APPLYING KAHOOT IN FORMATIVE ASSESSMENT IN EFL CLASSROOM

The standard defense developmental evaluation is to improve understudies' learning and it ought to be viewed as a piece of the learning affiliation. Game-based learning has gotten more normal in the coaching and one of the arising game-based learning stage utilized in direction establishments is Kahoot. This paper examined the impression of understudies towards Kahoot as a developmental evaluation instrument in school understudies in Indonesia. The evaluation utilized a review that contains 12 things through Kahoot study stage. An aggregate of 170 subjects took an interest in this appraisal. The understudies essentially clear Kahoot as fun, viable and better than e-learning stage for commitment as its middle score was 4. The remainder of things were acceptably seen by the understudies as demonstrated by the score of 3 next to managing complex subjects that acquired inadmissible level. There were essential focus score contrasts among male and female understudies for inspiration and saw information upkeep, whereby people scored higher than females (p < 0.05). Kahoot is a promising developmental evaluation instrument that is possible, objective and makes learning fun and beguiling. It very well may be utilized to nudge understudies to learn. Regardless, Kahoot was not the best contraption to manage complex subjects as seen by school understudies.

AB0317 ADHERENCE TO MEDITERRANEAN DIET AND NUTRITIONAL STATE IN ITALIAN WOMEN WITH ISOLATED SJÖGREN’S SYNDROME

Background:The Mediterranean Diet (MD) has anti-inflammatory and immunomodulatory effects1,2 suggesting a protective role in rheumatic diseases. There is limited knowledge about the eating habits and the nutritional state in patients with isolated Sjögren Syndrome (SS) living within the Mediterranean area.Objectives:assessment of adherence to the MD and analysis of the nutritional state in women with SS and their correlations with the clinical, laboratory and histological data of the disease.Methods:patients classified as isolated SS according to AECG criteria 20023 who had undergone to minor salivary gland biopsy during the previous twelve months were consecutively enrolled during follow-up visits. The adherence to the MD was assessed by the Med Diet (MDiet)4 which includes eleven groups of foods; to each group is assigned a value ranging between 0 and 5 based on the frequency of monthly intake. The total score spans from 0 (poor adherence) to 55 (maximum adherence). The level of physical activity was measured by the 6-minutes walking test (6MWT) and by the International Physical Activity Questionnaire (IPAQ). Systemic disease activity was evaluated with the EULAR SS disease activity index (ESSDAI); EULAR SS patient-reported index (ESSPRI) was calculated as well. A subgroup of patients was asked to fill a daily food diary processed with FOOD CONS software which allows to study in detail their eating habits. Nutritional state, muscle strength and basal metabolic rate were assessed. Alcoholism or drug abuse, diabetes mellitus, specific dietary models, treatment with drugs and/or food supplements with anti-inflammatory and/or antioxidant activity were considered exclusion criteria. Multivariate linear regression was performed with R project for Statistical Computing.Results:N= 40 N= 26Age, median (range) 53 (25-80) 33 (25-71)BMI, median (range) 21 (19-29.3) 25.1 (19-33.7)MedDiet score, median (range) 33 (26-43) 33 (23-40)ESSDAI, median (range) 2 (0-16) 1 (0-16)ESSPRI, median (range) 6 (0-8.6) 5.3 (1.6-9)ESSPRI dryness, median (range) 6 (0-10) 6 (2-10)Focus score, median (range) 2.5 (0-9.6) 1.7 (0.8-6.24)ASM kg, median (range) - 16.8 (13.3-21.7)IPAQ meters, median (range) - 1386 (99-11865)6MWT meters, median (range) - 595 (536-680)BMI, body mass index; ASM appendicular skeletal mass; IPAQ International Physical Activity Questionnaire; 6MWT, six minute walking test.MDiet was administered to 40 female SS outpatients. Even if not reaching significativity, patients with a higher focus score in their MSG have a lower value of MDiet score (p = 0.058, r = -1.00). The MDiet score is not associated with ESSDAI (p = 0.85, r 0.02), but only with lower serum levels of C3 (p = 0.004, r = - 0.08).In 26 patients, daily food questionnaire shows that their diet consists of 43% of carbohydrates while fats represent 40% of total energy intake, the remaining 17% daily energy comes from proteins. Fat consumption is higher compared to the levels of energy and nutrient intake for the Italian population5. Six patients had a reduction in muscle mass; sarcopenia is not associated to ESSDAI (p = 0.610).The MDiet score and the amount eaten of polyunsaturated fatty acids (PUFA) were reduced in patients with high value of subscale dryness of ESSPRI (p = 0.057, r -1.21; p =0.610, r -1.00).Conclusion:This study highlights a lower degree of glandular lymphocytic infiltration (expressed as focus score) in minor salivary glands in patients following MD, so its anti-inflammatory role of seems to be confirmed. SS patients have an unbalanced diet because of a higher intake of fat foods, likely for their lubricating effect. Despite the absence of correlation with objective parameters, the increased dryness in patients with a reduced intake of PUFA arouses our interest in a future study including omega-3 supplementation.References:[1]Schwingshackl L et al., Nutr Metab Cardiovasc Dis 2014[2]Mena MP et al., Am J Clin Nutr. 2009[3]Vitali C et al, ARD 2002[4]Panagiotakos D et al., J Med Food 2007[5]LARN 2014Disclosure of Interests:None declared

