AB1584-PARE UNDERSTANDING HETEROGENEITY IN PATIENTS’ CONCEPTUALIZATION OF TREATMENT FOR RHEUMATOID ARTHRITIS: A CLUSTER ANALYSIS

Background

Uptake of treat to target strategies for the management of rheumatoid arthritis (RA) is low. System-related barriers to accessing treatment are known, but poor adherence to starting and continuing treatment are prevalent causes of suboptimal care.

Objectives

To better understand heterogeneity in patients’ conceptualization of RA treatment to inform interventions aimed at improving appropriate utilization of disease modifying antirheumatic drugs (DMARDs).

Methods

Participants (pts) were recruited from the ArthritisPower US online research registry. Pts who met eligibility criteria [physician diagnosed RA currently being treated with DMARD(s)] rated 56 items (coded on 5-point scales) reflecting concepts raised during in-depth patient interviews. To combine similar items for ease of analysis and interpretation, we conducted a principal components analysis using Varimax rotation. We then entered mean scores, weighted by how heavily each item loaded onto each factor, into a k-means cluster analysis. We examined whether demographic characteristics differed across clusters using ANOVA for continuous and chi-square for categorical variables.

Results

Pts (N= 621) ranged in age from 22 to 93, with a mean of 57 years (SD= 11.5). Most (89%) were female and reported as non-Hispanic white (89%); 27% reported having a post-graduate degree. A scree plot revealed that a 4-factor solution explaining 36.8% of the variance would provide desirable interpretability, with a discontinuous drop in eigenvalues for additional factors slowly tapering and adding little discriminability between later solutions. The four factors (% variance explained, number of items) were: 1) Access to high quality care and support (12.10%, n= 21); 2) Comfortable adding/switching DMARDs (9.73%, n= 14); 3) Perceived favorable DMARD risk/benefit ratio (8.74%, n= 15); and 4) Confidence that testing reflects disease activity (6.20%, n= 6).

A 5-cluster solution showed the most stable convergence of cluster centers after 10 iterations. Figure 1 shows the weighted mean scores for each factor across clusters. The largest group (31.7%) is characterized by mean scores on each of the four factors toward the high end of mean responses for the sample, reflecting positive experiences; we labeled this group “Successfully Engaged in Care” to indicate a positive rheumatologist relationship, feeling well-informed and active participation in care. The next group (24.3%) also had high scores for Factor 1 (access to high quality care/support) and Factor 3 (perceived favorable DMARD risk/benefit ratio), but were less comfortable adding/switching DMARDs (Factor 2) and had less confidence in testing reflecting their disease activity (Factor 4); we labeled this group “Worried About Medication”.

The three remaining clusters are smaller. The third cluster (16.4%), labeled “Skeptical of Testing,” had a favorable view of DMARDs (Factor 3) despite lower scores related to access and quality of care (Factor 1) and confidence in testing (Factor 4). The fourth cluster (14.3%) expressed low perceived value of DMARDs as well as reduced scores for DMARD risk/benefit and confidence in testing; we labeled this group “Resistant to DMARDs.” The last cluster (13.2%) scored lowest on their rating of access to high quality care and support, indicating less access to, and satisfaction with, information needed to support decision making. Their perceived risk/benefit ratio for DMARDs was still favorable, so we labeled this group “Dissatisfied with Care.”

Conclusion

Patients’ conceptualization of RA treatment varies, but discomfort with adding/switching DMARDs appears to be ubiquitous regardless of perceived benefits associated with DMARDs and access to high quality care/support. Interventions outside of the traditional physician-patient relationship are needed to facilitate treatment escalation in patients with RA. Further research is required to understand residual variance not explained by our model.

Acknowledgements

The authors thank the patients for their participation.

Disclosure of Interests

Betty Hsiao: None declared, Julie Downs: None declared, Mandy Lanyon: None declared, Jeffrey R. Curtis Consultant of: Gilead, Novartis, and Samsung, Grant/research support from: AbbVie, Amgen, BMS, Corrona, Eli Lilly and Company, Janssen, Myriad, Pfizer, Regeneron, Roche, and UCB, Susan Blalock: None declared, Carole Wiedmeyer: None declared, Shilpa Venkatachalam: None declared, W. Benjamin Nowell Grant/research support from: •William B. Nowell is the Principal Investigator on grants/contracts from AbbVie, Eli Lilly and Company, and PCORI, and an employee of the Global Healthy Living Foundation (GHLF). GHLF receives grants, sponsorships and contracts from pharmaceutical manufacturers and private foundations. A full list of GHLF funders is publicly available here: https://www.ghlf.org/our-partners/., Liana Fraenkel: None declared

POS0088-PARE CHANGES IN PATIENT-REPORTED OUTCOME SCORES DURING COVID-19 PANDEMIC: DATA FROM THE ArthritisPower REGISTRY

Background

The COVID-19 pandemic causes concern among patients with autoimmune and rheumatic disease (ARD) due to increased risk of infection and heightened isolation from social distancing.1

Objectives

Examine how mean patient-reported outcome (PRO) scores for mental, social and physical health fluctuated after COVID-19 vaccine availability was widespread in US.

Methods

We conducted and reported on2 an initial analysis of January 2020 – April 2021 where US participants (pts) of the ArthritisPower (AP) registry completed PROMIS measures of physical health (Physical Function, Pain Interference, Fatigue, Sleep Disturbance), mental health (Anger, Anxiety, Depression) and social health (Social Isolation, Emotional Support). Follow-up analysis was conducted May – December 2021. Only pts from initial analysis were included in follow-up. Null hypothesis was no change in monthly average scores across 23-month pandemic period. Analysis of means compared monthly assessment mean scores to overall mean score for each measure during study period. Pts with < 2 assessment time points and osteoarthritis with no ARD were excluded from analysis.

Results

Total of 49,940 PRO scores were contributed by 2,266 pts during 23-month period, with 8,393 of the scores contributed from May – December 2021. Mean (standard deviation, SD) number of observations per pt was 5.6 (12.5). Pts were 87.6% female, 86.7% white, mean age of 52.1 (12.7) years. Rheumatoid arthritis (n=1,131, 49.9%) was the most common condition. Most commonly reported measures were Pain Interference, Fatigue, Sleep Disturbance and Physical Function, each with >11,000 total results (Table 1).

Table 1.

Avg assessment scores+ by month, mean (SD)

Pain Interf (n= 11536)Fatigue (n= 11591)Sleep Disturb (n= 11257)Physical Func (n= 11202)Depression (n=1489)Anxiety (n= 1066)Social Iso (n=698)Emot Support (n=578)Anger (n=523)Study Period^63.3 (7.8)62.6 (9.5)58.1 (9.0)37.7 (7.6)60.8 (9.2)62.4 (10.5)61.9 (10.2)40.8 (9.8)61.5 (12.8)May 202161.9 (8.2)*60.9 (9.7)*55.2 (8.8)*38.9 (8.5)59.5 (9.2)61.9 (9.8)60.2 (13.3)38.1 (8.3)59.6 (14.5)June61.6 (6.9)*60.9 (9.6)*54.8 (8.9)*38.3 (7.8)59.2 (7.0)60.6 (9.6)61.8 (12.0)39.3 (10.3)60.2 (10.9)July61.8 (7.4)*60.8 (10.2)*56.0 (8.6)*38.1 (7.9)61.0 (7.8)59.9 (12.1)66.8 (8.5)*39.4 (9.7)62.4 (9.7)Aug61.2 (8.5)*60.7 (10.4)*55.8 (9.6)*38.5 (8.5)57.7 (7.9)*58.2 (10.3)*57.2 (11.1)36.9 (12.2)53.3 (19.4)Sep62.4 (8.5)62.3 (10.0)56.2 (8.3)37.3 (7.6)58.7 (8.0)57.7 (11.3)*68.1 (12.8)36.7 (12.1)58.7 (12.0)Oct63.1 (8.4)63.3 (9.9)57.6 (8.6)37.3 (8.0)59.9 (9.9)62.3 (9.0)64.3 (10.3)37.3 (11.4)64.6 (10.2)Nov62.6 (6.8)63.2 (10.0)55.8 (8.6)*36.9 (7.0)59.1 (8.8)61.3 (6.8)61.4 (10.9)38.6 (11.7)60.3 (12.4)Dec62.9 (8.3)64.0 (9.6)56.5 (8.4)37.4 (8.1)60.7 (8.4)63.8 (5.3)65.1 (7.5)38.5 (13.5)68.6 (5.0)*

+PROMIS measures scored 0-100; mean 50 for general US population; 1SD = 10 points

^Study period: January 2020 – December 2021

. *Statistical significance (p<0.05); analysis of means (ANOM)

Pts’ mental and social health assessment scores improved then worsened during last 8 months of 2021 (Figure 1). Overall mean scores were: Anxiety 62.4 (12.5), Social Isolation 61.9 (10.5), and Anger 61.5 (12.8). From July – August, Social Isolation decreased by 1 SD. Compared to overall assessment mean, Anger declined by > ½ SD (53.3 [19.4]) in August and Anxiety declined by ½ SD (57.7 [11.3]) in September. By December, Anger rose by > ½ SD (68.6 [5.0]) of assessment mean. Pain Interference (mean: 63.3 [7.8]), Fatigue (62.6 [9.5]), and Sleep Disturbance (58.1 [9.0]) scores were significantly lower in May, June, July and August compared to the assessment mean, though none decreased by > ½ SD.

