ACR20 - Day 1.2 Save

This is the RheumNow podcast, and you're listening to highlights from the ACR twenty twenty virtual meeting. Our faculty reporters have been doing videos and recordings so that you could stay up to date. Hope you enjoy these and our panel discussions.

Hello, everyone. I'm Richard Conway from Dublin, Ireland, reporting from ACR, 2020. And I'm going to talk to you about a study by Doctor. Fernandez Diaz and colleagues. It's abstract number two thirty three, and was presented on Friday in the session, poster session, RA treatments one.

So this study was looking at patients with rheumatoid arthritis and interstitial lung disease, who were treated with abadacept. So this is an important study. Interstitial lung disease is a big problem in rheumatoid arthritis. It's common up to ten percent of people with rheumatoid arthritis have interstitial lung disease. And it's a very severe manifestation of the disease.

Respiratory disease is second leading cause of death for patients with rheumatoid arthritis. And the prognosis, once patients have significant established interstitial lung disease in historical cohorts is not good. And we've had very little data on how to treat this manifestation of rheumatoid arthritis. So we have some observational data on rituximab, and that's really the best evidence that we do have. So we desperately need more research in this area and more treatment options.

So in this setting, Doctor. Fernandez Diaz and colleagues did the study, was a multicenter study done in Spain. And it was an observational study. There were two sixty three patients included in this study, all of whom had rheumatoid arthritis and interstitial lung disease. And they looked at the outcomes in these patients after they were treated with abatacept.

And when we're interpreting these outcomes, we have to remember that again, rheumatoid arthritis interstitial lung disease has a very, very poor prognosis. It tends to be inextricably progressive and cause progressive deterioration in function, in measures of lung function, and ultimately often results in mortality. And in this study, in the patients who were treated with Abadecept, the authors found that there was no worsening in a number of key measures in the majority of patients. So they found that there was no worsening in dyspnea in ninety two percent of patients, no worsening in forced vital capacity on pulmonary function tests in eighty eight percent of patients, no worsening in DLCO on pulmonary function tests in ninety one percent of patients, And nowhere sitting in high resolution CT thorax findings in seventy seven percent of patients. So they're very impressive numbers.

Of course, there are significant limitations to the study. The main one being that this is observational data and there is no control arm, it's not blinded. So really, do need randomised controlled trials in this area to look at Abadecept and evaluate how well it works. But the bottom line with the data that we have now is that abadacept seems to be as good as anything else we have for treating rheumatoid arthritis interstitial lung disease. The data seems to be equivalent to that which we have for rituximab.

And that's great, it gives us another option. It's also in some settings rituximab is an intravenous infusion, so a Baticept is more easily administered because it can be given subcutaneously. So thank you very much. Follow me on Twitter at Richard P. I.

Conway and tune into RheumNow for further updates from ACR twenty twenty.

Hi, this is Doctor. Artie Cavanagh, University of California San Diego, and I'm coming to you on RheumNow right before ACR Convergence. I guess they did have a first session today, but really all the abstracts and a lot of the oral presentations and the lectures and the symposia, all those are coming up in the next few days. So I just thought I'd give you my perspective having looked through the schedule and looking through the different posters, ton of posters, a little bit down from years past, about 2,000 to 3,000. But I thought I'd give you sort of my global thoughts because I really haven't had a chance to talk to any of the poster presenters or ask questions or go to the actual oral sessions themselves.

So my idea, my sense of going into the meeting, a couple of big themes that I say. One is COVID. My gosh, there are so many COVID abstracts, and understandably, it's a hot topic. It's really it's the reason why we're having a conversion instead of an actual meeting in an actual meeting hall. But having looked through a lot of the abstracts, it's a topic that I think we still need to learn more about.

These abstracts are kind of, I had 20 patients with COVID. I had 50 patients with COVID. The left handed people stayed in the hospital one day longer. It's a lot of anecdotes, and the plural of anecdote is anecdotes. It's not actually data.

So I think this is an important topic, and I think it's one that has certainly resonated with rheumatologists throughout the year. But I think we need maybe to put many of these data together to see if we can make a comprehensive story that is still going to be important to our patients. And next year, I think at the ACR twenty twenty one, if it's live or virtual or maybe some sort of hybrid, that we'll be hearing about the vaccine, which I think is also gonna be fascinating. I didn't see much about those, of course, because the vaccines are not out yet, but they're gonna be out soon, I imagine. And then we're going to see about the immunogenicity and the impact on the clinical outcomes for patients, specifically with rheumatic diseases.