POS0177 POTENTIAL INVOLVEMENT OF IL-40 AND IL-40-PRODUCING CELLS IN PRIMARY SJOGREN’S SYNDROME (pSS) AND pSS-ASSOCIATED LYMPHOMA

Background:The pathogenesis of pSS relies on a complex interplay between both innate and adaptive immune responses in which B cells play a pivotal role. Their chronic aberrant hyperactivation may drive clonal escape and consequent lymphomagenesis [1]. In the last few years, B cells have emerged as potential effector cells, able to release a wide range of cytokines that actively contribute to shape the microenvironment they act in. Recently, IL-40, a novel B cell associated cytokine encoded by an uncharacterized gene (C17orf99; chromosome 17 open reading frame 99) was described. Naïve B cells can express IL-40 at both tissue and peripheral level and the stimulation of B cells with IL-4 and TGF-β significantly increases IL-40 release. In addition, human B cells lymphomas are able to constitutively produce IL-40 [2]. Taking into account this emerging evidence and considering the well-known role of IL-4 and TGF-β in pSS pathogenesis, as well as the association with lymphomas, we decided to focus our attention on IL-40 in pSS patients.Objectives:The aim of the present study was to investigate IL-40 expression in the salivary glands of patients affected by pSS and pSS-associated non-Hodgkin’s lymphoma (NHL).Methods:Minor salivary gland biopsies were obtained from 22 patients with pSS and 12 patients with non-specific chronic sialoadenitis (nSCS), included as controls. Paraffine-embedded samples of parotid glands from patients with a previous diagnosis of pSS-associated NHL (n=10) were selected from the biopsy bank of the Pathology Unit of the Ospedale Cervello (Palermo, Italy). Quantitative gene expression analysis by TaqMan real-time PCR and immunohistochemistry (IHC) for IL-40, IL-4, TGF-β1 was performed on salivary glands from patients and controls. The cellular sources of IL-40 among infiltrating inflammatory cells were determined by fluorescence-activated cell sorting (FACS) analysis and immunofluorescence (IF). Serum IL-40 levels were measured by ELISA in both patients (n=10) and controls (n=9).Results:IL-40 was significantly increased at both protein and mRNA level in the inflamed salivary glands of patients with pSS where a positive strong correlation between the IL-40 mRNA levels and the focus score (FS) was evidenced. The expression of IL-40 in parotid glands of pSS-associated NHL was also markedly increased (Figure 1). IL-40 expression correlated with the presence of IL-4 and TGF-β; both cytokines were significantly increased in pSS at mRNA and protein level. Among infiltrating immune cells, CD19+ B cells resulted the major source of IL-40. However, we identified CD4+, CD8+ T cells and CD68+ macrophages as additional producers of IL-40 in both FACS and IF analysis. The ELISA test also showed a significant increase of serum IL-40 concentration in pSS patients (p value = 0.0190), compared to controls.Conclusion:Our preliminary results suggest that IL-40 may play a role in the pathogenesis of pSS and pSS-associated NHL. To the best of our knowledge, this is the first demonstration of the overexpression of this cytokine in salivary gland tissue and sera in pSS. Moreover, we demonstrated that IL-40 is produced by several cellular types, such as T cells and macrophages, and is not exclusively released by B cells. Further studies are necessary to clarify IL-40 pathways and functions in order to unravel IL-40 possible role in pSS development.References:[1]Mariette X, Criswell LA. Primary Sjogren’s Syndrome. N Engl J Med. 2018;379(1):97.[2]Catalan-Dibene J, Vazquez MI, Luu VP, Nuccio SP, Karimzadeh A, Kastenschmidt JM, et al. Identification of IL-40, a Novel B Cell-Associated Cytokine. J Immunol. 2017;199(9):3326-35.Figure 1.IL-40 overexpression in pSS and pSS-associated lymphoma A, Salivary gland biopsies stained for IL-40 showing a marked increase in IL-40 expression in presence of higher focus score. B, Parotid gland specimens of pSS-associated lymphoma showing intense staining for IL-40.Disclosure of Interests:Chiara Rizzo: None declared, Marianna Lo Pizzo: None declared, Leila Mohammadnezhad: None declared, Vincenzo Luca Lentini: None declared, Diana Di Liberto: None declared, Giulia Grasso: None declared, Piero Ruscitti Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly, Rorberto Giacomelli Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly, francesco ciccia Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly, Giuliana Guggino Consultant of: Pfizer, Novartis, Celgene, Abbvie, Roche, Lilly

