Neuropathic‐like pain symptoms in inflammatory hand osteoarthritis lower quality of life and may not decrease under prednisolone treatment

Background

Pain is common in hand osteoarthritis (OA) and multiple types may occur. We investigated the prevalence, associated patient characteristics, influence on health‐related quality of life (HR‐QoL) and response to anti‐inflammatory treatment of neuropathic‐like pain in inflammatory hand OA.

Methods

Data were analysed from a 6‐week, randomized, double‐blind, placebo‐controlled trial investigating prednisolone treatment in 92 patients with painful inflammatory hand OA. Neuropathic‐like pain was measured with the painDETECT questionnaire. Associations between baseline characteristics and baseline neuropathic‐like pain were analysed with ordinal logistic regression, association of baseline neuropathic‐like pain symptoms with baseline HR‐QoL with linear regression, painDETECT and visual analogue scale (VAS) change from baseline to week 6 and interaction of painDETECT with prednisolone efficacy on VAS pain change from baseline to week 6 with generalized estimating equations (GEE).

Results

Of 91 patients (79% female, mean age 64) with complete painDETECT data at baseline, 53% were unlikely to have neuropathic‐like pain, 31% were indeterminate and 16% were likely to have neuropathic‐like pain. Neuropathic‐like pain was associated with female sex, less radiographic damage and more comorbidities. Patients with neuropathic‐like pain had lower HR‐QoL (PCS‐6.5 [95% CI −10.4 to −2.6]) than those without. Neuropathic‐like pain symptoms remained under prednisolone treatment and no interaction was seen between painDETECT and prednisolone efficacy on VAS pain.

Conclusions

In this study, 16% of inflammatory hand OA patients had neuropathic‐like pain. They were more often female, had more comorbidities and had lower QoL than those without. Neuropathic‐like pain symptoms remained despite prednisolone treatment and did not seem to affect the outcome of prednisolone treatment.

Significance

Pain is the dominant symptom in hand OA, with an unclear aetiology. In this study, we found that neuropathic‐like pain may play a role in hand OA, that it showed associations with female sex, younger age and more comorbidities and that it lowered health‐related quality of life in hand OA. Neuropathic‐like pain in hand OA seems resistant to prednisolone therapy but did not seem to interfere with the treatment of inflammatory pain with prednisolone.

AB0384 THE EFFECT OF A LIFESTYLE PROGRAM ON PATIENTS AT RISK FOR RHEUMATOID ARTHRITIS:THE “PLANTS FOR JOINTS” PILOT RANDOMIZED CLINICAL TRIAL

Background

An unhealthy lifestyle increases the risk of developing rheumatoid arthritis (RA). Interventions including plant-based diets, physical activity, and stress management have shown benefits for RA patients but have not yet been evaluated in a program for patients at risk for RA.

Objectives

To investigate preliminary effectiveness of a multidisciplinary lifestyle program on RA risk in patients at risk for RA, in comparison to usual care.

Methods

In the “Plants for Joints” (PFJ) pilot RCT, patients with anti-citrullinated protein antibody (ACPA) positive arthralgia were randomized to the PFJ or control group. Both groups received usual care while the PFJ group additionally followed a 16-week lifestyle program based on a whole food plant-based diet, physical activity, and stress management.1 The primary outcome was risk of developing RA as quantified by the RA risk score (including family history, symmetry, stiffness, pain level, RF/ACPA level).2 The maximum score (13 points) was given to participants who developed RA. Secondary outcomes included self-reported pain intensity, inflammatory, anthropometric, and metabolic markers, and serum levels of ACPA and rheumatoid factor (RF). A linear mixed model for between group analysis was used, adjusted for baseline values.

Results

14 out of 17 included patients completed the study (all female, mean age 47 years). Three patients (n = 2 PFJ group, n = 1 control group) were diagnosed with RA after mean 9.6 weeks and remained in the study. After 16 weeks there was no significant difference in RA risk score between PFJ and control groups (Figure 1). Compared to the control group, the PFJ group had significantly lower fat mass and LDL-cholesterol after 16 weeks (Table 1). After the intervention the PFJ group had an average weight loss of 4.9 kg, of which 2.7 kg was fat mass.

Table 1.

Results reported as mean (SD) when normally distributed and median [Q1 – Q3] when skewed. P-value <0.05 = significant. RA = rheumatoid arthritis, ACPA = anti-citrullinated protein antibody, RF = Rheumatoid factor, ESR = erythrocyte sedimentation rate, CRP = C-reactive protein.

Plants for Joints group (n = 7)Control group (n = 7)BaselineWeek 16BaselineWeek 16p-valueRA risk and related outcomesRA risk score6.1 (1.4)8.6 (3.4)7.1 (1.4)8.3 (2.3)0.56Pain intensity4.9 (2.6)3.8 (1.9)5.7 (2.6)4.0 (2.1)0.74ACPA, kU/l330 [94 - 530]225 [116 - 550]256 [79 - 462]202 [94 - 403]0.86RF, kU/l13 [3 - 68]11 [3 - 56]12 [3 - 21]5 [4 - 12]0.96RA diagnosis, N0201-InflammationESR, mmol/hour9 [6 - 15]7 [6 - 9]7 [6 - 12]12 [8 -17]0.79CRP, mg/l0.7 [0.6 - 2.5]0.6 [0.6 - 1.2]3.0 [1.1 - 3.6]3.3 [1.3 - 6.7]0.58AnthropometricWeight, kg78.4 (18.6)73.5 (16.4)77.4 (16.2)77.0 (16.3)0.28BMI, kgm-226.8 (5.3)25.1 (4.5)28.2 (6.2)28.0 (6.0)0.23Fat mass, kg30.6 (14.3)27.9 (12.3)31.2 (12.8)29.8 (13.0)<0.01Waist circumference, cm87.9 (13.3)86.6 (11.6)91.6 (15.5)90.6 (16.1)0.33MetabolicLDL-cholesterol, mmol/l3.1 (0.87)2.83 (0.75)3.07 (0.36)3.05 (0.36)<0.01HbA1C, mmol/mol34.9 (3.2)34.4 (3.1)35.1 (3.0)36.9 (3.6)0.97