Another theme that I think we saw a little bit of, but boy, it's really gotten much, much more of, artificial intelligence and machine learning. So we're really in the era of big data, certainly as it comes to biomarkers for the prediction of response to therapies in rheumatic diseases across rheumatic diseases. There's too much information to be able to sort of rationally gain much insight from. Also in imaging, if you think about x rays, but certainly MRIs, I think these are areas where machine learning is going to have an impact probably relatively soon. There's just so much data available that we can't digest it.

We've tried making sense of proteomics and genomics and now most recently metabolomics. And we try because we want to know at the end of the day what's the right medicine for the right person. So I think we will see more on how do we take advantage of machine learning to be able to do that. And then lastly, the topic I just mentioned, metabolomics. For years before the human genome was sequenced, genetics were going to be the answer.

If only we would get everyone's genes sequenced, we would be able to tell who was going to get rheumatoid arthritis and what was the best treatment for them. Of course, that really didn't pan out, and it's probably due to the fact that humans are quite similar to the genetic level. Epigenetics is probably much more important, and that is influenced in turn by some of the other omics, if you will, particularly metabolomics. I know that many of us started our careers in the lab, and of course you're most interested in proteins because those are the important mediators, the chemokines, the cytokines, etcetera. But lipid based mediators, which is the essence of metabolomics, are also looking to be very important and may actually give us some better clinical insight into who develops diseases among people who are at similar risk.

So as I look going into ACR, I think that those are the things that I wanna see. We'll look at some of the the COVID abstracts. We'll look at the machine learning, artificial intelligence, and I think all of us will also look at some of the new topics like metabolomics. So it's all about to start, so we're going to get some good rest tonight, and the meeting starts in earnest tomorrow. Keep following it on RheumNow.

Hi, everyone. I'm Nicola Delbeth, a rheumatologist from Auckland, New Zealand. And I'm really pleased to be part of the RheumNow panel this year. I'm going to be focusing on crystal arthritis, particularly gout and also some CPPD throughout my videos. Today, I'm just going to talk through some of the highlights that I think we'll hear at the 2020 meeting.

And I'm hoping that I will be able to present some of these in more detail to you over the next few days. So some of the really big highlights, I think, from the sessions are going to be in CPPD. So there's been really amazing progress in our understanding of how CPP crystals form. And I'm really looking forward to the session that Doctor. Anne Rosenthal will be presenting later at the meeting.

The other big news in crystal arthritis in 2020 has been presentation of the 2020 ACR Gout Management Guidelines. And again, there's going to be a session discussing those guidelines and giving some perspective on those during the session as well. And I think that's going to be a really interesting discussion led by Doctor. Bob Turkletop. As far as original data presented, I think we're going to see some really interesting data on dual energy CT, and particularly the utility of dual energy CT, both for gout and also for CPPD interestingly.

Interestingly. There's a lot of work being done on multi morbidity and comorbidities in people with gout. We're going to hear a lot more about that at this meeting. And I think one of the really fascinating developments has been the role or the putative role of SGLT2 inhibitors in lowering urate and potentially having gout being preventive of development of gout. So again, we're going to see quite a lot of data at this meeting, and I think that'll be really interesting to see.

A couple of other big highlights. There's a lot of abstracts this year on mechanisms to reduce immunogenicity with peglodecase. And we're going to see the first clinical trial of mycophenolate and peglodecase, which looks again really exciting. That's going to be presented by Doctor. Puchikana later this week.

And finally, I think the trial that we're all really excited about and looking out for is the FAST study, and that's going to be presented as a late breaking abstract later this week. And so this is the large cardiovascular outcome study done in Europe, comparing cardiovascular safety of febuxostat versus allopurinol. And I think this is going to be really interesting in the context of the CARES trial, which was published several years ago now. So I'm looking forward to giving you some updates throughout the meeting, and I hope to see you soon. Thanks.

Hi, everybody. I'm John Hammerly with RheumNow, and I'm joined by doctor Neil Bernbaum. He, besides all of his other accolades, my understanding, he's a damn good Sunday golfer and past president of the ACR. So as maybe as as the, from the standpoint of being the past president and not from the first tee, what do you anticipate bringing to, ACR twenty twenty? Is it, it's gonna be different than any other.

Well, it's gonna be very different. I I think we're already getting some experience doing Zoom things because we've been seeing patients this way for now six months, but to go to a meeting, is a whole different story. So I think it's going to be interesting. I think it'll be and there's a tendency to perhaps be more focused when you're it's just you and you're looking at somebody's face on on the screen. But I think what we'll miss is is the camaraderie.

