[The subanalysis of Rheuma-VOR demonstrates a considerable need for rheumatological care]

BACKGROUND

Early diagnosis and treatment of inflammatory rheumatic diseases can prevent consequential damage such as permanently limited mobility and joint or organ damage. Simultaneously, there is an increasing deficit in medical care owing to the lack of rheumatological capacity. Rural regions are particularly affected.

OBJECTIVES

The available unconfirmed diagnoses of the study Rheuma-VOR were analysed regarding another definitive inflammatory rheumatic disease.

MATERIALS AND METHODS

The returned questionnaires of the rheumatologists participating in Rheuma-VOR were screened for definitive inflammatory rheumatic diseases other than the required diagnosis of rheumatoid arthritis, psoriatic arthritis or spondyloarthritis.

RESULTS

Of 910 unconfirmed diagnoses, in 245 patients another definitive diagnosis could be confirmed. A total of 29.8% of the diagnoses corresponded to degenerative joint changes or chronic pain syndrome, whereas 26.1% involved different forms of inflammatory arthritis. The majority of diagnoses (40.5%) were collagenosis or vasculitis, DISCUSSION: The available data show that a rheumatological presentation was indicated for the majority of patients. Owing to the increasing deficits in medical care a prior selection of the patients is crucial to make optimal use of restricted rheumatological capacities.

Health workforce needs of small medical specialties: findings from rheumatology in Germany

Background

Small medical specialties may be more vulnerable to workforce shortage and the COVID-19 pandemic and this may directly impact in the provision of care for chronically-ill patients. This study aims to explore health workforce development and new needs, using rheumatology in Germany as a case study.

Methods

An explorative multi-methods approach was applied, combining health labour market assessment of rheumatology physicians (public statistics 2000-2019) and a questionnaire-based online survey conducted in early 2021 (n = 101 respondents; rheumatology physicians and residents). Main selected topics: work hours, workload, mental health issues, discrimination and sexual harassment experiences, impact of COVID-19. Descriptive statistical analysis was performed and qualitative content analysis for free-text information.

Results

Health labour market analysis showed that the numbers of rheumatologists increased markedly between 2000 and 2019 in the groups aged +50 years, but only 9% in younger groups under 50 years; since 2010 the group 40-50 years showed decreases. In 2019, the absolute number of rheumatologists working in healthcare after retirement-age exceeded those aged 40 and under. Survey data revealed a strong mismatch between actual and desired work hours for women and men. 81% rated their workload as high or very high; every sixth rheumatologist has suffered from stress or burnout syndromes at least once in the past. Experiences of gender discrimination and sexual harassment/violence were frequently reported, mostly by women. COVID-19 was an amplifier of stress with major stressors being digitalisation and increased demand for communication and patient education.

Conclusions

Decreasing health workforce capacities in German rheumatology combine with negative perceptions of work and workplace conditions, threatening both retention and service delivery.

Key messages

• Small medical specialties, like rheumatology, face severe shortage that threaten healthcare for chronically-ill patients and need greater attention.

• COVID-19 has reinforced rheumatologists’ workload and stressors, thus worsing mental health and retention.

POS0684 IS UPADACITINIB CAPABLE OF IMPROVING PATIENT-REPORTED OUTCOMES OF RHEUMATOID ARTHRITIS IN A REAL-WORLD SETTING? RESULTS FROM THE POST-MARKETING OBSERVATIONAL UPwArds STUDY

Background

The efficacy of Upadacitinib (UPA), a selective Janus kinase inhibitor, has been evaluated in the SELECT clinical program 1-6. In addition, recent results from the non-interventional UPwArds study further confirmed UPAs clinical effectiveness regarding standard disease activity scores for rheumatoid arthritis (RA) in a real-world setting 7. However, patient-reported outcomes (PROs) as another cornerstone of clinical decision making yet remain to be addressed in the context of a post-marketing setting. This interim analysis, conducted after 250 patients had completed the 6-month follow-up visit, aims to fill this gap.

Objectives

To evaluate the change of selected PROs over 6 months in patients treated with UPA in a real-world data environment.

Methods

UPwArds is a prospective, open-label, multicenter, non-interventional, post-marketing study including adult patients with moderate-to-severe RA (swollen joint count [SJC28] ≥ 3 and inadequate response or intolerance to at least one previous disease-modifying antirheumatic drug). According to the German label, patients were treated with UPA 15 mg once daily, as monotherapy or in combination with methotrexate. For this analysis, the following PROs were included: 0-10 numerical rating scales (NRS) for pain and fatigue, the Health Assessment Questionnaire Disability Index (HAQ-DI), the duration and severity of morning stiffness, the Patient Health Questionnaire 9 (PHQ-9), and the Rheumatoid Arthritis Impact of Disease Questionnaire (RAID). Changes from baseline were evaluated for follow-up periods of 1 month, 3 months, and 6 months. Results are presented for the total sample using descriptive measures reflecting sample size (N), average values (standard deviation) for each assessment and average change scores (standard deviation) for follow-up visits. All data were analyzed as observed, with no imputation of missing data.

Results

483 patients (369 female, 114 male) were included in the study, with available baseline PRO information for 481 patients. 6-months follow-up data were yet available from 279 patients The baseline average age and disease duration were 58.0 (12.3) years and 9.0 (8.0) years, respectively, whereas the mean initial DAS28-CRP was 4.6 (1.0). At baseline, 60.8% of enrolled patients had previously been treated with biologic or targeted synthetic disease-modifying antirheumatic drugs. Overall, PRO scores improved from baseline throughout month 6 with a considerable amelioration at month 3, which was maintained at month 6. Responses were rapid, with improvement already evident at month 1 (Table 1). The NRS pain as a crucial PRO in RA confirmed the previously described pattern of results seen for most of the other PROs (Figure 1).

Table 1.

Baseline scores and average changes from baseline scores

NBaseline scores (SD)NChange from baseline - month 1 (SD)NChange from baseline - month 3 (SD)NChange from baseline - month 6(SD)Pain (NRS)4816.2 (2.2)393-2.2 (2.3)392-2.5 (2.5)258-2.4 (2.4)Fatigue (NRS)4815.5 (2.6)393-1.4 (2.3)393-1.6 (2.4)259-1.5 (2.3)HAQ-DI4711.3 (0.6)380-0.2 (0.3)376-0.2 (0.4)253-0.2 (0.4)Morning stiffness (duration, minutes)43968.9 (63.9)313-25.0 (55.3)296-29.6 (54.9)179-31.6 (51.7)Morning stiffness (severity)4785.2 (2.7)386-1.8 (2.3)393-2.2 (2.6)258-2.2 (2.9)PHQ-94778.7 (5.2)383-1.9 (3.9)381-2.3 (4.0)255-2.2 (3.8)RAID4815.6 (2.0)393-1.7 (1.8)392-2.0 (2.0)258-1.9 (1.9)

Conclusion

This interim analysis confirmed a meaningful improvement regarding included PROs that cover various RA-related symptoms, depressiveness and the impact of symptoms of RA on daily life.

References

[1]Smolen JS, et al. Lancet 2019;393:2303–11

[2]Burmester GR, et al. Lancet 2018;391:2503–12

[3]Genovese MC, et al. Lancet 2018;391:2513–24

[4]van Vollenhoven R, et al. Arthritis Rheumatol 2020;72:1607–20

[5]Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800

[6]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21

[7]Witte T et al. P0833 at ACR, Nov 5–9, 2021

Acknowledgements

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and in the writing, review, and approval of the abstract. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. No honoraria or payments were made for authorship. The medical writing support was provided by Matthias Englbrecht, Freelance Healthcare Data Scientist (Eckental, Germany) and was funded by AbbVie. Statistical analyses were provided by Dr. Daniela Adolf of StatConsult GmbH (Magdeburg, Germany) which was funded by AbbVie.

Disclosure of Interests

Torsten Witte Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Chugai, Gilead, Janssen, Lilly, MSD, Mylan, Novartis, Pfizer, Roche, and UCB, Uta Kiltz Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, and Pfizer, Florian Haas Consultant of: AbbVie, Celgene, Novartis, and Pfizer, Grant/research support from: AbbVie, BMS, Celgene, Chugai, MSD, Novartis, Pfizer, Roche, and Sanofi Genzyme, Elke Riechers Consultant of: AbbVie, Chugai, Novartis, and UCB, Grant/research support from: AbbVie, Chugai, Lilly, Janssen, Novartis, Pfizer, Roche, and UCB, Ulrich Prothmann Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Glaxo Smith Kline, Novartis, Pfizer, Roche, Sanofi, SOBI, and UCB, Daniela Adolf Shareholder of: Employee of StatConsult and may own stock or options, Employee of: Employee of StatConsult, Carsten Holland Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Alexander Roessler Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Kirsten Famulla Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Konrad Götz Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Klaus Krueger Grant/research support from: AbbVie, Biogen, BMS, Celltrion, Gilead, Hexal, Janssen, Lilly, Medac, MSD, Novartis, Pfizer, Roche, and UCB

POS0789 CLINICAL FEATURES OF SJÖGREN’S SYNDROME WITH AND WITHOUT NEUROLOGICAL INVOLVEMENT (NEURO-SJÖGREN)

Background

Sjögren’s Syndrome is well known for its characteristic sicca symptoms due to autoinflammatory destruction of the salivary and lacrymal glands, but neurological involvement is also common in this entity. Nevertheless, previously published smaller studies suggested distinct clinical features for Sjögren’s syndrome with and without neurological involvement, such as a more balanced gender distribution and lower IgG levels in patients with Sjögren‘ syndrome and neurological involvement1,2.

Objectives

We therefore aimed to systematically assess clinical features of patients with Sjögren’s syndrome with and without neurological involvement, find relevant in-between group differences and hereby aid early detection of both patient groups in the clinical routine to facilitate further studies, potentially with new therapeutic approaches.

Methods

We retrospectively assessed patients with Sjögren’s syndrome treated at the neurological and rheumatological/ immunological departement of our university hospital between 05/2014 and 09/2021 for available laboratory and clinical data. The displayed data represent preliminary results of this ongoing study.

Results

405 patients, who fulfilled the current ACR/EULAR classification criteria for Sjögren’s syndrome3 were currently included in the study (median age 59years [IQR 50-70 years], median ESSDAI 10 [IQR 3-16]). 228 patients (56%) showed neurological involvement. They were significantly more often male (32% vs. 14%; p<0.001) and showed lower IgG serum levels (median 11 g/l [IQR 9-13 g/l] vs 12 g/l [IQR 10-16 g/l], p<0.01) in comparison to patients with Sjögren’s syndrome but without neurological involvement. However, presence of objective xerostomia, objective xerophthalmia, SSA(Ro)-antibody-positivity or sialadenits grade 3 or 4 (Chisholm and Mason) on salivary gland biopsy did not differ between the two groups.

Conclusion

Preliminary analysis of this ongoing study supports the hypothesis, that patients with Sjögren’s syndrome and neurological impairment might express a distinct clinical phenotype in comparison to patients with Sjögren’s syndrome but without neurological involvement.

References

[1]Sjögren’s syndrome should be considered in patients with motor neuropathy. Zeitschrift fur Rheumatologie 2020; 79: 707–709.

[2]Seeliger T, Prenzler NK, Gingele S, et al. Neuro-Sjögren: Peripheral neuropathy with limb weakness in Sjögren’s syndrome. Front Immunol 2019; 10: 1600.

[3]Shiboski CH, Shiboski SC, Seror R, et al. 2016 American College of Rheumatology/European League Against Rheumatism classification criteria for primary Sjögren’s syndrome. Ann Rheum Dis 2017; 76: 9–16.

Disclosure of Interests

Tabea Seeliger: None declared, Emelie Kramer: None declared, Franz F. Konen: None declared, Sonja Beider: None declared, Alexandra Jablonka: None declared, Torsten Witte: None declared, Thomas Skripuletz Employee of: Honoraria for lectures: Alexion, Alnylam, Bayer Vital, Biogen, Celgene, CSL Behring, Euroimmun, Janssen, Merck Serono, Novartis, Pfizer, Roche, Sanofi, Siemens, Diana Ernst Consultant of: Participation in Advisory Boards: Abbvie, Galapagos, Amgen, Novartis, Employee of: Fees for Presentations: Abbvie, Amgen, BMS, Chugai, Cilag-Janssen, Galapagos, GSK, Medac, Lilly, Pfizer, Novartis, Roche

POS0096 SJÖGREN’S DISEASE AND SYSTEMIC LUPUS ERYTHEMATOSUS DDX6-CXCR5 RISK INTERVALS REVEAL COMMON SNPS WITH FUNCTIONAL SIGNIFICANCE IN IMMUNE AND SALIVARY GLAND CELLS

Background

Sjögren’s Disease (SjD) and Systemic Lupus Erythematosus (SLE) are autoimmune diseases with several shared characteristics and similar genome-wide significant associations with the DDX6-CXCR5 locus. DDX6 suppresses interferon-stimulated gene expression and CXCR5 regulates T cell functions implicated in autoimmunity.