Conclusion

The results of this pilot study do not suggest the PFJ lifestyle program influenced RA risk score, pain, or autoantibody levels, although possible effects cannot be excluded due to the small sample size. However, metabolic health clearly improved in the PFJ group.

References

[1]Walrabenstein, Trials 2021

[2]van de Stadt, Ann Rheum Dis 2013

Acknowledgements

C. W. was funded by ZonMW (The Netherlands Organization for Health Research and Development) grant number 555003210.

Disclosure of Interests

Carlijn Wagenaar: None declared, Wendy Walrabenstein: None declared, Marieke van der Leeden: None declared, Franktien Turkstra: None declared, Jos Twisk: None declared, Maarten Boers Consultant of: Consultant for Novartis, Henriët van Middendorp: None declared, Peter Weijs: None declared, Dirkjan van Schaardenburg: None declared

AB0396 EFFECT OF A MULTIDISCIPLINARY LIFESTYLE PROGRAM IN PATIENTS WITH RHEUMATOID ARTHRITIS: THE PLANTS FOR JOINTS RANDOMIZED CONTROLLED TRIAL

Background

Lifestyle factors have been associated with the development and progression of rheumatoid arthritis (RA). Interventions involving whole food plant-based diets (WFPDs), physical activity or stress management have shown promising results for people with RA but were not yet evaluated in an integrated program.

Objectives

To determine the effect of a 16-week multidisciplinary lifestyle program on disease activity in patients with RA.

Methods

In the “Plants for Joints” (PFJ) parallel-arm, assessor-blind randomized clinical trial, patients with RA and a 28-joint Disease Activity Score [DAS28] score ≥ 2.6 and ≤ 5.1, were assigned to the PFJ group or the control group. The PFJ group followed a lifestyle program based on a WFPD, physical activity, and stress management in addition to usual care. The control group received usual care. Medication was kept stable three months before and during the trial. Secondary outcomes included anthropometric, and metabolic markers. An intention-to-treat analysis with a linear mixed model, adjusted for baseline values was used to analyze between-group differences of continuous outcomes.

Results

Of 115 people screened, 85 were randomized and 79 completed the study. Participants were 91% female with a mean (SD) age of 55 (12) and body mass index of 26 (4) kg/m2. After 16 weeks the PFJ group had a mean 0.85-point greater improvement of the DAS28 versus the control group (95% CI 0.40 to 1.30; p < 0.001) (Figure 1). Subgroup analyses showed significant improvements in the seropositive as well as the seronegative subgroup, although the effect was more profound in the seronegative group. Weight, fat mass, HbA1c, LDL and triglycerides also showed significant improvements in the PFJ versus control group, while blood glucose and HDL remained unchanged (Table 1). No serious adverse events occurred.

Conclusion

The 16-week PFJ lifestyle program substantially decreased disease activity in people with RA with low-moderate disease activity.

Disclosure of Interests

Wendy Walrabenstein: None declared, Carlijn Wagenaar: None declared, Marike van der Leeden: None declared, Franktien Turkstra: None declared, Jos Twisk: None declared, Maarten Boers Consultant of: Consultant for Novartis, Henriët van Middendorp: None declared, Peter Weijs: None declared, Dirkjan van Schaardenburg: None declared

POS0123 NEUROPATHIC PAIN SYMPTOMS IN INFLAMMATORY HAND OSTEOARTHRITIS(OA) LOWERS HEALTH RELATED PHYSICAL QUALITY OF LIFE AND MAY REQUIRE ANOTHER APPROACH THAN ANTI-INFLAMMATORY TREATMENT

Background:

Pain is a common, difficult to manage symptom in hand osteoarthritis (OA). Multiple pain mechanisms may play a role in hand OA.

Objectives:

To investigate presence of neuropathic pain symptoms in patients with inflammatory hand OA, characteristics of those patients, their impact on health related quality of life (HR-QoL), and the influence of anti-inflammatory treatment on neuropathic pain symptoms.

Methods:

Data from a randomised, double-blind, placebo-controlled trial of prednisolone including 92 patients with hand OA fulfilling ACR criteria were used. At baseline patients had signs of synovial inflammation, a VAS finger pain of ≥30 mm and who flared ≥20 mm upon NSAID washout. The primary endpoint was VAS finger pain (0-100) at week 6.

