IMPACT OF CHRONIC KIDNEY DISEASE IN PATIENTS WITH AS USING BIOLOGIC AGENTS

BackgroundAlthough renal involvement is an rare extra-articular involvement in patients with ankylosing spondylitis (AS), medications and accopamyning comorbidities may adversly affect renal functions [1].ObjectivesTo determine the frequency and impact of CKD in patients with AS using biologic disease modyfying anti-rheumatic drugs (bDMARDs).MethodsBetween 2005 and November 2021, 3207 patients diagnosed with AS according to the modified New York criteria were enrolled in the Hacettepe University biological database (HUR-BIO). The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guideline was used for the definition of CKD to evaluate the renal function of patients. Glomerular filtration rate (GFR) was calculated with the MDRD (modified Modification of Diet in Renal Disease) formula, taking into account the creatinine value, age and gender parameters of the patients [2]. CKD was detected in 39 (1,2%) patients. Age-sex matched 41 non-CKD AS patients were selected as the control group. Demographic and clinical characteristics and mortality rates of AS patients with and without CKD were compared.ResultsOf 39 AS-CKD patients, 25 (64.1%) had CKD before the initation of bDMARD and and 14 (35.8%) developed CKD during follow-up after treatment was started. Patients with AS-CKD had longer duration of symptoms and disease (Table 1). Comorbidities such as hypertension, coronary artery disease and amyloidosis were more prevalent in patients with AS-CKD. At a median follow-up of 2.48(0.1-20.1) years, mortality was observed in 11(28.2%) patients in the AS-CKD group, while no mortality was observed in the age-sex matched AS-nonCKD group (p<0.001, Figure 1). The mortality rate in patients with AS-CKD was 12.6 per 1000 patient-years, and 4 (10.2%) of deaths were during the COVID-19 pandemia.Figure 1.Table 1.AS-CKD group (n=39)AS-nonCKD group (n=41)PTotal AS patients, (n=3207)Age, mean(SD), years68.2 (12.0)58.8(12.6)-47.9±(11.2)Male, n(%)27 (69.2)27(65.9)-1716(53.5)53.1)Symptom duration, years median (min-max)20 (5-42)11(2-30)0.0110(1-44)Disease duration, years median (min-max)14,5(5-42)7(1-29)0.046(1-37)HLA-B27 positivity, n(%)13(33.3)12(29.2)0.5826/2014(41.0)Uveitis, n(%)6/354/360.2339/2946(11.5)Inflammatory bowel disease, n(%)4/353/360.4135/2946(4.58)Smoking, ever, n(%)22/34 (64.7)20/36(55.5)0.31781/2942(60.5)BMI (kg/m2), mean(SD)28 (6.08)28.2(5.01)0.828.1(5.5)Amiloidosis, n(%)14/36(38.9)1(2.4)<0.00133/2949(1.11)Comotbidities n(%)• Diabetes Mellitus,7/34(20.6)4/36(11.1)0.2199/2949(6.7)• Hypertension27/34(79.4)9/36(25)<0.001442/2949(14.9)• CAD8/21(38.1)1/25(4)0.005110/1882(5.8)• COPD5/21(23.8)0/240.004117/1774(6.59)CRP, med(min-max)1.6(0.4-12.4)1.77(0.1-23.6)0.81.07(0.1-45)• at the initiation of bDMARDs, at the last visit,0.7(0.16-14)0.55(0.1-7.5)0.30.5(0.1-14)ESR, med(min-max)• at the initiation of bDMARDs,48(12-140)30(2-96)0.119(1-140)• at the last visit, med(min-max)25(3-93)15(2-70)0.113(1-110)BASDAI, mean (SD)• At the initiation of bDMARDs4.5(±2.1) 5.46(±2.07) 0.5 5.7(±2.04) • At the last vizit3.94(±2.35)2.95(±2.33)0.093.69(±2.5)CAD: Coronary artery disease, COPD: Chronic Obstructive pulmonary disease, BMI: Body mass index, BASDAI: Bath AS Disease Activity IndexConclusionBoth comorbid disease burden and mortality seem to be increased in patients with AS-CKD. Increased mortality was more pronounced during the COVID-19 pandemia.References[1]Coşkun, B.N., et al., Anti-TNF treatment in ankylosing spondylitis patients with chronic kidney disease: Is it effective and safe? Eur J Rheumatol, 2022. 9(2): p. 68-74.[2]Stevens, P.E. and A. Levin, Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med, 2013. 158(11): p. 825-30.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

