The impact of severe perinatal events on maternity care providers: a scoping review

BACKGROUND

Severe events during the perinatal period can be experienced as traumatic by pregnant women, their partners or others who are closely involved. This includes maternity care providers who can be affected by being involved in or observing these events. This may have an impact on their personal well-being and professional practice, influencing quality of care. The aim of this study is to map research investigating the impact of severe events during the perinatal period on maternity care providers, and how these experiences affect their well-being and professional practice.

METHOD

A scoping review following the manual of the Joanna Briggs Institute was undertaken. The electronic bibliographic databases included PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX, Cochrane, Scopus, Web of Science and databases for grey literature. Records passing the two-stage screening process were assessed, and their reference lists hand searched. We included primary research papers that presented data from maternity care professionals on the impact of severe perinatal traumatic events. A descriptive content analysis and synthesis was undertaken.

RESULTS

Following a detailed systematic search and screening of 1,611 records, 57 papers were included in the scoping review. Results of the analysis identified four categories, which highlighted the impact of traumatic perinatal events on maternity care providers, mainly midwives, obstetricians and nurses: Traumatic events, Impact of traumatic events on care providers, Changes in care providers' practice and Support for care providers; each including several subcategories.

CONCLUSION

The impact of traumatic perinatal events on maternity care providers ranged from severe negative responses where care providers moved position or resigned from their employment in maternity care, to responses where they felt they became a better clinician. However, a substantial number appeared to be negatively affected by traumatic events without getting adequate support. Given the shortage of maternity staff and the importance of a sustainable workforce for effective maternity care, the impact of traumatic perinatal events requires serious consideration in maintaining their wellbeing and positive engagement when conducting their profession. Future research should explore which maternity care providers are mostly at risk for the impact of traumatic events and which interventions can contribute to prevention.

Effects of Hibernation Site, Temperature, and Humidity on the Abundance and Survival of Overwintering Culex pipiens pipiens and Anopheles messeae (Diptera: Culicidae)

Knowledge of the hibernation site preferences and the factors which influence winter survival in these hibernation sites may enhance understanding of mosquito population dynamics after winter and how arboviruses persist in temperate regions. Our study quantified the number of adult overwintering mosquitoes in cellars and aboveground constructions and analyzed survival rates in relation to the environmental conditions in these sites. During the winters 2016/2017 and 2018/2019, 149 different constructions in Northwest Germany were sampled for mosquitoes. Mosquitoes were detected in 44% of the cellars and in 33% of the aboveground constructions. Culex p. pipiens Linnaeus was the most abundant species in cellars, whereas high numbers of Anopheles messeae Falleroni were collected from a single barn. Subsequently, an enclosure study was conducted during 2019/2020. Overwintering field-collected Cx. p. pipiens and An. messeae were divided into groups with or without fructose availability, and placed in cages with different man-made hibernations sites, where temperature and relative humidity were recorded hourly. For both species, increasing mean temperatures (5-16°C) but not mean relative humidity (58-94%) were correlated with winter mortality rates of the mosquitoes. The lipid measurements were greater and mortality rates were lower when both species were provided fructose. Larger specimens (determined by wing length) stored more lipids, and in Cx. p pipiens, but not in An. messeae, survival probability of large specimens was significantly greater than for small females. Mosquitoes showed a distinct pattern in the selection of overwintering sites, while temperature was an important driver for survival.

Effects of different exercise intensity on bone mineral density in adults: a comparative systematic review and meta-analysis

PURPOSE

The primary objective of the present systematic review and meta-analysis was to determine the effect of differing exercise intensity on (areal) bone mineral density (BMD) at lumbar spine and hip in adults by a comparative meta-analysis.

METHODS

A systematic review of the literature according to the PRISMA statement included: (a) exercise trials, (b) with ≥two study arms that compared different exercise intensities, (c) intervention ≥6 months, (d) BMD assessments at lumbar spine (LS) or hip. Five electronic databases were scanned without language restrictions up to July 2021. The present analysis of exercise intensity was conducted as a mixed-effect meta-analysis and applied "type of exercise" and "study duration" as moderator in subgroup analyses. Outcome measures were standardized mean differences (SMD) for BMD changes at the LS, and hip.

RESULTS

Eleven exercise studies with 26 study arms were included. Although the effect of high-intensity exercise was more pronounced on LS-BMD (SMD: 0.19, 95%-CI: 0.61 to -0.23) and hip-ROI (0.17, 0.38 to -0.04), we did not observe significant differences between the groups (LS-BMD: p=0.373 and hip-BMD: p=0.109). We observed a substantial level of heterogeneity between the trials for LS- but not for hip-BMD. Applying "type of exercise" and "study duration" as moderators did not significantly modify the differences between low and high exercise intensity on BMD at LS or hip.

CONCLUSION

There is insufficient evidence for a superior effect of high-intensity exercise on areal BMD at lumbar spine and hip in people aged 50 years and older. Varying exercise intensity with periods of lower exercise intensity intermitted by higher intensity might be a promising option to address the issue of exercise intensities in intervention studies.

