Teacher support in language learning: a picture of the effects on language progress, academic immunity, and academic enjoyment

Teacher support encompasses the provision of educational, instrumental, sentimental, or evaluative assistance by a teacher to a student, regardless of the setting. Learning a new language brings with it different ups and downs that may hinder the actual progress of the learners. The journey of learning may be made easier by supportive instructors. During the course of this inquiry, two groups (85 participants in total) including the experimental and control groups were chosen to gauge the influence of Teacher support in virtual instruction on English as a foreign language (EFL) learners' progress, academic immunity, and academic enjoyment. In contrast to the experimental group (EG, n = 42), which had the chance to connect with a teacher in order to ask questions and get feedback plus the off-line education, the control group (CG, n = 44) was subjected to off-line instruction of language input (Top Notch 3). The status of the participants' language growth, immunity, and enjoyment was investigated both before and after the treatment. The findings of independent samples t-tests as well as the multivariate analysis of variance (MANOVA) indicated that learners in EG did much better than their counterparts in CG. In addition, the ramifications and recommendations for potential future directions are analyzed.

POS0314 IDENTIFICATION OF CIRCULATING microRNA SIGNATURES IN PATIENTS WITH PSORIASIS WITH SUBCLINICAL JOINT DISEASE AND PATIENTS WITH PSORIATIC ARTHRITIS

Background

MicroRNAs (miRNAs) are small non-coding RNAs that control gene expression. Specific miRNA signatures have been identified in numerous diseases and may serve as potential biomarkers or new drug targets. Whether certain miRNA signatures are associated with psoriatic joint disease is currently unknown.

Objectives

To search for circulating miRNA signatures in psoriasis patients with subclinical joint disease and in patients with psoriatic arthritis (PsA).

Methods

Analyses of serum miRNA were done in three groups: (1) PsA patients fulfilling CASPAR criteria (PsA), (2) healthy controls without past or present signs of musculoskeletal disease (HC) and (3) psoriasis patients with musculoskeletal pain but no signs of clinical PsA (PsO). PsO and PsA patients received a hand MRI, which was scored according to PsAMRIS method. miRNA analysis of serum samples was performed stepwise using RT-qPCR (TAmiRNA Vienna). In the discovery phase 192 miRNA assays were analyzed in 48 samples (N=16 each group). In the validation phase 17 miRNAs (Table 1) were selected and analyzed in 94 samples (N=35 PsA, N=24 PsO, N=35 HC) based on results of discovery phase and previous reports in literature. Results presented as mean±SD/median (IQR), p-values are adjusted for multiple testing.

Table 1.miRNAsPsA vs HCPsO vs HCPsA vs PsODiscovery PhaseValidation PhaseDiscovery PhaseValidation PhaseDiscovery PhaseValidation Phasep-adj.p-adj.p-adj.p-adj.p-adj.p-adj.miR-93-5p0.0001<0.0010.0080.0050.0390.947miR-29b-3p0.0001<0.00010.0040.00020.1910.522miR-19b-3p0.0070.7080.00020.0200.1380.147miR-320d0.0010.619<0.00010.1350.9410.247miR-144-5p0.0030.0060.00010.1690.3500.444miR-188-5p0.0140.9900.9750.6470.0530.839let-7b-5p0.0250.00030.8890.0260.00030.472miR-92a-3p0.0430.0010.0050.773<0.00010.0005miR-324-3p0.1381.0000.2570.3920.8140.518miR-126-3p0.0140.1690.0130.5980.9220.654miR-223-3p0.1690.8720.6170.7460.5191.000miR-130a-3p0.0390.0350.5560.0090.0060.724miR-140-3p0.3500.0530.0020.0060.1180.683miR-155-5p0.1590.9950.1690.5490.9220.604miR-21-5p0.2970.9900.0030.1160.080.014miR-146a-5p0.7060.0040.8360.0380.9050.941miR-122-5p0.9600.7340.6950.7990.9050.444

Results

51 PsA patients (age: 51.3±11.4 years; 56.9% females), 40 PsO patients (51.4±11.0; 37.5%) and 50 HC (51.0±10.5; 52.9%) were assessed. Duration of psoriasis was 12(25) years in PsA and 15(22.8) years in PsO. Duration of joint disease in PsA was 1.0(4.8) year. 51% of PsA and 5% of PsO patients were on biological disease modifying drugs (bDMARDs), 49% vs. 10% on conventional DMARDs. The most frequent findings in the MRI were erosions (PsA 59.6%; PsO 40%) and synovitis (PsA 48.9%; PsO 42.5%). PsA patients had higher number of tenosynovitis compared to PsO (p=0.04). In discovery phase 51 miRNAs in PsO and 64 miRNAs in PsA were down- or upregulated compared to HC, with an overlap of 33 miRNAs changed in PsA and PsO (p<0.05). Results of the selected 17 miRNAs are presented in Table 1. The top candidates to differentiate PsA and HC were miR-29b-3p (AUC=0.87), miR-93-5p (AUC=0.83) and let-7b-5p (AUC=0.79). For differentiating PsO and HC, they were miR-29b-3p (AUC=0.82), miR-140-3p (AUC=0.81) and miR-19b-3p (AUC=0.80) and for PsO vs. PsA miR-92a-3p (AUC=0.87), let-7b-5p (AUC=0.72) and miR-21-5p (AUC=0.70). miR-93-5p was lower in patients with erosions (p=0.01). miR-92a-3p, let-7b-5p and miR-21-5p were lower in patients with tenosynovitis, bone proliferations or erosions.

Conclusion

PsA and PsO patients show miRNA signatures different from HC. Top candidate miRNAs differentially regulated in PsA and PsO have been previously reported in alteration of bone metabolism and osteoarthritis indicating the intimate association of psoriatic inflammation with bone and cartilage changes.

References

[1]Faustini F et al. Ann Rheum Dis 2016 Dec;75(12):2068-2074

[2]Hackl, M et al. Molecular and Cellular Endocrinology Elsevier Ireland Ltd 432, pp 83–95

[3]Feichtinger X et al. Sci Rep 2018 Mar 20;8(1):4867

Disclosure of Interests

None declared

AB1528-HPR FULL BODY HAPTIC BODYSUIT - AN INSTRUMENT TO MEASURE THE RANGE AND SPEED OF MOTION IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS (axSpA) - PRELIMINARY RESULTS

Background

Movement of the spine is restricted in axial spondyloarthritis (axSpA) [1]. Spine function is usually assessed by the Bath Ankylosing Spondylitis Metrology Index (BASMI), which is based on a limited set of defined motions that are measured semiquantitatively in the spatial dimension but not in the temporal dimension. Sensor-based measurement of spine function in axSpA patients is in its infancy but may provide a deeper and more detailed understanding of the impact of axSpA on the impairment of spine function [2,3]. In theory, unbiased full body assessment of spine motion may open a new dimension in function analysis in axSpA.

Objectives

To test if a of a full-body based haptic capturing of spine motion is technically feasible and can pick up the measurements of BASMI items 1-5. Furthermore, we aimed to investigate whether such measurements are accurate and reproducible comparing to BASMI scores done by rheumatologists. Lastly, we sought to measure velocity of spine movements to allow spatiotemporal analysis of motion.

Methods

For full-body haptic assessment of spine motion a full-body haptic suit (Teslasuit; VR Electronics Ltd, London) was used that consists of a smart textile two-piece bodysuit that not only captures range and speed of motion but also provides biometric and haptic feedback. This device is currently tested in clinical trials (https://teslasuit.io/rehabilitation/) but has not been tested in rheumatic diseases such as axSpA [4]. Since there is no pre-defined technical solution for measuring BASMI, we used the integrated inertial measurement units (IMUs) of the suit (Figure 1a). The suit is recording the position and rotations of its IMUs and is transforming the raw data to position coordinates and joint angle of the bones. We implemented an algorithm that is accessing the sensor data and is calculating the BASMI measurements as well as velocity. Assessment were done in healthy individuals. BASMI was obtained 3 times by teslasuit followed by standard BASMI measurement by 2 independent rheumatologists. In addition, rotational movements with their maximum torso speed to evaluate angular velocity were performed (Figure 1b). Measurements were compared using absolute values and relative standard deviation (which is the standard deviation normalized by the mean).

Results

Five healthy individuals (all males, age: 27.6 ± 1.8 years, height: 178 ± 5 cm; weight 70.0 ± 8.0 kg) were assessed. Teslasuit measurements were well tolerated. Technically, we were able to calculate BASMI item 3 and 5, finger-to-floor distance and the velocity of the spine movement using the position data of hand, talus and upper back sensors (Figure 1a, b). Due to absence of sensors at the head and the required back areas, BASMI 1, 2, 4 could only partially be captured and require further programming, which is currently performed. Only marginal differences were detected regarding the relative standard deviations of measurements between teslasuit and rheumatologists (BASMI 3: rheumatologists 8,5%: suit 10%; BASMI 5: rheumatologists 5,4%: suit 4,9%) (Figure 1c). The speed of spinal motion could be measured with an average angular velocity of 172.2 degrees/sec over the entire rotation motion and an average maximum angular velocity of 417.2 degrees/sec.

Conclusion

This study shows that full-body haptic-suits can capture spinal motion including parts of the BASMI score. In addition, they allow to measure the speed of spinal movement, which might be an important and so far unrecognized factor to test the impact of axSpA on spinal function. Based on these results, full-body haptic-suits will be tested in axSpA patients in the future. Furthermore, technical solutions are currently developed to implement the remaining BASMI scores into the suit as well as connections from the suit to virtual reality devices for patients and doctors.

References

[1]Sieper, J. and D. Poddubnyy, Axial spondyloarthritis. Lancet 2017.

[2]Gardiner, P.V., et al., Rheumatology (Oxford) 2020.

[3]Kiefer, D., et al., S J Rheumatol 2022.

[4]Caserman, P. et al Sensors (Basel) 2021.

Acknowledgements

This work was (partly) funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) – SFB 1483 – Project-ID 442419336, EmpkinS.

