Dutch Arthritis Foundation Research Articles

Physical therapy in patients with rheumatoid arthritis and axial spondyloarthritis: the patients’ perspective

Objective To assess the duration, frequency, and content of individual physical therapy (PT) in patients with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA). Method In this cross-sectional study, an electronic questionnaire aimed at people with RA and axSpA was distributed through various communication channels of the Dutch Arthritis Foundation. It comprised questions on sociodemographic and health characteristics, received PT (currently and/or in the past year) and, if applicable, its duration, frequency, and content (active exercises, manual treatment, physical modalities, and/or counselling/education). Results The study included 257 and 94 patients with self-reported diagnoses of RA and axSpA, of whom 163 (63%) and 77 (82%) currently or had recently received individual PT. The duration of individual PT was long-term (> 3 months) in 79% of RA and 83% of axSpA patients, with an average frequency of once per week in most. Although active exercises and counselling/education were each reported by ≥ 73% of the patients with RA and axSpA who received long-term individual PT, passive treatment modalities were also often offered (≥ 89%), in particular massage, kinesiotaping, and/or passive mobilization. The same pattern was seen in patients receiving short-term PT. Conclusion The majority of patients with RA and axSpA received PT currently or in the past year, usually individually, long-term, and at a frequency of once a week. Although active exercises and education are recommended in guidelines, passive treatment options that are not advised were relatively often reported. An implementation study to identify barriers and facilitators regarding adherence to clinical practice guidelines seems warranted.

P271 To what extent are baseline characteristics in biologic-experienced patients with psoriatic arthritis associated with achievement of minimal disease activity at week 24 of guselkumab treatment: a post hoc analysis of the phase IIIb COSMOS clinical trial

Abstract Background/Aims Guselkumab (GUS), a human monoclonal antibody targeting the interleukin-23p19-subunit, has demonstrated efficacy at Week 24 (W24) in the Phase IIIb COSMOS clinical trial of patients with active psoriatic arthritis (PsA) and inadequate response or intolerance to one or two tumour necrosis factor inhibitors (TNFis). This post hoc analysis aimed to identify predictors of minimal disease activity (MDA) with GUS at W24 in this population. Methods Multiple logistic regression analysis was performed to identify potential predictors of MDA with GUS at W24 in TNFi-refractory patients with PsA; odds ratios, 95% confidence intervals and p-values were calculated. Baseline characteristics assessed as predictors included sex, body mass index (BMI), C-reactive protein (CRP), other medication use and disease duration; clinical features included tender and swollen joint counts (TJC/SJC), affected joint location, dactylitis, enthesitis, spondylitis, Psoriasis Area Severity Index (PASI) score and psoriasis (PsO) localisation (Table). Missing data for MDA at W24 were imputed as non-response; missing baseline values were imputed for two patients. Results Patients (n = 187; female, 54.6%; mean disease duration, 8.3 years) had mean TJC 0-68 and SJC 0-66 of 21.0 and 10.3, respectively, mean PASI score of 11.6, and mean BMI of 28.9; 67.9% had enthesitis and 35.8% had dactylitis at baseline. One prior TNFi had been received by 88.2% of patients, with two received by 11.8%. At W24, 17.1% (32/187) of patients achieved MDA. Wrist involvement (p = 0.031) and scalp PsO (p = 0.049) were positive predictors of MDA. Women were significantly less likely to achieve MDA vs. men; other negative predictors included hand small joints or shoulder involvement and hand/foot PsO (all p < 0.05). Age, BMI, CRP, TJC/SJC, HAQ-DI, PASI, spondylitis, enthesitis, dactylitis, other medication and number of prior TNFis were not predictive of MDA (Table). Conclusion Baseline characteristics and clinical features may be positively (wrist involvement, scalp PsO) or negatively (female sex, hand small joints or shoulder involvement, hand/foot PsO) associated with achieving MDA with GUS at W24 in a TNFi-refractory population. Though the low patient number limits the generalisability of this analysis, assessment of Week 48 data may further elucidate potential predictors of MDA after longer-term treatment. Disclosure W. Tillett: Other; William Tillett has received research grants and consulting or speaker fees from AbbVie, Amgen, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer and UCB. S. Ohrndorf: Other; Sarah Ohrndorf has received fees from AbbVie, BMS, Janssen, Novartis and Pfizer. J. Ramírez: Other; Julio Ramírez has received consulting or speaker fees from AbbVie, Amgen, Eli Lilly, Janssen, Novartis and UCB. M. Neuhold: Other; Marlies Neuhold is an employee of Janssen and owns stocks in Johnson & Johnson. R. Wapenaar: Other; Robert Wapenaar is an employee of Janssen and owns stocks in Johnson & Johnson. E. Theander: Other; Elke Theander is an employee of Janssen and owns stocks in Johnson & Johnson. C. Contre: Other; Christine Contre is an employee of Janssen and owns stocks in Johnson & Johnson. M. Sharaf: Other; Mohamed Sharaf is an employee of Janssen and owns stocks in Johnson & Johnson. M. Shawi: Other; May Shawi is an employee of Janssen and owns stocks in Johnson & Johnson. M. Vis: Other; Marijn Vis has received research grants and consulting or speaker fees from AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer, UCB and the Dutch Arthritis Foundation.