[Healthcare in Pregnancy and Access to Midwives according to Socio-Economic Situation: An Analysis with Routine Data from BARMER Health Insurance]

BACKGROUND

Socio-economic status is an important cause of inequality in health status and access to healthcare. This also applies to pregnancy, birth and the postpartum period. Healthcare during pregnancy plays a crucial role in the success of the life phase around birth. On the basis of routine data from BARMER health insurance, the study investigated which services pregnant women received during pregnancy depending on their socio-economic situation.

METHODS

The study population comprised 237,251 women insured with BARMER with 278,237 births in 2015-2019. The services billed by gynaecologists and midwives during pregnancy were considered in relation to the socio-economic situation of the women involved.

RESULTS

Physicians dominated the provision of preventive healthcare. For almost 98% of the pregnant women, a medical preventive healthcare flat rate was billed in at least three quarters. A regular participation of the midwife in preventive healthcare from the fourth month of pregnancy with more than four preventive services was the case in only 1.2% of women. Women from low-income backgrounds received fewer antenatal healthcare services from both gynaecologists and midwives, with 31% of women with low income having no antenatal midwife contact at all, compared to only 11% of high-income women. High-income earning women were also more likely to have had early contact with a midwife (47 vs. 37% in the first trimester). The timing of the first contact seemed to be relevant for the subsequent cooperative antenatal healthcare by both professional groups.

CONCLUSION

The potentials of midwifery healthcare are not being leveraged. Midwives should be significantly more involved in prenatal healthcare overall, and access to midwives must be improved, especially for socially disadvantaged women. These women could benefit in particular from midwifery healthcare, as it takes greater account of social aspects in healthcare and also provides outreach services.

Study protocol for a mixed methods exploratory investigation of aftercare services for gestational diabetes in women to develop a new patient-centred model in Germany: the GestDiNa_basic study

INTRODUCTION

Women with gestational diabetes mellitus (GDM) have a higher risk of developing type 2 diabetes mellitus compared with women who never had GDM. Consequently, the question of structured aftercare for GDM has emerged. In all probability, many women do not receive care according to the guidelines. In particular, the process and interaction between obstetrical, diabetic, gynaecological, paediatric and general practitioner care lacks clear definitions. Thus, our first goal is to analyse the current aftercare situation for women with GDM in Germany, for example, the participation rate in aftercare diabetes screening, as well as reasons and attitudes stated by healthcare providers to offer these services and by patients to participate (or not). Second, we want to develop an appropriate, effective and patient-centred care model.

METHODS AND ANALYSIS

This is a population-based mixed methods study using both quantitative and qualitative research approaches. In various working packages, we evaluate data of the GestDiab register, of the Association of Statutory Health Insurance Physicians of North Rhine and the participating insurance companies (AOK Rheinland/Hamburg, BARMER, DAK Gesundheit, IKK classic, pronova BKK). In addition, quantitative (postal surveys) and qualitative (interviews) surveys will be conducted with randomly selected healthcare providers (diabetologists, gynaecologists, paediatricians and midwives) and affected women, to be subsequently analysed. All results will then be jointly examined and evaluated.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of the Faculty of Medicine, Heinrich-Heine-University Düsseldorf (Ethics Committee No.: 2019-738). Participants of the postal surveys and interviews will be informed in detail about the study and the use of data as well as the underlying data protection regulations before voluntarily participating. The study results will be disseminated through peer-reviewed journals, conferences and public information.

TRIAL REGISTRATION NUMBER

DRKS00020283.

POS0314 PROSPECTIVE EVALUATION OF A DEDICATED, SERIAL OCCUPATIONAL THERAPY EXERCISE PROGRAM ON HAND FUNCTION IN RHEUMATOID ARTHRITIS (RA)

Background:

Rheumatoid arthritis (RA) frequently affects the joints of the hands causing severe pain and significant functional impairment affecting all activities of daily living. At early stages, functional impairment is primarily caused by reversible joint and tendon sheath effusions while at later stages synovial thickening, muscular atrophy and irreversible damage to cartilge, bone, tendons and ligaments cause a reduced range of motion and deformities. Occupational therapy aims to maintain and improve joint mobility and function. However, there is limited data on the effectiveness of serial exercise programs specifically aiming at maintaining and improving hand function in RA.

Objectives:

To prospectively evaluate the effects of a dedicated exercise program on hand function, grip strength, joint mobility and pain compared with conventional outpatient physiotherapy not specifically targeting hand function.

Methods:

A total of 51 RA patients receiving outpatient physiotherapy once a week were enrolled and randomized to either continue their usual therapy (control group) or to participate in a dedicated hand function training (HFT) twice a week in addition to their usual therapy (HFT group). The HFT program was supervised by an occupational therapist who conducted once weekly HFT sessions and instructed the participants to perform an additional self-administered HFT session at home once a week. Study duration was six months with an option to continue HFT for additional 6 months. Study participants were evaluated at baseline and every 3 months.

The primary outcomes hand function and grip strength were assessed using standardized questionnaires (Cochin hand function scale (CHFS), Australian/Canadian Osteoarthritis Hand Index (AUSCAN), Michigan Hand Outcomes Questionnaire (MHOQ)) and dynamometer/pinch gauge readings for different types of grip (cylindrical grasp, spherical grasp, hook grasp, tip to tip pinch and key pinch), respectively. The secondary outcomes joint mobility and pain were assessed using a digital goniometer and visual analogue scales (VAS), respectively. Statistical analysis used the Wilcoxon test for evaluating changes of parameters over time within the groups and the Kruskal Wallis test for group comparisons and Bonferroni-Holm correction.

