Rasch analysis of a patient-reported outcome measure for self-perceived health among psychiatric patients in Denmark

BACKGROUND

Patient-reported outcome measures (PROMs) are valuable and necessary tools for establishing and maintaining patient-centred healthcare. The PRO-Psychiatry initiative was primarily initiated to support the patient's voice in treatment decision-making and secondarily to monitor patient-perceived quality of care. The result of the initiative is a patient-reported instrument developed in collaboration between patients and clinicians. We aimed to validate the PROM developed for measuring self-perceived health among psychiatric patients in North Denmark Region, in terms of internal consistency, criterion validity and responsiveness.

METHOD

Patients in contact with a psychiatric hospital in the North Denmark Region from September 2018 to March 2021 were included in the study. The PROM constitutes a scale of 17 items covering various aspects of self-perceived health including well-being (7 items), lack of well-being (5 items) and social functioning (5 items), where the former domain entails the WHO-5 Well-Being Index. The potential range of the total scale score is 0-85. We applied McDonald's omega, average inter-item correlation (AIIC) and differential item functioning (DIF). In addition, we used mixed effects analyses to estimate temporal correlations. The instrument was compared with self-rated overall mental and psychiatric health.

RESULTS

The patient population consisted of 1132 unique patients and a total of 2476 responses corresponding to one response per patient pathway. McDonald's omega was found to be 0.92 (95% CI 0.92 to 0.93), while the AIIC was found to be 0.42 (95% CI 0.39 to 0.44). For DIF, the largest systematic variation resulted in a maximum difference of 2.3 points on the total score when adjusting for the latent trait and was found when comparing initial measurements with follow-up measurements. The correlation between the total score and the outcomes regarding overall physical and mental health was 0.52 (95% CI 0.48 to 0.56) and 0.74 (95% CI 0.72 to 0.76). Similar correlations were found for the corresponding changes over time.

CONCLUSION

The scale showed high consistency and little systematic variation between the comparison groups. The concurrent correlations and analyses of responsiveness coincided with the prespecified hypotheses. Overall, we deem the Danish PRO-Psychiatry instrument to possess suitable psychometric properties for measuring self-perceived health among a psychiatric population.

Quantitative sensory testing, psychological profiles and clinical pain in patients with psoriatic arthritis and hand osteoarthritis experiencing pain of at least moderate intensity

BACKGROUND

Chronic pain is the hallmark symptom of joint diseases. This study examined the differences in quantitative sensory testing between patients with psoriatic arthritis (PsA), hand osteoarthritis (hand-OA) and a pain-free control group and differences between patients with and without concomitant fibromyalgia (cFM).

METHODS

All patients and pain-free controls were assessed using pressure pain thresholds (PPT), temporal summation of pain (TSP), conditioned pain modulation (CPM) and clinical pain intensities. Psychological distress was assessed with the Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, and Pittsburgh Sleep Quality Index. Disability was assessed with the Health Assessment Questionnaire and pain quality with the painDETECT questionnaire. cFM was identified using the revised 2016 American College of Rheumatology diagnostic criteria.

RESULTS

Patients with hand-OA (n = 75) or PsA (n = 58) had statistically significant lower PPTs and CPM, greater TSP, and higher scores of psychological distress (p < 0.05) than controls (n = 20). Patients with cFM (58%) had higher scores of depression (p = 0.001), anxiety (p = 0.004), catastrophizing (p = 0.012), disability (p < 0.001), higher painDETECT score (p = 0.001), TSP (p = 0.027), and reduced sleep quality (p = 0.021) when compared to patients without cFM.

CONCLUSION

Patients with hand-OA and PsA exhibited signs of pain sensitization and a higher degree of psychological distress and disability than pain-free individuals. Patients with cFM had greater TSP, painDETECT score, disability, catastrophizing, and reduced sleep quality, than patients without, indicating greater degree of pain sensitization, psychological burden, and disability.

STATEMENT OF SIGNIFICANCE

This paper shows that a significant proportion of patients with hand osteoarthritis and psoriatic arthritis with moderate pain intensity have significantly increased signs of pain sensitization and markers of psychological distress. A large proportion of these patients fulfil the criteria for concomitant fibromyalgia and these patients show even greater propensity towards pain sensitization and psychological distress.

Review: application of the Safety Attitudes Questionnaire (SAQ) in primary care - a systematic synthesis on validity, descriptive and comparative results, and variance across organisational units

Patient safety research has focused mostly on the hospital and acute care setting whereas assessments of patient safety climate in primary health care settings are warranted. Valid questionnaires as e.g., the Safety Attitudes Questionnaire (SAQ) may capture staff perceptions of patient safety climate but until now, an overview of the use of SAQ in primary care has not been systematically presented. Thus, the aim of this systematic review is to present an overview of SAQ used in primary care.Methods The electronic databases: PubMed, Embase, Cinahl, PsycInfo and Web of Science were used to find studies that used any version of SAQ in primary care. Studies were excluded if only abstract or poster was available, as the information in abstract and posters was deemed insufficient. Commentaries and nonempirical studies (e.g., study protocols) were excluded. Only English manuscripts were included.Results A total of 43 studies were included and 40 of them fell into four categories: 1) validation analysis, 2) descriptive analysis, 3) variance assessment and 4) intervention evaluation and were included in further analyses. Some studies fell into more than one of the four categories. Seventeen studies aimed to validate different versions of SAQ in a variety of settings and providers. Twenty-five studies from fourteen different countries reported descriptive findings of different versions of SAQ in a variety of settings. Most studies were conducted in primary health care centres, out-of-hours clinics, nursing homes and general practice focusing on greatly varying populations. One study was conducted in home care. Three studies investigated variance of SAQ scores. Only five studies used SAQ to assess the effects of interventions/events. These studies evaluated the effect of electronic medical record implementation, a comprehensive Unit-based Safety Program or COVID-19.Conclusion The synthesis demonstrated that SAQ is valid for use in primary care, but it is important to adapt and validate the questionnaire to the specific setting and participants under investigation. Moreover, differences in SAQ factor scores were related to a variety of descriptive factors, that should be considered in future studies More studies, especially variance and intervention studies, are warranted in primary care.Trial registration This systematic review was not registered in any register.

Disease activity-guided tapering of biologics in patients with inflammatory arthritis: a pragmatic, randomized, open-label, equivalence trial

OBJECTIVE

To evaluate whether disease activity-guided tapering of biologics compared to continuation as usual care enables a substantial dose reduction while disease activity remains equivalent.

METHOD

In this pragmatic, randomized, open-label, equivalence trial, adults with rheumatoid arthritis, psoriatic arthritis, or axial spondyloarthritis in low disease activity on stable-dose biologics for ≥ 12 months were randomized 2:1 into either the tapering group, i.e. disease activity-guided prolongation of the biologic dosing interval until flare or withdrawal, or the control group, i.e. maintaince of baseline biologics with a possible small interval increase at the patients request. The co-primary outcome in the intention-to-treat population was met if superiority in ≥ 50% biologic reduction at 18 months was demonstrated and disease activity was equivalent (equivalence margins ± 0.5).

RESULTS

Ninety-five patients were randomized to tapering and 47 to control, of whom 37% (35/95) versus 2% (1/47) achieved ≥ 50% biologic reduction at 18 months. The risk difference was statistically significant [35%, 95% confidence interval (CI) 24%-45%], while disease activity remained equivalent [mean difference 0.05, 95% CI -0.12-0.29]. A statistically significant flare risk was observed [tapering 41% (39/95) vs control 21% (10/47), risk difference 20%, 95% CI 4%-35%]; but, only 1% (1/95) and 6% (3/47) had persistent flare and needed to switch to another biological drug.

CONCLUSIONS

Disease activity-guided tapering of biologics in patients with inflammatory arthritis enabled one-third to achieve ≥ 50% biologic reduction, while disease activity between groups remained equivalent. Flares were more frequent in the tapering group but were managed with rescue therapy.

Patient safety culture and associated factors in secondary health care of the Capital Region of Denmark: influence of specialty, healthcare profession and gender

BACKGROUND

We aimed to explore (1) the influence of healthcare professionals' (HCPs') specialty, profession, gender and length of employment on their perception of six dimensions of patient safety culture (PSC) and (2) the relation between these characteristics and the two dimensions of safety climate and perception of management.

METHODS

In a cross-sectional study, a Danish version of the Safety Attitudes Questionnaire was sent to all HCPs at a large regional hospital organisation. This included hospitals, the Emergency Services, the Regional Pharmacy and the Centre for Diabetes corporations. A total of 30 230 HCPs received the survey. Differences between specialties, professions, gender and years of employment were tested for each dimension of PSC. Differences in mean attitude scores were tested using analysis of variance and differences in having a positive attitude were tested using logistic regression.

RESULTS

In total, 15 119 (50%) HCPs returned the survey. Significant differences are seen across hospitals and corporations for all dimensions of PSC. The proportion of HCPs with a positive attitude was largest regarding job satisfaction (74.8%) and lowest regarding perception of management (43.9%). Significant differences are seen in physicians' and nurses' perception of PSC in the different specialties within all dimensions of PSC except for the dimension of recognition of stress. Significant differences in positive perception of teamwork climate are seen between anaesthesiologists' (69.4%) and surgeons' (41.7%). No significant gender differences were found between physicians' and nurses' perception of safety climate and of management. In addition, we found an influence of years of employment on PSC.

DISCUSSION

Significant differences were found in HCPs' perception of PSC between corporations, specialties and professions. The lowest proportion of HCPs with a positive perception of PSC was found within the dimensions of safety climate and perception of management. These differences may have implications for teamwork and patient safety.

Perioperative atrial fibrillation in major emergency abdominal surgery: does it affect postoperative outcome?

Background

Atrial fibrillation (AF) in relation to surgery remains a clinical challenge. Major emergency abdominal surgery (e.g. ileus, perforation) is associated with postoperative complications and mortality. However, the prevalence and impact of perioperative AF in this setting is not well examined.

Purpose

We compared 30-days and 1-year outcomes (i.e. hospitalization of any causes, AF-related hospitalization, thromboembolic events and all-cause mortality) in patients who did and did not develop perioperative AF (POAF) in relation to their major emergency abdominal surgery.

Methods

We crosslinked data from Danish nationwide registries and identified all patients who underwent major emergency abdominal surgery (2000–2018) and discharged alive. Patients who developed POAF during hospitalization were matched in a 1:3 ratio on age, sex, year of surgery and category of surgery with those without POAF. Starting follow up at discharge, we examined the rates of outcomes at 30-days and 1-year post-discharge. The cumulative incidences and ratios of outcomes were assessed with the Aalen Johanson estimator together with Kaplan-Meier estimator and multivariable Cox regression analysis, respectively.

Results

We identified 891 patients with POAF and 64,914 patients without POAF. The matched cohort were composed of 889 patients with POAF and 2667 patients without POAF with a median age of 79 years [25th-75th percentile; 72–84 years] and 45.2% males. In general, patients with POAF had higher comorbid burden compared with patients without POAF. The cumulative incidences of a hospitalization of any cause after 30-days post-discharge were 31.2% and 22.3% in patients with and without POAF, respectively. The corresponding numbers for AF-related hospitalization were 20.8% and 1.2%, respectively. In adjusted analyses, POAF was associated with a significantly higher risk of hospitalization of any causes together with AF-related hospitalization (Figure 1 and 2).

The cumulative incidences of a thromboembolic event after 30-days post-discharge were 2.2% and 0.9% in patients with and without POAF, respectively. The corresponding numbers for all-cause mortality were 9.7% and 3.2%, respectively. In adjusted analyses, POAF was associated with a significantly higher risk of a thromboembolic event together with all-cause mortality within 30-days of follow up as well as 1-year of follow up. However, the results regarding thromboembolic events did not reach statistical significance after 1-year of follow up (Figure 1 and 2).

Conclusions

Perioperative atrial fibrillation in relation to major emergency abdominal surgery was associated with higher 30-days and 1-year rates of hospitalizations of any causes, atrial fibrillation related hospitalization, a thromboembolic event and all-cause mortality. These findings suggest that perioperative atrial fibrillation is a strong prognostic marker of increased morbidity following major emergency abdominal surgery.

Funding Acknowledgement

Type of funding sources: None.

A synopsis of global frontiers in fertility preservation

Since 2007, the Oncofertility Consortium Annual Conference has brought together a diverse network of individuals from a wide range of backgrounds and professional levels to disseminate emerging basic and clinical research findings in fertility preservation. This network also developed enduring educational materials to accelerate the pace and quality of field-wide scientific communication. Between 2007 and 2019, the Oncofertility Consortium Annual Conference was held as an in-person event in Chicago, IL. The conference attracted approximately 250 attendees each year representing 20 countries around the world. In 2020, however, the COVID-19 pandemic disrupted this paradigm and precluded an in-person meeting. Nevertheless, there remained an undeniable demand for the oncofertility community to convene. To maintain the momentum of the field, the Oncofertility Consortium hosted a day-long virtual meeting on March 5, 2021, with the theme of "Oncofertility Around the Globe" to highlight the diversity of clinical care and translational research that is ongoing around the world in this discipline. This virtual meeting was hosted using the vFairs ® conference platform and allowed over 700 people to participate, many of whom were first-time conference attendees. The agenda featured concurrent sessions from presenters in six continents which provided attendees a complete overview of the field and furthered our mission to create a global community of oncofertility practice. This paper provides a synopsis of talks delivered at this event and highlights the new advances and frontiers in the fields of oncofertility and fertility preservation around the globe from clinical practice and patient-centered efforts to translational research.

P-517 Validating reference gene expression stability in human ovarian follicles, oocytes, cumulus cells, ovarian medulla, and ovarian cortex tissue

Study question

How does the expression stability of commonly used reference genes (RG) vary in different human ovarian cells and tissues?

Summary answer

The RG stability differed among human ovarian cell types and tissues, but an RG with high stability was identified for each cell and tissue type.

What is known already

The expression of RGs used to normalize RT-qPCR may vary between different tissues, cell types, and experimental conditions. Hence, selecting the most appropriate RGs is critical in any experimental design to interpret data generated by RT-qPCR with the best accuracy. Human ovarian cells are phenotypically very different and often only available in limited amounts. In several animal species RG expression stability has been validated in oocytes and other ovarian cells, however, the suitability of a single universal RG in the different human ovarian cells and tissues has not been determined.

Study design, size, duration

This is an experimental study performed at a university hospital from January 2021 to September 2021.

Participants/materials, setting, methods

The freely available NormFinder software was used to analyze the expression stability of five commonly used RGs (GAPDH, B2M, RPLP0, ACTB, and PPIA) in human oocytes (n = 160), preantral follicles (n = 160), cumulus cells (n = 13), ovarian medulla (n = 8), and ovarian cortex tissue (n = 60). Samples were collected from 29 patients (aged 28 years on average; range 14–36) undergoing unilateral oophorectomy and ovarian tissue cryopreservation for fertility preservation.

Main results and the role of chance

The Normfinder software identified ACTB as the best RG for oocytes and cumulus cells; and B2M for medulla tissue and isolated follicles. Overall, comparisons of the cycle threshold (Ct) values demonstrated a wide variation among the RGs within the same group of samples (P &lt; 0.05), especially for oocytes and preantral follicles with normalized RNA. The genes ACTB and RPLP0 showed the highest levels of expression and PPIA the lowest levels of expression in all types of samples, except for cortex tissue, where PPIA had the highest level of expression and B2M the lowest. These results infer that different results could be obtained when using different RGs for data normalization. The combination of two RGs only marginally increased stability, indicating that using a single validated RG would be sufficient when the available testing material is limited. For cultured ovarian cortex culture, GAPDH or ACTB were found to be the most stable genes depending on culture conditions.