Conclusion

ARD members of AP had mental, social and physical health scores improve during summer of 2021, corresponding with widespread availability of vaccines. However mental and social health scores worsened by December as US faced new variants of the virus.

References

[1]George M, et al. Rheumatol. 2021;48:603-7.

[2]Gavigan K, et al. Arth Rheumatol. 2021;73(suppl 10).

Acknowledgements

This work was partially supported through a Patient-Centered Outcomes Research Institute (PCORI) award (PPRN-1306-04811). All statements in this poster, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of PCORI, its Board of Governors or Methodology Committee.

Disclosure of Interests

Kelly Gavigan: None declared, Esteban Rivera: None declared, Jeffrey R. Curtis Consultant of: Gilead, Novartis, and Samsung, Grant/research support from: AbbVie, Amgen, BMS, Corrona, Eli Lilly and Company, Janssen, Myriad, Pfizer, Regeneron, Roche, and UCB, Shilpa Venkatachalam: None declared, Laura Stradford: None declared, David Curtis: None declared, W. Benjamin Nowell Grant/research support from: William B. Nowell is the Principal Investigator on grants/contracts from AbbVie, Eli Lilly and Company, and PCORI, and an employee of the Global Healthy Living Foundation (GHLF). GHLF receives grants, sponsorships and contracts from pharmaceutical manufacturers and private foundations. A full list of GHLF funders is publicly available here: https://www.ghlf.org/our-partners/.

POS1564-PARE EDUCATION TOPICS AND SMARTPHONE APP FUNCTIONS PRIORITIZED BY PEOPLE WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES

Background

Generating information that people living with a rheumatic and musculoskeletal disease (RMD) find useful while making decisions about their treatment requires identifying and understanding educational needs and interests directly expressed from people living with RMD.

Objectives

To identify what types of information US adults with RMD perceive as important to know about their disease and how they express and prioritize such information.

Methods

Using nominal group technique, focus groups of participants (pts) with RMD generated sets of rank-order educational items which were then aggregated across groups into themes. Based on nominal group results, a survey with the final 28 items was administered online, along with a question about desired functions of a smartphone app for RMD, to members of the ArthritisPower registry in January 2022.

Results

Six nominal groups (n=47) yielded 28 unique items for the online survey of educational priorities. To date, a total of 570 pts completed the survey, of whom 85.4% were female, 89.5% white, mean age of 59.6 (SD 11.2) years. Rheumatoid arthritis (52.5%), osteoarthritis (16.0%), psoriatic arthritis (12.5%), and axial spondyloarthritis (7.5%) were the most common RMDs. Knowing how to tell when a medication is not working, how RMD affects other medical conditions, understanding the results of tests used to monitor their RMD, available treatment options and possible side effects, and how life will change as an RMD progresses were each items that > 75% of pts considered extremely important (Table 1). Top functions pts listed as useful for a smartphone app included being able to participate in research, view lab results, record symptoms or flares, share how they are doing with their provider, and get educational information about their disease (Table 2).

Table 1.

Top Education Topics Adults with Rheumatic and Musculoskeletal Disease Consider Extremely Important (N=570).

Itemn (%)Knowing when the medication is not working505 (88.6)Knowing how a rheumatologic condition can affect your other health conditions or medical issues481 (84.4)Understanding the results of tests used to monitor your condition471 (82.6)Knowing the side effects of available drugs, and how the drugs interact with each other461 (80.9)Finding the right rheumatologist453 (79.5)Having realistic expectations of the effectiveness of the medications445 (78.1)Knowing how the disease will progress, even if the news is bad439 (77.0)Knowing the available medications and treatments for your rheumatologic condition437 (76.7)Knowing how long it takes drugs to work436 (76.5)Understanding how your life will change as your disease progresses434 (76.1)Table 2.

Desired Smartphone App Functions Rated By Adults with Rheumatic and Musculoskeletal Disease (N=570).

App Functionn (%)Participate in patient-centered research299 (52.5)View my lab results283 (49.7)Record my symptoms (e.g. pain, fatigue) or disease flares to track my health over time278 (48.8)Record my symptoms and share how I am doing with my rheumatology provider to know if I am meeting my treatment goals230 (40.4)Get educational information about my disease225 (39.5)Keep track of the medications prescribed by doctor200 (35.1)Schedule and keep track of my medical appointments, rheumatology and other199 (34.9)Track the vaccines I get (i.e. vaccination record)188 (33.0)Help me improve some of my health habits (e.g. sleep, diet, exercise)187 (32.8)Keep track of my use of over-the-counter, complementary or alternative therapies (herbs, tinctures, acupuncture, massage, stretching, etc.)174 (30.5)Get support for my disease from trained patients with my same health condition (i.e. ‘peer coaching’)144 (25.3)

Conclusion

People with RMD prioritized information about medications and prognosis in educational materials, providing guidance for the development of educational tools. A sizeable minority felt educational materials were an important component of a smartphone app, but also identified other important features such as participation in research.

Disclosure of Interests

W. Benjamin Nowell Grant/research support from: Research support from AbbVie, Amgen, Eli Lilly and Scipher, Kelly Gavigan: None declared, Kimberly Garza: None declared, Alexis Ogdie: None declared, Michael George: None declared, Jessica A. Walsh Consultant of: AbbVie, Amgen, Eli Lilly and Company, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Merck, and Pfizer, Maria Danila: None declared, Shilpa Venkatachalam: None declared, Laura Stradford: None declared, Jeffrey Curtis Consultant of: AbbVie, Amgen, BMS, Corrona, Eli Lilly and Company, Gilead, Janssen, Myriad, Novartis, Pfizer, Regeneron, Roche, and UCB, Grant/research support from: AbbVie, Amgen, BMS, Corrona, Eli Lilly and Company, Janssen, Myriad, Pfizer, Regeneron, Roche, and UCB

AB1585-PARE DO PATIENT AND PHYSICIAN ASSESSMENTS OF A HEALTH CARE VISIT MATCH FOR HISPANIC/LATINX PATIENTS WITH RHEUMATOID ARTHRITIS IN THE UNITED STATES AND PUERTO RICO?

Background

Nonlinear associations in rheumatoid arthritis (RA) prevalence and sociodemographic indices suggest social determinants of health affect RA.1 RA screening tools have lower sensitivity and specificity for Hispanic/Latinx individuals compared with white individuals (77% vs 85% sensitivity and 45% vs 87% specificity).2 Hispanic/Latinx people also present to physicians later and with more severe RA.3 There is little research in this population to explain these differences or how they can be addressed. Because it is known the Hispanic/Latinx population has lower English-language proficiency, we hypothesized this is in part because of the lack of validated Spanish-language educational materials and research tools for RA.

Objectives

To validate a Spanish-language patient-provider questionnaire (PPQ) for Hispanic/Latinx patients with RA that had previously been validated as concordant for primary care visits in Sweden.4

To understand if rheumatologist and patient assessments for Hispanic/Latinx people with RA are concordant when using a Spanish-language digital PPQ.

To determine if a Spanish-language rheumatologist-completed PPQ could be a proxy for patient impressions in a prospective clinical study.

Methods

A Spanish-language PPQ for RA was created by translating 9 of 13 questions previously validated in the Swedish study,4 and adding a question about treating to target specific to RA. The survey was made available on tablet devices in 4 rheumatology clinics in the U.S. and Puerto Rico. Clinic staff obtained patient consent and gathered demographic information to generate a unique confidential identifier code for each visit, which was inputted into surveys on tablet devices. After the visit ended the patient and rheumatologist were each given the PPQ coded for that visit to complete independently of one another. The PPQs were submitted electronically to a secure database in which the visit code was the only identifier recorded.

Results

Across 114 clinical visits, 96.75% of possible answers were recorded and were almost invariably positive with scores of 5 (strongly agree; 88%), 4 (agree; 12%), or 3 (neither agree nor disagree; 0.09%). Physicians responded with 4 (agree) more often than patients (18% vs 6% of responses). Responses from both patient and physician were available for (96.64%) of answered questions. Within these paired answers, 80.67% were concordant (same answer from both patient and physician). Physicians answered 4 when patients answered 5 in 76.5% of discordant responses (different ratings from patient and physician). Most physician ratings of 4 came from 1 of the 4 physicians involved and only 12.5% of patients were responsible for 75% of the patient responses of 4.

Conclusion

Hispanic/Latinx patients with RA and their rheumatologist rated their communication, goal setting, and relationships extremely positively, making it difficult to evaluate true concordance and not possible to use rheumatologist-completed PPQs as proxy for patient assessments. Notably, ratings were substantially different from what is typically seen on Likert scales, which normally skew positively but with a normal distribution. This finding may reflect social determinants of health or cultural differences such as a social-desirability bias toward positive statements about physician-patient interactions. Heterogeneity within the participants is also a plausible explanation, considering that a distinct subset of respondents account for almost all responses below the 5 rating. Further research is needed to identify best practices for measuring treatment to target and patient-rheumatologist interactions in the Hispanic/Latinx population with RA.

