ACR Meeting Abstracts

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Abstracts tagged "COVID-19"

  • Abstract Number: L03 • ACR Convergence 2021

    COVID-19 Vaccine Antibody Responses in Patients Treated with B-Cell Agents Depend on B-Cell Counts at Time of Vaccine

    Kyriakos Kirou and Jeffrey Zhang-Sun, Hospital for Special Surgery, New York, NY

    Background/Purpose: Optimal COVID-19 vaccine responses are necessary to protect against severe infection. Patients with systemic rheumatic diseases (SRD) are at risk for not mounting adequate…
  • Abstract Number: L04 • ACR Convergence 2021

    SARS-CoV-2 Infections Among Vaccinated Individuals with Rheumatic Disease: Results from the COVID-19 Global Rheumatology Alliance Provider Registry

    Jean Liew1, milena Gianfrancesco2, Carly Harrison3, zara Izadi2, Stephanie Rush2, Lindsay Jacobsohn2, Clairissa Ja2, Saskia Lawson-Tovey4, Kimme Hyrich5, Laure Gossec6, Anja Strangfeld7, Loreto Carmona8, Martin Schaefer7, ELSA MATEUS9, Samar Al Emadi10, Claire Cook11, Fatemah Abutiban12, Dfiza Dey13, Emily Kowalski14, Marco Martinez-Martinez15, Naomi Patel11, Evelyn Salido16, Jeffrey Sparks17, leanna Wise18, Suleman Bhana19, Wendy Costello20, Rebecca Grainger21, Jonathan Hausmann22, Emily Sirotich23, Paul Sufka24, Zachary Wallace25, Pedro Machado26, Philip Robinson27 and Jinoos Yazdany2, 1Boston University School of Medicine, Boston, MA, 2University of California San Francisco, San Francisco, CA, 3Lupus Chat, New York, NY, 4Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom, 5Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom, 6INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Sorbonne Universite, Paris, France APHP, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France, Paris, France, 7German Rheumatism Research Center (DRFZ Berlin), Epidemiology and Health Care Research, Berlin, Germany, 8Instituto de Salud Musculoesquelética, Madrid, Spain, 9EULAR, Lisboa, Portugal, 10Hamad Medical Corporation, Doha, Qatar, 11Massachusetts General Hospital, Boston, MA, 12Rheumatology Unit, Department of Medicine, Jaber Alahmed Alsabah Hospital, KUWAIT, Kuwait, 13Rheumatology Unit , Department of Medicine and Therapeutics, University of Ghana Medical School, Korle Bu Teaching Hospital, Accra, Ghana, 14Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, 15Instituto Mexicano del Seguro Social, San Luis Potosí, Mexico, 16University of the Philippines Manila, Manila, Philippines, 17Brigham and Women's Hospital, Boston, MA, 18University of Southern California, Los Angeles, CA, 19Pfizer, Montvale, NJ, 20Irish Children's Arthritis Network (iCAN), Bansha, Ireland, 21University of Otago, Wellington, New Zealand, 22Boston Childrens Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 23McMaster University, Hamilton, ON, Canada, 24HealthPartners, Eagan, MN, 25Massachusetts General Hospital, Harvard Medical School, Boston, MA, 26Centre for Rheumatology & Department of Neuromuscular Diseases, University College London; National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust; Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, United Kingdom, 27University of Queensland School of Clinical Medicine, Herston, Queensland; Department of Rheumatology, Royal Brisbane and Women’s Hospital, Metro North Hospital and Health Service, Queensland, Australia., Brisbane, Australia

    Background/Purpose: While COVID-19 vaccinations are a critical tool to prevent severe infections, poor immunogenicity in immunocompromised people threatens vaccine effectiveness. We analyzed clinical characteristics of…
  • Abstract Number: L09 • ACR Convergence 2021

    A Prediction Model to Distinguish Patients with Multisystem Inflammatory Syndrome in Children

    Matthew Clark1, Danielle Rankin2, Alisa Gotte1, Alison Herndon1, William McEachern1, Andrew Smith3, Daniel Clark1, Edward Hardison1, Anna Patrick1, Lauren Peetluk1, Natasha Halasa1, James Connelly1 and Sophie Katz1, 1Vanderbilt University Medical Center, Nashville, TN, 2Vanderbilt University, Nashville, TN, 3The Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL

    Background/Purpose: Multisystem inflammatory syndrome in children (MIS-C) is a rare consequence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). MIS-C shares features with common infectious and…
  • Abstract Number: L16 • ACR Convergence 2021

    Breakthrough COVID-19 Infections Post-vaccination Among Immunocompromised Patients with Autoimmune or Inflammatory Rheumatic Diseases: A Retrospective Cohort Analysis from a U.S. Nationally-sampled Electronic Medical Record Data Repository

    Jasvinder Singh1, Namrata Singh2, Alfred Anzalone3, Amy Olex4, Jing Sun5, Vithal Madhira6 and Rena Patel7, 1University of Alabama at Birmingham, Birmingham, AL, 2University of Washington, Bellevue, WA, 3University of Nebraska, Omaha, NE, 4Virginia Commonwealth University, Richmond, VA, 5Johns Hopkins University, Baltimore, MD, 6Palila Software, Reno, NV, 7Unviersity of Washington, Seattle, WA

    Background/Purpose: National U.S. data on breakthrough COVID-19 infection in people with autoimmune or inflammatory rheumatic diseases (AIRD) are limited. Our objective was to assess whether breakthrough COVID-19 infections were increased post-COVID-19-vaccination…
  • Abstract Number: 0091 • ACR Convergence 2021

    Vaccination of Patients with Chronic Inflammatory Rheumatic Diseases: An Analysis of Barriers and Facilitators in a Prospective Cohort

    Ioana Andreica, Iulia Roman, Xenofon Baraliakos, Juergen Braun and Uta Kiltz, Rheumazentrum Ruhrgebiet Herne, Ruhr-Universität Bochum, Herne, Germany

    Background/Purpose: Patients (pts.) with chronic inflammatory rheumatic diseases (CIRD) are often not adequately protected against infectious diseases. As shown in an earlier study, less than…
  • Abstract Number: 0108 • ACR Convergence 2021

    Efficacy of SARS-CoV-2 Vaccine in Patients with Rheumatic Diseases: A Systematic Review and Meta-Analysis

    Akhil Sood1, Vijaya Murthy1 and Emilio Gonzalez2, 1University of Texas Medical Branch, League City, TX, 2University of Texas Medical Branch (utmb Health), Galveston, TX

    Background/Purpose: The mRNA-based SARS-CoV-2 vaccine has shown efficacy in large vaccine trials. However, patients on immunosuppressive therapies including those with rheumatic disease (RD) were excluded.…
  • Abstract Number: 0437 • ACR Convergence 2021

    Factors Associated with Reduced Immunogenicity of the BNT162b2 mRNA COVID-19 Vaccine in Patients with Autoimmune Inflammatory Rheumatic Diseases (AIIRD) Treated with Rituximab

    Victoria Furer1, Tali Eviatar2, Devy Zisman3, Hagit Peleg4, Daphna Paran5, David Levartovsky1, Ilana Kaufman6, Michael Zisapel1, Ofir Elalouf7, Roni Meidan1, Adi Broyde8, Ari Polachek9, Jonathan Wollman7, Katya Meridor10, Hila Nochomovitz1, Adi Silberman1, Dana Rosenberg1, Joy Feld11, Amir Haddad12, Tal Gazitt13, Muna Elias3, Nizar Hijaze14, Fadi Kharouf4, Gabi Shefer1, Orly Sharon1, Sara Pel1, Sharon Nevo1 and Ori Elkayam15, 1Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 2Tel Aviv Sourasky Medical Center, Givataim, Israel, 3Carmel Medical Center, Haifa, Israel, 4Hadassah Medical Center, Jerusalem, Israel, 5Tel Aviv Sourasky Medical Center-Ichilov Hospital, Even Yehuda, Israel, 6Tel Aviv Sourasky Medical Center, Petach Tiqwa, Israel, 7Tel Aviv Medical Center, Herzliya, Israel, 8Tel Aviv Sourasky Medical Center, KIBBUTZ GIVAT HAIM I, Israel, 9Sourasky Medical Center, Petah-Tikva, Israel, 10Tel Aviv Sourasky Medical Center, Kfar Saba, Israel, 11Carmel and Zvulun Medical Centre, Haifa, Israel, 12Carmel Medical Centre, Haifa, Israel, 13Carmel Hospital, Haifa, Israel, 14Carmel medical centre, Tamra, Israel, 15Tel Aviv Medical Center, Tel Aviv, Israel