Limitations, reasons for caution

Since human oocytes are scarce and contain a small amount of RNA, only five RGs were evaluated. Moreover, only germinal vesicle (GV) oocytes and preantral follicles (60-80 µm) were tested. Future studies may validate other genes and investigate the effect of oocyte maturation and follicle growth on RG stability.

Wider implications of the findings

Our findings highlight the importance of validating RGs for each cell type or tissue and culture condition. Hence, our results can be of use as guidance for future studies involving gene expression analyses in human ovarian cells and tissues, including oocytes and preantral follicles.

Trial registration number

Not applicable

Patient safety culture in an orthopaedic surgery centre in Denmark

INTRODUCTION

Measuring and developing patient safety culture (PSC) is a focal point in creating a highly reliable organisation, and patient safety is the cornerstone of quality healthcare. The purpose of this study was to describe PSC in an elective orthopaedic surgery centre in Denmark.

METHODS

A total of 445 healthcare workers were invited to participate. A cross-sectional study design using the Safety Attitudes Questionnaire (SAQ) was applied.

RESULTS

A total of 356 invitees (80%) answered the SAQ. The proportion of employees with a positive perception of the PSC was above the anticipated 60% threshold in five out of six dimensions. Perceptions of PSC varied by gender across four of six dimensions. Thus, significantly more female than male participants had a positive perception of the PSC. A significant variation was observed in the proportion of employees with a positive perception of PSC at the unit level except for teamwork climate and stress recognition.

CONCLUSIONS

This is the first Danish study of PSC in an elective orthopaedic surgical setting. Across dimensions, % positive were more favourable than reported in the international literature.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

POS1498-HPR NEWLY DIAGNOSED WITH INFLAMMATORY ARTHRITIS – DEVELOPMENT OF A COMPLEX SELF-MANAGEMENT INTERVENTION

Background

People newly diagnosed with inflammatory arthritis (IA) request regular consultations and support from health professionals (HPRs) in rheumatology to manage physiological, emotional, and social challenges. Evidence suggests that providing a tailored tailormade multi-component self-management program may benefit disease management (1). However, there is a lack of evidence in interventions with multiple components targeting people newly diagnosed with IA.

Objectives

To develop a complex evidence- and theory-based intervention in co-creation with patients and HPRs for better self-management in newly diagnosed people with IA in a rheumatology out-patient clinic.

Methods

This study followed the Medical Research Council (MRC) Framework (2,3) for developing a complex intervention. The development phase comprised 1) identifying the evidence base, 2) identifying theory, 3) modelling process and outcomes, resulting in 4) a final description of all components and outcomes of the intervention.

1) Identifying the evidence base

We conducted two literature reviews, on which, we described a preliminary nurse-led intervention.

2) Identifying theory

Given the fact that the theory of Self-management is built upon Social Cognitive Theory (4) this was chosen as the underlying theory along with Acceptance and Commitment Theory (5) to support our communication strategy.

3) Modelling process and outcomes

The preliminary intervention was discussed and further developed in seven workshops to ensure that the intervention was in accordance with patients’ needs and feasible in clinical practice. Three patients and 38 HPRs (nine therapists, 10 rheumatologists, one psychologist, one social worker, and 17 registered nurses) attended.

During the workshops we identified the competencies needed in the HPRs delivering the intervention. In addition, relevant outcomes to measure self-management in a subsequent feasibility study were discussed. Discussions were digitally recorded and analysed using Thematic Analysis (6). Subsequently, the project group discussed the analysis and consensus was reached.

Results

4) Description of all components and outcomes of the intervention

Our intervention, ready for testing in a feasibility study, was a 9-month nurse-led intervention, and consisted of four individual and two group sessions. A physiotherapist and an occupational therapist should attend the group sessions along with the nurse (Figure 1). All sessions should target inflammatory arthritis-specific self-management.

Figure 1.

Intervention activities and

A comprehensive intervention manual has been developed. Our patient research partner and experts in rheumatology and self-management commented on the content to secure content validity. Subsequently, we conducted cognitive interviews with the HPRs to determine the face validity of the manual. In addition, we completed a two-day competence program to train HPRs in delivering the intervention.

The selected patient reported outcomes were: Physical activity levels, Health assessment, Fatigue, Quality of life, Anxiety and depression, Illness intrusiveness, Illness perception, and Self-efficacy, supplemented with objective measures for diseases activity.

Conclusion

NISMA - a nurse-led complex self-management intervention embedded in a multidisciplinary team has been developed and described based on MRC’s framework for the development of complex interventions. The intervention is currently being tested in a feasibility study.

References

[1]Nikiphorou et al., Annals of the Rheumatic Diseases. 1. oct 2021.

[2]Skivington et al., BMJ. 30. sep. 2021.

[3]Craig et al., nt J Nurs Stud. may 2013.

[4]Bandura A. SOCIAL COGNITIVE THEORY.

[5]Newman et al., Lancet. oct 2004.

[6]Braun et al., Springer; 2019.

Acknowledgements

First, I would like to thank the patients and health professionals who attended the workshops.

Secondly, I would like to thank The Novo Nordic Foundation for funding.

Disclosure of Interests

None declared

AB0272 DEEP BREATHING INCREASES HEART RATE VARIABILITY IN HEALTHY PARTICIPANTS AND IN PATIENTS WITH RHEUMATOID ARTHRITIS AND SYSTEMIC LUPUS ERYTHEMATOSUS: AN INTERVENTIONAL DOSE-RESPONSE STUDY

Background

Patients with Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE) are known to have an autonomic dysfunction, especially reduced parasympathetic activity. The dysfunction can be measured through heart rate variability (HRV), an indicator of vagus nerve tone. Studies have found a potential anti-inflammatory effect of the vagus nerve and proposed vagus nerve stimulation (VNS) as an anti-inflammatory treatment. A way of stimulating the vagus nerve non-invasively could be through deep breathing (DB).

Objectives

The aims of this study were to examine the dose-response of DB on HRV in healthy participants and to examine the reliability of the effect of DB on HRV in patients with RA and SLE across two days.

Methods

The study was designed as an interventional study, more specifically the healthy subjects participated in a dose-response study and the patients with RA and SLE participated in a study of reliability. Forty-one healthy participants performed DB for 5, 15, and 30 minutes (4 seconds of inspiration and 6 seconds of expiration) in a randomized order on three different days. Fifty-two patients with RA and SLE performed the optimal dose of DB found in healthy participants, and the intervention was repeated on two different days to examine the reliability of the effect. The outcome measure was HRV, which was derived from a 5-minute electrocardiogram recording measured twice before and three times after DB. The extracted HRV measures included in the further analysis were the time domain parameters: a) The standard deviation of the R-R intervals (SDNN), b) the root mean square of successive R-R intervals (RMSSD), and c) the proportion of NN50 (pairs of successive R-R intervals that differ more than 50 milliseconds) divided by the total number of R-R intervals (PNN50).

Results

Thirty minutes of DB increased HRV and was the optimal dose of DB in healthy participants. In patients with RA and SLE 30 minutes of DB increased all HRV-parameters similarly across two days indicating reliability, see Figure 1. The effect of DB remained for at least 30 minutes after the intervention.

Figure 1.

Bar chart showing the heart rate variability-parameters plotted as mean ± standard error in patients with RA and SLE. RA: Rheumatoid Arthritis. SLE: Systemic Lupus Erythematosus. SDNN: The standard deviation of the R-R intervals. RMSSD: The root mean square of successive R-R intervals. PNN50: The proportion of NN50 (pairs of successive R-R intervals that differ more than 50 milliseconds) divided by the total number of R-R intervals.

Conclusion

DB increases HRV in healthy participants and in patients with RA and SLE, indicating a stimulation of the vagus nerve. Future studies are needed to investigate the potential anti-inflammatory effect as well.

Acknowledgements

The authors thank patients and research personnel at Aalborg University Hospital, Denmark.

Disclosure of Interests

None declared

OP0065 INFLIXIMAB BIOSIMILAR-TO-BIOSIMILAR SWITCHING IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES: CLINICAL OUTCOMES IN REAL-WORLD PATIENTS FROM THE DANBIO REGISTRY

Background

In routine care, biosimilar-to-biosimilar infliximab switching may occur to save costs (=non-medical switching). Previous studies have investigated the efficacy and safety of switches from originator infliximab to a corresponding biosimilar in patients with inflammatory rheumatic diseases (1). However, the outcomes after switching from one infliximab biosimilar to a second infliximab biosimilar remain scarcely investigated.

Denmark has recently conducted a nationwide mandatory infliximab biosimilar-to-biosimilar switch.

Objectives

To investigate the effectiveness of infliximab biosimilar-to-biosimilar switch (CTP-13 to GP1111) among patients with RA, PsA and AxSpA, including patients who had previously switched from originator (originator-experienced) to CT-P13 as well as patients who were originator-naïve.

Methods

Observational cohort study based on DANBIO registry (for clinical data upon switch =baseline) linked with national patient registries (to identify prior comorbidities). Patients with RA, PsA or AxSpA who performed a biosimilar-to-biosimilar switch from CT-P13 to GP1111 between April 1st 2019 and February 1st 2020 were included. Patient were divided into two groups: originator-naïve and originator-experienced. Main outcomes in the two groups were one-year GP1111 treatment retention (Kaplan Meier “drug survival curves”) and changes in disease activity 4 months before versus 4 months after switch in individual patients. Also, factors associated with GP1111 treatment retention for both groups combined were explored with Cox proportional hazard regression analyses, stratified by diagnosis (univariate-, age-and gender adjusted and fully adjusted). Analyses were adjusted for relevant clinical factors (for details: see Table 1)

Table 1.

Baseline variables associated with GP1111 withdrawal (RA shown below, similar findings for PsA and AxSpA)

UnivariateAge- and gender adjustedMultivariateHR (95% CI)p-valueHR (95% CI)p-valueHR (95%CI)p-valueRAFemale gender0.9 (0.6-1.3)0.4-0.7 (0.5-1.2)0.2Age, years1.0 (0.9-1.0)0.9-1.0 (0.9-1.1)0.6Originator-experienced versus originator naïve to infliximab0.5 (0.3-0.8)0.0020.5 (0.3-0.8)0.0020.4 (0.2-0.9)0.01Methotrexate use, yes0.5 (0.3-0.7)<0.0010.5 (0.3-0.7)<0.0010.6 (0.4-0.9)0.01Comorbidities ≥11.1 (0.7-1.5)0.81.1 (0.7-1.5)0.80.9 (0.6-1.4)0.7In remission (yes)0.4 (0.3-0.6)<0.0010.4 (0.2-0.6)<0.0010.5 (0.3-0.7)<0.001DAS281.7 (1.4-1.9)<0.0011.7 (1.5-1.9)<0.001--Patient global VAS, mm1.0 (1.0-1.1)<0.0011.0 (1.0-1.1)<0.001--

Results

In total, 1,605 patients underwent an infliximab biosimilar-to-biosimilar switch and were included; 1,171 were originator-naïve and 434 were originator-experienced, 685 RA/314 PsA/606 AxSpA, median disease duration was 9 years, 42% were in DAS28/ASDAS remission at the time of switch.

At one year, 83% (95% CI 81-85) of the originator-naive and 92% (95% CI 90-95) of the originator-experienced switchers maintained GP1111 treatment (Figure 1). Changes in disease activity 4 months pre- and post-switch were close to zero for all disease activity measures (e.g. DAS28, ASDAS, VAS pain, not shown).

The risk of GP1111 withdrawal was lower in originator-experienced compared to originator-naïve patients in patients with RA and PsA: HR 0.4 (95% CI 0.2-0.9, p-value 0.01) and HR 0.1 (0.1-0.6, p=0.01), but not significantly for AxSpA 0.56 (0.27-1.13, p=0.1). Across all indications, lower disease activity at baseline (DAS28/ASDAS remission) was associated with higher retention (Table 1).

Conclusion

Biosimilar-to-biosimilar infliximab switch was effective and well-tolerated in >1,500 real-world patients. Retention was higher in originator-experienced switchers and patients, who were in remission at the time of the switch, suggesting retention to be more affected by patient-related than drug-related factors.

References

[1]Glintborg et al, ARD, 2017; 76: 1426–1431

Acknowledgements

We thank departments reporting to the DANBIO registry.

Disclosure of Interests

Hafsah Nabi Grant/research support from: Research grant from Sandoz, who had no influence on the analysis, interpretation and presentation of data., Merete L. Hetland Speakers bureau: Biogen, Celltrion, Janssen Biologics B.V, MSD, Pfizer, Samsung Biopis, Consultant of: Biogen, Celltrion, Janssen Biologics B.V, MSD, Pfizer,

Samsung Biopis, Grant/research support from: AbbVie, Biogen, BMS, Eli Lilly Denmark A/S,

Lundbeck Fond, Pfizer, Roche, Sandoz, Novartis, Anne Gitte Loft Paid instructor for: AbbVie, Eli Lilly Denmark A/S, Janssen- Cilag A/S, MSD, Novartis, Pfizer, UCB, Consultant of: AbbVie, Eli Lilly Denmark A/S, Janssen-Cilag

A/S, MSD, Novartis, Pfizer, UCB, Grant/research support from: Novartis, Oliver Hendricks Speakers bureau: AbbVie, Pfizer, Novartis, Dorte Jensen: None declared, Jens Kristian Pedersen: None declared, Søren Andreas Just: None declared, Kamilla Danebod: None declared, Heidi Lausten Munk: None declared, Salome Kristensen: None declared, Natalia Manilo: None declared, Ada Colic: None declared, Asta Linauskas: None declared, Pia Høger Thygesen: None declared, Louise Brot Christensen: None declared, Maren Høgberget Kalisz: None declared, Niels Lomborg: None declared, Jolanta Grydehøj: None declared, Johnny Raun: None declared, Rabiah Ahmed: None declared, Frank Mehnert: None declared, Niels Steen Krogh: None declared, Bente Glintborg Grant/research support from: BMS, Pfizer, Sandoz.

POS0761 TIME-DEPENDENT ANALYSES OF CLINICAL MANIFESTATIONS OF SYSTEMIC LUPUS ERYTHEMATOSUS IDENTIFY PATIENTS AT HIGH RISK OF INCIDENT PROTEINURIA

Background

Nephritis (LN) in systemic lupus erythematosus (SLE) is still a major determinant of poor prognosis[1].

The vast majority of LN occurs in proximity to the SLE diagnosis[2]. Identification of individuals at high risk, especially early onset SLE, is therefore warranted. Inclusion of risk factors prior to the SLE diagnosis may thus be of importance to enable sufficient risk factor profiling. SLE-patients seem to cluster according to clinical and serological phenotypes suggesting distinct disease trajectories[3-5].

Objectives

To determine if incident proteinuria associated with the debut age of non-renal SLE characteristics.

Methods

Data of SLE patients from six Danish centers were obtained from the Danbio-database from 2017 – 2020. The occurrence and timing of proteinuria was compared with first time onset of any non-renal manifestations as defined by the 1997 American College of Rheumatology Classification Criteria. Cox-regression models were used to identify risk factors for incident proteinuria. Time from first occurring non-renal manifestation to incident proteinuria or censoring defined time at risk. Covariates were eliminated if p >0.01 in a ‘backwards’ manner. After the model reduction process p-values <0.05 were considered statistically significant.

