Defining oligometastatic pancreatic cancer: a systematic review and critical synthesis of consensus

BACKGROUND

Small retrospective series suggest that local consolidative treatment (LCT) may improve survival in oligometastatic pancreatic ductal adenocarcinoma (PDAC). However, no uniform definition of oligometastatic disease (OMD) in PDAC exists; this impedes meaningful conclusions.

PATIENTS AND METHODS

A systematic literature search using PubMed, Web of Science, and Cochrane CENTRAL registries for studies and protocols reporting on definitions and/or LCT of OMD in PDAC was performed. The primary endpoint was the definition of OMD. Levels of agreement were categorized as consensus (≥75% agreement between studies), fair agreement (50%-74%), and absent/poor agreement (<50%).

RESULTS

After screening of 5374 abstracts, the full text of 218 studies was assessed, of which 76 were included in the qualitative synthesis. The majority of studies were retrospective (n = 66, 87%), two were prospective studies and eight were study protocols. Studies investigated mostly liver (n = 38, 51%) and lung metastases (n = 15, 20%). Across studies, less than one-half (n = 32, 42%) reported a definition of OMD, while 44 (58%) did not. Involvement was limited to a single organ (consensus). Additional criteria for defining OMD were the number of lesions (consensus), metastatic site (poor agreement), metastatic size (poor agreement), treatment possibilities (poor agreement), and biomarker response (poor agreement). Liver OMD could involve three or fewer lesions (consensus) and synchronous disease (fair agreement), while lung metastases could involve two or fewer lesions and metachronous disease (consensus). The large majority of studies were at a high risk of bias or did not include any control groups.

CONCLUSION

Definitions of OMD were not used or varied widely between studies hampering across-study comparability and highlighting an unmet need for a consensus. The present study is part of a multistep process that aims to develop an interdisciplinary consensus on OMD in pancreatic cancer.

Detection of a knockdown mutation in the voltage-sensitive sodium channel associated with permethrin tolerance in Sarcoptes scabiei var. hominis mites

BACKGROUND

Increasing evidence has sparked a debate on the loss of sensitivity of scabies mites to conventional permethrin therapy. Mutations in the voltage-sensitive sodium channels (VSSC) were associated with knockdown resistance (kdr) in many arthropods, but have never been identified in Sarcoptes scabiei variatio (var.) hominis mites.

OBJECTIVES

To identify factors contributing to therapy failure.

METHODS

Sixty-seven mites were collected from 64 scabies-infested patients in Vienna, Austria, of whom 85.9% were refractory to prior permethrin-based treatments, and genotyped for the presence of nucleotide polymorphisms in Domain II of the VSSC, known to be associated with kdr. Information regarding previous antiscabietic therapies, decontamination procedures and possible re-infestations by contacts as well as the response to re-imposed therapies were obtained.

RESULTS

Sequence alignment comparisons revealed previously unidentified mutations in the coding region of Domain II of the VSSC. A novel A1663T transversion was detected in 97.0% of the mites, resulting in a non-synonymous substitution from methionine to leucine, M918L, a mutation known to confer kdr in other arthropods. In addition, a synonymous G1659A transition was identified in one mite, which otherwise showed a nucleotide sequence identical to the wild-type reference. No major inconsistencies were observed within the previous therapeutic and decontamination procedures, which could have accounted for the observed non-responsiveness to permethrin-based therapies. Subsequent cure of infestation was achieved in 65.6% of the participants, predominantly by combination therapies with topical permethrin and systemic ivermectin. However, in 14.6% of the cured cases, permethrin monotherapy sufficed for eradication of scabies, albeit in some cases prolonged exposure was necessary.

CONCLUSIONS

The kdr-associated M918L mutation in the VSSC gene has now emerged in S. scabiei var. hominis mites. Hence, loss of sensitivity to permethrin due to kdr-type resistance may be more prevalent than anticipated and may be decisive for the therapy responsiveness of scabies-infested patients.

[Lay version of the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis : Translation into German and linguistic validation in German-speaking countries with people affected]

BACKGROUND

Physical activity and exercise are beneficial for people with rheumatic diseases; however, recommendations for the management of rheumatoid arthritis (RA), spondyloarthritis (SpA) and hip- and knee osteoarthritis (HOA/KOA) are usually unspecific with respect to mode and dose of exercise. This is why the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis were formulated. The recommendations consist of 4 overarching principles and 10 recommendations. These were also published as a lay version in the English language.

AIM

Translation of the lay version into German and its linguistic validation in Austria, Germany and Switzerland.

METHODS

A professional translation was reviewed by the authors, including people with, RA, SpA, HOA/KOA from the three German-speaking countries, which provided a prefinal lay version. Subsequently, eight interviews with people with RA, SpA, HOA/KOA were conducted in each country to evaluate understandability, wording, completeness and feasibility of the prefinal lay version. Finally, the authors, i.e. those with RA, SpA, and osteoarthritis, anonymously rated their agreement to the final lay version on a 0-10 scale.

RESULTS

The professional translation was substantially revised by the authors and based on the interviews. Formulations were adapted to increase readability and understandability and specify statements. Comments that would have changed content or structure were not considered. Average agreement with the particular recommendations was between 10 (SD 0) and 7.6 (SD 1.67).

DISCUSSION

For people with RA/SpA/HOA/KOA the EULAR physical activity recommendations should be available in their mother language. The final German lay version is valid and accepted across all three German-speaking countries. Thus, the physical activity recommendations can be provided to people with rheumatic diseases in an understandable and feasible way.

AB1177 SEXUALITY, FAMILY PLANNING AND MENTAL HEALTH AMONG REPRODUCTIVE-AGE WOMEN WITH RHEUMATIC DISEASE DURING THE COVID-19 PANDEMIC

Background

Women with rheumatic disease are more likely to suffer from sexual dysfunction, infertility, depression, and anxiety. The pandemic may have affected these constraints.

Objectives

To investigate the effect of the Covid-19 pandemic on sexuality, family planning and mental health in a sample of women with rheumatic disease.

Methods

Women aged 18-50 with a rheumatic disease and women in an age-matched healthy control group received questionnaires featuring: 1) demographic information, sexual frequency, family planning; 2) the Female Sexual Function Index (FSFI); 3) the Depression, Anxiety and Stress Scale (DASS-21); and 4) the Coronavirus Anxiety Scale (CAS). Recruitment took place 3/21-12/21. Patients with rheumatic conditions were recruited at the Vienna University Clinic (AKH) and the control group through social media. Parameters were compared between the patients and the healthy control group, and with data on sexuality from women with rheumatic disease from 2019.

Results

A preliminary analysis was conducted with 83 patients with rheumatic disease and 124 healthy controls. The rheumatic disease group exhibited lower levels of stress (6.46 vs. 8.36 p<0.01) and Coronavirus Anxiety (6.27 vs 7.50 p<0.01) than the control group and was less likely to report that the pandemic led to a reduction of their sexual frequency (p<0.01). The control group cited “stress” frequently the decrease of sexual frequency. The FSFI analysis revealed that patients with rheumatic disease experienced higher levels of pain (p<0.001) during sex than the control group but were more satisfied with their relationships (p<0.05). In comparison to 58 patients with rheumatic conditions, whose data was collected in 2019, the 2021 cohort reported reduced FSFI values in the domains of desire (p<0.01), arousal (p<0.05), lubrication (p<0.05), and orgasms (p<0.01).

Conclusion

Consistent with research on female sexuality during the pandemic among healthy women, we found that patients with rheumatic conditions reported lower FSFI values in 2021, in comparison to 2019. Our finding that the pandemic had less impact on the patient group than a healthy control group, is consistent with research on MS and IBD patients, who showed surprising resilience in the face of the Covid-19 pandemic.

Disclosure of Interests

None declared

POS1506-HPR SYSTEMATIC LITERATURE REVIEW TO INFORM THE EULAR TASK FORCE FOR RECOMMENDATIONS/POINTS TO CONSIDER FOR THE NON-PHARMACOLOGICAL MANAGEMENT OF SYSTEMIC LUPUS ERYTHEMATOSUS AND SYSTEMIC SCLEROSIS

Background

The heterogeneity and complexity of the chronic autoimmune diseases systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) necessitate comprehensive person-centred management, including non-pharmacological approaches. Recommendations for non-pharmacological management are currently lacking.