The effect of level of doing sports activities and attitude towards recreational activities on burnout level and COVID-19 phobia in physicians

It has been recommended to implement physically active lifestyles against the negative consequences of the COVID-19 pandemic. During the pandemic process, many healthcare professionals had to lead a stressful life due to long hours of intensive healthcare. This situation directly affected the burnout levels of physicians as well as indirectly affected patients seeking treatment. The goal of this study was to look into the effects of physicians' levels of participation in sports, their attitudes toward sporting recreational activities, and the effects of COVID-19 phobias on burnout. 272 physicians participated in the study. The Health Belief Scale Regarding Sports Recreational Activities (HBSSRA), Maslach Burnout Scale (MBI), and COVID-19 Phobia Scale (C19P-S) were used during data collection. Spearman correlation coefficient was used for correlation analysis, Kruskal-Wallis test was used to compare groups, and logistic regression analysis was used to establish a model. MBI total and emotional exhaustion scores were significantly different according to the physicians' participation levels in sportive activities (P=0.740, P=0.136). Statistically significant correlation was found between HBSSRA and MBI total scores (r=-0.313, P=0.009). The probability of emotional exhaustion was 1.45 times higher in physicians with low level of participation in sports activities. The increase in HBSSRA scores had a protective effect on emotional burnout (P=0.028, OR: 0.72). We are hopeful that the findings obtained from physicians will highlight the importance of sports and recreational activities, paving the way for improvement strategies that will benefit those who are most affected by the COVID-19 crisis.

THE BIOPSYCHOSOCIAL-BASED EXERCISE MODEL VIA TELEREHABILITATION in PATIENTS with INFLAMMATORY and NON-INFLAMMATORY RHEUMATIC DISEASES: A PROSPECTIVE COHORT STUDY during the COVID-19 PANDEMIC

Background: During the COVID-19 pandemic, the patients with rheumatic disease in the biopsychosocial perspective have been adversely affected by social isolation, uncertainty, and the thought that their chronic disease will worsen and increase in their symptoms. ACR/EULAR (American College of Rheumatology/European League Against Rheumatism) defnes recommendations about continuing current pharmacotherapy and the signifcance of the biopsychosocial approach and exercise for patients with rheumatic diseases during a COVID-19 infection 1, 2. Objectives: This study aims to investigate the effectiveness of the biopsychoso-cial exercise performed by telerehabilitation on biopsychosocial status, general health status, and anxiety-depression levels in the patients with infammatory and non-infammatory rheumatic diseases. Methods: Fourteen patients with infammatory rheumatic diseases (rheumatoid arthritis: 4;ankylosing spondylitis: 4;sjogren's syndrome: 3;polymyalgia rheumatica: 2;and vasculitis: 1) and eight patients with non-infammatory rheumatic diseases (fbromyalgia: 6;and osteoarthritis: 2) performed a biopsychoso-cial-based exercise model (named as 'Bilişsel Egzersiz Terapi Yaklaşimi'-(BETY) in original;'Cognitive Exercise Therapy Approach' in English) via telerehabilita-tion continued for three sessions per week for 12 months 3. Outcome measures were Health Assessment Questionnaire (HAQ), Hospital Anxiety and Depression Scale (HADS), and BETY-Biopsychosocial Questionnaire (BETY-BQ) 4. All outcomes were measured baseline and at the 12th month. The Wilcoxon's test was used for statistical analysis. Results: All of the 22 patients were female. The mean age was 57.4 and 55.8 years in the infammatory and non-infammatory rheumatic diseases groups respectively, and they had a mean BMI of 25.9 and 25.3 kg/m2. There was no signifcant difference by time for HAQ score (p = 0.125), HADS anxiety and depression (p = 0.916 and p = 0.663, respectively), and BETY-BQ score (p = 0.753) between the baseline and at the 12th month follow-up in the patients with infammatory rheumatic diseases. Similarly, in the patients with non-in-fammatory rheumatic diseases, there was no signifcant difference by time for HAQ score (p = 0.546), HADS anxiety and depression (p = 0.343 and p = 0.527, respectively), and BETY-BQ score (p = 0.068) between the baseline and at the 12th month follow-up. Conclusion: This study showed that biopsychosocial-based exercise through real-time telerehabilitation was able to maintain their conditions before pandemic in biopsychosocial status, general health, and anxiety-depression levels on the patients with infammatory and non-infammatory rheumatic diseases during COVID-19 pandemic period in one-year follow-up.