Objectives

To identify and characterize functional SNPs in the DDX6-CXCR5 interval.

Methods

ImmunoChip data from European populations (3785 SLE cases; 1916 SjD cases; 6893 controls) were imputed and SNP-trait associations tested. Bayesian statistics defined a credible SNP set that was refined using bioinformatic analyses (RegulomeDB, Haploreg, ENCODE, promoter capture Hi-C, eQTLs, etc.). Electrophoretic mobility shift assays (EMSAs) and luciferase expression assays were used to test allele-specific SNP function in EBV-transformed B (EBV B) cells, Daudi B cells, Jurkat T cells, THP1 monocytes, and A253 salivary gland cell lines. Chromatin conformation capture with quantitative PCR (3C-qPCR) was used to assess long-range chromatin interactions.

Results

Fine mapping of the SjD and SLE associations found similar SNP associations. Bioinformatic analyses identified 5 common SNPs with strong evidence of functionality in immune cell types: rs57494551 in an intron of DDX6, and rs4938572, rs4936443, rs7117261, and rs4938573 in the promoter/enhancer region of DDX6 and CXCR5. EMSAs and luciferase experiments showed cell type-specific differences in protein binding and promoter or enhancer activity, respectively, at each SNP. Risk allele of rs57494551 increased enhancer activity in B cells and A253 cells (p<0.001), but decreased promoter activity in T cells and A253 cells (p<0.01). SNP rs4938572 is an eQTL of DDX6 in T cells, and the risk allele significantly increased protein binding, promoter and enhancer activity in T cells (p<0.01). Risk allele of rs4938572 also increased promoter activity in A253 cells (p<0.001), but had no effect on promoter or enhancer activity in B cells. SNP rs4936443 showed no promoter or enhancer activity in immune cells, but the risk allele showed significant promoter and enhancer (p<0.001) activity in A253 cells. SNP rs7117261 showed decreased enhancer activity in EBV B cells, T cells, and A253 cells (p<0.05) and increased promoter activity in A253 cells (p<0.001). SNP rs4938573 showed decreased promoter activity in EBV B cells, T cell and A253 cells (p<0.05), decreased promoter activity in EBV B cells (p<0.05), and increased enhancer activity in A253 cells (p<0.0001). Overall, A253 cells exhibited more allele-specific effects on promoter and enhancer activity across the five SNPs compared to tested immune cells. In addition to DDX6 and CXCR5, rs57494551 and/or rs4938572 are reported eQTLs for several other genes of interest in the local chromatin regulatory network: IL10RA in T cells, TRAPPC4 in salivary gland and activated macrophages, and long non-coding (lnc)RNA AP002954.1 in T cells and whole blood. 3C-qPCR in EBV B and A253 cells showed that the two regulatory regions carrying rs4938572 or rs57494551 interacted with a region upstream of DDX6 that includes AP002954.1. Hi-C data showed looping between AP002954.1 and the regulatory region carrying rs4938572 and rs57494551 in T cells.

Conclusion

SjD and SLE share similar genomic architecture across the DDX6-CXCR5 risk interval with several common SNPs showing immune and salivary gland cell type-specific allelic effects on protein binding and/or enhancer/promoter activity. Extensive bioinformatic analyses suggest that the SNPs likely work within the local chromatin regulatory network to regulate cell type-specific expression of several genes on the interval. Ongoing studies will use 3C-qPCR to assess allele-specific chromatin interactions between the SNPs and these genes in different cells types, and CRISPR to determine how the risk alleles alters expression.

Disclosure of Interests

Mandi M Wiley: None declared, Bhuwan Khatri: None declared, Kandice L Tessneer: None declared, Michelle L Joachims: None declared, Anna M Stolarczyk: None declared, Anna Nagel: None declared, Astrid Rasmussen: None declared, Simon J. Bowman Consultant of: Abbvie, Galapagos, and Novartis in 2020-2021, Lida Radfar: None declared, Roald Omdal: None declared, Marie Wahren-Herlenius: None declared, Blake M Warner: None declared, Torsten Witte: None declared, Roland Jonsson: None declared, Maureen Rischmueller: None declared, Patrick M Gaffney: None declared, Judith A. James: None declared, Lars Ronnblom: None declared, R Hal Scofield: None declared, Xavier Mariette: None declared, Wan Fai Ng: None declared, Kathy Sivils Employee of: current employee of Janssen., Gunnel Nordmark: None declared, Betty Tsao: None declared, Christopher Lessard: None declared

OP0111 INTEGRATION OF GWAS AND EPIGENETIC STUDIES IDENTIFIES NOVEL GENES THAT ALTER EXPRESSION IN THE MINOR SALIVARY GLAND IN SJÖGREN’S DISEASE

Background

Sjogren’s disease (SjD) is an autoimmune disease characterized by reduced function of exocrine glands (i.e., salivary and lacrimal glands). Epithelial cell damage resulting from lymphocytic infiltration has been implicated in SjD etiology [1]. How genetic and epigenetic changes influence epithelial-immune cell interactions in SjD pathogenesis remain understudied.

Objectives

Evaluate the role of SjD risk loci in salivary gland tissue to gain insights into the potential genes involved in salivary gland dysfunction.

Methods

SNPs from 16 regions with SNP-SjD associations (P<5x10-8) in our GWAS study (3232 SjD cases) and meta-analysis of ImmunoChip data (619 SjD cases) [2] were interrogated for eQTLs using Genotype-Tissue Expression (GTEx) minor salivary gland data. Subsequent analysis identified genes that were both eQTLs in the minor salivary gland and significantly expressed in RNA-seq and ATAC-seq data from the submaxillary salivary gland epithelial cell line, A253. Pathway enrichment analysis was performed using gProfiler on the genes where coalescence of eQTL, RNA-seq, and ATAC-seq data was observed. To further validate the results, we performed transcriptome-wide association study (TWAS) analysis using GWAS summary statistics and minor salivary gland eQTL GTEx data.

Results

In total, 5884 genome-wide significant SNPs from 16 SjD risk loci were identified as potential minor salivary gland eQTLs using two discovery thresholds: p(FDR)<0.05 provided by eQTL study (3566 SNPs) and p(FDR)>0.05 and p<0.05 in eQTL study (2318 SNPs). Further analysis revealed 10 SjD risk loci with SNPs that were minor salivary gland eQTLs for a total of 155 unique genes that had a coalescence of RNA- and ATAC-seq data in A253 cells. Many SNPs altered the expression of the nearest gene to the risk allele (i.e., index gene), such as IRF5 and TNPO3 on chromosome 7 at 128Mb; however, this locus had 12 additional genes that were eQTLs in minor salivary gland. In contrast, other loci had no reported eQTLs for the index gene, but several reported eQTLs for other genes, such TYK2 on chromosome 19 at 10Mb that showed no change in TYK2 expression but eQTLs for 8 distant genes, including ICAM1. Pathway enrichment analysis revealed an enrichment in Butyrophilin (BTN) family interactions (R-HSA-8851) (PAdj=1.564x10-5), including the BTN2A1, BTN2A2, BTN3A1, BTN3A2 and BTN3A3 gene cluster in the MHC region. In further support, TWAS of the minor salivary gland and the SjD GWAS summary statistics (after Bonferroni correction) showed association between SjD and BTN3A2 (p=1.24x10-42), as well as many other loci in the MHC region. In addition, several long non-coding (lnc) RNAs on chromosome 17 were significant, peaking at RP11-259G18.1 (p=4.43x10-10).

Conclusion

This study shows that SjD-associated risk alleles influence disease by altering gene expression in immune cells and minor salivary glands. Further, our analysis suggests that altered gene expression in the minor salivary gland expands beyond effects on the index gene to several genes on each locus. Interestingly, we observed minor salivary gland eQTLs for several BTN family genes, which act as cell-surface binding partners to regulate cell-cell interactions, including interactions between epithelial cells and activated T cells [3]. Future work will assess chromatin-chromatin-interactions within the 10 SjD risk loci in salivary gland cells and tissues to map local chromatin regulatory networks that regulate gene expression. Additional transcriptional studies of SjD minor salivary gland tissues will provide further insights into how altered gene expression in the salivary gland influences SjD pathology.

References

[1]Verstappen. Nat Rev Rheumatol 2021;17(6):333-348.

[2]Khatri, et al. Annals of Rheumatic Diseases 2020;79:30-31.

[3]Arnett HA, Viney JL. Nature Reviews Immunology 2014;14:559-569.

Disclosure of Interests

Farhang Aghakhanian: None declared, Mandi M Wiley: None declared, Bhuwan Khatri: None declared, Kandice L Tessneer: None declared, Astrid Rasmussen: None declared, Simon J. Bowman Consultant of: Abbvie, Galapagos, and Novartis in 2020-2021., Lida Radfar: None declared, Roald Omdal: None declared, Marie Wahren-Herlenius: None declared, Blake M Warner: None declared, Torsten Witte: None declared, Roland Jonsson: None declared, Maureen Rischmueller: None declared, Patrick M Gaffney: None declared, Judith A. James: None declared, Lars Ronnblom: None declared, R Hal Scofield: None declared, Xavier Mariette: None declared, Marta Alarcon-Riquelme: None declared, Wan Fai Ng: None declared, Kathy Sivils Employee of: Current employee of Janssen, Gunnel Nordmark: None declared, Umesh Deshmukh: None declared, A Darise Farris: None declared, Christopher Lessard: None declared

POS1483-HPR DYSFUNCTIONAL COPING CORRELATES WITH DEPRESSION AND ANXIETY AND PREDICTS WORSE OUTCOME IN PATIENTS WITH A HIGH DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS

Background

Disease flares of rheumatoid arthritis (RA) are important stressors for patients (pts) who may use coping for disease management. Some coping styles are thought to be beneficial and may help to improve disease outcome whereas others are thought to be harmful.

Objectives

We investigate the frequency and intensity of different coping styles in pts with an acute flare of seropositive RA and its impact on disease outcomes after 12 month of therapy.

Methods

Coping was analysed with the Brief-COPE (1) using a 4 point Likert scale in 222 pts participating in the ERFASS study (2). Coping styles were analysed by confirmatory and exploratory factor analysis (CFA, EFA). Disease activity was measured via DAS28 (CRP), depression and/or anxiety using Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire 9 (PHQ-9). Repeated measures ANOVA was used to identify the effect of different coping strategies on disease activity and Spearman-Rho to identify correlations.

Results

Factor analysis revealed five dominant coping styles (problem oriented, emotion oriented, dysfunctional, religion, alcohol/drugs) which were consistent during 6 and 12 months follow up. When analysing the relative intensity of each coping strategy over time there was no significant change during treatment (Table 1). The usage of only a single coping style at baseline (“I am doing this a medium amount” or “a lot”) was reported by 70 pts (31,5%). 65 pts (29,3%) reported the use of 2 coping styles simultaneously, 25 pts (11,3%) 3 coping styles and 4 pts (1,8%) four coping styles. Problem oriented coping was used by 125 pts (56,3%), emotional coping by 97 pts (43,7%), dysfunctional coping by 41 pts (18,5%), religion by 24 pts (10,8%) and alcohol/drugs by only 4 pts (1,8%). 58 pts (26,1%) reported not to use any of the coping styles (“I am doing this not at all” or “only a little bit”) and these pts had a lower DAS28 during the course of the study (p=0.036) as compared to pts who use one or more coping strategies. When analysing the group with high disease activity (DAS28 >5.1) at baseline (n=60), pts with medium or high dysfunctional coping had a significantly higher disease activity after 12 months as compared to those with no or little dysfunctional coping (U = 187,00, Z = -2.025, p = 0.043) (Figure 1). The other coping styles did not significantly predict the outcome of disease activity. We observed a strong correlation between dysfunctional coping and depression (PHQ9 r = 0.590; HADS depression r = 0.569) as well as anxiety (HADS anxiety r = 0.639) but not for the other coping strategies at baseline.