Disclosure of Interests

None declared

POS0699 SIMILAR EFFICACY AND DRUG SURVIVAL RATES OF BARICITINIB MONOTHERAPY AND BARICITINIB/METHOTREXATE COMBINATION THERAPY IN REAL-LIFE TREATMENT OF RHEUMATOID ARTHRITIS - RESULTS FROM A PROSPECTIVE COHORT OF BARICITINIB-TREATED PATIENTS

Background

In clinical trials, baricitinib (BARI), in combination with methotrexate (MTX), demonstrated efficacy in patients with rheumatoid arthritis (RA) who have not responded adequately to conventional (cs)or biologic (b) DMARDs [1]. Since MTX is often not tolerated very well [2], BARI monotherapy may be preferable over BARI/MTX combination in some patients with RA. Therefore, real-life data on BARI mono- vs. combination therapy are needed to support such decisions.

Objectives

The aim of our study was to evaluate the efficacy of BARI as mono- or combination therapy in a prospective, open label cohort of RA patients failing previous cs/bDMARD therapy.

Methods

Patients with active RA (DAS28-ESR >3.2), fulfilling the ACR/EULAR 2010 classification criteria and failing previous cs/bDMARD therapy were included. All patients received BARI either as monotherapy or in combination with MTX based on the judgement of the treating physician. Demographics, medical history, disease activity parameters such as 66/68 TJC/SJC, composite scores such as DAS28-ESR, HAQ-DI, as well as medication were prospectively recorded every 3 months according to a pre-defined protocol. Informed consent and ethics approval (19_18 B) were obtained. To evaluate clinical efficacy, DA28 ESR responses was recorded at respective visit dates (until week 96). We estimated least-square mean DAS-28 scores over time using linear mixed effects models including time-group interactions. Kaplan-Meier method was used to estimate baricitinib survival and probability of remission over time.

Results

139 patients (98 women/41 men; aged 58.4 (12.8) years; mean disease duration of 9.7 years) were included between 4/2017-10/2021. Of these, 46 patients received a combination of BARI with MTX (BARI/MTX) and 93 patients BARI monotherapy. Baseline demographic and disease-specific characteristic were comparable between BARI/MTX and BARI patients (Table 1). Median follow up was 53.1 weeks (IQR 23.0-109.3). Decrease in DAS28-ESR showed a similar dynamics in BARI/MTX (baseline DAS28-ESR: 4.2+/-1.3; 48 weeks: 2.9 (95%CI 2.6 to 3.2)) and BARI (4.3+/-1.3; 48 weeks: 3.0 (95%CI 2.8 to 3.3)) with numerical but no significant differences (Figure 1a). 62% (95%CI 40 to 76%) patients in the BARI/MTX group and 51% (95%CI: 37 to 61%) patients in the BARI attained DAS28ESR remission after 48 weeks. Drug survival was comparable among BARI/MTX and BARI patients. (69 vs.67% at 1 year and 62 vs 56% at 2 years) (Figure 1b).

Conclusion

These data show that BARI monotherapy is efficacious in real life treatment in RA patients with insufficient response to MTX. Clinical efficacy and drug survival is comparable between BARI monotherapy and BARI/MTX combo in a real-life setting.

References

[1]Genovese, M.C., et al., Baricitinib in Patients with Refractory Rheumatoid Arthritis. N Engl J Med, 2016.

[2]Michaud, K., et al., Real-World Adherence to Oral Methotrexate Measured Electronically in Patients With Established Rheumatoid Arthritis. ACR Open Rheumatol, 2019

Acknowledgements

The analysis of the data of this study is partially financially supported by Elli Lilly.

Disclosure of Interests

None declared

OP0292 CLASSIFICATION OF PSORIATIC ARTHRITIS, SERONEGATIVE RHEUMATOID ARTHRITIS, AND SEROPOSITIVE RHEUMATOID ARTHRITIS USING DEEP LEARNING ON MAGNETIC RESONANCE IMAGING

Background

While MRI evaluation of joints has been primarily used to quantify inflammation at a cross-sectional and longitudinal level, less is known about the potential of MRI in distinguishing different patterns of inflammation in the various forms of arthritis.

Objectives

To evaluate (i) whether deep learning using neural networks can be trained to distinguish between seropositive rheumatoid arthritis (RA+), seronegative RA (RA-), and psoriatic arthritis (PsA) based on structural inflammatory patterns on hand magnetic resonance imaging and (ii) to assess if psoriasis patients with subclinical inflammation fit into such patterns.

Methods

ResNet 3D [1] neural networks were trained to distinguish (i) RA+ vs. PsA, (ii) RA- vs. PsA and (iii) RA+ vs. RA- with respect to hand MRI data. Diagnosis of patients was determined using the following guidelines: ACR/EULAR 2010 [2] for RA and CASPAR [3] for PsA. Results from T1 coronal, T2 coronal, T1 coronal and axial fat suppressed contrast-enhanced (CE) and T2 fat suppressed axial sequences were used. The performance of such trained networks was analyzed by the area-under-the-receiver-operating-characteristic curve (AUROC) with and without imputation of demographic and clinical parameters (Figure 1A). Additionally, the trained networks were applied to psoriasis patients without clinical signs of PsA.

Figure 1.

(A) Neural network combining MR sequences with optional additional clinical data. The prediction for a single case is formed by averaging the prediction of all sequences and the clinical data. (B) Plot of the AUROC for increasing percentages (0.6 – 60%) of training data for the differentiation between RA+ and PsA by the neural network. The light blue area around the dark blue mean indicates the uncertainty measured using a 5-fold cross-validation.

Results

MRI scans from 649 patients (135 RA-, 190 RA+, 177 PsA, 147 psoriasis) were included (Table 1). The AUROC for differentiation between disease entities was 75% (SD 3%) for RA+ vs. PsA, 74% (SD 8%) for RA- vs. PsA, and 67% (6%) for RA+ vs. RA-. All MRI sequences were relevant for classification, however, when deleting CE sequences, the loss of performance was only marginal. The addition of patient-specific data to the networks did not provide significant improvements. Increasing amounts of training data demonstrated improved performance of the networks (Figure 1B). Psoriasis patients were mostly assigned to PsA by the neural networks, suggesting that PsA-like MRI pattern may be present early in the course of psoriatic disease.

Table 1.

Overview of demographic and clinical information.

RA+RA-PsAPsoriasisTotal Number (N)649Number (N)190135177147Age (years), mean±SD56.9±12.660.5±10.356.3±12.049.6±13.8Sex (female/male)126/6493/4292/8571/76BMI (kg/m2), mean±SD26.6±10.527.6 ±9.329.1±11.326.7±6.9Disease duration (years), mean±SD2.6±4.91.3±2.30.8±2.34.2±5.1DAS28, mean±SD3.3±1.33.4±1.23.2±1.3-CRP (mg/L), mean±SD0.9±2.50.7±1.20.5±0.80.5±1.3HAQ, mean±SD0.8±0.60.9±0.80.6±0.60.3±0.4MedicationbDMARD88.46%83.87%81.32%35.01%csDMARD89.52%88.89%80.54%12.28%

Conclusion

Deep learning can be successfully applied to differentiate MRI inflammatory patterns related to RA+, RA-, and PsA. Early changes in psoriasis patients can be recognized by neural networks and are characterized by a pattern that allowed the networks to classify them as PsA.

References

[1]Kensho Hara, Hirokatsu Kataoka, and Yutaka Satoh 2018. Can Spatiotemporal 3D CNNs Retrace the History of 2D CNNs and ImageNet? In Proceedings of the IEEE Conference on Computer Vision and Pattern Recognition (CVPR) (pp. 6546–6555).

[2]Aletaha D, Neogi T et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sep;62(9):2569-81.

[3]Helliwell PS, Taylor WJ. Classification and diagnostic criteria for psoriatic arthritis. Annals of the Rheumatic Diseases 2005;64:ii3-ii8.

Acknowledgements

The study was supported by the Deutsche Forschungsgemeinschaft (DFG-FOR2886 PANDORA and the CRC1181 Checkpoints for Resolution of Inflammation). Additional funding was received by the Bundesministerium für Bildung und Forschung (BMBF; project MASCARA), the ERC Synergy grant 4D Nanoscope, the IMI funded projects HIPPOCRATES and RTCure, the Emerging Fields Initiative MIRACLE of the Friedrich-Alexander-Universität Erlangen-Nürnberg and the Else Kröner-Memorial Scholarship (DS, no. 2019_EKMS.27). Furthermore, infrastructural and hardware support was provided by the d.hip Digital Health Innovation Platform.

Disclosure of Interests

None declared

AB0385 BARICITINIB LEADS TO RAPID AND PERSISTENT RESOLUTION OF SYNOVITIS AS MEASURED BY HAND MRI IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS (RA) FAILING cs/bDMARD THERAPY

Background

RA is characterized by synovial inflammation resulting in local bone loss [1]. Inhibitors of JAK/Stat pathways, such as baricitinib, demonstrated efficacy in reducing signs and symptoms of RA in clinical trials, however, little is known about their effects on synovitis and bone structure [2]. Preclinical and clinical observations suggest a positive effect JAK inhibitors on bone mass and microstructure, however no prospective, interventional clinical trial has been performed so far [3].

Objectives

The aim of this study is to evaluate the effect of baricitinib on local inflammation (synovitis and osteitis) and bone structure (erosions) in RA patients failing on cs/bDMARD therapy using hand MRI.

Methods

BAREBONE is a prospective, interventional, open label, monocentric single center study (EUDRACT 2018-001164-32 / NCT03701789) to assess the effect of baricitinib (4mg/day) on local MRI inflammation and structure in patients with active RA. Besides demographic and clinical characteristics, hand joint inflammation was assessed by magnetic resonance imaging (MRI) using a 1.5 Tesla scanner (Siemens Magnetom Aera T1w TSE cor, T2w TIRM cor, T2w TSE fat-sat trans, T1w TSE fat-sat trans + cor after KM;). at baseline, week 24 and week 48. Scans were assessed for synovitis, osteitis and bone erosions using the RAMRIS scoring system using two independent blinded readers (SK and SB). Intraclass correlation coefficients were calculated for total RAMRIS and synovitis, erosion and osteitis subscores and in a second step differences between cs and bDMARD failure were elaborated. Variables are summarized descriptively using means and 95% bootstrap confidence intervals for continuous outcomes and as number and percentages for categorical outcomes.