OP0041 SALIVA AND SERUM LEVELS OF CXCL13: ASSOCIATION WITH THE SEVERITY OF SALIVARY GLAND LESIONS AND LYMPHOMA IN PATIENTS WITH SJÖGREN’S SYNDROME (SS)

Background:CXCL13 has been implicated in the formation of ectopic germinal centers (GC) in minor salivary gland (MSG) inflammatory lesions of SS patients. Recent studies suggest that serum CXCL13 levels associate with disease severity and risk for non-Hodgkin’s lymphoma (NHL) development.Objectives:To validate the clinical utility of CXCL13 by investigating potential associations of saliva and serum CXCL13 levels with various histopathologic (including severity of MSG autoimmune infiltrates and GC formation), serologic and clinical features of the disease, as well as NHL.Methods:CXCL13 levels were measured by a commercially available ELISA (sensitivity: 1 pg/ml; Abcam, Cambridge, UK) in paired serum and saliva specimens from 25 SS patients (9 with NHL; SSL), 9 sicca controls (SC; sicca-complaining individuals with no infiltrates in diagnostic MSG biopsy and negative autoantibody profile) and 6 healthy controls (HC). From the 16 SS patients without evidence of NHL, 5 had mild, 6 intermediate and 5 severe lesions at MSGs, as arbitrarily defined by focus (FS) and Tarpley (TS) biopsy scores (mild: FS:1-1.7, TS:1, intermediate: FS:1.8-2.95, TS:2 and severe: FS: 3.0-11, TS: 3-4). Furthermore, the organization of the MSG infiltrates to GCs has been evaluated in 23 patients revealing 10 with GCs.Results:Kruskal-Wallis analysis revealed that serum CXCL13 levels were significantly increased in SS patients without or with NHL (median: 94.83 pg/ml and 96.70 pg/ml, respectively), compared to SC and HC (35.44 and 40.92 pg/ml respectively; p<0.05), whereas saliva levels were only marginally increased (76.47, 84.10, 55.98 and 65.30 pg/ml in SS, SSL, SC and HC, respectively, p=0.051). Among SS patients with distinct MSG lesion severity, only those with severe lesions were found to express significantly higher serum CXCL13 levels (149.3 pg/ml) from SC and HC (p: 0,0051 and 0.0166, respectively). Spearman’s Rank correlation analysis showed that both serum and saliva levels correlated with SG biopsy focus score (r: 0.6889, p=0.0001 and r: 0.4222, p=0.01, respectively). Mann-Whitney test revealed that serum CXCL13 levels were significantly elevated in patients with GCs at MSG lesions (156.1 vs 69.64 pg/ml, p:0.0015), rheumatoid factor (105.0 vs 53.72 pg/ml, p: 0.015) and marginally with anti-Ro/La antibodies (121.8 vs 65.05 pg/ml, p: 0.06) compared to those without. Furthermore, CXCL13 levels were significantly increased in SS patients at high risk to develop NHL compared to low risk (149.3 vs 71.54 pg/ml, respectively, p: 0.0275). Saliva levels were not found to associate with the studied features.Conclusion:Serum and to a lesser extend saliva CXCL13 levels are increased in SS and SSL patients and associate with the degree of MSG infiltration, as assessed by focus score. Serum, but not saliva, CXCL13 associates with various disease features, including GC formation, and may have a clinical utility in identifying SS patients at high risk to develop lymphoma.Disclosure of Interests:None declared