References

[1]Safiri S, et al. Ann Rheum Dis. 2019;78(11):1463-71. doi:10.1136/annrheumdis-2019-215920

[2]Potter J, et al. J Rheumatol. 2008;35(8):1545-9. PMID: 18597406

[3]Riad M, et al. J Clin Rheumatol. 2019. doi:10.1097/RHU.0000000000001085

[4]Ahlén GC, et al. Fam Pract. 2007;24(5):498503. doi.org/10.1093/fampra/cmm043

Acknowledgements

We wish to acknowledge the important contributions of our HOPE CAPE RA participants, including the patients and providers and Anne Sydor, PhD for her invaluable advice and help throughout the project.

This project was funded by the Bristol Myers Squibb Foundation.

Disclosure of Interests

Daniel Hernandez Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, Julio Bravo Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, Juan Jose Maya Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, Oscar Soto-Raíces Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, Angel Tapia Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, Guillermo Valenzuela Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, W. Benjamin Nowell Grant/research support from: This research was supported by the Bristol Myers Squibb Foundation, Shilpa Venkatachalam Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation

P33 A female with a drooping eyelid and positive autoantibodies: mystery solved?

Case report - Introduction

The presence of autoantibodies in IgG4-related disease (IgG4-RD) can lead to confusion and we present a case to highlight the diagnostic difficulty in this condition.

Case report - Case description

A 63-year-old Indian female presented with progressive ptosis and swelling of the left eyelid for 2 months. She was referred to the stroke clinic where she was found to have left ptosis with associated swelling. An MRI of the orbit revealed an enlarged left lacrimal gland and mucosal thickening in paranasal sinuses. Her ESR was 20, CRP 2, 15% peripheral eosinophils and IgG 17.55 g/L (6-16). A referral was made to rheumatology due to an abnormal immunological profile: cANCA +, MPO ANCA positive 32 IU/ml (0-3.5) and a strongly positive anti-Ro antibody >600 U/ml (0-10). Differential diagnosis considered: ANCA associated vasculitis (AAV), Primary Sjögren’s syndrome (SS), and IgG4-related orbital disease. She was assessed by the ENT surgeon and there was no sinusitis or evidence of vasculitis. Chest X-ray and CT scan of chest were normal.

A left lacrimal gland biopsy revealed reactive lymphoid hyperplasia with numerous plasma cells and eosinophils. Immunohistochemistry revealed over 50% of plasma cells to be IgG4-positive (approximately 100/HPF) suggestive of IgG4-RD. There was no evidence of granuloma formation or malignancy. Serum IgG4 was raised 6.82 g/l (<1.3). A review by ophthalmology revealed no objective evidence of dry eyes. She was treated as IgG4-RD and demonstrated a marked improvement following treatment with oral steroids and azathioprine.

Case report - Discussion

IgG4-RD is an immune-mediated systemic fibro inflammatory disease characterised by tumefactive lesions with abundant IgG4-positive plasma cells infiltrating into multiple organs. Isolated IgG4-related ophthalmic disease is present in 23% of patients with IgG4-RD, in whom the lacrimal gland is the most commonly involved structure, followed by orbital fat and extraocular muscles. IgG4-related ophthalmic disease is rare and we need to exclude commoner causes of orbital inflammation (such as thyroid ophthalmopathy, granulomatosis with poly-angiitis, sarcoidosis, and tuberculosis) or malignancy.

Case report - Key learning points

The diagnosis of IgG4-RD is often challenging. It is well recognised that small vessel vasculitis can increase the number of IgG4-positive plasma cells in tissue biopsies. Additionally, literature reveals biopsy-proven IgG4-RD can have ANCA positivity with and without concomitant presence of ANCA-associated vasculitis and there are case reports of patients who fulfil criteria for both Sjogren’s syndrome and IgG4-RD. As such, diagnosis requires careful correlation of clinical, radiologic and histological features due to the overlapping features in differential diagnoses.

OP0280-PARE A MINDFULNESS PROGRAM DOSING STUDY TO EVALUATE IMPROVEMENT IN EMOTIONAL DISTRESS AMONG PEOPLE WITH RHEUMATIC DISEASE

Background:

Mindfulness-based interventions for chronic pain and emotional distress have increased in popularity as complementary therapies among people living with rheumatic and musculoskeletal disease (RMD).1,2 Despite growing evidence that mindfulness meditation reduces pain and anxiety associated with RMD, more research is needed to specify the optimal duration of mindfulness training necessary to be effective for short- and long-term benefit.

Objectives:

To evaluate and compare the effectiveness of full-length versus brief mindfulness training programs for improving anxiety among people living with RMD.

Methods:

Adult US participants (pts) within the ArthritisPower registry were invited to participate in the Healthy Mind Healthy You study comparing the effectiveness of two online mindfulness training programs of different lengths accessed via the MoodNetwork platform. The full-length mindfulness based cognitive therapy program lasted 8 weeks, while the brief evidence-based mindfulness program lasted 3 weeks. Pts were randomized to one of the two programs and completed assessments every two weeks during the program and then every four weeks during the 12-week follow-up period. Assessments included World Health Organization-Five Well-Being Index (WHO-5), Five Facet Mindfulness Questionnaire (FFMQ), Perceived Stress Scale (PSS), and two measures of emotional distress, PROMIS Short Forms for Anxiety and Depression. Analyses compared demographic characteristics and assessment scores by program length.

Results:

324 pts completed assessments at baseline and 70 pts completed them at week 8, an attrition rate of 78% in each of the program arms. The majority of pts were female, White, with 67% between the ages of 45-64 years. No statistically significant differences were observed at baseline between participants randomized to each of the two programs, and in their assessment scores at week 8 (Table 1); PROMIS Anxiety and Depression scores improved from baseline to week 8 for pts in both programs (Figure 1). Overall, mean (SD) PROMIS Depression scores improved from 58.4 (7.7) at baseline to 55.4 (7.2) at week 8 (p=0.018), a meaningfully important difference, among the 70 pts reporting scores at both time points.

Table 1.

Assessment Scores at Baseline and Week 8, Mean (SD)

BaselineWeek 8All (n=324)8-week course (n=163)3-week course (n=161)p-valueAll (n=70)8-week course (n=35)3-week course (n=35)p-valueWHO-5 b10.6 (4.9)10.4 (4.8)10.9 (5.0)0.37812.0 (5.1)12.5 (5.5)11.6 (4.7)0.488FFMQ c42.7 (6.1)42.7 (6.1)42.7 (6.1)0.93239.2 (5.7)38.9 (6.1)39.4 (5.3)0.741PSS d18.7 (7.5)19.2 (6.8)18.3 (8.2)0.30416.6 (7.3)15.7 (7.8)17.6 (6.8)0.291PROMIS Depression e56.5 (8.3)57.3 (8.0)55.7 (8.6)0.09755.1 (8.5)54.8 (9.3)55.5 (7.8)0.735PROMIS Anxiety f58.7 (8.2)59.0 (8.2)58.4 (8.1)0.47055.4 (7.2)54.6 (7.4)56.1 (7.1)0.404

a denotes use of Fisher’s Exact Test b Range 0 (worse) to 25 (better), c Range 3 (worse) to 15 (better), d Range 0 (better) to 40 (worse), e Range 24.7 (better) to 63.5 (worse), f Range 25.7 (better) to 62.0 (worse)

Conclusion:

People living with RMD who are part of a real-world US registry are willing to participate in an online mindfulness training program study, but may require additional support to remain engaged and adherent throughout the program and to participate to study conclusion. Participation in a mindfulness training program, whether full-length or brief, appears to improve symptoms of emotional distress among people with RMD.

References:

[1]Zhou, B. et al. Comp. Ther. in Clin. Prac. 2020; 39:1-7

[2]Reiner, K. et al. Pain Medicine. 2013; 14(2): 230-242

Acknowledgements:

The authors would like to thank ArthritisPower members for participating in the study, and the Healthy Mind Healthy You study team at Massachusetts General Hospital (see MoodNetwork.org) for leading it. The study was funded by the Patient-Centered Outcomes Research Institute (XPPRN-1512-33786).

Disclosure of Interests:

Julia Thompson: None declared, Nupur Parikh: None declared, Kelly Gavigan: None declared, Shilpa Venkatachalam: None declared, W. Benjamin Nowell Grant/research support from: Full-time employee of Global Healthy Living Foundation, an independent nonprofit organization, which has received funding to conduct research; Principal Investigator for studies with grant support from AbbVie, Amgen and Eli Lilly.

OP0009-PARE SUCCESSFUL PATIENT EDUCATION ON COVID-19 VACCINE SAFETY IN A LARGE RHEUMATOLOGY COHORT USING INTERACTIVE MOBILE-PHONE VIDEO TECHNOLOGY: CONTEXT, RESULTS, AND NEXT STEPS

Background:

There are reported concerns of patient misunderstanding of the COVID-19 pandemic and vaccination safety. It is particularly important that these are understood in patients taking complex immunusuppressive therapies. Rapid delivery of targeted and up-to-date video messages from clinicians sent directly to patients could address patient uncertainty, and improve COVID-19 vaccination uptake. Innovative SMS (short message service) based video message has already shown promise in delivering COVID-19 information to patients [1]. We present our experience in creating a tailored vaccine information video sent directly to our large cohort of patients in the UK with a range of rheumatic diseases and report on the learning points going forward.

Objectives:

Our three objectives were: (1) educate our patients using an interactive mobile video information resource outlining the safety of the COVID vaccination in these patient groups; (2) better understand our patients’ views of the COVID-19 vaccine; (3) evaluate the patient experience of this approach.