Results

Thirty- two RA patients were screened and 30 patients were included (age: 53.4 [SD 12.6] years; sex: f/m N 24/6; disease duration: 3 [IQR 2.0 – 8.0] years; biologic naïve/bDMARD failure 16/14). 27 patients completed the trial while MRI data was available for 24 patients at week 48. Demographics and clinical characteristics can be seen in Table 1. Total RAMRIS scores slightly decreased from 20.6 (95% CI 14.4 -27.8) at baseline (BL) to 18.3 (11.5 -26.5) at week 48. The synovitis subscore mainly contributed to total RAMRIS reduction by significantly improving from 5.3 (4.0 - 6.8) at BL to 2.7 (1.5 - 4.0) at week 48 with a score change of -2.9 (-4.0 to -1.8). At week 48, 12 patients (44.4%) had no signs of synovitis compared to only 3 patients at BL. In contrast, RAMRIS osteitis subscores only marginally decreased from 4.9 (2.2 - 8.4) at BL to 4.0 (1.9 - 6.7) at week 48. RAMRIS erosion score remained stable over the 48-week observation time. A significant difference in RAMRIS synovitis change for biologic naïve -3.8 (-5.2 to -2.6) vs biologic failure -1.0 (-2.2 to 0.4 could be observed at week 48).

With respect to clinical disease activity, DAS 28 score decreased from 4.8 (4.5 – 5.1) at BL to 2.9 (2.5 – 3.3) at week 48. Detailed results can be found in Table 1 and Figure 1. Intraclass coefficient (95%CI) for RAMRIS scoring was high for both readers 0.997 (0.994 to 0.998).

Table 1.

Demographics, DAS 28 ESR, RAMRIS total score and RAMRIS subset scores at baseline, week 24 and week 48 are shown as well as number of patients with improvement and resolution of synovitis.

BaselineWeek 24Week 48N303027AgeMean [SD]53.5 (12.6)Genderfemalen [%]24 (80.0)malen [%]6 (20.0)Disease duration, yearsMedian (IQR)3.0 (2.0-8.0)DAS-28 ESRMean [95%CI]4.8 (4.5 to 5.1)3.0 (2.7 to 3.3)2.7 (2.4 to 3.0)MRI availablen [%]30 (100.0)28 (93.3)24 (88.9)RAMRIS totalMean [95%CI]20.6 (14.4 to 27.6)18.4 (12.6 to 25.4)18.3 (11.5 to 26.5)RAMRIS total changeMean [95%CI]0.0 (0.0 to 0.0)-2.1 (-4.0 to -0.4)-3.9 (-7.2 to -0.5)RAMRIS synovitisMean [95%CI]5.3 (3.9 to 6.9)3.5 (2.2 to 4.9)2.7 (1.5 to 4.0)RAMRIS synovitis changeMean [95%CI]0.0 (0.0 to 0.0)-1.8 (-2.5 to -1.0)-2.9 (-4.0 to -1.8)RAMRIS synovitis improvedpatients n [%]10 (33.3)13 (48.1)RAMRIS synovitis resolvedpatients n [%]10 (33.3)12 (44.4)RAMRIS osteitisMean [95%CI]4.9 (2.2 to 8.4)3.7 (1.5 to 6.2)4.0 (1.9 to 6.7)RAMRIS osteitis changeMean [95%CI]0.0 (0.0 to 0.0)-0.9 (-3.1 to 1.0)-1.9 (-5.7 to 1.1)RAMRIS osteitis improvedpatients n [%]2 (6.7)4 (14.8)RAMRIS erosionMean [95%CI]10.4 (7.3 to 14.6)11.2 (7.7 to 15.0)11.6 (7.5 to 16.6)RAMRIS erosion changeMean [95%CI]0.0 (0.0 to 0.0)0.6 (0.1 to 1.2)0.9 (0.0 to 2.1)RAMRIS erosion worsenedpatients n [%]2 (6.7)3 (11.1)

Conclusion

Our study shows that baricitinib primarily reduces MRI synovitis in RA patients that have previously failed csDMARD and bDMARD therapy and particularly in patients who are biologic naïve.

References

[1]McInnes, I.B. and G. Schett, The pathogenesis of rheumatoid arthritis. N Engl J Med, 2011.

[2]Genovese, M.C., et al., Baricitinib in Patients with Refractory Rheumatoid Arthritis. N Engl J Med, 2016

[3]Adam, S., et al., JAK inhibition increases bone mass in steady-state conditions and ameliorates pathological bone loss by stimulating osteoblast function. Sci Transl Med, 2020.

Acknowledgements

Lilly Deutschland GmbH funded the Barebone trial

Disclosure of Interests

Stephan Kemenes: None declared, Sara Bayat: None declared, David Simon Speakers bureau: Lilly Pharma Deutschland GmbH, Janssen, Consultant of: BMS, Pfizer, Sanofi, Abbvie, Janssen, Medac, Novartis,

Lilly Deutschland GmbH, GileaBMS, Pfizer, Sanofi, Abbvie, Janssen, Medac, Novartis,

Lilly Deutschland GmbH, Gilead, Amgen

d,

, Grant/research support from: Novartis, Gilead, Abbvie, Lilly, Gerhard Krönke Speakers bureau: GSK, Novartis, Consultant of: GSK, Lilly, Novartis, Janssen, Grant/research support from: Lilly, Novartis, BMS, Janssen, Daniela Bohr: None declared, Larissa Valor: None declared, Fabian Hartmann: None declared, Louis Schuster: None declared, Koray Tascilar Speakers bureau: Gilead speaker, Consultant of: UCB, Lilly, Georg Schett Speakers bureau: Janssen, Abbvie, BMS, Lilly, Novartis, Roche, AMGEN, Gilead, UCB, Consultant of: Lilly, Novartis, Abbvie, Grant/research support from: Chugai, Lilly, Novartis, Arnd Kleyer Speakers bureau: Lilly, Novartis, Abbvie, Consultant of: BMS, Pfizer, Sanofi, Abbvie, Janssen, Medac, Novartis,

Lilly Deutschland GmbH, Gilead, Amgen

, Grant/research support from: Novartis, Lilly Deutschland GmbH, Gilead

POS1476-HPR FEASIBILITY OF USING OPTOELECTRONIC MEASUREMENT OF HAND MOVEMENT FOR CHARACTERIZING HAND FUNCTION IN RHEUMATOID ARTHRITIS

Background

Physical function is an important factor determining disease burden in arthritis. Monitoring function in rheumatoid arthritis (RA) patients is essential for effective treatment [1]. The currently used tools to assess physical function (e.g. patient reported outcomes) have limitations with respect to sensitivity and specificity to measure functional impairment in RA [2,3]. A marker-based optoelectronic measurement of hand function enables detailed analysis of hand movements such as spatial-temporal parameters and joint angles [4]. This may provide new possibilities to quantitatively and qualitatively analyze the changes of hand function in patients with RA in so far unprecedented way.

Objectives

To test the feasibility of optoelectronic measurement of hand function in RA patients and healthy controls (HC) when performing standard functional tests such as the Moberg Pick-Up-Test (MPUT) as well as standard movements such as finger flexing and to detect disease specific patterns.

Methods

RA patients (ACR/EULAR 2010 criteria [1]) recruited from the Internal Medicine 3 outpatient clinic, Erlangen, Germany and HC were included (Ethics #125_16B). Participants were asked to perform the MPUT and a simple movement of flexing the interphalangeal (DIP) and proximal interphalangeal joint (PIP). Spatial-temporal data of hand movements and hand segment kinematics were captured using an optoelectronic measurement system (Qualisys AB, Sweden) with 29 retroreflective markers (Figure 1). Transport time for each of the 12 MPUT objects was divided into a grasping phase (GP) (first touch to safe grip) and a manipulation phase (MP) (safe grip to drop) using the video recording or marker trajectories. For the flexing movement, the ratios between the flexion angle of the DIP and PIP joint (DIPPIP) were calculated. We used linear mixed-effects models accounting for within-participant clustering of hands and adjusting for age and sex differences to compare RA with controls.

Figure 1.

Marker setup and the 12 objects transported during the MPUT.

Results

Twenty-four RA patients and 23 healthy controls were evaluated (Table 1). Mean GP times across all objects showed higher absolute differences between the groups (RA 0.43 [0.35-0.52]; HC 0.33 [0.27-0.40] sec) while MP times were identical (RA 0.36 [0.30-0.44]; HC 0.36 [0.30-0.44] sec) showing a significant group-phase interaction (p<0.001). Objects safety pin, key, and paper clip showed the highest absolute between-group mean differences for unadjusted time data (0.41, 0.36, 0.34 sec respectively). Measured angle ratios (RA 0.60±0.15; HC 0.68±0.17 (DIPPIP)) and their linear fit (RA 0.96±0.05; HC 0.97±0.03 R2) were similar for RA and controls (p>0.05).

Table 1.

Subject characteristics; mean (SD)

RAHCmale: female [N]7: 1711: 12Age [years]62.3 (9.1)50.2 (16.1)Disease duration [years]11.8 (10.8)Disease Activity Score (DAS28)2.5 (1.3)

Conclusion

Optoelectronic measurement of hand function is feasible and allows to gain a more detailed picture of impairment in hand function in RA patients. For instance, tasks like reaching for an object are significantly impaired. Further, objects causing the greatest difficulty for RA patients in the GP were identified. The previously described linear relationship of angle ratios for the distal finger joints in healthy individuals [5] seems also valid for RA patients in our cohort and no significant group differences for the ratio could be observed. This may reflect that DIP and PIP joints are less affected in RA compared to e.g. psoriasis arthritis [6]. In conclusion, optoelectronic hand movement analysis allows a more accurate and differentiated analysis of hand function in RA patients.

References

[1]Aletaha, D. et al. Arthritis Rheum. 2010, 62, 2569-2581

[2]Günay, S. M. Reumatismo. 2016, 68, 183-187

[3]Liphardt, A.M. et al. ACR Open Rheumatol. 2020, 2, 734-740

[4]Sancho-Bru, J. et al. Proc. Inst. Mech. Eng. Part H J. Eng. Med.2014, 228, 182-189

[5]Lee, J. & Kunii, T. IEEE Comput. Graph. Appl. 1995, 77-86

[6]Veale DJ, et al. RMD Open 2015, 1: e000025

Acknowledgements

The study was supported by the German Research Foundation (DFG) under Grant SFB 1483 – Project-ID 442419336 and the major instruments at the Institute of Applied Dynamics, FAU Erlangen-Nürnberg were used in this study – reference number INST 90 / 985-1 FUGG.