Results

586 SLE patients, mainly white (94%) women (88%), mean age at inclusion of 34.6 years (standard deviation, SD = 0.6 years) and observed for a mean of 14.9 years (SD =0.5 years), were recruited. The cumulative prevalence of proteinuria was 40%. Male gender hazard ratio, HR = 1.35 (range 0.77-2.35), p=0.009, lymphopenia HR = 1.77 (range 1.24-2.52), p=0.005 were associated with incident proteinuria. In contrast, patients with discoid rash had lower risk of incident proteinuria HR 0.42 (range 0.21-0.83), p=0.01. Male patients with lymphopenia had the highest risk of proteinuria with a one-, 5- and 10-year risk of proteinuria ranging from 9-27%, 34-75% and 51-89 %, depending on the age at presentation (debut at 20, 30, 40 or 50 years). The corresponding risk-profiles for women with lymphopenia were 3-9%, 8-34% and 12-58%, respectively, as illustrated in Figure 1.

Conclusion

The occurrences of lymphopenia and discoid rash were oppositely associated with risk of incident proteinuria and the risk effects varied according to gender and patient age at onset of these manifestations. Thus, the risk of proteinuria may not be constant but could vary according to presentation of non-renal manifestations that may call for a differentiated clinical follow-up. Based on these findings, we suggest that the debut age of known prognostic factors, even prior to the SLE diagnosis should be considered when designing prognostic statistical models.

References

[1]Faurschou, M., et al., Prognostic factors in lupus nephritis: diagnostic and therapeutic delay increases the risk of terminal renal failure. J Rheumatol, 2006. 33(8): p. 1563-9.

[2]Hanly, J.G., et al., The frequency and outcome of lupus nephritis: results from an international inception cohort study. Rheumatology (Oxford), 2016. 55(2): p. 252-62.

[3]Diaz-Gallo, L.M., et al., Four Systemic Lupus Erythematosus Subgroups, Defined by Autoantibodies Status, Differ Regarding HLA-DRB1 Genotype Associations and Immunological and Clinical Manifestations. ACR Open Rheumatol, 2022. 4(1): p. 27-39.

[4]Jacobsen, S., et al., A multicentre study of 513 Danish patients with systemic lupus erythematosus. II. Disease mortality and clinical factors of prognostic value. Clin Rheumatol, 1998. 17(6): p. 478-84.

[5]Leffers, H.C.B., et al., Smoking associates with distinct clinical phenotypes in patients with systemic lupus erythematosus: a nationwide Danish cross-sectional study. Lupus Sci Med, 2021. 8(1).

Disclosure of Interests

Martin Andersen Employee of: Novo Nordisk A/S: 2010-2014, Anders Stockmarr: None declared, Henrik Leffers: None declared, Anne Troldborg: None declared, Anne Voss: None declared, Salome Kristensen: None declared, Bent Deleuran: None declared, Lene Dreyer Speakers bureau: Speakers bureau: Eli Lilly, Galderma and Janssen, Grant/research support from: Grant from BMS outside the present work, Laura Johnsen: None declared, Ada Colic: None declared, Søren Jacobsen: None declared

POS1192 INCIDENCE AND RISK FACTORS OF COVID‑19 IN PATIENTS WITH VASCULITIS: A DANISH NATIONWIDE COHORT STUDY

Background

Patients with small vessel vasculitis (SVV) and large vessel vasculitis (LVV, including giant cell arteritis (GCA)) are considered at higher risk of infections compared to the general population, owing to their underlying condition and the use of immunosuppressive drugs. Thus, the risk of COVID-19 infection and related outcomes during the global pandemic is of immediate concern to rheumatologists worldwide.

Objectives

To estimate the incidence of COVID-19 hospitalisation in patients with vasculitis, and to evaluate the impact of glucocorticoid treatment on the outcome between March 2020 and February 2021.

Methods

With use of the Danish nationwide registers, a cohort of patients with LVV and SVV, respectively, and general population controls (GPCs) matched on age and gender was established. Hazard ratios (HR) for COVID-19 hospitalisation was estimated. National COVID-19 surveillance data was used to calculate the odds ratio (OR) of having had a positive SARS-CoV2 PCR test. Lastly, a nested case-control design and conditional logistic regression was used to estimate the impact of glucocorticoids on the risk of hospitalisation.

Results

Patients with SVV (n=1090) had an increased incidence of COVID-19 hospitalisation compared with GPCs (comorbidity-adjusted HR 2·73; 95% CI 1·64-4·55), whereas no increased risk was seen in patients with LVV. Patients with vasculitis had similar likelihoods of having had a positive PCR test as GPCs. Glucocorticoids did not increase the HR of hospitalisation among patients with LVV or SVV.

Conclusion

Patients with SVV were more likely to be admitted with COVID-19 than the GPCs. The impact of glucocorticoid treatment on the risk of hospitalisation needs further investigation.

References

[1]Cordtz R, Lindhardsen J, Soussi BG, et al. Incidence and severeness of COVID-19 hospitalization in patients with inflammatory rheumatic disease: a nationwide cohort study from Denmark. Rheumatology. Published online 2020. doi:10.1093/rheumatology/keaa897

[2]Rutherford MA, Scott J, Karabayas M, et al. Risk factors for severe outcomes in patients with systemic vasculitis & COVID-19: a bi-national registry-based cohort study. Arthritis Rheumatol. Published online 2021. doi:10.1002/art.41728

[3]Tomelleri A, Sartorelli S, Campochiaro C, Baldissera EM, Dagna L. Impact of COVID-19 pandemic on patients with large-vessel vasculitis in Italy: A monocentric survey. Ann Rheum Dis. Published online 2020. doi:10.1136/annrheumdis-2020-217600

Disclosure of Interests

Salome Kristensen: None declared, René Lindholm Cordtz: None declared, Kirsten Duch: None declared, Jesper Lindhardsen: None declared, Christian Torp-Pedersen Grant/research support from: Recieved grants from Bayer and Novo Nordisk outside the present work, Lene Dreyer Grant/research support from: Received research grant/research support from BMS, and speakers bureau from EliLilly and Galderma outside the present work.

POS1021 THE EFFECT OF CANNABIDIOL ON QUANTITATIVE SENSORY TESTING PARAMETERS IN PATIENTS WITH HAND OSTEOARTHRITIS AND PSORIATIC ARTHRITIS: A RANDOMIZED DOUBLE-BLIND PLACEBO-CONTROLLED TRIAL

Background

Cannabidiol (CBD) has been proposed as an analgesic/anti-inflammatory treatment modality for joint pain. This study is based on a randomised, placebo controlled, double blind study (NORDCAN), investigating the effect of CBD in patients with painful hand osteoarthritis or psoriatic arthritis [1].

Objectives

The aim of the present study was to investigate the effect of CBD on quantitative sensory testing (QST) parameters.

Methods

The present randomised, placebo controlled, double blind study included 128 patients with hand osteoarthritis or psoriatic arthritis with chronic pain of moderate intensity. The trial compared 12 weeks of 20-30 mg CBD treatment with placebo. The QST parameters were assessed at baseline and after treatment. Pressure pain thresholds was measured at the most painful finger joint (local site) and the shin of the right leg (distal non-painful site). Temporal summation of pain and conditioned pain modulation were assessed using computer-controlled cuff algometry with the tourniquets on lower leg at the level of the upper portion of the gastrocnemius.

Results

Baseline characteristics (demographics and pain) for the CBD treated group and placebo group were comparable. No significant differences were observed in QST variables between baseline and end of treatment when comparing CBD and placebo.

Conclusion

No differences in modulation in QST parameters were demonstrated in patients in treatment with 20-30 mg CBD compared to placebo. Further studies of patients with rheumatic diseases treated with different dosage of CBD are needed to clarify the effect of CBD on pain in this patient group.

References

[1]Vela J, Dreyer L, Petersen KK, Nielsen LA, Duch KS, Kristensen S. Cannabidiol treatment in hand osteoarthritis and psoriatic arthritis. Pain 2021;Publish Ah. doi:10.1097/j.pain.0000000000002466.

Figure 1.

Flow-diagram of participant in the NORDCAN study

Table 1.

Difference in QST outcomes after 12 weeks of treatment with CBD or placebo.

Placebo groupCBD groupDifference95% CIpDifference95% CIpPPT Joint, kPa*18.62-19 to 56.760.3242.561.95 to 86.310.03PPT Shin, kPa*35.02-8.72 to 78.760.115.88-30.12 to 41.890.75CPM, kPa3.23-2.11 to 8.580.173.92-1.75 to 9.590.17TSP0.18-0.58 to 0.940.640.12-0.41 to 0.650.63

* Assessed using handheld algometer.

Abbreviations: CPM, Conditioned pain modulation; PPT, Pressure pain threshold; TSP, Temporal summation of pain

Acknowledgements

The authors thank patients, research personnel, the patient research partners, the Danish Rheumatism Association and the Psoriasis Association for their contribution to the NORDCAN trial.

Disclosure of Interests

Jonathan Vela: None declared, Kristian Kjær Petersen: None declared, Lene Dreyer Grant/research support from: Has received research grants from BMS and honorariums from Eli Lilly, Galderma, and Janssen, Lars Arent-Nielsen Speakers bureau: Has received speaker and advisory fees from GSK, Pfizer and Grünenthal., Salome Kristensen: None declared

OP0022 DISEASE ACTIVITY-GUIDED TAPERING OF BIOLOGICS IN PATIENTS WITH INFLAMMATORY ARTHRITIS: A RANDOMISED, OPEN-LABEL, EQUIVALENCE TRIAL

Background

Traditionally, biologics are maintained lifelong at standard dose in patients with inflammatory arthritis (IA) when sustained low disease activity (LDA) is reached. However, evidence of possible tapering is emerging but data on the optimal approach is lacking.

Objectives

The primary outcomes at 18 months follow-up are:

Methods

The BIODOPT trial was a randomised, open-label, equivalence trial (EudraCT 2017-001970-41). Eligible patients were adults with RA, PsA, or axSpA in LDA on stable biologic doses during ≥12 months. The randomisation ratio was 2:1 (tapering:continuation) stratified by diagnosis, centre, and repeated biologic failures. In the tapering group, the biologic dosing interval was prolonged by 25% every four months until flare or discontinuation. The continuation group was kept on their baseline biologic dosing interval; however, a small increase was allowed (as usual practise) if requested by the patient. The sample size calculation was based on a pre-defined equivalence margin of ±0.5 disease activity points (<half of the minimal important difference in DAS28-CRP [>1.2] or ASDAS [>1.1]) yielding a power of 87% for 180 enrolled patients. All analyses were based on the intention-to-treat population. Continuous outcomes were analysed with repeated-measures linear mixed-effects models with group, diagnosis, centre, repeated biologic failures, time point, and the interaction between group and time as fixed factors and the baseline value of the relevant variable as a covariate. Categorical outcomes were analysed using logistic regression with missing data imputed as trial failures.

Results

Between May, 2018, and March, 2020, 142 patients were enrolled of which 95 were randomised to tapering and 47 to continuation; inclusion was closed in April 2020 due to national implications of the coronavirus pandemic.

At 18 months, significantly more patients in the tapering group (35 patients [(37%]) achieved a significant reduction in their biologic dose (≥50%) compared to the continuation group (one patient [2%]), absolute risk difference (RD) 35%, 95%CI: 24% to 45%, p<0.0001, Table 1. Furthermore, disease activity at 18 months was within the equivalence margins of ±0.5, mean difference between groups 0.08, 95%CI: -0.12 to 0.29; Table 1 and Figure 1. Flares were more frequent in the tapering group (39 [41%] vs 10 [21%], RD 0.20, 95%CI: 0.04 to 0.35, p=0.011) but managed with rescue therapy (e.g. biologic dose escalation or glucocorticoids) as only one patient (1%) in the tapering group and three patients (6%) in the continuation group lost therapeutic response and were switched to another biological agent.

Table 1.

Comparison at 18 months in the ITT population

OutcomeTapering group N = 95Continuation group N = 47Group difference (95%CI)p-valuePrimary outcome:Biologics reduced to ≤50%, n (%)35 (37%)1 (2%)0.35 (0.24 to 0.45)<0.001Disease activity, LSMeans (SE)1.84 (0.15)1.75 (0.16)0.08 (-0.12 to 0.29)0.428Key secondary outcomes:Remission1, n (%)63 (66%)33 (70%)-0.04 (-0.20 to 0.12)0.637Low disease activity2, n (%)79 (83%)41 (87%)-0.04 (-0.16 to 0.08)0.511Flares3, n (%)39 (41%)10 (21%)0.20 (0.04 to 0.35)0.011

N: number, CI: confidence interval, LSMeans: Least squares means, SE: Standard error.

1: RA or PsA: DAS28-CRP <2.6. AxSpA: ASDAS <1.3.

2: RA or PsA: DAS28-CRP <3.2. AxSpA: ASDAS <2.1.

3: RA or PsA: ΔDAS28-CRP >1.2 or ΔDAS28-CRP >0.6 AND current DAS28-CRP ≥3.2. AxSpA: inflammatory back pain AND ΔASDAS ≥0.9 and/or ≥1 swollen joint.

Conclusion

Across IA conditions, a significant reduction of biologic dose is possible with disease activity-guided tapering while maintaining a similar disease activity state compared to continuation of biologic as usual care.

Acknowledgements

The authors thank patients, research personnel, and the patient research partners for their contribution to the BIODOPT trial, data manager JHW for technical support and for uploading the concealed allocation sequence, and CCH for data management. The Parker Institute, Bispebjerg and Frederiksberg Hospital is supported by a core grant from the Oak Foundation (OCAY-18-774-OFIL).

Disclosure of Interests

Line Uhrenholt Speakers bureau: Abbvie, Eli Lilly, Janssen, and Novartis, Robin Christensen: None declared, Lene Dreyer Speakers bureau: Eli Lilly, Galderma and Janssen, Grant/research support from: BMS (outside the present work), Ellen-Margrethe Hauge Speakers bureau: AbbVie, Sanofi, Sobi, and SynACT Pharma, Grant/research support from: Roche, Novartis, and Novo Nordic Foundation (outside the present work), Annette Schlemmer Speakers bureau: Eli Lilly, Anne Gitte Loft Speakers bureau: AbbVie, MSD, Novartis and UCB, Consultant of: Eli-Lilly, Janssen-Cilag, MSD, Novartis, and UCB, Mads Nyhuus Bendix Rasch Speakers bureau: Sobi, Hans Christian Horn: None declared, Katrine Gade: None declared, Peter C. Taylor Consultant of: AbbVie, Biogen, Eli Lilly, Fresenius, Galapagos, Gilead Sciences, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Inc, Roche, and Sanofi, Grant/research support from: Celgene, and Galapagos (outside the present work), Salome Kristensen: None declared.

POS0604 THE EFFECT OF TRANSCUTANEOUS AURICULAR VAGUS NERVE STIMULATION AND DEEP BREATHING EXERCISES ON HEART RATE VARIABILITY IN HEALTHY PARTICIPANTS AND PATIENTS WITH RHEUMATOID ARTHRITIS AND SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are chronic autoimmune diseases associated with a reduced function of the autonomic nervous system including an impaired function of the vagus nerve (VN). The VN has potential anti-inflammatory effects, which could be utilized in a new treatment approach using vagus nerve stimulation (VNS). Different types of VNS exist, but no direct comparison has been made of the methods in patients with RA and SLE.

