OP0004 AUTOMATED RECOGNITION AND MONITORING OF DORSAL SKIN FOLDS BY A CONVOLUTIONAL NEURAL NETWORK AS A POTENTIAL DIGITAL BIOMARKER FOR JOINT SWELLING IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

To monitor rheumatic diseases, digital biomarkers such as wearables are of increasing interest, but they lack disease specificity.

Objectives

In this study, we apply convolution neural networks (CNN) to real world hand photographs in order to automatically detect, extract and analyse dorsal finger folds lines as a correlate of proximal interphalangeal (PIP) joint swelling in patients with rheumatoid arthritis (RA).

Methods

Hand photographs from 190 RA patients were taken by a smartphone camera in a standardized manner. PIP joints were categorised as either swollen or not swollen based on clinical judgement and ultrasound. Images were automatically preprocessed by cropping PIP joints and extracting dorsal finger folds. Subsequently, metrical analysis of dorsal finger folds was performed and a CNN was trained to classify the dorsal finger lines into swollen versus non-swollen joints. Representative horizontal finger folds were also quantified in a subset of patients before and after resolution of PIP swelling and in patients with disease flares, respectively.

Results

In swollen joints, the number of automatically extracted double-contoured, deep skinfold imprints was significantly reduced compared to non-swollen joints (1.3, SD 0.8 vs. 3.3, SD 0.49). The joint diameter / deep skinfold ratio was significantly higher in swollen (4.1, SD 1.4) versus non-swollen joints (2.1 SD 0.6). The CNN model successfully differentiated swollen from non-swollen joints based on finger fold patterns with a validation accuracy of 0.84. A heatmap of the original images obtained by an extraction algorithm confirmed finger folds as the region of interest for correct classification. After significant response to DMARD +/- corticosteroid therapy, longitudinal metrical analysis of eight representative deep finger folds showed a decrease of the mean diameter/ finger fold length (finger fold index, FFl) from 3.03 (SD 0.68) to 2.08 (SD 0.57). Conversely, the FFI increased in patients with a flare of joint swelling.

Conclusion

Automated preprocessing and the application of CNN algorithms in combination with longitudinal metrical analysis of dorsal finger fold patterns extracted from real world hand photos might serve as a digital biomarker in RA.

Figure 1.

Automated finger fold recognition to monitor rheumatoid arthritis (RA). Hand photographs are taken by a smartphone (A). Hands, and subsequently proximal interphalangeal (PIP) joints, are automatically recognized and extracted. Finger fold lines are isolated from the images, measured and related to the joint diameter (B,C). A convolutional deep neural network was used to train a model for classification of extracted finger fold patterns into swollen vs. non swollen joints (D). On cropped PIP joint images, the heatmap of the same classification task confirms finger folds as the region of interest (E).

Disclosure of Interests

Thomas Hügle Shareholder of: Atreon SA., Speakers bureau: Multiple. Not relevant for this work., Grant/research support from: Multiple. Not for this work., Leo Caratsch: None declared, Matteo Matteo Caorsi Employee of: MC is an employee of L2F., Jules Maglione: None declared, Diana Dan: None declared, Alexandre Dumusc Speakers bureau: Multiple. Not relevant for this work., Marc Blanchard Shareholder of: Atreon SA., Gabriel Kalweit: None declared, Maria Kalweit: None declared.

AB1066 TREATMENT OF ACUTE CALCIUM DEPOSITS IN HAND AND WRIST WITH ANAKINRA

Background

Acute calcium deposits (ACD) of hydroxyapatite in hand and wrist are a rare cause of acute pain due to crystal-induced soft tissue inflammation. There are no standard management guidelines for this condition, which is frequently treated with non-steroid anti-inflammatory drugs or steroid infiltrations with variable efficacy, some patients presenting symptoms for several months1. Anakinra, an interleukin-1 receptor antagonist, showed non-inferiority compared to usual care in the treatment of acute gout arthritis in a randomized controlled study2 and demonstrated effectiveness in comorbid patients with recurrent crystal-related arthritis. Due to our local experience with anakinra to treat calcific periarthritis3, we started using anakinra in the treatment of selected patients with ACD in hand and wrist with severe pain.