Results:

41 of the 51 patients (HFT group: n = 20, mean age 60.3 ± 8.4 years; control group: n = 21, mean age 60.5 ± 11.5 years) completed the 6-month study period, 14 patients extended their HFT to 12 months. Within the 6-month study period there were no significant improvements of the primary outcome parameters and of pain within the groups vs. baseline and no significant differences between the groups. Only the CHFS improved significantly in the HFT group as of month 9. A significant improvement of the range of motion vs. baseline was achieved by HFT as early as 3 months after baseline which persisted up to month 12. As some improvement was also seen in the control group, there was no significant difference between the groups. Hand mobility improved particularly in the subgroup of patients >60 years of age. There was no influence by pain intensity at baseline (VAS ≤50 mm vs. VAS >50 mm).

Conclusion:

Serial dedicated HFT for 6 months resulted in improved joint mobility but did not improve global hand function, grip strength and pain in RA patients. A longer treatment duration (≥12 months), a higher treatment frequency (>2 times/week) and a larger cohort of patients may be required.

Disclosure of Interests:

None declared

AB0043 EFFECT OF ANTI-INFLAMMATORY MEDICATION ON INTERACTION OF SYNOVIAL FIBROBLASTS WITH MACROPHAGES IN RHEUMATOID ARTHRITIS

Background:

One of the key mechanisms in the pathogenesis of rheumatoid arthritis (RA) is the interaction of macrophages and synovial fibroblasts during joint inflammation. Increased synergistic proinflammatory activity of both cell types leads to the release of high levels of proinflammatory cytokines, especially of interleukin-6 (IL-6), and of matrix degrading enzymes. If this mechanism is uncontrolled, progressive destruction of articular cartilage and bone will take place.

In active disease, immediate anti-inflammatory treatment with glucocorticoids is usually replaced by disease-modifying anti-rheumatic drugs (DMARDS), especially by methotrexate (MTX) and biologics such as TNF-α- or IL-6-inhibitors. This led to great improvements in prognosis and outcome for RA patients. However, about 40% of patients experience no remission or suffer from side effects of medication. To optimize established substances and to develop new treatment strategies, it is necessary to understand the mechanisms underlying the limited therapeutic effects.

Objectives:

Evaluation of the effect of prednisolone, MTX, adalimumab, tocilizumab on IL-6 secretion by RA synovial fibroblasts (RASF) and macrophages.

Methods:

RA synovium was used for RASF isolation. Peripheral blood mononuclear cells (PBMCs) were isolated from blood of healthy donors and RA patients by using Ficoll© medium followed by density gradient centrifugation. Mononuclear cells were seeded on six well plates (6x10^6/well) and incubated for one week. Then they were stimulated with Interferon-у (20 ng/ml) and LPS (50 ng/ml) for 48h to initiate differentiation into proinflammatory M1 macrophages. The M1 macrophages were co-cultured with RASF (100.000/well) and different treatments added (prednisolone: 10, 25, 50, 75, 100 nM, 1 µM; adalimumab: 100, 500 µg/ml; tocilizumab: 1, 5 µg/ml; MTX: 0,5, 1, 5, 10, 100 nM, 1µM). After 24h culture supernatants were collected and IL-6- and TNFα-ELISAs were performed.

Results:

IL-6 concentrations of untreated controls were comparable, regardless whether M1 macrophages from healthy donors or RA-patients were used for co-culture. Prednisolone reduced co-culture-induced IL-6 up to 56% (p<0.001) in co-culture of RASF and M1 macrophages of healthy donors and up to 60% (p<0.001) in co-culture of RASF and RA M1 macrophages. Adalimumab reduced IL-6 up to 28% (p<0.05) in M1 of healthy donors and up to 45% (p<0.01) in RA M1 macrophage co-cultures. A minor reduction by 10-20% of IL-6 was observed with tocilizumab and no significant effect could be achieved after treatment with MTX.

Conclusion:

Prednisolone and adalimumab clearly decrease but do not eliminate proinflammatory synergistic activity of RASF and M1 macrophages. These results confirm the clinical observation, that there is a large number of RA-patients that independent of anti-inflammatory treatment still suffer from low-level joint inflammation.

The synergistic proinflammatory activity of M1 macrophages and RASF seems to be a complex and multifactorial mechanism that is difficult to eliminate by a single treatment substance. Since it is one of the key mechanisms in RA pathogenesis, there is a critical need to investigate how therapy effects could be optimized. This study confirmed RASFs as one of the leading effector cells of increased synergistic proinflammatory activity, thus underlining their promising role as a treatment target in rheumatoid arthritis.

Disclosure of Interests:

None declared

POS0844 EFFECTS OF SERIAL LOCALLY APPLIED WATER-FILTERED INFRARED A RADIATION IN PATIENTS WITH SYSTEMIC SCLEROSIS WITH SEVERE RAYNAUD’S SYNDROME RECEIVING PROSTAGLANDINE TREATMENT – A RANDOMIZED CONTROLLED TRIAL

Background:

More than 95% of patients with systemic sclerosis (SSc) suffer from Raynaud’s syndrome (RS) leading to digital ulcerations (DU). In severe RS, intravenous application of prostaglandins is required. Moreover, these patients profit from an additional non-pharmacological treatment using hyperthermia to increase vasodilatation and perfusion, and to reduce pain.