Objectives

To perform a systematic literature review to inform the EULAR task force for recommendations/points to consider for the non-pharmacological management of adult patients with SLE and SSc. Among research questions formulated by the task force, we aimed at identifying (i) non-pharmacological interventions that have been evaluated and (ii) their target health domains or organ systems.

Methods

We searched the Medline, Embase, Web of Science Core Collection and CINAHL for articles published between January 2000 and June 2021. From the initial search (n=15,803), 2 researchers independently performed the article selection. Conflicts were discussed until consensus with 2 additional researchers. Subsequent data extraction from the selected articles was performed by 4 researchers, with an overarching guidance by 2 additional researchers. Risk of bias assessment was performed according to Joanna Briggs Institute Critical Appraisal Checklists.

Results

A total of 111 articles for SLE and 75 for SSc were selected for analysis.

Non-pharmacological interventions identified for SLE included physical exercise (n=34), psychological support (n=21), dietary therapy and nutrition (n=15), patient education and self-management (n=14), photoprotection (n=5), medication adherence interventions (n=5), complementary and alternative medicine (CAM) e.g., Chinese medicine (n=5), multidisciplinary care (n=4), and phototherapy/laser modalities (n=4).

Interventions identified for SSc included physical exercise e.g., hand, oral and general exercise (n=21), phototherapy/laser modalities or shockwave therapy (n=15), patient education and self-management (n=10), CAM (n=8), hand-bathing e.g., in paraffin (n=5), manual therapy e.g., osteopathic manipulative treatment (n=5), dietary therapy and nutrition (n=5), oral hygiene (n=2), hyperbaric oxygen or ozone therapy (n=2) and multidisciplinary care (n=2).

Target health domains and organ systems identified within SLE included (in descending order) (i) disease activity, (ii) health-related quality of life (HRQoL), (iii) depression/anxiety, (iv) fatigue, (v) organ damage, (vi) inflammatory markers, (vii) psychological stress, (viii) pain, (ix) body composition/anthropometry, and (x) aerobic capacity.

Intervention targets in SSc included (i) functional impairment e.g., hand mobility, (ii) skin sclerosis including microstomia, (iii) HRQoL, (iv) pain, (v) circulation e.g., Raynaud’s phenomena and telangiectasias, (vi) skin ulcers, (vii) oral hygiene, (viii) fatigue, (ix) digestion, and (x) depression/anxiety.

Conclusion

Physical exercise was a frequently researched non-pharmacological intervention within both SLE and SSc. While psychological support and dietary therapy/nutrition were frequently investigated in SLE, phototherapy modalities were common in SSc. Patient education and self-management was advocated in both SLE and SSc literature. HRQoL was a frequent target domain in both diseases; while disease activity and psychosocial domains emerged as important targets in SLE, functional impairment and skin-related aspects constituted predominant targets in SSc. Efficacy of interventions varied considerably across studies. Current evidence is limited by the overall small study populations, and the lack of large RCTs.

Table 1.

Studies categorised by design.

Study designSLESScMeta-analysis of RCTs51RCT (including long-term follow-up or post-hoc analysis)4128Non-randomised longitudinal controlled/cohort studies287Retrospective cohort study, cross-sectional or case-control study162Case series or open pilot studies2137

Acknowledgements

The authors would like to thank the members of the EULAR task force for recommendations/points to consider for the non-pharmacological management of systemic lupus erythematosus and systemic sclerosis (in alphabetical order by family name) i.e., Helene Alexanderson, Laurent Arnaud, Oliver Distler, Andrea Domján, Els van den Ende, Kim Fligelstone, Agnes Kocher, Maddalena Larosa, Martin Lau, Alexandros Mitropoulos, Mwidimi Ndosi, Gunilla von Perner, Janet Poole, Anthony Redmond, Valentin Ritschl, Yvonne Sjöberg, Tillmann Uhlig, Cecília Varjú, Joke Vriezekolk, Elisabet Welin, and Rene Westhovens, for their contribution to the formulation of the research questions together with IP, CG, TS and CB.

Disclosure of Interests

None declared

POS0160 THE EMPLOYMENT GAP IN PEOPLE WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES COMPARED WITH THE GENERAL POPULATION: A SYSTEMATIC LITERATURE REVIEW

Background

Many people with rheumatic and musculoskeletal diseases (RMDs) experience problems at work and some may even have to stop working due to ill health. In most countries, RMDs are a major cause of worker productivity loss. The peak age of onset of many adult onset RMDs is between ~30-50 years, meaning that the majority of patients are still in employment when diagnosed with their chronic disease. Uncertainty about employment prospects and job attainment is also a major concern for young adults with juvenile idiopathic arthritis (JIA) for whom their first job may influence their future employment prospects. From both a societal and patient perspective it is important to gain an understanding about the impact of juvenile and adult onset RMDs on work outcomes. Data comparing productivity loss with the general population are more relevant for care and healthcare planning. However, these data are more scarce and have not been summarized recently across RMDs.

Objectives

To systematically summarize the literature on work outcomes in people with RMDs compared with the general population.

Methods

A systematic literature review (SLR) was conducted to compare work outcomes in people with various RMDs (i.e. JIA, RA, PsA, AxSpA, SSc, SLE, gout, FM, and OA) with the general population or healthy controls as part of the EULAR Task Force on work. A search for eligible observational studies was performed in Medline, Embase and PsycInfo between 2000 and May 2021. Work outcomes were categorizedaccortding to employment status, work disability/stopped working due to ill health, absenteeism, presenteeism and other.

Results

541 abstracts were extracted and screened for eligibility. Results of 65 studies fulfilling the inclusion criteria were evaluated for this study, including 28 prospective/retrospective longitudinal cohort studies, 34 cross-sectional studies and 3 (nested) case-control studies. The majority of the studies were conducted in Europe (63.1%). The most common RMD evaluated was RA (26.2%) followed by OA (15.4%), SLE (15.4%), AxSpA (12.3%), FM (9.2%), mixed population (7.7%), JIA (7.7%), PsA (3.1%), SSc (1.5%), and gout (1.5%). In papers reporting disease duration (n=38), the majority of the study population had established disease (76.3%). Several work outcomes were evaluated with some papers reporting more than one work outcome: employment/work status (41.5%), unemployment (9.2%), work disability/pension or stopping work due to ill health (38.5%), absenteeism (52.3%), presenteeism (10.8%), and other (e.g. reduced working hours) (29.2%). Fifty-two papers applied statistical tests (e.g. indirect standardisation, logistic regression analysis, Cox regression analysis) to compare work outcomes in people with RMDs with a control/general population. The percentage of papers reporting the work outcomes to be worse, not significantly different or better in the RMD population compared to the control population (n papers included per work outcome; %) was, respectively: employment/work status (n=26; 73.1%, 23.0%, 3.8%), unemployment (n=6; 66.7%, 33.3%, 0%), work disability/stopping work (n=22; 90.9%, 9.4%, 0%), absenteeism (n=26; 92.3%, 7.7%, 0%), presenteeism (n=8; 87.5%, 12.2%, 0%), other (n=19; 84.2%, 15.8%, 0%).

Conclusion

Despite better disease management during the last two decades there is still a significant employment gap between people with RMDs and the general population. It is therefore essential that health professional organisations, policy makers, patient organisations and employers should collaborate to minimize the employment gap and optimize employment opportunities among people with juvenile and adult onset RMDs.

Disclosure of Interests

Suzanne Verstappen Consultant of: EUOSHA, Grant/research support from: BMS, AbbVie, Pfizer, EULAR, Annelies Boonen Speakers bureau: Abbvie / Galapagos, Consultant of: Galapagos, Nicola Goodson Consultant of: UCB, Lilly, Abbvie, Novartis and Janssen, Grant/research support from: Novartis, Casper Webers: None declared, Maarten Butink: None declared, Neil Betteridge Consultant of: Amgen, Eli Lilly, EULAR, GAfPA, Grunenthal, Heart Valve Voice and Sanofi, Tanja Stamm Consultant of: AbbVie and Sanofi Genzyme, Grant/research support from: AbbVie and Roche, Dieter Wiek: None declared, Anthony Woolf: None declared, Hans Bijlsma: None declared, Gerd Rüdiger Burmester: None declared

AB1393 RHEUMABUDDY4.0 LEADING THE PATH TO A PATIENT-DRIVEN ELECTRONIC SUPPORT AND MONITORING TOOL

Background

The use of health apps has become more popular in recent years, but it is still a small and rather unregulated market. Few apps have been designed in collaboration with patients and these mostly address patient reported symptoms. Some clinical registries have already developed patient apps to complete patient-reported outcome measures (PROMs) on smartphones, which normally would have been collected during an outpatient visit and have shown interchangeability. The next step would be providing a patient app offering possibilities not only of individual disease tracking, but to provide automated peer support, health information and behavioural advice.

