMS, Juliana J. Petersen Grant/research support from: BMS, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai

AB1111 PREDICTIVE VALUE OF FLUORESCENCE-OPTICAL IMAGING TECHNIQUE IN DETECTION OF PSORIATIC ARTHRITIS IN PSORIASIS PATIENTS

Background:

Psoriasis (Pso) is one of the most common chronic inflammatory skin diseases in Europe. Psoriatic arthritis (PsA) is closely associated to Pso whereas the skin manifestation appears usually years before PsA-related symptoms emerge. Up to 30% of Pso patients develop PsA, but there is no clear correlation between disease duration of Pso and PsA development. Therefore, biomarkers for its early detection are of major importance. In early PsA, changes in synovial vascularisation combined with increased expression of proangiogenic factors appear first. Therefore, imaging biomarkers for detection of changes in vascularisation might be useful for early detection of musculoskeletal disease. Fluorescence-optical imaging (FOI) is a new method to detect changes in microvascularisation of the hands.

Objectives:

To determine the number of positive PsA diagnosis within a 24 month follow-up period in PsO only patients with subclinical MSK-inflammation detected in FOI.

Methods:

Sensitivity of FOI for detection of subclinical signs of musculoskeletal inflammation as biomarker for early PsA was observed in a prospective, multicentre study (XCITING) including patients with dermatological confirmed skin psoriasis. 411 patients were included from dermatology care units across Germany without diagnosis of PsA but potential risk factors for its development (nail psoriasis and/or joint pain or swelling within the last 6 months). Clinical examination (CE; swollen (66) and tender (68) joint count, enthesitis, dactylitis assessment) and standardised ultrasound (US) assessment was performed by a qualified rheumatologist to assess musculoskeletal inflammation. FOI was performed additionally. Data was analysed in focus on increased vascularisation of musculoskeletal structures as inflammatory markers. In case of discrepant results (positive FOI and negative CE and US), MRI was performed to prove the findings. In case of MRI negativity, a follow-up period of 24-months was performed including FOI, CE, US and MRI assessment.

Results:

83 of the 411 patients of the cohort were negative in all assessments (Pso only), 136 of the 411 patients were classified as PsA by rheumatologic assessments. 119 patients showed subclinical signs of musculoskeletal inflammation in the central reading of FOI, whereas CE and US were negative. In 37,5% of those patients, subclinical inflammation was confirmed by MRI assessment. 22 patients of the cohort without MRI positivity were willing to be followed up until month 24. 5 (7.5%) patients developed a clinical PsA until month 24 whereas 7 (10.5%) patients converted to be FOI negative. In 5 patients an additional MRI examination was performed in which one patient showed positive signs for inflammation.

Conclusion:

FOI is an innovative method for measurement of changes in microvascularisation in the hands. 6/22 patients initial only positive in FOI (no clinical signs for PsA, negative US, negative MRI) developed either clinical evident PsA (n=5) or new inflammation in MRI (n=1) during follow-up of 24 months. Therefore, FOI positive signals in PsO patients increase the probability for PsA development.

Figure 1.

Flow Chart of the Follow-up period of the XCITING study.

Disclosure of Interests:

Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis, Sarah Ohrndorf: None declared, Tanja Rossmanith Grant/research support from: Janssen, BMS, LEO, Pfizer, Marina Backhaus Grant/research support from: Pfizer, Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Siegfried Wassenberg: None declared, Benjamin Köhler Grant/research support from: Pfizer, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai

Diagnostic efficacy of bedside ultrasound to detect dehydration in older patients attending an emergency care unit

BACKGROUND

The diagnosis of dehydration in older patients remains a challenge because clinical and laboratory signs are unspecific. The use of B‑Mode ultrasound of the inferior vena cava is proposed to aid in the diagnosis but data concerning diagnostic efficacy of bedside ultrasound are lacking.

METHODS

In this study 78 patients ≥65 years old referred to the emergency unit of a university hospital and identified as being dehydrated by applying clinical signs were compared with a reference of 121 patients. The diameter of the inferior vena cava (IVC) was assessed by ultrasound while compressing the IVC during an inspiratory maneuver and the minimum and maximum diameter in M‑Mode.

RESULTS

Significant differences were found concerning compressibility, variability of the diameter assessed by M‑Mode and the diameter during an inspiratory maneuver of the IVC (<0.001); however, a receiver operator characteristics (ROC) showed only moderate values for diagnostic efficacy for all these parameters where the best result was found for the inspiratory maneuver (Area under the curve [AUC] = 0.73). To reach a specificity of 0.8 to diagnose dehydration, a cut-off value of ≤0.4 cm for IVC diameter was suitable.