Serial locally applied water-filtered infrared A radiation (sl-wIRAR) is a hyperthermia treatment modality using infrared heat radiation in the range of 780-1400nm with high tissue penetration and low thermal load on the skin surface [1]. wIRAR has both, temperature-dependent and non-dependent effects, which do not inherit thermal energy transfer and/or relevant temperature changes [1]. It is therefore not only used in acute and chronic wound healing as it promotes perfusion, alleviates pain and has anti-infectious effects [2], but is also used in oncology [3] and rheumatology [4].

Objectives:

We conducted a randomized controlled trial with a follow-up visit after 2 weeks to evaluate the value of a high-frequent hyperthermia treatment using sl-wIRAR in comparison to a low-frequent hyperthermia treatment (our standard) in SSc patients with severe RS receiving Iloprost treatment.

Methods:

Eligible patients had SSc according to the 2013 ACR/EULAR classification criteria, were 18 to 80 years old and had RS requiring treatment with Iloprost in an in-patient setting. Key exclusion criteria were contraindications to any hyperthermia treatment such as infection or heat insensitivity. The trial was conducted at Campus Kerckhoff of Justus-Liebig University Giessen. Eligible patients were equally randomized to the intervention group (IG) receiving additional sl-wIRAR treatment (2 treatments for 30 min per day for 8 days) plus the standard of care (Iloprost treatment over 8 days plus daily carbon dioxide hand baths of 20 min) and the control group (CG) receiving only the standard of care. Primary outcome was the between-group difference in pain measured on a numeric rating scale (NRS) after intervention. Key secondary outcomes included a change in RS frequency, RS duration, and a change in Interleukin (IL) -6 and VEGF levels.

Results:

From 01.03.2020 to 31.12.2020 49 SSc patients met the inclusion criteria. 42 patients were enrolled (IG: 21, CG: 21). 38 patients (IG:19, CG: 19) completed the full trial period and were analyzed. There was no statistically significant between-group difference in pain levels (NRS) (p=0.284, Z -1.082 (Mann-Whitney U Test)) and thus the primary outcome was not met. Therefore, all p values for secondary outcomes are nominal. Intensity (Visual analogue scale 0-100mm) and duration (min) of RS were reduced in the IG (mean ± standard error) -14.579 ± 7.214 mm (p=0.058) and -2.917 ± 1.510 min (p=0.08), respectively. Intra- and inter-group comparison of IL-6 and VEGF levels showed no relevant change.

Conclusion:

The additive and frequent use of sl-wIRAR in the treatment of SSc patients with RS requiring Iloprost treatment does not improve outcomes regarding pain levels, RS intensity or frequency nor IL-6 and VEGF levels when compared to Iloprost treatment and low-frequent hyperthermia application.

References:

[1]Hoffmann G. Clinical applications of water-filtered infrared-A (wIRA) – a review. Phys Med Rehab Kuror. 2017;27(05):265–274.

[2]Hoffmann G, Harte M, Mercer JB. Heat for wounds – water-fil- tered infrared-a (wIRA) for wound healing – a review. GMS Ger Med Sci. 2016;14:Doc08.

[3]Notter M, Thomsen AR, Nitsche M, et al. Combined wIRA-hyperthermia and hypofractionated re-irradiation in the treatment of locally recurrent breast cancer: evaluation of therapeutic outcome based on a novel size classification. Cancers (Basel). 2020;12(3): 606.

[4]Klemm P, Eichelmann M, Aykara I et al. Serial locally applied water-filtered infrared a radiation in axial spondyloarthritis – a randomized controlled trial, International Journal of Hyperthermia, 37:1, 965-970.

Acknowledgements:

We acknowledge the help of Carina Schreiyäck.

This study was in part supported by the Dr. med. h.c. Erwin Braun Foundation, Basel, a charitable, nonprofit Swiss scientific foundation approved by the Swiss Federal Administration. The foundation supports clinical investigation of waterfiltered infrared-A. The foundation was not involved in any content- or decision-related aspect of the study.

This study was prospectively registered at www.drks.de (German Registry of Clinical Studies): DRKS00021098

Disclosure of Interests:

None declared

POS1492-HPR EVALUATION OF A VIRTUAL REALITY-BASED APPLICATION TO EDUCATE HEALTHCARE PROFESSIONALS AND MEDICAL STUDENTS ABOUT INFLAMMATORY ARTHRITIS

Background:

Inflammatory arthritides (IA), such as rheumatoid arthritis or psoriatic arthritis, are disorders that can be difficult to comprehend for health professionals and students in terms of the heterogeneity of clinical symptoms and pathologies. New didactic approaches using innovative technologies such as Virtual Reality (VR) applications could be helpful to demonstrate disease manifestations as well as joint pathologies in a more comprehensive way. However, the potential of using a VR education concept in IA has not yet been evaluated.

Objectives:

We evaluated the feasibility of a VR application to educate healthcare professionals and medical students about IA.