Objectives

We aimed to further develop and validate RheumaBuddy, a health app for patients with rheumatoid arthritis (RA), from a standard monitoring app to an intelligent health app tailored to the needs of the user that provides transparency to all important stakeholders in Rheumatology care.

Methods

This is an international interdisciplinary project between Austrian and Danish partners funded by the EUREKA program. Rheumatologists, health scientists, digital data experts and patients with RA joined forces in a 4 phase-program, running from 2020 to 2023. Phase 1 continues to develop the app in a co-creation approach in several iterations with patients. Phase 2 concerns developing an automated learning algorithm based on user data to identify patient strata and connect these with helpful non-pharmacological interventions. Phase 3 connects healthcare system data on diagnosis, medication prescription, healthcare facility usage with a large clinical RA database. By that we develop patient pathways that correlate high granularity data with system resources to retrieve results on socioeconomic impact. In phase 4 a randomised clinical trial will evaluate the effect of the developed RB4.0 on clinical disease activity and quality of life.

Results

Currently, RB is regularly being used by more than 3100 patients in 35 countries and 8 languages throughout Europe. The current RheumaBuddy version offers logging of symptoms using Likert scale questions, a joint mannequin to mark painful body parts and a peer-support forum. Additionally, the user can anytime display his/her entries over time in a graphical report and also share data with the healthcare provider. This version is extended with tracking of sleep, working hours and other behaviours. A consultation compass function helps the patient to reflect on goals and issues before the rheumatologist visit.

Within this project, we already established a first version of a Recommender System (RS), which computes correlations between user entries (e.g. between a user’s mood and pain), thus providing individual feedback. Through integration of information obtained from the app with claims data and clinical data from a RA registry, patterns can be identified and translated into different case models that concern the impact of common RA symptoms. By mapping these scenarios with evidence based behaviour and lifestyle advice, the “virtual coach” (advanced RS) will be developed and integrated into the RB4.0 system. During continuous data collection on app users, similarities in user behaviour can be identified, and similar entry patterns can be grouped. This will allow users to exchange and learn from each other regarding certain difficult situations (ex. “life-hack”) etc.

We are creating a comprehensive system in providing feedback to both clinical and psychosocial aspects of coping and disease management, as well as everyday practicalities for living with a chronic disease. Figure 1 displays these aspects, contributing the empowerment of patients.

Figure 1.

RB4.0 shall support people living with RA in dealing with disease impact

Conclusion

RheumaBuddy4.0 will provide RA patients the means to improve their quality of life on an individual level, better understand their needs and therapy which could support overcoming barriers of successful shared decision making to achieve better outcomes.

Disclosure of Interests

Paul Studenic: None declared, Tanja Stamm Speakers bureau: AbbVie, Novartis, Roche, Sanofi, and Takeda, Consultant of: AbbVie and Sanofi Genzyme, Grant/research support from: AbbVie and Roche, Yuki Seidler: None declared, Andreas Dam Speakers bureau: Gilead, Galapagos, BMS, Roche, Takeda, Merck, Consultant of: Gilead, Galapagos, BMS, Roche, Takeda, Merck, Nadine Weibrecht: None declared, Günther Zauner: None declared, Thomas H Jakobsen: None declared, Rebekka L. Hansen: None declared, Nikolas Popper Speakers bureau: Roche, Consultant of: as CSO of dwh GmbH, Tanita-Christina Wilhelmer: None declared, Helga Radner Speakers bureau: Gilead, Merck Sharp, Pfizer, Abbvie, Consultant of: Gilead, Merck Sharp, Pfizer, Abbvie, Romualdo Ramos: None declared, James Rickmann: None declared, Christoph Urach: None declared, Lars Erik Kristensen Speakers bureau: AbbVie, Pfizer Janssen, Novartis, Galapagos, UCB, Biogen and Eli Lilly, Consultant of: AbbVie, Pfizer, Janssen, Novartis, Galapagos, UCB, Biogen and Eli Lilly, Grant/research support from: IIT grants from UCB, Biogen, Eli Lilly, Novartis, Tanja Schjødt Jørgensen Speakers bureau: AbbVie, Pfizer, Roche, Novartis, UCB, Biogen and Eli Lilly, Consultant of: AbbVie, Pfizer, Roche, Novartis, UCB, Biogen and Eli Lilly

POS1552-HPR A SYNTHESIS OF GUIDANCE AVAILABLE FOR ASSESSING METHODOLOGICAL QUALITY AND GRADING OF EVIDENCE FROM QUALITATIVE RESEARCH TO INFORM CLINICAL RECOMMENDATIONS: A SYSTEMATIC REVIEW

Background

Qualitative research is crucial to understand key stakeholders experiences and perspectives of care and health services. However, there is a lack of explicit frameworks and guidelines about how best to use qualitative evidence to formulate clinical recommendations. Part of the problem includes uncertainties about the contributions of qualitative research to the evidence, and the empirical and theoretical basis for appraising and synthesizing qualitative evidence in a standardized manner. In addition, most existing grading systems of qualitative research originates from quantitative research, and there is no clear guidance about how to incorporate qualitative research into the evidence hierarchy.

Objectives

To conduct a systematic literature review (SLR) to answer two research questions (RQ):

RQ1) What guidance (e.g., tools, checklists, frameworks) exists to assess the methodological quality of qualitative research employed to inform clinical recommendations?;

RQ2) What methods exist specifically to grade levels of evidence for qualitative research?

Methods

The protocol for this review was registered on www.researchregistry.com (reviewregistry1240). Electronic databases (PubMed/Medline, EMBASE, Web of Science, COCHRANE, Emcare, PsycINFO, ERIC, Academic Search Premier, Sociological Abstracts, ProQuest Dissertations and Thesis Global) were searched for published and unpublished studies. Searches were completed from inception to 23rd October 2020. No restrictions were applied to clinical population. Eligible studies for both questions included primary articles and guideline documents available in English, describing the: i) development; ii) application of validated tools (e.g., checklists); iii) guidance on how to assess methodological quality of qualitive research and iv) guidance on how to grade levels of qualitative evidence. Opinion pieces and conference abstracts were excluded. Manual searches of the reference lists of full text articles were conducted. Two reviewers independently screened the titles, abstracts, and full text. A narrative synthesis was conducted to identify key aspects between the included studies.

Results

9071 records were retrieved (Figure 1). After de-duplication and title/abstract screening, 51 full-articles articles were assessed for eligibility yielding 15 included articles. For RQ1, six articles were included that described six tools (1) The society for Critical Care Medicine Family – Cantered Care Guidelines; 2) Nursing Management of the Second Stage of Labour evidence based clinical practice guidelines; 3) Jonna Briggs Institute Critical Appraisal of Qualitative Studies; 4) Critical Skill’s Appraisal Programme (CASP) and 6) the Modified CASP checklist). All tools ranged from 10 to 30 items, and evaluated research design, recruitment, ethical rigour, data collection and data analysis. Seven articles described one approach (GRADE CER-Qual) to assess methodological quality of qualitative research. This approach advised on the importance for assessing methodological limitations. For RQ2, two articles were included, one described a qualitative hierarchy of evidence, and another described a research pyramid that included a section on qualitative research.

Figure 1.

PRISMA diagram of included papers

Conclusion

This review highlights lack of consensus and limited availability of tools, checklists, and approaches to 1) appraise the methodological quality of qualitative research used to inform clinical recommendations and 2) grade levels of evidence for qualitative research. Current research agendas will need to determine the most relevant and appropriate method for the quality appraisal of qualitative research. This way, qualitative research could be more consistently and appropriately applied to the development of clinical recommendations.