Neuropathic pain symptoms were measured at baseline and week 6 using the validated painDETECT questionnaire, consisting of questions on pain quality, pain intensity over time and radiating pain. Scores range -1 to 38 and patients are classified as having unlikely (<13), indeterminate (13-18) and likely (>18) neuropathic pain. HR-QoL was measured with physical component scale (PCS) of Short-Form 36 (SF36; 0-100), comorbidities with the Self-administered Comorbidities Questionnaire (SCQ; 0-45), radiographic severity with Kellgren-Lawrence (KL) sum score (0-120), and treatment response with OMERACT-OARSI responder criteria.

Association of patient characteristics with neuropathic pain symptoms was analysed with univariate and multivariate ordinal logistic regression, with painDETECT as dependent variable. Association of neuropathic pain symptoms with HR-QoL was analysed with multivariate linear regression, adjusted for age, sex, BMI, VAS finger pain, SCQ score and KL sum score, with PCS as dependent variable. Response of neuropathic pain symptoms and VAS pain to prednisolone was analysed with generalised estimating equations. Association of neuropathic pain symptoms at baseline with response to treatment was analysed using χ2-tests and GEE.

Results:

91 patients had complete painDETECT data at baseline (mean painDETECT score 12.8 [SD 5.9]). Scores were <13 in 53%, 13-18 in 31% and >18 in 16%. Higher painDETECT score categories were associated with less radiographic damage, more comorbidities, female sex and higher VAS finger pain in multivariate analysis. (table 1)

Table 1.

Ordinal logistic regression with painDETECT categories as dependent variable

VariablesMean (SD) N=91 (100%)Odds ratio (95% CI)Age64 (9)0.96 (0.90 to 1.02)Female sex; N (%)72 (79%)3.84 (1.19 to 12.39)*BMI; median (SD)27 (24 to 29)0.97 (0.89 to 1.06)SCQ score; median (SD)2 (1 to 5)1.04 (1.04 to 1.36)*VAS finger pain53.8 (2.1)1.02 (1.00 to 1.04)*KL sum score37 (16)0.96 (0.93 to 1.00)*

*p<0.05. BMI = body mass index. SCQ = Self-administered comorbidities questionnaire. VAS = visual analog scale. KL= Kellgren-Lawrence.

Patients with painDETECT scores >18 had a lower HR-QoL (PCS -6.5 [95%CI -10.4 to -2.6]) than those with painDETECT scores <13.

PainDETECT scores remained unchanged throughout the trial in both prednisolone-treated and placebo-treated patients, and there was no between-group difference at week 6. VAS pain improved more in the prednisolone group than in the placebo group (mean between-group difference -16.5 [95%CI -26.1 to -6.9]) (figure 1). No association between the presence of neuropathic pain symptoms at baseline and OMERACT-OARSI response to treatment was found.

Conclusion:

Patients with inflammatory hand OA and additional neuropathic pain symptoms are more often female and have more comorbidities, and report a lower QoL, than those without. Neuropathic pain symptoms seem unresponsive to anti-inflammatory therapy. Clinicians should be aware of neuropathic pain symptoms in their patients as they might benefit from additional, specific treatment.

Acknowledgements:

The authors thank all patients for their participation in the HOPE study, and participating rheumatologists for inclusion of patients in the HOPE study. We also thank research nurses B.A.M.J. van Schie-Geyer and S. Wongsodihardjo, and technicians J.C. Kwekkeboom and E.I.H. van der Voort, for their contributions.

Disclosure of Interests:

Coen van der Meulen: None declared, Lotte van de Stadt: None declared, Féline Kroon: None declared, Marion Kortekaas: None declared, Annelies Boonen Speakers bureau: Lecture for UCB; paid to department., Consultant of: Yes. Advisory board meetings at Galapagos, Eli Lilly and Abvvie; paid to department., Grant/research support from: Yes. Grants by Celgene and Abbvie; paid to department., Stefan Böhringer: None declared, Marieke Niesters: None declared, Monique Reijnierse: None declared, Frits Rosendaal: None declared, Naghmeh Riyazi: None declared, M. Starmans: None declared, Franktien Turkstra: None declared, Jende van Zeben: None declared, Cornelia Allaart: None declared, Margreet Kloppenburg Consultant of: For Abbvie, Pfizer, Levicept, GlaxoSmithKline, Merck-Serono, Kiniksa, Flexìon, Galapagos, Jansen, CHDR and local investigator of industry-driven trial (Abbvie). All fees were paid to the institution., Grant/research support from: Grant by the Dutch Arthritis Society

POS1361 EVALUATION OF PATIENTS WITH (SUSPECTED) BEHÇET SYNDROME; DIAGNOSTIC VALUE OF PATHERGY TESTING AND OPHTHALMOLOGIC EXAMINATION

Background:

Behçet syndrome (BS) is a multisystem vasculitis of unknown etiology. A positive pathergy test (PT) is part of the ISG criteria for the classification of BS [1]. The added value of PT in the diagnostic workup is unknown. Also, it is unknown whether real time assessment of the pathergy reaction after 48 hours by a physician can be replaced by patient assessment.

The diagnostic value of routine eye examination in patients with suspected BS is unclear.

Objectives:

Assess the diagnostic value of PT and ophthalmologic examination in (suspected) BS patients. Examine the correlation between physician and patient assessment of PT results.

Methods:

This prospective cohort study in (suspected) BS patients was conducted from 2009 to 2020.