Senescent Progenitor Cells in the Skin of Patients with Cutaneous Lupus Erythematosus

Senescent Progenitor Cells in the Skin of Patients with Cutaneous Lupus Erythematosus

Long-term efficacy of low-dose radiation therapy on symptoms in patients with knee and hand osteoarthritis: follow-up results of two parallel randomised, sham-controlled trials.

Low-dose radiation therapy is commonly used as treatment for benign diseases, including osteoarthritis, in some countries (eg, Germany). We have previously presented our 3-month follow-up results of two randomised sham-controlled trials, in which no substantial effects of low-dose radiation therapy on clinical outcomes were seen in patients with knee and hand osteoarthritis. Here we report the 6-month and 12-month results of these studies. In one randomised sham-controlled trial, patients with knee osteoarthrosis were recruited, and in the other trial patients with hand osteoarthritis were recruited. All patients were recruited from the department of rheumatology of Sint Maartenskliniek (Nijmegen, The Netherlands) and the trials were undertaken in parallel. Patients were eligible if they had knee or hand osteoarthritis according to American College of Rheumatology (ACR) criteria, had a pain score of 5 or more on a 0-10 scale for at least 15 of the past 30 days, and did not meet 2011 modified ACR criteria for fibromyalgia. In each study, patients were randomly assigned (1:1), stratified by pain score (<8 vs ≥8) using a computer-generated randomisation list and stratified block randomisation, to low-dose radiation therapy (six fractions of 1 Gy low-dose radiation therapy in 2 weeks) or sham (six sessions with 0 Gy of radiation therapy in 2 weeks) intervention. Patients and researchers involved in patient contact or assessments were masked to group allocation, whereas the radiotherapy technologist who did the treatment was unmasked. Patients completed questionnaires (numeric rating scale of patients' global assessment and validated measures for pain and functioning) at baseline and at 1, 2, 3, 6, and 12 months after starting treatment. The primary outcome was the proportion of participants who responded according to the Outcome Measures in Rheumatology Osteoarthritis Research Society International responder criteria at 3 months, which has been reported previously. Here we report the proportion of participants who responded at 6 months and 12 months, and other clinical outcomes of pain, functioning, and patients' global assessment of their symptoms. We used logistic and linear mixed-models analyses to assess differences in number of responders and continuous outcomes. Safety was assessed in all participants who received at least one fraction of low-dose radiation or sham treatment. This study is registered with the Netherlands Trial Registry, NTR4574, and is closed to accrual. Between Oct 14, 2015, and May 3, 2017, 213 patients were screened for inclusion for the knee osteoarthritis study, of whom 55 were eligible and randomly assigned to low-dose radiation therapy (n=27) or sham intervention (n=28). In parallel, for the hand osteoarthritis study, 368 patients were screened and 56 were randomly assigned low-dose radiation (n=28) or sham intervention (n=28). Some minor imbalances in baseline demographic characteristics in terms of sex and age were seen in both the knee and hand cohorts. In the knee osteoarthritis cohort, 48 patients were assessible at 6 months and 50 were assessible at 12 months, and in the hand osteoarthritis cohort 52 patients were assessible at 6 and 12 months. We found no significant differences at 6 or 12 months in the proportion of participants who had a response for both groups. In the knee osteoarthritis group, at 6 months, the number of responders was nine (41%) of 22 patients who received low-dose radiation therapy versus nine (35%) of 26 patients who received the sham intervention (difference in proportion 7% [95% CI -20 to 33]; odds ratio [OR] 1·34 [95% CI 0·41 to 4·42]); and at 12 months, 13 (52%) of 25 patients versus 11 (44%) of 25 patients responded (difference in proportion 8% [-19 to 35]; OR 1·41 [0·45 to 4·48]). In the hand osteoarthritis group, at 6 months, the number of responders was seven (28%) of 25 patients who received low-dose radiation therapy versus 11 (31%) of 27 patients who received the sham intervention (difference in proportion 12% [-38 to 13]; OR 0·57 [0·18 to 1·81]); and at 12 months, eight (31%) of 26 patients versus seven (27%) of 26 patients responded (difference in proportion 4% [-20 to 29]; OR 1·23 [0·37 to 4·12]). We did not find any difference between groups in other clinical outcomes at 6 or 12 months. Three participants with knee osteoarthritis in the sham intervention group and two participants with hand osteoarthritis in the low-dose radiation therapy group had serious adverse effects, none of which were considered to be related to the intervention. We did not find evidence of a delayed effect of low-dose radiation therapy for patients with knee and hand osteoarthritis. Our placebo-controlled results suggest that the large effects of low-dose radiation therapy reported in clinical practice and observational studies can probably be explained by a regression to the mean effect and response to placebo. Dutch Arthritis Foundation and Stichting Landelijk Katholiek Reumacentrum, Netherlands.