References

N/A

Disclosure of Interests

Mandeep Sekhon: None declared, Annette de Thurah: None declared, George E. Fragoulis: None declared, Tanja Stamm: None declared, T.P.M. Vliet Vlieland: None declared, Bente Appel Esbensen: None declared, Heidi Lempp: None declared, Lindsay Bearne: None declared, Marios Kouloumas: None declared, Polina Pchelnikova: None declared, Thijs W. Swinnen: None declared, Chris Blunt: None declared, Ricardo J. O. Ferreira: None declared, Loreto Carmona: None declared, Elena Nikiphorou Speakers bureau: Celltrion, Pfizer, Sanofi, Gilead, Galapgos, AbbVie, Eli Lilly, Grant/research support from: Pfizer, Eli Lilly

POS1470-HPR KNOWING WHAT TO DO WITH THE DATA - A QUALITATIVE STUDY ON CHALLENGES OF USING SMARTPHONE-BASED ePROs IN RHEUMATOID ARTHRITIS

Background

Using patient-reported outcomes (PROs) has a long tradition in rheumatology, and PRO measurement is included in many composite indices evaluating disease progression and treatment response [1]. However, little is known about patients´ and health professionals´ (HPs) perceptions of using digitally collected PROs, the so-called ePROs, with a personal smartphone app.

Objectives

To identify main challenges in utilising ePROs for management and treatment of rheumatoid arthritis from patients’ and HPs’ perspectives.

Methods

We interviewed 25 people with rheumatoid arthritis (RA) and 17 HPs (nurses, rheumatologists, and physiotherapists) from Austria and Denmark. We used the RheumaBuddy app as a practical example to illustrate the digital data collection and the feedback that patients would get from entering their self-reported outcomes. Interviews were recorded and transcribed. We applied a qualitative thematic analysis to identify major themes using a procedure of rigorous coding. Analysis was done by two researchers, and conflicts were solved by consensus. Ethical approval was obtained in both countries.

Results

Three main themes emerged: 1) Being simple yet comprehensive; 2) Resources to interpret, use and act upon the collected data; and 3) Being reminded of the disease. Within the first theme, many valued the intuitiveness and simplicity of ePROs, especially when used as a monitoring tool in between clinical visits. HPs were concerned about not to overwhelm the patients with too many questions. On the other hand, the short ePROs asked in the app were not comprehensive enough to capture psychosocial and lifestyle aspects of the disease which were considered important both by patients and HPs. Within the second theme, patients and HPs expressed that ePROs could be the basis for shared decision making. Nevertheless, some patients had clearer ideas on making use of the feedback they could get from their self-reported data than the others. Participants from Denmark, who experienced a higher level of digital health maturity in official institutions, expressed more proactive use of the data than participants from Austria who were on average younger than their Danish counterparts. One patient in Austria even asserted having no idea what to do with the collected data but believed that the “doctor will make good use of it”. HPs in both countries, however, indicated that they needed more resources, skills, and time to make sense of the ePRO data and act accordingly. Under the third theme, patients considered the collection of ePROs to be very important when pain and disease activity were high. HPs, on the other hand, were more concerned that the regular collection of ePROs might constantly remind patients that they are living with the disease.

Conclusion

The potential adoption of ePROs in practice depends on both patients and HPs’ motivations and ideas to use the feedback they would get from the collected data. This might be influenced by the level of digital health maturity of a country, as well as available resources. In addition, ePROs need to be intuitive and simple, but at the same time comprehensive and reliable enough so that they can be used for shared decision making. Challenges remain for the ePROs to be used as supporting and empowering tools, and not as reminders of the disease and pain.

Table 1.

Demographic data of the participants (N=42)

DemographicAustriaDenmarkTotalDataPatientHPPatientHPPatientHPN14101172517Women (%)10(71)6(60)7(64)5(71)17(68)11(65)Men (%)4(29)4(40)4(36)2(29)8(32)6(35)AgeMean (Range)54(30-76)41(29-63)65(37-77)47(31-59)60(30-77)44(29-63)

References

[1]T Stamm, I Parodis, and P Studenic. Patient-reported outcomes with anifrolumab in patients with systemic lupus erythematosus, Lancet Rheumatol, (2022), in Press.

Acknowledgements

We would like to express our particular thank you to all those who have taken part in the interview study and for their valuable inputs.

Disclosure of Interests

Yuki Seidler: None declared, Tanja Schjødt Jørgensen Speakers bureau: AbbVie, Pfizer, Roche, Novartis, UCB, Biogen and Eli Lilly., Consultant of: AbbVie, Pfizer, Roche, Novartis, UCB, Biogen and Eli Lilly, Paul Studenic: None declared, Helga Radner Speakers bureau: Gilead, Merck Sharp, Pfizer, Abbvie, Consultant of: Gilead, Merck Sharp, Pfizer, Abbvie, Thomas Nygaard: None declared, Nadine Weibrecht: None declared, Nikolas Popper Speakers bureau: Roche, Consultant of: dwh GmbH (as CSO), Lars Erik Kristensen Speakers bureau: Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals, Consultant of: Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals, Grant/research support from: IIT research grants from Novo, UCB, Eli Lilly; Novartis and Abbvie, Tanita-Christina Wilhelmer: None declared, James Rickmann: None declared, Erika Mosor: None declared, Valentin Ritschl: None declared, Tanja Stamm Speakers bureau: AbbVie, Novartis, Roche, Sanofi, and Takeda., Consultant of: AbbVie and Sanofi Genzyme., Grant/research support from: AbbVie and Roche.

POS0380 EFFECTIVENESS OF REMOTE CARE INTERVENTIONS: A SYSTEMATIC REVIEW INFORMING THE 2022 EULAR POINTS TO CONSIDER FOR REMOTE CARE IN RHEUMATIC AND MUSCULOSKELETAL DISEASES

Background

While the number of patients with rheumatic musculoskeletal diseases (RMDs) is increasing worldwide, there is no adequate increment in the number of health care professionals, leading to the urgent need for new forms of care to take pressure from health care systems.1 2 Telehealth comprises a number of different types of interventions with the scope of performing certain steps of care, ranging from diagnostics to follow-up visits, in a remote manner. The use of remote care is heterogenous and guidance is needed to optimize the combination with conventional face-to-face (F2F) visits.

Objectives

To perform a systematic literature review (SLR) on different outcomes of remote care compared to F2F care, its implementation into clinical practice and to identify drivers and barriers in order to inform a task force formulating the European Alliance of Associations for Rheumatology (EULAR) Points to Consider for remote care in RMDs.

Methods

Prospective, retrospective, and qualitative studies testing different types of remote care in patients with RMDs were included. Medline, Embase and the Cochrane Library were searched through February 28th, 2021. Two reviewers independently performed standardized data extraction, synthesis, and risk of bias assessment.

Results

A total of 2,240 references were identified. Forty-seven studies, consisting of 26 randomized controlled trials, 8 prospective cohort studies, 8 cross sectional studies, and 5 qualitative studies were included.

Fifty-one percent of the studies involved patients with inflammatory RMDs, including rheumatoid arthritis, and spondyloarthritis, while 49% were on patients with non-inflammatory conditions, such as osteoarthritis and fibromyalgia. Remote monitoring (n=35) was most frequently studied, with telephone/video calls being the most common mode of delivery (n=30). Thirty-four studies investigated outcomes of remote care in comparison to F2F care. The most frequently assessed outcomes concerned efficacy and user perception of remote care, with 34% and 21% of studies, respectively, reporting superior results for the remote care intervention.

Time savings and flexibility were reported as major drivers, while inadequate technical knowledge and concerns in data security were the main barriers to implementing remote care. Implementation of remote care methods into clinical practice was not reported by the included studies. The main limitations were the heterogeneity of outcomes and interventions, and the substantial risk of bias (50% of studies with high risk of bias).

Conclusion

Studies on remote care reported similar to partially better results compared to F2F care concerning efficacy, and user perception outcomes, with the limitation of heterogeneity and considerable risk of bias.

References

[1]World Health Organization. WHO Guideline: recommendations on digital interventions for helath system strengthening. 2019 [Available from: https://apps.who.int/iris/bitstream/handle/10665/311941/9789241550505-eng.pdf?ua=1 accessed 10.01.2022.

[2]James SL, Abate D, Abate KH, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392(10159):1789-858. doi: https://doi.org/10.1016/S0140-6736(18)32279-7

Disclosure of Interests

Andrea Marques: None declared, Philipp Bosch: None declared, Annette de Thurah Speakers bureau: Pfizer, Eli Lily, Grant/research support from: Novartis, Yvette Meissner Speakers bureau: Pfizer, Louise Falzon: None declared, Chetan Mukhtyar: None declared, Hans Bijlsma Speakers bureau: Abbvie, Arthrogen, BMS, Lilly, MSD, Pfizer, Roche, Sun, UCB, Consultant of: Abbvie, Arthrogen, BMS, Lilly, MSD, Pfizer, Roche, Sun, UCB, Grant/research support from: Roche, Sun, Christian Dejaco Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos, Sanofi, Consultant of: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos, Sanofi, Grant/research support from: Celgene, Pfizer, Tanja Stamm Speakers bureau: AbbVie, Roche, Sanofi, Takeda, Consultant of: Abbvie, Sanofi, Grant/research support from: Abbvie, Roche

RECOMMENDATIONS FOR USE AND SCORING OF ORAL HEALTH IMPACT PROFILE VERSIONS

BACKGROUND

OHIP's original seven-domain structure does not fit empirical data, but a psychometrically sound and clinically more plausible structure with the four OHRQoL dimensions Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact has emerged. Consequently, use and scoring of available OHIP versions need to be revisited.