Figure 1.Table 1.

Development of disease activity (DAS28) and coping strategies over time

TimeBaseline mean (SD)Month 6 mean (SD)Month 12 mean (SD)DAS284.32 (1.14)2.79 (1.23)2.47 (1.05)Problem oriented53.10 (14.93)49.69 (14.10)47.43 (14.00)Emotion oriented49.94 (13.00)50.73 (12.76)50.46 (13.45)Dysfunctional40.25 (14.59)36.44 (11.76)36.00 (12.26)Religion36.15 (18.30)35.53 (17.02)34.68 (16.64)Alcohol / Drugs27.03 (7.81)27.15 (8.75)26.53 (6.07)

Conclusion

Different ways of coping may be used simultaneously during an acute flare of seropositive RA. In pts with high disease activity dysfunctional coping is the only coping strategy predicting a worse disease outcome after 12 months and dysfunctional coping correlates with depression and anxiety.

References

[1]Carver CS (1997) You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behav Med 4(1):92–100.

[2]Hoeper JR, Zeidler J, Meyer SE, et al. Effect of nurse-led care on outcomes in patients with ACPA/RF-positive rheumatoid arthritis with active disease undergoing treat-to-target: a multicentre randomised controlled trial. RMD Open 2021

Disclosure of Interests

Juliana Rachel Hoeper: None declared, Ioana Iliadis: None declared, Marianne Richter: None declared, Sara Eileen Meyer: None declared, Kai Kahl: None declared, Torsten Witte: None declared, Kirsten Hoeper Speakers bureau: Abbvie, Novartis, Galapagos, Sandoz Hexal, Chugai, Lilly, Consultant of: Abbvie, Novartis, Galapagos, Sandoz Hexal, Dirk Meyer-Olson Speakers bureau: Bristol Myers Squibb, Celltrion, Chugai, Fresenius Kabi, Galapagos, Lilly, Sandoz Hexal

, Consultant of: Abbvie, Amgen, Astra Zeneca, Biogen, Novartis, Viatris

AB0536 RELATIONSHIP OF EXERTIONAL ACTIVITY AND MENTAL WELLBEING IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a variety of clinical manifestations [1] and has a profound effect on physical health [2]. Anxiety and depression are common symptoms of SLE which can have a significant impact on the quality of life [3].

Objectives

To study whether or not the physical state of health relates to the extent of anxiety and depression in SLE patients.

Methods

The Physical Component Summary Score (PCS) was determined using the 36-Item Short Form Survey (SF-36) in a cohort of 146 SLE patients consecutively visiting our outpatient clinic. Two groups were compared: one group with low PCS<50 % (LPCS) and the comparison group with high PCS ≥50 % (HPCS). Patients with SLE who visited our Rheumatology clinic between March 2019 and December 2020 as part of a monocentric cross-sectional study completed additional standardized questionnaires: Hospital Anxiety and Depression Scale (HADS), Beck’s Depression Inventory (BDI II), Multidimensional Assessment of Fatigue (MAF), Functional questionnaire Hanover (FFbH) and the international questionnaire on physical activity in short form (IPAQ-SF). The data was analyzed with SPSS 27 (IBM, Armonk, NY, USA). The tests include bivariate and partial correlations. Significance tests were performed using non-parametric tests.

Results

In total, 146 patients participated in the study. 14.4 % (n = 21) were male and the mean age was 48.6 ± 12.2 years. The mean state of physical health according to SF36 was 54.9 % ± 25.6 % in the examined cohort.

There were 62 (42.5 %) patients with LPCS, of average age 50.4 ± 10.3 years and 84 (57.5 %) with HPCS, of average age 47.2 ± 13.3 years. The majority of patients in both groups were female (55/7, 88.7 % and 70/14, 83.3 %).

A SLEDAI score > 2 was confirmed in 33.9 % (n = 21) of the patients with LPCS and in 25 % (n = 21) of patients with HPCS, the mean SLEDAI score did not significantly differ between LPCS and HPCS patients (2.4 versus 1.9, p = 0.261). Among patients with LPCS, 54.8 % (n = 34) presented low physical activity and 64.5 % reported functional impairment (FFbH < 80). More than half of LPCS-patients (53.2 %, n = 33) showed a low Mental Health summary score (MCS < 50 %) and over a third of them had moderate to severe depression (BDI II > 19, 38.7 %, n = 24) and indicated pathological anxiety (HADS > 10, 37.1 %, n = 23).

Compared to the LPCS group, a smaller number of patients with HPCS had low physical activity (36.9 %, n = 31, p = 0.031) and the difference in mean weekly MET between the two groups was 2730 counts (p = 0.003). There was no impairment of functional capacity in patients with HPCS (FFbH mean Score 90.9 %, p < 0.001). In contrast to the LPCS group, only 17.9 % (n = 15) of the patients with HPCS showed MCS < 50 % (p < 0.001). Completely free of depressive symptoms were 65.5 % (n = 55) of the patients with HPCS and only 4 patients (4.8 %) reported moderate to severe depression (p < 0.001).

Patients with LPCS reported fatigue (GFI > 20) more often than patients with HPCS (98.4 % versus 54.8, p < 0.001).

Conclusion

SLE patients with low physical health conditions have highly significant mental health impairment, particularly anxiety and depression. Physical functioning and limitations due to physical health should be considered and physical activity needs to be improved. Measurement of the PCS should be a routine tool in the overall assessment of the health conditions of SLE patients.

References

[1]Lisnevskaia, L., G. Murphy, and D. Isenberg, Systemic lupus erythematosus. Lancet, 2014. 384(9957): p. 1878-1888.

[2]O’Dwyer, T., L. Durcan, and F. Wilson. Exercise and physical activity in systemic lupus erythematosus: A systematic review with meta-analyses. in Seminars in arthritis and rheumatism. 2017. Elsevier.

[3]Figueiredo-Braga, M., et al., Depression and anxiety in systemic lupus erythematosus: the crosstalk between immunological, clinical, and psychosocial factors. Medicine, 2018. 97(28).

Disclosure of Interests

None declared

POS0737 SICCA SYNDROME: A MULTIMODAL ASSESSEMENT TO CHARACTERIZE PATIENT COHORTS BEYOND SJÖGREN’S SYNDROME CLASSIFICATION CRITERIA

Background

Sicca syndrome represents a heterogeneous group of conditions, including Sjögren syndrome, causing xerophthalmia and xerostomia.

Objectives

This study characterizes in depth patients with Sicca syndrome and evaluates salivary gland ultrasound (SGUS) in this cohort.

Methods

Principal component analysis and hierarchical clustering of clinical parameters, including ESSPRI, ESSDAI and laboratory data were performed on all referrals for assessment of Sicca symptoms between October 2018 and March 2021. SGUS and labial gland biopsies were compared across groups.

Results

583 patients were assessed. Objective dryness was confirmed in 73% of patients. Cluster analysis identified 3 groups with post-hoc analysis confirming distinct phenotypes: Somatic Group (283/583; 49%) with higher reported symptoms but limited objective dryness; Dry Without Autoimmune Features (DAFneg, 206/532; 35%) and Dry With Autoimmune Features (DAFpos, 94/532; 16%). DAFpos patients had highest autoantibody titres (SSA 240 vs 3.6 vs 3.8; p<0.001), most extra-glandular manifestations (p<0.001) and highest median SGUS Score (DAFpos: 8 [IQR 4-10] vs SG: 2 [1-4] vs DAFneg 4 [2-5]; p< 0.001). No tangible correlation primary Sjögren syndrome criteria was observed.

Conclusion

SGUS score correlated with a subset of Sjögren syndrome patients, identified in the DAFpos cluster. This study highlights heterogeneity within Sicca and indeed Sjögren syndrome, highlighting the need for further studies.

References

[1]Chisholm DM, Mason DK. Labial salivary gland biopsy in Sjogren’s disease. J Clin Pathol. 1968;21(5):656-60

[2]De Vita S, Lorenzon G, Rossi G, Sabella M, Fossaluzza V. Salivary gland echography in primary and secondary Sjogren’s syndrome. Clin Exp Rheumatol. 1992;10(4):351-6

Table 1.

Comparing and contrasting the clinical demographics and attributes of the entire cohort subdivided into the three groups identified through principal component analysis and subsequent hierarchical clustering. Results are shown as mean and interquartile range unless otherwise stated.

SomaticDAFnegDAFposp N (%)283(49)206(35)94(16) Female, n (%)239(84)142(69)81(86%)<0.001 Age at Onset, yrs47.3[36.6-55.9]60.2[51.1-67.3]50.1[35.5-59.4]<0.001 BMI, kgm-226.1[23.0-31.0]24.7[21.7-27.7]24.6[22.4-28.0]0.003 Smoker, n (%)50(18)15(7)4(4)0.06ESSPRI Scores  - Dryness6[3-7]2[1-3]4[2-7]<0.001  - Limb Pain7[5-8]5[2-6]6[4-8]  - Fatigue8[6-9]3[2-5]5[3-8]Reported Symptoms Raynaud, n (%)86(30)51(25)44(47)0.006 Arthralgia, n (%)222(78)118(57)61(65)0.002 Myalgia, n (%)197(70)87(42)40(43)0.003 Stiffness, n (%)98(35)37(18)23(25)0.001 Parotitis, n (%)62(22)24(12)33(35)0.001 Sand corn, n (%)168(59)62(30)44(47)0.001 Ocular Inf, n (%)120(42)45(22)26(27)0.005ESSDAI  - Score5[2-12]5[0-11]11[4-17]<0.001Antibody Titres  - ANA ≥ 1:160178(63)152(74)44(47)<0.001  - RhF U/ml10.0[10.0-10.9]10.0[10.0-11.3]23.3[11.7-71.0]<0.001 - Alpha-Fodrin U/ml9[5-22]9[6-19]12[6-25]0.05  - anti-SSA(Ro) U/ml3.6[0.3-101.3]3.8[0.3-102.3]240.0[192.8-240.0]<0.001  - anti-SSB(La) U/ml0.4[0.3-3.4]0.3[0.3-1.9]73.1[3.8-312.5]<0.001Measurable Dryness Saxon, g3.5[2.4-4.9]4.2[3.3-5.3]2.3[0.6-3.7]<0.001 Schirmer, mm7.0[2.0-17.9]3.0[0.5-12.0]2.5[0.0-7.1]<0.001Labial Gland Biopsy, n (%) - Biopsy performed150(53)120(58)18(19) - Chisholm Score ≥366(44)64(53)9(50) - Median Score2[1-3]3[2-3]3[3-4]Salivary Gland Ultrasound, n (%) - SGUS = 039(14)39(19)1(1) - SGUS ≥673(26)55(27)38(41) SGUS Score2[1-4]4[2-5]8[4-10]<0.001Figure 1.

A 3D scatterplot composed of the first 3 dimensions of the principal component analysis, identified as providing greatest inertia gain on hierarchical clustering. The Somatic Group (SG) are represented by the black points. Patients in the Dryness without autoimmune features (DAFneg) are represented by pink points and Dryness with autoimmune features (DAFpos) patients with green dots.

Acknowledgements

We would like to express our gratitude to the staff of the Rheumatology Outpatients Department at Hannover Medical School for their continual help in organization of patients: G Mielke, A Lahn, Dr. S Hirsch.

Disclosure of Interests

Emelie Kramer: None declared, Tabea Seeliger: None declared, Thomas Skripuletz: None declared, Vega Gödecke: None declared, Sonja Beider: None declared, Alexandra Jablonka: None declared, Torsten Witte: None declared, Diana Ernst Grant/research support from: This study was financially supported by Novartis. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.

Increasing planning targets is not enough: health workforce management in rheumatology in Germany

Background

Health workforce shortage in German rheumatology and its negative impact in healthcare are increasingly recognised. Health policy has increased staffing targets, but effective intervention strategies are lacking. This paper aims to systematically map the rheumatology workforce and to explore opportunities for intervention, thus contributing to better health workforce management.

Methods

The WHO National Health Workforce Accounts (NHWA) provided a conceptual framework for the mapping exercise. Four major sets of indicators were selected, comprising staffing levels, health labour market flows, skill-mix and education/training. Comparison of age-groups and time series was applied to explore trends. Public statistics and other secondary sources served the analysis, using descriptive methodology.

