Impact of previous glucocorticoid therapy on diagnostic accuracy of [18F] FDG PET-CT in giant cell arteritis

OBJECTIVE

To evaluate the impact of prior glucocorticoid (GC) treatment on the diagnostic accuracy of ¹⁸F-FDG PET-CT in giant cell arteritis (GCA).

METHODS

Retrospective study of a consecutive cohort of 85 patients with proven GCA who received high-dose GC before PET-CT.

RESULTS

Thirty-nine patients previously treated with methylprednisolone (MP) boluses, of whom 37% were PET-CT (uptakes grade 3 or 2) positive. The positivity rate was 80% with MP doses of 125 mg, 33% with 250 or 500 mg, and 0% with doses of 1 g.  If we also classify as positive those cases with a grade 1 uptake (with a circumferencial uptake and smooth linear or long segmental pattern, possibly indicative of "apparently inactive" vasculitis), the positivity rate increases to 62% (100%, 50-60%, and 33% for the different MP doses, respectively). In patients with new-onset GCA treated with high-dose oral GC, PET-CT positivity was 54.5% in patients treated for less than two weeks, 38.5% in those treated for 2 to 4 weeks, and 25% in those treated for 4 to 6 weeks (increasing to 91%, 77%, and 50%, respectively, if we include cases with grade 1 uptake and these characteristics). In patients with relapsing/refractory GCA, or who developed GCA having a prior history of PMR, PET-CT positivity reached 54% despite long-term treatment with low-to-moderate doses of GC (68% including cases with a grade 1 uptake).

CONCLUSION

A late ¹⁸F-FDG PET-CT (beyond the first 10 days of treatment) can also be informative in a considerable percentage of cases.

AB1343 ON THE DEVELOPMENT OF NEW DISEASE ACTIVITY SCORES FOR REMOTE ASSESSMENT OF PATIENT WITH RHEUMATOID ARTHRITIS USING THERMOGRAPHY AND MACHINE LEARNING

Background

Disease activity scores are used in the follow-up of patients with rheumatoid arthritis (RA). These scores include variables obtained through physical examination, such as the tender and swollen joint count. In telematic consultations it is not possible to determine these variables. Thermography is a safe and fast technique that measures heat through infrared imaging. Inflammation of the joints causes an increase in temperature and could therefore be detected by thermography. Machine learning methods are highly accurate in analyzing medical images, and could be used to analyze thermal images automatically. Thermography of hands, patient global health (PGH) and acute phase reactants could be combined to develop new activity scores that facilitate remote assessment of RA patients.

Objectives

To develop new disease activity scores based on the machine learning analysis of thermal images of the hands, PGH and acute phase reactants.

Methods

Multicenter observational study conducted in the rheumatology and radiology service of two hospitals. Patients with RA, psoriatic arthritis, undifferentiated arthritis and arthritis of hands secondary to other diseases that attended the follow-up visits were recruited. Companions of patients and healthcare professionals were also recruited as healthy subjects. In all cases, a thermographic image of the hands was taken using a Flir One Pro or a Thermal Expert TE-Q1 camera connected to a smartphone. Ultrasound (US) of both hands was performed. The degree of synovial hypertrophy (SH) and power doppler (PD) was assessed for each joint (score from 0 to 3). Machine learning was used to quantify joint inflammation from the thermal images using US (SH+PD) as ground truth. This score has been named ThermoJIS. RA patients whose thermal image was taken with the Thermal Expert TE-Q1 camera were used to evaluate the performance (test dataset). The other participants were used as training dataset. The PGH, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were also assessed in the test dataset. ThermoDAS (ThermoJIS + PGH), ThermoDAS-ESR (ThermoJIS + PGH + ESR) and ThermoDAS-CRP (ThermoJIS + PGH + CRP) activity scores were developed using a linear regression. The Spearman’s correlation coefficient of ThermoJIS, ThermoDAS, ThermoDAS-ESR and ThermoDAS-CRP vs. SH, PD, PGH, ESR and CRP were used to characterize the new developed disease activity scores. The study was approved by the Clinical Ethics and Research Committee of both centers.

Results

The total number of recruited subjects were 616 (475 for the training and 141 for the testing dataset). The correlations obtained between the different activity scores (ThermoJIS, ThermoDAS, ThermoDAS-ESR and ThermoDAS-CRP) vs. SH, PD, PGH, ESR and CRP are shown in Table 1. All correlations are statistically significant.

Table 1.

Spearman’s correlations of the developed scores vs synovial hypertrophy (SH); vs power doppler (PD); vs patient global health (PGH); vs erythrocyte sedimentation rate (ESR) and vs C-reactive protein (CRP).

SHPDPGHESRCRPThermoJIS0.420.430.180.160.12ThermoDAS0.500.530.870.160.19ThermoDAS-ESR0.540.530.790.490.33ThermoDAS-CRP0.600.600.770.490.54

Conclusion

ThermoJIS shows moderate correlation with US but weak correlation with PGH and acute phase reactants, suggesting that ThermoJIS is non-redundant with symptoms and laboratory assessment. Adding PGH and acute phase reactants to ThermoJIS improves all correlations, including correlation with US. These thermographic scores do not require a physical examination, opening an opportunity to facilitate remote consultations in RA patients.

References

[1]Lynch CJ et al. New machine-learning technologies for computer-aided diagnosis. Nat Med. 2018 Sep;24(9):1304-1305.

[2]Tan YK et al. Thermography in rheumatoid arthritis: a comparison with ultrasonography and clinical joint assessment. Clin Radiol. 2020 Dec;75(12): 963.