CARDIOVASCULAR EVENT, VENOUS THROMBOEMBOLIZM, and INFECTION RISK with TOFACITINIB in RHEUMATOID ARTHRITIS PATIENTS AGED ≥ 60 YEARS

Background: Tofacitinib is a targeted synthetic DMARD that selectively inhibits Janus kinase (JAK) and is approved for the treatment of RA by the FDA in 2012. In recent years, an important safety concern related to incidence of adverse events after treatment with tofacitinib has emerged. Objectives: To evaluate the risk of major adverse cardiovascular events (MACE), venous thromboembolism (pulmonary embolism or deep vein thrombosis), serious infections requiring hospitalization, and herpes zoster with tofacitinib in RA patients aged ≥ 60 years. Methods: HUR-BIO (Hacettepe University Rheumatology Biologic Registry) is a single center biological and targeted synthetic DMARD registry since 2005. We analyzed RA patients aged ≥ 60 years receiving tofacitinib who had at least 1 control visit registered in the HURBIO database. Phone calls were made with these patients for the current health status information until the end of January 2022. The data of the patients who lost the follow-up in our clinic were obtained from the personal health record system of the Republic of Turkey Ministry of Health by patients' permission. The coprimary end points were adjudicated MACE, VTE, serious infections, and herpes zoster. These events were identi-fed using patients' medical records. Crude incidence rates were expressed in patients with frst events per 100 patient-years, with two-sided 95% confdence intervals. Results: A total of 132 RA patients (109, 82.6% female) aged ≥ 60 years received tofacitinib at a dose of 5 mg twice daily. The median (25-75% percentiles) age was 67 (63-73) years and median duration under tofacitinib was 18 (5-33) months. Approximately 70% of patients were biologically naive. During a median follow-up of 1. 5 years, the incidences of serious infection requiring hospitalization and herpes zoster were higher (5.5% [95%CI 3.12-9.86] and 3.4% [1.67-7.17], respectively) while there was no increase in the incidences of MACE and VTE. The causes for hospitalization were as follows: COVID-19 (n=4), pneumonia (n=3), soft-tissue infection (n=3), and GIS infection (n=1). Tw o of these patients deceased. Conclusion: Older patients with RA are at increased infection risk because of age and comorbid conditions. Although adverse events are reported with 10 mg tofacitinib twice daily, clinicians should be careful against the risk of infection at a dose of 5 mg twice daily, especially in elderly patients.

COVID-19 and force majeure clauses: An examination of arbitral tribunal's awards

The coronavirus (COVID-19) pandemic has taken a toll on people all across the world in various aspects. The severe consequences of this pandemic can be seen in international trade and commercial contracts. The underlying principle of contract law is that the parties are bound by the promises given under an agreement;however, events such as COVID-19 affect the parties' performance of contractual duties. The harsh measures, such as prohibition on importation and exportation of goods or travel bans, have seriously affected the parties' performances. In such situations, force majeure clauses, which serve as an exemption from non-performance, come into play. This article aims to reveal how COVID-19 will be assessed in terms of force majeure and the possible attitudes of arbitral tribunals towards these cases. This assessment is undertaken in light of force majeure clauses laid under the Convention on Contracts for the International Sales of Goods, the Unidroit Principles of International Commercial Contracts, and the International Chamber of Commerce's 2020 Force Majeure Clause. © 2020 The Author(s) (2020). Published by Oxford University Press on behalf of UNIDROIT. All rights reserved. For permissions, please email journals.permissions@oup.com.