Results

Rheumatologists nearly doubled in absolute numbers since 2000, but this trend shows a problematic demographic bias. Between 2000 and 2019 numbers increased markedly in the groups aged +50 years, but only about 9% in younger groups under 50 years. Most alarming, since 2010 the group 40 to 50 years showed a reverse trend and strong decreases. In 2019, absolute numbers of rheumatologists working in healthcare after retirement-age exceeded those aged 40 and under. Since 2015 an expanding workforce trend overall flattened, but strongest in the hospital sector; annual inflows do not show relevant growths.

Conclusions

Health workforce assessment reveals negative demographic trends and decreasing appeal of the specialty especially to men, thus highlighting a need for more effective health workforce management. Intervention strategies should target innovation in resident training and task shifting and improve gender equality.

Key messages

Health workforce trends indicate that new health policy planning targets cannot be met with an available stock of rheumatologist. The WHO NHWA provide a useful toolbox to map health workforce trends and identify weaknesses and gaps.

OP0019 DEFINING SYSTEMIC LUPUS ERYTHEMATOSUS MOLECULAR TAXONOMY THROUGH DATA-DRIVEN RESTRATIFICATION AND IDENTIFICATION OF CLUSTER-TAILORED DRUGS FOR A PERSONALIZED MEDICINE APPROACH

Background:

Systemic Lupus Erythematosus (SLE) is characterized by lack of treatment diversity, largely empirical treatment decisions, and paucity of novel compound development.

Objectives:

We sought to stratify SLE patients based on their molecular phenotype and predict personalized therapeutic compounds, tailored to the molecular fingerprint of each subgroup.

Methods:

We performed a co-expression analysis using our publicly available whole blood RNA-seq data of 120 SLE patients. Modules of commonly regulated genes were established and used to re-stratify patients through hierarchical clustering, in a data-driven, clinically independent, manner. Next, we established an in silico, subgroup signature-based, drug prediction pipeline. Investigated drugs included both those currently in practice and those who have been tested in SLE clinical trials and are listed in the iLINCS prediction databases. Finally, drug repurposing analysis was performed, to identify novel perturbagens that counteract group-specific SLE signatures.

Results:

Molecular taxonomy identified five distinct lupus molecular endotypes, each characterized by a unique gene module enrichment pattern. A group defined by strong neutrophilic signature encompassed almost exclusively patients with active nephritis, while a B-cell expression group included patients with severe lupus phenotype. Metabolic processes enrichment defined a group of patients with disease of moderate severity and serologic activity. Finally, patients with mild lupus features were distributed in two groups, which demonstrated enhanced basic cellular functions, myelopoiesis, and autophagy. The ability of different compounds to reverse the transcriptomic aberrancies observed in each patient group was examined. Bortezomib efficiently reversed disturbances in the “neutrophilic” cluster. Azathioprine and ixazomib might be a reasonable option for patients of the “B-cell” cluster, whereas fostamatinib appeared efficacious for the “Metabolism” patient subgroup.

Conclusion:

The clinical spectrum of SLE encompasses distinct molecular endotypes, each defined by unique pathophysiologic aberrancies, which can be utilized to guide personalized care and direct novel compound development.

Acknowledgements:

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390).

Disclosure of Interests:

None declared

OP0260-HPR PREDICTORS OF WORK PARTICIPATION IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS AFTER 12 MONTHS OF T2T THERAPY INTERVENTION

Background:

Rheumatoid arthritis (RA) is associated with restrictions on work participation (WP) caused mainly by periods of sick leave (absenteeism), reduced productivity at work due to disease (presenteeism) and occupational disability, which account for a significant proportion of indirect costs.

Objectives:

We investigate the predictors of WP after 12 months of Treat-to-Target (T2T) intervention.

Methods:

Data were analyzed from the multi-center ERFASS study, which included patients with rheumatoid factor and/or APCA positive RA after initiation or escalation of disease modifying anti rheumatic drug (DMARD) therapy following a T2T regimen prospectively over 12 months from 01/2018 to 12/2019. A total of 157 patients of working age (18 to 65 years) were included in this evaluation. Socio-demographic and occupational characteristics (WPAI, self-conducted work questionnaire), clinical parameters including disease activity (DAS28, RADAI), impact of disease (RAID), functional capacity (FFbH), depression (PHQ-9) and fatigue (VAS) were analyzed and logistic regression analysis to detect baseline predictors for unimpaired WP after 12 months was performed.

Results:

The mean age of the patients was 52.9 years (standard deviation (SD): 8.19) and 117 (74.5%) were female. 51 patients (32.5%) started first line DMARDs and in 106 patients (67.5%) treatment was escalated. T2T resulted in a significant decrease in mean DAS28 from 4.2 (SD 1.10) at baseline to 2.5 (SD 1.11; p<0.001) after 12 months, 64.3% of the patients were in remission (DAS28<2.6) and 12.1% had low disease activity (DAS28 2.6-3.2). The proportion of patients with no impairment of WP increased significantly and presenteeism and absenteeism became significantly less prevalent, but the proportion of patients with reduced WP at month 12 remained high (74.1%; graph 1). We observed a moderate positive significant correlation between presenteeism and absenteeism (rMo12=0.446; p<0.001). Patients with no restrictions on WP showed a significantly greater decrease in mean DAS28 from 3.7 (SD 1.15) at baseline to 1.9 (SD 0.61) at month 12 as compared to patients with restrictions (mean DAS28: 4.4 (SD 1.04) at baseline to 2.7 (SD 1.15) at month 12; p<0.001). Results from univariate and logistic regression analyses revealed high functional capacity and low depression score at baseline as major contributing factors for unimpaired WP (Table 1).

Table 1.

Baseline predictors of work participation1 at month 12

Predictors (independent variables)Univariate analysis2:p-valuesMultivariate analysis3: Odds Ratios, p-valuesgender0.117+OR: 0.412; p=0.113age0.010*+OR:0.951; p=0.071school graduation0.150+professional degree0.739duration of complaints0.127+therapy group (starters vs. escalation/ change)0.004*+DAS-28(CRP)0.001*CRP0.906tender joints0.004*swollen joints0.021*disease activity (VAS)0.003*+OR: 0.827; p=0.086subjective disease activity (RADAI)<0.001*disease burden (RAID)<0.001*functional capacity (FFbH)<0.001*+OR: 1.477; p=0.031*fatigue (VAS)<0.001*+depression (PHQ-9)<0.001*+OR: 0.876; p=0.035*working time model (full vs. part-time)0.498physical work load0.427

1 dependant variable: 0=reduced WP (not working/ absenteeism/ presenteeism (≥2)); 1=full WP (working without absenteeism/ presenteeism (≥2))

2 according to applicability chi-square test, t-test for independent variables, Mann-Whitney-U test

3 binary logistic regression analysis, stepwise-backward procedure

+ included into logistic regression model

* significance level: p<0.05

Conclusion:

Despite T2T and high DAS28 remission, we observed persistent limitations in WP. Impaired WP was associated with increased disease activity but logistic regression revealed a significant influence of depression and functional capacity. Our data underscore the multifactorial causes of impaired WP, which should be targeted by vocational rehabilitation.

Disclosure of Interests:

Sara Eileen Meyer: None declared, Juliana Rachel Hoeper: None declared, Torsten Witte: None declared, Kirsten Hoeper Speakers bureau: She has received consultancy and speaker honoraria from Abbvie, Chugai, Gilead, Lilly, Novartis, Sandoz Hexal and Sanofi., Dirk Meyer-Olson Speakers bureau: He has received consultancy and speaker honoraria from Abbvie, Amgen, Berlin Chemie, Bristol Myers Squibb, Cellgene, Chugai, Fresenius Kabi, GSK, Jansen Cilag, Lilly, Medac, Merck Sharp & Dome, Mylan, Novartis, Pfizer, Sandoz Hexal, Sanofi and UCB.

AB0322 ASSOCIATION OF DEPRESSIVE SYMPTOMS ASSESSED BY BDI II WITH PHYSICAL ACTIVITY IN PATIENTS WITH PRIMARY SJÖGREN´S SYNDROME

Background:

Patients with primary Sjögren´s syndrome (pSS) suffer from pain, oral or ocular dryness and fatigue. Such symptoms can have a detrimental impact on health-related quality of life. The prevalence of mental health disorders in patients with pSS is considerably higher than in the general population [1]. Regular physical activity, such as nordic walking, improves aerobic capacity and may reduce reported fatigue [2]. According to current European League Against Rheumatism (EULAR) recommendations, management of pSS concomitant diseases should be evaluated in patients presenting with fatigue and pain, and severity scored using specific tools [3].

Objectives:

This study analyses the frequency and severity of depressive symptoms in patients with pSS and their relationship to fatigue and physical activity.

Methods:

In this monocentric, cross-sectional study, patients with pSS attending our Rheumatology clinic between January 2019 and March 2020 completed standardized questionnaires: Beck´s depression inventory second edition (BDI II) and the international physical activity questionnaire short form (IPAQ-SF). Data were analyzed using SPSS 26 (IBM, Armonk, NY, USA). The tests include bivariate and partial correlations and nonparametric Kruskal-Wallis-Test.

Results:

In total, 134 patients were included. The majority were female (117/134, 87.3 %), and the patients median age was 57 [21 – 85] years. Median duration of disease-related symptoms at inclusion was 56 months (range 0-388 months). Physical activity was low in 44. 8 % (n = 60), moderate in 32.1 % (n = 43), and high in 23.1 % (n = 31) of patients. Depressive symptoms of varying severity were identified in 76/134 (56.7%) of patients. Severe depression occurred in 10/76 (13.2%) and moderate depression in 14/76 (18.4%) patients. The remaining 52/76 (68.4%) patients had minimal or mild depression. Over two-thirds (67.7%) of patients reporting high physical activity showed no depression and no one with a high level of physical activity had severe depression. There was a clear association between the BDI II depression score and the level of physical activity (p = 0.003) regardless of age and illness duration. However, not all the symptoms assessed by BDI II had the same impact. From 21 items of the BDI II Inventory, symptoms such as loss of energy and fatigue were profoundly relevant, being reported by over 75 % of patients. The main depressive symptoms, which had a strong negative correlation with the level of physical activity were loss of energy (p < 0.001), sadness (p=0.018), inability to make decisions (p=0.007) and loss of pleasure (p=0.004). Somatic symptoms of decreased activation such as fatigue (p=0.026) and concentration difficulty (p=0.013) were also significant. The cognitive, self-negative symptoms were not associated with the level of physical activity.

Conclusion:

A negative correlation of physical activity with fatigue and depression in patients with pSS has been demonstrated. The somatic symptoms of decreased activation played a profound role in this association, while the cognitive self-negotiation symptoms were not influenced by physical activity in our patients. Such symptoms as fatigue and loss of energy could potentially be reduced by exercises and functional training and consequently decrease the level of depression. An intervention study in this regard would be recommended.

References:

[1]Cui, Y., et al., Anxiety and depression in primary Sjögren’s syndrome: a cross-sectional study. BMC psychiatry, 2018. 18(1): p. 1-8.

[2]Strömbeck, B., E. Theander, and L. Jacobsson, Effects of exercise on aerobic capacity and fatigue in women with primary Sjögren’s syndrome. Rheumatology, 2007. 46(5): p. 868-871.

[3]Ramos-Casals, M., et al., EULAR recommendations for the management of Sjögren’s syndrome with topical and systemic therapies. Annals of the rheumatic diseases, 2020. 79(1): p. 3-18.

Disclosure of Interests:

None declared

AB0255 BASELINE CHARACTERISTICS OF PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH UPADACITINIB IN GERMAN REAL-WORLD PRACTICE: RESULTS FROM THE POST-MARKETING OBSERVATIONAL UPwArds STUDY

Background:

The efficacy and safety of upadacitinib (UPA), a selective Janus kinase inhibitor, has been evaluated in the SELECT rheumatoid arthritis (RA) clinical program,1–6 but its real-world effectiveness remains to be investigated. The UPwArds study will assess the association of C-reactive protein (CRP) level with remission and other efficacy outcomes in patients with RA treated with UPA in German real-world practice.

Objectives:

To describe the baseline characteristics of patients enrolled in the UPwArds study.