Challenges in the design and regulatory approval of 3D-printed surgical implants: a two-case series

Additive manufacturing or three-dimensional (3D) printing of metal implants can provide novel solutions for difficult-to-treat conditions, yet legislation concerning patient-specific implants complicates the implementation of these techniques in daily practice. In this Article, we share our acquired knowledge of the logistical and legal challenges associated with the use of patient-specific 3D-printed implants to treat spinal instabilities. Two patients with semiurgent cases of spinal instability presented to our hospital in the Netherlands. In case 1, severe kyphotic deformity of the thoracic spine due to neurofibromatosis type 1 had led to incomplete paralysis, and a strong metallic strut extending from C6 to T11 was deemed necessary to provide long-term anterior support. In case 2, the patient presented with progressive paralysis caused by cervicothoracic dissociation due to vanishing bone disease. As the C5-T1 vertebral bodies had mostly vanished, an implant spanning the anterior spine from C4 to T2 was required. Because of the complex and challenging nature of both cases, conventional approaches were deemed inadequate; instead, patient-specific implants were designed with use of CT scans and computer-aided design software, and 3D printed in titanium with direct metal printing. For each implant, to ensure patient safety, a comprehensive technical file (describing the clinical substantiation, technical and design considerations, risk analysis, manufacturing process, and labelling) was produced in collaboration with a university department certified for the development and manufacturing of medical devices. Because the implants were categorised as custom-made or personalised devices under the EU Medical Device Regulation, the usual procedures for review and approval of medical devices by a notified body were not required. Finite-element analyses, compression strength tests, and cadaveric experiments were also done to ensure the devices were safe to use. The planning, design, production, and insertion of the 3D-printed personalised implant took around 6 months in the first patient, but, given the experience from the first case, only took around 6 weeks in the second patient. In both patients, the surgeries went as planned and good positioning of each implant was confirmed. Both patients were discharged home within 1 week after the surgery. In the first patient, a fatigue fracture occured in one of the conventional posterior fusion rods after 10 months, which we repaired, without any deformation of the spine or signs of failure of the personalised implant observed. No other adverse events occurred up to 25 months of follow-up in case 1 and 6 months of follow-up in case 2. Patient-specific treatment approaches incorporating 3D-printed implants can be helpful in carefully selected cases when conventional methods are not an option. Comprehensive and efficient interactions between medical engineers and physicians are essential to establish well designed frameworks to navigate the logistical and regulatory aspects of technology development to ensure the safety and legal validity of patient-specific treatments. The framework described here could encourage physicians to treat (once untreatable) patients with novel personalised techniques. Interreg VA Flanders-The Netherlands programme, Applied and Engineering Sciences research programme, the Netherlands Organisation for Scientific Research, and the Dutch Arthritis Foundation VIDEO ABSTRACT.