Disclosure of Interests

None declared

POS1384 NON-INVASIVE IN VIVO METABOLIC PROFILING OF INFLAMMATION IN JOINTS AND ENTHESES BY OPTOACOUSTIC IMAGING

Background

An in-depth metabolic characterization of joints and entheses at the tissue level can help in the early diagnosis and treatment selection for patients with inflammatory arthritis [1]. However, current knowledge about the metabolic profiles of synovitis and enthesitis is limited. Multispectral optoacoustic tomography (MSOT), a novel metabolic imaging technology, could be used to undertake metabolic profiling of joints and entheses non-invasively using near-infrared multispectral laser to stimulate tissues and detect the emitted acoustic energy, enabling quantification of tissue components in vivo based on differential absorbance at multiple wavelengths [2, 3].

Objectives

To explore the metabolic characteristics of arthritis and enthesitis using MSOT.

Methods

We performed a cross sectional study on healthy controls (HC) and patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) (Table 1). Participants underwent clinical, ultrasound (US), and MSOT examination of metacarpophalangeal joints, wrists, entheses of lateral epicondyles, patellar, quadriceps and Achilles tendons. MSOT-derived hemoglobin, oxygen saturation, collagen and lipid levels were measured. We calculated scaled mean differences (SMD) between affected and unaffected joints and entheses as defined by clinical examination or US using linear mixed effects models.

Table 1.

Baseline characteristics.

OverallHealthyPsARAN87363417Age, mean (SD)47.0 (15.7)34.7 (12.0)52.4 (11.5)62.5 (9.1)Sex, n (%) Female48 (55.2)18 (50.0)17 (50.0)13 (76.5) Male39 (44.8)18 (50.0)17 (50.0)4 (23.5)Tender joints, median (IQR)0 (0-2)0 (0-0)1 (0-5)2 (1-6)Swollen joints, median (IQR)0 (0-1)0 (0-0)0 (0-2)2 (1-6)Tender entheses, median (IQR)0 (0-2)0 (0-0)1 (0-3)0 (0-0)csDMARD, n (%)22 (25.3)-13 (38.3)9 (53.0)b-tsDMARD, n (%)31 (35.6)-20 (58.8)11 (64.7)

SD, standard deviation; IQR, interquartile range; csDMARD, conventional synthetic disease modifying anti-rheumatic drug; b-tsDMARD, biologic or targeted synthetic disease modifying anti-rheumatic drug.

Results

We obtained 1535 MSOT and 982 US scans from 87 participants (36 HC, 34 PsA, 17 RA). Entheseal tenderness was not associated with metabolic changes, whereas US enthesitis was associated with increased total hemoglobin, oxygen saturation and collagen content. In contrast, clinical and US arthritis showed increased hemoglobin levels but reduced oxygen saturation and reduced collagen content. Synovial hypertrophy was associated with increased lipid content in the joints (Figure 1).

Figure 1.

Scaled differences and 95% confidence intervals of MSOT-measured metabolite values by clinical and ultrasonographic findings of enthesitis (A-C) and arthritis (D-F). Two differences are plotted for each metabolite indicating two multispectral processing algorithms used for estimation. P values were adjusted for multiple testing using a false discovery rate of 5%. NS, not significant. sO2, oxygen saturation.

Conclusion

MSOT allows a non-invasive characterization of metabolic changes in arthritis and enthesitis. These findings can be interpreted as a reflection of increased synovial cellularity, collagen degradation, and metabolic demand in synovitis, and of an increased tissue apposition and vascularization in enthesitis. Our results suggest that synovitis and enthesitis do not only differ at the clinical and anatomical-functional level, but also exhibit divergent metabolic changes.

References

[1]Falconer J, et. al. Arthritis Rheumatol. 2018;70(7):984-99.

[2]Regensburger AP, et. al. Biomedicines. 2021;9(5).

[3]Regensburger AP, et al. Nature Medicine. 2019;25(12):1905-15.

Conflict of Interest

AR., FK, MW are co-inventors, together with iThera Medical GmbH, Germany on an EU patent application (no. EP 19 163 304.9) relating to a device and a method for analysis of optoacoustic data, an optoacoustic system and a computer program. All other authors declare no conflict of interest.

Acknowledgements

We thank Ms. Nairouz Al Ahmad, assistant medical technician (Department of Internal Medicine 3), for her assistance in conducting the study and Dr. Yi Qiu, PhD (iThera Medical GmbH) for her assistance in data analysis and interpretation.

Disclosure of Interests

None declared

POS0009 SUBJECTIVE ASSESSMENT OF PHYSICAL FUNCTION DOES NOT SUFFICIENTLY EXPLAIN VARIANCE OF MEASURED HAND FUNCTION AND GRIP STRENGTH IN ARTHRITIS PATIENTS AND NON-ARTHRITIS CONTROLS

Background

Monitoring disease activity in patients with inflammatory arthritis is essential for effective treatment. While the health assessment questionnaire (HAQ) is commonly used to assess physical function, additional functional tests, such as isometric grip strength and the Moberg Pick-Up-Test (MPUT), provide objective measures for hand function and allow assessing hand function across different diseases (1). It remains unclear to date, if measured hand function is already reflected by the HAQ, as the most widely used patient reported outcome measure of physical function in arthritis.

Objectives

To estimate the proportion of hand function and grip strength variability explained by HAQ, patient-reported hand function, and between-person variation in patients with inflammatory arthritis and non-arthritic controls.

Methods

Patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), psoriasis without PsA (PsO) and healthy controls (HC) were investigated. Subject characteristics (age, sex, disease) and HAQ were recorded. Hand function was assessed by vigorimetric grip strength, MPUT, and a patient-reported tool (Michigan Hand Questionnaire, MHQ). Mixed pure-random-effect linear regression models were used to estimate the proportion of variance in measured hand function or grip strength explained by subject characteristics (age, hand dominance, sex, reported hand function, disease group).

Results

299 subjects were tested, 101 with RA (Age: 59.1±13.3 years, BMI: 27.2±5 kg/m2, HAQ-DI score: 0.9±06), 92 with PsA (Age: 58.8±11.6 years, BMI: 29±6.1kg/m2, HAQ-DI score: 0.6±0.7) and 106 non-arthritic controls (51 with Pso (Age: 47.3±14.1 years, BMI: 29.8±7.3 kg/m2, HAQ-DI score: 0.4±06) and 55 HC (Age: 54.6±16.5 years, BMI: 25.2±3.3 kg/m2, HAQ-DI score: 0.1±0.2). Overall variation of MPUT is mostly accounted for by between-person variation (43.1%), followed by HAQ (20.3%) and MHQ (20.2%) (Figure 1A). Overall variation in grip strength is mostly accounted for by sex (59.8%), between-person variation (21.1%) and HAQ (11.3%) (Figure 1B). Overall variation in MHQ is mostly accounted for by HAQ (59.2%) and residual variation (28.3%). Study group specific result are summarized in Table 1.

Table 1.

Variance proportions for each of the four study groups.

Variance proportions (%)Hand function (MPUT)Grip strengthGroupControlPsAPsORAControlPsAPsORAMHQ3.439.00.00.00.02.10.00.0ID34.836.251.652.816.112.921.327.9Age0.013.80.00.78.48.40.00.0HAQ35.810.834.316.43.83.110.312.0Dominant hand0.60.20.00.03.50.61.30.2Sex12.10.00.04.364.268.963.755.0Residual13.30.014.125.83.94.03.45.0

Conclusion

While the variance variation in grip strength is mainly explained by sex and between-person variation for all subject groups, the proportions of explained variance for measured hand function is not similar between diseases. In all groups > 50% of the variation in measured hand function remains unexplained by the variables used. Especially in arthritis patients, HAQ explained less than 25% of the variance in measured hand function. Grip-strength can be considered a poor surrogate for hand function in this context due to its large gender dependence. The explainability of MHQ variation largely by HAQ indicates that it has limited potential to provide further information beyond overall functional impairment. In contrast, the large between-person variation in MPUT likely indicates unexplored movement patterns of hand motion that may be further dissected using sensor-based analyses (2) and can help identify movement components a potential for an in-depth assessment of subtle hand-function alterations in inflammatory arthritis.

References

[1]Liphardt AM et al. ACR Open Rheumatol 2020, 2, 734-740. 2. Phutane U et al. Sensors (Basel) 2021, 21.

Acknowledgements

This study was supported by the German Research Council (SFB 1483 – Project-ID 442419336, INST 90 / 985-1 FUGG, FOR2438/2886; SFB1181), the German Ministry of Science and Education (project MASCARA), the European Union (H2020 GA 810316 - 4D-Nanoscope European Research Council Synergy Project) and Novartis Germany GmbH.

Disclosure of Interests

None declared

TRANSCOV, a multidisciplinary project to evaluate long distance COVID patients transfers

Background

Faced with an abrupt surge of severe COVID patients in March and April 2020, intensive care units (ICU) from four French regions transferred around 660 patients towards six other regions and four neighbouring countries. The intensity and the diversity of the vectors used (plane, helicopter, train, ambulance), during this wave of medical evacuations make it an unprecedented event. The aim of TRANSCOV is to examine the impact of long distance transfers on patient's health and to understand how actors collaborated to overcome clinical and logistical challenges.

Methods

TRANSCOV is made of three disciplinary components: 1) interviews with clinicians and health authorities staff involved in the organisation and realisation of the transfers as part of the qualitative component; 2) a retrospective cohort collecting clinical parameters and pathway details before during and after transfer; 3) a collection of data regarding human and logistical resources mobilised during transfers as part of an economical evaluation.

Results

Preliminary results indicate that prior experience in medical evacuations proved useful to collaborate effectively in the exceptional circumstances prevailing in spring 2020. Clinicians had to establish quickly eligibility criteria for transfer. Actors' opinions may vary on the appropriateness of vectors to transfer isolated (e.g. via helicopter) or grouped (train) patients. Early epidemiological data suggest that transferred patients were younger and experienced comparable, if not lower, in-hospital mortality compared to other patients. The economic evaluation is in progress.

Conclusions

Initial results indicate that effective collaborations led to the selection of clinically eligible patients and the realisation of safe distant transfers.

Key messages

Healthcare organisations have been able to adapt and create organizational innovations to respond to COVID-19. Multidisciplinary approaches are appropriate to evaluate such complex innovations.