Methods:

The prospective, open-label, multicenter, non-interventional, post-marketing UPwArds study included adult patients with moderate-to-severe RA (swollen joint count [SJC28] ≥3 and inadequate response or intolerance to ≥1 disease-modifying antirheumatic drug [DMARD]). Patients were treated with UPA 15 mg once daily, as monotherapy or in combination with methotrexate (MTX; 50:50 mono:combo enrollment planned), according to the German label. Variables assessed included medical history (disease duration, previous RA therapy, and vaccination status), CRP level, and disease activity (disease activity score [DAS28(CRP)], tender joint count [TJC28], and SJC28). There was no recruitment restriction regarding CRP level. This descriptive interim analysis reports patient baseline characteristics after enrollment was complete. All data were analyzed as observed, with no imputation of missing data.

Results:

533 patients (UPA monotherapy: 257 [48%]; UPA plus MTX: 276 [52%]) were included. Mean patient age was 58 years; mean disease duration was 9 years (Table 1). Despite having active RA, almost half the population (44%; n=237) did not have elevated CRP at the start of UPA treatment. Mean DAS28(CRP) was 4.6; mean TJC28 and SJC28 were 7.7 and 5.6, respectively. Overall, 39% of patients had not been treated with any biologic (b) DMARD or targeted synthetic (ts) DMARD before enrollment; 25% and 36% had previously been treated with 1 or ≥2 bDMARDs or tsDMARDs, respectively (Figure 1). 8.7% of patients had previously received a herpes zoster vaccination (8.1% Shingrix; 0.6% Zostavax).

Conclusion:

In German clinical practice, the population of patients with RA in the UPwArds study was predominantly treatment-refractory. Half of these patients had no elevated CRP despite active disease; future analyses will assess the impact of CRP on efficacy outcomes.

References:

[1]Smolen JS, et al. Lancet 2019;393:2303–11;

[2]Burmester GR, et al. Lancet 2018;391:2503–12;

[3]Genovese MC, et al. Lancet 2018;391:2513–24;

[4]van Vollenhoven R, et al. Arthritis Rheumatol 2020;72:1607–20;

[5]Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800;

[6]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21.

Table 1.

Baseline characteristics

Age, yearsUPAUPA + MTXTotal57.7 (13.2)n=25758.1 (11.4)n=27657.9 (12.3)n=533Disease duration, years9.4 (8.3)8.5 (7.7)9.0 (8.0)n=253n=272n=525CRP, mg/dL1.3 (1.9)1.1 (1.7)1.2 (1.8)n=257n=276n=533CRP >ULN, n (%)137 (53.3)159 (57.6)296 (55.5)n=257n=276n=533TJC287.4 (6.0)7.9 (6.4)7.7 (6.2)n=257n=276n=533SJC285.5 (3.7)5.6 (4.1)5.6 (3.9)n=257n=276n=533Patient’s Global Assessment6.2 (1.9)6.3 (1.8)6.3 (1.8)n=257n=276n=533Physician’s Global Assessment5.8 (1.5)5.9 (1.6)5.9 (1.6)n=257n=276n=533DAS28(CRP)4.6 (1.0)4.6 (1.0)4.6 (1.0)n=257n=276n=533DAS28(ESR)4.8 (1.1)4.9 (1.2)4.9 (1.1)n=224n=239n=463CDAI24.9 (10.2)25.7 (10.8)25.4 (10.5)n=257n=276n=533SDAI26.2 (10.5)26.9 (11.3)26.6 (10.9)n=257n=276n=533RAID5.7 (2.0)5.7 (2.0)5.7 (2.0)n=255n=275n=530Pain (RAID-1)6.2 (2.2)6.1 (2.3)6.2 (2.2)n=255n=275n=530SF-12 Physical Component Summary32.6 (8.5)33.9 (8.6)33.3 (8.6)n=245n=262n=507SF-12 Mental Component Summary42.4 (11.6)42.6 (11.3)42.5 (11.5)n=245n=262n=507HAQ-DI1.3 (0.7)1.3 (0.6)1.3 (0.6)n=250n=270n=520PHQ-98.9 (5.3)8.6 (5.3)8.7 (5.3)n=252n=272n=524Erosions, n (%)87 (33.9)95 (34.4)182 (34.1)n=257n=276n=533

Data are mean (SD), n unless otherwise stated

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and in the writing, review, and approval of the abstract. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. No honoraria or payments were made for authorship. Medical writing support was provided by Grant Thomas Kirkpatrick, MSc, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Torsten Witte Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Chugai, Gilead, Janssen, Lilly, MSD, Mylan, Novartis, Pfizer, Roche, and UCB., Uta Kiltz Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, and Pfizer, Florian Haas Consultant of: AbbVie, Celgene, Novartis, and Pfizer, Grant/research support from: AbbVie, BMS, Celgene, Chugai, MSD, Novartis, Pfizer, Roche, and Sanofi Genzyme, Elke Riechers Consultant of: AbbVie, Chugai, Novartis, and UCB, Grant/research support from: AbbVie, Chugai, Lilly, Janssen, Novartis, Pfizer, Roche, and UCB, Ulrich Prothmann Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Glaxo Smith Kline, Novartis, Pfizer, Roche, Sanofi, SOBI, and UCB, Daniela Adolf Employee of: Employee of StatConsult and may own stock or options, Carsten Holland Employee of: Employee of AbbVie and may own stock or options, Rouven Hecht Employee of: Employee of AbbVie and may own stock or options, Alexander Roessler Employee of: Employee of AbbVie and may own stock or options, Kirsten Famulla Employee of: Employee of AbbVie and may own stock or options, Klaus Krueger Grant/research support from: AbbVie, Biogen, BMS, Celltrion, Gilead, Hexal, Janssen, Lilly, Medac, MSD, Novartis, Pfizer, Roche, and UCB.

AB0707 RHEUMATOLOGY PATIENT CARE IN THE COVID-19 PANDEMIC: TELEMEDICINE, DELEGATION, PATIENT SATISFACTION AND VACCINATION BEHAVIOUR

Background:

Use of telemedicine in Germany has increased due to the COVID-19 lockdown. Between March and May 2020, government restrictions led to cancellation of routine outpatient appointments to limit viral spread and optimize resources.

Objectives:

This study assesses patient satisfaction of follow-up telemedicine appointments among patients known to be in disease remission, attending either secondary or tertiary care Rheumatology clinics. Appointments were conducted either by a rheumatologist or a qualified medical assistant for rheumatology (RFA). Additional data regarding perceived concerns arising from the COVID-19 pandemic as well as attitudes to vaccination were collected.

Methods:

Methods: Patients not requiring adjustment of their DMARDs at the two previous attendances were considered stable. At cancellation of the planned attendance, patients were offered participation in the study and provided verbal informed consent. Participants were randomized to a telemedicine appointment by either a physician or RFA. Telemedicine appointments consisted of a standardized patient interview, including assessment of disease activity (modified CDAI score), attitudes to vaccination as well as current vaccine status and concerns about COVID-19. Following participation, all patients received a pseudonymized postal questionnaire to evaluate appointment satisfaction (FAPI-Score).

Results:

In total 112/116 (96%) patients that were offered appointments, participated in the study (RA 50%, axSpA 30%, PsA 20%). Of these 88/112 (79%) returned their postal questionnaires. Overall patient satisfaction was excellent (mean 4.3/5 modified FAPI score) and did not differ between care setting or clinical status of the interviewer. RFAs conducted 19/112 (17%) of appointments, 6 (32%) of which required additional physician intervention. Change of DMARDs occurred in 19/112 (17%) appointments. Patients reporting a pain score ≥7 (VAS 1-10) were most dissatisfied with the telemedicine appointment (p=0.036). Concerns about COVID-19 correlated with disease activity: high disease activity (p = 0.031), presence of tender joints (p=0.001), high pain levels (p=0.009) correlated with concern of contracting COVID-19 or experiencing severe disease course. Only 38% of the patients had been vaccinated against pneumococci in the past 5 years and 54% had been vaccinated against influenza in 2019/2020.

Conclusion:

Telemedicine can contribute to patient care in stable patients. RFAs can also contribute to patient care especially for follow-up appointment when patients are in remission. Vaccination rates and motivation needs to be improved as influenza and pneumococcal vaccination is recommended to all patients with rheumatic diseases without contraindications.

Disclosure of Interests:

None declared

[Association of physical activity with fatigue and functional capacity in patients with rheumatoid arthritis]

BACKGROUND

Patients with rheumatoid arthritis (RA) tend to be less physically active. Physical activity has been shown to have a positive impact on disease activity and quality of life and is recommended by the European League Against Rheumatism (EULAR) as an integral component of standard treatment.

OBJECTIVE

A cross-sectional analysis of RA patients was carried out assessing disease activity, functional capacity and fatigue associated with physical activity.

MATERIAL AND METHODS

Physical activity, functional capacity and the global fatigue index (GFI) were examined using standardized questionnaires: the international physical activity questionnaire short form (IPAQ-SF), the functional questionnaire Hannover (FFbH) and the multidimensional assessment of fatigue (MAF). The data were evaluated using SPSS 26 (IBM, Armonk, NY, USA). The level of significance was tested with bivariate and partial correlations and nonparametric tests.

RESULTS

In total 164 patients were included in the study. The majority of the patients were female (127/164; 77%) and the median age of the cohort was 58.3 years (range 21-86 years). The median duration of disease-related symptoms at inclusion was 169 months (range 0-713 months). Physical activity was low in 39%, moderate in 37% and high in 24%. Patients reporting higher levels of physical activity reported significantly lower GFI (p < 0.001), functional limitations (p < 0.001) and disease activity (p = 0.045) scores than those with less physical activity.

CONCLUSION

Physical activity in RA patients was significantly correlated with functional capacity and levels of fatigue. In order to reduce the proportion of patients with low physical activity, the possibilities for functional training should be expanded and the patients should be encouraged to undertake sporting activities.

[Rheumatology in German MD curricula]

Transmitting a substantial amount of basic knowledge in Rheumatology to all medical students is essential for the future medical care of patients with rheumatic diseases for two reasons: on the one hand, future general practitioners will need to master the patterns of rheumatic diseases to recognize them fast enough in new-onset patients and to refer them in time and directly to rheumatologists. On the other hand, the shortage of rheumatologists can only then be relieved in the future when we are able to inspire enthusiasm for our specialty. Adequate rheumatological structures are established only in some of the German faculties of medicine. Structural improvements happen in small steps only but were achieved at several sites. The better the local structures, the higher the chances of committed university teachers in rheumatology to reach all medical students. Probably from 2026 onwards, the learning objectives relevant for examinations will be defined by the national competence-based catalogue of learning objectives in medicine (NKLM), which is currently in the final stages of completion together with the German Federal Institute for Medical and Pharmaceutical Examinations (IMPP). It now appears that systemic autoimmune diseases and inflammatory rheumatic diseases are adequately depicted in this catalogue. If this is achieved, students will know more about these diseases in the future and will diagnose them faster in patients. Work on the NKLM is therefore of highest importance. In addition to the work on the learning objectives, up to date learning materials are required, which have to be available throughout Germany. A Rheumatology script just finished by the committee for medical student education of the German Society of Rheumatology (DGRh) and now available on the DGRh homepage should close this gap.

OP0139 FUNCTIONAL EVALUATION OF THE SJÖGREN’S SYNDROME AND SYSTEMIC LUPUS ERYTHEMATOSUS DDX6-CXCR5 RISK INTERVAL

Background:

Sjögren’s Syndrome (SS) and Systemic Lupus Erythematosus (SLE) are distinct chronic, complex autoimmune diseases with shared characteristics such as autoantibodies, heightened interferons, and polyarthritis. SS and SLE genome-wide association studies (GWAS) report strong associations with theDDX6-CXCR5risk interval. DDX6 suppresses interferon stimulated gene expression and CXCR5 regulates T cell functions implicated in autoimmunity.

Objectives:

To identify functional variants that impact regulation in theDDX6-CXCR5interval.

Methods:

Fine-mapping was done using ImmunoChip data from 3785 SLE, 1916 SS cases and 6893 population controls of European ancestry that were imputed and tested for SNP-trait association. Bayesian statistics assigned posterior probabilities to SNPs and defined a credible set of risk variants. Bioinformatic analyses further prioritized variants with predicted functionality. Electrophoretic mobility shift assays (EMSAs) and luciferase expression were used to validate predicted SNPs in EBV transformed B (EBV B) cells.