CONCLUSION

Ultrasound of the IVC can easily be applied in a bedside setting and may be helpful in identifying dehydration in older patients; however, this remains challenging and a synopsis covering clinical and technical data is indispensable.

Erratum to: Multicomponent, nonpharmacological delirium interventions for older inpatients : A scoping review

Erratum to: the article "Multicomponent, nonpharmacological delirium interventions for older inpatients. A scoping review." Unfortunately, on 18.10.2019 a preliminary and incorrect version of the flowchart (Fig. 1) was published online. In the corrected and final version one additionally identified record is listed in the flowchart. The records after removal the duplicates are n = 4451 and the records that are excluded after title abstract screening are 4571. The studies included are n = 25. In addition, a further exclusion category is added after full text screening (Study not available: n = 1) and an existing exclusion category (Repeated data use of the original study) was corrected to n = 1, which can also be found in the corrected online supplement No. 2.Z Gerontol Geriat 2019 https://doi.org/10.1007/s00391-019-01627-y Please note the correct version of Fig. 1.The original article has been corrected.

Multicomponent, nonpharmacological delirium interventions for older inpatients : A scoping review

Background

Older people represent a risk group for acquiring or further development of delirium during hospitalization, therefore requiring suitable nonpharmacological delirium interventions.

Objective

This scoping review analyzed nonpharmacological intervention programs for older inpatients with or without cognitive decline on regular or acute geriatric wards to present the range of interventions.

Methods

A systematic literature search was conducted using scientific databases. A total of 4652 records were screened by two independent reviewers, leaving 81 eligible articles for full-text screening and 25 studies were finally included. Inclusion criteria were older patients ≥65 years in regular or acute geriatric wards and nonpharmacological multicomponent interventions.

Results

More than a half of the included studies (14, 56%) recruited patients with pre-existing cognitive decline as part of the study population and 12% focused exclusively on patients with cognitive decline. On average 11 intervention components were integrated in the programs and two programs included full coverage of all 18 identified components.

Conclusion

Only few programs were described for older inpatients and even fewer regarding pre-existing cognitive decline. The low numbers of interventions and data heterogeneity restricted the assessment of outcomes; however, delirium incidence, as reported by two thirds of the studies was reduced by nonpharmacological multicomponent interventions.

Electronic supplementary material

The online version of this article (10.1007/s00391-019-01627-y) contains supplementary material, which is available to authorized users.

[Biomarkers and imaging for diagnosis and stratification of rheumatoid arthritis and spondylarthritis in the BMBF consortium ArthroMark]

Rheumatic diseases are among the most common chronic inflammatory disorders. Besides severe pain and progressive destruction of the joints, rheumatoid arthritis (RA), spondyloarthritides (SpA) and psoriatic arthritis (PsA) impair working ability, reduce quality of life and if treated insufficiently may enhance mortality. With the introduction of biologics to treat these diseases, the demand for biomarkers of early diagnosis and therapeutic stratification has been growing continuously. The main goal of the consortium ArthroMark is to identify new biomarkers and to apply modern imaging technologies for diagnosis, follow-up assessment and stratification of patients with RA, SpA and PsA. With the development of new biomarkers for these diseases, the ArthroMark project contributes to research in chronic diseases of the musculoskeletal system. The cooperation between different national centers will utilize site-specific resources, such as biobanks and clinical studies for sharing and gainful networking of individual core areas in biomarker analysis. Joint data management and harmonization of data assessment as well as best practice characterization of patients with new imaging technologies will optimize quality of marker validation.

Higher Fit-fOR-The-Aged (FORTA) Scores Comprising Medication Errors are Associated with Impaired Cognitive and Physical Function Tests in the VALFORTA Trial

BACKGROUND

The Fit fOR The Aged (FORTA) list, a drug classification combining positive and negative labelling of drugs, has been clinically (VALFORTA-trial) validated to improve medication quality and clinical endpoints.

OBJECTIVE

The objective of this study was to determine the association of medication quality with functional abilities tested in cognitive and physical function tests.

PATIENTS AND METHODS

Data from the prospective, randomized controlled VALFORTA trial on 409 geriatric (mean age 81.53 years) in-hospital patients were tested for associations between the FORTA score (sum of over- and under-treatment errors) on admission and cognitive and physical function tests. Univariate and multivariate linear correlations corrected for age, sex, number of medications, number of chronic conditions, and body mass index as well as comparisons between high and low FORTA-score (cut-off 3) patients were performed.