Effects of metformin on autoimmune immunoglobins and interferon-γ in patients with early diagnosed pemphigus vulgaris: a prospective clinical trial

The management of pemphigus vulgaris (PV) is challenging. This study aimed to evaluate the immunomodulating effects of metformin on PV. The study was conducted in two phases: in the first phase, patients received routine first-line treatment (prednisolone plus azathioprine) for 2 months, then in the second phase, metformin was added to this regimen for another 2 months. After addition of metformin to the first-line medications, significant reductions were seen in serum IgG1 (reduced from 534.92 ± 134.83 mg/dL to 481.58 ± 130.46 mg/dL, P < 0.001), IgG4 (51.83 ± 27.26 mg/dL to 44.50 ± 26.05 mg/dL, P < 0.001) and interferon-γ (277.99 ± 108.71 pg/mL to 45.05 ± 17.080 pg/mL, P = 0.03) concentrations. The suppressant effect of metformin was greatest on IgG4 (coefficient of variation 1.28), the dominant subclass of IgG involved in PV. Metformin could have immunomodulating effects on PV with controlling effects on steroid complications.

POS1394 ACCURACY AND PERFORMANCE OF A HANDHELD ULTRASOUND DEVICE TO ASSESS ARTICULAR AND PERIARTICULAR PATHOLOGIES IN PATIENTS WITH INFLAMMATORY ARTHRITIS

Background:

Handheld ultrasound (HHUS) devices have increasingly found their way into clinical practice due to several advantages (e.g. portability, significantly lower purchase cost). However, there is no evidence to date on the accuracy and performance of HHUS in patients with inflammatory arthritis (IA).

Objectives:

To assess accuracy and performance of a new HHUS machine in comparison to a conventional cart-based sonographic machine in patients with IA.

Methods:

Consecutive IA patients of our outpatient clinic with at least one tender and swollen joint in the 66/68 joint count were enrolled. US was performed on clinically affected joints with corresponding tendons/entheses using a cart-based sonographic device (“Samsung HS40”) and a HHUS device (“Butterfly iQ”) in standard scan positions. One blinded reader scored all images for the presence of following pathologic findings: erosions, bony enlargement, synovial hyperthrophy, joint effusion, bursitis, tenosynovitis and enthesitis. In addition, synovitis was graded (B Mode and power Doppler (PD)) by the 4-level EULAR-OMERACT scale [1]. To avoid bias by the blinded reader, who otherwise would have been tempted to identify pathological findings for each examined joint, we also included 67 joints of two healthy volunteers into the evaluation. We calculated the overall concordance and the concordance by type of joint and type of pathological finding between the two devices (percentage of observation pairs in which the same rating was given by both devices). The Cohen’s kappa coefficient (κ) with 95% bootstrap confidence intervals was used to assess the agreement between the two US devices. We also measured the time required for the US examination of one joint with both devices.

Results:

32 patients (20 rheumatoid arthritis, 10 psoriatic arthritis, 1 gouty arthritis, 1 systemic lupus erythematosus) were included in this study. Mean age of patients was 58.2±13.7 years, 63% were females. In total 186 joints were examined. The overall raw concordance in B-mode between the two devices was 97 %, with an overall κappa for agreement of 0.90, 95% CI (0.89, 0.94). No significant differences were found in relation to type of joint or pathological finding examined. The PD-mode of the HHUS device did not detect any PD-signal, whereas the cart-based device detected a PD-signal in 61 joints (33%). The portable device did not offer any time saving compared to the cart-based device (mean time in seconds per examined region: 47 seconds for the HHUS device versus 46.3 seconds for the cart-based device).

Conclusion:

The HHUS device “Butterfly iQ” has been shown to be accurate in the assessment of structural joint damage and inflammation in patients with IA, but only in B-mode. Significant improvements are still needed to reliable demonstrate blood flow detection by PD mode.

References:

[1]D’Agostino, M.A., et al., RMD Open, 2017. 3(1): p. e000428.

Table 1.

Concordance between a handheld and a conventional cart-based US device in B-mode

Agreement by siteN joints (%)Concordance (%)Kappa 95%CIOverall186970.90 (0.89 to 0.94)Wrist32 (17.2)960.86 (0.77 to 0.93)Finger/toe joint (MCP, PIP, DIP, MTP)114 (61.3)970.92 (0.88 to 0.95)Elbows11 (5.9)950.87 (0.75 to 0.97)Shoulder4 (2.2)1001.00 (NA to NA) *Knee20 (10.7)980.96 (0.90 to 1.00)Ankle5 (2.7)1001.00 (NA to NA) *Agreement by pathological findingJoint effusion950.81 (0.68 to 0.92)Synovitis940.87 (0.79 to 0.93)Synovitis OMERACT grade (0– 3)900.84 (0.76 to 0.91)Bone enlargement980.88 (0.71 to 1.00)Erosion980.89 (0.77 to 0.89)Tenosynovitis980.83 (0.61 to 0.96)Entheseopathy1001.00 (NA to NA) *Bursitis970.90 (0.89 to 0.94)

* unreliable kappa statistics because of small number of shoulders/ankles examined and small number of entheseopathies

Figure 1.

Pathological US findings in MCP joints (1, 2, 3) and wrist (4) depicted by the two different ultrasound devices

B-mode erosive (arrow) and synovial (asterisk) changes could be detected by both devices (1-2), while PD changes of different grades only by the conventional US device (3-4).

Acknowledgements:

This study was supported by the Deutsche Forschungsgemeinschaft (DFG- FOR2886 PANDORA and the CRC1181). Additional funding was received by the Bundesministerium für Bildung und Forschung (BMBF; project METARTHROS, MASCARA), the H2020 GA 810316 - 4D-Nanoscope ERC Synergy Project, the IMI funded project RTCure, the Emerging Fields Initiative MIRACLE of the Friedrich-Alexander-Universität Erlangen-Nürnberg, the Else Kröner-Memorial Scholarship (DS, no. 2019_EKMS.27) and Innovationsfond Lehre / FAU Erlangen-Nürnberg 2019.

Disclosure of Interests:

None declared

AB0495 BIOMECHANICAL STRESS IN THE CONTEXT OF COMPETITIVE SPORTS TRAINING TRIGGERS ENTHESITIS

Background:

Preclinical models have indicated that biomechanical stress can trigger entheseal inflammation (1). Furthermore, enthesitis is a hallmark of psoriatic arthritis (PsA) and spondyloarthritis (SpA), suggesting that mechanoinflammation is an important step in their pathogenesis (2). However, the relation between mechanical stress and enthesitis in humans is poorly investigated. Competitive badminton is a demanding stop-and-go sport that strains entheseal sites in particular and provides an opportunity to assess the impact of physical activity on the development of an instant inflammatory response in the entheses.

Objectives:

To evaluate the influence of mechanical stress on the development of immediate enthesitis.

Methods:

BEAT (Badminton Enthesitis Arthrosonography Study) is an interventional study that assessed entheses in competitive badminton players before and immediately after a 60-minute intensive training session by ultrasound. Power Doppler (PD) signal and Gray-Scale (GS) changes were evaluated at the insertions sites of both Achilles tendon, patellar tendons and lateral humeral epicondyles and quantified using a validated scoring system (3). Pre- and post-training scores were compared using linear mixed-effects models. We used interaction terms to assess possible differential effects on patellar, elbow and Achilles entheses.

Results:

Thirty-two badminton players (22 men, 10 women) with an average age of 31.1±13.0 years were included (Table 1). On average, they had been playing badminton for 16.2±10.1 years. 192 entheseal sites were examined twice. The respective empirical total scores for PD examination were 0.1 (0.3) before and 0.5 (0.9) after training (Figure 1). Mean total GS scores were 2.9 (2.5) and 3.1 (2.5) before and after training, respectively. The mean total PD score difference of 0.4 between pre- and post -training was significant with a p value of 0.0014, whereas the p value for the mean total GS score difference of 0.2 was 0.63. Overall, seven participants (22%) showed an increased empirical total PD score. A mixed-effects model showed a significant increase of PD scores after training, with a mean increase per site of 0.06 (95%CI 0.01 to 0.12, p=0.017).

Table 1.

Baseline characteristics

Demographic characteristicsN, total32Females, N (%)10 (31.3)Age, years (mean ± SD)36.1 ± 13.0Height, cm (mean value ± SD)178.6 ± 9.9Body weight, kg (mean value ± SD)74.7 ± 13.5Smoking, N (%)11 (34.4)Alcohol, N (%)24 (75.0)Concomitant DiseasesInflammatory bowel disease, N (%)0Psoriasis, N (%) 0Uveitis, N (%)0Diabetes mellitus, N (%)0Hypertension, N (%)2 (6.3)Sports historyYears Badminton (mean ± SD)16.2 ± 10.1Figure 1.

Ultrasound scores before and after training Figure 1. A Spaghetti plots depicting inividual Gray-Scale and Power Doppler ultrasound scores before and after training

Conclusion:

Mechanical stress leads to rapid inflammatory responses in the entheseal structures of humans. These data support the concept of mechanoinflammation in diseases associated with enthesitis. However, while such responses may be self-contained in healthy subjects, they may be prolonged and more pronounced in certain risk groups, such as patients with PsA or SpA.

References:

[1]Cambré I, et al. Mechanical strain determines the site-specific localization of inflammation and tissue damage in arthritis. Nature Communications. 2018; 9:4613.

[2]Schett G, et al. Enthesitis: from pathophysiology to treatment. Nat Rev Rheumatol. 2017; 13:731-741.

[3]Balint PV, et al. Reliability of a consensus-based ultrasound definition and scoring for enthesitis in spondyloarthritis and psoriatic arthritis: an OMERACT US initiative. Annals of the Rheumatic Diseases. 2018; 77:1730.

Disclosure of Interests:

David Simon: None declared., Arnd Kleyer: None declared., Sara Bayat: None declared., Johannes Knitza: None declared., Larissa Valor: None declared., Marina Schweiger: None declared., Georg Schett: None declared., Koray Tascilar: None declared., Axel Hueber Grant/research support from: Novartis Research Grant.

OP0148 SPATIOTEMPORAL DYNAMICS OF BONE LOSS BEFORE AND AFTER THE ONSET OF RHEUMATOID ARTHRITIS

Background:

Rheumatoid Arthritis (RA) is preceded by a clinically silent pre-phase characterized by autoimmunity against anti-modified protein antibodies including anti-citrullinated protein antibodies (ACPA). At this pre-stage patients already experience significant loss of volumetric peripheral bone mineral density (vBMD) compared to healthy controls measured by high-resolution peripheral quantitative computed tomography (HR-pQCT) (1-2). However, the longitudinal course of vBMD changes during the preclinical phase, after diagnosis, and its association with time to disease onset have not been investigated.