Results:

While some differences were observed, the overall SS and SLE association signals were similar. SNP-SS rs9736016 nearCXCR5and SNP-SLE rs76409436 nearDDX6were the most significant but did not show evidence of functionality. Bayesian statistics defined credible sets of variants in strong D’ in common between both SS and SLE. Bioinformatics analyses (Haploreg, RegulomeDB, ENCODE data, etc) further refined the credible set and identified 5 common SNPs with strong evidence of functionality in immune cell types: rs4938572, rs4936443, rs57494551, rs7117261 and rs4938573. EMSAs showed a significant increase in protein binding to the risk allele of rs57494551 (p=0.0001), rs7117261 (p=0.0001) and rs4938573 (p=0.0003), but not the others, using nuclear lysates from EBV B cells. Luciferase vectors with a minimal promoter or no promoter were used to test for enhancer or promoter activity, respectively. To this end, the rs57494551 risk allele exhibited a significant increase in enhancer activity (p=0.0001). In contrast, the rs7117261 risk allele decreased enhancer activity (p=0.018). The rs4938573 risk allele decreased enhancer (p=0.043) and promoter (p=0.024) activity. While rs7117261 or rs4938573 were not reported in eQTL databases, GTex data reported rs57494551 as an eQTL that altersDDX6expression in whole blood (p=1.8E-7). Additionally, these functional SNPs have been associated with looping events to several proximal promoters in nearby genes in immune cells.

Conclusion:

SS and SLE have similar genomic architecture across theDDX6-CXCR5risk interval. Multiple variants in the credible set exhibited allele specific changes in protein binding, as well as modified enhancer activity, promoter activity or both. Ongoing studies will use Cas9 in EBV B cells to determine which other loci are within the local regulatory network.

Disclosure of Interests:

Mandi M Wiley: None declared, Bhuwan Khatri: None declared, Kandice L Tessneer: None declared, Michelle L Joachims: None declared, Anna M Stolarczyk: None declared, Astrid Rasmussen Speakers bureau: Novartis, ThermoFischer, Simon J. Bowman Consultant of: Astrazeneca, Biogen, BMS, Celgene, Medimmune, MTPharma, Novartis, Ono, UCB, xtlbio, Glapagos, Speakers bureau: Novartis, Lida Radfar: None declared, Roald Omdal: None declared, Marie Wahren-Herlenius: None declared, Blake M Warner: None declared, Torsten Witte: None declared, Roland Jonsson: None declared, Maureen Rischmueller: None declared, Patrick M Gaffney: None declared, Judith A. James Grant/research support from: Progentec Diagnostics, Inc, Consultant of: Abbvie, Novartis, Jannsen, Lars Ronnblom Grant/research support from: AZ, Speakers bureau: AZ, R Hal Scofield Grant/research support from: Pfizer, Xavier Mariette: None declared, Wan-fai Ng: None declared, Kathy L Sivils: None declared, Gunnel Nordmark: None declared, Betty Tsao: None declared, Christopher Lessard: None declared

FRI0312 ANTI-CD74 IGA ANTIBODIES ARE MOST SENSITIVE AND SPECIFIC TO IDENTIFY YOUNG MALE AXIAL SPONDYLOARTHRITIS PATIENTS

Background:

CD74 is involved in the assembly of and the prevention of premature peptide-binding to major histocompatibility complex (MHC) class II. IgG autoantibodies directed against CD74 have been shown to be highly prevalent in patients with ankylosing spondylitis (AS). In contrast, conflicting results have been reported on the sensitivity and specificity of anti-CD74 IgA both in patients with non-radiographic axial spondyloarthritis (nr-axSpA) as well as AS.

Objectives:

To assess the performance of anti-CD74 IgA for identification of patients classified as nr-axSpA or AS compared to non-SpA controls.

Methods:

Serum samples of patients who were classified as having axial SpA according to the ASAS classification criteria, were collected at inclusion in the Be-Giant (a Belgian observational cohort enrolling patients in 7 peripheral and an academic hospital). Patients with chronic back pain of non-inflammatory origin and rheumatoid arthritis patients without back pain served as a control group. Serum aliquots were stored immediately after sampling at -80°C until further analysis. Anti-CD74 IgA antibodies were measured using the AESKULISA SpA Detect Kit (AESKU Diagnostics, Wendelsheim, Germany) as described in (1); values are expressed in U/mL. Analyses were restricted to patients ≤ 45 years of age who were anti-TNF naïve prior to inclusion.

Results:

Table 1 shows the patients’ demographic and clinical characteristics. Mean±SD anti-CD74 IgA concentration was significantly higher in AS (18.3±11.20) and nr-axSpA (19.3±12.6) compared to controls (9.8±6.35) (Figure 1). However, anti-CD74 IgA levels were higher in males than in females (p = 0.01) and in old (≥32 y/o) vs. younger patients (p = 0.13). Anti-CD74 IgA yielded an adjusted OR (95% CI) of 1.10 (1.03 – 1.19) for discrimination of nr-axSpA from controls. Table 2, which shows the performance of anti-CD74 IgA in 4 subgroups of patients divided by age and sex, shows that the highest AUC was seen in young male nr-axSpA patients. Similar results were found on the discrimination between AS patients and controls (AUC 0.827 in young males).

Table 1.

Demographic and clinical characteristics

nr-axSpAAScontroln = 150n = 58n = 14Age, y (mean, SD)31 (6.9)32 (7.4)30 (7.0)Male, n (%)68 (45.3)26 (44.8)4 (28.5)Symptom duration, m (median, IQR)35 (13 - 98)111 (27 - 176)-HLA B27 positive, n (%)103 (68.7)48 (82.8)-Peripheral manifestations, n (%)41 (27.3)18 (31.0)-Extra-articular manifestations, n (%)32 (21.3)19 (32.8)-BASDAI (mean, SD)4.4 (1.97)4.1 (2.03)-CRP > ULN, n (%)45 (30.0)33 (56.9)-Table 2.

Performance of anti-CD74 IgA in discriminating nr-axSpA from controls, according to sex and age (young: <32 y/o). AUC= area under the curve, PPV/NPV = positive/negative predictive value, LR+ = positive likelihood ratio.

Cut-off (U/mL)AUCSensitivity (%)Specificity (%)PPV (%)NPV (%)LR+Male & young16.90.80665.892.396.248.08.6Male & old17.40.79555.692.393.850.07.2Female & young16.70.64750.092.394.441.46.5Female & old16.90.74146.892.395.742.26.0Figure 1.

Univariate comparison of anti-CD74 IgA concentrations between nr-axSpA, AS and control patients (<45 y/o).

Conclusion:

In this study, mean anti-CD74 IgA concentrations were higher in axial SpA patients compared to non-SpA controls. Application of this biomarker in young (<32 y/o) male nr-axSpA or AS patients yielded the highest sensitivity and specificity.

References:

[1]Riechers E, Baerlecken N, Baraliakos X, et al. Sensitivity and Specificity of Autoantibodies Against CD74 in Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019;71(5):729-35.

Acknowledgments:

Aesku.Diagnostics (Wendelsheim, Germany) provided the ELISA kits.

Disclosure of Interests:

Ann-Sophie De Craemer: None declared, Torsten Witte: None declared, Liselotte Deroo: None declared, Thomas Renson: None declared, Philippe Carron: None declared, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Dirk Elewaut: None declared

[Severe polyneuropathy in primary Sjögren's syndrome : Sjögren's syndrome should be considered in patients with motor neuropathy]

A 64-year-old male patient developed over a period of 20 years a peripheral neuropathy symmetrically affecting the upper and lower limbs. The histological examination of a sural nerve biopsy revealed a severe axonal neuropathy. Despite extensive laboratory investigations including immunological and metabolic tests the origin could not be identified. Finally, a Schirmer test revealed xerophthalmia. A subsequent salivary gland biopsy from the lower lip revealed a grade III lymphocytic inflammation according to Chisholm and Mason and confirmed the diagnosis of Sjögren's syndrome.

OP0047 GENOME-WIDE ASSOCIATION STUDY OF SJÖGREN’S SYNDROME IDENTIFIES TEN NEW RISK LOCI

Background:

Sjögren’s syndrome (SS) is a complex autoimmune disease with exocrine gland dysfunction leading to substantial morbidity. There are 10 published genetic susceptibility loci.

Objectives:

Our genome-wide association study (GWAS) aimed to identify additional risk loci of genome-wide significance (GWS; p<5E-08) in European-derived primary SS.

Methods:

A total of 3232 cases and 17481 controls genotyped on GWAS arrays and 619 cases and 6171 controls genotyped on ImmunoChip (IC) arrays were imputed after quality control. Logistic regression was calculated adjusting for ancestry using the first 4 principal components to identify SS-associated SNPs. GWAS and IC results were meta-analyzed using weighted Z-scores. Bayesian statistics were used to assign posterior probabilities and define credible SNP sets for each locus. Bioinformatic analyses were used to predict functionality.

Results:

Seven novel loci exceeded GWS in the GWAS analysis:NAB1,MIR146A-PTTG1,XKR6,MAPT-CRHR1,RPTOR-CHMP6-BAIAP2,TYK2andSYNGR1. Meta-analysis with IC data identified three more novel loci exceeding GWS:CD247,PRDM1-ATG5andTNFAIP3. Several additional loci with suggestive association (p<1E-05) were also identified:ADAMTSL2,CGNL1andPHRF1.

Several identified loci have reported functional implications in immune regulation and autoimmune disease. In lupus, rs2431697 correlated with rs2431098, which was shown to alterMIR146Aexpression, resulting in type I interferon pathway imbalance. Similarly,TYK2risk association reportedly drives interferon, IL10 and RET signaling pathways.PRDM1encodes Blimp-1, a master regulator of immune cell differentiation.CD247encodes the zeta subunit of the T cell receptor complex.XKR6is implicated in apoptotic cell ingestion.ATG5is also involved in apoptosis, as well as autophagy and antigen presentation.

Additional bioinformatics analyses (Haploreg, Regulome DB, ENCODE, etc.) revealed immune-relevant functional implications for each risk locus. The SS-associated credible set included variants downstream ofTNFAIP3in a region reported to abolish looping between an enhancer and theTNFAIP3promoter in lupus and a coding variant that has been shown to alter NF-kB activity and neutrophil extra-cellular traps. The rs2293765 in the 5’ UTR ofNAB1showed evidence of enhancer/promoter activities. The rs2069235 in theSYNGR1locus showed enhancer and transcription start site activities in B and T cells. The rs7210219 in theMAPT-CRHR1locus showed enhancer/promotor activities in various tissues.

Conclusion:

We have identified ten novel genetic susceptibility loci associated with SS pathology. Our finding increases the current number of GWS regions in SS patients of European origin, from 10 to 20. Future work is needed to identify and characterize the functional variants in each region.

Disclosure of Interests:

Bhuwan Khatri: None declared, Tove Ragna Reksten: None declared, Kandice L Tessneer: None declared, Astrid Rasmussen Speakers bureau: Novartis, ThermoFischer, R Hal Scofield Grant/research support from: Pfizer, Simon J. Bowman Consultant of: Astrazeneca, Biogen, BMS, Celgene, Medimmune, MTPharma, Novartis, Ono, UCB, xtlbio, Glapagos, Speakers bureau: Novartis, Joel Guthridge Grant/research support from: Xencor, Bristol Myers Squibb, DXterity, Judith A. James Grant/research support from: Progentec Diagnostics, Inc, Consultant of: Abbvie, Novartis, Jannsen, Lars Ronnblom Grant/research support from: AZ, Speakers bureau: AZ, Blake M Warner: None declared, Xavier Mariette: None declared, Roald Omdal: None declared, Javier Martin Ibanez: None declared, Maria Teruel: None declared, Janicke Liaaen Jensen: None declared, Lara A Aqrawi: None declared, Øyvind Palm: None declared, Marie Wahren-Herlenius: None declared, Torsten Witte: None declared, Roland Jonsson: None declared, Maureen Rischmueller: None declared, A Darise Farris Speakers bureau: Biogen, Marta Alarcon-Riquelme: None declared, Wan-fai Ng: None declared, Kathy L Sivils: None declared, Gunnel Nordmark: None declared, Christopher Lessard: None declared

AB1298-HPR RHEUMA-VOR: A PROOF-OF-CONCEPT NETWORK STUDY FOR THE IMPROVEMENT OF RHEUMATOLOGICAL HEALTH CARE THROUGH COORDINATED COOPERATION

Background:

Rheumatoid arthritis (RA), psoriasis arthritis (PsA) and spondyloarthritis (SpA) are the most common chronic inflammatory rheumatic diseases. For all three diseases, the so-called “window of opportunity” [1,2,4] has been identified as the decisive factor affecting the outcome.