If been somebody like me who's been active in the college for a long time, practice for a long time, a large part of why we go to the meeting is to see old friends and renew acquaintance. You

stole my question in terms of what besides the obvious being personal contact, what are some other the other disadvantages of this virtual format?

Well, I don't know. I I think it's gonna be interesting to to see. There are some advantages, which is, of course, you don't have to fly across the country and pay money for a hotel and and all of that. So often less time away from the office, which in a year like this where people's incomes have suffered from the pandemic is is a good thing, but there's a trade off certainly and not being able to have the in person interaction. How that'll affect the interactions with speakers and programs and things is hard to know, but I think it's clearly the social aspects will suffer.

You've taken a peek obviously at what is to come in the next few days. What is excited you personally?

Well, think that the opening session today was very good, that the year in review was well done. The president's address, the talk by the editor of the New England Journal of Medicine were all very, very well done. I always look forward to the year in review, which was done today. And then tomorrow's the great, great debate, which is fun. I think some of the updates on real clinical controversies that still exist in the field, hearing about the new guidelines that are coming out are all things that are good for somebody like me who's basically a clinician, a practitioner, a teacher, I'm not a lab person.

So that the real basic science things are not as important to me.

Well, from a clinician standpoint, what guidelines do you think will be most important in terms of this year's conference?

Well, from what I have read, there's an update on the rheumatoid arthritis guidelines and also gout guidelines. Whether or not they'll be dramatically different than what we're currently doing remains to be seen.

You hearing any buzz about anything else from, young or old, attendees alike or, how are poster sessions going to be?

I have no idea. I'm kind of intrigued. I'm gonna get up real early in the morning because out here in San Francisco, the poster session starts at 6AM and I'm gonna see what it's like and whether it's worthwhile. I've often felt that the poster sessions at the annual meeting frequently weren't that worthwhile because you go through this huge room with thousands of posters and can you really remember anything about them, unless it happens to be about a patient you've seen recently. And then fairly often you run into somebody you haven't seen it in a long time in the hall and you end up talking to them.

So I've become less enamored of the poster sessions, the live poster sessions the last few years. So I'm quite intrigued to see how the online ones are gonna go.

I talked to a junior faculty member earlier today, and he said he was looking forward to the poster sessions where he'd go and literally, you know, in, pardon the expression, with the author of the specific poster and ask him or her specific questions about what's going on.

Well, interesting to see how how that works. And, will it be like oftentimes at a live poster session that you go, and if it's a really interesting poster, there's a whole crowd around the presenter and you may not get to spend a whole lot of time with them or get your question answered.

I guess my last question is, does this mean that ACRs will never be the same? Do you think that we'll return to the ACRs of old?

Well, I would suggest there will probably be hybrid meetings, that once the genie's out of the bottle, it's gonna be hard to put it back in. We're experiencing that now with direct patient care. We've if someone would have asked me a year ago, would I be doing Zoom visits and phone visits? I would have said, you know, no one's gonna pay me for it.

They're not gonna

work very, very well. And now all of a sudden it's okay. It's a good thing. The patients love it by and large. And I would say 95% of time, we can accomplish what we need to in a Zoom visit as opposed to an office visit.

I think the college is gonna have to really work hard and I know how hard the staff works and the meeting planners work to come up with exciting sessions. And then it's gonna also get into the economics of what it means to try to put on a hybrid meeting. And I don't know how that's gonna work out, but I've strongly suspect that they're gonna have to come up with something like that.

Well, I look forward to what, this year's meeting will portend for future meetings, and I'll look forward to seeing that handicap of yours drop significantly.

It has a long way to go. Sunday golf. I'm a I'm a lot better rheumatologist than I am a golfer. That's for sure. Thank thank you for being optimistic for me.

And I I hope that we will be greeting people next year. The meeting is in San Francisco. The convention center is about a mile from my office. So I really hope that we'll have a live session.

Great. Well, Doctor. Birnbaum, thanks so much for your time. Really appreciate it. And if you'd like any more information, about where Doctor.

Birnbaum is going to be going post recession wise or anything else, just tune in to RheumNow.

All right. Thank you for having me. Bye bye now.

Take care. Hi everybody, I'm John Hammerly with RheumNow. I'm joined by, with Doctor. Vinikka Strand from the West Coast, where she tells me it's still warm. What's the temperature out there, Doctor.