Objectives:

To longitudinally characterize the changes of metacarpal and radial vBMD before and after the clinical onset of RA and its association with time to onset of arthritis.

Methods:

To explore the development of arthritis, we initiated a RA-at-risk cohort in 2011. (Ethics 334_16B). This prospective cohort includes adults positive for CCP-AB with or without musculoskeletal symptoms, excluding arthritis. Participants are regularly followed with clinical examination and HR-pQCT imaging of the MCP and radial bone to monitor early bone changes. HR-pQCT images with low motion grade artefacts were analyzed to obtain the total (D100), cortical (DComp) and trabecular (DTrab) vBMD (D100) in mg HA cm3.

We descriptively analyzed the vBMD time course in patients who developed RA by fitting regression curves separately for the pre-clinical and clinical periods and estimated time-conditional marginal mean VBMDs for the 5-year peri-RA period. We analyzed time to diagnosis of clinical RA defined by the 2010 ACR/EULAR classification criteria using Cox regression models. Hazard ratios indicate the relative risk of clinical disease onset associated with 1 standard deviation reduction in bone density.

Results:

130 subjects (mean [SD] age 47.0 [12.2], 89 female [68%]) between 2011 and 2020 were analyzed. Median (IQR) follow-up duration for the cohort was 18.6 (4.6-47.6) months. Participants underwent 233 HR-pQCT scans and 58 (45%) underwent 2 to 6 scans with a median interval of 16.2 (12.2-21.2) months. 49 (38%) patients who developed RA had a pre-diagnosis follow-up of 4.1 (2.5-13.4) months and post-diagnosis follow-up of 22.0 (8.8-38.9) months. The time course of scaled bone mineral densities depicted in Figure 1A suggest that bone density around the MCP joints deteriorate in the preclinical phase of RA, which is mostly prominent in the trabecular bone. Modelling (Figure 1B) suggests that trabecular bone loss around the MCP joints has a constant pace regardless of the clinical status. Whereas the radial bone densities are relatively stable in the preclinical phase and show a reduction after the clinical onset of RA. Age and sex adjusted hazard ratios (95%CI) for the risk of RA clinical onset were 1.52 (1.03 to 2.25) for radius D100 and 1.66 (1.07 to 2.55) for radius DComp (Table-1).

Table 1.

Relative risk of RA development in the total cohort; crude and age/sex adjusted hazard ratios for one standard-deviation reduction in vBMD.

CrudeAdjustedHR (95%CI)PHR (95%CI)PMCP.D-Comp1.16 (0.86 to 1.57)0.3361.20 (0.89 to 1.63)0.229MCP.D-Trab1.14 (0.83 to 1.57)0.4051.17 (0.85 to 1.62)0.341MCP.D1001.16 (0.83 to 1.61)0.3921.21 (0.86 to 1.71)0.265Rad.D-Comp1.42 (0.97 to 2.07)0.0711.66 (1.07 to 2.55)0.023Rad.D-Trab1.20 (0.87 to 1.66)0.2571.23 (0.88 to 1.71)0.223Rad.D1001.43 (0.99 to 2.06)0.0561.52 (1.03 to 2.25)0.033

Conclusion:

Metacarpal bone showed a constant decline that started already in the pre-phase of RA and continued after its clinical onset. In contrast, bone loss in the radius was not observed in the pre-phase but started at onset of RA. Low radial vBMD in the pre-clinical phase, however, was associated with a higher risk of RA onset. These findings suggest different spatiotemporal dynamics of bone loss before and after RA onset

References:

[1]Kleyer A. et. al. Ann Rheum Dis. 2014, 73:854-60

[2]Simon D. et. al. Ann Rheum Dis. 2020, doi:10.1002/art.41229

Disclosure of Interests:

None declared

Soft Tissue Characterization with Temporal Enhanced Ultrasound through Periodic Manipulation of Point Spread Function: A Feasibility Study

Temporal enhanced ultrasound (TeUS) is a tissue characterization approach based on analysis of a temporal series of US data. Previously we demonstrated that intrinsic or external micro-motions of scatterers in the tissue contribute towards the tissue classification properties of TeUS. This property is beneficial to detect early stage cancer, for example, where changes in nuclei configuration (scatteres) dominate tissue properties. In this study, we propose an analytical derivation and experiments to acquire TeUS through manipulation of US imaging parameters, which may be simpler to translate to clinical applications. The feasibility of the proposed method is demonstrated on tissue-mimicking phantoms. Using an autoencoder classifier, we are able to classify phantoms of varying elasticities and scattering sizes.

OP0051 STRUCTURAL ENTHESEAL LESIONS IN PSORIASIS PATIENTS ARE ASSOCIATED WITH AN INCREASED RISK OF PROGRESSION TO PSORIATIC ARTHRITIS - A PROSPECTIVE COHORT STUDY

Background:

We have previously reported that the presence of musculoskeletal pain in psoriasis patients is associated with a higher risk of developing psoriatic arthritis (PsA) (1). Furthermore, a subset of psoriasis patients shows evidence for structural entheseal lesions (SEL) in their hand joints (2), sometimes also referred as “Deep Koebner Phenomenon”, which are highly specific for psoriatic disease and virtually absent in healthy controls, rheumatoid arthritis and hand osteoarthritis patients (2-4). However, it remains unclear whether SEL alone or in combination with musculoskeletal pain are associated with the development of PsA.

Objectives:

To test whether the presence of SEL in psoriasis patients increases the risk for progression to PsA and how this is related to the presence of musculoskeletal pain.

Methods:

Psoriasis patients without evidence of PsA were enrolled in a prospective cohort study between 2011 and 2018. All patients underwent baseline assessment of SEL in their 2ndand 3rdMCP joints by high-resolution peripheral quantitative computed tomography (HR-pQCT). The risk of PsA development associated with SEL and arthralgia was explored using survival analyses and multivariable Cox regression models.

Results:

114 psoriasis patients (72 men/42 women) with a mean (SD) follow-up duration of 28.2 (17.7) months were included, 24 of whom developed PsA (9.7 /100 patient-years, 95%CI 6.2 to 14.5) during the observation period. Patients with SEL (N=41) were at higher risk of developing PsA compared to patients without such lesions (21.4/100 patient-years, 95%CI 12.5 to 34.3, HR 5.10, 95%CI 1.53 to 16.99, p=0.008) (Kaplan Meier plot A). Furthermore, while patients without arthralgia and without SEL had a very low progression rate to PsA (1/29; 3.4%), patients with arthralgia but no SEL showed higher progression (5/33; 15.2%), which was in line with previous observations (1) (Kaplan Meier plot B). Presence of SEL further enhanced the risk for progression to PsA both in the absence (6/16; 37.5%) and presence (6/14; 42.8%) of arthralgia with the highest progression rate in those subjects with both arthralgia and SEL (p<0.001 by log rank test for trend) (Kaplan Meier plot B).

Conclusion:

Presence of SEL is associated with an increased risk of developing PsA in patients with psoriasis. If used together with pain, SEL allow defining subsets of psoriasis patients with very low and very high risk to develop PsA.

References:

[1]Faustini F et al. Ann Rheum Dis. 2016;75:2068-2074

[2]Simon D et al. Ann Rheum Dis. 2016;75:660-6

[3]Finzel S et al. Ann Rheum Dis. 2011;70:122-7

[4]Finzel S et al. Arthritis Rheum. 2011;63:1231-6

Disclosure of Interests:

David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly, Koray Tascilar: None declared, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, Sara Bayat Speakers bureau: Novartis, Eleni Kampylafka Speakers bureau: Novartis, BMS, Janssen, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, Jürgen Rech Consultant of: BMS, Celgene, Novartis, Roche, Chugai, Speakers bureau: AbbVie, Biogen, BMS, Celgene, MSD, Novartis, Roche, Chugai, Pfizer, Lilly, Louis Schuster: None declared, Klaus Engel: None declared, Michael Sticherling Grant/research support from: Novartis, Consultant of: Advisory boards Abbvie, Celgene, Janssen Cilag, Lilly, Pfizer, MSD, Novartis, Amgen, Leo, Sanofi, UCB, Speakers bureau: Abbvie, Celgene, Janssen Cilag, Leo, MSD, Novartis, Pfizer, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB

SAT0055 PREDICTION OF FLARES FOR RHEUMATOID ARTHRITIS PATIENTS ON BIOLOGIC DMARDS USING MACHINE LEARNING AND SUBSETS OF VARIABLES AVAILABLE TO PHYSICIANS, PATIENTS AND PAYERS

Background:

Today approximately 50 percent of patients with RA reach sustained remission. In a specific subset of RA patients in stable remission, biological Disease Modifying Anti-Rheumatic Drugs (bDMARDs) may be successfully tapered. However, it remains challenging to predict the patients’ individual flare risk. As we have recently shown, machine learning based on extensive clinical and laboratory data could be used to estimate individual flare risk [1].

Objectives:

In this study we aimed to investigate the performance of machine learning models trained with variables that are typically (1) immediately available to a physician during patient visits (clinical and demographic variables without laboratory values and composite disease activity scores), (2) theoretically available to patients at home and (3) available to payers in large health-system databases.

Methods:

Longitudinal clinical data of RA patients on bDMARDs from the first interim analysis of the phase-3, multicentre, randomised, open, prospective, controlled, parallel-group RETRO study (EudraCT number 2009-015740-42) was used [2] to build a predictive model for estimating the flare probability within 3 months from the current patient visit. A flare was defined as a DAS-28 ESR score over 2.6. Four different models (log. regression, random forest, k-NN and naïve Bayes) were trained which output the flare probability at each patient visit. These probabilities were used as an input for a stacking logistic regression meta-classifier [3]. The final model performance expressed as the AUROC was assessed using nested cross-validation [4]. We applied this method to three variable subsets (physician, patient, payer, Table 1).

Table 1.