Methods:

We developed a VR application using IA patients data as well as two- and three-dimensional visualized pathological joints from X-ray and computed tomography generated images (1). This VR application (called Rheumality) allows the user to interact with representative arthritic joint and bone pathologies of IA patients (Figure 1 A, B). In a consensus meeting an online questionnaire was designed to collect basic demographic data (age, sex), profession of the participants, and their feedback on the general impression, knowledge gain and potential areas of application of the VR application. The VR application was subsequently tested and evaluated by healthcare professionals (physicians, researchers, and other healthcare professionals) and medical students at predefined events (two annual rheumatology conferences and academic teaching seminars at two sites in Germany).

Results:

125 individuals participated in this study (56% female, 43% male, 1% non-binary). 59% of the participants were between 18-30 years of age, 18% between 31-40, 10% between 41-50, 8% between 51-60 and 5% were between 61-70. Of the participants, 50 were physicians, five researchers and four other health care professionals, the remaining were medical students (66). The participants rated the application as excellent (Figure 1 C, D), the mean rating of the VR application was 9.0/10 (SD 1.2) and many participants would recommend the use of the application, with a mean recommendation score of 3.2/4 (SD 1.1). A large majority stated that the presentation of pathological bone formation improves the understanding of the disease (120 out of 125 (96%)).

Conclusion:

The data show that IA-targeting innovative teaching approaches based on VR technology are feasible. The use of VR applications enables a disease-specific knowledge visualization and may add a new educational pillar to conventional educational approaches.

References:

[1]Kleyer A et al. Z Rheumatol 78, 112–115 (2019)

Figure 1.

Illustration of the VR application and evaluation results

Two- and three-dimensional visualized pathological joints from X-ray and computed tomography generated images in a patient with long-standing (inadequately treated) RA (A) and a patient with early RA (B). Overall rating (range 0-10) on the VR application divided into four different professional subgroups (C); recommendations of VR application in the four different professional subgroups (D). HC, health care professionals; Boxplot explanation: Crossbars represent medians, whiskers represent 5-95 percentiles (points below the whiskers are drawn as individual points), box always extends from the 25th to 75th percentiles (hinges of the plot).

Disclosure of Interests:

Philipp Klemm Consultant of: Lilly Deutschland GmbH, Arnd Kleyer Speakers bureau: Lilly Deutschland GmbH, Consultant of: Lilly Deutschland GmbH, Grant/research support from: Lilly Deutschland GmbH, Koray Tascilar: None declared, Louis Schuster: None declared, Timo Meinderink: None declared, Florian Steiger: None declared, Uwe Lange: None declared, Ulf Müller-Ladner: None declared, Johannes Knitza Speakers bureau: Lilly Deutschland GmbH, Philipp Sewerin Speakers bureau: Lilly Deutschland GmbH, Paid instructor for: Lilly Deutschland GmbH, Johanna Mucke Consultant of: Lilly Deutschland GmbH, Alexander Pfeil Speakers bureau: Lilly Deutschland GmbH, Paid instructor for: Lilly Deutschland GmbH, Consultant of: Lilly Deutschland GmbH, Georg Schett: None declared, Fabian Hartmann Consultant of: Lilly Deutschland GmbH, Axel Hueber Consultant of: Lilly Deutschland GmbH, Grant/research support from: Lilly Deutschland GmbH, David Simon Speakers bureau: Lilly Deutschland GmbH, Paid instructor for: Lilly Deutschland GmbH, Consultant of: Lilly Deutschland GmbH, Grant/research support from: Lilly Deutschland GmbH

OP0075 EVALUATION OF A VIRTUAL REALITY TEACHING CONCEPT FOR MEDICAL STUDENTS DURING THE SARS-COV-2 PANDEMIC

Background:

The ongoing COVID-19 pandemic has disrupted face-to-face teaching of medical students and forced efforts in finding alternative approaches. In order to help maintain high-quality education, a new virtual reality (VR)-based concept for training medical students in rheumatic and musculoskeletal diseases (RMD) has been developed. This VR training concept is based on the integration of real patient data with two- and three-dimensional visualized pathological joints from X-ray and computed tomography generated images.

Objectives:

To evaluate the practicability and acceptance of the VR training application in the digital curricular education of medical students during the COVID-19 pandemic.

Methods:

A short refresher lecture on rheumatic diseases (duration 60 minutes) was followed by presenting the VR training concept to the students. The VR training concept included the demonstration of three virtual patients with early rheumatoid arthritis, rheumatoid arthritis psoriatic arthritis regarding the symptoms, current medical problems, disease patterns at the imaging (conventional radiographs and high-resolution computed tomography) and therapy options. The practicability and acceptance of the VR was evaluated by medical students using a survey.

Results:

The study encompassed 237 medical students (163 female, 73 male, one diverse, age range 20 to 40 years). 72 % of the participants rated the virtual teaching as good or very good. 87 % presented an expanded knowledge for rheumatoid arthritis and psoriatic arthritis through the VR. Moreover, 91 % reported that the lecture provided a deeper understanding of RMD. Furthermore, 60 % of the students asked for additional courses by VR.