At baseline, patients were classified as “true” (≥3 criteria), “probable” (2 criteria) or “no” (0-1 criteria) BS according to ISG criteria and were referred to a dermatologist and/or ophthalmologist for PT and/or eye examination. The percentage of positive PT and eye examination in each group was assessed and the percentage of patients with a changed classification (probable to true BS) was determined.

PT results were scored by both patients and physicians.

Results:

Baseline characteristics are reported in Table 1. Figure 1 displays the flowchart of diagnostic value of PT.

Figure 1.

Flowchart of the results of PT in (suspected) BS patients

In 22 patients with two ISG criteria, grade I uveitis was diagnosed in 1 patient (4.5%, 95% CI [0.8,21.8]) and retinal vasculitis in 1 patient (4.5%, 95% CI [0.8,21.8]). He had shortly experienced photophobia 3 months earlier. Both patients (9%, 95% CI [2.5,27.8]) changed from “probable” to “true” BS, the latter also had a positive PT.

47 patients assessed the results of their own PT. The dermatologist scored PT as positive in one patient. This patient scored the results as unsure on all six PT points. In 46 patients, the dermatologist scored PT as negative, a total of 26 patients (56.5%, 95% CI [42.2,69.7]) scored their results negative as well.

Conclusion:

The added diagnostic value of PT in patients fulfilling 2 features of the ISG criteria was limited in our study, i.e. 5.7% 95% CI [1.6,18.6]. Furthermore, half of patients scored their true negative PT result as negative. The added diagnostic value of routine eye examination in probable BS patients was limited in our study.

References:

[1]Criteria for diagnosis of Behcet’s disease. International Study Group for Behcet’s Disease. Lancet 1990;335(8697):1078–8

Table 1.

Baseline characteristics of (suspected) BS patients.

All patientsn=153ISG +1n=59ISG+ after FU2 n=11ISG –3n=83P-value (+ vs -)Age (mean ± SD4 years)39.5 (12)41.8 (11.6)33.6 (7.5)38.5 (12.6)0.294Male n (%)47 (30.7)16 (27.1)4 (36.4)27 (32.5)0.360HLA-B51+ n/n (%)8/18 (44.4)5/7 (71.4)1/3 (33.3)2/8 (25)0.070Ethnicity: endemic5 n (%)82 (53.6)38 (64.4)6 (54.5)38 (45.8)0.114Oral aphthae n (%)145 (94.8)59 (100)11 (100)75 (90.4)0.008Genital ulcers n (%)82 (53.6)50 (84.7)8 (72.7)24 (28.9)0.000Skin n (%)71 (46.4)51 (86.4)1 (9.1)19 (22.9)0.000Pathergy + n/n (%) 23/58 (39.7)17/33 (51.5) 2/3 (66.7)4/22 (18.1)0.000Eye n (%) 28 (18.3)17 (28.8)1 (9.1)10 (12)0.035Superficial thrombophlebitis n (%)15 (9.8)11 (18.6)1 (9.1)3 (3.6)0.018Vascular n (%)11 (7.2)5 (8.5)1 (9.1)5 (6)0.360Venous n (%)10 (6.5)5 (8.5)1 (9.1)4 (4.8)Arterial n (%)2 (1.3)1 (1.7)01 (1.2)Neurological n (%)5 (3.3)3 (5.2)02 (2.4)0.433Arthritis n (%)40 (26.1)20 (33.9)2 (18.2)18 (21.7)0.197Gastro- intestinal n (%)6 (3.9)3 (5.1)03 (3.6)1.00Epididymitis n (% of males)5 (10.6)5 (31.3)000.002

1.patients fulfilling the ISG criteria at enrollment

2.patients who fulfilled the ISG criteria during FU

3.patients did not fulfill the ISG criteria after FU

4.standard deviation

5.Turkey, Asia, Middle and Far Eastern, Arabic countries and Northern Africa

Disclosure of Interests:

None declared

AB0536 EFFECT OF HYDROXYCHLOROQUINE TREATMENT IN MUCOCUTANEOUS MANIFESTATIONS IN PATIENTS WITH BEHÇET’S SYNDROME

Background:

Behçet syndrome (BS) is a rare multisystemic vasculitis, most commonly seen in regions along the ancient Silk Road. It runs a relapsing and remitting course. Mucocutaneous disease, consisting of oral ulcers, genital ulcers and skin lesions is often reported. EULAR recommendations advise colchicine and topical agents for the treatment of these lesions.1Not all patients respond adequately, thus, it is important to explore alternative treatment options.

Objectives:

To study the efficacy of hydroxychloroquine (HCQ) 400 mg daily in patients with mucocutaneous BS.

Methods:

Data on all patients who presented at the outpatient Behçet clinic in New York were recorded. Patients with a first prescription with HCQ and a follow-up of 3 months (range: 2.75-41.2 months) were included. Patient reported outcomes BSAS and RAPID3 were used to evaluate the effect of HCQ. Results of all patients and of International Study Group (ISG) positive patients were analyzed separately using Wilcoxon rank tests.

Results:

We included 94 patients with a first prescription of HCQ. 72 patients (76.6%) fulfilled ISG criteria. Mean age was 36.1 years (SD 12.5), 76 patients (80.9%) were female and 11 patients (11.7%) were from Silk Road countries.

Mean duration until follow-up was 6.5 months (SD 5.7). Median BSAS scores in ISG+ patients at baseline did not differ significantly from ISG- patients, except for skin lesions (5.0 in ISG+ vs. 0.5 in ISG- p=0.005). BSAS scores at follow-up did not differ significantly (ISG+ vs. ISG-).