RESULTS

The FORTA score was significantly correlated with Instrumental Activities of Daily Living (p < 0.0001), the Tinetti test (p < 0.002), Essen Questionnaire on Age and Sleepiness (p < 0.0001), Mini-Mental State Examination (p < 0.0001), and handgrip strength (p < 0.04) in the univariate analysis, and with Instrumental Activities of Daily Living (p < 0.003), the Tinetti test (p < 0.003), and the Essen Questionnaire on Age and Sleepiness (p < 0.0001) in the multivariate analysis. Effect size was weak for Instrumental Activities of Daily Living (R-squared = 0.12) and the Tinetti test (R-squared = 0.03) and medium for the Essen Questionnaire on Age and Sleepiness (R-squared = 0.22). Significant differences between patients with high and low FORTA scores were found for Instrumental Activities of Daily Living, the Tinetti test, mini-nutritional assessments, Mini-Mental State Examination, Essen Questionnaire on Age and Sleepiness, and the Geriatric Depression Scale. All significant tests revealed that higher FORTA scores (lower medication quality) were associated with less favorable test outcomes.

CONCLUSIONS

The FORTA score is associated with relevant aspects of comprehensive geriatric assessment, underlining the importance of medication quality for the functional and cognitive well-being of older patients.

TRIAL REGISTRATION NUMBER

DRKS00000531.

Immunogenicity assay development and validation for biological therapy as exemplified by ustekinumab

Introduction of biotherapeutics has been a major milestone in the treatment of different chronic diseases. Nevertheless, the immune system can recognize the administered biological as non-self and respond with generation of anti-drug antibodies (ADA), including neutralizing ADA (nADA). Immunogenic responses may result in altered drug dynamics and kinetics leading to changes in safety and efficacy. However, there are several challenges with standard techniques for immunogenicity testing. Ustekinumab (UST), used in different inflammatory diseases, is a therapeutic antibody directed against the shared p40 subunit of interleukin (IL)-12 and IL-23, interfering in the pathogenically crucial T helper type 1 (Th1)/Th17 pathway. We established and validated different approaches for detection and quantitation of UST, UST-specific ADA and nADA. Addressing the obstacle of complex formation of UST with nADA, we developed an acidification assay to approach the total amount of nADA. Validated methods were based on surface plasmon resonance spectroscopy (SPR), enzyme-linked immunosorbent assay (ELISA) and a cell-based approach to characterize neutralizing capacity of nADA. Parameters assessed were determination and quantitation limits, linearity, range, precision, accuracy and selectivity. Quantitation of ADA and UST was feasible at lower concentrations using ELISA, whereas SPR showed a wider linear range for determination of ADA and UST. Accuracy, precision and linearity for quantitation were comparable using ELISA, SPR and the cell-based approach. All validated parameters fulfill the requirements of regulatory agencies. A combination of the testing approaches could address the increasing demand of precision medicine as it can be suitable for capturing the whole spectrum of immunogenicity and is transferable to other biologicals.

Changes in prescription patterns in older hospitalized patients: the impact of FORTA on disease-related over- and under-treatments

PURPOSE

Physicians often face difficulties in choosing appropriate medications for multimorbid older people. The FORTA (Fit for the Aged) classification (A: absolutely, B: beneficial, C: careful, D: don't) was proposed as a clinical tool for improving the quality of drug treatment in the aged. As an implicit tool, FORTA has been shown to aid medication optimization and improve clinical end points in the VALFORTA trial. In this prospective randomized controlled study, 207 older hospitalized patients received standard geriatric treatment and 202 patients received FORTA-guided treatment.

METHODS

Here, changes of drug prescriptions at the anatomical-therapeutic-chemical system (ATC) level were evaluated separately for important diagnoses in descriptive analyses; over- and under-treatment rates were compared between groups.

RESULTS

At the individual drug/drug class level related to all important diagnoses, the application of FORTA significantly improved under-treatments for 12 drugs/drug classes (e.g., ACE inhibitors to treat arterial hypertension) and over-treatments for 7 drugs/drug classes (e.g., proton pump inhibitors to treat gastroesophageal reflux disease).

CONCLUSIONS

FORTA representing the first combined positive/negative labeling approach at the individual drug level aids the optimization of drug treatment in older people as detected for drugs/drug classes at the ATC level in important indications. FORTA is effective in addressing over- and under-treatments even if analyzed for smaller subgroups of VALFORTA.

[Expectations and attitudes concerning geriatric counseling : Results of a survey among general practitioners and hospital-based providers in two German states]

BACKGROUND

Expertise in geriatrics in the field of ambulatory and hospital-based treatment does not have access to comparable medical specialist structures, such as those in internal medicine and neurology; therefore, it is recommended that geriatric diagnostics by general practitioners can be supported by networking with hospital-based geriatric centers for geriatric counseling. The attitudes and experiences of both faculties in Germany are, however, not well known.