Objectives

To report our experience with anakinra to treat ACD in hand and wrist in terms of efficacy and safety.

Methods

We retrospectively included all patients treated with anakinra for ACD in hand or wrist in our department in 2020. We extracted data on treatment duration, pain, range of motion, skin erythema, hypervascularization, oedema and X-ray findings when available.

Results

Ten patients (mean age 45, SD 11) were treated for ACD in hand or wrist with anakinra 100 mg per day for a mean duration of 2.7 days. We observed a fast and significant improvement of pain at rest on a 0-10 VAS scale (mean pain reduction at day 2 (SD): -3.9 (2.8), p=0.01). All patients were free of pain at rest after day 6 and at motion after day 21. Range of motion significantly improved at day 2 (+41° (24), mean (SD), p=0.03). We observed local erythema and oedema improvement from day 2 and a decrease in skin temperature from day 3. Calcifications decreased in size or disappeared in the majority of the patients. We did not observe any adverse events. Patients did not report recurrence after phone contact, 12 months after treatment.

Conclusion

Anakinra was associated with a significant clinical improvement after only two days of treatment of ACD in hand or wrist and may be considered to treat patients with this condition, especially those with contraindication to NSAIDs or glucocorticoids. Further controlled studies are needed to confirm our observations.

References

[1]Nikci V, Doumas C. Calcium deposits in the hand and wrist. J Am Acad Orthop Surg. 2015, 23: 87-94.

[2]Janssen CA, Oude Voshaar MAH, Vonkeman HE, et al. Anakinra for the treatment of acute gout flares: a randomized, double-blind, placebo-controlled, active-comparator, non-inferiority trial. Rheumatology. 2019 Jan 2.

[3]Zufferey P, Valcov R, Thomas M, et al. Efficacy of anakinra in acute hydroxyapatite calcification-induced joint pain: A retrospective study of 23 cases. Joint Bone Spine. 2019, 86: 83-8.

Figure 1:

Graph 1. Box plot of pain at rest (0-10 VAS scale) and range of motion (ROM) at day 0, 1, 2, 3, 7 and 21 after treatment with anakinra 100 mg per day.

Disclosure of Interests

None declared

POS1415 SOCIO-ECONOMIC IMPACT OF SJÖGREN’S SYNDROME IN WESTERN SWITZERLAND: A CROSS-SECTIONAL STUDY

Background:

Several studies investigated the socio-economic impact of Sjögren’s syndrome (SS) showing an increased risk of work disability and a reduced health-related quality of life. SS is also associated with increased direct and indirect healthcare costs. There are no published data about Switzerland, a country with high resources and easy access to healthcare except dental care, which is rarely reimbursed.

Objectives:

To evaluate the professional and economic impact of SS in patients living in Western Switzerland.

Methods:

Cross-sectional survey-based study conducted in December 2020, during the pandemic. Patients suffering from SS and living in Western Switzerland (Geneva and Lausanne region) were invited by the regional association of patients with SS to complete a survey assessing the socio-economic impact of SS.

Results:

Among the 86 patients who were contacted, 55 (64%) completed the survey. Participants were predominantly female (95%) with a mean (SD) age of 54.2 (12.3). Mean (SD) EULAR SS Patient Reported Index (ESSPRI) was 6.5 (1.6), assessing pain, fatigue and dryness.

In the working age population (under 65, n=39), 64% of the participants reported to be employed, 88% of whom working part-time. They reported to work 23.3 (10.1) hours per week (mean, SD). 60% reported SS-related work incapacity periods during the past year. 72% of participants had to reduce their working hours and 27% had to change careers due to their medical condition. 16% benefited from an adaptation of their workstation to their health status.