Most Important Frequently Asked Questions From Patients With Hip or Knee Osteoarthritis: A Best‐Worst Scaling Exercise

To collect and prioritize the frequently asked questions (FAQs) that patients with hip or knee osteoarthritis (OA) and health care professionals consider to be the most important; to identify informational needs that go beyond guideline recommendations. FAQs were collected among health care professionals and from the arthritis helpline of the Dutch Arthritis Foundation. After deleting overlapping FAQs, the remaining FAQs were prioritized by patients and health care professionals using a maximum difference scaling method. A hierarchical Bayesian method was used to calculate relative importance scores. Differences between health care professionals and patients were analyzed using independent t-tests. A total of 28 health care professionals and the arthritis helpline provided 192 FAQs. After deleting overlapping FAQs, 60 FAQs were prioritized by 94 patients (57 [60.6%] women, mean age 67.3 years) and 122 health care professionals (67 [54.9%] women, mean age 45.7 years). The FAQ "What can I do myself to decrease symptoms and to prevent the OA from getting worse?" was prioritized as the most important by both patients and professionals. FAQs that were highly prioritized by patients but significantly different from professionals were more directed toward treatment options offered by health care professionals, whereas highly prioritized FAQs of professionals were more often focused on treatment options involving self-management. The health care professionals' perspective on informational needs differs from that of OA patients. These differences are important to address in order to achieve more active involvement of patients in their own treatment process.

Analgesic Use in Dutch Patients With Osteoarthritis: Frequent But Low Doses.

The aim of this study was to examine which analgesics are used by patients with osteoarthritis (OA)-related pain and how the analgesics are used in the preceding month. In addition, their beliefs about (pain) medication and the rationale of those declining to use analgesics were explored. An online cross-sectional survey was sent to 1521 patients participating in the panel of the Dutch Arthritis Foundation. Descriptive analyses and logistic regression were used to analyze data. Of the 842 participants (56%) with OA that responded, 70% had generalized OA, 26% had concomitant fibromyalgia, and 34% had another musculoskeletal morbidity. Of all participants, 71% used analgesics, and 34% used more than 1 type. Analgesics were used for more than 14 days in the preceding month by most participants, with paracetamol being used most frequently (51%). Doses used were predominantly lower than the daily defined dose: 58.2% for paracetamol, 31.2% for nonsteroidal anti-inflammatory drugs/cyclooxygenase-2 inhibitors, and 75.7% for weak opioids. Compared with participants with concomitant fibromyalgia or other musculoskeletal morbidities, participants with OA alone significantly more frequently declined to use analgesics (p < 0.01) and significantly less frequently used 2 or 3 types of analgesics (p < 0.05). In this population with generalized OA and musculoskeletal comorbidities, medication use was high, and more than 1 type of analgesic was frequently used. Patients with concomitant fibromyalgia or other musculoskeletal morbidities more frequently used 2 or 3 types of analgesics; however, this use was often intermittent and in low doses. Medication use on a daily basis and at higher doses may lead to improved analgesic effect.

Evaluating quality of care in rheumatoid arthritis: the patient perspective

As rheumatoid arthritis (RA) is a potentially disabling disease, affecting up to 1% of the population, structural monitoring of standardised outcomes to identify best healthcare practices is vital to quality...

The Role of Caveolin-1 in Intervertebral Disc Degeneration and Regeneration

Introduction During intervertebral disc (IVD) degeneration, the main cell type in the nucleus pulposus (NP) shifts from notochordal cells (NCs) to chondrocyte-like cells (CLCs). Microarray analysis revealed that caveolin-1 expression was correlated with IVD degeneration. The aim of this study was to determine the role of caveolin-1 in NC and CLC physiology to assess its potential role in IVD regeneration. Material and Methods Protein expression (caveolin-1, apoptosis, progenitor cell markers, extracellular matrix, TGF-β-signaling pathway) was determined in IVDs of wild type (WT) and caveolin-1 knockout (KO) mice and canine IVDs of different degeneration grades (immunofluorescence, immunohistochemistry, TUNEL assay). Micro-aggregate cultures of CLCs from canine and human degenerated IVDs (Thompson grade III) were treated with chondrogenic medium (incl. TGF-β1) alone or in combination with (a) caveolin-1 scaffolding domain peptide (CSD) and/or (b) siRNA against caveolin-1. DNA, glycosaminoglycan (GAG) content, collagen type I and II immunohistochemistry and gene expression profiling (RT-qPCR) for extracellular matrix production/degradation-, cell proliferation- and apoptosis markers was performed. Results The NP of WT mice was rich in viable NCs, whereas the NP of caveolin-1 KO mice contained more collagen type II-rich matrix and less cells together with an increased progenitor cell surface marker (Tie2+/GD2+) expression and a higher apoptotic activity. Caveolin-1 expression increased in the later stages of canine IVD degeneration, together with a significantly increased apoptotic activity. Caveolin-1 knockdown significantly decreased GAG deposition in the CLC aggregates (6–14%), whereas CSD treatment significantly rescued and increased GAG deposition (11–16%). Conclusion Caveolin-1 plays a crucial role in preservation of NCs, underscored by the NP phenotype of caveolin-1 KO mice. Caveolin-1 may be related with cell senescence given its increased expression in degenerated IVDs. However, caveolin-1 knockdown decreased extracellular matrix production, while CSD supplementation rescued this effect. The latter implies that CSD may be a useful disease modifying agent since it is known to influence degeneration-related signaling pathways (incl. TGF-β signaling). Altogether, this indicates that the increased caveolin-1 expression during IVD degeneration may also be a repair mechanism rather than being merely a senescence marker. Acknowledgment This work was supported by AOSpine Research Network grants (SRN2011_11, AOSPINE 106540) and the Dutch Arthritis Foundation (LLP22).