List of variables used in three subsets:

Variable / RolePhysicianPatientPayerGender (m/f)xxxDisease duration (years)xxxMethotrexate co-use (yes/no)xxxOther DMARDs co-use (yes/no)xxxDrug ATC codexxxIV-administration (yes/no)xxxDose percentagexxxAgexxxBody mass indexxxxDose percentage changexxxSwollen joint countxTender joint countxVAS_GH (pat. global disease activity)xxHAQ (health assessment questionnaire)xxSmoking status (yes/no/ex)xxAlcohol consumption (yes/no)xxPrevious flares (yes/no)x

Results:

Data from 135 follow-ups of 41 patients were used. The measured AUROC of the best performing model using all RETRO variables was 0.802 (95%CI 0.717 – 0.887) [1]. When a subset based on demographic and clinical variables is used that is available to a physician immediately during a patient visit the AUROC drops about 5 percent points. When only variables theoretically available to patients at home are used, the performance drops about 10 percent points comparing to the original model. Similar observation holds for the variable subset typically available to payers (Figure 1).

Conclusion:

This study shows that predictive models for flares have the potential to support physicians in making decisions immediately during the patient visit, even though laboratory values and respective activity scores are not yet available. In the future, machine learning applications may allow fast and reliable decisions on flare prediction in RA patients. These data can guide decisions about DMARD tapering at in real time during the physician-patient contact and allow to reduce costs not only by selective treatment tapering but also by sparing additional laboratory examinations.

References:

[1] Vodencarevic A. et al. Arthritis Rheumatol. 2019; 71

[2] Haschka J et al. Ann Rheum Dis 2016; 75:45-51.

[3] Tang J et al. CRC Press 2015; 498-500

[4] Cawley GC et al. J Mach Learn Res 2010; 11:2079-2107

Disclosure of Interests:

Asmir Vodencarevic Shareholder of: Siemens Healthcare GmbH. Siemens Healthcare GmbH is a medical technology company (NOT a pharmaceutical company)., Employee of: Siemens Healthcare GmbH. Siemens Healthcare GmbH is a medical technology company (NOT a pharmaceutical company)., Koray Tascilar: None declared, Fabian Hartmann: None declared, Michaela Reiser: None declared, Sara Bayat Speakers bureau: Novartis, Johannes Knitza Grant/research support from: Research Grant: Novartis, Larissa Valor: None declared, Melanie Hagen: None declared, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, Marcus Zimmermann-Rittereiser Shareholder of: Siemens Healthcare GmbH. Siemens Healthcare GmbH is a medical technology company (NOT a pharmaceutical company)., Employee of: Siemens Healthcare GmbH. Siemens Healthcare GmbH is a medical technology company (NOT a pharmaceutical company)., Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly

AB0330 HIGH REMISSION RATES IN RA – REAL LIFE DATA FROM BARITICINIB

Background:

Recent developments of targeted treatments such as targeted synthetic DMARDs (tsDMARDs) increase the chances of a sustained low disease activity (LDA) or remission state for patients suffering rheumatoid arthritis (RA). tsDMARDs such as baricitinib, an oral inhibitor of the Janus Kinases (JAK1/JAK2) was recently approved for the treatment of RA with an inadequate response to conventional (cDMARD) and biological (bDMARD) therapy. (1, 2).

Objectives:

Aim of this study is to analyze the effect of baricitinb on disease activity (DAS28, LDA) in patients with RA in real life, to analyze drug persistance and associate these effects with various baseline characteristics.

Methods:

All RA patients were seen in our outpatient clinic. If a patient was switched to a baricitinib due to medical reasons, these patients were included in our prospective, observational study which started in April 2017. Clinical scores (SJC/TJC 76/78), composite scores (DAS28), PROs (HAQ-DI; RAID; FACIT), safety parameters (not reported in this abstract) as well as laboratory biomarkers were collected at each visit every three months. Linear mixed effects models for repeated measurements were used to analyze the time course of disease activity, patient reported outcomes and laboratory results. We estimated the probabilities of continued baricitinib treatment and the probabilities of LDA and remission by DAS-28 as well as Boolean remission up to one year using survival analysis and explored their association with disease characteristics using multivariable Cox regression. All patients gave informed consent. The study is approved by the local ethics.

Results:

95 patients were included and 85 analyzed with available follow-up data until November 2019. Demographics are shown in table 1. Mean follow-up duration after starting baricitinib was 49.3 (28.9) weeks. 51 patients (60%) were on monotherapy. Baricitinib survival (95%CI) was 82% (73% to 91%) at one year. Cumulative number (%probability, 95%CI) of patients that attained DAS-28 LDA at least once up to one year was 67 (92%, 80% to 97%) and the number of patients attaining DAS-28 and Boolean remission were 31 (50%, 34% to 61%) and 12(20%, 9% to 30%) respectively. Median time to DAS-28 LDA was 16 weeks (Figure 1). Cox regression analyses did not show any sufficiently precise association of remission or LDA with age, gender, seropositivity, disease duration, concomitant DMARD use and number of previous bDMARDs. Increasing number of previous bDMARDs was associated with poor baricitinib survival (HR=1.5, 95%CI 1.1 to 2.2) while this association was not robust to adjustment for baseline disease activity. Favorable changes were observed in tender and swollen joint counts, pain-VAS, patient and physician disease assessment scores, RAID, FACIT and the acute phase response.

Conclusion:

In this prospective observational study, we observed high rates of LDA and DAS-28 remission and significant improvements in disease activity and patient reported outcome measurements over time.

References:

[1]Keystone EC, Taylor PC, Drescher E, Schlichting DE, Beattie SD, Berclaz PY, et al. Safety and efficacy of baricitinib at 24 weeks in patients with rheumatoid arthritis who have had an inadequate response to methotrexate. Annals of the rheumatic diseases. 2015 Feb;74(2):333-40.

[2]Genovese MC, Kremer J, Zamani O, Ludivico C, Krogulec M, Xie L, et al. Baricitinib in Patients with Refractory Rheumatoid Arthritis. The New England journal of medicine. 2016 Mar 31;374(13):1243-52.

Figure 1.

Cumulative probability of low disease activity or remission under treatment with baricitinib.

Disclosure of Interests:

Sara Bayat Speakers bureau: Novartis, Koray Tascilar: None declared, Veronica Kaufmann: None declared, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly, Johannes Knitza Grant/research support from: Research Grant: Novartis, Fabian Hartmann: None declared, Susanne Adam: None declared, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, EIT Health, EU-IMI, DFG, Universität Erlangen (EFI), Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB

SAT0556 FINE STRUCTURE ANALYSIS OF THE INTER-RELATION BETWEEN TOPHUS DEPOSITION AND BONE LESIONS IN GOUT USING A COMBINATION OF DUAL ENERGY AND HIGH-RESOLUTION CT

Background:

Deposition of uric acid crystals cause an inflammatory reaction, which can lead to structural bone changes, if such deposits form adjacent to cortical bone [1, 2]. Both erosions and bony spurs can form in conjunction with tophus deposition. The exact spatial inter-relation between tophi and structural bone lesions in humans in vivo is not fully characterized.

Objectives:

To spatially relate structural bone changes (erosions, osteophytes) to the deposition of monosodium urate crystals in the first metatarsophalangeal (MTP1) joint in patients with tophaceous gout.

Methods:

Tophaceous gout patients with clinically detected tophi at the MTP1 joint underwent simultaneous dual energy computed tomography (DECT) and high-resolution peripheral quantitative computed tomography (HR-pQCT) of the feet. Tophi detected by DECT and erosions and osteophytes detected by HR-pQCT were overlayed to define their exact anatomical relation. Furthermore, feet of sex- and age-matched healthy controls (HC) were scanned to define the normal architecture of the MTP1 joint.

Results:

Gout patients (N=20) had significantly higher numbers (5 (0–17 vs. 1 (1– 2)) and volumes (45.32 mm3(7.26–550.32) vs. 0.82 mm3(0.15–21.8)) of bone erosions as well as significantly higher numbers (10.5 (0-26) vs. 1 (0-10)) and sizes of osteophytes (4.93 mm (0.77-7.19 mm vs. 0.93 mm (0.05-7.61 mm))than healthy controls (N=20). Erosions were in direct spatial relation to bone erosions, while osteophytic responses were more widespread and affected bone regions on the MTP1, which were not directly adjacent to tophi. Median tophus volume detected by DECT (0.12 mm3(0.01–2.53)) was associated with the total volume of erosions (r=0.597, p=0.005).

Conclusion:

This study demonstrates that bone changes in gout are substantial and not only include erosions but also widespread architectural bone remodeling associated osteophyte formation. While there is a direct spatial relation between tophi and bone erosions the anabolic bone responses in gout are more widespread.

References:

[1]Dalbeth, N. et al. Ann Rheum Dis. 2015 Jun;74(6):1030-6.

[2]Dalbeth, N. et al. Arthritis Res Ther. 2012; 14(4): R165.

Data are based on high-resolution peripheral quantitative computed tomography (HR-pQCT) of metatarsophalangeal joints I in gout patients (grey boxplots) and healthy controls (white boxplots). (A) number of bone erosions, (B) volume of bone erosions, (C) number of osteophytes and (D) size of osteophytes. Data are shown as medians and inter-quartile ranges (boxes).

Distribution of (A) tophi based on dual-energy computed tomography (DECT) as well as (B) bone erosions and (C) osteophytes based on high-resolution peripheral quantitative computed tomography (HR-pQCT) of metatarsophalangeal (MTP) I head in gout patients. Data are shown for the different regions of the MTPI head including the plantar, medial, dorsal and lateral region of the metatarsal head, as well as the medial and lateral sesamoid bones. Data indicate percentage of patients with tophi, erosions and osteophytes in respective region.