Objectives

The aim of this study was to compare the effect of transcutaneous auricular VNS (taVNS) and deep breathing (DB) on vagal tone in patients with RA or SLE and healthy participants and to investigate the washout effect assessed through time domain heart rate variability (HRV) measures (RMSSD (root-mean-square of successive differences), SDNN (standard deviation of N-N intervals), and PNN50 (percentage of adjacent N-N intervals that differ from each other by more than 50 milliseconds)).

Methods

The study was designed as an open label cross-over study. 42 healthy participants and 52 patients with RA or SLE performed two interventions, 30 minutes of taVNS and 30 minutes of DB. The interventions were separated by at least 24 hours. Before each intervention, two 5-minutes ECG-recordings were made to determine the participants’ baseline HRV. After each intervention three 5-minutes ECG-recordings were conducted in the following 30 minutes to investigate the potential washout effect.

Results

Healthy participants: A significant increase in SDNN, RMSSD, and PNN50 were found after DB. SDNN increased significantly immediately after taVNS. SDNN was significantly higher after DB compared to taVNS. Otherwise, there were no significant differences between the effects of the two interventions. Patients: A significant increase in SDNN, RMSSD, and PNN50 were present after both DB and taVNS. No significant differences were found between the effects of the two interventions. The effects of the interventions were still measurable 30 minutes after intervention, indicating no washout.

Conclusion

DB causes the greatest increase in HRV for healthy participants, while both DB and taVNS can equally elevate HRV in patients with RA and SLE, which support their use as a potential new treatment approach. However, their clinical effect needs to be investigated in future studies.

Acknowledgements

The authors thank patients and research personnel at Aalborg University Hospital.

Disclosure of Interests

None declared

POS0076 DRUG SURVIVAL OF BIOLOGICS AND NOVEL IMMUNOMODULATORS FOR RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS, PSORIATIC ARTHRITIS, AND PSORIASIS - A NATIONWIDE COHORT STUDY FROM THE DANBIO AND DERMBIO REGISTRIES

Background

Drug survival is an important proxy measure for effectiveness of treatments for inflammatory diseases such as rheumatoid arthritis (RA), axial spondyloarthritis (AxSpA), psoriatic arthritis (PsA), and psoriasis [1-4].

Objectives

The objective of this study was to examine the real-life drug survival of biologics and novel small-molecule therapies across various disease entities such as RA, AxSpA, PsA, and psoriasis.

Methods

We performed a nationwide cohort study using the prospective nationwide registries DANBIO and DERMBIO, comprising all patients treated with biologics or novel small-molecule therapies for RA, AxSpA, PsA, and psoriasis between January 2015 through May 2021 (DANBIO) and November 2009 to November 2019 (DERMBIO). Drug survival was visualized using Kaplan-Meier curves, and Cox proportional hazards models were used to calculate adjusted Hazard Ratios (HRs) with 95% confidence intervals (CIs) for risk of discontinuing therapy.

Results

The study comprised a total of 12,089 patients (17,903 treatment series), including 5,104 RA patients (7,867 series), 2,157 AxSpA patients (3,016 series3), 2,551 PsA patients (3,313 series), and 2,577 psoriasis patients (3,707 series). In confounder-adjusted models drug survival in RA was highest for rituximab followed by baricitinib, etanercept and tocilizumab respectively. For AxSpA drug survival was high for golimumab compared to all other drugs, followed by secukinumab and etanercept and lowest for infliximab. For PsA tofacitinib and infliximab had the lowest drug survival compared to all other drugs. All other drugs performed almost equally well with a tendency of a generally higher drug survival for golimumab, followed by secukinumab and ixekizumab. For psoriasis drug survival was generally highest for guselkumab.

Figure 1.

Conclusion

Differing treatment responses to drugs with various types of action across RA, AxSpA, PsA and psoriasis emphasize that although these diseases have many overlaps in their pathogenesis, there is a need for an individualized treatment approach that considers the underlying disease, patient profile, and treatment history.

References

[1]Egeberg A, Ottosen MB, Gniadecki R, et al. Safety, efficacy and drug survival of biologics and biosimilars for moderate-to-severe plaque psoriasis. Br J Dermatol 2018; 178(2): 509-19.

[2]Gron KL, Glintborg B, Norgaard M, et al. Comparative Effectiveness of Certolizumab Pegol, Abatacept, and Biosimilar Infliximab in Patients With Rheumatoid Arthritis Treated in Routine Care: Observational Data From the Danish DANBIO Registry Emulating a Randomized Trial. Arthritis Rheumatol 2019; 71(12): 1997-2004.

[3]Lindstrom U, Glintborg B, Di Giuseppe D, et al. Comparison of treatment retention and response to secukinumab versus tumour necrosis factor inhibitors in psoriatic arthritis. Rheumatology 2020.

[4]Glintborg B, Lindstrom U, Di Giuseppe D, et al. One-year treatment outcomes of secukinumab versus tumor necrosis factor inhibitors in Spondyloarthritis. Arthritis Care Res (Hoboken) 2020.

Acknowledgements

We acknowledge the substantial contribution of the academic hospitals and private clinics and their physicians that report data to DANBIO and DERMBIO.

Disclosure of Interests

Alexander Egeberg Speakers bureau: AbbVie, Almirall, Leo Pharma, Zuellig Pharma Ltd., Galápagos NV, Sun Pharmaceuticals, Samsung Bioepis Co., Ltd., Pfizer, Eli Lilly and Company, Novartis, Galderma, Dermavant, UCB, Mylan, Bristol-Myers Squibb, and Janssen Pharmaceuticals, Paid instructor for: AbbVie, Almirall, Leo Pharma, Zuellig Pharma Ltd., Galápagos NV, Sun Pharmaceuticals, Samsung Bioepis Co., Ltd., Pfizer, Eli Lilly and Company, Novartis, Galderma, Dermavant, UCB, Mylan, Bristol-Myers Squibb, and Janssen Pharmaceuticals, Consultant of: AbbVie, Almirall, Leo Pharma, Zuellig Pharma Ltd., Galápagos NV, Sun Pharmaceuticals, Samsung Bioepis Co., Ltd., Pfizer, Eli Lilly and Company, Novartis, Galderma, Dermavant, UCB, Mylan, Bristol-Myers Squibb, and Janssen Pharmaceuticals, Grant/research support from: Pfizer, Eli Lilly, Novartis, Bristol-Myers Squibb, AbbVie, Janssen Pharmaceuticals, Nana Lippert Rosenoe: None declared, David Aagaard: None declared, Erik Lørup: None declared, Lea Nymand: None declared, Lars Erik Kristensen Speakers bureau: Dr. LE Kristensen has received fees for speaking and consultancy from Pfizer, AbbVie, Amgen, Forward pharma, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals, Paid instructor for: Dr. LE Kristensen has received fees for speaking and consultancy from Pfizer, AbbVie, Amgen, Forward pharma, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals, Consultant of: Dr. LE Kristensen has received fees for speaking and consultancy from Pfizer, AbbVie, Amgen, Forward pharma, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals, Grant/research support from: Dr. LE Kristensen has received fees for speaking and consultancy from Pfizer, AbbVie, Amgen, Forward pharma, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals, Jacob Thyssen Speakers bureau: Dr. Thyssen has attended advisory boards for Almirall, Eli Lilly & Co, Pfizer, LEO Pharma, Asana, Regeneron, AbbVie, Union Therapeutics, and Sanofi-Genzyme and received speaker honorarium from LEO Pharma, Regeneron, Almirall, Abbvie, Eli Lilly & Co, and Sanofi-Genzyme, and been an investigator for AbbVie, Pfizer, Eli Lilly & Co, LEO Pharma and Sanofi-Genzyme., Paid instructor for: Dr. Thyssen has attended advisory boards for Almirall, Eli Lilly & Co, Pfizer, LEO Pharma, Asana, Regeneron, AbbVie, Union Therapeutics, and Sanofi-Genzyme and received speaker honorarium from LEO Pharma, Regeneron, Almirall, Abbvie, Eli Lilly & Co, and Sanofi-Genzyme, and been an investigator for AbbVie, Pfizer, Eli Lilly & Co, LEO Pharma and Sanofi-Genzyme., Consultant of: Dr. Thyssen has attended advisory boards for Almirall, Eli Lilly & Co, Pfizer, LEO Pharma, Asana, Regeneron, AbbVie, Union Therapeutics, and Sanofi-Genzyme and received speaker honorarium from LEO Pharma, Regeneron, Almirall, Abbvie, Eli Lilly & Co, and Sanofi-Genzyme, and been an investigator for AbbVie, Pfizer, Eli Lilly & Co, LEO Pharma and Sanofi-Genzyme., Grant/research support from: Dr. Thyssen has attended advisory boards for Almirall, Eli Lilly & Co, Pfizer, LEO Pharma, Asana, Regeneron, AbbVie, Union Therapeutics, and Sanofi-Genzyme and received speaker honorarium from LEO Pharma, Regeneron, Almirall, Abbvie, Eli Lilly & Co, and Sanofi-Genzyme, and been an investigator for AbbVie, Pfizer, Eli Lilly & Co, LEO Pharma and Sanofi-Genzyme., Simon F. Thomsen Speakers bureau: Dr. Thomsen has been a speaker or has served on advisory boards for Sanofi-Genzyme, AbbVie, LEO Pharma, Pfizer, Eli Lilly and Company, Novartis, UCB Pharma, Almirall, and Janssen Pharmaceuticals; has received research support from Sanofi-Genzyme, AbbVie, LEO Pharma, Novartis, UCB Pharma, and Janssen Pharmaceuticals; and has been an investigator for Sanofi-Genzyme, Regeneron, AbbVie, LEO Pharma, Novartis and Pfizer., Paid instructor for: Dr. Thomsen has been a speaker or has served on advisory boards for Sanofi-Genzyme, AbbVie, LEO Pharma, Pfizer, Eli Lilly and Company, Novartis, UCB Pharma, Almirall, and Janssen Pharmaceuticals; has received research support from Sanofi-Genzyme, AbbVie, LEO Pharma, Novartis, UCB Pharma, and Janssen Pharmaceuticals; and has been an investigator for Sanofi-Genzyme, Regeneron, AbbVie, LEO Pharma, Novartis and Pfizer., Consultant of: Dr. Thomsen has been a speaker or has served on advisory boards for Sanofi-Genzyme, AbbVie, LEO Pharma, Pfizer, Eli Lilly and Company, Novartis, UCB Pharma, Almirall, and Janssen Pharmaceuticals; has received research support from Sanofi-Genzyme, AbbVie, LEO Pharma, Novartis, UCB Pharma, and Janssen Pharmaceuticals; and has been an investigator for Sanofi-Genzyme, Regeneron, AbbVie, LEO Pharma, Novartis and Pfizer., Grant/research support from: Dr. Thomsen has been a speaker or has served on advisory boards for Sanofi-Genzyme, AbbVie, LEO Pharma, Pfizer, Eli Lilly and Company, Novartis, UCB Pharma, Almirall, and Janssen Pharmaceuticals; has received research support from Sanofi-Genzyme, AbbVie, LEO Pharma, Novartis, UCB Pharma, and Janssen Pharmaceuticals; and has been an investigator for Sanofi-Genzyme, Regeneron, AbbVie, LEO Pharma, Novartis and Pfizer., René Lindholm Cordtz: None declared, Nikolai Loft Speakers bureau: speaker for Eli Lilly and Janssen Cilag., Lone Skov Speakers bureau: Dr. Skov has been a paid speaker for AbbVie, Eli Lilly, Novartis, and LEO Pharma, and has been a consultant or has served on Advisory Boards with AbbVie, Janssen Cilag, Novartis, Eli Lilly, LEO Pharma, UCB, Almirall, and Sanofi. She has served as an investigator for AbbVie, Sanofi, Janssen Cilag, Boehringer Ingelheim, AstraZenica, Eli Lilly, Novartis, Regeneron, and LEO Pharma, and has received research and educational grants from Novartis, Sanofi, Janssen Cilag, and LEO Pharma., Paid instructor for: Dr. Skov has been a paid speaker for AbbVie, Eli Lilly, Novartis, and LEO Pharma, and has been a consultant or has served on Advisory Boards with AbbVie, Janssen Cilag, Novartis, Eli Lilly, LEO Pharma, UCB, Almirall, and Sanofi. She has served as an investigator for AbbVie, Sanofi, Janssen Cilag, Boehringer Ingelheim, AstraZenica, Eli Lilly, Novartis, Regeneron, and LEO Pharma, and has received research and educational grants from Novartis, Sanofi, Janssen Cilag, and LEO Pharma., Consultant of: Dr. Skov has been a paid speaker for AbbVie, Eli Lilly, Novartis, and LEO Pharma, and has been a consultant or has served on Advisory Boards with AbbVie, Janssen Cilag, Novartis, Eli Lilly, LEO Pharma, UCB, Almirall, and Sanofi. She has served as an investigator for AbbVie, Sanofi, Janssen Cilag, Boehringer Ingelheim, AstraZenica, Eli Lilly, Novartis, Regeneron, and LEO Pharma, and has received research and educational grants from Novartis, Sanofi, Janssen Cilag, and LEO Pharma., Grant/research support from: Dr. Skov has been a paid speaker for AbbVie, Eli Lilly, Novartis, and LEO Pharma, and has been a consultant or has served on Advisory Boards with AbbVie, Janssen Cilag, Novartis, Eli Lilly, LEO Pharma, UCB, Almirall, and Sanofi. She has served as an investigator for AbbVie, Sanofi, Janssen Cilag, Boehringer Ingelheim, AstraZenica, Eli Lilly, Novartis, Regeneron, and LEO Pharma, and has received research and educational grants from Novartis, Sanofi, Janssen Cilag, and LEO Pharma., Lars Erik Bryld: None declared, Mads Rasmussen Speakers bureau: Dr. Rasmussen has been a paid speaker for AbbVie, Almirall, and LEO Pharma. Consulting, or serving on expert/advisory boards with AbbVie, Almirall, Janssen Cilag, and Eli Lilly. He served as investigator for Janssen Cilag, UCB, and Novartis., Paid instructor for: Dr. Rasmussen has been a paid speaker for AbbVie, Almirall, and LEO Pharma. Consulting, or serving on expert/advisory boards with AbbVie, Almirall, Janssen Cilag, and Eli Lilly. He served as investigator for Janssen Cilag, UCB, and Novartis., Consultant of: Dr. Rasmussen has been a paid speaker for AbbVie, Almirall, and LEO Pharma. Consulting, or serving on expert/advisory boards with AbbVie, Almirall, Janssen Cilag, and Eli Lilly. He served as investigator for Janssen Cilag, UCB, and Novartis., Grant/research support from: Dr. Rasmussen has been a paid speaker for AbbVie, Almirall, and LEO Pharma. Consulting, or serving on expert/advisory boards with AbbVie, Almirall, Janssen Cilag, and Eli Lilly. He served as investigator for Janssen Cilag, UCB, and Novartis., Pil Højgaard: None declared, Salome Kristensen: None declared, Lene Dreyer Speakers bureau: Dr. Dreyer has received research grant/research support from BMS, and speakers bureau from Eli Lilly and Galderma., Paid instructor for: Dr. Dreyer has received research grant/research support from BMS, and speakers bureau from Eli Lilly and Galderma., Consultant of: Dr. Dreyer has received research grant/research support from BMS, and speakers bureau from Eli Lilly and Galderma., Grant/research support from: Dr. Dreyer has received research grant/research support from BMS, and speakers bureau from Eli Lilly and Galderma.