Strand?

I think we were up to 79 today. It's very nice, but I was inside.

I understand, attending sessions. What was the highlight of today's sessions for you?

I think they did a good opening plenary, And that of course included a very nice talk by the editor of New England Journal of Medicine about COVID and about developing a vaccine and vaccines in general, very enlightening. And then we had the year end review by Doctor. Yostani for clinical and then Doctor. Buchala for research, and those were both excellent.

We talked a little off camera about the advantages and disadvantages of this virtual session. What have you, in the very short time on this first day, seen as far as what glitches may have happened?

Well, I think it's a very in-depth platform and they're servicing people from all over the world. We could see in the chat where people were coming from, but they were all saying they were getting good service and they were quite impressed. And I had some minor times when it stopped, but it would come back on. And so I think altogether, it's really good. It's even better than EULAR was when they didn't have as much time to get all set up after COVID started.

But they've also made everything downloadable. You can get the slides and all of that so that and you can go back and listen to it once it's recorded up until March 11. So that's a pretty good advertisement.

Biggest disadvantage of this virtual non contact meeting?

We don't get to see each other, but I was just at an RRF meeting where we were going between breakouts so we could all talk among ourselves as a small group. And that was very nice.

And how about advantages?

No travel. Think that's It's the biggest been really nice. I've been doing a lot of lectures essentially all over the world. Thank God I haven't had to fly at all. It's so nice not to be on a plane for long periods of time.

And also people are not so tired when they're at a Zoom meeting because they haven't had to get up early, stay up late, then get up before their usual time zone to be sentimental and thoughtful. And so I generally think if you haven't done too many Zoom meetings in one day, which can be really tough, you get a lot more participation.

Do you think that this format has changed the face of ACR forever?

Well, I'm wondering if it can't be used at least to some extent so that we can all, shall we say archive, go back and look at presentations, whereas before we would see them briefly for ten minutes and they were gone. And you might be able to see the abstract. I think if they're gonna be able to make this all virtually then and hold it out till March, the same kind of thing can be done even when we go back to live meetings. And maybe then you can make the choice depending on how far you have to travel, whether you're going to travel or whether you're gonna be virtual.

And maybe there's some type of hybrid involved.

Yeah, that's what I think they're thinking. I think it'd be a good idea.

Know that some, I was talking to Doctor. Birnbaum just a few minutes ago and he was a little anxious and looking forward to seeing what it's like to visit some poster sessions. Certainly much different than seeing them in a poster hall with thousands upon thousands end to end.

Yeah, but the nice thing with this is that we've all recorded three minutes of what our poster's about. So you can be looking at the poster while you're listening to it, and you can download the PDF of the poster so you can come back to it and look at it again. And I guess you can go back and listen to the recording anytime you want up till March. In you a get more exposure to the poster, but you miss seeing everybody that you like to talk to.

Do you know whether or not you'll have any time to have live discussions with people visiting the posters or vice versa?

I don't really know. I think there may be something during the poster sessions, but also there's all these times in the middle of the meeting when people can get together informally. So that should work kind of like what we just did in the RRF get together. But I think it really depends on how much people wanna try and do that.

Any sort of guidelines that will be released that you're looking forward to reviewing?

Yeah. There's gonna be new guidelines for the treatment of RA on Monday. I think it's Monday. Let me just check.

Yeah. Monday.

Monday. So that'll be relevant to the debate. What they're going to say about when we can use or when we should use or when we should think about using an oral versus a biologic. So I think that's important. And I have one point about the debate that I will share with you and that is that

Okay, I promised I wasn't going to ask any questions.

Yeah, I know you did, thank you. We have twenty two years of use of the TNF inhibitors. So we really know their safety. We've really only had, the JAK inhibitors for just about seven, little over seven years, just about eight. And so it's really kind of hard to say that when you know the depth of a class for which you have five members and treating many different diseases.

I think now we're seeing is an oral set of therapies that are very similar to each other also, but are probably gonna treat a lot more different diseases than just rheumatologic. So they're probably gonna have much broader applications.

Well, appreciate the little peek into the great debate.

Yes.

I promise I won't ask any other questions. I wanna stay on your good side. Doctor.

Streak That's fine.

Thank you very much for your time today. I'm looking forward to maybe doing another interview with you along the way and we'll see you somewhere along this virtual highway called ACR 2020.

Great, thank you.

Thank you very much.