Methods:

We designed and recorded an 8-minute interactive web-based video delivered education resource designed for mobile phones. This included: aims of the video; details of licenced vaccines; UK vaccination schedule; frequently asked questions; links to national charity resources; our clinician recommendations; a rheumatologist being vaccinated; case studies; and summary data. We produced a simple mobile phone web-based evaluation of the resource, including anonymised patient demographics, their understanding of the safety of the vaccine pre/ post video, and their user experience. Resource and evaluation were piloted by local healthcare professionals, our Patient Participation Group, a national charity, and approved by senior management. We distributed this to our follow-up patient cohort via our hospital SMS provider on 21.12.20, at the start of roll-out of UK vaccines, containing a link to the resource and evaluation.

Results:

Of a cohort of 10,981 patients, we had 8886 mobile phone numbers. At Day 14, we recorded 2358 video views (26.3%) and 664/2358 completed evaluations (28.1%). Only one person reported being unable to watch the video. Before watching the video, 348/664 patients (52.4%) were unsure if the vaccine was safe and/or recommended for them, rising to 626/664 (94.3%) post-video.Reasons for uncertainty after the video (38/664) included drug allergy and fertility concerns. Following the video, 509/664 patients (76.6%) reported that they were more likely to have the vaccination. The majority of the patients (614/660, 93.0%) agreed that the method was a helpful method to share such information.Age distribution of our whole cohort, patients with mobile phones, and responders were similar: Age >50 was 80.4%,76.3%,and 88.6% respectively. A large proportion was treated with immunosuppressive medication (61.3% conventional DMARD, 39.4% biological DMARD and 17.6% corticosteroids). Gender and case mix for responders were similar to published data from our cohort: female 74.0%; rheumatoid arthritis commonest disease (389/664, 58.5%).

Conclusion:

To our knowledge, this is the first study to show the potential for SMS linked interactive multimedia message for patient education. The multimedia component allows users to easily navigate to relevant sections, and access a choice of linked resources. We demonstrate this low-cost technology is simple, effective and well placed to assist physicians in educating patients during a time when face-to-face contact is proving to be difficult. We have shown high levels of patient satisfaction, reassurance, and self-reported behaviour change. Such technology has potential utility for national bodies, primary and secondary care groups, and merits further research.

References:

[1]The Lancet Rheumatology. Rapid distribution of information by SMS-embedded video link to patients during a pandemic. June 2020,Volume2,Number 6,e309-e368

Acknowledgements:

We would like to thank the Hibbs Lupus Trust, and our Patient Participation Group.

Disclosure of Interests:

None declared

The impact of COVID-19 on rheumatology patients in a large UK centre using an innovative data collection technique: prevalence and effect of social shielding

OBJECTIVES

We sought to gain insight into the prevalence of COVID-19 and the impact stringent social distancing (shielding) has had on a large cohort of rheumatology (RD) follow-up patients from a single large UK centre.

METHODS

We linked COVID-19-related deaths, screening and infection rates to our RD population (1.2.20-1.5.20) and audited active rheumatology follow-up patients through survey data communicated via a linked mobile phone SMS message. We assessed epidemiology, effect of stringent social distancing (shielding) and quality of life (HRQoL) by Short Form 12 (SF12).

RESULTS

There were 10,387 active follow-up patients, 7911 had linked mobile numbers. 12/10,387 RD patients died from COVID-19 (0.12%); local population 4131/7,415,149 (0.12%). For patients with mobile phones, 1693/7911 (21%) responded and of these, 1605 completed the SF12. Inflammatory arthritis predominated 1174/1693 (69%); 792/1693 (47%) were shielding. Advice on shielding/distancing was followed by 1372/1693(81%). 61/1693 (4%) reported COVID-19 (24/61 shielding); medication distribution was similar in COVID and non-COVID patients. Mental SF12 (MCS) but not physical (PCS) component scores were lower in COVID (60) vs. non-COVID (1545), mean differences: MCS, - 3.3; 95% CI - 5.2 to - 1.4, P < 0.001; PCS, - 0.4; 95% CI, - 2.1 to 1.3). In 1545 COVID-negative patients, those shielding had lower MCS (- 2.1; 95% CI - 2.8 to - 1.4) and PCS (- 3.1, 95% CI - 3.7 to - 2.5), both P < 0.001.

CONCLUSIONS

Our full RD cohort had no excess of COVID deaths compared to the general local population. Our survey data suggest that shielding adversely affects both mental and physical health in RD. These data broaden our understanding of shielding, indicating need for further study.

A pragmatic proposal for triaging DXA testing during the COVID-19 global pandemic

The COVID-19 pandemic has resulted in huge disruption to healthcare provision, including to dual-energy X-ray absorptiometry (DXA) imaging. Increased waiting lists for DXA from the pandemic mean potential long and uncertain delays in treatment for osteoporosis. To address these increased waiting lists, we propose a rapid, simple, one-stop algorithm incorporating medication use (aromatase inhibitor, corticosteroid) and clinical risk stratification supplementing a standard FRAX assessment. Our pragmatic algorithm produces a recommendation to treat empirically, image with DXA, or observe. If applied, we model a significant reduction in DXA scan requirements with a corresponding reduction in treatment delays for those awaiting DXA. We estimate this will reduce DXA scan numbers by about 50%, whilst pragmatically ensuring those with the highest clinical need correctly receive treatment without delay. This algorithm will help many clinicians including general practitioners/family physicians prioritise DXA when they may not always have the expertise to make this judgement based on clinical information alone. Although we have used UK guidelines as an example, this approach is flexible enough for adaptation by other countries based on their local guidelines, licensing, prescribing requirements, and DXA waiting list times. There are some limitations to our proposal. However, it represents one way of managing the uncertainty of the current COVID-19 pandemic.

THU0564 PARTICIPANT ENGAGEMENT IN AN ARTHRITISPOWER REAL-WORLD STUDY TO CAPTURE SMARTWATCH AND PATIENT-REPORTED OUTCOME DATA AMONG RHEUMATOID ARTHRITIS PATIENTS

Background:

Clear characterization of how different types of patient-generated data reflect patient experience is needed to guide integration of electronic patient-reported outcome (ePRO) measures and biometrics in generating real-word evidence (RWE) related to rheumatoid arthritis (RA).

Objectives:

To characterize the level of participant (pt) engagement/adherence and data completeness in an ongoing study of 250 RA pts enrolled in the Digital Tracking of Arthritis Longitudinally (DIGITAL) study1of the ArthritisPower real-world registry.

Methods:

ArthritisPower pts with RA were invited to join a digital RWE study with 14-day lead-in and 12-week main study period. In the lead-in, pts were required to electronically complete: a) two daily single-item Pain and Fatigue numeric rating scales and b) longer weekly sets of ePROs. Successful completers of the lead-in were mailed a smartwatch (Fitbit Versa) and study materials. The smartwatch collected activity, heart rate, and sleep duration/quality biosensor data; a study-specific customization of the ArthritisPower mobile application collected ePROs. The main study period included automated and manual reminders/prompts about completing ePROs, wearing the smartwatch and regularly syncing it. Study coordinators monitored pt data and contacted pts via email, text and/or phone to resolve adherence issues during the conduct of the study based on pre-determined rules triggering pt contact. Rules were based chiefly on consecutive spans of missing data. Pts were considered adherent in giving complete data for each week if providing (1) daily ePROs for ≥5 of 7 days/week, (2) weekly ePROs and (3) ≥80% of synced activity data for ≥5 of 7 days/week. Composite adherence for the first month of the main study period required meeting >70% weekly adherence parameters during the first 30 days, ie completing daily ePROs for ≥5 of 7 days/week, weekly ePROs ≥3 of 4 weeks and ≥80% of synced activity data for ≥5 of 7 days/week.

Results:

As of December 2019, 170 ArthritisPower members enrolled and completed at least 30 days of the main study period; 92.9% female with mean (SD) age 52.5 (10.7) and 10.5 (10.4) years since diagnosis. The overall conversion rate from initial interest to successful completion of the lead-in period was 49.0%. Pts who advanced to the main study were significantly more likely than those who did not to be currently employed (52.9% vs. 41.8%, p=0.038) and be on biologic DMARD monotherapy (64.7% vs. 47.5%, p=0.001). Overall, daily ePRO data had the lowest adherence with 70.0% of pts providing >70% of the requested data consistently across the first 30 days of the main study period (Figure 1). Composite adherence was met by 66.5% of pts. The most common time of day to provide ePRO data was morning, in the hours around scheduled app and email notifications at 10 a.m. in pt’s local time zone. Activity data had the highest adherence and persistence, with 92.9% of pts providing 80% or more of activity data for each 24-hour period in the first 30 days (Figures 1 & 2). Observed weekly adherence did not decline over time. Of 5100 possible person days in the study at day 30, we observed 643 days (91.0% of actual to maximum possible total patient days) where activity data was provided for at least 80% of the 24-hour period.

Conclusion:

RWE studies involving passive data collection in RA require pt-centric implementation and design to minimize pt burden, promote longitudinal engagement and maximize adherence. Passive data capture via activity trackers such as smartwatches, along with regular contact such as automated reminders, may facilitate greater pt adherence in providing longitudinal data for clinical trials.

References:

[1]Nowell WB, et al. JMIR Res Protoc. 2019;8(9):e14665.