Disclosure of Interests:

Sara Bayat Speakers bureau: Novartis, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly, Caroline Pecherstorfer: None declared, Hanna Ellmann: None declared, Camille Figueiredo: None declared, Matthias Englbrecht: None declared, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, EIT Health, EU-IMI, DFG, Universität Erlangen (EFI), Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, Jürgen Rech Consultant of: BMS, Celgene, Novartis, Roche, Chugai, Speakers bureau: AbbVie, Biogen, BMS, Celgene, MSD, Novartis, Roche, Chugai, Pfizer, Lilly, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB

Comparison of pleural and esophageal pressure in supine and prone positions in a porcine model of acute respiratory distress syndrome

Patients with moderate to severe acute respiratory distress syndrome (ARDS) benefit from prone positioning. Although the accuracy of esophageal pressure (Pes) to estimate regional pleural pressure (Ppl) has previously been assessed in the supine position, such data are not available in the prone position in ARDS. In six anesthetized, paralyzed, and mechanically ventilated female pigs, we measured Pes and Ppl into dorsal and ventral parts of the right pleural cavity. Airway pressure (Paw) and flow were measured at the airway opening. Severe ARDS [arterial partial pressure of oxygen ([Formula: see text])/fraction of inspired oxygen ([Formula: see text]) < 100 mmHg at positive end-expiratory pressure (PEEP) of 5 cmH₂O] was induced by surfactant depletion. In supine and prone positions assigned in a random order, PEEP was set to 20, 15, 10, and 5 cmH₂O and static end-expiratory chest wall pressures were measured from Pes (PEEPtot,es) and dorsal (PEEPtot,PplD) and ventral (PEEPtot,PplV) Ppl. The magnitude of the difference between PEEPtot,es and PEEPtot,PplD was similar in each position [-3.6 cmH₂O in supine vs. -3.8 cmH₂O in prone at PEEP 20 cmH₂O (PEEP 20)]. The difference between PEEPtot,es and PEEPtot,PplV became narrower in the prone position (-8.3 cmH₂O supine vs. -3.0 cmH₂O prone at PEEP 20). PEEPtot,PplV was overestimated by Pes in the prone position at higher pressures. The median (1st-3rd quartiles) dorsal-to-ventral Ppl gradient was 4.4 (2.4-6.8) cmH₂O in the supine position and -1.5 (-3.5 to +1.1) cmH₂O in the prone position (P < 0.0001) and marginally influenced by PEEP (P = 0.058). Prone position narrowed end-expiratory dorsal-to-ventral Ppl vertical gradient, likely because of a more even distribution of mechanical forces over the chest wall.NEW & NOTEWORTHY In a porcine model of acute respiratory distress syndrome, we found that static end-expiratory esophageal pressure did not change significantly in prone position compared with supine position at any positive end-expiratory pressure (PEEP) tested between 5 and 20 cmH₂O. Prone position was associated with an increased ventral pleural pressure and reduced end-expiratory dorsal-to-ventral pleural pressure (Ppl) vertical gradient, likely due to a more even distribution of mechanical forces over the chest wall.

Care trajectories of patients initiating dialysis as planned versus emergency procedure

Background

Emergency dialysis is defined as a first dialysis session performed within 24 hours after the nephrologist’s assessment due to a life-threatening risk. Starting dialysis in emergency (ES) is associated with poorer outcomes compared to a planned start (PS). The aim of this study was to compare the pre-dialysis care trajectory between ES and PS patients.

Methods

Patients ≥ 18 years old who started dialysis in 2015 in France were included. Data from REIN were linked with the French national health database (SNDS). Individual characteristics at dialysis initiation, inpatient stays (number, duration and diagnosis), and consultations with general practitioners (GP) and nephrologists during the year before dialysis start were compared between ES and PS patients, as well as with national clinical practice guidelines.

Results

Among 8964 patients included, 30.6% started dialysis in emergency. These patients had more comorbidities than PS patients (19% of ES patients had 3 or more cardiovascular diseases versus 12.6% of PS patients, p &lt; 0.001). In the year before dialysis start, ES patients had a lower median number of inpatient stays (1 versus 2 for PS patients, p = 0.001) but had a longer mean duration of hospital stay (8.1 days versus 5.8 days for PS patients, p &lt; 0.001). ES patients had less consultations with a nephrologist (2.5 versus 4.5 for PS patients, p &lt; 0.001). However, the number of GP consultations was not different between the two groups (9.7 versus 9.4 for PS patients, p &lt; 0.064).

Conclusions

Nearly 1 in 3 patients started dialysis in emergency with more comorbidities at baseline than PS patients. Their one year pre-dialysis care trajectory was characterized by less frequent nephrological follow-up and a similar GP follow up, compared with PS patients. These results raise questions regarding access to coordinated care associating GPs and nephrologists. This issue of coordination will be investigated using qualitative methods.

Education and hypertension in the CONSTANCES cohort: which factors mediate this association?

Background

Individual socioeconomic characteristics and in particular education have been shown to be strongly associated with hypertension (HTN). Few studies have examined the mechanisms involved in such associations and understanding them would help to reduce the burden of social inequalities. We aimed to investigate whether specific risk factors of HTN intervene as mediators in the association between individual education and HTN in a large sample of French adults.

Methods

In this cross-sectional analysis, participants are adults aged between 18 and 69 years old recruited to the CONSTANCES cohort over the period 2012-2015. We included behavioral (poor diet, physical inactivity, alcohol consumption), anthropometric (body mass index) and socioeconomic risk factors (income and longest occupation) as potential mediators. Analyses were stratified by sex. Natural direct and indirect effects of education on HTN were estimated using weighted Poisson regression models with inverse odds weighting.

Results

A total of 62,247 individuals (53% women, mean age 48±13 years) were included. Prevalence of HTN was 37.3% [95%-Confidence Interval (95%-CI) =36.6-38.0] in men and 23.2% [95%-CI=22.7-23.8] in women. We found a steep educational gradient of HTN in both sexes, larger among young adults in relative terms. Low education was strongly associated with HTN: RRTotal Effect=1.16 [95%-CI=1.12-1.21] in men and 1.26 [95%-CI=1.21-1.32] in women. Behavioral, anthropometric and socioeconomic risk factors accounted for 49% and 32% of the total effect in men and women respectively.

Conclusions

This study underlines the importance of education in inequalities in HTN and suggests that behavioral, anthropometric and socioeconomic risk factors substantially mediate the association between education and HTN. Future research using longitudinal data should be done to help understand the causal pathway linking education and HTN.

Key messages

A strong gradient of decreased prevalence of hypertension with higher individual education is observed in both sexes and in early adulthood, suggesting that prevention should start early. Behavioral, anthropometric and socioeconomic characteristics at adulthood substantially mediate the association between education and hypertension.

The ageing joint-standard age- and sex-related values of bone erosions and osteophytes in the hand joints of healthy individuals

OBJECTIVE

To analyze the age-related changes of the physiological hand joint architecture.

METHOD

To address this concept, healthy individuals (each 10 women and 10 men in six different age decades spanning from 21 to 80 years) were recruited through a field campaign, investigated for the absence of rheumatic diseases and other comorbidities and received high-resolution quantitative computed tomography (HR-pQCT) examination of the hand joints. Number and extent of erosions and osteophytes were quantified across the ages and different sexes.

RESULTS

Bone erosions [median (Q1-Q3), 1 (0-2)] and osteophytes [2 (1-4)] were found in healthy women and men with no significant sex differences. Structural changes however accumulated with age: the overall incidence rate ratio (IRR) for the number of erosions and osteophytes per age were 1.04 (95% CI: erosions 1.03-1.06; osteophytes: 1.03-1.05). This means a 4% increase in the number of erosions and osteophytes per year. Using third decade as reference, healthy individuals in the age decades from 50 years had higher IRR for erosion numbers (sixth, seventh, eigth decade: 4.87 (2.20-11.75), 6.81 (3.08-16.46) and 6.92 (3.11-16.79)) compared to younger subjects (fourth, fifth decade: 1.80 (0.69-4.87), 1.53 (0.59-4.10)). The IRRs of osteophytes also indicate a gradual increase after the fifth decade, with IRRs of 2.32 (1.32-4.17), 4.17 (2.38-7.49) and 6.86 (3.97-12.20) for the sixth, seventh and eigth decades, respectively.

CONCLUSIONS

Structural changes in the hand joints of healthy individuals are age dependent. While being rare under 50 years of age, erosions and osteophytes accumulate above the age of 50, suggesting that the threshold between "normal" and "pathological" is shifted with the increase of age.

Differential expression of S1P receptor subtypes in human bladder transitional cell carcinoma

PURPOSE

Sphingosine 1 phosphate (S1P), S1P receptors (S1PRs) and their signaling pathways play an important role in the fate of cancer cells. The expression pattern of S1PR subtypes (S1PR1-S1PR5) may alter in cancer development stages, depending on the origin and the pathologic features of tumors. The present study aimed to examine the relationship between plasma S1P levels and the expression of S1PR subtypes in bladder tumors.

METHODS/PATIENTS

These changes were evaluated in terms of the pathologic grades and stages of human bladder cancer samples. For this, tumor biopsies from 41 new bladder cancer patients as well as 26 normal-looking bladder tissues were collected and processed for immunohistochemistry (IHC) and quantitative real-time RT-PCR of S1PR subtypes. Plasma S1P level was measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS).

RESULTS

The results show that tissue S1PR1, S1PR2 and S1PR3 are over-expressed in all tumors regardless of their pathological grade (~ 3, ~ 6 and ~ 104 folds, respectively). These results were corroborated by IHC data showing accumulation of S1PR subtypes 1 and 2 in the tissues. Plasma S1P in the plasma samples from patients was in the range of control samples (Controls; 256 ± 47; patients, 270 ± 41).

CONCLUSIONS

Overexpression of S1PR1, S1PR2 and S1PR3 in bladder tumor biopsies which were corroborated with the pathological grades and stages may suggest that S1PR profile in tumor biopsies is a promising marker in the diagnosis of bladder carcinoma.

Quantitative Imaging of Regional Aerosol Deposition, Lung Ventilation and Morphology by Synchrotron Radiation CT

To understand the determinants of inhaled aerosol particle distribution and targeting in the lung, knowledge of regional deposition, lung morphology and regional ventilation, is crucial. No single imaging modality allows the acquisition of all such data together. Here we assessed the feasibility of dual-energy synchrotron radiation imaging to this end in anesthetized rabbits; both in normal lung (n = 6) and following methacholine (MCH)-induced bronchoconstriction (n = 6), a model of asthma. We used K-edge subtraction CT (KES) imaging to quantitatively map the regional deposition of iodine-containing aerosol particles. Morphological and regional ventilation images were obtained, followed by quantitative regional iodine deposition maps, after 5 and 10 minutes of aerosol administration. Iodine deposition was markedly inhomogeneous both in normal lung and after induced bronchoconstrition. Deposition was significantly reduced in the MCH group at both time points, with a strong dependency on inspiratory flow in both conditions (R² = 0.71; p < 0.0001). We demonstrate for the first time, the feasibility of KES CT for quantitative imaging of lung deposition of aerosol particles, regional ventilation and morphology. Since these are among the main factors determining lung aerosol deposition, we expect this imaging approach to bring new contributions to the understanding of lung aerosol delivery, targeting, and ultimately biological efficacy.