Hi, I'm Doctor. Janet Pope. I'm reporting here at RheumNow on our ACR20 Virtual or Convergence Conference. I have invited some trainees, some PGY45 trainees to talk to me about what it's like going to virtual conferences and learning and also a little bit about what it's like in their program because we are such a specialty that we really have always valued the physical exam. So Arpita, can you tell me who you are and what year you're in?

Hi, so I'm a fifth year rheumatology fellow at Western University in London, Ontario.

Great, wonderful. Gabe, can you tell me about who you are and what you're doing?

Absolutely, so my name is Gabriel J. S. Sam. I'm one of the PGY4s also here at Western University in London, Ontario.

Great. Gemma, what are you up to?

Hi, I'm Gemma. I'm PGY4 in Rheumatology in Toronto, Ontario.

Great. And Melissa?

Hi, I'm Melissa Holdren. I'm a PGY4 in Rheumatology at Western Ontario.

Great. So thank you for joining us here at RheumNow. So my first question is pretty general, but how has it been where you're not seeing too many people in clinic? Do you feel you're getting a valuable training experience?

So I can start. I'm in Toronto, and I've been going through different hospital sites. So every site does it a little differently. But I would say I'm seeing 90% of patients virtually, whether that be through zoom, through Ontario's own kind of telemedicine module system or kind of through telephone. So it has been a big shift kind of in terms of not getting little access to the physical exam, I would say, on average, in a week, I'm seeing between one and four patients actually in person.

So it is a little bit daunting and scary in terms of losing those joint skills. But I think we're making the best of it. I think we're getting better and better at trying to show patients how they can show us their joints on Zoom or whatever we're using or kind of getting them to kind of do their own measurements like for AS with the Sjogren's test. So I think patients are learning a little bit more about their disease by us trying to get them to do things over Zoom. But it's definitely been tough as PGY4 just starting rheumatology.

Right. And at Western, I know Toronto has had more cases, of course, per capita than us in London, Ontario. So anyone from London, can you sort of give us the case mix that you're seeing?

So I can chime in. So I'd say we're about fiftyfifty, like 50% in person and 50% virtual. It definitely is different doing virtual care. I think I'm getting a bit better at asking kind of specific ways to figure out exactly what joint a patient is talking about in their hands to figure out, you know, are they complaining more of OA pain versus their rheumatoid arthritis? And then sometimes we're finding we just have to bring patients in anyways because you can't get a good enough history over the phone to tell, you know, are they really having a flare or is this just pain?

So I have a question. Have you all been able to bring a patient in if they're flaring or there's been too many restrictions?

I can speak to that. I think I've personally, when I feel that someone may be flaring or it's hard to determine what's going on, I think in most cases we have been able to bring people in usually within the next few weeks. So I haven't found that too much of a problem so far.

Right, great. And what I can say is so Doctor. Cush has done actually a lovely video on getting patients to do range of motion and following him if you're doing video. I know in London we do a lot of phone calls. They're almost in a way solely phone calls.

I know in Toronto you've had a mix. So he has that. There's also a neat abstract including the CATCH cohort as well as the CATCH US side combining to say comparing patient reported CEDAI where they're doing their own counts and CEDAI when we see the patient and done on the same day. And it's quite telling that in general, if they say they're in low disease activity, high concordance, pretty good agreement. And if they say they're in high disease activity, the patient, sometimes it's concordance, sometimes it isn't.

So that's where when you're uncertain, you bring the patients in. So I'd like to shift gears now and because now many of you have had your you've written your exams, it's, know, they were delayed. You've had maybe even virtual OSCEs, so physical exams virtually, and you've done other meetings such as some of the meetings for education and grand rounds virtually. So does anyone want to talk about the pros of having the virtual learning? And then we'll talk about maybe some of the downsides.

I think a pro, at least in Toronto, is that we have many different sites. So a lot more people are able to attend our rheumatology rounds and journal clubs because they're not rushing to clinic at a different centre. So that's been one good thing in terms of turnout has increased. And I guess at the same time, kind of it's been difficult in that you're not necessarily seeing people as much in person. So I feel like there's definitely kind of less interaction in these rounds than there would be because it's a little bit more challenging sometimes to ask the question over Zoom.

Right, absolutely. That interactivity is sometimes lost. Anyone from Western have that kind of perspective and or other perspectives?

Yeah, I agree. The interaction, it's sometimes difficult to keep Yeah, that up because even if you do ask the question, sometimes it's lost in translation. But it has been very helpful in terms of being able to record lectures and slides that are helpful. It's easier to screenshot them, keep them for future and learning. So that way I feel like it's been very helpful.