Disclosure of Interests:

W. Benjamin Nowell: None declared, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Fenglong Xie: None declared, Hong Zhao: None declared, David Curtis: None declared, Kelly Gavigan: None declared, Shilpa Venkatachalam: None declared, Laura Stradford: None declared, Jessica Boles: None declared, Justin Owensby: None declared, Cassie Clinton: None declared, Ilya Lipkovich Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Amy Calvin Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Virginia S. Haynes Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company

SAT0150 CHANGES IN PATIENT-REPORTED OUTCOME (PRO) SCORES FOR NAUSEA AND FATIGUE FOLLOWING WEEKLY METHOTREXATE DOSE IN A REAL-WORLD SAMPLE OF RA AND PSA PATIENTS IN THE ARTHRITISPOWER REGISTRY

Background:

Methotrexate (MTX) is frequently used in patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) because of its beneficial effects in both populations1-3. Despite the well-known benefits of MTX, it is associated with a number of potential side effects4-6These include nausea and fatigue, are often temporally related to the timing of weekly MTX administration, and can be severe. The combined patient-reported side effects, along with potential of long-term toxicity, may make use of MTX more burdensome. Currently, there is a gap in patient-centered studies that focus on patients’ experience with MTX.

Objectives:

Examine patient temporal experience of fatigue and nausea relating to oral MTX therapy for the treatment of RA and PsA.

Methods:

Adult US patients in the ArthritisPower registry with self-reported RA or PsA taking MTX for less than 10 years were invited to participate in the study via email invitation. Participants (pts) completed a screener and brief online survey. In an ancillary study to the ArthritisPower registry and using a self-controlled case series study design where pts serve as their own control to avoid between-person confounding, pts were asked to complete a set of up to 8 assessments within 6-36 hours (‘risk’) and 96-144 hours (‘control’) after taking their oral dose of MTX each week, for up to 4 weeks. Risk and control windows were selected based on the expected temporal relationship between MTX use and peak onset of these symptoms. Assessments included PROMIS short forms for same-day Fatigue, same-day Nausea/Vomiting, and Patient Global. Descriptive statistics were conducted using paired t-tests two-way comparisons. Within-person change in PROMIS scores between the risk (1-2 days after MTX) and control (4-6 days after MTX) windows were analyzed using mixed models for repeated measures, stratified on whether pts reported fatigue or nausea with MTX at baseline. Recruitment for this study is ongoing.

Results:

As of December 2019, 91 pts had participated, of whom 76.9% were living with RA and 28.6% with PsA, with mean baseline PROMIS Patient Global score (SD) of 39.5 (7.1). Mean age (SD) was 50.9 (12.0) years, 84.6% female, 92.3% White, with mean BMI 33.7 (8.8). Mean duration of MTX treatment among current users was 2.1 (2.8) years. Among pts, 41.8% were on a biologic DMARD and 58.2% on non-biologic DMARDs only. Among pts reporting baseline nausea (n=30, 33.0%) where paired within-week measures were observed (n=64 observations among 20 pts), the mean increase in the PROMIS Nausea score was 4.5 units (adjusted p=0.003). Among those reporting MTX-associated fatigue (n=39, 42.9%) as a side effect of MTX on their baseline survey where paired within-week measures were observed (n=96 observations among 28 pts), the mean increase in PROMIS Fatigue was 4.7 (adjusted p=0.004) units. In those pts, the proportion of pts with worsened nausea and fatigue with minimally important difference of >5 units7-8was 40.0% (nausea), and 60.7% (fatigue) [Figures 1 and 2].

Conclusion:

People taking MTX to manage RA or PsA commonly experience bothersome side effects, notably fatigue and nausea, that are temporally related to weekly MTX dosing. In this sample, one-third or more of pts were bothered by nausea or fatigue shortly after MTX dosing, many of them with clinically meaningful symptoms.

References:

[1]Singh JA, et al.Arthritis Rheumatol. 2016;68:1-26.

[2]Singh JA, et al.Arthritis Rheumatol. 2019;71:5-32.

[3]Mease P.Bull NYU Hosp Jt Dis. 2013;71.(suppl 1):S41.

[4]Wang W, et al.Eur J Med Chem. 2018;158:502-516.

[5]Wilsdon TD, et al.Cochrane Database Syst Rev. 2019;1:CD012722.

[6]Husted JA, et al.Ann Rheum Dis. 2009;68:1553-1558.

[7]Norman GR, et al.Med Care. 2003;41:582-92.

[8]Bingham CO, et al.J Patient Rep Outcomes. 2019;3:14.

Disclosure of Interests:

W. Benjamin Nowell: None declared, Elaine Karis Shareholder of: Amgen Inc., Employee of: Amgen Inc., Kelly Gavigan: None declared, Laura Stradford: None declared, Scott Stryker Shareholder of: Amgen Inc., Employee of: Amgen Inc., Huifeng Yun Grant/research support from: Bristol-Myers Squibb and Pfizer, Shilpa Venkatachalam: None declared, Greg Kricorian Shareholder of: Amgen Inc., Employee of: Amgen Inc., Lang Chen: None declared, Hong Zhao: None declared, Fenglong Xie: None declared, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB

PARE0026 WHICH PATIENT-REPORTED OUTCOMES DO RHEUMATOLOGY PATIENTS FIND IMPORTANT TO TRACK DIGITALLY? A REAL-WORLD LONGITUDINAL STUDY IN ARTHRITISPOWER

Background:

Development of a standardized approach to assess key elements of disease activity in rheumatology clinical trials has been the goal of Outcome Measures in Rheumatology Clinical Trials (OMERACT), American College of Rheumatology (ACR), and European League Against Rheumatism (EULAR).1,2,3The core sets of measures developed include assessments and composite indices incorporating use of patient-reported outcomes (PROs) and clinical measures and clinicians’ assessments to quantify disease activity over time.2PROs are important indicators of disease activity and variability, and they are increasingly used to evaluate treatment effectiveness. Little is known about PROs that patients with rheumatic conditions find most important to convey their experience with their condition and its treatment.

Objectives:

To examine PROs selected by patients with rheumatic conditions in the ArthritisPower registry to identify symptoms they found most important to track digitally.

Methods:

Adult US patients within the ArthritisPower registry with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE), osteoporosis (OP), osteoarthritis (OA), and fibromyalgia syndrome (FMS) were invited via email to participate in this study. Enrolled participants (pts) were prompted to select ≤10 PRO symptom measures they felt were important to track for their condition at baseline via the ArthritisPower app. At 3 subsequent time points (Month [m] 1, m2, m3), pts were given the option to continue tracking their previously selected PRO measures or to add, remove and/or select different measures. At m3, pts completed an exit survey to prioritize ≤5 measures from all measures selected during study participation and to specify other symptoms not available that they would have wanted to track. Measures were rank-ordered based on number of pts rating the item as their 1st, 2nd, 3rd, 4th or 5th choice and weighted by multiplying the rank number by its inverse for a single, weighted summary score for each measure. Values were summed across all pts to produce a summary score for each measure.

Results:

Among pts who completed initial selection of PRO assessments at baseline (N=253), 184 pts confirmed or changed PRO selections across m1-3. Mean (SD) age of pts was 55.7 (9.2) yrs, 89.3% female, 91.3% White, mean disease duration of 11.6 (10.6) yrs. The majority (64.8%) self-reported OA, followed by RA (48.6%), FMS (40.3%), PsA (26.1%), OP (21.0%), AS (15.8%) and SLE (5.9%), not mutually exclusive, and were similar to the overall ArthritisPower population. The average number of instruments (SD) selected for baseline completion was 7.0 (2.5), 7.1 (2.4) at m1, 7.2 (2.4) at m2, and 7.0 (2.5) at m3. The top 5 PROs ranked by pts overall as most important (weighted summary score) for tracking were Fatigue (71), Physical Function (58), Pain Intensity (50), Pain Interference (49), Duration of Morning Joint Stiffness (41) (Figure 1). Fatigue, Physical Function, and Pain were consistently in the top 5 across diseases while Depression was more frequent among pts with OA, AS and FMS. Pts’ PRO selections showed stability over time except for the RA Flare measure which decreased from 70.5% of RA pts at baseline to 13.6% at m3.

Conclusion:

The symptoms prioritized by pts included fatigue, physical function, pain, and joint stiffness. Pts‘ choices were consistent over time. These findings provide insights into symptoms rheumatology patients find most important and will be useful to inform design of future patient-centric clinical trials and real-world evidence generation.

References:

[1]Boers M, et al. J Rheumatol Suppl. 1994;41:86–89.

[2]Felson DT, et al. Arthritis Rheum. 1993;36:729–740.

[3]Tugwell P, et al. J Rheumatol. 1993;20:555–556.

Disclosure of Interests:

W. Benjamin Nowell: None declared, Carol L. Kannowski Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Kelly Gavigan: None declared, Zhihong Cai Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Anabela Cardoso Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Theresa Hunter Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Shilpa Venkatachalam: None declared, Julie Birt Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Jennifer Workman Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB

O10 Combining clinical and ultrasound assessment to taper biologic therapies in patients with RA in routine clinical practice

Background

There is growing evidence for tapering biologic therapies in patients with rheumatoid arthritis in sustained clinical remission to avoid overtreatment and minimise side-effects. Ultrasound assessment for subclinical synovitis adds to clinical assessment of patients with rheumatoid arthritis suitable for tapering biologic therapies. Our primary objective was to combine clinical and ultrasound assessment to select patients with rheumatoid arthritis for tapering biologic therapies in routine clinical practice. The secondary objectives were to identify predictors for successful tapering and assess the cost savings to the local health economy by optimising the use of high cost drugs.