The Effect of Bone Morphogenetic Protein-2 on Chondrocyte-like Cells Derived from Degenerated Human and Canine Intervertebral Discs

Introduction Both humans and dogs experience low back pain, which is related to intervertebral disc (IVD) degeneration. Biologic repair of the degenerated IVD is mainly based on growth factors that exert anabolic matrix effects, and mesenchymal stromal cells (MSCs) to replenish the cell population of the degenerated IVD. Thus far, the anabolic effects of different growth factors have not been compared. The aim of this study was to study the effect of the frequently used growth factors transforming growth factor β 1 (TGF-β1) and bone morphogenetic protein-2 (BMP-2) on canine and human chondrocyte-like cells (CLCs) from degenerated IVDs alone and in combination with MSCs. Material and Methods CLCs from degenerated human, canine chondrodystrophic (CD) and non-chondrodystrophic (NCD) IVDs (Thompson score III) were cultured in micro-aggregates in base culture medium (negative control), or supplemented with TGF-β1 (10 ng/mL) or BMP-2 (100 or 250 ng/mL) for 28 days. The additive effect of MSCs was studied in CD CLCs. Canine male CD CLCs were cultured in an albumin-based hydrogel (3*106 cells/mL) with or without the addition of female bone marrow-derived MSCs (BMSCs) (CLC:BMSC 1:1) in control or 250 ng/mL BMP-2-supplemented culture medium for 28 days. Read out parameters were extracellular matrix (ECM) production (RT-qPCR, glycosaminoglycan (GAG) production, Safranin O/Fast Green staining, immunohistochemistry), cell proliferation (DNA content, RT-qPCR) and apoptosis (RT-qPCR). Results TGF-β1 treatment increased GAG deposition in human and canine CLC micro-aggregates, but also induced collagen type I deposition and a fibrotic rim. The latter was not observed in BMP-2-treated micro-aggregates. 250 ng/mL BMP-2 was more potent than 100 ng/mL BMP-2 in increasing GAG deposition and DNA content in canine and human micro-aggregates. Similarly, in the hydrogel culture system, BMP-2 induced GAG and collagen type II deposition and a higher DNA content compared with untreated controls. DNA and GAG content of BMSC+CLC hydrogels was higher than hydrogels with CLCs alone in the absence of BMP-2. In the BMP-2-treated hydrogels, DNA content of BMSC+CLC was higher than hydrogels with CLCs alone; GAG deposition or release was comparable between BMSC+CLC and CLC alone in the presence of BMP-2. Conclusion In two different 3D culture systems, BMP-2 exerted comparable regenerative effects as TGF-β1 on human and canine CLCs in terms of GAG deposition and cell proliferation, but BMP-2 did not induce fibrotic (re)differentiation as observed with TGF-β1 treatment. Moreover, in the BMP-2-treated BMSC:CLC-containing hydrogels, where only half of the amount of CLCs were seeded compared with CLC alone, the DNA content was higher and an equal amount of GAGs was deposited, indicating that the BMSCs exerted an additional, regenerative effect in addition to BMP-2 treatment. PCR for SRY:GAPDH genes on DNA will indicate the ratio male(CLCs):female(BMSCs) present at the end of the study. This will indicate whether the BMSCs exerted trophic effects or chondrogenically differentiated. Acknowledgments This work was supported by an AOSpine Research Network grant (SRN2011_11) and the Dutch Arthritis Foundation (LLP22).