AIM

We assessed how well the overall construct OHRQoL and its four dimensions were measured with several OHIP versions (20, 19, 14, and 5 items) to derive recommendations which instruments should be used and how to score them.

METHODS

Data came from the "Dimensions of OHRQoL Project" and used the project's learning sample (5,173 prosthodontic patients and general population subjects with 49-item OHIP data). We computed correlations among OHIP versions' summary scores. Correlations between OHRQoL dimensions, on one hand, and OHIP versions' domain scores or OHIP-5's items, on the other hand, were also computed. OHIP use and scoring recommendations were derived for psychometrically solid but also practical OHRQoL assessment.

RESULTS

Summary scores of 5-, 14-, 19- and 49-item versions correlated highly (r = 0.91-0.98), suggesting similar OHRQoL construct measurement across versions. The OHRQoL dimensions Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact were best measured by the OHIP domain scores for Physical Disability, Physical Pain, Psychological Discomfort, and Handicap, respectively.

CONCLUSION

Recommendations were derived which OHIP should be preferably used and how OHIP versions should be scored to capture the overall construct and the dimensions of OHRQoL. Psychometrically solid and practical OHRQoL assessment in all settings across all oral health conditions can be achieved with the 5-item OHIP.

POS1468-HPR THE IMPACT OF COVID-19 ON RHEUMATOLOGY HEALTH CARE WORKERS AND THEIR SCIENTIFIC OUTPUT: HEAVY LIES THE CROWN ON FEMALE RHEUMATOLOGISTS

Background:

COVID-19 has changed daily practice in medicine and affected teaching as well as research activities of medical personnel. Meanwhile, the pandemic´s impact on private life and responsibilities for dependents also affected health care workers in rheumatology.

Objectives:

To examine the adaptability of clinician-researchers in rheumatology in a time of crisis focusing on academic output in the first six months of the COVID-19 pandemic and to investigate the professional and private burden experienced by health care workers in rheumatology.

Methods:

A systematic search in PubMed, medRxiv and bioRxiv for reports of rheumatic diseases and COVID-19/SARS-CoV-2 submitted (or published) from January 1 to June 30 2020 was carried out. As comparison, publications from April 6 to 13 2019 of the same rheumatic diseases without COVID-19 were analysed in terms of author characteristics and journal metrics. Additionally, a questionnaire was circulated via EULAR countries rheumatology societies and individual working group members. The participants were asked to answer 43 questions regarding their family situation, professional background, research output, changes in work and private responsibilities during the pandemic as well as the burden experienced. Responses were collected using an online survey tool and data analyses performed with SPSS Statistics 25; missing variable analysis was performed, excluding records with >15% missing responses. Descriptive and summary statistics were calculated for the entire dataset and split by gender.

Results:

Whereas the overall number of publications and authors was equal between 2020 and 2019, the portion of female first authors of review articles and original studies decreased substantially in the first phase of the pandemic (Table 1). The numerical contribution of female authors in highly ranked journals (impact factor>6) was comparable in 2019 and 2020, however, the percentage of female first authors dropped from 50% to 32% (P=0.07).

Table 1.

Author and journal metrics of publications

AuthorsProportion female2019 (%)N=13862020 (%)N=1361P-valueoverall46,841.1n.s.first authorshipsall publications46,835,30.021reviews56,730n.s.original studies46,218,20.004other reports*42,639,9n.s.last authorshipsall publications34,727,9n.s.reviews33,315n.s.original studies32,130,3n.s.other reports*40,729,1n.s.

*other reports: letters/editorials/case reports

In the survey, a total dataset was available for N=180 responders. On average, female respondents (52.5%) were younger, more likely to live alone (19,1% vs 10,5%) and have no caring responsibilities (51.1% vs. 36.3%) than male respondents.

Male doctors were more often tenure-track/tenured or chairmen (31.4% vs 12.8% female) and worked less often part-time (9,3% vs. 19.1%). Unpaid overtime hours of all participants were striking with 46.3/44,2% (female/male) reporting to accumulate >10 hours/ week.

Regarding gender differences in scientific output, male respondents more frequently revealed >20 publications as first (57,6% vs. 26,9%) or last authors (34.1% vs. 10,1%). Similarly, 44,7% of male respondents reported a last author publication during COVID-19 vs. 26,4% of female respondents.

While female and male respondents reported similar experience of burden during the pandemic, more female respondents reported increased family care as a major source of this (38,2% vs. 22,2%). Both genders would like to see increased support from superiors and official institutions.

Conclusion:

In a time of acute crisis, the adaptability of scientifically active female health care workers in rheumatology is lower than that of their male counterparts. This is reflected in a lower scientific output, especially as first or last authors. However, the burden experienced in the current pandemic is similar between the genders.

Disclosure of Interests:

None declared

OP0169-PARE DEVELOPMENT OF POINTS TO CONSIDER WHEN SUPPORTING PERSONS WITH REUMATIC AND MUSCULOSKELETAL DISEASES TO PARTICIPATE IN HEALTHY AND SUSTAINABLE PAID WORK

Background:

Despite earlier diagnosis and improved management of rheumatic and musculoskeletal diseases (RMDs), a work participation gap remains when compared to the general population. To bridge this work participation gap, EULAR’s current strategy states that ‘by 2023, EULAR’s activities and related advocacy will have increased participation in work by people with RMDs’. To achieve this goal, guidance is needed how to support people with RMDs to remain in paid work or (re)-enter the labour force.

Objectives:

To develop Points to Consider (PtC) when supporting people with RMD to participate in healthy and sustainable paid work.

Methods:

An international expert group, established by Eular in 2019, convened twice to agree on a protocol for the development of PtC. EULAR’s standard operating procedures were followed. The group (a) defined the target audience, (b) identified areas from which knowledge should be derived to enable formulation of the PtC, (c) agreed on a strategy to collect evidence, (d) established an international taskforce to formulate and agree on the PtC, and (e) proposed an implementation plan.

Results:

The target audience are professionals involved in clinical care for patients with RMDs as well as their organisations, persons with RMDs and their organisations, and administrators responsible for healthcare and work policies. Six knowledge areas are identified (Table). Depending on the specific knowledge area, strategies for collecting evidence comprise synthesis of published and grey literature, surveys among various organisations and collection of case studies from employers. Whenever evidence in RMDs is limited, evidence from other chronic diseases will be sought. The international taskforce includes experts from different disciplines in rheumatology (one in other chronic diseases), EU policy makers, and representatives of PARE, HCP, EULAR Public Affairs and EMEUNET. As part of the implementation, close cooperation with national professional and patients societies is planned. Additionally, results will be included in EULAR‘s activities at the EU policy level.

Table 1.

Knowledge areas and strategy to retrieve evidence

In persons with RMDs:Sources of evidence1Is work relevant for the clinical outcome of diseaseLR; Review of managament recommendations and Care Standards2What are barriers and facilitators to enter or stay in the labor forceSLR3What is the effectiveness of interventions to enter or stay in the labor forceSLR; Survey among professional and patient organisations4Which social security systems are more effective when entering or staying in the labor forceLR5How does disease influence the cycle of workSLR; Grey literature6What (not) to do by employers to let patients enter or stay in the work forceSLR; Survey among large companies; case studies

LR: Literature review; SLR: Systematic literature review

Conclusion:

The proposed initiative to develop PtC should ultimately result in improvement of healthy and sustainable labor force participation of people with RMDs.