POS0778 ULTRA HIGH-RESOLUTION ULTRASOUND (UHFUS) OF LABIAL GLANDS IS A STRONG PREDICTOR OF SALIVARY GLAND HISTOPATHOLOGY IN SJÖGREN’S SYNDROME (PSS)

Background:Last-generation ultra high-resolution ultrasound (UHFUS) transducers, producing frequencies up to 70 MHz and achieving tissue resolution up to 30 μm, are opening up new possibilities for the study of labial salivary glands (LSG) in patients clinically suspected with primary Sjögren’s syndrome (pSS).Objectives:To explore the value of LSG-UHFUS as a predictor of the intensity of the histological inflammation in LSG biopsy in an inception cohort of patients with sicca symptoms derived from daily clinical practice.Methods:Consecutive patients undergoing a LSG for clinically suspected pSS were included in this study from January 2018 to October 2020. UHFUS of LSG was performed by using VEVO MD, equipped with a 70 MHz probe, scanning first the central compartment of the inferior lip, and then both peripheral compartments. Parenchymal homogeneity was graded on a scale of 0 (normal) to 3 (evident). UHFUS imaging was used to locate the LSG for the US-guided biopsy. For each of the LSG specimens the area of the glandular tissue, the presence and number of foci and the focus score (FS) were assessed. Immunostaining for CD21 was performed to evaluate the presence of follicular dendritic cells (FDC) in foci.Results:We included a total of 171 patients with suspected pSS: out of them, 83 (48.5%) received a diagnosis of pSS (ACR 2016 criteria) and 88 (51.5 %) were diagnosed as no-SS sicca controls. Out of the 171 LSG biopsies, 73/171 (42.7%) were characterized by a nonspecific chronic sialadenitis (NSCS) whereas a focal lymphocytic sialadenitis (FLS) was described in the remaining 98/171 (57.3%). UHFUS-LSG scores were differently distributed in pSS patients with respect to no-SS sicca controls: a score 0 was detected in 16/88 no-SS sicca controls and in none of the 83 pSS patients, whereas a score 3 was detected in 12/83 pSS and in none of no-SS sicca controls. (p<0.001). The higher was the UHFUS grading, the higher was the number of foci (from a mean (S.D) = 0.38 (0.72) in UHFUS-score 0 to 4.58 (3.11) in UHFUS-score 3, p<0.001) and the focus score (from 0.17 (0.32) in UHFUS-score 0 to 1.88 (0.90) in UHFUS-score 3, p<0.001) of the samples. Overall, out of the 16 no-SS controls with LSG-UHFUS score 0, only 4/16 showed histological features of focal lymphocytic infiltrate; however, the mean FS of those 4/16 samples was 0.17 (0.32). In fact, considering a FS≥1, negative UHFUS-LSG was highly predictive of a negative histology (100 %). By contrast, out of the 12 pSS patients with the highest score at LSG-UHFUS (score 3), 10/12 presented FDC networks in their biopsies, with a positive predictive value of 83% of the severity of the infiltrate.Conclusion:UHFUS of LSG appeared feasible and sensitive in pSS; due to its striking negative predictive value this novel tool can help to identify negative patients on subsequent lip biopsy, thus avoiding invasive procedures in selected cases. Besides its diagnostic role, considering the association with the presence of FDC networks, UHFUS-LGS may also have a role in patients prognostic stratification.Disclosure of Interests:None declared