Methods

All patients with rheumatoid arthritis on a biologic therapy for 2 years and in sustained clinical remission (DAS28≤2.6) over the previous year were seen in the remission clinic. They had an Ultrasound scan of the small joints of the hands, wrists and other symptomatic joints. Patients with no activity on Power Doppler were advised to lengthen the interval of their biologic therapy gradually and were followed once every 3 months. Patients were not on oral steroids but continued conventional DMARDs. Patients had a dedicated helpline if they had a flare.

Results

Ninety-three of the 120 patients with rheumatoid arthritis on biologic therapy seen in the biologic remission clinic between January and October 2019 were eligible and all but one agreed to taper. They were 70% female with a mean age of 62.8 years and mean duration of disease 14.6 years. Their mean duration of biologic therapy was 6.3 years; mean baseline DAS28 was 6.3 pre-biologic therapy and 1.7 before tapering. Fifty-seven of the patients were on a TNF inhibitor and 35 were on other biologic therapies. Forty of the ninety-two patients were co-prescribed DMARDs. Screening failure was due to clinical activity in 13 patients, Ultrasound Power Doppler activity in 23 patients, interstitial lung disease in 2 patients and shoulder surgery in one. Only two of the 40 patients who had completed 6 months had a flare and reverted to the baseline frequency. Of the remaining 52 patients, 22 patients had completed 3 months at the tapered dose and 3 patients who were in the initial 3 months had a flare and reverted to the baseline frequency. Initial drug-cost savings at 6 months was approximately £45,000.

Conclusion

Tapering of biologic therapies in patients with rheumatoid arthritis is feasible in routine clinical practice. Ultrasound is helpful to stratify patients for biologic tapering and has enabled a higher proportion of patients to remain in remission after tapering.

Disclosures

H. Pillai: None. N. Nolkha: None. A. Yau: None. S. Matthews: None. A. Hall: None. G. Hirsch: None. S. Venkatachalam: None.

Conducting Fabrics as a Shield Against Electromagnetic Interference (EMI)

The paper reports a method to design and develop a highly flexible EMI shielding material based on newly emerging technology of in situ grafting of conducting polymers onto insulating surfaces such as fabrics.

Diversity and functional traits of culturable microbiome members, including cyanobacteria in the rice phyllosphere

The diversity and abundance of culturable microbiome members of the rice phyllosphere was investigated using cv. Pusa Punjab Basmati 1509. Both diversity and species richness of bacteria were significantly higher in plants in pots in a semi-controlled environment than those in fields. Application of fertilisers reduced both diversity and species richness in field-grown plants under a conventional flooded system of rice intensification (SRI) and in dry-seeded rice (DSR) modes. Sequence analyses of 16S rDNA of culturable bacteria, those selected after amplified ribosomal DNA restriction analysis (ARDRA), showed the dominance of α-proteobacteria (35%) and actinobacteria (38%); Pantoea, Exiguobacterium and Bacillus were common among the culturable phyllospheric bacteria. About 34% of 83 culturable bacterial isolates had higher potential (>2 μg·ml(-1) ) for indole acetic acid production in the absence of tryptophan. Interestingly, the phyllosphere bacterial isolates from the pot experiment had significantly higher potential for nitrogen fixation than isolates from the field experiment. Enrichment for cyanobacteria showed both unicellular forms and non-heterocystous filaments under aerobic as well as anaerobic conditions. PCR-DGGE analysis of these showed that aerobic and anaerobic conditions as well as the three modes of cultivation of rice in the field strongly influenced the number and abundance of phylotypes. The adaptability and functional traits of these culturable microbiome members suggest enormous diversity in the phyllosphere, including potential for plant growth promotion, which was also significantly influenced by the different methods of growing rice.

Chromodomain helicase DNA-binding protein 2 affects the repair of X-ray and UV-induced DNA damage

Eukaryotic cells have evolved a variety of parallel and redundant DNA damage response pathways that function in a coordinated fashion to prevent the fixation of DNA damage as mutations. Despite the wealth of knowledge on DNA damage signaling on downstream cellular events, the mechanisms of DNA damage recognition, DNA repair as well as DNA damage signaling in the context of chromatin is poorly understood. Chromodomain helicase DNA-binding proteins (CHD) belong to a group of highly conserved chromatin remodeling proteins that are implicated in regulation of transcription. In an effort to understand the physiological role of one of the CHD members in a mammalian model system, we developed a mutant mouse model for the Chd2 gene. The Chd2 mutant mice are highly susceptible to spontaneous lymphoid tumor formation. In this study, we present evidence that the Chd2 mutant cells are defective in their ability to repair DNA damage induced by ionizing and ultraviolet radiation. Consistent with the role of Chd2 in regulating DNA damage responses, the Chd2 mutant cells are also sensitive to DNA damaging agents in clonogenic assays. In summary, our data suggest that the Chd2 protein is involved in regulating the DNA damage responses at the chromatin level.

Fatal pulmonary embolism following conservatively managed tendo achilles rupture-A case report

INTRODUCTION

Tendo achilles (TA) ruptures are commonly encountered in orthopaedic practice. These can be managed operatively or conservatively depending on various factors like patient age, activity levels, co morbidities, patient expectations and surgeon preference. They are usually treated in plaster cast immobilisation if managed conservatively.

CASE REPORT

We present a case of fatal pulmonary embolism following conservatively managed Tendo achilles (TA) rupture in a young man treated as an orthopaedic outpatient.

DISCUSSION

There are no current clear guidelines on venous thromboembolism (VTE) prophylaxis in conservatively managed outpatients with cast immobilisation.

CONCLUSION

Our case report highlights the importance of recognition of this aspect of patient management and reviews the current literature available on this debatable topic.

Results of locked flexible intramedullary nailing of metacarpal fractures: a case series

PURPOSE

We present our case series on the use of flexible locked intramedullary nails in the management of metacarpal fractures.

METHODS

This was a prospective study over a period of 2 years of all patients with metacarpal fractures with 100% displacement or rotational deformity operated by the flexible locked intramedullary nails from January 2008 to April 2010 at Queen Elizabeth Hospital, Gateshead, UK RESULTS: Twenty-six patients with fractures of metacarpal neck and shaft were included in the study. All fractures went on to union by an average of 6.3 weeks with full metacarpophalangeal joint movement and grip strength.

CONCLUSION

In our experience, this device helps to achieve good functional results with minimal soft tissue disruption and complications in the management of unstable metacarpal fractures.

The multiple roles of Bub1 in chromosome segregation during mitosis and meiosis

Aneuploidy, any deviation from an exact multiple of the haploid number of chromosomes, is a common occurrence in cancer and represents the most frequent chromosomal disorder in newborns. Eukaryotes have evolved mechanisms to assure the fidelity of chromosome segregation during cell division that include a multiplicity of checks and controls. One of the main cell division control mechanisms is the spindle assembly checkpoint (SAC) that monitors the proper attachment of chromosomes to spindle fibers and prevents anaphase until all kinetochores are properly attached. The mammalian SAC is composed of at least 14 evolutionary-conserved proteins that work in a coordinated fashion to monitor the establishment of amphitelic attachment of all chromosomes before allowing cell division to occur. Among the SAC proteins, the budding uninhibited by benzimidazole protein 1 (Bub1), is a highly conserved protein of prominent importance for the proper functioning of the SAC. Studies have revealed many roles for Bub1 in both mitosis and meiosis, including the localization of other SAC proteins to the kinetochore, SAC signaling, metaphase congression and the protection of sister chromatid cohesion. Recent data show striking sex specific differences in the response of germ cells to alterations in Bub1 activity. Proper Bub1 functioning is particularly important during oogenesis in preventing the generation of aneuploid gametes that can have detrimental effects on the health status of the fetus and the newborn. These data suggest that Bub1 is a master regulator of SAC and chromosomal segregation in both mitosis and meiosis. Elucidating its many essential functions in regulating proper chromosome segregation can have important consequences for preventing tumorigenesis and developmental abnormalities.

Medical management of uterine fibroids with medroxyprogesterone acetate (Depo Provera): a pilot study

The aim of this study was to determine the effectiveness of medroxyprogesterone acetate (Depo Provera) in the treatment of menorrhagia attributed to uterine fibroids and to determine whether it reduces fibroid volume. Twenty premenopausal women with menorrhagia attributed to uterine fibroids received Depo Provera (150 mg/month) for 6 months. Control of bleeding was assessed by menstrual diary, haematologic parameters (Hb) and uterine and fibroid size measured sonargraphically. Following a period of 6 months after the initiation of Depo Provera, 30% became amenorrhoeic, 70% noticed improvement in their bleeding pattern and 15% had an increase in their haemoglobin levels. The mean uterine and fibroid volume was also reduced by 48% and 33%, respectively. Medical therapy with Depo Provera with symptomatic fibroids causes significant improvement in bleeding pattern as well as a reduction in fibroid volume.