Disclosure of Interests:

Annelies Boonen Grant/research support from: Abbvie, Suzanne Verstappen: None declared, Maarten Butink: None declared, Casper Webers: None declared, Neil Betteridge: None declared, Tanja Stamm: None declared, Dieter Wiek: None declared, Anthony Woolf: None declared, Gerd Rüdiger Burmester: None declared, Hans Bijlsma: None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

References:

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

Disclosure of Interests:

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

THU0579 “EVOLVING THE MANAGEMENT OF RA” PROGRAMME: EDUCATIONAL TOOLS TO SUPPORT DAILY PRACTICE

Background:

The eRA (evolving the management of RA) programme was initiated in Europe to provide practical educational tools that address unmet needs in the management of rheumatoid arthritis (RA). Several eRA tools – covering early access to care, management of comorbidities, treat-to-target strategies, and patient empowerment – are available to the rheumatology community. Through ongoing activities, the eRA Steering Committee (SC) identified a need for tools on non-pharmacological management of RA.

Objectives:

To improve accessibility to eRA tools for rheumatology professionals; to review the evidence base of non-pharmacological interventions to create new eRA resources that may support management decisions.

Methods:

A web platform providing information on eRA programme and tools was developed in 2019. The platform collects survey-based metrics to quantify perception of eRA and use of eRA tools in clinical practice. Platform and tools are translated to further support access and use across Europe.

To address unmet needs in non-pharmacological patient management, the eRA SC reviewed the core literature on agreed priority interventions, including physical activity, diet, patient education and self-management, psychosocial interventions, occupational therapy and orthotics, hand exercises, and hydrotherapy/balneotherapy. Available evidence for each intervention was assessed and graded according to the Oxford Centre for Evidence-based Medicine Levels of Evidence.

Results:

The eRA web platform is now live in 3 countries (www.evolvingthemanagementofRA.com), hosting translated copies of the eRA tools, with additional countries launching throughout 2020.

From a review of core literature on non-pharmacological interventions, the eRA SC determined that strong evidence exists to support use of physical activity, patient education and self-management, psychosocial interventions, and occupational therapy and orthotics. Evidence was lacking or conflicting for diet and nutrition, hand exercises, and balneotherapy/hydrotherapy. A set of educational slides was produced by the eRA SC to summarise the evidence (Fig. 1) and provide top-line guidance on use of interventions in practice that should engage relevant members of the multi-disciplinary team. These slides are available through eRA dissemination activities.

Conclusion:

The eRA programme content is now freely available to health care professionals in several countries on a web platform, supported by translations of the eRA tools. An additional slide set on non-pharmacological management serves to further increase the practical guidance of this programme’s educational offering.

Acknowledgments:

The eRA programme is funded by Sanofi Genzyme. Programme direction and content creation are driven by an independent Steering Committee

Disclosure of Interests:

Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Neil Betteridge Consultant of: Amgen, Eli Lilly and Company, Grunenthal, GSK, Sanofi Genzyme, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Patrick Durez Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Pfizer, Sanofi, Ricardo J. O. Ferreira Grant/research support from: Abbvie, Consultant of: Sanofi Genzyme, Amgen, MSD, Paid instructor for: UCB, Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi, Carlomaurizio Montecucco: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Andrea Rubbert-Roth Consultant of: Abbvie, BMS, Chugai, Pfizer, Roche, Janssen, Lilly, Sanofi, Amgen, Novartis, Tanja Stamm Grant/research support from: AbbVie, Roche, Consultant of: AbbVie, Sanofi Genzyme, Speakers bureau: AbbVie, Roche, Sanofi, Zoltán Szekanecz Grant/research support from: Pfizer, UCB, Consultant of: Sanofi, MSD, Abbvie, Pfizer, Roche, Novertis, Lilly, Gedeon Richter, Amgen, Peter C. Taylor Grant/research support from: Celgene, Eli Lilly and Company, Galapagos, and Gilead, Consultant of: AbbVie, Biogen, Eli Lilly and Company, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Roche, and UCB, Mart van de Laar Consultant of: Sanofi Genzyme, Speakers bureau: Sanofi Genzyme

AB0312 REAL-LIFE DATA ON THE USE OF BIOLOGICAL DMARDS IN RHEUMATOID ARTHRITIS IN AUSTRIA WITH SPECIAL ATTENTION TO SWITCHING AFTER FIRST BDMARD FAILURE

Background:

The introduction of biological disease modifying anti-rheumatic drugs (bDMARDs) offered new dimensions in controlling disease progress for patients with Rheumatoid Arthritis (RA). According to the recommendations by EULAR, treatment should be commenced with a conventional synthetic DMARD as soon as diagnosis is made, followed by a bDMARD after treatment failure. The choice of drug is done in respect to comorbidities, preference of the patient and to costs.

Objectives:

Drug expenditure data of 2012-2016 were retrieved to evaluate frequency of prescription and drug survival with special focus on switching habits after first bDMARD failure.

Methods:

Data were extracted from 11 Austrian social health insurance funds covering 86% of the Austrian population. Only patients with first prescriptions of bDMARDs were included. Absolute and relative frequencies of first bDMARD prescriptions, second and third courses of bDMARDs (switches) and probabilities of drug survival of first line bDMARDs were calculated. Baselines were set individually at the beginning of the first bDMARD course. A Sankey diagram was used to illustrate the relationships between first, second and third courses of bDMARDs (Figure). The first left column represents the first bDMARDs, the second and third columns the second and third switched bDMARDs, respectively. The quantity of the bDMARDs is reflected in the width of the lines.

Results:

7637 RA patients on bDMARD therapy were retrieved in total. With a presumed prevalence of 0.5% (Ref) this would account for 27% of RA patients being treated with a bDMARD. Of these, 3813 were first time prescriptions. The most commonly prescribed drug in bDMARD naïve patients was Etanercept with 26%, followed by Adalimumab with 25%. Third was Tocilizumab followed by Golimumab (16% and 15%), Abatacept with 9% and Certolizumab and Infliximab with both 4%. Tocilizumab showed the longest drug survival with 80% after one and 61% of patients still on the drug after 3 years. Golimumab was clearly favorable among TNF inhibitors with a drug survival of 71% after one and 50% after 3 years compared to Certolizumab showing the lowest with 63% after one year and only 38% after three years. Tocilizumab was the drug most often switched to after first course failure, followed by Adalimumab. The choice of second bDMARD was different: After Adalimumab failure more patients were switched to another mode of action (almost 50%), predominately Tocilizumab. This is also seen after Golimumab failure and is less pronounced in the other TNF inhibitors: they were mostly switched to second TNF inhibitor, mainly Adalimumab. The majority of patients started on Tocilizumab and Abatacept were switched to a TNF inhibitor (74% and 58%, respectively). In third DMARD choice again Tocilizumab is mostly chosen followed by Abatacept, leaving 42% to a TNF inhibitor, mostly Golimumab.

Conclusion:

Patients were most often started on a TNF inhibitor as first bDMARD, namely Etanercept and Adalimumab. Golimumab was prescribed less often but showed the longest drug survival among TNF inhibitors. Tocilizumab showed the longest drug survival overall and was the bDMARD most often switched to as second bDMARD. When starting with Adalimumab or Golimumab there was a tendency towards change of mode of action, which was not as pronounced for the other three TNF inhibitors. After failing twice Tocilizumab and Abatacept were the most often prescribed drugs.

References:

[1]Kobelt G, Fasteng F: Access to Innovative Treatments in Rheumatoid Arthritis in Europe. A Report prepared for the EFPIA, 2009

Acknowledgments:

Austrian Main Social Health Association (Dachverband österreichische Sozialversciherung)

Disclosure of Interests:

Valerie Nell-Duxneuner Speakers bureau: MSD, Pfizer, Jansen, Abbvie, Lilly, Novartis, Berthold Reichardt: None declared, Tanja Stamm Grant/research support from: AbbVie, Roche, Consultant of: AbbVie, Sanofi Genzyme, Speakers bureau: AbbVie, Roche, Sanofi

SAT0608-HPR EULAR POINTS TO CONSIDER FOR THE DETECTION, ASSESSMENT AND MANAGEMENT OF NON-ADHERENCE IN PEOPLE WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES

Background:

Non-adherence to medication and non-pharmacological interventions precludes reaching an optimal outcome. 30 to 80% of patients with rheumatic and musculoskeletal diseases (RMDs) do not adhere to their recommended treatment regimens.

Objectives:

The objective of this EULAR task force was to establish recommendations/points to consider (PtC) for the detection, assessment and management of non-adherence in people with RMDs.

Methods:

A EULAR task force (TF) was established, and the EULAR standardised operating procedures for the development of PtCs were followed. The TF included rheumatologists, health professionals in rheumatology (HPRs), and patient-representatives from 12 countries. A systematic literature review of reviews was conducted in advance to support the TF in formulating the PtC. Agreement was obtained by Delphi technique in three rounds (0-10 rating scale).