Median BSAS scores were significantly lower at follow-up compared to baseline for oral ulcers (p=0.010), skin lesions (p=0.018) and overall activity (p=0.019). Regarding genital ulcers there was no significant result, due to only 37 patients reporting complaints of genital ulcers. Performing these analyses in ISG+ patients only did not change these results, except for BSAS overall activity, which lost significance (p=0.057).

RAPID3 scores were not statistically different between baseline and follow-up (9.67 vs. 8.75, p=0.145), nor were its separate components function (p=0.67 vs. 0.67, 0.713), pain (4.0 vs. 4.0, p=0.157) and patient global (5.0 vs. 4.5, p=0.095).

The majority of patients used prednisone at baseline (58.5%) and at follow-up (57.4%). In 15 patients, prednisone was stopped at follow up, in 13 patients it was started.

Table 1.

Median BSAS scores of patients treated with HCQ.

Baseline(median, IQR)Follow-up 3 months(median, IQR)P-valuesAll patients (n=94)Oral ulcers5.0 (2.00-7.88)3.0 (1.00-6.00)0.010Genital ulcers0.0 (0.00-3.88)0.0 (0.00-3.00)0.371Skin lesions5.0 (1.25-7.00)2.5 (0.00-7.00)0.018Overall activity5.5 (4.00-8.00)5.0 (2.00-7.25)0.019ISG+ patients (n=72)Oral ulcers5.25 (2.00-7.63)3.25 (1.00-6.00)0.007Genital ulcers0.5 (0.00-4.00)0.0 (0.00-3.00)0.684Skin lesions5.0 (2.00-7.13)3.0 (0.00-7.00)0.015Overall activity6.0 (4.00-8.00)5.0 (2.00-7.50)0.057

Conclusion:

HCQ improves median BSAS scores for oral ulcers, skin lesions and overall activity at 3 months follow-up compared to baseline. These results were similar in ISG+ patients (except for overall activity). Additional research is needed to assess the effect of HCQ in more patients and over multiple time points.

References:

[1]Hatemi G et al. 2018 update of the EULAR recommendations for the management of Behçet’s syndrome. Ann Rheum Dis 2019;77:808-818

Disclosure of Interests:

Floor Kerstens: None declared, Shreen Mohamed: None declared, Ingrid Visman: None declared, Franktien Turkstra: None declared, Christopher Swearingen: None declared, Yusuf Yazici Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant, Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant

Results of a questionnaire on the treatment of patients with Behçet's syndrome: a trend for more intensive treatment

OBJECTIVES

To determine the preferred treatment for patients with Behçet's syndrome.

METHODS

A questionnaire was given to all participants of the 2010 meeting of the International Society for Behçet's Disease.

RESULTS

Forty-one respondents from 6 different subspecialties. In the case of a patient with (severe) posterior uveitis or parenchymal central nervous system (CNS) disease no consensus was seen. A diffuse spectrum of different schedules were given. In both uveitis and CNS disease the majority of respondents preferred treatment options consisting of combination systemic therapy and systemic corticosteroids. TNF was preferred as first line drug in uveitis in 7.5% and in severe uveitis in 32.5% of respondents. In parenchymal CNS disease TNF blockage was given by 17% of the respondents. EULAR guidelines regarding uveitis were followed by 12/40 physicians. In patients with a new deep vein thrombosis, 90% of respondents would intensify immunosuppression. More than half would also anticoagulate.

CONCLUSIONS

Although consensus about how to treat patients with Behçet syndrome in different clinical situations is far from present, treatment has become more intensive when compared to 10-20 years ago. More uniformity should be sought for in the decision process in individual patients with Behçet's syndrome, regarding their treatment, as well as adhering to evidence, as presented in the EULAR guidelines, when present.

Venous and arterial thromboembolic events in adalimumab-treated patients with antiadalimumab antibodies: a case series and cohort study

OBJECTIVE

We observed 3 patients who developed severe venous and arterial thromboembolic events during treatment with adalimumab, 2 of whom had rheumatoid arthritis (RA) and 1 of whom had psoriatic arthritis. Antiadalimumab antibodies were detected in all 3 patients. We undertook this study to determine whether the development of antiadalimumab antibodies was associated with thromboembolic events during adalimumab treatment.

METHODS

A retrospective search (with blinding with regard to antiadalimumab antibody status) for thromboembolic events was performed in a prospective cohort of 272 consecutively included adalimumab-treated RA patients. Incidence rates were calculated and hazard ratios (HRs) were estimated using Cox regression. None of the index patients were part of the cohort.

RESULTS

Antiadalimumab antibodies were detected in 76 of 272 patients (28%). Eight thromboembolic events were found, 4 of which had occurred in patients with antiadalimumab antibodies. The incidence rate was 26.9/1,000 person-years for patients with antiadalimumab antibodies and 8.4/1,000 person-years for patients without those antibodies (HR 3.8 [95% confidence interval 0.9-15.3], P = 0.064). After adjustment for duration of followup, age, body mass index, erythrocyte sedimentation rate, and prior thromboembolic events, the HR was 7.6 (95% confidence interval 1.3-45.1) (P = 0.025).