Conclusion:

The study highlighted the usefulness of innovative VR tools for teaching medical students digitally about RMD. VR applications can be a complementary educational modality for medical students, especially during the COVID-19 pandemic, to provide students with the best possible clinical experience while ensuring that patient, student, and staff safety is not compromised.

Figure 1.

A Screen view of virtual reality included three virtual patients with early rheumatoid arthritis (RA), RA, and psoriatic arthritis (PsA) and B demonstration of structural damage in RA and PsA using hand X-ray and high-resolution quantitative computed tomography images.

Disclosure of Interests:

Alexander Pfeil Speakers bureau: Lilly Pharma Deutschland GmbH, Franz Marcus: None declared, Tobias Hoffmann: None declared, Philipp Klemm Consultant of: Lilly Pharma Deutschland GmbH, Peter Oelzner: None declared, Ulf Müller-Ladner Consultant of: Lilly Pharma Deutschland GmbH, Axel Hueber Consultant of: Lilly Pharma Deutschland GmbH, Uwe Lange: None declared, Gunter Wolf: None declared, Georg Schett: None declared, David Simon Consultant of: Lilly Pharma Deutschland GmbH, Arnd Kleyer Consultant of: Lilly Pharma Deutschland GmbH

[Paget's disease of bone-a current review of clinical aspects, diagnostics and treatment]

Paget's disease is a monostotic or polyostotic progressive skeletal disease with a genetic predisposition. The affected bone areas show osseous swelling and often grotesque deformation, chronic pain and fractures. Many cases are asymptomatic for a long time resulting in a late diagnosis. The pathogenesis is still unknown. In addition to a genetic predisposition, viral factors are also discussed. Laboratory tests and imaging are used for diagnosis. The effective principle of medicinal bisphosphonate treatment is to inhibit osteoclastic bone resorption and should be initiated early to prevent secondary complications. This article presents the current knowledge about this rare osteological disease.

[Biological therapy after COVID-19 infection : No reactivation of a COVID-19 infection with positive SARS-CoV-2 antibody status under biological therapy]

Berichtet wird über einen Fall mit rheumatoider Arthritis und unzureichender Kompensation unter einer Kombinationslangzeittherapie mit Methotrexat und Leflunomid. Nach durchgemachter COVID-19-Infektion erfolgte eine Neueinstellung auf einen Tumornekrosefaktor(TNF)-Blocker. Hierunter zeigte sich bisher keine Reaktivierung der COVID-19-Infektion bei positivem Antikörperstatus SARS-CoV‑2.

THU0350 LOGOPEDIC TESTING IN SSC PATIENTS REVEALS HIGH FREQUENCY OF OROPHARYNGEAL DYSFUNCTION: A MONOCENTRIC EXPERIENCE

Background:

Up to 98% of patients with systemic sclerosis (SSc) show involvement of the gastrointestinal system (GI) [1]. While meteorism, heartburn and GI dysmotility are very common and accessible to pharmacologic treatment on an evidence based level [1–3], checking for oropharyngeal dysfunction is usually not part of the standard diagnostic algorithm. However, in a survey of the German Network for Systemic Sclerosis (DNSS) patients reported coughing and/or a sore voice in up to 78% [1]. As impairment in speaking or swallowing for example does not only substantially reduce quality of life, it can also be very stigmatizing. In addition, the usual prokinetic therapy of GI-involvement, e.g. metoclopramide, does not appear to improve these symptoms. As the first step to approach this problem is the qualitative and quantitative description, we evaluated the oropharyngeal function in our cohort of SSc patients by detailed logopedic assessment.

Objectives:

To evaluate the frequency and type of oropharyngeal dysfunction, e.g. swallowing or speaking, in patients with SSc and to elucidate the correlating and associated factors, e.g. disease duration or modified Rodnan Skin Score.

Methods:

After obtaining written consent, oropharyngeal function using a standardized assessment protocol was evaluated in patients with SSc fulfilling the ACR/EULAR criteria by a speech therapist. Furthermore, we investigated whether oropharyngeal dysfunction is associated with patients’ characteristics. In addition, all patients received instruction for a training program to treat their individual oropharyngeal dysfunction.

Results:

37 patients with d/lSSc were assessed for eligibility. 34 patients met the inclusion criteria (3 patients did not speak German) and written consent was obtained.

Oropharyngeal dysfunction (impairment of speaking, swallowing, breathing or oropharyngeal muscle function) was found in 29 of 34 (85%) of both l/dSSc patients. Neither the subtype of SSc, disease duration nor mRSS were significantly correlated with oropharyngeal dysfunction in general. Only GI involvement in general was associated with oropharyngeal dysfunction.

After logopedic therapy, 28 of the 34 (82%) patients with oropharyngeal dysfunction reported a benefit after 3 days of training and were motivated to continue logopedic training at home.

Oropharyngeal dysfunctionPresent(n=29)absent(n=5)p-values (x2-test)dcSSc800,027lcSSc2240,027disease duration (mean)12,7 y12 y0,462mRSS<4920,322mRSS>42030,322Raynauds syndrom2950,673digital ulcers1920,812lung fibrosis1120,596eosophageal dilatation1520,566eosophageal dysmotility1900,015GI-involvement2310,007

Conclusion:

Logopedic assessment revealed a high incidence of oropharyngeal dysfunction in our cohort of SSc patients. Oropharyngeal dysfunction was not associated with disease duration, skin- or lung-involvement or dcSSc/lcSSc differentiation. A logopedic training program seems to be of benefit for this currently not pharmacologically treatable problem.

