AB0295 HIGHER PREVALENCE OF DEPRESSION WITH LINK TO CHILDHOOD TRAUMA IN AN EARLY ARTHRITIS COHORT – A SELECTIVE DATA ANALYSIS (PSYRA-STUDY)

Background

In patients with arthritis, psychological co-morbidities are very common. Previous studies have found a relatively high prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD), especially in long-term disease. Recent research has begun to study psychiatric co-morbidities not just as an outcome, but also as a probable risk factor, evaluating patients in the early disease stages. [1] Furthermore, some sources suggest that childhood adversities could impact the autoimmune process in adulthood. [2]

Objectives

To compare the prevalence of depression, anxiety, PTSD, and childhood trauma in a prospective early arthritis cohort to a healthy age- and gender-matched control group. Moreover, to explore whether these factors may contribute to the early arthritis development.

Methods

This selective data analysis of prospective single-centre, observational study included 60 patients with an early arthritis and 60 healthy controls. The control group was defined as no inflammatory joint pain and further subdivided into 2 subgroups, differentiating 24 patients with arthralgia and 36 with no arthralgia and not from the outpatient consultation. Early arthritis was defined as the presence of at least one inflammatory joint from 4 weeks to 12 months, independent of rheumatic diagnosis. For the assessment of current and prior psychological co-morbidities, included patients underwent semi-structured interview and received the standardized questionnaires for depression/anxiety (Hospital Anxiety and Depression Scale (HADS)), childhood trauma (Childhood Trauma Questionnaire (CTQ)) and PTSD (Posttraumatic Diagnostic Scale (PDS)) respectively. Differences among the groups were analyzed with Chi Square and Mann-Whitney U tests. A backwards binominal logistic regression model in reference to the healthy patients was performed to identify the significant factors for the early arthritis group.

Results

The mean age of the total group was 47.4 ± 16.0 (♀ 58.3%, mean symptom duration 4.5±3.3 months). Depression rate of 41.7% according to interview was significantly higher in early arthritis group compared to 16.7% in healthy patients (p=0.03). Regarding arthralgia subgroup, depression was also high with 34%. HADS-D score was also significantly higher in early arthritis (5.4±4.8) to healthy cohort (3.6±3.3) (p=0.047). Compared to 3.3% in healthy patients, PTSD rate of 13.3% was also significantly higher in the arthritis group (p=0.048). We could not detect a significant difference between these two groups using the U test while evaluating CTQ dimensions. We performed a subsequent subgroup analysis and found that childhood trauma dimensions were relevant in arthralgia group, as 25% presented with high emotional abuse score. The logistic regression model showed that emotional neglect, sexual abuses in childhood as well as HADS-D were significant covariates for early arthritis. (p=0,048 OR=1.2; p=0.040 OR=1.4, p=0.025 OR=1.2 respectively).

Conclusion

As the rates of depression and PTSD, as well as HADS-D score were significantly higher in the early arthritis cohort compared to healthy individuals, our findings suggest a potential link between psychiatric outcomes and inflammation. According to our regression model certain childhood adversities and depression are significant factors for an early arthritis group. Arthralgia group had similar aberrant scores regarding childhood trauma, implying that early-life stress might be an important factor in understanding this condition.

References

[1]Vallerand IA et al. Depression as a risk factor for the development of rheumatoid arthritis: a population-based cohort study. RMD Open.2018; 4(2)

[2]Dube SR et al. Cumulative childhood stress and autoimmune diseases in adults. Psychosom Med. 2009; 71(2):p.243-50.

Disclosure of Interests

None declared

AB1363 IMAGE PATTERN ANALYSIS IN FLUORESCENCE OPTICAL IMAGING FOR DIFFERENTIAL DIAGNOSIS IN RHEUMATIC JOINT DISEASES

Background

As outlined in previous studies, different rheumatic joint diseases present specific characteristic patterns and features in fluorescence optical imaging (FOI) (1-4).

Objectives

We tested different features in FOI for their ability to differentiate various rheumatic joint diseases such as rheumatoid arthritis (RA), osteoarthritis (OA) and psoriatic arthritis (PsA) with the aim to identify clear FOI criteria for the diseases.