CONCLUSION

These findings suggest that the occurrence of venous and arterial thromboembolic events during adalimumab treatment is higher in patients with antiadalimumab antibodies than in those without antiadalimumab antibodies. Patient numbers were relatively small; therefore, validation in other cohorts is mandatory.

Prevalence of and risk factors for the metabolic syndrome in women with systemic lupus erythematosus

OBJECTIVE

To examine the prevalence of the metabolic syndrome and the relationship between metabolic syndrome score (MetS score) and disease characteristics and cardiovascular events (CVEs) in women with SLE.

METHODS

Demographic and clinical data were collected in 141 female SLE patients. The prevalence of the metabolic syndrome was defined by a modified National Cholesterol Education Program (NCEP/ATP III) definition. Metabolic syndrome was defined as MetS score >or= 3.

RESULTS

Twenty-three (16%) of the 141 SLE patients (mean age 39+/-12 years, mean disease duration 6.2+/-6.6 years) fulfilled the criteria of the metabolic syndrome. The mean MetS score was significantly higher in patients with SLE and a history of cardiovascular events (CVEs) than in those without a previous CVE. In linear multiple regression analysis, a high MetS score was significantly associated with previous intravenous methylprednisolone use, older age, higher ESR, higher C3 levels and higher serum creatinine levels.

CONCLUSIONS

In our female SLE patients, a high prevalence of the metabolic syndrome was found as compared to healthy women in the Amsterdam Growth and Health Longitudinal Study. Independent risk factors for high MetS score in patients with SLE are previous treatment with intravenous methylprednisolone, renal insufficiency, older age, higher ESR and higher C3 levels. These results suggest that assessment of the metabolic syndrome in patients with SLE might be important to identify subgroups of patients that are at disproportional high risk of developing cardiovascular disease and diabetes mellitus.

Survey of the management of deep vein thrombosis in general practice in the Netherlands

BACKGROUND

To investigate the management of (suspected) deep vein thrombosis in general practice.

METHODS

Self completing postal questionnaire among a random sample of 692 general practitioners in the Netherlands.

RESULTS

The overall response rate was 58%. Eighty-nine percent of the respondents initiated objective evaluation. Less than 3% usually make the diagnosis on clinical grounds only. Ninety-two percent initiated adequate treatment for the last patient with deep vein thrombosis. No more than 4% usually treat patients with acenocoumarol alone. Respondents frequently referred a patient to a specialist, 41% to confirm the diagnosis and 85% for treatment. Already 44% feel that management of deep vein thrombosis is a mandate of the general practitioner. For those who do not, the availability of diagnostic and therapeutic facilities are the main obstacles.

CONCLUSION

In general practice objective diagnostic methods to evaluate suspected deep vein thrombosis are routinely used and patients receive adequate treatment. Although patients are frequently referred to the hospital many general practitioners feel that they should be able to take care of these patients themselves. (See Editorial p. 133)

Postthrombotic syndrome after hip or knee arthroplasty: a cross-sectional study

BACKGROUND

Although the incidence of the postthrombotic syndrome (PTS) has been addressed in patients with symptomatic deep vein thrombosis (DVT), less information is available on the incidence in patients who develop asymptomatic DVT after major hip or knee arthroplasty.

OBJECTIVES

To determine whether symptomatic PTS occurs more frequently in patients who develop DVT after hip or knee arthroplasty than those who are free of DVT and to provide an estimate of the incidence of PTS in patients who had undergone major hip or knee arthroplasty and had proximal DVT, distal (calf) DVT, or no DVT.

DESIGN AND SETTING

A cross-sectional study conducted at the Hamilton Health Sciences Corporation, Hamilton, Ontario, and the Academic Medical Centre, Amsterdam, the Netherlands.

SUBJECTS AND METHODS

Two hundred fifty-five subjects who had undergone major hip or knee arthroplasty 2 to 7 years previously and had routine predischarge venography showing proximal DVT (n = 25), distal DVT (n = 66), or no DVT (n = 164) were enrolled from March 1993 through December 1998. The presence of symptomatic PTS confirmed by the presence of objectively confirmed venous valvular incompetence was ascertained.

RESULTS

The rates of PTS were low and not significantly different among the 3 subgroups: 1 (4.0%, 95% confidence interval [CI] = 0.1%-20.4%) of 25 patients with proximal DVT, 4 (6.1%, 95% CI = 1.7%-14.8%) of 66 patients with distal DVT, and 7 (4.3%, 95% CI = 1.7%-8.6%) of 164 patients with no DVT.

CONCLUSIONS

Symptomatic PTS is an uncommon complaint after major hip or knee arthroplasty. Patients who develop postoperative proximal or distal DVT and who receive 6 to 12 weeks of anticoagulant therapy are not predisposed to PTS.

Value of chest X-ray combined with perfusion scan versus ventilation/perfusion scan in acute pulmonary embolism

BACKGROUND

The main purpose of ventilation scanning, as adjunct to perfusion lung scintigraphy, in acute pulmonary embolism is to allow for the classification of segmental perfusion defects as mismatched, which is generally accepted as proof for the presence of pulmonary embolism. We examined whether this function of the ventilation scan could be replaced by the chest X-ray.

METHODS

In 389 consecutive patients with suspected pulmonary embolism and at least one segmental perfusion defect we classified the ventilation/perfusion (V/Q) scan and chest X-ray/perfusion (X/Q) scan as either mismatched or matched. Furthermore we analyzed whether this comparison was different in subgroups of patients with concomitant congestive heart failure or chronic obstructive pulmonary disease.