    Background/Purpose: Rituximab (RTX) has been associated with impaired humoral response to vaccination. This study aim was to identify the predictors for a lack of humoral…
  • Abstract Number: 0866 • ACR Convergence 2021

    Characteristics Associated with Poor COVID-19 Outcomes in People with Systemic Lupus Erythematosus (SLE): Data from the COVID-19 Global Rheumatology Alliance (GRA)

    Manuel Ugarte-Gil1, Graciela Alarcn2, Andrea Seet3, Zara Izadi3, Ali Duarte-Garcia4, Cristina Reategui-Sokolova5, Ann Clarke6, Leanna Wise7, Guillermo Pons-Estel8, Maria José Santos9, Sasha Bernatsky10, Sandra Lúcia Ribeiro11, Samar Al Emadi12, Jeffrey Sparks13, Tiffany Hsu14, Kristin D'Silva15, Naomi Patel15, Emily Gilbert16, Maria Valenzuela-Almada17, Andreas Jnsen18, Gianpiero Landolfi19, Micaela Fredi20, Tiphaine Goulenok21, Mathilde Devaux22, Xavier Mariette23, Viviane Queyrel24, Vasco C Romão25, Graça Sequeira26, Rebecca Hasseli27, Bimba Franziska Hoyer28, Reinhard Voll29, Christof Specker30, Roberto Baez31, Vanessa Castro Coello32, Edgard Neto33, Gilda Ferreira34, Odirlei Andre Monticielo35, Emily Sirotich36, Jean Liew37, Jonathan Hausmann38, Paul Sufka39, Rebecca Grainger40, Suleman Bhana41, Wendy Costello42, Zachary Wallace43, Lindsay Jacobsohn44, Anja Strangfeld45, Elsa Frazão Mateus46, Kimme Hyrich47, Laure Gossec48, Loreto Carmona1, Saskia Lawson-Tovey47, Lianne Kearsley-Fleet49, Martin Schaefer50, Pedro Machado51, Philip Robinson52, Milena Gianfrancesco3 and Jinoos Yazdany3, 1Hospital Guillermo Almenara Irigoyen, Essalud/Universidad Científica del Sur, Lima, Peru, 2University of Alabama at Birmingham, Birmingham, AL, 3University of California San Francisco, San Francisco, CA, 4Mayo Clinic, Rochester, MN, 5Hospital Guillermo Almenara Irigoyen, Lima, Peru, 6University of Calgary, Calgary, AB, Canada, 7LAC+USC/Keck Medicine of USC, Pasadena, CA, 8Centro Regional de Enfermedades Autoinmunes y Reumaticas (CREAR), Rosario, Argentina, 9Rheumatology Department, Hospital Garcia de Orta, Almada, Portugal, 10McGill University, Montréal, QC, Canada, 11Universidade Federal do Amazonas, Amazonas, Brazil, 12Hamad medical corporation, Doha, Qatar, 13Brigham and Women's Hospital, Boston, MA, 14Brigham and Women's Hospital, Jamaica Plain, MA, 15Massachusetts General Hospital, Boston, MA, 16Mayo Clinic, Jacksonville, FL, 17Division of Rheumatology, Mayo Clinic, Rochester, MN, 18Lund University, Lund, Sweden, 19Epidemiology Research Unit, Italian Society for Rheumatology, Milan, Italy, 20Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, Brescia, Italy, 21Internal Medicine Department, Bichat Claude Bernard Hospital, Paris, France, 22Service de Médecine Interne, CHI Poissy Saint Germain, Poissy, France, 23Université Paris- Saclay, Rheumatology, Paris, France, 24University Hospital of Nice, Nice, France, 25Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ERN-ReCONNET); Rheumatology Research Unit, Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal, 26Centro Hospitalar Universitário do Algarve, Unidade de Faro, Faro, Portugal, 27Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus Liebig University Giessen, Bad Nauheim, Germany., Bad Nauheim, Germany, 28Universittsklinikum Schleswig-Holstein, Kiel, Germany, 29Department of Rheumatology and Clinical Immunology, University Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany, 30Evangelisches Krankenhaus, Kliniken Essen-Mitte, Essen, Germany, 31Hospital Francisco Lopez Lima, General Roca, Rio Negro, Argentina, 32Sanatorio Güemes, Buenos Aires, Argentina, 33UNIFESP, São Paulo, Brazil, 34Federal University of Minas Gerais, Belo Horizonte, Brazil, 35Serviço de Reumatologia do Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, 36McMaster University, Hamilton, ON, Canada, 37Boston University, Boston, MA, 38Boston Children's Hospital / Beth Israel Deaconess Medical Center, Cambridge, MA, 39HealthPartners, Eagan, MN, 40University of Otago, Wellington, New Zealand, 41Crystal Run Health, Montvale, NJ, 42Irish Children's Arthritis Network, Bansha, Ireland, 43Massachusetts General Hospital, Newton, MA, 44University of California San Francisco, Antioch, CA, 45Deutsches Rheuma-Forschungszentrum Berlin, Berlin, Germany, 46Liga Portuguesa Contra as Doenças Reumáticas (LPCDR), Lisbon, Portugal, 47University of Manchester, Manchester, United Kingdom, 48Sorbonne Université; APHP, Rheumatology Department, Pitié-Salpêtrière Hospital, Paris, France, 49Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom, 50German Rheumatism Research Center, Berlin, Germany, 51Centre for Rheumatology & Department of Neuromuscular Diseases, University College London, London, United Kingdom, 52Faculty of Medicine, The University of Queensland, Herston, Australia