Methods

FOI images from patients with RA, OA, PsA and healthy volunteers were evaluated by two readers blinded for diagnosis and calibrated against each other, using the prima vista mode (PVM) and the 5-phase model. For the latter, the overall time course of FOI in each hand was divided into 5 phases with a computational algorithm. Phases 1 and 2 describe the inflow (start to 15% and 15%-90% on rising edge), phase 3 is the peak phase and phases 4 and 5 comprise the outflow (90%-36.8% and 36.8% to end on falling edge). Twenty-six different features were defined by an atlas, for example the streaky pattern feature (T) as a signal enhancement around the PIP area that appears streaky, whereby the stripes are orthogonal to the finger axis (Figure 1a). The cloudy pattern (W) is visible during the inflow on the back of the hand (Figure 1b). The enthesis feature (E) depicts a V shaped and filled pattern between nail and DIP (Figure 1c). The feature frequency in each patient and phase (PVM, 5-phase) was counted and statistically analysed.

Figure 1.

Examples for FOI patterns and features: a) (T) Streaky pattern in PVM image (OA); b) (W) Cloudy pattern on the back of the hand in phase 1 (PsA); c) (E) Enthesis pattern in phase 3.

Results

In total, 128 patients (RA (age mean 54.2; SD 10.6; median 52.4), OA (58.0; 14.3; 60.1), and PsA (47.9; 12.7; 46.8)) and healthy volunteers (32 in each group) were included in the feature reading. In our analysis, OA can be differentiated from RA on the basis of the feature T. Feature T is found in phase 3 (χ2: 4.61; diagnostic odds ratio (DOR): 7.49; sensitivity (TPR) 0.11; specificity (TNR): 0.98; positive predictive value (PPV): 0.87; negative predictive value (NPV): 0.52), phase 5 (χ2: 18.5; DOR: 5.60; TPR 0.55; TNR: 0.82; PPV: 0.76; NPV: 0.64 and PVM (28.3; 12.1; 52%; 92% 87%; 65%). By means of the feature E, a distinction between RA and PsA is only limited possible (χ2: 9.58; DOR: 3.65; TPR 0.40; TNR: 0.84; PPV: 0.71; NPV: 0.59). But PsA can well be distinguished from RA by the appearance of pattern W in phase 1 (χ2: 7.68; DOR: 6.92; TPR 0.19; TNR: 0.97; PPV: 0.86; NPV: 0.54).

Other significant features yield high specificity (70%-98%) while having low sensitivity (12%-52%).

Conclusion

This work demonstrates that FOI feature analysis has the potential for differential diagnosis with FOI, which could optimize the (early) diagnostic process of rheumatic joint diseases. A majority of features yield high specificity, but only low sensitivity. The combination of different features using artificial intelligence might lead to improved diagnostic accuracy.

References

[1]Werner SG, et al. Inflammation assessment in patients with arthritis using a novel in vivo fluorescence optical imaging technology. Ann Rheum Dis. 2012; 71(4):504-510.

[2]Glimm AM, et al. Analysis of distribution and severity of inflammation in patients with osteoarthitis compared to rheumatoid arthritis by ICG-enhanced fluorescence optical imaging and musculoskeletal ultrasound: a pilot study. Ann Rheum Dis. 2016; 75(3):566-570.

[3]Wiemann O, et al. The “green nail” phenomenon in ICG-enhanced fluorescence optical imaging - a potential tool for the differential diagnosis of psoriatic arthritis. J Dtsch Dermatol Ges. 2019;17(2):138-147.

[4]Schmidt A, et al. Detection of subclinical skin manifestation in patients with psoriasis and psoriatic arthritis by fluorescence optical imaging. Arthritis Res Ther. 2020; 22(1):192.

Disclosure of Interests

None declared

Monitoring of patients with rheumatoid arthritis by indocyanine green (ICG)-enhanced fluorescence optical imaging treated with anti-TNFα therapy

BACKGROUND

Fluorescence optical imaging (FOI) enables visualisation of inflammation in both hands in rheumatoid arthritis (RA).

OBJECTIVE

To investigate the usefulness of FOI in treatment monitoring under anti-TNFα therapy with certolizumab pegol (CZP) in patients with RA in comparison to clinical and laboratory outcome parameters.

METHODS

CZP-naïve patients with RA were eligible for this open-label study with an observational period of 52 weeks. Disease activity was monitored by the clinical score DAS28, tender/swollen joint count (TJC-28/SJC-28) and laboratory outcomes for systemic inflammation (CRP and ESR). FOI results were analysed in three different phases (P1-3) and PrimaVistaMode (PVM) by the FOI activity score (FOIAS).