RESULTS

Overall agreement between the X/Q and V/Q scan diagnostic category was found in 341 of 389 patients (88%; 95% CI 84-92%). The positive predictive value for obtaining a mismatched V/Q scan result in case of a mismatched X/Q scan result was 86% (95% CI 81-90%). If the X/Q scan yielded only matched defects the V/Q scan resulted in the same classification in 90% (95% CI 85-95%). Analysis of the small subgroup of patients with chronic obstructive pulmonary disease showed that a mismatched X/Q scan was confirmed by V/Q scanning in 21 of 34 cases (62%; 95% CI 45-78%).

CONCLUSION

This study shows that in the great majority of patients with clinically suspected acute pulmonary embolism combination of chest X-ray with perfusion scintigraphy reliably replaced ventilation/perfusion scintigraphy in defining (mis)-matching of segmental perfusion defects. These results need confirmation before the chest X-ray can fully obviate the use of ventilation scintigraphy.

Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group

Recent studies have suggested that both the subjective judgement of a physician and standardized clinical models can be helpful in the estimation of the probability of the disease in patients with suspected pulmonary embolism (PE). We performed a multi-center study in consecutive in- and outpatients with suspected PE to compare the potential diagnostic utility of these methods. Of the 517 study patients, 160 (31%) were classified as having PE. Of these patients, 14% had a low probability as estimated by the treating physician, while 25 to 36% were categorized as having a low clinical probability with the use of two previously described clinical models. The objectively confirmed prevalence of PE in these three low probability categories was 19%, 28% and 28%, respectively. The three methods yielded comparable predictive values for PE in the other probability categories. We conclude that a physician's clinical judgement alone and two standardized clinical models, although comparable, perform disappointingly in categorizing the pre-test probability in patients with suspected PE.

Is the prevalence of the factor V Leiden mutation in patients with pulmonary embolism and deep vein thrombosis really different?

INTRODUCTION

Previous investigations have suggested a lower prevalence of the factor V Leiden mutation in patients with pulmonary embolism, as compared to patients with deep leg vein thrombosis.

METHODS

We studied unselected patients with pulmonary embolism, in whom we also assessed the presence of deep vein thrombosis by ultrasonography. We assessed the prevalence of heterozygosity for the factor V Leiden mutation and compared the outcome of patients with a normal ultrasound (primary pulmonary embolism) to those with an abnormal ultrasound (combined form of venous thromboembolism). Furthermore, we performed a literature search to identify all articles regarding the prevalence of heterozygous factor V Leiden mutation in patients with primary deep vein thrombosis, primary pulmonary embolism and a combined form of venous thromboembolism. We calculated a (common) odds ratio for these 3 manifestations of venous thromboembolism, including the current findings.

RESULTS

In 92 patients with proven pulmonary embolism, 25 (27%) had also an abnormal ultrasound. In these patients, the prevalence of the factor V Leiden mutation was 24% (95% CI 9%-45%), whereas the mutation was present in 5 of 67 patients with primary pulmonary embolism (7%; 95% CI 2%-16%). The literature analysis indicated the common odds ratio for the presence of heterozygous factor V Leiden mutation in patients with primary deep vein thrombosis, primary pulmonary embolism and the combined form of venous thromboembolism to be 7.9 (95% CI 5-12), 3.5 (95% CI 2-6) and 6.8 (95% CI 3-14), respectively.

CONCLUSION

In patients with primary pulmonary embolism the prevalence of the factor V Leiden mutation appears to be half of that reported in patients with primary deep vein thrombosis. The mechanism remains unclear.

[Recombinant factor VIIa (eptacog alfa): a new therapeutic option for patients with severe bleeding disorder due to inhibitory antibodies against a coagulation factor]

In 2 patients with severe haemorrhage (a 63-year-old man with haemophilia A (the factor VIII level was 29%) and a 44-year-old woman), of an inhibitory antibody against factor VIII was diagnosed. The development of recombinant factor VIIa (eptacog alpha) has made available a new therapeutic option for patients with an inhibitory antibody against a coagulation factor. Both patients were treated successfully with the new factor after other forms of treatment had failed. The new concept of the coagulation cascade on which the treatment with eptacog alpha is based assumes that the lack of an amplifying loop in the coagulation which takes place via factor IX (in combination with factor VIII) can be compensated by extra stimulation of the principal route (tissue factor-factor VIIa --> factor X) by pharmacological amounts of factor VIIa.

Observer and biological variation of a rapid whole blood D-dimer test

In consecutive patients with suspected venous thromboembolism the interobserver variability of the SimpliRED D-dimer test was evaluated by two observers who independently scored one plate, the between assay variation was performed simultaneously by a third independent observer, who assessed a second plate. The biological variation was studied, 1-4 hours later by an independent evaluation. A total of 155 patients entered the study, venous thromboembolism was present in 42 patients (28%). The interobserver variability was 2/83 samples, with a kappa of 0.95 (95% confidence interval 0.88-1.0). The between assay variation was 2/98, with a kappa value of 0.96 (95% confidence interval 0.90-1.0). When testing the biological variation the observers disagreed in 2 of 69 patients (3%). The SimpliRED D-dimer assay has a good to excellent interobserver variability, between assay variation and reproducibility.