In terms of work disability, 27% of the participants depended on disability insurance pension, of whom 38% received a full pension. 16% of the participants applied for a disability pension and were waiting for an administrative decision. A minority of participants (11%) reported to receive a minimum subsistence allowance from the local social service.

Participants estimated to pay 2752 CHF (3000) per year (median, IQR) out of their own pocket (Swiss monthly median wage: 6500 CHF) for health care not covered by health insurances. 95% of the patients had to pay for dental medicine costs, at least partially. Public health insurance contributed to dental costs for 44% of the patients and private health insurance for 28% of them. 22% of the patients reported to limit dental care for financial reasons.

Conclusion:

Two-thirds of the patients with SS remained in active employment, but the majority of them working in part-time, with a substantial loss of income. One third of the patients are work disabled and depend on a disability pension. Dental care was not reimbursed in half of the patients by their health insurance, leading to dental care access restriction for 20% of the patients with SS. Despite a relatively high wage level in Switzerland, SS represents a substantial financial burden for most of the patients.

References:

[1]Mandl T, Jørgensen TS, Skougaard M, Olsson P, Kristensen LE. Work Disability in Newly Diagnosed Patients with Primary Sjögren Syndrome. J Rheumatol. 2017 Feb;44(2):209-215.

[2]Meijer JM, Meiners PM, Huddleston Slater JJ, Spijkervet FK, Kallenberg CG, Vissink A, Bootsma H. Health-related quality of life, employment and disability in patients with Sjogren’s syndrome. Rheumatology. 2009 Sep;48(9):1077-82.

[3]Westhoff G, Dörner T, Zink A. Fatigue and depression predict physician visits and work disability in women with primary Sjögren’s syndrome: results from a cohort study. Rheumatology. 2012 Feb;51(2):262-9.

[4]Miyamoto ST, Valim V, Fisher BA. Health-related quality of life and costs in Sjögren’s syndrome. Rheumatology. 2019 Feb 15:key370. doi: 10.1093/rheumatology/key370. Epub ahead of print.

Disclosure of Interests:

None declared

FRI0522 OPIOIDS PRESCRIPTION AT DISCHARGE IN HOSPITALIZED PATIENTS: AN ANALYSIS FROM A RHEUMATOLOGY WARD OF A SWISS TERTIARY HOSPITAL

Background:

Opioids prescription for non-cancer pain has come under intense scrutiny as opioids abuse has become a major public health issue. Chronic opioid use is common among patients with rheumatic diseases. There are data showing that opioids are associated with a higher mortality in osteoarthritis patients receiving joint replacement. However, more data are needed on opioids use and prescription in rheumatology inpatients [1].

Objectives:

To evaluate inpatient characteristics on opioid prescription at discharge from our rheumatology ward in 2017 and 2019.

Methods:

We prospectively recorded analgesics prescription patterns of paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), weak opioids (tramadol/codeine) and strong opioids at discharge for all patients hospitalized in the Rheumatology Department from May to October 2017 and from October to December 2019. Statistical analyses consisted of descriptive statistics and univariate/multivariate logistic regression. P≤0.05 was considered statistically significant.

Results:

We analysed 240 hospital inpatient stays of 223 patients (mean age 64 years). At discharge, 25% of patients were respectively on weak opioids (tramadol/codeine) and 23% were on strong opioids, at a fixed dosage.

Overall, a minority of patients were on opioids monotherapy (20% for weak opioids and 22% for strong opioids), the majority receiving combined treatments with WHO class I analgesics.

The highest rate of opioids prescription at discharge was observed in patients hospitalized for severe low back pain (40%) and osteoporotic fracture (30%). At discharge, all patients transferred to a nursing home and 35% of patients transferred to a transitional care unit were on opioids compared to only 16% of the patients discharged home. The majority of patients being on opioids when transferred to a transitional care unit were prescribed opioids when discharged home (86%).