References:

[1]Schmeiser T, Saar P, Jin D, Noethe M, Müller A, Soydan N, et al. Profile of gastrointestinal involvement in patients with systemic sclerosis. Rheumatol Int 2012;32:2471–8.doi:10.1007/s00296-011-1988-6.

[2]Boeckxstaens GE, Bartelsman JFWM, Lauwers L, Tytgat GNJ. Treatment of GI dysmotility in scleroderma with the new enterokinetic agent prucalopride. Am J Gastroenterol 2002;97:194–7.doi:10.1016/S0002-9270(01)03958-2.

[3]Mercado U, Arroyo de Anda R, Avendaño L, Araiza-Casillas R, Avendaño-Reyes M. Metoclopramide response in patients with early diffuse systemic sclerosis. Effects on esophageal motility abnormalities. Clin Exp Rheumatol 2005;23:685–8.

Disclosure of Interests:

Miriam Wirths: None declared, Ole Hudowenz: None declared, Ulrike Hoffmann: None declared, Ulf Müller-Ladner Speakers bureau: Biogen, Uwe Lange: None declared, Philipp Klemm Consultant of: Lilly, Medac

Modellprojekt zur interdisziplinären universitären Lehre – Studierende der Medizin und der Psychologie lernen erstmals gemeinsam

Eine interdisziplinäre Zusammenarbeit ist in der medizinischen Versorgung chronisch erkrankter Patienten mit komplexen Erkrankungen erforderlich. Vor allem im Bereich der internistischen Rheumatologie ist eine interdisziplinäre Arbeit unerlässlich, um die komplexen somatischen und psychosozialen Aspekte einer chronischen Erkrankung zu berücksichtigen. Dennoch werden die Aspekte der interprofessionellen Arbeit im Studium der Medizin und Psychologie unzureichend thematisiert. Aus diesem Grund wurde ein Modellprojekt zur interdisziplinären universitären Lehre konzipiert, welches beide Fächer miteinander vereint. Die Veranstaltung wurde im Wintersemester 2019/20 erstmalig durchgeführt und stieß bei den Teilnehmer*innen auf positive Resonanz. Das Hauptziel der Veranstaltung ist die Implementierung interprofessioneller Arbeit in die Ausbildung des medizinischen Personals. Zusätzlich konnte das Fach der internistischen Rheumatologie den Studierenden nähergebracht werden.

Ecarin Chromogenic Assay

Der ECA (ecarin chromogenic assay) wurde zur quantitativen Bestimmung von direkten Thrombininhibitoren entwickelt. Er ist eine Weiterentwicklung der ECT (ecarin clotting time) und basiert wie diese auf der Prothrombinaktivierung durch Ecarin, einem Schlangengiftenzym aus Echis carinatus. Durch die entstehenden Aktivierungsprodukte Meizothrombin und Meizothrombin-Des-Fragment 1 wird im ECA ein chromogenes Substrat gespalten, während im Gerinnungsassay ECT plasmatisches Fibrinogen zu Fibrin umgesetzt wird.

Die Aktivität von Meizothrombin und Meizothrombin-Des-Fragment 1 wird konzentrationsabhängig durch direkte Thrombininhibitoren gehemmt. Der ECA kann als ECA-H zur quantitativen Hirudinbestimmung und als ECA-T zur Bestimmung von synthetischen Thrombinhemmstoffen eingesetzt werden. Am Beispiel von Hirudin, Argatroban und Melagatran erwies sich der ECA als äußerst präzise und sensitive Methode, die die Vorteile der ECT mit denen chromogener Tests verbindet. Im Vergleich zu aPTT und ECT weist der ECA sehr geringe interindividuelle Schwankungen auf. Er wird weder von der Prothrombin-noch von der Fibrinogenkonzentration im Plasma beeinflusst.

[Treat to participation : Position paper of the German Society for Rheumatology on sustained improvement of functional health of patients with rheumatic and musculoskeletal diseases]

From the perspective of patients with rheumatic diseases, the reduction of inflammatory disease activity alone is not a sufficient treatment goal. In addition the functional health and participation also have to be improved. Starting with the first symptoms the empowerment for the self-management of the disease is important for the patients; therefore, the established treat to target-strategy has to be expanded by the functional dimension to treat to participation. The position paper of the German Society for Rheumatology (GSR) summarizes the relevant fields of the multiprofessional action that is frequently necessary. This includes the acquirement of function-related competencies during training, further education and advanced training as well as implementation in the everyday practice of patient care. Furthermore, the GSR acknowledges the need for research related to functional and sociomedical consequences of rheumatic diseases and to individual and combined function-related programs in outpatient and inpatient care in rheumatology.

[The experiences of chronically ill women in the time of pregnancy, birth and postnatal period - a review of qualitative studies]

BACKGROUND

Chronic diseases are an increasing problem worldwide, especially in the industrialized countries. In pregnancy, during birth and in the post natal period the affected women are confronted with interventions and medical treatment in addition to the general physical and psychological challenges. However, there is only little knowledge about coping strategies and the experiences of women with chronic diseases during the childbirth period.