Disruption of chromodomain helicase DNA binding protein 2 (CHD2) causes scoliosis

Herein we characterize an apparently balanced de novo translocation, t(X;15)(p22.2;q26.1)dn, in a female patient with scoliosis, hirsutism, learning problems, and developmental delay (DGAP025). Other clinical findings include a high-arched palate, 2-3 syndactyly of the toes, and mildly elevated serum testosterone. No known or predicted genes are disrupted by the Xp22.2 breakpoint. The 15q26.1 breakpoint disrupts chromodomain helicase DNA binding protein 2 (CHD2). Another member of the chromatin-remodeling gene family, CHD7, has been associated with a defined constellation of congenital anomalies known as coloboma, heart anomaly, choanal atresia, mental retardation, genital and ear anomalies syndrome (CHARGE) and idiopathic scoliosis. Monosomy of 15q26 also has been associated with a spectrum of congenital abnormalities and growth retardation that overlaps with those of DGAP025. To provide a biological correlate, we characterized a mutant mouse model with Chd2 disruption that is associated with embryonic and perinatal lethality. Expression analysis indicated that Chd2 is expressed in the heart, forebrain, extremities, facial and dorsal regions during specific times of embryonic development. Chd2(+/m) mice showed pronounced lordokyphosis, reduced body fat, postnatal runting, and growth retardation. These data suggest that haploinsufficiency for CHD2 could result in a complex of abnormal human phenotypes that includes scoliosis and possibly features similar to CHARGE syndrome.

Differential gene expression analysis in antimony-unresponsive Indian kala azar (visceral leishmaniasis) clinical isolates by DNA microarray

In this study, cDNA microarray analysis of a closely related species, Leishmania major, was used as a screening tool to compare antimonial-resistant and susceptible clinical isolates of Leishmania donovani in order to to identify candidate genes on the basis of antimony resistance. Clinically confirmed resistant isolate 39 and sensitive isolate 2001 were used in this study. Many differentially regulated genes were identified whose expression levels differ in sodium antimony gluconate (SAG)-treated patients. Interestingly, genes on the array, showing changes in expression of over 2-fold revealed the identity of ABC transporters, which are known determinants of drug resistance in laboratory mutants. The functionality of the transporters was validated by flow cytometry which, being biologically informative, provides direct clues to gene function. The results suggest that isolate 39 could have developed resistance by an increased multidrug resistance protein (MRP)-like pump. This study provides preliminary clues to the role of a thiol-dependent efflux system in antimonial resistant clinical isolates of Leishmania donovani.

Complicating the role of p53 in aging

The p53 tumor suppressor protein plays a pivotal role in integrating various DNA damage response pathways and has been shown to be mutated in a variety of human cancers. In an effort to study the effects of a mutant p53 protein in a mouse model we generated a p53 targeting vector with a mutation in codon 245, equivalent to the mutational hot spot (codon 248) in humans. However, due to an aberrant gene targeting event in ES cells, we developed a p53 mutant mouse model that expressed a truncated p53 transcript that lacked the first six exons while retaining the intended mutation in exon 7. This mouse model was shown to exhibit serendipitous phenotypes that resembled premature aging as well as increased resistance to spontaneous tumors. Based on the genetic and molecular information available at that time, we hypothesized that the truncated p53 allele (m-allele) and its effect on wt p53 activity might be responsible for the observed phenotypes. However, the availability of the mouse genome data has allowed us to further characterize the genetic deletion present in the p53+/m mouse model. Our analyses indicate that there are 24 genes (including the p53 truncation) deleted in the p53+/m mouse model. These results suggest that the p53 tumor suppressor protein may not be solely responsible for the various phenotypes exhibited by p53+/m mouse model [corrected]

Insights into aging obtained from p53 mutant mouse models

Cancer suppression is an integral component of longevity in organisms with renewable tissues. A number of genes in the mammalian genome function in cancer prevention, and some of these have been directly implicated in longevity assurance. One such longevity assurance gene is the tumor suppressor p53, a transcription factor that is mutated or dysregulated in most human cancers. Early studies have linked p53 to the induction of cellular senescence, whereas recent reports implicate it as a potential regulator of organismal aging. We have shown by gene inactivation studies that loss of p53 function enhances tumor susceptibility and reduces longevity in the mouse. A recent serendipitously generated p53 mutant allele resulted in a hypermorphic version of p53 that displays increased cancer resistance, yet also mediates decreased longevity. The reduced longevity is accompanied by the accelerated onset of a variety of aging phenotypes. These include a 20% decrease in median life span, early osteoporosis, lordokyphosis, organ atrophy, delayed wound healing, and a reduced regenerative response after various stresses. Since the initial characterization of these mutant mice, we have attempted to elucidate the underlying molecular and cellular mechanisms that could be influencing the early aging phenotypes. Molecular studies of the p53 mutant allele product indicate that it induces an increase in p53 activity in both in vitro and in vivo contexts. The age-associated loss of organ cellularity and reduced tissue regenerative responses in the mutant mice are consistent with an accelerated loss of stem cell functional capacity. Our model is that enhanced growth inhibitory activity of p53 produces an earlier loss of the ability of stem cells to produce adequate numbers of progenitor and mature differentiated cells in each organ. Currently, we are performing stem cell functional assays from p53 mutant and wild-type mice to test this model. One challenge for the future will be to find ways to manipulate p53 function to provide increased cancer resistance, yet still enhance overall organismal longevity.

Cooperativity of p19ARF, Mdm2, and p53 in murine tumorigenesis

The p19ARF gene product responds to oncogenic stresses by interfering with the inhibitory effects of Mdm2 on p53, thus enhancing p53 activity and its antiproliferative functions. The absence of p19ARF in the mouse leads to early tumor susceptibility, presumably in part due to decreased p53 activity. To examine the tumorigenic cooperativity of p19ARF, Mdm2, and p53 in vivo, p19ARF-deficient mice were crossed first to p53-deficient mice and then to Mdm2 transgenic mice. The progeny were monitored for tumors. Cooperativity between p19ARF and p53 deficiencies in accelerating tumor formation was observed for most genotypes except p53-/- p19ARF-/- mice. p53-/- p19ARF-/- mice had a tumor incidence similar to p53-/- mice. In this context, tumor suppression by ARF appears to be primarily p53 dependent. The majority of the p19ARF+/- tumors deleted the wildtype p19ARF allele, in agreement with the previous studies, suggesting that p19ARF is a classic 'two hit' tumor suppressor. In a p53+/- background, however, all p19ARF+/- tumors retained a wildtype ARF allele and most also retained wildtype p53. In the second cross between p19ARF-deficient and Mdm2 transgenic mice, cooperativity in tumor incidence between Mdm2 overexpression and ARF deficiency was observed, consistent with the role of p19ARF in negatively regulating Mdm2 activity. These experiments further demonstrate in vivo the inter-relationships of the p19ARF-Mdm2-p53 signaling axis in tumor suppression.

Misoprostol for cervical ripening at and near term--a comparative study

OBJECTIVE

To compare the safety and efficacy of misoprostol with that of dinoprostone for the induction of labour at term, or near term.

DESIGN

Three hundred and ninety-six women with term pregnancies were randomised to receive either oral or vaginal misoprostol, or dinoprostone. Women who had had a previous caesarean section (CS) or those with a malpresentation or who were parity > or = 5, were excluded. The control group received dinoprostone 1 mg inserted in the posterior fornix and repeated 6-hourly to a maximum of three doses. The study group received either oral misoprostol 20 micrograms 2-hourly to a maximum of four doses (80 micrograms), or vaginal misoprostol 25 micrograms in the posterior fornix with a switch to the oral misoprostol regimen if there was no change in the Bishop's score or no palpable uterine contractions.

RESULTS

There was no significant difference in vaginal delivery rate within 24 hours between the groups (58.1% v. 58%, p = 0.633). There were no significant differences in CS rates between the groups; however, more CSs were performed for fetal distress in the misoprostol group than in the dinoprostone group (28% v. 25%). There was a significantly higher incidence of hyperstimulation in the vaginal misoprostol group (21.4%) than in the other two groups (oral misoprostol 16.5%, dinoprostone 8.9%) (p = 0.004). The incidence of meconium staining of liquor was comparable between the groups.

CONCLUSIONS

In selected women, the efficacy of misoprostol for the induction of labour at term is similar to that of dinoprostone but misoprostol is associated with a higher incidence of hyperstimulation.

Adsorption of ammonium dinitramide (ADN) from aqueous solutions. 1. Adsorption on powdered activated charcoal

Investigations on the adsorption of ammonium dinitramide (NH(4)N(NO(2))(2)) (ADN) from aqueous solutions on powdered activated charcoal (PAC) were carried out in order to find out an effective and easier method of separating ADN from aqueous solutions. The effectiveness of PAC in the selective adsorption of ADN from aqueous solutions of ADN (ADN-F) and ADN in presence of sulfate (SO(4)(2-)) and nitrate (NO(3)(-)) ions (ADN-PS) was examined and compared using batch and column methods. The adsorption process follows both Langmuir and Freundlich adsorption isotherms and the isotherm parameters for the models were determined. The observed data favor the formation of monolayer adsorption. The adsorption capacities were found to be 63.3, 119, 105.3 and 82 mg of ADN per g of PAC for ADN-F (batch), ADN-PS (batch), ADN-F (column) and ADN-PS (column), respectively. Break-through curves for ADN-F and ADN-PS were obtained for the optimization of separation of ADN from aqueous solutions. Elution curves were generated for the desorption of ADN from PAC using hot water as eluent.