Objectives:

The aim of the prospective study is to improve the early diagnosis of RA, PsA and SpA and thus positively impact the quality of care for patients with the support of coordinating centers.

Methods:

Primary care providers are given access to screening questionnaires to document potential early cases of RA, PsA, and SpA, based on characteristic symptoms. These are evaluated by multidisciplinary teams at the regional coordinating centers. If they fulfill the criteria for referral, patients get an appointment at a cooperating rheumatology specialist within weeks. If a rheumatic disease is diagnosed, physicians and patients receive questionnaires about sociodemographic, physilogical and psychological parameters.

In order to increase the quality of referrals, a 15-minute rheumatological consultation at the ACURA Rheumatology Center was implemented for all patients from Rhineland-Palatinate whose suspected diagnosis was confirmed by the coordination centre. In course of this, the Rheuma-VOR Screening-App will also be developed and optimized. The cooperating partners and additional information are already published [5].

Results:

Preliminary data (31 Dec 2019) are presented. In Rhineland-Palatinate, Saarland and Lower Saxony, 4942 suspected diagnoses of 1526 different referring physicians have now been reported. A total of 2578 patients were referred by the three coordination centres to one of the 49 participating rheumatological specialists. 1004 patients were diagnosed with one of the three diseases. About 306 patients have already taken the follow-up appointment after one year.

In course of a screening consultation 736 patients have been screened to date. The patients have to wait in average about 42 days from the suspected diagnosis to the rejected or confirmed rheumatological diagnosis.

Conclusion:

Although the average waiting time for all three diseases is currently almost twice as long as the 23.9 days in the Rhineland-Palatinate predecessor project ADAPTHERA which just focuses on RA, the current results are very positive compared to the national average [3]. The aim is to further increase the screening quality and screening numbers, especially in the 1-year follow-up.

Current data will be presented at the conference.

References:

[1]Boehncke WH, Menter A (2013) Burden of disease: psoriasis and psoriatic arthritis. Am J Clin Dermatol 14:377-388

[2]Claudepierre P (2014) Spondyloarthritis: a window of opportunity? Joint Bone Spine 81:197-199

[3]Lauter A, Triantafyllias K, Leiß R et al. (2019) ADAPTHERA—Statewide cross-sectoral care network for patients with early rheumatoid arthritis shows sustained remission in standard care. ZRheumatol. 78 (7): 660–669

[4]O’dell JR (2002) Treating rheumatoid arthritis early: a window of opportunity? Arthritis Rheum 46:283-285

[5]Schwarting A (2018) From ADAPTHERA to Rheuma-VOR: Concept of Coordinated Cooperation to Improve the Quality of Rheumatology Care Akt Rheumatol 43 (05): 406-409

Acknowledgments:

The authors thank all partners and participants of Rheuma-VOR

Disclosure of Interests:

Matthias Dreher: None declared, Reinhold E. Schmidt: None declared, Torsten Witte: None declared, Gunter Assmann: None declared, Kirsten Hoeper Consultant of: AbbVie, Celgene,, Speakers bureau: Abbvie, Chugai, Novartis, Lilly, Celgene, Sandoz Hexal, Konstantinos Triantafyllias: None declared, Jan Zeidler: None declared, Harald Binder: None declared, Andreas Schwarting: None declared

AB1088 NAIL PSORIASIS: THE UNDERESTIMATED DISORDER IN PSORIASIS AND PSORIASIS ARTHRITIS. CAN ULTRASOUND AND CAPILLARY MICROSCOPY IN PATIENTS WITH NAIL PSORIASIS SPEED UP OUR DIAGNOSIS AND THERAPY?

Background:

Nail psoriasis is an extreme diagnostic and therapeutic challenge and represents an enormous physical and psychological burden for affected patients.50% of patients with psoriasis vulgaris develop nail involvement (NailPso)during the course of their disease. NailPso is the strongest predictor of psoriatic arthritis (PsA). Through the synovio-enthesial concept we have learned that there is an anatomical-pathophysiological relationship between DIP joint, extensor tendon and nail matrix. We have observed in daily practice that hypervascularization (HV) in ultrasound Power Doppler (US-PD)the nail matrix may be a pathognomonic element in its own right. There are no data on this in the literature.

Objectives:

Is there a difference in the ultrasound PD examination of the DIP joint and nail area and in the capillary microscopy of the corresponding nail fold in patients with psoriasis vulgaris and nail psoriasis versus patients with psoriasis vulgaris without nail psoriasis.

Methods:

Monocentric prospective study of all consecutive patients with psoriasis vulgaris who have come to a rheumatic practice to clarify a PsA. In

addition to demographic data, assessments (PASI,DLQI,CASPAR,GEPARD, DAS28, SJ,TJ,FFBH), clinical examination, a standardized ultrasound PD examination and capillary microscopy of the affected fingertips in PsO patients suffering from nail psoriasis was performed as well as corresponding examinations of the 2nd and 3rd finger right in PsO patients without nail involvement.

Results:

79 patients could be included during the study period. Thereof 25 PsO patients without nail involvement and 44 PsO patients with nail involvement. Since the patients were examined consecutively, the difference results. There was no difference in age, BMI and sex in both groups (Pso and NailPso). The Caspar criteria as classification criteria for a PsA were positive in 65% of the NailPso patients and positive in 50% of all PsO patients without nail infestation. Hypervascularization in the US-PD examination in the area of the nail matrix could be seen significantly more frequently in NailPso compared to non-NagelPso patients. Such a difference did not exist in the HV of the extensor tendons.Capillary microscopy showed a significant difference in the number of torsions/twist capillaries in NailPso compared to Pso patients without NailPso.Hypervascularization of the nail matrix is seen significantly more frequently in patients with psoriasis of the nail than in patients without psoriasis of the nail. Such a difference does not exist in DIP joint -extensor tendon- enthesitis. At the same time, torsions are significantly more frequently seen in capillary microscopy in NailPso than in patients without NailPso.

Conclusion:

The US-PD examination is a simple and non-invasive procedure which can be performed routinely in daily practice. The hypervascularization of the nail matrix should also make one think of nail psoriasis in the early stage of PsO, in order to be able to start early an appropriate therapy for this very stigmatizing and therapeutically extremely difficult manifestation of PsO. It seems to occur independently of extensor tendon synovitis as an independent manifestation phenomenon.

The occurrence of torsions in capillary microscopy >50 % also seems to be groundbreaking for a NagelPso, whereby capillary microscopy is a temporal challenge in daily routine.

References:

§ The present study (7734-BO-S2018 Ethics Commission of the MHH, Medical School Hannover, Germany) contains parts of the PhD thesis of M.Töllner

Disclosure of Interests:

Becker-Capeller Detlef Grant/research support from: Novartis, Speakers bureau: Pfizer, Soham El-Nawab-Becker: None declared, Malo Toellner: None declared, Andreas Kleinheinz: None declared, Torsten Witte: None declared

THU0263 LUNG INVOLVEMENT IN PRIMARY SJÖGREN SYNDROME – AN UNDER-DIAGNOSED ENTITY

Background:

Interstitial lung disease (ILD) represents a frequent extra-glandular manifestation of primary Sjögren’s Syndrome (pSS). Limited published data regarding phenotyping and treatment exists. Advances in managing specific ILD phenotypes have not been comprehensively explored in patients with coexisting pSS.

Objectives:

This retrospective study aimed to phenotype lung diseases occurring in a well-described pSS cohort and describe treatment course and outcomes.

Methods:

Between April 2018 and September 2019, all pSS patients attending our Outpatient clinic were screened for possible lung involvement. Clinical, laboratory and computer tomography (CT) findings were analysed. Patients were classified according to CT findings into 5 groups: usual interstitial pneumonia (UIP), non-specific interstitial pneumonia (NSIP), desquamative interstitial pneumonia (DIP), combined pulmonary fibrosis and emphysema (CPFE) and unspecific-ILD.

Results:

Lung involvement was confirmed in 24/240 patients (10%). Clinically manifest pSS occurred later in patients with ILD vs. non-ILD (53.2 [42.0-61.7]vs.62.3 [55.6-68.8] years; p=0.0016). The commonest phenotype was UIP n=10 (41%), followed by NSIP n=7 (29%), DIP n=2 (8%), CPFE n=2 (8%) and unspecific-ILD n=3 (13%). Forced vital capacity (FVC) and carbon monoxide diffusion capacity (DLCO) appeared lower in UIP and DIP, without reaching a significant difference. Treatment focused universally on intensified immunosuppression, with 12/24 patients (50%) receiving cyclophosphamide. No anti-fibrotic treatments were used. Follow-up was median 13.2 [7.9-72.3] months, during which 6/24 (25%) patients exhibited a further decline in FVC. No deaths occurred.

Conclusion:

Lung involvement in pSS is heterogeneous. Better phenotyping and tailored treatment may improve outcomes and requires further evaluation in larger prospective studies.

Disclosure of Interests:

None declared

Autoantibodies against P29ING4 are associated with complex regional pain syndrome

INTRODUCTION

Complex regional pain syndrome (CRPS) is a complication following trauma or surgery and may be difficult to diagnose since biomarkers are lacking. Using protein array technology, we found antibodies binding to p29ING4, which we further characterized using ELISA.

METHODS

Thirty-six sera of early-stage type 1 CRPS, 66 sera of rheumatoid arthritis (RA), 53 sera of axial spondyloarthritis (axSpA), 29 sera of psoriatic arthritis (PsA), 22 sera of patients after radial fractures (trauma control), and 100 sera of blood donors (BD) were analyzed for anti-p29ING4. We established ELISAs with 7 different antigens and using different secondary antibodies binding to IgG, IgG1, IgG2, IgG3, IgG4, IgA, and IgM, and 2 different tests to detect immune complexes (IC) of p29ING4 and IgG or IgG1.

RESULTS

The highest likelihood ratios versus CRPS and trauma control were observed considering the A1-23 (sensitivity 19%, specificity 100%, LR > 19) using IgG as a secondary antibody, the A120-165 (sensitivity 17%, specificity 100%, LR = 17) using IgG as a secondary antibody and the A120-165 (sensitivity 31%, specificity 95%, LR = 6.2) using IgA as a secondary antibody. IC of p29ING4 and IgG were present in 11/36 (31%) CRPS sera, 17/64 (27%) RA sera, 13/53 (25%) SpA sera, 5/29 (17%) PsA sera, 1/22 (5%) trauma control sera, and 4/100 (4%) sera of BD. IC of p29ING4 and IgG1 were present in 14/36 (39%) CRPS sera, 19/64 (30%) RA sera, 13/53 (25%) SpA, 1/29 (3%) PsA, 2/22 (9%) trauma control, and 4/100 (4%) of the BD sera.

CONCLUSION

Due to the lack of other biomarkers of type 1 CRPS, P29ING4 autoantibodies could be helpful in its diagnostic work-up.

Thermally Induced Crossover from 2D to 1D Behavior in an Array of Atomic Wires: Silicon Dangling-Bond Solitons in Si(553)-Au

The self-assembly of submonolayer amounts of Au on the densely stepped Si(553) surface creates an array of closely spaced "atomic wires" separated by 1.5 nm. At low temperature, charge transfer between the terraces and the row of silicon dangling bonds at the step edges leads to a charge-ordered state within the row of dangling bonds with ×3 periodicity. Interactions between the dangling bonds lead to their ordering into a fully two-dimensional (2D) array with centered registry between adjacent steps. We show that as the temperature is raised, soliton defects are created within each step edge. The concentration of solitons rises with increasing temperature and eventually destroys the 2D order by decoupling the step edges, reducing the effective dimensionality of the system to 1D. This crossover from higher to lower dimensionality is unexpected and, indeed, opposite to the behavior in other systems.

[Treatment of systemic sclerosis-associated interstitial lung disease]

BACKGROUND

Systemic sclerosis (SSc) is a fibrosing autoimmune disease of the connective tissue. In addition to skin fibrosis, pulmonary involvement and interstitial lung disease (ILD) in particular are the most common and severe manifestations of SSc. The disease is associated with a substantial risk of morbidity and mortality, especially in progressive ILD. In the last 5 years new treatment concepts for SSc-ILD have been investigated in numerous clinical studies.

MATERIAL AND METHODS

This review is based on a literature search in PubMed, focusing on the most relevant papers published up to the end of 2018 with the keywords "SSc" and "treatment".