AB0006 ESTABLISHED RISK LOCI FOR SYSTEMIC LUPUS ERYTHEMATOSUS AT NCF2, STAT4, TNPO3, IRF5 AND ITGAM ASSOCIATE WITH DISTINCT CLINICAL MANIFESTATIONS: A DANISH GENOME-WIDE ASSOCIATION STUDY

Background

Systemic lupus erythematosus (SLE) has been associated with more than 100 genetic loci. This parallels positively to the clinical diversity that is reflected by the classification of SLE.

Objectives

We aimed to investigate associations between disease manifestations of SLE and risk gene variants relevant to Danish subjects of European ancestry.

Methods

We included 427 SLE patients of European ancestry similar to previous reports.[1] We also included 89,699 controls from the Danish Blood Donor Study Genomic Cohort. SLE risk loci in this population were identified by genome-wide association methodology and hereafter correlated to cumulative occurrence of SLE classification items.

Results

Fourteen variants mapped to the following genes: NCF2, STAT4, TNPO3/TPI1P2, IRF5, and ITGAM, were significantly associated (p<5E-8) with SLE.

The five lead variants were associated (p<0.05) with the following manifestations; NCF2: proteinuria and anti-phospholipid antibodies, STAT4: arthritis, serositis, neurologic disorder, lymphopenia, and anti-Smith antibodies, IRF5: seizures and proteinuria, TNPO3: proteinuria, and ITGAM: photosensitivity (Table 2).

Conclusion

Our findings support the future use of select, relevant genetic markers in predicting various SLE phenotypes.

References

[1]Leffers HCB, Troldborg A, Voss A, et al. Smoking associates with distinct clinical phenotypes in patients with systemic lupus erythematosus: a nationwide Danish cross-sectional study. Lupus Sci Med 2021;8(1).

Table 1.

Associations between five SLE risk loci and specific disease manifestations in 427 Danish patients with SLE*.

NCF2STAT4IRF5TNPO3ITGAMrs17849502_Trs7574865_Trs4728142_Ars13239597_Ars11860650_TN (%)Malar rash233 (55%)1.28 (0.84-1.96)0.83 (0.62-1.11)1.01 (0.74-1.38)1.44 (0.97-2.12)1.14 (0.80-1.61)Discoid rash46 (11%)1.49 (0.81-2.73)0.90 (0.56-1.45)1.01 (0.62-1.66)1.16 (0.63-2.12)0.76 (0.42-1.41)Photosensitivity219 (51%)0.96 (0.63-1.46)1.09 (0.81-1.47)0.98 (0.71-1.34)0.84 (0.57-1.25)0.67 (0.47-0.97)Oral ulcers132 (31%)0.96 (0.61-1.50)0.90 (0.65-1.23)0.83 (0.60-1.16)1.30 (0.87-1.96)1.43 (0.99-2.05)Non-erosive Arthritis342 (80%)0.84 (0.52-1.37)1.49 (1.02-2.18)0.93 (0.63-1.36)1.04 (0.64-1.68)1.16 (0.74-1.80)Serositis-Pleuritis124 (29%)0.63 (0.38-1.05)1.38 (1.01-1.89)1.22 (0.87-1.72)0.85 (0.56-1.29)0.84 (0.57-1.24)-Pericarditis72 (17%)0.75 (0.41-1.40)1.35 (0.93-1.96)1.05 (0.70-1.58)1.15 (0.70-1.89)1.09 (0.70-1.72)Persistent proteinuria158 (37%)1.63 (1.07-2.49)1.08 (0.80-1.46)0.68 (0.49-0.94)1.74 (1.16-2.61)1.09 (0.76-1.57)Neurologic disorder-Seizures23 (5%)1.58 (0.75-3.35)1.49 (0.80-2.76)2.10 (1.04-4.25)0.61 (0.26-1.44)0.93 (0.42-2.06)-Psychosis8 (2%)0.76 (0.097-5.87)2.77 (0.94-8.15)0.35 (0.10-1.23)0 (0)2.96 (0.85-10.3)Haematologic disorder-Haemolytic anaemia38 (9%)0.78 (0.34-1.76)1.37 (0.85-2.22)0.75 (0.44-1.29)1.11 (0.57-2.19)1.24 (0.70-2.20)-Leukopenia130 (30%)1.04 (0.67-1.61)1.19 (0.87-1.63)1.00 (0.72-1.39)0.90 (0.60-1.37)0.94 (0.64-1.37)-Lymphopenia228 (53%)0.95 (0.63-1.44)1.35 (1.01-1.81)0.95 (0.70-1.29)1.16 (0.79-1.70)1.09 (0.77-1.54)-Thrombocytopenia102 (24%)1.42 (0.91-2.22)0.84 (0.60-1.18)0.83 (0.58-1.18)1.35 (0.86-2.11)0.91 (0.60-1.37)Immunologic disorder-anti-DNA ab.330 (77%)0.69 (0.44-1.09)1.02 (0.72-1.44)0.94 (0.65-1.35)0.97 (0.62-1.53)1.08 (0.71-1.65)-anti-Smith ab.44 (10%)1.44 (0.79-2.64)1.58 (1.00-2.49)1.23 (0.73-2.07)1.47 (0.80-2.69)1.07 (0.61-1.84)-anti-phospholipid ab.183 (43%)1.63 (1.07-2.49)1.05 (0.79-1.41)0.84 (0.61-1.14)1.14 (0.77-1.68)1.14 (0.80-1.62)

* Logistic regression models for each manifestation included all five lead variants (multivariate) and were adjusted for age and sex

Disclosure of Interests

Henrik Leffers: None declared, David Westergaard: None declared, Saedis Saevarsdottir: None declared, Ingileif Jonsdottir: None declared, Ole Birger Pedersen: None declared, Anne Troldborg: None declared, Anne Voss: None declared, Salome Kristensen: None declared, Jesper Lindhardsen: None declared, Prabhat Kumar: None declared, Asta Linauskas: None declared, Lars Juul: None declared, Niels Steen Krogh: None declared, Bent Deleuran: None declared, Lene Dreyer Speakers bureau: Speakers bureau: Eli Lilly, Galderma and Janssen, Grant/research support from: from BMS outside the present work, Michael Schwinn: None declared, Lise wegner Thørner: None declared, Lotte Hindhede: None declared, Christian Erikstrup: None declared, Henrik Ullum: None declared, Søren Brunak Shareholder of: SB has ownerships in Intomics A/S, Hoba Therapeutics Aps, Novo Nordisk A/S, Lundbeck A/S, Kari Stefansson: None declared, Karina Banasik: None declared, Søren Jacobsen: None declared

OP0173 INCIDENCE OF COVID-19 INFECTION AND HOSPITALISATION ACCORDING TO VACCINATION STATUS AND DMARD TREATMENT IN PATIENTS WITH RHEUMATOID ARTHRITIS: A NATIONWIDE MATCHED COHORT STUDY FROM DENMARK

Background

Patients with rheumatoid arthritis (RA) may have impaired immunogenicity to COVID-19 vaccines.

Objectives

To investigate the incidence of COVID-19 infection and hospitalisation in unvaccinated and vaccinated patients with RA compared with matched individuals; and secondarily in patients with RA according to DMARD treatment.

Methods

Danish nationwide matched cohort study from January to October 2021. Patients with RA were identified in DANBIO and matched 1:20 with individuals from the general population on age, sex, and vaccination status (month and exact type of vaccination). Primary and secondary outcomes were COVID-19 hospitalisation (Danish National Patient Register) and positive SARS-CoV2 PCR test (Danish COVID-19 Surveillance Register), respectively. Stratified by vaccination status, incidence rates (IRs) per 1000 person years (PY) and comorbidity-adjusted hazard ratios (aHRs) in cause-specific Cox models were calculated with 95% confidence intervals. Using the Aalen-Johansen estimator, the cumulative incidence of COVID-19 hospitalisations was visualised according to RA and vaccine exposure status.

Results

Regardless of vaccination status, patients with RA had increased incidence of COVID-19 hospitalisation compared to matched individuals (Table 1). However, the absolute risk was 0.20% for unvaccinated patients at 60 days and 0.08% for comparators, whereas it remained below 0.05% at 180 days of follow-up in both groups when fully vaccinated (Figure 1). Increased SARS-CoV2 infection rates were seen only among unvaccinated patients with RA (Table 1). Unadjusted analyses showed increased incidence of COVID-19 hospitalisation among rituximab-treated compared with conventional DMARD treated: unvaccinated HR 4.71 (1.98 to 11.18) and vaccinated HR 11.69 (2.07 to 66.06). However, the proportions of patients with previous cancer and treated with prednisolone were higher among the rituximab treated.

Table 1.UnvaccinatedPartially vaccinatedFully vaccinatedRAControlsRAControlsRAControlsN28 447568 94027 154542 61026 217523 826Women, %71.371.371.271.271.071.0Age in years, median [IQR]67.7 [34.2 to 88.3]67.8 [34.2 to 88.4]68.4 [36.4 to 88.6]68.4 (36.5 to 88.6)68.9 [40.9 to 88.7]68.9 (41.0 to 88.7)Methotrexate /55.5 /0.5 /55.4 /1.2 /55.7 /1.3 /Sulfasalazine /14.2 /0.1 /13.7 /0.3 /13.5 /0.3 /Hydroxychloroquine /10.4 /0.1 /10.3 /0.0 /10.3 /0.0 /Other csDMARD,11.0 /0.2 /10.7 /0.3 /10.6 /0.3 /Prednisolone,all in %12.52.012.20.512.20.5TNFi /16.9 /0.1 /17.2 /2.9 /17.1 /3.1 /abatacept /1.5 /0.0 /1.5 /0.5 /1.5 /0.5 /tocilizumab /3.0 /0.0 /3.0 /0.0 /2.9 /0.0 /rituximab, all in %2.20.12.10.12.10.1COVID-19 hospitalisationN65727119511131Median [IQR] days of follow-up102 [62 to 137]115 [88 to 146]28 [22 to 35]30 (21 to 39)150 [111 to 189]150 (111 to 189)Rate per 1000 PY10.4 (8.0 to 13.4)4.7 (4.3 to 5.1)5.5 (3.0 to 10.0)2.2 (1.8 to 2.7)0.9 (0.5 to 1.6)0.5 (0.4 to 0.6)Adjusted HRa1.88 (1.44 to 2.46)1 (Ref.)2.47 (1.25 to 4.89)1 (Ref.)1.94 (1.03 to 3.66)1 (Ref.)SARS-CoV2 infectionRate per 1000 PY37.8 (33.6 to 42.6)33.9 (33.1 to 34.8)27 (20.7 to 35.1)28.5 (27 to 30.2)11.3 (9.2 to 13.9)10.4 (9.9 to 10.9)Adjusted HRa1.22 (1.09 to 1.57)1 (Ref.)0.87 (0.95 to 1.74)1 (Ref.)1.09 (0.92 to 1.14)1 (Ref.)

IQR, Interquartile range. a Adjusted for cancer history, cardiovascular disease, diabetes mellitus, chronic kidney disease, and chronic lung disease.

Figure 1.

Cumulative incidence of COVID-19 hospitalisation (%) as a function of follow-up time (days) for (A) unvaccinated, (B) partially vaccinated and (C) fully vaccinated patients and comparators.

Conclusion

The incidence of COVID-19 hospitalisation was increased for both unvaccinated and vaccinated patients with RA compared with controls. Importantly, the parallel decreasing risk for patients with RA suggests a comparable relative benefit of vaccination. Less favourable outcomes among rituximab-treated warrant that this drug should be considered with extra care.

Acknowledgements

The authors wish to acknowledge The Danish Departments of Clinical Microbiology and Statens Serum Institut for carrying out laboratory analysis, registration, and release of the national SARS-CoV-2 surveillance data use in the present study. Further, the authors wish to thank all the Danish departments of rheumatology for reporting to the DANBIO register.

Disclosure of Interests

René Cordtz: None declared, Salome Kristensen: None declared, Rasmus Westermann: None declared, Kirsten Duch: None declared, Fiona Pearce Grant/research support from: Pearce reports a grant from Vifor Pharma outside the submitted work., Jesper Lindhardsen: None declared, Christian Torp-Pedersen Grant/research support from: Torp-Pedersen reports grants from Bayer and Novo Nordisk outside the submitted work., Mikkel Porsborg Andersen: None declared, Lene Dreyer Speakers bureau: Dreyer has received speakers bureau from Eli Lilly and Galderma., Grant/research support from: Dreyer has received research grant/support from BMS.

Using patient-reported outcome measures in psychiatric hospital care: an observational study describing an iterative implementation process in Denmark

BACKGROUND

Patient-reported outcomes (PROs) are increasingly recognized as valuable sources of information to enhance our understanding of the quality of healthcare from the patient's perspective.

OBJECTIVE

This study aimed to describe the implementation process of the Danish nationwide PRO-Psychiatry project, including iterative tests of previously developed PRO measurement concept and an online data collection tool. Additional aims were to identify the 'best practice' for the routine use of PROs in hospital-based psychiatry and design information material about the project.

METHODS

We conducted an action-oriented observational study to explore the pilot implementation of the PRO-Psychiatry project, which was initiated in February 2018. The study was based on an iterative plan-do-learn approach. An inpatient unit and an outpatient unit from the same psychiatric department in the North Denmark Region were selected for the pilot implementation. The implementation was anchored in multidisciplinary implementation teams at unit level. These teams managed the implementation process according to four tasks defined by the department management.

RESULTS

The teams designed, tested, evaluated and adjusted the localized work practices relating to the use of PRO-Psychiatry. The comprehensibility of the predesigned PROs, the usability of the Information Technology(IT) system and the routine use of PROs during clinical consultations were repeatedly tested and adjusted until the functionality was satisfactory. Furthermore, the teams designed information material for patients (emails, posters, handouts and webpages) and clinicians (online clinical guidelines). The team members informed their colleagues about the progress of PRO-Psychiatry at staff meetings and rolled out the initiative through one-to-one teaching.

CONCLUSIONS

The pilot implementation was deemed successful. PRO-Psychiatry was rolled out to other units in the region, and a national decision was made to pilot implement the initiative in the other four Danish regions.

Evaluating the implementation and use of patient-reported outcome measures in a mental health hospital in Denmark: a qualitative study

BACKGROUND

Reporting of barriers and successes associated with the implementation and use of patient-reported outcomes (PROs) is limited as a means to ensure enhanced patient involvement, shared decision-making and improved treatment and care. We set out to evaluate the implementation and use of the PRO-Psychiatry initiative on patient-reported outcome measures in Danish mental health care. We aimed to described four specific areas: the quality of the clinical consultations before and after the implementation of PRO-Psychiatry as perceived by the patients (objective A), the motivation for participating in PRO-Psychiatry as perceived by patients and clinicians (objective B), the implementation process as perceived by patients, clinicians and managers (objective C) and suggestions for improvement (objective D).

METHODS

The PRO-Psychiatry initiative was evaluated through a participatory approach, including patients, clinicians and managers. A repeated cross-sectional interview-based survey explored the quality of the clinical consultation before and after the implementation of PRO-Psychiatry. A three-step semi-structured group interview, inspired by the modified mini-Delphi method, was used to establish consensus on the evaluation of the implementation and use of the initiative.

RESULTS

The evaluation pointed at PRO-Psychiatry as a meaningful initiative, which motivated patients and supported clinicians. The patients emphasised the importance of PROs, but they also found that PROs were not used enough. Clinically relevant improvements were detected after the implementation of the initiative; more patients felt heard and experienced that clinicians took a greater interest in their problems. The clinicians valued the easily accessible real-time graphical display of the PRO responses in the electronic health record (EHR). Clinicians and managers agreed that clinical PRO practices, patient compliance and use of PROs in treatment and care should be supported during implementation.