OP0291 SEVERITY OF LABIAL MINOR SALIVARY GLAND FOCUS SCORE AND FUTURE LYMPHOMA DEVELOPMENT IN SJÖGREN’S SYNDROME

Background:The typical histologic picture of focal sialadenitis in the labial minor salivary gland (LMSG) tissues has been incorporated as a parameter in the majority of Sjögren’s syndrome (SS) classification criteria, with focus score (FS) being the most widely used (1). In previous studies, higher FS has been associated with the presence of autoantibodies and extra-glandular manifestations including lymphoma, implying that FS can predict severe disease (2,3). However, there are no studies exploring the association of FS with lymphoma development along with the time interval from SS diagnosis to lymphoma diagnosis.Objectives:To investigate an association of focus score grading with lymphoma development and time to lymphoma occurrence.Methods:From a total population 1998 consecutive patients fulfilling the 2016 ACR-EULAR criteria for SS who were followed-up in 5 Rheumatology centers from Greece and Italy (Universities of Athens, Pisa, Udine, Harokopio and Ioannina) (UPAHI group), those with positive (LMSG) (FS ≥1) were identified. (1). Patients who had not been subjected to an LMSG biopsy or had a negative biopsy (FS<1) or the biopsy was evaluated using other histologic classifications were excluded from the present study. Lymphoma patients with diagnostic LMSG biopsy performed within a year from lymphoma diagnosis as well as non-lymphoma patients with less than 1 year between SS diagnosis and their last follow up, were also excluded. Cumulative clinical and histologic data attributed to SS as defined by ESSDAI and/or ESSPRI, up to lymphoma diagnosis or last follow up, were recorded. A combined data driven Fast Correlation Based Feature selection (FCBF)/Logistic Regression (LR) model was applied on the unified dataset to identify independent lymphoma associated risk factors. A correlation between FS and time interval until lymphoma diagnosis was performed using the Pearson formula.Results:A unified dataset of 618 SS patients with FS≥1 and at least one year of disease duration from SS diagnosis to lymphoma diagnosis or last follow up, with 30 clinical, laboratory and histologic features, was constructed. The median age at SS diagnosis was 53 (range: 15 – 80) years old, the female to male ratio was 20:1 and the median disease duration was 6 years (range: 1-35). Half (49%) of the study population had focus score between one and two (1≤FS<2), followed by a declining proportion of patients accounted for every subsequent escalating FS group. No statistically significant difference was found regarding disease duration among the various FS escalating groups (p= 0.1603, Kruskal-Wallis test). Fifty eight patients had lymphoma with no statistically significant difference in disease duration compared to non-lymphoma controls. The data driven FCBF/LR algorithm with lymphoma on the whole dataset revealed that cryoglobulinemia (p=0.021), salivary gland enlargement (p=0.008) and FS (p=0,049) are independent lymphoma associated risk factors. A statistically significant negative correlation was found using a Pearson formula (R=-0.32 and p=0.015) regarding the focus score and the time to lymphoma diagnosis.Conclusion:This is the largest study of SS patients’ histologic analysis exploring the association of LMSG FS grading with lymphoma development and the time interval until its diagnosis. Higher FS values correlate with increased lymphoma risk and early lymphoma occurrence.Figure 1.Pearson correlation between FS and time interval until lymphoma diagnosisReferences:[1]Shiboski et al. Arhtritis Rheumatol. 2017[2]Carrubi et al. Lupus 2015[3]Risselada AP et al. Ann Rheum Dis 2014Disclosure of Interests:None declared