Is p53 haploinsufficient for tumor suppression? Implications for the p53+/- mouse model in carcinogenicity testing

The p53 tumor suppressor gene has been shown to be critical in preventing cancer in humans and mice. We have generated and extensively characterized p53-deficient mice lacking one (p53+/-) or both (p53-/-) p53 alleles. The p53-deficient mice are much more susceptible to an array of different tumor types than their wild-type (p53+/+) littermates. The enhanced tumor susceptibility of the p53+/- mice has made them one of several transgenic mouse models that are being considered as substitutes for standard 2-year rodent carcinogenicity assays. In order to fully exploit this model, it will be important to understand some of the basic biological and molecular mechanisms that underlie its enhanced tumor susceptibility. With this in mind, we have explored the fate of the remaining wild-type p53 allele in spontaneously arising p53+/- tumors and have shown that over half of these tumors retain an intact, functional wild-type p53 allele. This suggests that p53 is haploinsufficient for tumor suppression and that mere reduction in p53 dosage is sufficient to promote cancer formation. To support the idea that p53 is indeed a haploinsufficient tumor suppressor, we show here that normal p53+/- cells exhibit reduced parameters of growth control and stress response compared to their p53+/- counterparts. We hypothesize that the reduced p53 dosage in the p53+/- cells provides an environment more conducive to the development of further oncogenic lesions and the initiation of a tumor. Finally, we have assessed p53 loss of heterozygosity (LOH) in carcinogen-induced p53+/- tumors and have found that some agents induce tumors that almost invariably exhibit p53 LOH, whereas other agents induce tumors that often retain the wild-type p53 allele. Our preliminary data suggest that LOH is dependent on both the mechanism of genotoxicity of the agent utilized and the tissue type targeted.

p53 mutant mice that display early ageing-associated phenotypes

The p53 tumour suppressor is activated by numerous stressors to induce apoptosis, cell cycle arrest, or senescence. To study the biological effects of altered p53 function, we generated mice with a deletion mutation in the first six exons of the p53 gene that express a truncated RNA capable of encoding a carboxy-terminal p53 fragment. This mutation confers phenotypes consistent with activated p53 rather than inactivated p53. Mutant (p53+/m) mice exhibit enhanced resistance to spontaneous tumours compared with wild-type (p53+/+) littermates. As p53+/m mice age, they display an early onset of phenotypes associated with ageing. These include reduced longevity, osteoporosis, generalized organ atrophy and a diminished stress tolerance. A second line of transgenic mice containing a temperature-sensitive mutant allele of p53 also exhibits early ageing phenotypes. These data suggest that p53 has a role in regulating organismal ageing.

Differential regulation of IL-1beta and TNF-alpha RNA expression by MEK1 inhibitor after focal cerebral ischemia in mice

Activation of the extracellular-signal-responsive kinase (ERK 1/2) by MAP kinase/ERK kinase (MEK1/2) following ischemia/reperfusion in the brain has been associated with cell death since inhibition of MEK1/2 provides neuroprotection in cerebral ischemia injury. Since inflammation has been implicated in ischemic brain injury, the present study investigated whether MEK1/2 modifies expression of two key inflammatory cytokines, IL-1beta and TNFalpha, that have been shown to exacerbate ischemic brain injury. A mouse model of transient cerebral ischemia was deployed to test the effect of selective MEK1/2 inhibitor (SL327) on infarct size and cytokine expression. SL327 (100 mg/kg, i.p.) administered 15 min prior to ischemia resulted in 64% reduction in infarct size over controls (n = 8, P < 0.01). Under the same condition, SL327 significantly reduced peak expression of IL-1beta mRNA (59% reduction compared to vehicle, P < 0.01, n = 4) but not TNF-alpha mRNA. A parallel reduction in IL-1beta protein (67%, P < 0.05, n = 6) was also observed using ELISA analysis. These data suggest that the neuroprotective effect of MEK1/2 inhibition may be mediated by suppression of IL-1beta. The study also demonstrates for the first time that these two cytokines are differentially regulated by kinase mediated signaling pathways.

Review of the clinical results of arthroscopic meniscal repair

A total of 62 arthroscopic meniscal repairs (60 knees in 59 patients) over a 5-year period were evaluated retrospectively to assess outcome and to identify factors that might improve future clinical results. The overall success rate was 66.1%. Early repair within 3 months of sustaining the tear gave better results (91%) than if carried out later (58%). Suture repair alone yielded better results (78%) than meniscal arrows or a T-fix device (56%). Healing rates of atraumatic meniscus tears were much lower than for traumatic tears (42 vs. 73%). The isolated atraumatic medial meniscal tear appeared to do particularly poorly (33% healing) and may be better treated by meniscectomy.

Enhanced sensitivity to anti-benzo(a)pyrene-diol-epoxide DNA damage correlates with decreased global genomic repair attributable to abrogated p53 function in human cells

DNA damage from exposure to environmental chemical carcinogens and failure of repair systems to eliminate these lesions from the genome are considered as the crucial initial steps in the development of various human malignancies. Many cellular proteins are known to play vital roles to overcome the effects of DNA damage. Among such proteins, p53 is known to respond to DNA damage by accumulating in the nucleus and inhibiting cell cycle progression to facilitate DNA repair and the maintenance of genomic stability. In this study, we have investigated the role of p53 protein in modulating nucleotide excision repair of anti-benzo-(a)pyrene-diol-epoxide (BPDE)-DNA adducts and related effects using human fibroblasts with normal (p53-WT) and altered p53 protein (p53Mut and p53-Null). Interestingly, irrespective of the presence or absence of p53, the anti-BPDE dose-dependent p21 protein induction response was qualitatively comparable in all of the three cell lines. However, cells with defective p53 function were deficient for the removal of anti-BPDE-DNA adducts from the overall genome compared to cells with wild-type p53 activity. Strand-specific repair analysis within the individual strands of the p53 gene revealed decreased repair of adducts from the nontranscribed strand in p53-Mut and p53-Null cells. However, the repair of the transcribed strand appeared to be identical in all of the three cell lines. Furthermore, p53-Mut and p53-Null cells were more sensitive than p53-WT cells and displayed increased levels of anti-BPDE-induced apoptosis. Thus, wild-type p53 is required for the efficient global genomic repair of anti-BPDE-induced DNA adducts from the overall genome, but not for transcription-coupled repair of actively transcribed genes. These findings indicate that inefficient DNA repair of potentially cytotoxic and mutagenic lesions from the nontranscribed strand due to the loss of p53, but not the loss of p21, function might be responsible for enhanced cytotoxicity and apoptosis in human cells upon DNA damage.

Ultra-miniature headstage with 6-channel drive and vacuum-assisted micro-wire implantation for chronic recording from the neocortex

We describe a head-stage, with precision microtranslators for the chronic placement of micro-wire electrodes in the neocortex, that minimizes compressive damage to the brain. The head-stage has a diameter of 5.8 mm and allows six electrodes, separated by 450 microm on a hexagonal grid, to be individually and continuously positioned throughout a depth of approximately 3 mm. Suction is used to transiently support the dura against a curved array of tubes that guide and stabilize the electrodes as a means to prevent compression of the neocortex as the electrodes breach the dura. With this headstage we recorded extracellular signals in a rat immediately after surgery. Single-unit waveforms at a given electrode position were stable for at least several hours in the freely behaving animal and were obtained throughout the depth of the neocortex for at least 2 months. Electrophysiological records and histological examination showed that the upper layers of the neocortex were intact and minimally damaged after the implantation.

Retention of wild-type p53 in tumors from p53 heterozygous mice: reduction of p53 dosage can promote cancer formation

Tumor suppressor genes are generally viewed as being recessive at the cellular level, so that mutation or loss of both tumor suppressor alleles is a prerequisite for tumor formation. The tumor suppressor gene, p53, is mutated in approximately 50% of human sporadic cancers and in an inherited cancer predisposition (Li-Fraumeni syndrome). We have analyzed the status of the wild-type p53 allele in tumors taken from p53-deficient heterozygous (p53+/-) mice. These mice inherit a single null p53 allele and develop tumors much earlier than those mice with two functional copies of wild-type p53. We present evidence that a high proportion of the tumors from the p53+/- mice retain an intact, functional, wild-type p53 allele. Unlike p53+/- tumors which lose their wild-type allele, the tumors which retain an intact p53 allele express p53 protein that induces apoptosis following gamma-irradiation, activates p21(WAF1/CIP1) and Mdm2 expression, represses PCNA expression (a negatively regulated target of wild-type p53), shows high levels of binding to oligonucleotides containing a wild-type p53 response element and prevents chromosomal instability as measured by comparative genomic hybridization. These results indicate that loss of both p53 alleles is not a prerequisite for tumor formation and that mere reduction in p53 levels may be sufficient to promote tumorigenesis.

Murine tumor suppressor models

Tumor suppressor genes have been shown to be necessary for proper maintenance of cell growth control. Inactivation of these genes in the germline of humans is linked to inherited cancer predisposition. Moreover, sporadically arising human tumors often have somatic mutations in tumor suppressor genes. During the past few years, advances in molecular and cellular biology have led to the creation of animal models that have germline mutations of various tumor suppressor genes. Such mice potentially represent important animal models for familial cancer predisposition syndromes, and the study of the tumorigenesis process has been greatly assisted by their development. Such models have also demonstrated the importance of tumor suppressor function in embryonic development. In this review, we describe mice with inactivated germline tumor suppressor genes that are genetically analogous to 10 different inherited cancer syndromes in humans. We describe the variable usefulness of the mutant mice as models for human disease.