RESULTS

Twenty-eight RA patients (median age 52.5 years, 26 females, thirteen with a history of other biologic therapy) were included. DAS28 (CRP) decreased from moderate disease activity at baseline (median 4.6, IQR 1.8) to low disease activity at week (w)52 (median 2.7, IQR 2.1; p < 0.001). Statistically significant decreases could also be demonstrated for SJC-28 and TJC-28. CRP/ESR were reduced numerically from baseline to w52. FOIAS in P1 (early phase) showed a continuous decrease of enhancement during the course of treatment period: from baseline (median 1.5, IQR 9.3) over w6 (median 1.0, IQR 3.0; p = 0.069), w12 (median 0.5, IQR 3.0; p = 0.171), w24 (n = 27, median 0.0, IQR 3.0; p = 0.004), until w52 (n = 18, median 0.0, IQR 2.8; p = 0.091), which could not be presented for FOIAS in P2, P3 and PVM.

CONCLUSION

FOI in P1 appears to be a valuable tool for fast and easy monitoring of treatment response to certolizumab in a clinical setting.

Is the fluorescence optical imaging (FOI) able to discriminate between rheumatoid arthritis patients with and without need of rituximab retherapy? A cohort study

OBJECTIVE

To evaluate the ability of fluorescence optical imaging (FOI) Xiralite in the discrimination between rheumatoid arthritis (RA) patients with and without need of rituximab (RTX) retherapy-in comparison to clinical, laboratory and musculoskeletal ultrasound parameters.

PATIENTS AND METHODS

Patients with established RA were prospectively followed over 1 year by Disease Activity Score 28, patient's global disease activity (visual analogue scale 0-100 mm), C reactive protein and erythrocyte sedimentation rate, ultrasound seven joint (US7) score and FOI in phases 1-3 and automatically generated PrimaVista mode (PVM) at baseline (before RTX) and after 3, 6 and 12 months. The need for RTX retherapy was decided by the treating rheumatologist-blinded to imaging data.

RESULTS

31 patients (female 77.4%, mean age 60.1±11.4, mean disease duration 14.9±7.1 years) were included. Fourteen (45.2%) patients received RTX retherapy within 12 months. In the group with RTX retherapy, FOI in PVM mode was the only parameter that presented significant increase over time (β: 0.40, 95% CI: 0.08 to 0.71, p=0.013)-compared with the group without retherapy. In the prediction model via ROC analysis, FOI in PVM reached the highest values of all imaging, clinical and laboratory parameters which was associated with retherapy over 1 year with an area under the curve (AUC) of 0.78 (OR: 0.84, 95% CI: 0.72 to 0.98, p=0.031). US7 GS synovitis score revealed similar association with an AUC of 0.73 (p=0.049).

CONCLUSION

US7 GS synovitis score and FOI in PVM are able to discriminate between patients with and without need for RTX retherapy better than clinical and laboratory parameters.

Detection of subclinical skin manifestation in patients with psoriasis and psoriatic arthritis by fluorescence optical imaging

OBJECTIVES

To investigate the frequency of subclinical skin inflammation in both hands by fluorescence optical imaging (FOI) in patients with psoriasis/psoriatic arthritis (Pso/PsA) vs. rheumatoid arthritis (RA) and healthy individuals, and to correlate these findings with cardiovascular (CV) risk factors.

PATIENTS AND METHODS

The FOI scans were analyzed retrospectively to detect clinically invisible skin enhancement (0-3 scale) in both hands without relationship to underlying joints or blood vessels. We further characterized the FOI patterns and sorted the scans into groups based on the assumed diagnosis (Pso/PsA, RA, and healthy controls), which was compared with the physician's diagnosis. Furthermore, the associations between CV risk factors and imaging findings were investigated by regression analyses.

RESULTS

We included FOI scans of patients with Pso/PsA (n = 80), RA (n = 78), and healthy controls (n = 25). Subclinical skin enhancement on the back of their hands was more common in Pso/PsA (72.5%) than in RA patients (20.5%) and healthy individuals (28.0%) (p < 0.001). Based on the FOI pattern, the majority of patients with Pso/PsA (72.5%), RA (76.9%), and healthy controls (68.0%) were classified correctly using the physician-based diagnosis as reference (overall agreement of 74%, kappa = 0.57). No CV risk factors except body weight (kg) were associated with subclinical skin enhancement (OR 1.04, 95% CI 1.02-1.06; p < 0.001).

CONCLUSION

Subclinical subdermal skin inflammation was common in Pso/PsA patients using FOI. Based on the FOI pattern, most patients with Pso/PsA and were classified with the correct diagnosis. We demonstrated an important influence of the body weight on our FOI results. FOI may be a helpful novel tool to study microcirculation in rheumatic diseases with skin involvement.