CONCLUSION

The evaluation was overall positive. Patients and clinicians were willing to participate, found the online reporting easy and valued the direct access to PRO responses in the EHR. An essential feature was the integration of well-defined and functional PRO practices into the existing clinical workflow. Using PROs in the clinical sessions in a way that was palpable to the patient was found to be a significant improvement need. At the individual level, PRO-Psychiatry can use patient outcome information to support dialogue, encourage shared decision-making and promote self-management during recovery. At the aggregated patient level, the PROs can be used for monitoring the patient-perceived quality of care and for research.

Exploring the relation between clinician ratings and patient-reported experience and outcomes

BACKGROUND

Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are increasingly recognized as important ways for patients to be more actively involved in their treatment and enhance shared decision-making.

OBJECTIVE

The current study investigated the associations between PROMs, PREMs and various symptoms measures reported by clinicians and psychiatric patients.

METHOD

One hundred and twenty people admitted to a psychiatric hospital completed two PREMs, one PROM (the shortened version of the Manchester Short Assessment of Quality of Life scale) and Effects of Symptoms on Daily Functioning (the Sheehan Disability Scale), the Patient Clinical Global Impression and the Modified Colorado Symptom Index. Their psychiatrists rated them using the Global Assessment of Functioning scale, the Health of the Nation Outcome Scales and the Therapist Clinical Global Impression.

RESULTS

There was a strong correlation between patient's evaluation of their quality of life (PROM), experience of their care (PREM) and the overall severity of their condition and their progress. The pattern of correlation between patients' and clinicians' measures revealed a three-layer structure representing a continuum from inner experience to external presentation of experiences.

CONCLUSION

Together these findings help identify and emphasize various domains of subjective experiences and their relation to external ratings.

Patient safety culture improvements depend on basic healthcare education: a longitudinal simulation-based intervention study at two Danish hospitals

Background

A growing body of evidence supports the existence of an association between patient safety culture (PSC) and patient outcomes. PSC refers to shared perceptions and attitudes towards norms, policies and procedures related to patient safety. Existing literature shows that PSC varies among health professionals depending on their specific profession and specialty. However, these studies did not investigate whether PSC can be improved. This study investigates whether length of education is associated with improvements in PCS following a simulation intervention.

Methods

From April 2017 to November 2018, a cross-sectional intervention study was conducted at two regional hospitals in Denmark. Two groups with altogether 1230 health professionals were invited to participate. One group included nurses, midwives and radiographers; the other group included doctors. A train-the-trainer intervention approach was applied consisting of a 4-day simulation instructor course that emphasised team training, communication and leadership. Fifty-three healthcare professionals were trained as instructors. After the course, instructors performed in situ simulation in their own hospital environment.

Outcomes

The Safety Attitude Questionnaire (SAQ), which has 6 dimensions and 32 items, was used to collect main outcome variables. All employees from both groups were surveyed before the intervention and again four and nine months after the intervention.

Results

Mean baseline scores were higher among doctors than among nurses, midwives and radiographers for all SAQ dimensions. At the second follow-up, four of six dimensions improved significantly (p ≤ 0.05) among nurses, midwives and radiographers, whereas no dimensions improved significantly among doctors.

Conclusion

Over time, nurses, midwives and radiographers improved more in PSC attitudes than doctors did.

Incidence and prevalence of rheumatoid arthritis in Denmark from 1998 to 2018: a nationwide register-based study

Objective: To investigate the incidence and prevalence of rheumatoid arthritis (RA) in the adult Danish population.Method: In this nationwide register-based cohort study, patients with incident RA between 1998 and the end of 2018 were identified using Danish administrative registries. The age- and sex-standardized incidence rate (IR), incidence proportion (IP), lifetime risk (LR), and point prevalence (PP) of RA were calculated. RA was defined as a first-time RA diagnosis registered in the Danish National Patient Registry combined with a redeemed prescription of a conventional synthetic disease-modifying anti-rheumatic drug in the following year. In addition, three different case definitions of RA were explored.Results: The overall age- and sex-standardized IR of RA from 1998 to 2018 was 35.5 [95% confidence interval (CI) 35.1-35.9] per 100 000 person-years while the IP was 35.2 (95% CI 34.8-35.5) per 100 000 individuals. The IR was two-fold higher for women than for men. The LR of RA ranged from 2.3% to 3.4% for women and from 1.1% to 1.5% for men, depending on the RA case definition used. The overall PP of RA was 0.6% (95% CI 0.5-0.6%) in 2018: 0.8% (95% CI 0.7-0.8%) for women and 0.3% (95% CI 0.3-0.4%) for men. The prevalence increased about 1.5-fold from 2000 to 2018.Conclusion: The IR and PP were approximately two-fold higher for women than for men. The prevalence of RA in Denmark increased significantly from 2000 to 2018. The RA case definition had more impact on the results than the choice of denominator.

From accreditation to quality improvement-The Danish National Quality Programme

The Danish government launched a new National Quality Programme (NQP) in healthcare in 2015. It has changed the focus from old public management in terms of accreditation, regulation, rules and standards to new public governance focusing on delivering high quality healthcare and outcomes of value for the patients, health professionals and the Danish healthcare system. The NQP aims to strengthen the focus on continuous quality improvement and the launch of the programme was accompanied by a decision to phase out accreditation of public hospitals. The NQP includes 1) eight specific national quality goals, 2) a national educational programme for quality management, and 3) establishment of quality improvement collaboratives. Since the establishment of the NQP the indicator results have improved in several important clinical areas. However, causal conclusions related to the effect of the NQP cannot yet be made. This perspective on quality paper aims to give a short introduction to the NQP and documented outcomes.

Characterization of apolipoprotein E-deficient rats as novel model for atherosclerosis imaging

Funding Acknowledgements

Type of funding sources: None.

Background

The apolipoprotein E-deficient (apoE-/-) mouse is a well-established atherosclerotic model with impaired lipoprotein clearance and development of vessel plaques. However, the small size of the mouse limits its use as an animal model in longitudinal positron emission tomography (PET) imaging studies of atherosclerosis. Recently, apoE-/- rats have become available. This study addresses the suitability of the apoE-/- rat as model for atherosclerotic PET imaging.

Methods

Ten male apoE-/- rats and ten male control rats (apoE+/+) (age 10+/-1 weeks), each fed with a Western diet, were injected at baseline week 4, 12, 26 and 51, with 60 MBq of [18F]2-fluoro-2-deoxy-D-glucose. Plasma cholesterol, body weight and fat were measured. 3h after injection, a computed tomography (CT) and a 20-min PET scan were made. After the final scan, aortic tissue was collected for histological staining.

Results

Cholesterol levels started to increase after 4 weeks in the apoE-/- rats, whereas in the apoE+/+ rats levels stayed stable. Body weight and body fat increased more rapidly in the apoE-/- rats but were similar in both strains at the end of the study. SUVmean and max in the aortic arch and abdominal aorta were significantly higher (p &lt; 0.001) in apoE-/- versus apoE+/+ rats at weeks 12, 26 and 51. Oil red O staining showed lesions in 20.0 % of the surface of the aortic arch in the apoE-/- rats. Hardly no fatty streaks were detected in the apoE+/+ rats (2.29%). More histology data is being analyzed.

Conclusion

Plasma cholesterol levels were elevated in apoE-/- rats. PET imaging demonstrated differences in [18F]-FDG uptake in the aortic arch and abdominal aorta after 12, 26 and 51 weeks. Combined, these data demonstrate that apoE-/- rats represent a useful preclinical model for the non-invasive assessment of atherosclerosis in longitudinal studies.

Using a novel smartphone application for capturing of patient-reported outcome measures among patients with inflammatory arthritis:A randomized, crossover, agreement study

Objectives: In Denmark, patients with inflammatory arthritis (IA) have completed patient-reported outcome measures (PROMs) via touchscreens in the outpatient clinic since 2006. However, current technology makes it possible for patients to use their own smartphone via an application (app) developed for the Danish Rheumatology Database (DANBIO). This study aims to evaluate the agreement of PROMs between the DANBIO app and outpatient touchscreen in patients with IA.Method: Patients with IA (rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis) were enrolled in a randomized, crossover, agreement study. Participants answered PROMs through the two device types in a randomized order. Differences in PROM scores with 95% confidence intervals (CIs) were evaluated for similarity according to prespecified equivalence margins.Results: The touchscreen invitation was accepted by 138 patients. Sixty patients (20 with each diagnosis) were included. The difference in Health Assessment Questionnaire Disability Index between the two device types was -0.007 (95% CI -0.043 to 0.030); thus, equivalence was demonstrated. In addition, all other PROMs obtained with the two device types were equivalent, except for the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), which was within the limits of minimally clinically important difference (MCID). In total, 78.3% preferred the DANBIO app.Conclusion: In patients with IA, equivalence was demonstrated between two device types for all PROMs except BASDAI; however, BASDAI was within the limits of the MCID. Implementation of the DANBIO app is expected to optimize outpatient visits, thereby improving healthcare for the individual patient and society.

POS0313 INCIDENCE AND PREVALENCE OF POLYAUTOIMMUNITY IN SEROPOSITIVE COMPARED WITH SERONEGATIVE PATIENTS WITH RHEUMATOID ARTHRITIS: A NATIONWIDE COHORT STUDY

Background:

Rheumatoid arthritis (RA) is categorized as seropositive or seronegative referring to the presence or absence of IgM rheumatoid factor (IgM-RF) and/ or anti-citrullinated protein antibodies (ACPA).

Patients with an autoimmune disease are more likely to develop additional autoimmune conditions than individuals without pre-existing autoimmune disease.

Objectives:

The aims of this study were to examine patterns of polyautoimmunity in seropositive compared with seronegative patients with recent-onset RA.

Methods:

The study was register-based and used the nationwide DANBIO register (identification of recent-onset (<1 year) seropositive, ICD-10 M05, and seronegative, M06, RA patients) linked to the Danish National Patient Registry and the Danish National Prescription Registry to obtain information on additional autoimmune diseases (see Table 1 for autoimmune conditions).

Table 1.

Characteristics, prevalence, and incidence of polyautoimmunity in incident RA patients.

SeropositiveSeronegativeN79834534Age in years59.4 (48.6 to 69.1)63.0 (51.5 to 72.3)Women5476 (69 %)2856 (63 %)HAQ-DI0.857 (0.375 to 1.375)0.875 (0.375 to 1.375)DAS28-CRP4.3 (3.3 to 5.2)4.6 (3.6 to 5.5)CRP, mg/mL10 (4 to 23)10 (3 to 26)VAS physician, 0-100mm27 (15 to 45)30 (16 to 47)Treated with methotrexate86 %84 %-other csDMARD, %24 %24 %-Biological DMARD, %5 %6 %Smoking status:Current / previous / never / unknown, %13 / 11 / 17 / 59 %9 / 9 / 23 / 59 %Prevalence of polyautoimmunity / diabetes mellitus type 1 / autoimmune thyroid disease / inflammatory bowel disease549 (10.6 %) / 1.4 % / 6.7 % / 1.4 %349 (12.8 %) / 1.5 % / 7.8 % / 1.5 %Age and sex adjusted odds ratio0.79 (0.71 to 0.89)1 (ref.)Incident cases of polyautoimmunity373 (4.7 %)242 (5.3 %)Adjusted hazard ratio0.86 (0.71 to 1.05)1 (ref.)

Continuous variables shown as median with interquartile ranges. Autoimmune conditions included:

autoimmune thyroid disease (redeemed prescriptions of ATC=H03A); diabetes mellitus type 1 (ICD-10 diagnosis E10 combined with redeemed prescriptions of insulin, ATC=A10A); pernicious anaemia (D51.0); autoimmune haemolytic anaemia (D59.1); idiopathic thrombocytopenic purpura (D69.3); Autoimmune adrenalitis (E27.1B); multiple sclerosis (G35); neuromyelitis optica (G36.0); Guillain-Barré syndrome (G61.0); myasthenia gravis (G70); inflammatory bowel disease (K50-1); primary biliary cirrhosis (K74.3); primary sclerosing cholangitis (K83.0); autoimmune hepatitis (K75.4); celiac disease (K90.0); pemphigus vulgaris (L10.0); bullous pemphigoid (L12.0); dermatitis herpetiformis (L13.0); alopecia areata (L63); vitiligo (L80); lichen sclerosis (L90.0); chronic interstitial cystitis (N30.1).

Using age and sex adjusted logistic regression analysis, the odds ratio (OR) of prevalent polyautoimmunity in seropositive compared with seronegative patients at the time of RA diagnosis was calculated.

To estimate the hazard ratio (HR) for developing yet another autoimmune disease in the 5 years after RA diagnosis, adjusted cause-specific Cox regression models were performed. Several sensitivity analyses were carried out including alternative exposure and outcome definitions.

Results:

In total, 12,517 patients with recent-onset RA were included. The groups were similar in terms of disease characteristics and DMARD treatment, but seropositive patients were younger and included more women, see Table 1. Patients with seropositive RA had an OR of 0.79 (95% CI 0.71-0.89) for baseline presence of polyautoimmunity compared with seronegative patients, whereas the 5-year HR was 0.86 (95% CI 0.71-1.05) for incident polyautoimmunity. The results remained similar in all sensitivity analyses.

Conclusion:

Patients with seropositive RA had a slightly lower prevalence and incidence of polyautoimmunity compared to seropositive patients. The results were somewhat surprising, yet very robust, and thus raises the question if seronegative RA is in fact “more autoimmune” despite the absence of (identified) autoantibodies.

Acknowledgements:

We acknowledge all patients and all Danish departments of rheumatology contributing to the DANBIO registry.

Disclosure of Interests:

Amalie Hagelskjær: None declared, René Cordtz: None declared, Sofie Bliddal: None declared, Anders Sandermann Mortensen: None declared, Salome Kristensen: None declared, Claus Henrik Nielsen: None declared, Ulla Feldt-Rasmussen: None declared, Christian Torp-Pedersen: None declared, Lene Dreyer Grant/research support from: Grants from BMS, Galderma, and Eli Lilly

POS0025 INCIDENCE RATES AND POINT PREVALENCE OF SEROPOSITIVE AND SERONEGATIVE RHEUMATOID ARTHRITIS IN DENMARK: A NATIONWIDE REGISTER-BASED STUDY FROM 1998 TO 2018 USING FOUR DIFFERENT CASE CRITERIA

Background:

Few previous studies have investigated the incidence rate (IR) and point prevalence (PP) of seropositive and seronegative rheumatoid arthritis (RA), and further, the estimates remain unknown in the Danish population.

Objectives:

To investigate the IR and PP of seropositive and seronegative RA in the adult Danish population from 1998 to 2018 using four register-based case definitions of RA.

Methods:

Nationwide register-based cohort study. Using the Danish administrative registers, patients with RA between 1998 and end of 2018 were identified. ICD-10 codes for RA were identified in the Danish National Patient Registry and information on DMARD prescriptions were obtained through the Danish National Prescription Registry using ATC codes. The used case definitions were1: Criteria A, first time M05/M06 RA diagnosis and redemption of a DMARD in the following year; Criteria B, two RA diagnoses within 90 days of each other, originating from department of rheumatology or general internal medicine, where the latest registered M05/M06 diagnosis defined the serologic status; Criteria C, a M05/M06 diagnosis recorded at any time preceded or followed by redemption of a DMARD prescription within one year, where the M05/M06 diagnosis recorded determined the serologic status; Criteria D, as Criteria A, but with the additional requirements that cases had no registration for other selected inflammatory diseases.