The Species-Specific Regenerative Effect of Notochordal Cell-conditioned Medium on Degenerated Human Nucleus Pulposus Cells

Introduction During human intervertebral disc (IVD) degeneration, the main cell type shifts from notochordal cells (NCs) to nucleus pulposus cells (NPCs). NCs secrete factors with regenerative potential, making them an interesting focus for regenerative strategies. Research into these strategies employs non-human donors due to easy availability of their NC-rich nucleus pulposus (NP) tissue. To determine the feasibility of translating these strategies toward clinical application, this study aimed to delineate whether NC-secreted factors of different species have a cross-species regenerative effect on degenerated human NPCs. Material and Methods Healthy human, porcine and canine NC-rich NP tissues (derived from Thompson grade I IVDs) were compared by histology, collagen, DNA and glycosaminoglycan (GAG) content per mg wet tissue weight. NP tissue of each species was cultured for 4 days and NC-conditioned medium (NCCM) was collected. Human NPC micro-aggregates from degenerated IVDs (Thompson grade III) were cultured for 28 days in human, canine or porcine NCCM. GAG content (corrected for DNA) was determined, and Safranin O/Fast Green staining, collagen type I, II and X IHC and gene expression profiling were performed. Results Canine and porcine NPs were richer in NCs than human NPs. Human NPs contained the highest collagen content, whereas the DNA and GAG content of canine NPs was significantly higher than human or porcine NPs. NCCM from all species significantly increased the DNA and GAG content of the human NPC micro-aggregates. Porcine and canine NCCM were significantly more potent than human NCCM in inducing GAG deposition, whereas only human NCCM induced collagen type II production. Conclusion Secreted factors from human, canine and porcine NC-rich NPs exerted regenerative effects on human NPCs, indicating a cross-species effect. The species-specific NP properties appear to influence the regenerative capacity of NCCM on human NPCs. Bioactive compound(s) with treatment potential for human IVD degeneration are present in NCCM of different species, implying that strategies based on NC-technology employing canine or porcine models have potential for successful translation into humans. Acknowledgments This work was supported by an AOSpine Research Network grant (SRN2011_11) and the Dutch Arthritis Foundation (LLP22).

Hydrogel encapsulation and micro-aggregation of co-culture MSC/AC for tissue regeneration

Event Abstract Back to Event Hydrogel encapsulation and micro-aggregation of co-culture MSC/AC for tissue regeneration Mylene De Ruijter1, Ferry P. Melchels1, 2, Riccardo Levato1 and Jos Malda1, 3 1 University Medical Center, Department of Orthopaedics, Netherlands 2 School of Engineering and Physical Sciences, Heriot-Watt University, Institute of Biological Chemistry, Biophysics and Bioengineering, United Kingdom 3 Faculty of Veterinary Medicine, Utrecht University, Department of Equine Sciences, Netherlands Introduction: Cell-laden hydrogels are promising and versatile biomaterial platforms to generate three-dimensional (3D) engineered cartilage tissue. 3D culture systems, beneficial for tissue regeneration, can be created using hydrogels such as gelatine-methacrylamide (gelMA), and might be improved by adding native matrix components such as hyaluronic acid[1],[2]. However, to achieve effective matrix synthesis by encapsulated cells, high cell densities are currently used. Both cell-cell contact and co-culture systems improve matrix production and aggregation of chondrocytes, ensuring cell-cell contact, can increase cartilage regeneration, using a feasible amount of cells[3],[4]. The aim of this study is to create a micro-aggregate system with co-culture of mesenchymal stromal cells (MSCs) and articular chondrocytes (ACs) that can be encapsulated in a hydrogel to enhance matrix deposition using a limited amount of cells, and with potential for biofabrication. Thus, gelMA hydrogels modified with hyaluronic acid methacrylate (HAMA) were synthesized, and tested for printability as micro-aggregate laden bioinks. Methods: First, a stamp consisting of 3924 pyramids (base area = 0.044 mm2, height = 0.31 mm) was made via stereolithography. Second, pyramid shaped micro-wells were stamped into an agarose gel (4% w/v) (Fig 1A & B). ACs and MSCs (20:80 ratio) were harvested from equine donors (n=3), and co-cultured in the micro-wells. Cell seeding densities of 25, 50, 75 and 100 cells/aggregate were used to evaluate aggregation reproducibility. After 6 days the aggregates were harvested and encapsulated in gelMA/HAMA (5%/1.5% w/v) hydrogels. The gels were UV-crosslinked, and cultured in co-culture medium[3] for 8 weeks. Viability and diameter of the aggregates was assessed via a live/dead assay. Distribution of MSC/AC was investigated using 1,1'-Dioctadecyl-3,3,3',3'-Tetramethylindocarbocyanine Perchlorate membrane staining. Finally, printability of aggregates in gelMA/HAMA was assessed. Results and Discussion: Diameter of the micro-aggregates was 27.8±2.6, 34.6±6.5, 46.1±3.3, 61.9±11 µm for 25, 50, 75, 100 cells/aggregate, respectively. Furthermore, cells showed high viability after aggregation (Fig 1C). Moreover, gelMA/HAMA hydrogel supported cell biosynthetic activity for the 8 weeks culture period, and micro-aggregates were not affected by the printing process, showing a viability of 89.26% ± 1.43. The advantageous effect of cell aggregation, in combination with co-culturing and 3D encapsulation, makes the micro-aggregate system a promising tool for tissue regeneration. Furthermore, the excellent printability of the aggregates in gelMA/HAMA (Fig 1D) provides opportunities for the biofabrication field. Conclusion: Fabricating micro-aggregates of MSC/AC succeeded with a high reproducibility and cell viability. Moreover, the printability of gelMA/HAMA 5%/1.5% is good, and shows great potential as aggregate carrier for tissue engineering applications. Dutch Arthritis Foundation