OP0311 DETECTION OF SUBCLINICAL SKIN MANIFESTATION IN PATIENTS WITH PSORIASIS AND PSORIATIC ARTHRITIS BY FLUORESCENCE OPTICAL IMAGING

Background:

Fluorescence optical imaging (FOI) as new imaging technique enables visualization of an impaired microcirculation in both hands caused by joint inflammation. A detection of psoriatic skin inflammation which may also signify an altered vessel composition via FOI has not yet been examined.

Objectives:

The aim of the present study was to investigate potential subclinical skin inflammation in both hands of psoriasis (Pso) and psoriatic arthritis (PsA) patients in comparison to rheumatoid arthritis (RA) and healthy individuals by FOI, and to correlate these findings with cardiovascular risk factors or events, since a connection to Psoriasis skin involvement is assumed.

Methods:

FOI scans of patients with Pso and PsA as well as RA and healthy subjects were analyzed retrospectively to detect subclinical skin enhancement in both hands that did not clinically show overt psoriasis skin changes. According to the ‘fluorescence optical imaging activity score’ (FOIAS) (1) used for evaluation of joint enhancement so far, a standardized definition was set in order to describe the degree of skin enhancement via a semi-quantitative (0-3) score (seeFigure). The score was applied for the first third of the FOI exam sequence (0-120 sec.). To be scored as potential subdermal skin enhancement, it had to be localized on the back of the hands without relationship to an underlying joint or blood vessel since the ICG enhancement was then most likely localized in the area of the (sub)dermis. Using this analysis method, we further characterized the patterns and sorted the scans into the groups PsA/Pso, RA and healthy controls to compare these with the final physician’s diagnosis. Furthermore, cardiovascular risk factors (e.g. obesity, smoking status, hypertension) were collected and correlated to imaging findings.

Results:

We included FOI scans of patients with PsA/Pso (n=80), patients with RA (n=78) and healthy controls (n=25). Significantly more PsA/Pso patients showed subclinical skin enhancement on the back of their hands than RA and healthy individuals (PsA/Pso: 72.5%, RA: 20.5%, healthy controls: 28.0%; p<0.001). By using the pattern of skin enhancement, it was possible to categorize 58 of 80 patients correctly as PsA/Pso (72.5%), 60 out of 78 as RA (76.9%) and seventeen out of 25 as healthy controls (68.0%; p-value <0.001). We could show an influence of the body weight (kg) (p<0.001, OR 1.04, CI 1.02; 1.06) on the FOI results; no further correlation with cardiovascular risk factors was detected.

Conclusion:

We were able to proof our primary hypothesis that it is possible to visualize subclinical subdermal skin inflammation in PsA/Pso patients using FOI. Furthermore, we were also able to categorize PsA/Pso and RA patients correctly by using our newly developed method. Although we could not establish a correlation between subdermal skin enhancement and cardiovascular risk factors, we demonstrated an important influence of the body weight on our FOI results. FOI may be a helpful novel tool to study microcirculation in rheumatic diseases with skin involvement.

References:

[1]Werner SG, et al. Inflammation assessment in patients with arthritis using a novel in vivo fluorescence optical imaging technology. Ann Rheum Dis. 2012;71(4):504-10.

Figure.

Left picture: The enhancement is mostly yellow on green ground classified as grade 1. Middle picture: The enhancement is red with minimal white signals classified as grade 2. Right picture: The enhancement in the marked area shows more white than red signals which presents grade 3.

Disclosure of Interests:

Angelique Schmidt Speakers bureau: Speakers fee from Novartis, Roche, Abbvie, BMS, Anne-Marie Glimm: None declared, Paula Hoff: None declared, Gabriela Schmittat: None declared, Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Jens Klotsche: None declared, Sarah Ohrndorf: None declared

Association between baseline clinical and imaging findings and the development of digital ulcers in patients with systemic sclerosis

Objective

Systemic sclerosis (SSc) can lead to ischemic complications such as digital ulcers (DUs). The aim of the study was to find predictors of DUs by clinical and new imaging methods.

Patients and methods

All 79 SSc patients included in the study received a clinical, colour Doppler ultrasound (CDUS), fluorescence optical imaging (FOI) and capillaroscopy examination at baseline, and their capacity to predict new DU development was analysed in 76 patients at 12 months follow-up.