    Background/Purpose: Preliminary data in people with SLE suggested that disease activity as well as SLE treatment at time of COVID-19 acquisition impact COVID-19 outcomes over…
  • Abstract Number: 1066 • ACR Convergence 2021

    Evaluation of a Non-Face to Face Multidisciplinary Health Care Model in a Population with Rheumatoid ArthritisVulnerable to Covid-19 in a Health Emergency Situation

    Pedro Santos-Moreno1, Rosangela Casanova2, Gabriel-Santiago Rodríguez-Vargas2, Laura Villareal1, Jaime-Andrés Rubio2, Josefina Chávez-Chávez2, Diana Patricia Rivera-Triana2, Ruth Alexandra Castiblanco-Montañez2, Sandra Milena Hernández-Zambrano2 and Adriana Rojas-Villarraga2, 1BIOMAB IPS, Bogotá, Colombia, 2Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, Colombia

    Background/Purpose: The COVID-19 pandemic impacted everyday practice pattern of health care in rheumatoid arthritis (RA) patients. The objective was to evaluate the implementation of a…
  • Abstract Number: 1452 • ACR Convergence 2021

    COVID-19 Infection Among Autoimmune/Auto-inflammatory Rheumatic Disease Patients: Data from an Observational Study

    Clio Mavragani1, Athanasios-Dimitrios Bakasis2, Kyriaki Boki3, Athanasios Tzioufas4, Panayiotis Vlachoyiannopoulos1, Ioanna Stergiou5, Fotini Skopouli6 and Haralampos Moutsopoulos7, 1National and Kapodistrian University of Athens, Athens, Greece, 21 Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece, Athens, Greece, 33 Rheumatology Unit, Sismanoglio General Hospital, Athens, Greece, Athens, Greece, 4Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece, 5Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, 6Department of Nutrition and Clinical Dietetics, Harokopio University of Athens, Athens, Greece, 7Athens Academy of Athens, Chair Medical Sciences/Immunology, Athens, Greece

    Background/Purpose: The impact of COVID-19 infection in patients with autoimmune/auto-inflammatory rheumatic diseases (AARD) under immunomodulatory treatment is not entirely clear and deeper knowledge is of…
  • Abstract Number: 1544 • ACR Convergence 2021

    Clinical Course and Risk Factors for Severe/Critical COVID-19 in Patients with Rheumatic Diseases – a Multicenter, Nationwide Study

    Sofia Carvalho Barreira1, Ana Rita Cruz-Machado1, Matilde Bandeira1, Catarina Duarte2, Maria Rato3, Bruno Fernandes4, Salomé Garcia3, Filipe Pinheiro3, Miguel Bernardes3, Nathalie Madeira5, Cláudia Miguel5, Rita Torres6, Ana Bento Silva6, Jorge Pestana7, Diogo Almeida8, Carolina Mazeda9, Filipe Cunha Santos10, Patrícia Pinto11, Marlene Sousa12, Hugo Parente13, Graca Sequeira14, Maria José Santos7, João Eurico Fonseca15 and Vasco C Romão15, 1Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Center; Rheumatology Research Unit, Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal, 2Rheumatology Research Unit, Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal, 3Rheumatology Department, Centro Hospitalar Universitário de São João EPE, Porto, Portugal, 4Rheumatology Department, Centro Hospitalar Universitário de São João EPE, Braga, Portugal, 5Rheumatology Department, Instituto Português de Reumatologia, Lisbon, Portugal, 6Rheumatology Department, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal, 7Rheumatology Department, Hospital Garcia de Orta, Almada, Portugal, 8Rheumatology Department, Hospital de Braga, Braga, 9Rheumatology Department - Centro Hospitalar do Baixo Vouga and Ibimed, Institute for Biomedicine, University of Aveiro, Aveiro, Portugal, 10Rheumatology Department, Local Health Unit of Guarda, Guarda, Portugal, 11Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, Portugal, 12Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 13Rheumatology Department, Unidade Local de Saúde do Alto Minho, Ponte de Lima, Portugal., Ponte de Lima, Portugal, 14Rheumatology Department, Centro Hospitalar Universitário do Algarve, Faro, Portugal, 15Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ERN-ReCONNET); Rheumatology Research Unit, Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal

    Background/Purpose: Since the beginning of the COVID-19 pandemic, some studies have addressed risk factors for severe forms of the disease in patients with rheumatic diseases.…
  • Abstract Number: 1562 • ACR Convergence 2021

    B Cell Reconstitution Is Strongly Associated with COVID-19 Vaccine Responsiveness in Rheumatic Disease Patients Treated with Rituximab

    Sarah Jinich, Deanna Jannat-Khah and Robert Spiera, Hospital for Special Surgery, New York, NY

    Background/Purpose: Rituximab (RTX) has previously been shown to impair antibody response to vaccines such as influenza and streptococcus. Recently, diminished COVID-19 vaccine responsiveness in RTX…
  • Abstract Number: 1604 • ACR Convergence 2021

    Perceptions About COVID-19 Vaccination Among Patients with Rheumatic Diseases Enrolled in a National Patient Registry

    Maria I. Danila1, Kelly Gavigan2, Esteban Rivera2, Michael George3, Jeffrey Curtis4, William Nowell2 and Shilpa Venkatachalam2, 1University of Alabama at Birmingham, Birmingham, AL, 2Global Healthy Living Foundation, Upper Nyack, NY, 3University of Pennsylvania, Philadelphia, PA, 4Division of Clinical Immunology and Rheumatology, Department of Medicine, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL

    Background/Purpose: COVID-19 vaccine confidence is key to promoting vaccination efforts to mitigate the spread of COVID-19 among people with rheumatic diseases. The goal of this…
  • Abstract Number: 1640 • ACR Convergence 2021

    Multisystem Inflammatory Syndrome in Children at Two Tertiary Hospitals in Cape Town, South Africa: Clinical Phenotype and Distinguishing Features from Similar Acute Inflammatory Conditions

    Claire Butters1, Deepthi Abraham2, Heidi Facey-Thomas1, Debbie Abrahams1, Ayodele Faleye3, Helena Rabie2, Christiaan Scott4, Liesl Zühlke5 and Kate Webb6, 1Paediatric Rheumatology, University of Cape Town, Cape Town, South Africa, 2Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa, 3Lagos state university teaching hospital Ikeja, Lagos, Nigeria, 4University of Cape Town, Faculty of Health Science, Cape Town, South Africa, 5Paediatric Cardiology, University of Cape Town, Cape Town, South Africa, 6University of Cape Town, Cape Town, South Africa

    Background/Purpose: Distinguishing Multisystem Inflammatory Syndrome in Children (MIS-C) associated with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) from acute, pyrexial childhood illness can be challenging.…
  • Abstract Number: 0092 • ACR Convergence 2021

    Clinical Outcomes of Patients with Systemic Rheumatic Diseases Hospitalized for COVID-19 at a Large Academic Center in New York City

    Caroline Siegel1, Jacky Choi2, Debra D'Angelo2, Paul Christos2, Lindsay Lally1, Parag Goyal2, Lisa Mandl1 and Medha Barbhaiya1, 1Hospital for Special Surgery, New York, NY, 2Weill Cornell Medicine, New York, NY

    Background/Purpose: While patients with systemic rheumatic diseases (SRDs) are in general more vulnerable to infections due to their underlying immune dysregulation and immunomodulatory therapies, data…
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All abstracts accepted to ACR Convergence are under media embargo once the ACR has notified presenters of their abstract’s acceptance. They may be presented at other meetings or published as manuscripts after this time but should not be discussed in non-scholarly venues or outlets. The following embargo policies are strictly enforced by the ACR.

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