The treatment of deep vein thrombosis and pulmonary embolism

Deep vein thrombosis and pulmonary embolism can be considered as one clinical entity, termed venous thromboembolism, because of their comparable pathogenesis, treatment and prognosis. In this clinical spectrum of venous thromboembolism a gradient in severity of the disease can be recognized. Therapeutic strategies should be adapted to the extent of the thrombotic disease, varying from surgical or thrombolytic therapy in life-threatening disease to a watchful waiting diagnostic follow-up approach in minimal disease. In patients with established venous thromboembolism (low molecular weight) (LMWH), heparin should be initiated. An overview will be given of the safety and efficacy of the different therapeutic modalities such as thrombectomy, thrombolytic therapy, a watchful waiting diagnostic approach and unfractionated heparin. Furthermore, clinical studies comparing LMWH with unfractionated heparin in the initial treatment of venous thromboembolism will be reviewed.

A survey of the diagnostic and therapeutic management of patients with suspected pulmonary embolism in the Netherlands

BACKGROUND

Pulmonary embolism (PE) remains a complex diagnostic problem. Many diagnostic modalities are available. Several published guidelines have failed to yield a uniform approach. We have assessed the current diagnostic and therapeutic management of patients with clinically suspected PE in the Netherlands.

METHODS

A questionnaire was sent to internists and pulmonologists, who were then asked to detail their diagnostic and therapeutic management in their last patient seen with suspected PE.

RESULTS

1571 questionnaires were sent out (response rate 64%). 95% of the patients with suspected PE underwent a perfusion scan (in 91% within 24 h). 1.6% of the respondents had no available perfusion scan facility. Of those who underwent a perfusion scan, 62% had ventilation scan (66% with segmental defects, 80% with subsegmental defects, 27% with a normal perfusion scan). Tests for deep vein thrombosis were performed in 58% of the patients and pulmonary angiography was carried out in 6.1%. Anticoagulant treatment was instituted in 73.2% of all patients.

CONCLUSIONS

The perfusion lung scan is appropriately used as the initial step in the diagnostic workup of patients with suspected PE. Ventilation scanning is overused in patients with subsegmental perfusion defects and normal scan results, whereas it is underused in patients with segmental defects. Additional ventilation scan results had a limited influence on treatment decisions. There is still considerable overtreatment of patients with suspected PE.

Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism

BACKGROUND

The standard diagnostic approach in patients suspected of having pulmonary embolism starts with perfusion-ventilation lung scanning. If the resulting scan is not diagnostic, pulmonary angiography should be done. The use of tests for deep venous thrombosis has been advocated as an adjunct to establishing the diagnosis of pulmonary embolism, but no prospective studies have provided adequate information about the value of these tests.

OBJECTIVE

To determine the accuracy and potential clinical utility of compression ultrasonography in the diagnosis of pulmonary embolism.

DESIGN

Prospective cohort study with blinded assessment of ultrasonographic results.

SETTING

Teaching hospital.

PATIENTS

397 consecutive inpatients and outpatients in whom pulmonary embolism was clinically suspected.

MEASUREMENTS

Sensitivity and specificity of compression ultrasonography. Perfusion-ventilation scanning and angiography were the conjoint gold standard for determining the presence or absence of pulmonary embolism. Also calculated were the number of angiograms and lung scans avoided and the number of patients unnecessarily treated when compression ultrasonography was included in the diagnostic strategy.

RESULTS

The overall sensitivity of compression ultrasonography for deep venous thrombosis in patients with pulmonary embolism was 29% (95% CI 22% to 37%); the specificity was 97% (CI, 94% to 99%). Adding ultrasonography to the diagnostic approach before lung scanning would avoid approximately 14% of lung scans and 9% of angiograms but would lead to unnecessary treatment of 13% of patients who have an abnormal ultrasonographic result (2% to 4% of all those receiving anticoagulation). When compression ultrasonography is done only in patients with a nondiagnostic lung scan, 9% of angiographies are prevented at the cost of unnecessarily treating 26% of patients who have an abnormal ultrasonographic result (2% of all patients receiving anticoagulation).

CONCLUSION

The diagnostic value of compression ultrasonography for the detection of deep venous thrombosis in patients suspected of having pulmonary embolism is limited; the gain in diagnostic efficiency obtained through the use of ultrasonography may be offset by a loss in diagnostic accuracy.

Reliable rapid blood test for the exclusion of venous thromboembolism in symptomatic outpatients

In this study we assessed the reliability of a rapid bed-side whole blood D-dimer assay prospectively in patients with clinically suspected venous thromboembolism, referred to the Academic Medical Centre, Amsterdam. In consecutive outpatients with clinically suspected deep vein thrombosis or pulmonary embolism we measured the sensitivity, specificity and negative predictive value of the assay compared to the outcome of standard diagnostic tests and 3-month follow-up. A total of 234 patients were included; the prevalence of venous thromboembolism was 29%. A sensitivity, specificity and negative predictive value of 100% (95% CI: 95% - 100%), 58% (95% CI: 50%-65%) and 100% (95% CI:96% - 100%), respectively, were obtained. The exclusion rate was 41% of all referred patients.

CONCLUSION

The SimpliRED whole blood D-dimer assay appears to be a simple and reliable method for the exclusion of venous thromboembolism in symptomatic outpatients.