METHOD

An international literature search was conducted from 11/2013 till 03/2014. Relevant papers were identified from databases including Cinahl, Cochrane Library and Pubmed. Key search terms were related to the topics of experiences regarding the medical system and the professional caregivers, the role of the partners and families and the effects on the mother-child relationship.

RESULTS

11 studies were eligible for inclusion. In the childbearing period women with chronic diseases often feel under pressure because their general condition can cause medical complications. This leads to inner conflicts due to the necessity to derive to varying decisions concerning possible risks for the baby and their own body. Additionally the given information and main medical concepts do often not fit to their special needs and problems. The women feel excluded from the main professional concepts for childbearing women.

CONCLUSION

RESULTS of international studies demonstrate differences in available settings, supportive persons and concepts and impede that the right conclusions can be drawn for the German context. National Research is needed to evaluate the experiences and situation of childbearing women with chronic diseases and to implement adjusted concepts of professional care for this group of woman.

[Trends in rehabilitation of patients with rheumatic diseases in Germany]

Recent Deutsche Gesellschaft für Rheumatologie (DGRh, German Society of Rheumatology) guidelines emphasized the significance of coordinated multidisciplinary care and rehabilitation of patients with inflammatory rheumatic diseases. Nationwide data from the German pension insurance funds showed that inpatient rehabilitation due to rheumatoid arthritis (RA) varied by a factor of 2.6 between the different German states. From 2000 to 2012 rehabilitation measures were reduced by one third, most significantly in men with ankylosing spondylitis (AS). Rehabilitation measures because of RA or AS were provided up to 14 times more frequently by the German statutory pension insurance scheme compared with a large compulsory health insurance which is responsible for rehabilitation measures after retirement. In rehabilitation centers with high numbers of patients with inflammatory rheumatic diseases, higher structural and process quality were demonstrated. In 2011 a total of 40 % of RA patients in the national database of the collaborative arthritis centers showed medium or severe functional limitations. Among these disabled RA patients inpatient rehabilitation was reduced by about 50 % between 1995 and 2011. Out of all RA patients from outpatient rheumatology care with severe functional limitations 38 % had no functional restoration therapy within the previous 12 months with a high variation between rheumatologists. Experiences from other European countries may inspire German rheumatologists and other involved health professionals to initiate a wider range of rehabilitative interventions in the future.

[Septic monarthritis caused by Sphingomonas paucimobilis]

Sphingomonas paucimobilis, formerly known as Pseudomonas paucimobilis, is a rare cause of septic arthritis and is therefore regarded as being of minor clinical interest in rheumatological diagnostics. In this connection the yellow pigmented, aerobic, glucose non-fermenting, Gram negative bacillus is usually associated with immunocompromised patients. A case of septic arthritis in a 70-year-old man with chronic obstructive pulmonary disease (COPD) initially presenting with right knee pain, swelling and redness is reported. After diagnosis of septic gonarthritis due to Sphingomonas paucimobilis, the infection was successfully treated by oral antibiotic therapy with ofloxacine based on the patient's antibiotic susceptibility profile, combined with analgesic and anti-inflammatory local physical therapy several times a day leading to a considerable improvement in the symptoms so that operative interventions could therefore be avoided.

[Osteoporosis - inflammatory effects on bone metabolism and fracture risk]

There is a large body of evidence that proinflammatory cytokines, particularly interleukin-1, interleukin-6, and tumour necrosis factor-α, play an important role in bone metabolism. Moreover, it is suspected that proinflammatory cytokines are also important in the pathogenesis of age- and estrogen deficiency-related bone loss. Although an accelerated decrease in bone mass is observed in patients with chronic inflammatory disorders, the definite meaning of proinflammatory cytokines in the aetiology of osteoporosis is still unclear. Some studies suggest a relationship between increased concentrations of proinflammatory cytokines and a decrease in bone mineral density, as well as an increased risk of fracture. In sum, the evidence is rather scarce and does not permit any clear conclusions about the effects of single cytokines in bone metabolism. To be able to define more exactly at which stage of the pathogenesis of osteoporosis parameters of a systemic inflammation take effect, further studies will be necessary, particularly for developing suitable diagnostic markers for clinicians. These diagnostic markers may be able to identify patients at risk for osteoporosis and therefore predict fracture risks. Thus, early interventions to preserve bone health, for example, by anti-cytokine therapy, could be more effective and efficient.

[Osteoimmunology: how inflammation influences bone metabolism]

Bone remodelling is characterized by a balance between bone resorption and bone formation. The osteoblasts are responsible for bone synthesis and the osteoclasts for bone resorption. A finely adjusted interaction between molecular mechanisms leads, via cytokines, hormones and growth factors, to a homeostasis of the bone metabolism. Here, the RANK/RANKL/OPG-system is actively involved in the differentiation and function of osteoclasts and seems to play a central role in most pathophysiological mechanisms. An increased osteoclast activity results in inflammatory destructive manifestations and/or osteoporosis whereas an increased osteoblast activity can result in osteopetrosis. The present overview describes the known pathophysiological relevant metabolic pathways in this remodelling process especially the effect of inflammation on bone metabolism, and presents the links from bench to bedside.