Results:

A definition of adherence, 4 overarching principles and 9 PtC were formulated (table).

Conclusion:

The PtCs can help health-care providers to support people with RMDs to adhere to the agreed treatment plan.

Table.

Overarching principles and points to consider.

Definition of AdherenceAdherence is defined as the extent to which a person’s behaviour corresponds with the agreed prescription.Overarching principlesAgreement1Adherence impacts the outcomes of people with RMDs.992Shared decision making is key, since adherence is a behaviour following an agreed prescription.963Adherence is influenced by multiple factors.984Adherence is a dynamic process that requires continuous evaluation.96Points to considerAgreement1All HCPs involved in the management of people with RMDs should take responsibility for promoting adherence.992Effective patient-health professional communication should be applied to enhance adherence.993Barriers and facilitators of adherence of a specific patient to a specific prescription should be appropriately evaluated.954Patient education should be provided for people with RMDs as an integral part of standard care.965Care should be tailored to patient preferences and goals to enhance adherence.986Adherence should be discussed regularly based on open questions and particularly when disease is not well controlled.997The HCP should explore which factors might negatively influence adherence, including: opportunity (e.g., availability or cost), capability, (e.g., memory problems), motivation (e.g., concerns).948Together with the patient, the HCP should tailor the approach to overcome individual barriers to adherence, e.g.,98- simplifying the regimen,- using reminders,- providing education,- discussing the patient’s beliefs on treatments.9When specific expertise or interventions for adherence are needed, they should be made available to patients.98

HCP, health-care providers; RMDs, rheumatic and musculoskeletal diseases

Disclosure of Interests:

Valentin Ritschl: None declared, Tanja Stamm Grant/research support from: AbbVie, Roche, Consultant of: AbbVie, Sanofi Genzyme, Speakers bureau: AbbVie, Roche, Sanofi, Daniel Aletaha Grant/research support from: AbbVie, Novartis, Roche, Consultant of: AbbVie, Amgen, Celgene, Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi Genzyme, Speakers bureau: AbbVie, Celgene, Lilly, Merck, Novartis, Pfizer, Sanofi Genzyme, UCB, Johannes WJ Bijlsma Grant/research support from: Roche, Speakers bureau: Roche, Lilly, Peter Boehm: None declared, Razvan Dragoi Speakers bureau: MSD, AbbVie, Novartis, Roche, Pfizer, Myllan, Sandoz, Emma Dures Grant/research support from: Independent Learning Grant from Pfizer, combined funding for a research fellow from Celgene, Abbvie and Novartis, Paid instructor for: A fee from Novartis to deliver training to nurses., Fernando Estévez-López: None declared, Laure Gossec Grant/research support from: Lilly, Mylan, Pfizer, Sandoz, Consultant of: AbbVie, Amgen, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sandoz, Sanofi-Aventis, UCB, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi, Michal Nudel: None declared, Andrea Marques: None declared, Ellen Moholt: None declared, Bart van den Bemt Grant/research support from: UCB, Pfizer and Abbvie, Consultant of: Delivered consultancy work for UCB, Novartis and Pfizer, Speakers bureau: Pfizer, AbbVie, UCB, Biogen and Sandoz., Kirsten Viktil: None declared, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Annette de Thurah Grant/research support from: Novartis (not relevant for the present study)., Speakers bureau: Lily (not relevant for the present study)., Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution)

OP0199 POINTS TO CONSIDER WHEN ANALYSING AND REPORTING COMPARATIVE EFFECTIVENESS RESEARCH WITH OBSERVATIONAL DATA IN RHEUMATOLOGY

Background:

Comparing drug effectiveness in observational settings is hampered by several major threats, among them confounding and attrition bias bias (patients who stop treatment no longer contribute information, which may overestimate true drug effectiveness).

Objectives:

To present points to consider (PtC) when analysing and reporting comparative effectiveness with observational data in rheumatology (EULAR-funded taskforce).

Methods:

The task force comprises 18 experts: epidemiologists, statisticians, rheumatologists, patients, and health professionals.

Results:

A systematic literature review of methods currently used for comparative effectiveness research in rheumatology and a statistical simulation study were used to inform the PtC (table). Overarching principles focused on defining treatment effectiveness and promoting robust and transparent epidemiological and statistical methods increase the trustworthiness of the results.

Points to consider

Reporting of comparative effectiveness observational studies must follow the STROBE guidelinesAuthors should prepare a statistical analysis plan in advanceTo provide a more complete picture of effectiveness, several outcomes across multiple health domains should be comparedLost to follow-up from the study sample must be reported by the exposure of interestThe proportion of patients who stop and/or change therapy over time, as well as the reasons for treatment discontinuation must be reportedCovariates should be chosen based on subject matter knowledge and model selection should be justifiedThe study baseline should be at treatment initiation and a description of how covariate measurements relate to baseline should be includedThe analysis should be based on all patients starting a treatment and not limited to patients remaining on treatment at a certain time pointWhen treatment discontinuation occurs before the time of outcome assessment, this attrition should be taken into account in the analysis.Sensitivity analyses should be undertaken to explore the influence of assumptions related to missingness, particularly in case of attrition

Conclusion:

The increased use of real-world comparative effectiveness studies makes it imperative to reduce divergent or contradictory results due to biases. Having clear recommendations for the analysis and reporting of these studies should promote agreement of observational studies, and improve studies’ trustworthiness, which may also facilitate meta-analysis of observational data.

Disclosure of Interests:

Delphine Courvoisier: None declared, Kim Lauper: None declared, Sytske Anne Bergstra: None declared, Maarten de Wit Grant/research support from: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Consultant of: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Speakers bureau: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Thomas Frisell: None declared, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Florenzo Iannone Consultant of: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Speakers bureau: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Joanna KEDRA: None declared, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Ziga Rotar Consultant of: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Speakers bureau: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Maria Jose Santos Speakers bureau: Novartis and Pfizer, Tanja Stamm Grant/research support from: AbbVie, Roche, Consultant of: AbbVie, Sanofi Genzyme, Speakers bureau: AbbVie, Roche, Sanofi, Simon Stones Consultant of: I have been a paid consultant for Envision Pharma Group and Parexel. This does not relate to this abstract., Speakers bureau: I have been a paid speaker for Actelion and Janssen. These do not relate to this abstract., Anja Strangfeld Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis, Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Axel Finckh Grant/research support from: Pfizer: Unrestricted research grant, Eli-Lilly: Unrestricted research grant, Consultant of: Sanofi, AB2BIO, Abbvie, Pfizer, MSD, Speakers bureau: Sanofi, Pfizer, Roche, Thermo Fisher Scientific

OP0198 A SYSTEMATIC REVIEW TO INFORM THE EULAR POINTS TO CONSIDER WHEN ANALYSING AND REPORTING COMPARATIVE EFFECTIVENESS RESEARCH WITH OBSERVATIONAL DATA IN RHEUMATOLOGY

Background:

Comparative effectiveness studies using observational data are increasingly used. Despite their high potential for bias, there are no detailed recommendations on how these studies should best be analysed and reported in rheumatology.

Objectives:

To conduct a systematic literature review of comparative effectiveness research in rheumatology to inform the EULAR task force developing points to consider when analysing and reporting comparative effectiveness research with observational data.

Methods:

All original articles comparing drug effectiveness in longitudinal observational studies of ≥100 patients published in key rheumatology journals (Scientific Citation Index > 2) between 1.01.2008 and 25.03.2019 available in Ovid MEDLINE® were included. Titles and abstracts were screened by two reviewers for the first 1000 abstracts and independently checked to ensure sufficient agreement has been reached. The main information extracted included the types of outcomes used to assess effectiveness, and the types of analyses performed, focusing particularly on confounding and attrition.

Results:

9969 abstracts were screened, with 218 articles proceeding to full-text extraction (Figure 1), representing a number of rheumatic and musculoskeletal diseases. Agreement between the two reviewers for the first 1000 abstracts was 92.7% with a kappa of 0.6. The majority of the studies used several outcomes to evaluate effectiveness (Figure 2A). Most of the studies did not explain how they addressed missing data on the covariates (70%) (Figure 2B). When addressed (30%), 44% used complete case analysis and 10% last observation carried forward (LOCF). 25% of studies did not adjust for confounding factors and there was no clear correlation between the number of factors used to adjust and the number of participants in the studies. An important number of studies selected covariates using bivariate screening and/or stepwise selection. 86% of the studies did not acknowledge attrition (Figure 2C). When trying to correct for attrition (14%), 38% used non-responder (NR) imputation, 24% used LUNDEX1, a form of NR imputation, and 21% LOCF.