A dual crosslinking strategy for reinforcing gelatine-methacrylamide hydrogels for tissue repair

Event Abstract Back to Event A dual crosslinking strategy for reinforcing gelatine-methacrylamide hydrogels for tissue repair Ferry Melchels1, 2, Kaj Blokland2, Mylène D. Ruijter2 and Jos Malda2, 3 1 Heriot-Watt University, Institute of Biological Chemistry, Biophysics and Bioengineering, United Kingdom 2 University Medical Center Utrecht, Department of Orthopaedics, Netherlands 3 Utrecht University, Faculty of Veterinary Medicine, Netherlands Introduction: Hydrogels are a suitable class of materials for cell-based cartilage repair, as they provide a 3D environment that can stimulate encapsulated cells to proliferate, differentiate, and form new tissue [1]. Their mechanical properties however are generally poor, and most measures taken to improve the mechanical properties make it a less permissive environment for cellular processes. There is a need for strategies that reinforce hydrogels without compromising chondrocyte performance. Here, we studied the reinforcement of cell-laden gelatine-methacrylamide (gelMA) hydrogels by thermal (physical) gelation prior to UV-initiated (chemical) crosslinking. Experimental Methods: Gelatine was methacrylamide-functionalised as reported previously [2]. Solutions of 10% or 20% gelMA + 0.1% Irgacure 2959 photo-initiator were crosslinked by exposure to 15 min UV-A, either in the sol state (purely chemical gel = C) or after thermal ageing at 5 °C (physical-chemical dual-crosslinked gel = PC). Compressive moduli of C and PC gels were measured after 24 h free swelling at 37 °C, whilst stiffness development of purely physical gels (P) was measured by oscillatory shear rheometry at 5 °C. All gels were subjected to proteolytic degradation in 0.05% trypsin + 0.006% EDTA. Chondrocytes were isolated from equine articular cartilage and passaged once before encapsulation in gels at 5.106 cells/mL under the same conditions as described above. After 24 h, live/dead and Alamar blue assays were performed. Cell-laden constructs (10% C, 10% PC and 20% C) were cultured in chondrogenic medium for 6 weeks, then assayed for DNA and glycosaminoglycan (GAG) content using Picogreen and DMMB, respectively. Results and Discussion: After photo-crosslinking, 10% gelMA gels crosslinked directly from the sol state (Figure 1, C) had a stiffness of 24 kPa. On the contrary, when allowed to gel thermally prior to photo-crosslinking, the stiffness increased up to 165 kPa for 10% dual-crosslinked gels (PC), reaching similar values as 20% gelMA gels crosslinked from the sol state (not shown). By comparison, the sum of stiffness of a purely physical gel and a purely chemical gel is only 51 kPa (P+C). Figure 1: Stiffness development of dual-crosslinked 10% gelMA gels, as a function of thermal gelation time prior to photo-initiated crosslinking. P = purely physical gel (thermal gelation) C = purely chemical gel (crosslinked from solution) P + C = sum of physical and chemical gel (for reference) PC = dual-crosslinked gel Whilst the stiffness of 10% PC gels was similar to that of 20% C gels, proteolytic degradation was much faster, and more akin to 10% C gels (Figure 2). Faster enzymatic degradation indicates the 10% dual-crosslinked gels being more permissive to matrix remodelling by encapsulated cells than 20% chemical gels. This was not yet corroborated in terms of cartilage tissue formation by encapsulated equine chondrocytes; after 6 weeks of culture, GAG/DNA was similar for all conditions evaluated. Nevertheless, the cold treatment did not reduce cell viability, nor chondrogenesis. Experiments are ongoing to reveal differential behaviour within the different gel types by other cell types. Figure 2: Proteolytic degradation of gelMA gels. Mass loss of dual-crosslinked (PC) 10 % gelMA gels compared to 10% and 20% only chemically crosslinked (C) gels. Discussion: Hydrogels that allow cells to develop new tissue are generally mechanically weak. Here, we present a straightforward method for the reinforcement of cell-laden gelMA gels, which showed seven-fold increase in stiffness whilst having no negative influence on cell viability, and only slightly decreased enzymatic degradation rates. Conclusion: Thermal ageing of gelatine-methacrylamide gels prior to UV-initiated crosslinking leads to a large increase in compressive stiffness, whilst still providing a permissive environment for enzymatic degradation, and for survival and tissue formation by encapsulated cells. Kim van Dorenmalen for technical assistance; European Union’s for funding under grant no. 309962 (HydroZONES) and no. 272286 (PrintCART); The Dutch Arthritis Foundation for funding