Opioids prescription at discharge was negatively associated with home discharge in multivariate analysis (0.23, 0.09 to 0.55, adjusted OR, 95%CI), Table 1. There was no significant association between inpatient stay length and opioids prescription at discharge. Between 2017 and 2019, we observed a non-significant decrease in opioids prescription at discharge (absolute difference -4.7%).

Conclusion:

Analysis of opioids prescription from a Swiss rheumatology service of a tertiary hospital show frequent opioids prescription at inpatients discharge, mainly for non-inflammatory disorders. Opioids prescription negatively predict home discharge.

References:

[1] Kim, S.C., Solomon, D.H. Towards defining the safer use of opioids in rheumatology. Nat Rev Rheumatol 16, 71–72 (2020).

Disclosure of Interests:

Alexandre Dumusc: None declared, Flore Valerio: None declared, Thomas Hügle Grant/research support from: Abbvie, Novartis, Consultant of: Abbvie, Pfizer, Novartis, Roche, Lilly, BMS

ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Soluble immune effector molecules [II]: agents targeting interleukins, immunoglobulins and complement factors)

BACKGROUND

The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies.

AIMS

To review, from an Infectious Diseases perspective, the safety profile of agents targeting interleukins, immunoglobulins and complement factors and to suggest preventive recommendations.

SOURCES

Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family.

CONTENT

Patients receiving interleukin-1 (IL-1) -targeted (anakinra, canakinumab or rilonacept) or IL-5-targeted (mepolizumab) agents have a moderate risk of infection and no specific prevention strategies are recommended. The use of IL-6/IL-6 receptor-targeted agents (tocilizumab and siltuximab) is associated with a risk increase similar to that observed with anti-tumour necrosis factor-α agents. IL-12/23-targeted agents (ustekinumab) do not seem to pose a meaningful risk of infection, although screening for latent tuberculosis infection may be considered and antiviral prophylaxis should be given to hepatitis B surface antigen-positive patients. Therapy with IL-17-targeted agents (secukinumab, brodalumab and ixekizumab) may result in the development of mild-to-moderate mucocutaneous candidiasis. Pre-treatment screening for Strongyloides stercoralis and other geohelminths should be considered in patients who come from areas where these are endemic who are receiving IgE-targeted agents (omalizumab). C5-targeted agents (eculizumab) are associated with a markedly increased risk of infection due to encapsulated bacteria, particularly Neisseria spp. Meningococcal vaccination and chemoprophylaxis must be administered 2-4 weeks before initiating eculizumab. Patients with high-risk behaviours and their partners should also be screened for gonococcal infection.

IMPLICATIONS

Preventive strategies are particularly encouraged to minimize the occurrence of neisserial infection associated with eculizumab.

[Elbow tendinopathy]

The lateral and medial epicondylitis is often manifested in a professional or in a sport context leading to repetitive wrist movements. The diagnosis is primarily clinical. Additional tests are indicated in chronic evolution and in searching for differential diagnoses. Elbow X-ray can be completed with ultrasound or MRI, the most efficient but expensive diagnostic procedure. There is no consensus on treatment. After a period of rest, stretching then strengthening exercises are recommended. Corticosteroid injections may provide a short-term beneficial effect. Platelet-Rich Plasma injections have recently gained notoriety. In case of failure of treatment, surgery is possible, but only in a minority of patients.

[Complications and systemic manifestations of rheumatoid arthritis]

Rheumatoid arthritis (RA), in addition to the traditional joint damage can affect all organs as a systemic disease. Extra-articular manifestations of RA are highly variable ranging from rheumatoid nodules (most common) to rheumatoid vasculitis presenting a significant morbidity and mortality (49% at 5 years). With the new algorithms of treatment (earlier) and the use of biologics, the incidence of severe extra-articular manifestations decreases. Regarding the treatment of rheumatoid vasculitis, rituximab looks promising. RA also increases cardiovascular risk and the risk of osteoporosis. It is therefore important to identify these risks and, if appropriate, treat them. Collaboration with the general practitioner is essential in this situation.