Conclusion:

Most of studies used multiple outcomes. However, the vast majority did not acknowledge missing data and attrition, and a quarter did not adjust for any confounding factors. Moreover, when attempting to account for attrition, several studies used methods which potentially increase bias (LOCF, complete case analysis, bivariate screening…). This systematic review confirms the need for the development of recommendations for the assessment and reporting of comparative drug effectiveness in observational data in rheumatology.

References:

[1]Kristensen et al. A&R. 2006 Feb;54(2):600-6.

Acknowledgments:

Support of the Standing Committee on Epidemiology and Health Services Research

Disclosure of Interests:

Kim Lauper: None declared, Joanna KEDRA: None declared, Maarten de Wit Grant/research support from: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Consultant of: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Speakers bureau: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Thomas Frisell: None declared, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Florenzo Iannone Consultant of: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Speakers bureau: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Ziga Rotar Consultant of: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Speakers bureau: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Maria Jose Santos Speakers bureau: Novartis and Pfizer, Tanja Stamm Grant/research support from: AbbVie, Roche, Consultant of: AbbVie, Sanofi Genzyme, Speakers bureau: AbbVie, Roche, Sanofi, Simon Stones Consultant of: I have been a paid consultant for Envision Pharma Group and Parexel. This does not relate to this abstract., Speakers bureau: I have been a paid speaker for Actelion and Janssen. These do not relate to this abstract., Anja Strangfeld Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis, Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Axel Finckh Grant/research support from: Pfizer: Unrestricted research grant, Eli-Lilly: Unrestricted research grant, Consultant of: Sanofi, AB2BIO, Abbvie, Pfizer, MSD, Speakers bureau: Sanofi, Pfizer, Roche, Thermo Fisher Scientific, Sytske Anne Bergstra: None declared, Delphine Courvoisier: None declared

Increased risk of death associated with the use of proton-pump inhibitors in patients with dementia and controls - a pharmacoepidemiological claims data analysis

Background and purpose

The use of proton‐pump inhibitors (PPIs) was reported to be associated with increased mortality risk and has been proposed as a potential risk factor for neurodegenerative diseases. We aimed to assess the impact of PPI use on survival in patients with dementia as compared with controls.

Methods

This register‐based control‐matched cohort study included 28 428 patients with dementia ascertained by the prescription of antidementia drugs and two control individuals matched by sex, age and area of residence for each patient with dementia during the study period from 1 January 2005 to 30 June 2016. Cumulative defined daily doses (DDDs) of PPIs were extracted from the health insurance prescription registries. A multivariate Cox regression model for non‐proportional hazards was used to analyse mortality risk in dependence of PPI exposure, which was limited to 1 year preceding the date of cohort entry (index date) in order to avoid immortal time bias.

Results

The PPI exposure of 100 DDDs in the year before the index date was associated with an increased mortality risk in patients with dementia (adjusted hazard ratio, 1.07; 95% confidence intervals, 1.03–1.12), but also in controls (adjusted hazard ratio, 1.47; 95% confidence intervals, 1.31–1.64). The mortality risk in relation to PPI use was significantly lower in patients with dementia as compared with controls (P < 0.0001) and highest in the first 2 years after the index date in both cohorts.

Conclusions

Our findings promote more stringent pharmacovigilance strategies to avoid PPI use in cases lacking a clear indication for therapy or where potential risks outweigh the benefits.

[Healthcare models for traumatized refugees in Germany]

People with a migration background are a risk group for psychiatric disorders. Innovative, transnational and sustainable projects are necessary to ensure adequate care for refugees and asylum seekers. Selected projects of the University of Munich, the Charité Berlin and the University of Konstanz show promising approaches in addition to other initiatives.

Neural alterations of fronto-striatal circuitry during reward anticipation in euthymic bipolar disorder

BACKGROUND

Bipolar disorder (BD), with the hallmark symptoms of elevated and depressed mood, is thought to be characterized by underlying alterations in reward-processing networks. However, to date the neural circuitry underlying abnormal responses during reward processing in BD remains largely unexplored. The aim of this study was to investigate whether euthymic BD is characterized by aberrant ventral striatal (VS) activation patterns and altered connectivity with the prefrontal cortex in response to monetary gains and losses.

METHOD

During functional magnetic resonance imaging 20 euthymic BD patients and 20 age-, gender- and intelligence quotient-matched healthy controls completed a monetary incentive delay paradigm, to examine neural processing of reward and loss anticipation. A priori defined regions of interest (ROIs) included the VS and the anterior prefrontal cortex (aPFC). Psychophysiological interactions (PPIs) between these ROIs were estimated and tested for group differences for reward and loss anticipation separately.

RESULTS

BD participants, relative to healthy controls, displayed decreased activation selectively in the left and right VS during anticipation of reward, but not during loss anticipation. PPI analyses showed decreased functional connectivity between the left VS and aPFC in BD patients compared with healthy controls during reward anticipation.

CONCLUSIONS

This is the first study showing decreased VS activity and aberrant connectivity in the reward-processing circuitry in euthymic, medicated BD patients during reward anticipation. Our findings contrast with research supporting a reward hypersensitivity model of BD, and add to the body of literature suggesting that blunted activation of reward processing circuits may be a vulnerability factor for mood disorders.

Influence of levothyroxine in augmentation therapy for bipolar depression on central serotonergic function

INTRODUCTION

Adjunctive treatment with supraphysiological doses of levothyroxine (L-T4) in bipolar depression shows promise, but the neurobiological mechanisms underlying clinical improvement are unknown. It has been postulated from animal studies that exogenous thyroid hormones may exert their modulatory effects in patients with affective disorders via an increase in serotonergic neurotransmission. Therefore, we investigated the loudness dependence of auditory evoked potentials (LDAEP) as a measure of central serotonergic activity and response to L-T4.

METHODS

This 6-week, double-blind, randomized, placebo-controlled study assessed the efficacy of L-T4 adjunctive to continuing treatment with mood stabilizer and/or antidepressant medication in 20 patients with bipolar depression. LDAEP was assessed before and after treatment with L-T4.

RESULTS

Scores of the Hamilton Depression Rating Scale and Montgomery Asberg Depression Rating Scale decreased significantly during the study. There was no difference in pre- and post-treatment LDAEP between the groups, and no correlation between LDAEP and psychometric measures in the course of the study.

DISCUSSION

The hypothesis of a relationship between response of augmentation therapy with levothyroxine in bipolar depression and serotonergic activity could not be confirmed.

Do rehabilitation tools cover the perspective of patients with rheumatoid arthritis? A focus group study using the ICF as a reference

BACKGROUND

Despite the advocated use of rehabilitation tools in clinical rehabilitation of with rheumatoid arthritis (RA) patients, little is known about the representation of the patient perspective in these tools.

AIM

Aim of the study was to explore the experiences of RA patients with rehabilitation and the coverage by rehabilitation tools.

DESIGN AND POPULATION

Qualitative focus group study with RA patients about experiences with rehabilitation.

SETTING

Rheumatology rehabilitation clinic of a Dutch university hospital.

METHODS

Focus groups were tape recorded and transcribed verbatim. From the meaningful units, concepts were extracted and linked to the International Classification of Functioning, Disability and Health (ICF). Rehabilitation tools validated for RA were identified using a structured literature search. Using the ICF as common framework, we determined for each concept identified in the focus groups the coverage by each rehabilitation tool.

RESULTS

Nineteen patients participated in 4 focus groups. Fifty-one concepts were identified in 368 meaningful units derived from the transcribed data. From the literature the ICF Core Sets for RA, Canadian Occupational Performance Measure, Rehabilitation Activities Profile and WHO Disability Assessment Schedule II were elected. The concepts from the focus groups were best covered by the ICF Core Sets (44 out of 51; 86%), followed by the WHODAS II (39%), RAP (35%) and COPM (16%).

CONCLUSION

With the exception of the ICF Core Sets for RA, current rehabilitation tools poorly cover the RA patients' perception on rehabilitation.

CLINICAL REHABILITATION IMPACT

The ICF Core Sets can serve as a checklist to guide multidisciplinary assessment, goal-setting and evaluation in RA rehabilitation.