Use of internet in adolescents and young adults with JIA

Background/Purpose: Internet-use is increasing since it is an efficient way to find information. Information obtained via Health Related Internet (HRI) sites, or online peer support groups might increase knowledge and self-management in adolescents and young adults with Juvenile Idiopathic Arthritis (JIA). This study evaluates the frequency of use and perceived relevance of HRI use and its association with demographic, disease-related and psycho-social variables. Methods: In a cross-sectional study, all consecutive JIA patients from the outpatient clinic (age 10 – 27 years) who gave informed consent were asked to complete a self-reported questionnaire. Frequency of using HRI-sites (regarding information about JIA, medication-use and aspects of JIA related to social life) as well as having online contact with fellow patients were evaluated. Perceived relevance of HRI use and contact with fellow patients were also investigated. Demographic variables, disease activity, medication and emotional behavior and coping were assessed as possible predictors. Results: 142 patients were included and 98% had access to internet. 71% had used internet to search general information on JIA, but specific topics such as medication, were less searched for (6–35%). Most favorite sites to look for information were www.reumafonds.nl (Dutch Arthritis Foundation; 20%); www.google.com (16%); www.jong-en-reuma.nl (UMCU hospital site for rheumatic diseases; 14%) and www.printo.it (Pediatric Rheumatology European Society information site; 3%). One in four adolescents had ever visited a forum or had online contact with peers. Most favorite discussion for a were www.reumaforum.nl (peer support for general rheumatic diseases; 14%); www.jeugdreuma.com (parents of children support forum; 5%) and www.Youth-R-Well.com (peer support information and forum for 16–30 year old patients; 5%). Whereas most had used the internet to find information about JIA, the perceived relevance of HRI-sites and of opportunities for online peer contact was rated low (medians respectively 2,0 and 1,0 on a scale 0–10). Female gender was positively associated with HRI use (P0.01), other demographic and disease related factors were not associated with HRI use. Coping styles “confrontation” and “reassuring thoughts” were associated with increased HRI use, but only in males. Internalizing and externalizing problem behavior were not significantly associated. Conclusion: Frequency of Health Related Internet use in young people with JIA was less than expected and considered of low relevance. Besides female gender no demographic and disease related factors were associated. HRI in present form cannot replace regular information as an additional source to increase knowledge.

AB0779 7 Years of Follow-Up of Early Symptomatic Oa: Characteristics of CHECK (Cohort HIP & Cohort Knee)

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PARE0016 Our Patient Relations in A Social Media Perspective

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OP0256 Changes of Microrna Expression in Lymph Node Stromal Cells of Rheumatoid Arthritis Patients

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