Results

Twenty-two of 76 patients (28.9%) developed new ulcers during follow-up (diffuse SSc 48.1%; limited SSc 18.4%). Receiver operating characteristic (ROC) curve analysis revealed an area under the curve of 0.7576 for DU development, with a specificity of 87% and a sensitivity of 54.6% (p = 0.0003, OR = 8.1 [95%CI 2.5–25.6]) at a cut-off of ≥ 21 points (ACR/EULAR classification criteria for SSc). Capillaroscopy and CDUS had high sensitivity (100% and 95.5%) but low specificity (28.9% and 22.2%) for ulcer occurrence when used alone, but better specificity (46.3%) when combined (OR = 18.1 [95%CI 2.3–144.4]; p = 0.0004). Using FOI, fingers with pathologic staining had a higher risk for new ulcer development in the same finger (p = 0.0153). General future DU (i.e. DU also in other fingers) was associated with a missing FOI signal in the right digit III at baseline (p = 0.048).

Conclusion

New imaging modalities can predict digital ulcer development in SSc patients with high sensitivity for capillaroscopy and CDUS and enhanced specificity when combined. A missing signal of FOI in the right digit III at baseline was associated with general future DU.

Patient Reported Outcomes (PROs) im rheumatologischen Praxisalltag – App hat sich bewährt

Hintergrund Patient-reported-outcomes (PROs) haben einen zunehmenden Einfluss auf die unmittelbare Therapieentscheidung des Arztes in der klinischen Praxis.

Zielstellung Überprüfung der Integration und des Nutzens von elektronisch erhobenen PROs per ScoreCheck Rheuma®-App (SCR App) im klinischen Praxisalltag der rheumatologischen Fachambulanz (Dispensaire) der Charité - Universitätsmedizin Berlin in Hinblick auf Praxistauglich, Patientenakzeptanz und medizinischen Mehrwert.

Patienten und Methoden N=190 Patienten (63% weiblich, mittleres Alter: 55 Jahre, min 23-max 82; Diagnosen: 52,9% Rheumatoide Arthritis, 28,6% Spondyloarthritis, 9,3% Kollagenosen, 3,6% Vaskulitis, 5,6% sonstiges) sowie 3 medizinische Fachangestellte (MFA) und 3 Ärzte (Rheumatologen) haben an diesem Pilotprojekt teilgenommen. Die folgenden PROs wurden elektronisch mittels SCR App von den eingeschlossenen Patienten ausgefüllt: FFbH (Funktionsfragebogen Hannover), BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) und BASFI (Bath Ankylosing Spondylitis Functional Index) sowie ein Fragebogen zur Selbsteinschätzung. Zusätzlich wurde für jeden eingeschlossenen Patienten je ein Beurteilungs-Protokoll vom Patienten selbst, von der zuständigen MFA und vom betreuenden Arzt ausgefüllt.

Ergebnisse Von den 190 teilnehmenden Patienten gaben 147 (77%) an, Vorerfahrungen mit Touchpad-Geräten zu haben. 96% der Patienten fühlten sich außerdem gut bis sehr gut in die Bedienung des iPADs und der SCR App durch die MFAs eingewiesen und fanden das Ausfüllen der Fragebögen auf dem iPAD einfach; Schwierigkeiten, wie z. B. mit der Schriftgröße, der Handhabung, usw. wurden nur von 10% der Patienten angegeben. Immerhin 74% der Patienten wünschten sich den vermehrten Einsatz elektronischer Hilfsmittel beim Arztbesuch und 75% bevorzugten den Einsatz des iPADs gegenüber dem Ausfüllen der Fragebögen auf Papier. Die MFAs gaben in über 80% der Fälle an, dass die Patienten die Fragebögen zu den PROs ohne oder mit nur wenig Hilfe selbstständig ausfüllen konnten. In ca. 2/3 der Fälle sahen die MFAs Vorteile durch die Anwendung der SCR App sowohl bezüglich der Qualität der Patientenbetreuung als auch bezüglich der Erfassung der Funktionsscores. Die Ärzte sahen in 2/3 der Fälle eher keine Zeitersparnis durch den Einsatz des iPADs. In 78% der Fälle konnte der Patientenscore in das Arzt-Patienten-Gespräch eingebracht werden, jedoch sparte die Anwendung der SCR App nur in 50% der Fälle Zeit im Praxisalltag. Die Ärzte sahen v. a. Vorteile bezüglich der Anamneseerhebung und der Therapieempfehlungen.

Schlussfolgerung Insgesamt zeigt das vorgestellte Pilotprojekt zur Anwendung und Integration der SCR App eine gute Resonanz bei den Patienten, MFAs und Ärzten. Die Arztbewertung ergibt, dass durch die SCR App bei jedem zweiten Patienten ein Vorteil bei der Therapieempfehlung gesehen wurde.