METHODS

Representative samples of general practitioners and hospital-based faculty departments for internal medicine in two regions of Germany (Baden-Württemberg and Hessen) were identified using a systematic selection method. All departments of geriatrics in these regions were also contacted. Participants were asked to give their attitudes and experiences regarding geriatric counseling using a questionnaire.

RESULTS

Responses to the questionnaire were received from 48 general practices (14.9%), 42 internal medicine departments (38.5%) and 25 hospital-based geriatric centers (34.7%). Of the general practices 79.2% reported performing geriatric assessments but only 31.3% had access to geriatric counseling. Of the faculties of internal medicine 71.4% reported providing geriatric counseling of which 16.7% also provided counseling on an outpatient basis. With respect to the spectrum of actual reasons for geriatric counseling, initiation of rehabilitative measures was the main reason in both geriatric and internal medicine departments. There were differences in the estimation of suitable rating topics for geriatric counseling. Geriatric departments more frequently indicated preventive aspects compared to general internal medicine (80% vs 47.6%) and general practices (56.3%). With respect to the domain level, general practitioners rated these in the order of cognition (72.9%), social situation (70.8%), emotion (50%), locomotion (50%) and incontinence (27.1%). Noteworthy was that they also rated much lower compared to hospital-based providers particularly with respect to locomotion and incontinence problems.

CONCLUSION

Geriatric assessment is widely used by general practitioners and there is generally a positive attitude to geriatric counseling and networking with hospital-based geriatric centers. At present, only a minority of general practitioners find local providers of geriatric counseling. Preventive aspects do not reach the same significance as rehabilitation topics and this discloses some potential for improvement. Differences in rating usefulness between the two groups may be explained by competing providers, e. g. specialists in these fields.

VALFORTA: a randomised trial to validate the FORTA (Fit fOR The Aged) classification

TRIAL DESIGN

to further validate the FORTA (Fit fOR The Aged) concept, a bicentric randomised, controlled trial was run in two geriatric clinics.

METHODS

patients (≥65 years, ≥3 drugs or ≥60 years, ≥6 drugs) with three relevant diseases and hospitalisation for ≥5 days were randomised. In the intervention, but not the control group, a FORTA team instructed ward physicians on FORTA. FORTA is the first positive/negative listing approach labelling medications used to treat chronic illnesses in older patients from A (indispensable), B (beneficial), C (questionable) to D (avoid). The primary end point was the FORTA score: sum of medication errors classified as over-, under- and mistreatment. Consecutive patients were randomised to the intervention and control ward; outcome assessment was blinded.

RESULTS

four hundred and nine patients (age 81.5 years, 64% female, hospitalisation 17.4 days) were included. The primary end point was significantly (P < 0.0001) more reduced in the intervention versus control groups (2.7 ± 2.25 versus 1 ± 1.8, mean ± SD, intergroup comparison of admission/discharge differences). Over- and under-treatment scores and use of A (increase) and D (decrease) drugs were significantly improved (P < 0.01). The total number of adverse drug reactions (ADRs) was significantly reduced by FORTA (P < 0.05, number needed to treat is 5). Activities of daily living and renal failure improved significantly (P < 0.05). Blood pressure remained constant in the intervention, but decreased significantly in the control group.

CONCLUSION

applying FORTA to hospitalised geriatric patients leads to improvement of medication quality and may improve secondary clinical end points (e.g. ADRs). The concept is amenable to successful communication and implementation. Registration (DRKS-ID): DRKS00000531.

FUNDING

DFG-German Research Foundation (WE 1184/15-1).

[Do we still need clinical studies in rheumatology?]

Despite a large number of approved therapies demonstrating efficacy in the treatment of rheumatic diseases, only 60-85 % of patients with the indications for rheumatoid arthritis are adequately treated in Germany. Additionally, approved therapies for other immune-mediated diseases are often entirely lacking, indicating the great medical need for the development of new innovative therapies in this specialized field. The development of new drugs is expensive due to the high costs of conducting clinical trials in all phases of development up to obtaining approval; therefore, pharmaceutical companies are looking for ways to save costs in the particular developmental stages. Although the classical regions for drug development (i.e. western Europe, the USA and Japan) offer both a high level of data quality and a good infrastructure to conduct clinical trials due to high standards of education and quality, clinical trials are expensive in these regions. Beside high costs, the comparatively low recruitment rates in these regions are one of the main reasons for the shifting of drug developmental stages from classical regions to eastern European, Latin American and Asian countries, which provide services for drug development and high recruitment rates for comparatively less money. However, there are many strong arguments for the participation of regions in western Europe, especially German sites in clinical trials. In this article these arguments are discussed and possible solutions and strategies for conducting and compensation of study centers in Germany for clinical trials in the field of rheumatology are provided.