In calculation of IRs the total Danish population from 1998 to 2018 was used as reference population for standardisation. The PP was calculated for years 2000, 2009, 2011 and 2018.

Results:

From 1998 to 2018 the overall IR was 18.0 (95%CI 17.7 to 18.3) per 100,000 person years (PY) for seropositive RA and 16.7 (95%CI 16.4 to 16.9) per 100,000 PY for seronegative RA using Criteria A. A higher IR for seropositive RA than for seronegative RA was found regardless of the case criteria used. Figure 1 shows the temporal IRs of seropositive and seronegative RA.

Regardless of case criteria used, the PP increased from 2000 to 2018 for both seropositive and seronegative RA, and the estimates were higher for seropositive RA than for seronegative RA (Table 1).

Table 1.

Point prevalence of rheumatoid arthritis in Denmark in year 2000, 2009, 2011 and 2018 using four different case definitions

2000200920112018SeropositiveSeronegativeSeropositiveSeronegativeSeropositiveSeronegativeSeropositiveSeronegativeCriteria AN3029274174747127871281211243711662Population3964040416629842028914269677PP, % (95%CI)0.08 (0.08 to 0.08)0.07 (0.07 to 0.07)0.18 (0.18 to 0.19)0.17 (0.17 to 0.18)0.21 (0.20 to 0.21)0.19 (0.19 to 0.20)0.27 (0.27 to 0.28)0.26 (0.25 to 0.26)Criteria BN7507489311565903312710100111633413340PP, % (95%CI)0.20 (0.19 to 0.20)0.13 (0.12 to 0.13)0.28 (0.28 to 0.29)0.22 (0.21 to 0.22)0.30 (0.30 to 0.31)0.24 (0.23 to 0.24)0.36 (0.35 to 0.36)0.29 (0.29 to 0.30)Criteria CN6701457011174912512417101491588113712PP, % (95%CI)0.18 (0.17 to 0.18)0.12 (0.12 to 0.12)0.27 (0.27 to 0.28)0.22 (0.22 to 0.23)0.29 (0.29 to 0.30)0.24 (0.24 to 0.25)0.35 (0.34 to 0.35)0.30 (0.30 to 0.31)Criteria DN272423906612598476956759108309452PP, % (95%CI)0.07 (0.07 to 0.07)0.06 (0.06 to 0.07)0.16 (0.16 to 0.16)0.15 (0.14 to 0.15)0.18 (0.18 to 0.19)0.16 (0.16 to 0.17)0.24 (0.23 to 0.24)0.21 (0.20 to 0.21)

PP = Point prevalence

Conclusion:

In Denmark, the IR and PP estimates were higher for seropositive compared to seronegative RA during the study period. However, when applying stricter case criteria for RA (Criteria A and D) the differences in IR and PP estimates were smaller, than when using less strict criteria (Criteria B and C). The findings of such small differences between seropositive and seronegative IRs warrant further investigation.

References:

[1]Soussi BG et al. Incidence and prevalence of rheumatoid arthritis in Denmark: a nationwide population based study investigating the effect of four different case definitions [abstract]. Ann Rheum Dis. 2020;79(supplement 1):46

Acknowledgements:

The authors will like to thank The Danish Rheumatism Association for supporting this work.

Disclosure of Interests:

Bolette Gylden Soussi: None declared, René Lindholm Cordtz: None declared, Salome Kristensen: None declared, Christian Sørensen Bork: None declared, Jeppe Christensen: None declared, Erik Berg Schmidt: None declared, Daniel Prieto-Alhambra Grant/research support from: Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier; and Janssen, on behalf of IMI-funded EHDEN and EMIF consortiums, and Synapse Management Partners have supported training programmes organised by DPA’s department and open for external participants, Lene Dreyer Grant/research support from: Grants from BMS, Galderma and Eli Lilly.

Patient safety culture improves during an in situ simulation intervention: a repeated cross-sectional intervention study at two hospital sites

OBJECTIVES

This study aimed to investigate staff's perceptions of patient safety culture (PSC) in two Danish hospitals before and after an in situ simulation intervention.

DESIGN

A repeated cross-sectional intervention study.

SETTING

Two Danish hospitals. Hospital 1 performs emergency functions, whereas hospital 2 performs elective functions.

PARTICIPANTS

A total of 967 healthcare professionals were invited to participate in this study. 516 were employed in hospital 1 and 451 in hospital 2. Of these, 39 were trained as simulation instructors.

INTERVENTION

A 4-day simulation instructor course was applied. Emphasis was put on team training, communication and leadership. After the course, instructors performed simulation in the hospital environment. No systematic simulation was performed prior to the intervention.

MAIN OUTCOME MEASURES

The Safety Attitude Questionnaire investigating PSC was applied prior to the intervention and again 4 and 8 weeks after intervention. The proportion of participants with a positive attitude and mean scale scores were measured as main outcomes.

RESULTS

The response rate varied from 63.6% to 72.0% across surveys and hospitals. Baseline scores were generally lower for hospital 1. The proportion of staff with positive attitudes in hospital 1 improved by ≥5% in five of six safety culture dimensions, whereas only two dimensions improved by ≥5% in hospital 2. The mean scale scores improved significantly in five of six safety culture dimensions in hospital 1, while only one dimension improved significantly in hospital 2.

CONCLUSIONS

Safety attitude outcomes indicate an improvement in PSC from before to after the in situ simulation intervention period. However, it is possible that an effect is more profound in an acute care hospital versus an elective setting.

Patient-reported indicators in mental health care: towards international standards among members of the OECD

BACKGROUND

Achieving people-centred health care systems requires new and innovative strategies to capture information about whether, and to what degree, health care is successful in improving health from the perspective of the patient. Patient-reported outcome measures (PROMs) and Patient-reported experience measures (PREMs) can bring some of these new insights, and are increasingly used in research, clinical care, and policymaking.

METHODS

This paper reflects the ongoing discussions and findings of the OECD PaRIS Working Group on Patient-reported Indicators for Mental Health Care.

RESULTS

The OECD has been measuring quality of care for mental health conditions over the last 14 years through the Health Care Quality and Outcomes (HCQO) program; nonetheless, information on how persons with mental health problems value the services they receive, and impact of the services, remains limited. As of 2018, a survey from the OECD showed that only five of the twelve countries surveyed (Australia, Israel, Netherlands, Sweden, United Kingdom) reported PROMs and PREMs collection on a regular basis in mental health settings. The paper details some of the challenges specific to the collection and use of PROMs and PREMs in mental health care, and examples from countries which have implemented comprehensive programmes to gather information about PROMs and PREMs for individuals receiving mental health services.

CONCLUSIONS

Given the health and economic impact of mental ill-health across all OECD countries, there is significant value to being able to assess the quality and outcomes of care in this area using internationally-comparable measures. Continued international harmonisation of PROMs and PREMs for mental health through international coordination is a key way to facilitate the sharing of national experiences, promote the use of PROMs and PREMs, and create meaningful indicators for national and international benchmarking.

Measuring patient voice matters: setting the scene for patient-reported indicators

BACKGROUND

Achieving people-centred health care systems requires new and innovative strategies to capture information about whether, and to what degree, health care is successful in improving health from the perspective of the patient. Patient-reported outcome measures (PROMs) and Patient-reported experience measures (PREMs) can bring some of these new insights, and are increasingly used in research, clinical care, and policymaking.

METHODS

This paper reflects the ongoing discussions and findings of the OECD PaRIS Working Group on Patient-reported Indicators for Mental Health Care.

RESULTS

The OECD has been measuring quality of care for mental health conditions over the last 14 years through the Health Care Quality and Outcomes (HCQO) program; nonetheless, information on how persons with mental health problems value the services they receive, and impact of the services, remains limited. As of 2018, a survey from the OECD showed that only five of the twelve countries surveyed (Australia, Israel, Netherlands, Sweden, United Kingdom) reported PROMs and PREMs collection on a regular basis in mental health settings. The paper details some of the challenges specific to the collection and use of PROMs and PREMs in mental health care, and examples from countries which have implemented comprehensive programmes to gather information about PROMs and PREMs for individuals receiving mental health services.

CONCLUSIONS

Given the health and economic impact of mental ill-health across all OECD countries, there is significant value to being able to assess the quality and outcomes of care in this area using internationally-comparable measures. Continued international harmonisation of PROMs and PREMs for mental health through international coordination is a key way to facilitate the sharing of national experiences, promote the use of PROMs and PREMs, and create meaningful indicators for national and international benchmarking.

Patient-Reported Outcome Measures in Mental Health Clinical Research: A Descriptive Review in Comparison with Clinician-Rated Outcome Measures

PURPOSE

To review how patient-reported outcomes measures in mental health clinical research complement traditional clinician-rated outcomes measures.

DATA SOURCES

Medline, Embase, PsycInfo and Scopus.

STUDY SELECTION

Latest update of the literature search was conducted in August 2019, using a specified set of search terms to identify controlled and uncontrolled studies (published since 1996) of pharmacological or non-pharmacological interventions in adults (≥18 years) in hospital-based mental health care.

DATA EXTRACTION

Two authors extracted data independently using a pre-designed extraction form.

RESULTS OF DATA SYNTHESIS

Among the 2962 publications identified, 257 were assessed by full text reading. A total of 24 studies reported in 26 publications were included in this descriptive review. We identified subjective and objective outcome measures, classified these according to the pharmacopsychometric triangle and compared them qualitatively in terms of incremental information added to the clinical study question. The data reviewed here from primarily depression and schizophrenia intervention studies show that results from patient-reported outcome measures and clinician-rated outcome measures generally point in the same direction. There was a relative lack of patient-reported outcome measures on functioning and medication side effects compared with patient-reported outcome measures on symptom burden and health-related quality of life.

CONCLUSION

Patient-reported outcomes and clinician-rate outcomes supplement each other and at most times support identical study conclusions. Future studies would benefit from a more systematic approach towards use of patient-reported outcomes and a clearer rationale of how to weigh and report the results in comparison with clinician-rated outcomes.

OP0068 INCIDENCE AND PREVALENCE OF RHEUMATOID ARTHRITIS IN DENMARK: A NATIONWIDE POPULATION-BASED STUDY INVESTIGATING THE EFFECT OF FOUR DIFFERENT CASE DEFINITIONS

Background:

The incidence rate (IR) and point prevalence (PP) of rheumatoid arthritis (RA) in Denmark is largely unknown. Two challenges in estimating the “true” IR and PP using nationwide registry data are the choice of the RA case definition, and the denominator used, i.e. the exact amount of person years (PY) or census count data.

Objectives:

To investigate the incidence and prevalence of RA in the adult Danish population using four different case definitions and two different denominator strategies.

Methods:

Nationwide register-based cohort study. Patients with RA between 1996 and the end of 2016 were identified using the Danish National Patient Registry (DNPR) and information on DMARD prescriptions were obtained through linkage with the Danish National Prescription Registry. Age and sex standardised incidence and prevalence of RA were calculated in different ways: we estimated the IR (denominator = actual recorded number of PY in each year using migration and vital data) and the incidence proportion (IP) (denominator = census count data); and the PP (%) of RA was calculated for years 2000, 2009, 2011 and 2016. The four case definitions were: Model A, a first time RA diagnosis (ICD-10: M05-06) in DNPR and a redeemed prescription of a conventional DMARD in the following year1; Model B, an RA diagnosis recorded twice in DNPR within 90 days with both records originating from a department of rheumatology or general internal medicine2; Model C, any RA diagnosis recorded in DNPR with a DMARD prescription redeemed in the year before or after the diagnosis; Model D, similar to Model A but with the additional requirement that cases had no registered ICD code for inflammatory diseases prior to the RA diagnosis1.

Results:

The overall IR of RA from 1996 to 2016 based on model A was 35.2 (95%CI 34.8 to 35.6) per 100,000 PY while the IP was 34.7 (95%CI 34.3 to 35.1) per 100,000 individuals. The age standardised IR was higher for women than for men (Figure 1), and this was observed across all age groups. The IR peaked at age 70 to 74 in both men and women. Regardless of which case definition was used, the temporal trend showed a peak in IR in 2010 followed by a plateau (Figure 2). The overall PP estimate for all four models increased from 2000 to 2016, data shown for Model A in Table 1.

Table 1.

Point prevalence (PP) of rheumatoid arthritis in years 2000, 2009, 2011 and 2016 based on Model A

2000N = 590670.3 % women2009N = 1503770.9 % women2011N = 1736371.0 % women2016N = 2299170.3 % womenPP (%) (95% CI)PP (%) (95% CI)PP (%) (95% CI)PP (%) (95% CI)All0.16 (0.15 to 0.16)0.37 (0.36 to 0.37)0.41 (0.41 to 0.42)0.52 (0.51 to 0.52)Women0.21 (0.20 to 0.22)0.50 (0.49 to 0.51)0.57 (0.56 to 0.58)0.71 (0.70 to 0.72)Men0.10 (0.10 to 0.11)0.23 (0.22 to 0.23)0.25 (0.25 to 0.26)0.32 (0.31 to 0.33)

Conclusion:

A peak in the IR of RA was observed in 2010, regardless of which case definition was used. We believe this was due to introduction of the new EULAR/ACR diagnostic criteria at that time. IP estimates were systematically lower than IRs calculated using exact migration and vital data as denominator. The PP increased over time regardless of which case definition we used. We conclude that the choice of RA case definition had a larger influence than the choice of denominator.

References:

[1]inauskas A et al. Positive predictive value of first-time rheumatoid arthritis diagnoses and their serological subtypes in the Danish National Patient Registry. Clin Epidemiol. 2018;10:1709-1720.

[2]Ibfelt E et al. Validity and completeness of rheumatoid arthritis diagnoses in the nationwide DANBIO clinical register and the Danish National Patient Registry. Clin Epidemiol. 2017:627-632.

Acknowledgments:

The study is funded by the Danish Rheumatism Association.

Disclosure of Interests:

Bolette Gylden Soussi: None declared, René Lindholm Cordtz: None declared, Salome Kristensen: None declared, Christian Sørensen Bork: None declared, Jeppe Christensen: None declared, Erik Berg Schmidt: None declared, Daniel Prieto-Alhambra Grant/research support from: Professor Prieto-Alhambra has received research Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier, Consultant of: DPA’s department has received fees for consultancy services from UCB Biopharma, Speakers bureau: DPA’s department has received fees for speaker and advisory board membership services from Amgen, Lene Dreyer: None declared

FRI0583 VALIDATION OF THE MODIFIED FATIGUE IMPACT SCALE IN DANISH PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Patients with systemic lupus erythematosus (SLE) experience significant fatigue, a debilitating symptom associated with reduced quality of life. A simple, reliable multidimensional method for assessing fatigue has not yet been validated for Danish patients with SLE.

Objectives:

The primary objective was to study the internal consistency, test-retest reliability, and construct validity (convergent and discriminant validity) of the multidimensional Modified Fatigue Impact Scale (MFIS) in patients with SLE. The secondary objective was to investigate the contribution of disease activity and organ damage to fatigue.

Methods:

Data from the ”Bio and Genome Bank Study in Centre for SLE and Vasculitis” obtained through routine visits were used. Fatigue was assessed using the MFIS and Short Form 36 (SF36). Internal consistency of the MFIS was assessed with Cronbach’s alpha (α). Test-retest reliability was evaluated using the intraclass correlation coefficient (ICC). Construct validity was studied using Spearman’s rank correlation coefficient (rs) and Principal Component Analysis (PCA) between MFIS and SF36 vitality (VT-SF36) and mental health (MH-SF36) subscales. Association between MFIS and disease activity and organ damage was estimated with Spearman’s rank correlation coefficient.