RESULTS

The treatment of SSc-ILD has changed over the last few years due to the results of many clinical studies. The updated guidelines of the European League Against Rheumatism (EULAR) recommend the use of cyclophosphamide or hematopoietic stem cell transplantation. Data for a positive influence on SSc-ILD are also available for mycophenolate, tocilizumab and anabasum. Because of the pathophysiological similarities to idiopathic pulmonary fibrosis, the use of the antifibrotic agents nintedanib and pirfenidone is currently being investigated in randomized, multicenter clinical trials and could be a novel and promising therapeutic strategy.

CONCLUSION

Current drug studies may provide innovative therapeutic perspectives for SSc-ILD and could significantly improve the prognosis of affected patients in the future.

Decelerated lattice excitation and absence of bulk phonon modes at surfaces: Ultra-fast electron diffraction from Bi(111) surface upon fs-laser excitation

Ultrafast reflection high-energy electron diffraction is employed to follow the lattice excitation of a Bi(111) surface upon irradiation with a femtosecond laser pulse. The thermal motion of the atoms is analyzed through the Debye–Waller effect. While the Bi bulk is heated on time scales of 2 to 4 ps, we observe that the excitation of vibrational motion of the surface atoms occurs much slower with a time constant of 12 ps. This transient nonequilibrium situation is attributed to the weak coupling between bulk and surface phonon modes which hampers the energy flow between the two subsystems. From the absence of a fast component in the transient diffraction intensity, it is in addition concluded that truncated bulk phonon modes are absent at the surface.

[Early recognition and screening consultation: a necessary way to improve early detection and treatment in rheumatology? : Overview of the early recognition and screening consultation models for rheumatic and musculoskeletal diseases in Germany]

In order to reduce the prognostically relevant time interval between the initial manifestation of a rheumatic and musculoskeletal disease and diagnosis as well as the consecutive initiation of an appropriate treatment, several rheumatological centers in Germany have improved the access to initial rheumatologic evaluation by establishing early recognition/screening clinics at their respective sites. Corresponding models located at Altoetting·Burghausen, Bad Pyrmont, Berlin Buch, Duesseldorf, Heidelberg, Herne, Mannheim as well as supraregional/multicenter initiatives Rheuma Rapid, RhePort and Rheuma-VOR are presented in this overview along with the respective characteristics, potential advantages and disadvantages, but also first evaluation results of several models. The aim of this publication is to promote early detection of rheumatic and musculoskeletal diseases as one of the most important challenges in current rheumatology by encouraging further rheumatologic centers and practices to launch their own early recognition/screening consultation model on the basis of aspects presented herein.

[Experiences and results from Rheuma-VOR]

Rheumatoid arthritis, psoriatic arthritis and axial spondylarthritis are the most common chronic autoimmune rheumatic diseases. For all three diseases an early diagnosis and initiation of treatment is crucial. The proof of concept network study "Rheuma-VOR" is a further developed version of the predecessor project ADAPTHERA and was extended to several federal states. The aim of this prospective study is to improve the early diagnosis of rheumatoid arthritis, psoriatic arthritis and axial spondylarthritis and thus positively impact the quality of care for patients with the help of multidisciplinary coordinating centers. To date 3710 disease-specific questionnaires from patients with the suspected diagnosis of rheumatoid arthritis, psoriatic arthritis or axial spondylarthritis from 1298 different primary care providers were registered in the multidisciplinary coordination centers. A total of 1958 appointments were made with 1 of the 53 participating rheumatology specialists. In 876 patients, 1 of the 3 rheumatic diseases was diagnosed in an early stage. The waiting period was on average 42.5 days depending on the federal state, which is well below the nationwide average. It should also be noted that the coordinated cooperation and risk stratification of the Rheuma-VOR coordination centers relieved the capacity of rheumatology specialists by 1281 appointments (34.5%). In addition, the 2‑week Rheuma Bus Tour and the accompanying initiatives in Rhineland-Palatinate (Rheuma-VOR screening app and the triage consultation) are showing first promising positive results.

Condensation of ground state from a supercooled phase in the Si(111)-(4 × 1) → (8 × 2)-indium atomic wire system

Strong optical irradiation of indium atomic wires on a Si(111) surface causes the nonthermal structural transition from the (8 × 2) reconstructed ground state to an excited (4 × 1) state. The immediate recovery of the system to the ground state is hindered by an energy barrier for the collective motion of the indium atoms along the reaction coordinate from the (4 × 1) to the (8 × 2) state. This metastable, supercooled state can only recover through nucleation of the ground state at defects like adsorbates or step edges. Subsequently, a recovery front propagates with constant velocity across the surface and the (8 × 2) ground state is reinstated. In a combined femtosecond electron diffraction and photoelectron emission microscopy study, we determined—based on the step morphology—a velocity of this recovery front of ∼100 m/s.

Pulsed electron gun for electron diffraction at surfaces with femtosecond temporal resolution and high coherence length

We present a newly designed 30 kV pulsed electron gun for ultrafast electron diffraction suited for pump-probe setups driven by femtosecond laser pulses. The electron gun can be operated both in transmission and reflection geometry. A robust design with a back illuminated Au photocathode, extraction fields of 7.5 kV/mm, and a magnetic focus lens ensures reliable daily use. Magnetic deflectors allow for beam alignment and characterization. Focusing of the UV pulse on the photocathode results in a small source size of photoemitted electrons and thus a high transverse coherence length of more than 50 nm in diffraction. A low difference of ΔE = 0.1 eV between the work function of the 10 nm Au photocathode and photon energy of the frequency tripled UV laser pulses results in an instrumental temporal resolution of 330 fs full width at half maximum. This resolution is discussed with respect to the number of electrons per pulse.

Non-equilibrium lattice dynamics of one-dimensional In chains on Si(111) upon ultrafast optical excitation

The photoinduced structural dynamics of the atomic wire system on the Si(111)-In surface has been studied by ultrafast electron diffraction in reflection geometry. Upon intense fs-laser excitation, this system can be driven in around 1 ps from the insulating [Formula: see text] reconstructed low temperature phase to a metastable metallic [Formula: see text] reconstructed high temperature phase. Subsequent to the structural transition, the surface heats up on a 6 times slower timescale as determined from a transient Debye-Waller analysis of the diffraction spots. From a comparison with the structural response of the high temperature [Formula: see text] phase, we conclude that electron-phonon coupling is responsible for the slow energy transfer from the excited electron system to the lattice. The significant difference in timescales is evidence that the photoinduced structural transition is non-thermally driven.

[Immunological principles of IgG4 related diseases]

In contrast to the other IgG subclasses, IgG4 does not bind to low affinity Fc receptors or activate the classical complement pathway. In addition, it is unstable and can dissociate into two hemimolecules; therefore, IgG4 most likely has an immunosuppressive role. On the other hand, there a few examples of an immunostimulatory role of IgG4 antibodies; therefore, the function of IgG4 in IgG4 related diseases is not yet entirely clear. The trigger factors of IgG4 related diseases (allergic or autoimmune) are still under debate. The activation of T helper (Th) 2 and regulatory T cells has been shown to be important in the pathophysiology of IgG4 related diseases as they produce cytokines which contribute to the formation of IgG4 and to fibrosis of various tissues.

[Magnetic resonance imaging (MRI) diagnostics in axial spondyloarthritis]

BACKGROUND

Axial spondyloarthritis (axSpA) is a frequent disorder, which is difficult to diagnose in the early phase. Currently, magnetic resonance imaging (MRI) of the sacroiliac joints and the spine is frequently applied in this phase, when conventional X rays still provide inconclusive results.

OBJECTIVE

To explain the typical pathological results and the role of MRI in diagnosing axSpA.

RESULTS

The use of MRI of the sacroiliac joints plays a central role in the assessment of the Spondyloarthritis International Association Society (ASAS) classification criteria of axSpA. Bone marrow edema is central to the definition of a positive MRI of the sacroiliac joints. In addition, chronic changes in the sacroiliac joints, such as fat depositions and erosion are taken into account in making the diagnosis of axSpA. When the results are not clear, an additional MRI of the area of the spine in which the patient reports the most pronounced complaints can be performed. A bone marrow edema in at least three vertebral edges can be associated with axSpA.

CONCLUSION

The MRI investigation of the sacroiliac joints has evolved into one of the most important methods in diagnosing axSpA.

[Therapeutic administration of immunoglobulins]

BACKGROUND

Intravenously administered immunoglobulins have multiple modes of action that are anti-inflammatory. They can therefore be beneficial in a number of autoimmune disorders.

OBJECTIVE

The aim of this article is to analyze and summarize studies on the administration of intravenous immunoglobulins in rheumatological diseases.

METHODS

A selective search and analysis of the literature was carried out related to the mode of action and efficacy of intravenous immunoglobulins in rheumatological diseases.

RESULTS AND CONCLUSION

Intravenous immunoglobulins have a broad mode of action and can therefore be beneficial in almost all autoimmune diseases. Conditions in which they are of special benefit include immunothrombopenia (ITP), Kawasaki disease and idiopathic inflammatory myopathies. In rare situations, they may also be indicated in systemic lupus erythematosus (SLE), Sjögren's syndrome and neuropathies, catastrophic antiphospholipid syndrome (APS), scleroderma, antineutrophil cytoplasmic antibody (ANCA) associated vasculitis, pyoderma gangrenosum and scleromyxedema. Severe adverse events are rare. In view of the high costs of the therapy, intravenous immunoglobulins are mostly applied in emergency situations, as salvage therapy when other standard therapies have failed or when severe infections are a contraindication to the administration of immunosuppressants.

[Musculoskeletal-related chest pain]

BACKGROUND

Approximately 10-50% of chest pains are caused by musculoskeletal disorders. The association is twice as frequent in primary care as in emergency admissions.

AIM

This article provides an overview of the most important musculoskeletal causes of chest pain and on the diagnostics and therapy.

METHODS

A selective search and analysis of the literature related to the topic of musculoskeletal causes of chest pain were carried out.

RESULTS AND CONCLUSION

Non-inflammatory diseases, such as costochondritis and fibromyalgia are frequent causes of chest pain. Inflammatory diseases, such as rheumatoid arthritis, spondyloarthritis and systemic lupus erythematosus are much less common but are more severe conditions and therefore have to be diagnosed and treated. The diagnostics and treatment often necessitate interdisciplinary approaches. Chest pain caused by musculoskeletal diseases always represents a diagnosis by exclusion of other severe diseases of the heart, lungs and stomach. Physiotherapeutic and physical treatment measures are particularly important, including manual therapy, transcutaneous electrical stimulation and stabilization exercises, especially for functional myofascial disorders.

Breast cancer in systemic lupus

Objective There is a decreased breast cancer risk in systemic lupus erythematosus (SLE) versus the general population. We assessed a large sample of SLE patients, evaluating demographic and clinical characteristics and breast cancer risk. Methods We performed case-cohort analyses within a multi-center international SLE sample. We calculated the breast cancer hazard ratio (HR) in female SLE patients, relative to demographics, reproductive history, family history of breast cancer, and time-dependent measures of anti-dsDNA positivity, cumulative disease activity, and drugs, adjusted for SLE duration. Results There were 86 SLE breast cancers and 4498 female SLE cancer-free controls. Patients were followed on average for 7.6 years. Versus controls, SLE breast cancer cases tended to be white and older. Breast cancer cases were similar to controls regarding anti-dsDNA positivity, disease activity, and most drug exposures over time. In univariate and multivariate models, the principal factor associated with breast cancers was older age at cohort entry. Conclusions There was little evidence that breast cancer risk in this SLE sample was strongly driven by any of the clinical factors that we studied. Further search for factors that determine the lower risk of breast cancer in SLE may be warranted.

[Immunological principles of IgG4 related diseases]

In contrast to the other IgG subclasses, IgG4 does not bind to low affinity Fc receptors or activate the classical complement pathway. In addition, it is unstable and can dissociate into two hemimolecules; therefore, IgG4 most likely has an immunosuppressive role. On the other hand, there a few examples of an immunostimulatory role of IgG4 antibodies; therefore, the function of IgG4 in IgG4 related diseases is not yet entirely clear. The trigger factors of IgG4 related diseases (allergic or autoimmune) are still under debate. The activation of T helper (Th) 2 and regulatory T cells has been shown to be important in the pathophysiology of IgG4 related diseases as they produce cytokines which contribute to the formation of IgG4 and to fibrosis of various tissues.