I think one thing too that I can say is there's been, we can have more international speakers because they don't have, they can do it from the comfort of their own clinic or their home. And also I would say if anything, we seem to have more nighttime CME because I guess in a way it's just an hour of your time or an hour and a half instead of a whole evening. And sometimes I think it's overwhelming how much CME we get. I think you're going to learn at this virtual meeting that you have to just like in person be organized. I think that you can rewatch the lectures, you can look at more posters.

So I think they're the plus side. The downside is I think the FIT program of the ACR allows a lot of people to be together and learn and meet other people from US, Canada and also obviously while you're having the week elsewhere. So I think that interactivity is kind of lost. However, I do think that with good discipline you can learn an awful lot and you can go back and refresh and look at things again which we could do when things were taped And frankly, I never did when it was in real time. I never went back and looked.

Any other comments from the group?

I think it's nice that we can kind of attend any session we want to because I remember going to other conferences kind of before I knew what I was doing. I didn't realize I had to sign up for certain things ahead of time and maybe the room would be full or you couldn't quite make it from one room to another in time. So it's kind of nice that you can pick anything you'd like to and everyone can attend.

That's right. So either whether it's live and a lot of things are taped and then there might be adequate time for discussion. We also have some neat tips that you can look on some of these encore things or meeting the expert and some of the symposium you can certainly look at in real time or later as well. Well, with everything, I'd like to thank you, and thank you for coming on to RheumNow, and I hope you have a wonderful ACR twenty twenty convergence. Thank you.

Hi, I'm Leanne Gensler, rheumatologist from San Francisco at UCSF, and at this ACR meeting, I will be going over the spondyloarthritis topics. Today is day one of the meeting, and really we've only had the opening ceremony, and so I'm going to look forward over the course of the meeting and highlight areas where I think are being well displayed at the meeting. So first I'd say this is such an atypical year for us not to be gathering in person. And so I would really encourage anyone interested in spondyloarthritis to gather virtually if possible, you would do that by going to one of the study groups in spondyloarthritis. There's two this year highlighting nomenclature and IBD.

And then also to think about joining groups of interested members in spondyloarthritis at the community hub, where we will gather at least in person on video. Beyond that, I think an interesting area at this year's meeting is the topic of enthesitis. And so there's actually a session on the anatomy of enthesitis by Dennis McGogonagle. And in addition to that, some interesting abstracts looking at what does it mean when you clinically evaluate enthesitis and then do MRI and really recognizing that what we believe is enthesitis on clinical exam may not be such an entity when you actually image patients. Beyond that, there's a session on MRI and the utility of MRI for the diagnosis of axial spondyloarthritis, and so this will be a very pragmatic session where we'll show lots of imaging.

And then following that session, we'll go to the community hub where we'll further discuss images, and you will be able to participate as a member interpreting imaging studies. There is a lot at this meeting on novel treatments to think about. So in particular, several abstracts looking at JAK inhibitors in spondyloarthritis. There is the first abstract looking at upadacitinib in psoriatic arthritis with a biologic DMARD inadequate response. In addition, the phase three study is a late breaker for tofacitinib in ankylosing spondylitis.

Beyond that, interesting data showing filgotinib, a JAK1 inhibitor's impact on MRI inflammation in axial spondyloarthritis, and some long term extension data from upadacitinib in ankylosing spondylitis. Other than that, novel mechanisms that are being highlighted, so some of the IL-twenty three monoclonal antibodies, tildecizumab in psoriatic arthritis, a phase 2b study, and then I think some very novel approaches at looking at axial manifestations of psoriatic arthritis, so a couple of abstracts on the MAXIMIZE trial, which is sacikinumab's trial for patients with psoriatic arthritis and axial manifestations, and guselkumab's impact from the DISCOVER one and two trials on axial manifestations in active psoriatic arthritis. Aside from that, some open label strategy trials looking at escalation of methotrexate compared to adding adalimumab in psoriatic arthritis. And then finally, thinking about whether our drugs have an impact on disease modification and some interesting data looking at COX-two perhaps selective impact on radiographic progression in ankylosing spondylitis, and then also looking at what happens short term when you give patients TNF inhibitors, and then look at osteoblastic activity on PET MRI. So fantastic abstracts coming to us this year at ACR.

I will be back on a daily basis to review the abstracts that are presented and any sessions that we should be highlighting. And for more information, please go to RheumNow.