Results:

The study included 30 patients with SLE. Internal consistency of the MFIS was excellent with Cronbach’s α = 0.97 for the complete scale. Excellent test-retest reliability was found with ICC = 0.95 (95% confidence interval: 0.88-0.98, p < 0.05). Construct validity was confirmed by Spearman’s correlation (VT-SF36: rs= −0.73, p < 0.001 (Fig. 1). MH-SF36: rs= −0.74, p < 0.001 (Fig. 2)) and PCA with explained variance from the first two principal components (PC) (VT-SF36: PC1 = 60.2%, PC2 = 8.5%. MH-SF36: PC1 = 58.5%, PC2 = 7.4%). No significant correlation was found between the MFIS and SLEDAI (rs= 0.04, p = 0.84) or SLICC Damage Index (rs= 0.32, p = 0.08).

Figure 1.

Scatter plot of the Modified Fatigue Impact Scale (MFIS) and the Short Form 36 vitality (VT-SF36) subscale.

Figure 2.

Scatter plot of the Modified Fatigue Impact Scale (MFIS) and the Short Form 36 mental health (MH-SF36) subscale.

Conclusion:

The present study found the multidimensional assessment of fatigue with MFIS to be a reliable and valid instrument in SLE. The MFIS might provide more detailed information about fatigue in future studies. In agreement with some previous studies we found no association between fatigue and SLEDAI or SLICC which raises questions about the cause of this symptom. Further and larger studies are needed to investigate if any association between fatigue and disease components exist.

Disclosure of Interests:

None declared

AB1255 AGREEMENT BETWEEN PATIENT-REPORTED OUTCOME MEASURES COLLECTED VIA A SMARTPHONE APPLICATION VS A TOUCHSCREEN SOLUTION IN AN OUTPATIENT CLINIC AMONG PATIENTS WITH INFLAMMATORY ARTHRITIS: A RANDOMISED, WITHIN-PARTICIPANT TRIAL

Background:

Patient-reported outcome measures (PROMs) are essential to understand the patient’s perception of arthritis activity. In Demark, PROMs are registered on a touchscreen in the outpatient clinic. However, some patients find it inconvenient due to e.g. waiting in queue, lack of privacy, uncomfortable seating position, reduced upper limb strength and dexterity with seeing the touchscreen due to deformity of the cervical spine. The widespread use of smartphones makes it possible for patients to register PROMs via an application (app) on their own device.

Objectives:

The primary aim is to evaluate the agreement (i.e. similarity) between the two devices assessed by the Health Assessment Questionnaire Disability Index (HAQ-DI) status among patients with inflammatory arthritis.

Methods:

The study was a randomised, crossover, agreement trial (NCT03486613) conducted at Aalborg University Hospital, Denmark. Participants were recruited through an invitation on the touchscreen in the outpatient clinic. Patients with an established diagnosis (≥ 12 months) of rheumatoid arthritis (RA), psoriatic arthritis (PsA) or axial spondyloarthritis (axSpA) and experience with the PROM questionnaires (≥ 3 previous registrations) were enrolled and randomised in ratio 1:1 (stratified by diagnosis) to PROM registration through the DANBIO app and the touchscreen in random order. Figure 1A and 1B shows the two devices.

The sample size calculation was based on a prespecified equivalence margin of ±0.11 HAQ-DI points (i.e. ≤ half of the minimal important difference of 0.22 points) yielding a power of 99.2% for 60 enrolled patients. There was a wash-out period of 1-2 days between the two device registrations to minimise the potential carryover effect.

A paired t-test was used to calculate the mean HAQ-DI score for the two devices and the difference in HAQ-DI score with a 95% confidence interval (CI). A Bland-Altman plot was used to assess limits of agreement (LoA).

Results:

60 patients (20 with RA, 20 with PsA and 20 with axSpA) were randomised of whom 51.7% were male. Mean age was 53.7 years (range 22-77) and mean disease duration was 12.5 years (range 1.0-34.8).

Mean HAQ-DI was 0.608 (95%CI 0.437;0.779) for the DANBIO app and 0.614 (95%CI 0.446;0.783) for the touchscreen (Table 1). Agreement between scores obtained with the two devices is illustrated with Bland-Altman plots in figure 2A and 2B. The paired mean difference of HAQ-DI between the two devices was -0.006 (95%CI -0.0424; 0.030); thus the 95% confidence interval for the mean difference was within the prespecified equivalence margin of ±0.11 HAQ-DI points.

Table 1.

HAQ-DI scores, difference and LoA for the two devices.

App, mean (SD)Touchscreen, mean (SD)Difference, mean (95%CI)LoAMissing valuesHAQ-DI (0-3)0.608 (0.656)0.614 (0.646)-0.006 (-0.042;0.030)-0.277;0.2641

Conclusion:

The current study showed no statistical or clinically important difference in HAQ-DI measurement captured by a smartphone app or outpatient touchscreen. Therefore, we feel confident that the two devices perform similarly enough to be used interchangeably in patients with inflammatory arthritis.

Disclosure of Interests:

Line Uhrenholt Speakers bureau: Abbvie, Eli Lilly and Novartis (not related to the submitted work), Robin Christensen: None declared, Lene Dreyer: None declared, Annette Mortensen Speakers bureau: MSD and Eli Lilly (not related to the submitted work)., Ellen-Margrethe Hauge Speakers bureau: Fees for speaking/consulting: MSD, AbbVie, UCB and Sobi; research funding to Aarhus University Hospital: Roche and Novartis (not related to the submitted work)., Niels Steen Krogh: None declared, Mikkel Kramme Abildtoft: None declared, 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, Salome Kristensen: None declared

THU0473 IS PAIN INTENSITY ASSOCIATED WITH EARLY MORTALITY IN PATIENTS WITH PSORIATIC ARTHRITIS?

Background:

Studies regarding excess mortality among patients with psoriatic arthritis (PsA) are conflicting due to the heterogenous nature of the disease. Thus, identifying risk factors for mortality is crucial, but few studies have examined these in PsA. Presence of chronic pain can cause excess mortality and since pain is prevalent among patients with PsA this association should be explored.

Objectives:

To investigate whether higher cumulative pain intensity is associated with an excess mortality ratio in patients with PsA.

Methods:

A nested case-control study was performed using data from the national Danish healthcare registers and the DANBIO rheumatology register. Cases were patients who died while followed in routine care. Cases were matched on sex, year of birth and calendar period of DANBIO entry with up to five controls. The main exposure of interest was the mean pain intensity (all causes) reported during the time followed in routine rheumatology practice. The pain intensity was measured on a visual analogue scale (VAS) ranging from 0 (no pain) to 100 (worst imaginable pain). Conditional logistic regression was used to calculate the odds of mortality per 5 unit increase in VAS pain while adjusting for inflammatory markers.

Results:

The Danbio PsA cohort consisted of 8019 patients. In total, 266 cases, i.e. PsA patients who died during the observational period, were identified and matched with 1198 controls (4.5 controls per case). Increasing pain intensity was associated with increased odds of mortality (OR 1.05, 95%CI 1.01 to 1.09) in the crude model, but the association disappeared when adjusting for age, sex, calendar time, socioeconomic status, average c-reactive protein and swollen joint count during the observation period (OR 0.98, 95%CI 0.93-1.03).

Age, average CRP, biological DMARD use, glucocorticoid use, and comorbidities (see table) increased the odds of mortality.

Table

regression estimates from fully adjusted model

Odds Ratio95% CIAge2,731,60-4,68C-reactive protein1,051,03-1,07Swollen joint count1,080,97-1,22Health assessment questionnaire1,250,84-1,86bDMARD use2,621,51-4,57cDMARD use0,690,46-1,03Glucocorticoid use3,902,51-6,05Chronic obstructive pulmonary disease2,191,20-4,02Diabetes mellitus2,651,62-4,31Cancer6,153,88-9,76Cardiovascular disease2,611,71-3,97

Conclusion:

These results indicate that experienced pain in itself is not associated with excess mortality. Age, recent glucocorticoid use, biological DMARD use, chronic pulmonary disease, diabetes, cancer and cardiovascular disease were all associated with an increased mortality.

Disclosure of Interests: :

None declared

AB1242 A NOVEL BIOMARKER OF MMP-CLEAVED PROLARGIN IS ELEVATED IN PATIENTS WITH PSORIATIC ARTHRITIS COMPARED TO OTHER FIBRO-INFLAMMATORY DISEASES

Background:

Psoriatic Arthritis (PsA) is a chronic inflammatory disease, characterized by involvement of skin, axial and peripheral skeleton. Prolargin is a class II small leucine-rich proteoglycan found to be expressed in connective tissues of patients with PsA, and previously suggested to be remodelled upon treatment. Fragments of prolargin could quantify tissue turnover in individuals with PsA and reflect pathological tissue changes in these patients.

Objectives:

This study aimed at developing an immunoassay targeting a neo-epitope of prolargin cleaved by matrix metalloproteinases (MMPs), named PROM; and measure PROM levels in serum from two cohorts of patients affected by PsA and healthy controls.

Methods:

Development of a novel immunoassay targeting a specific MMP-generated neo-epitope fragment of prolargin (PROM) together with technical validation was performed, and then evaluated in serum from two independent cohorts. The technical validation included inter- and intra-variation, linearity, spiking recovery, stability and specificity. Specificity was tested using an elongated peptide, a truncated peptide and a non-sense peptide. The Discovery Cohort consists of 13 healthy individuals and 11 PsA patients, mean age 58, 60.3% female and 100% caucasian. The Validation Cohort included 35 healthy individuals and 112 PsA patients with low disease activity included in a 24-week randomized, double-blind, placebo-controlled trial of 3g n-3 polyunsaturated fatty acids (PUFA), a cohort of patients diagnosed with PsA by the CASPAR criteria. These patients had a mean age of 50.8, 57.8 % female and 100 % caucasian. Clinical variables and serum samples were collected at baseline and after 24 weeks of follow-up. An unpaired t-test was used for evaluation of healthy individuals and patients affected by PsA, while a paired t-test was used for evaluation of treatment at baseline and after 24 weeks.

Results:

A technically robust and specific assay was developed. The inter- and intra-assay variation of PROM was determined as 14% and 4 % respectively. PROM showed a good dilution recovery, spiking recovery, and storage /freeze-thaw stability (All, 100%±20%). PROM showed to be specific towards the targeted sequence, and did not show any reactivity towards the truncated peptide, elongated peptide or non-sense peptide. In the Discovery Cohort, serum levels of PROM were increased in patients with PsA compared to healthy individuals (p=0.032, Figure 1A). This increase was confirmed by the Validation Cohort, where PsA patients were significantly increased compared to healthy individuals at baseline (p=0.002, Figure 1B). After 24 weeks, the levels of PROM were unchanged in the n-3 PUFA treated group.

Figure 1.

Conclusion:

The novel biomarker PROM, reflecting connective tissue remodeling, is elevated in PsA patients compared to healthy controls in two independent cohorts. No significant association was found for PROM in a low disease activity group of PsA patients treated with n-3 PUFA.

References:

None

Acknowledgments:

We thank the Innovation Foundation and Danish Research Foundation for providing funding for this study.

Disclosure of Interests:

Dovile Sinkeviciute Grant/research support from: Industrial PhD Student, Employee of: Industrial PhD Student, Annette Schlemmer: None declared, Erik Berg Schmidt: None declared, Anne-Christine Bay-Jensen Shareholder of: Nordic Bioscience A/S, Employee of: Full time employee at Nordic Bioscience A/S., Morten Karsdal Shareholder of: Nordic Bioscience A/S., Employee of: Full time employee at Nordic Bioscience A/S., Jeppe Hagstrup Christensen: None declared, Salome Kristensen: None declared, Signe Holm Nielsen Employee of: Full time employee at Nordic Bioscience

Conceptualizing patient-reported outcome measures for use within two Danish psychiatric clinical registries: description of an iterative co-creation process between patients and healthcare professionals

BACKGROUND

Denmark has national clinical indicator programs for adult patients diagnosed with depression and schizophrenia, respectively. Within each program, the responsible steering group (SG) decided to add some indicators based upon patient-reported outcome measures (PROMs).

AIMS

The primary aim was to describe the process of selecting PROMs and defining a national measurement concept for use in clinical practice and for indicator monitoring and the secondary aim s to collect patient recommendations for implementation.

METHODS

An interdisciplinary SG of healthcare professionals and a Patient Peer Board (PPB) representing both patient groups co-created the output in an iterative process. The work included literature search, PPB workshops, SG meetings, ratings of PROM topics and items, and a pilot. The PPB discussed the following: item relevance, mode of data collection, graphical format of the online PROMs, and display of results. Finally, requirements for PROM patient information were identified. Based upon input from the PPB, the SG selected the items and specified the measurement concept.

RESULTS

The PPB prioritized 20 of 53 suitable items and suggested alternative wording and answer categories. A pilot was performed and 19 items covering well-being, lack of well-being, impairment of functioning, and overall health were selected for clinical testing. The patients recommended concrete, unambiguous, easily understandable information and procedures for data collection and display of results.

CONCLUSIONS

The iterative co-creation process based upon a high degree of patient involvement resulted in a set of PROMs, a national measurement concept, and patient recommendations for implementation. The cooperation between patients and professionals was successful.

Beneficial effect of n-3 polyunsaturated fatty acids on inflammation and analgesic use in psoriatic arthritis: a randomized, double blind, placebo-controlled trial

OBJECTIVE

This study aimed to investigate the effects of marine n-3 polyunsaturated fatty acids (PUFAs) on disease activity, use of analgesics, and inflammatory biomarkers in patients with psoriatic arthritis (PsA).

METHOD

Patients with established PsA (n = 145) were investigated in a randomized, double-blind, placebo-controlled study. The participants received a supplement of 3 g n-3 PUFA/day or 3 g olive oil/day (control) for 24 weeks. Outcome measures for disease activity, use of analgesics, and leukotriene formation from activated granulocytes were assessed at baseline and at study end.

RESULTS

In total, 145 patients were included and 133 completed the study. After 24 weeks, the n-3 PUFA group showed a decrease in Disease Activity Score (DAS28-CRP), 68 tender joint count, enthesitis score, and psoriasis area and severity index, although not significantly different from the controls. There was a significant reduction in non-steroidal anti-inflammatory drug (NSAID) and paracetamol use compared with controls (p = 0.04). In addition, the participants in the n-3 PUFA group had significantly lower formation of leukotriene B₄ (p = 0.004) from stimulated granulocytes and significantly higher formation of leukotriene B₅ (p < 0.001) compared with controls.

CONCLUSION

The n-3 PUFA-supplemented group showed improvement in outcome measures for disease activity, although the difference between the groups was not statistically significant. However, use of NSAIDs and paracetamol was significantly reduced in the n-3 PUFA group compared to the control group. Finally, there was a significant decrease in leukotriene B₄ formation in the n-3 PUFA group compared with controls.

Muscular Hamartoma of the Breast

A case of a muscular hamartoma of the breast in a 47-year-old woman is presented. Tumors containing smooth muscle are rare in the breast. Radiologically it appears as a circumscribed tumor with homogeneous or varying density. Histologically these lesions are composed of ducts, lobules, stroma prominently adipose, and smooth muscle.