Disclosure of Interests

None declared

OP0300 USE OF THERMOGRAPHY OF HANDS AND MACHINE LEARNING TO QUANTIFY JOINT INFLAMMATION AND ESTIMATE DAS28, CDAI, SDAI IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Disease activity scores such as DAS28, CDAI and SDAI are used in the follow-up of patients with rheumatoid arthritis (RA). These scores include variables obtained on physical examination such as the tender joint count (TJC) and the swollen joint count (SJC). In telematic consultations, it is not possible to determine these variables by physical joint assessment. Therefore, it is necessary to develop new tools that allow detecting joint inflammation in places close to the patient. Thermography is a safe and fast technique that measures heat through infrared imaging. Inflammation of the joints causes an increase in temperature and can therefore be detect by thermography. Machine learning methods are highly accurate in analyzing medical images automatically.

Objectives:

To develop an algorithm that, based on thermographic images of hands and machine learning, learn to quantify joint inflammation in patients with RA and estimate the DAS28, CDAI, SDAI by including the patient global health (PGH).

Methods:

Multicenter observational study conducted in the rheumatology and radiology service of two hospitals. Patients with RA, psoriatic arthritis (PA), undifferentiated arthritis (UA) and arthritis of hands secondary to other diseases (SA) that attended the follow-up visits were recruited. Companions of patients and healthcare professionals were also recruited as healthy subjects (HS). In all cases, a thermographic image of the hands was taken using a Flir One Pro or a Thermal Expert TE-Q1 camera connected to a smartphone. Ultrasound (US) of both hands was performed in patients with RA, PA, UA and SA. The degree of synovial hypertrophy (SH) and power doppler (PD) was assessed for each joint (score from 0 to 3). Machine learning was used to quantify joint inflammation (SH+PD) from the thermal images using US as ground truth. RA patients whose thermal image was taken with the Thermal Expert TE-Q1 camera were used to evaluate the performance (test dataset). The other participants were used as training dataset. The TJC, SJC, PGH, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were also assessed in the test dataset. A linear regression was used to estimate the DAS28, CDAI and SDAI with the resultant joint inflammation quantification from the thermal images and the PGH. Performance was evaluated by means of Pearson’s correlation coefficient. The study was approved by the Clinical Ethics and Research Committee of both centers.

Results:

The total number of recruited subjects was 521 (422 for the training and 99 for the testing dataset). In the training dataset, the thermography of 296 patients was taken with the Flir One Pro (163 RA, 17 PA, 22 UA, 12 SA and 82 HS) and 126 with the Thermal Expert TE-Q1 camera (6 RA without clinical data, 20 PA, 7 UA, 23 SA and 70 HS).

We found higher correlations between joint inflammation variables (US and SJC) and thermography (0.48, p<0.01 for US and 0.48, p<0.01 for SJC) than between joint inflammation variables (US and SJC) and the PGH (0.29, p<0.01 for US and 0.35, p<0.01 for SJC). Thermography did not show statistically significant correlation with the PGH (0.14, p=0.164). The linear regression of thermography and the PGH showed strong correlation with the DAS28 (0.73, p<0.01), CDAI (0.84, p<0.01) and SDAI (0.82, p<0.01).

Conclusion:

Thermography of hands and machine learning can effectively quantify joint inflammation and can be used in combination with the PGH to estimate disease activity scores. These results open an opportunity to develop tools that facilitate telematic consultations in patients with RA.

References:

[1]Brenner M, Braun C, Oster M, Gulko PS. Thermal signature analysis as a novel method for evaluating inflammatory arthritis activity. Ann Rheum Dis. 2006;65(3):306-11

[2]Lynch CJ, Liston C. New machine-learning technologies for computer-aided diagnosis. Nat Med. 2018;24(9):1304-1305

[3]Tan YK, Hong C, Li H, Allen JC Jr, Thumboo J. Thermography in rheumatoid arthritis: a comparison with ultrasonography and clinical joint assessment. Clin Radiol. 2020;75(12):963

Disclosure of Interests:

None declared.

OP0060 COMPARATIVE STUDY ON ANTI-TNF VS TOCILIZUMAB FOR TREATMENT OF REFRACTORY UVEITIC CYSTOID MACULAR EDEMA DUE TO BEHCET’S DISEASE. MULTICENTER STUDY OF 49 PATIENTS

Background:

Posterior segment involvement is the most serious affection of uveitis in Behçet’s disease (BD), with cystoid macular edema (CME) being the leading cause of blindness. Anti-TNF, especially adalimumab (ADA) and infliximab (IFX), have demonstrated efficacy as first-line biologic agents in BD-related uveitis [1,2]. Moreover, the anti-IL6R tocilizumab (TCZ) has shown excellent results in highly refractory BD-uveitis and noninfectious uveitic CME [3-6].

Objectives:

To compare the efficacy of ADA vs IFX vs TCZ in patients with refractory CME due to BD.

Methods:

Observational multicenter study of patients with BD-associated CME refractory to conventional and/or biological immunosuppressive drugs. From a cohort of 177 patients treated with anti-TNF and 14 patients treated with TCZ, we selected those with CME at baseline. CME was defined as macular thickness > 300μm (measured by optic coherence tomography). We analyzed in the 3 groups of treatment (ADA, IFX, TCZ) from baseline up to 4 years the evolution of macular thickness (main outcome) and best-corrected visual acuity (BCVA). Differences between basal and final follow-up were evaluated. Multivariable linear regression was used to assess the differences between the 3 groups.

Results:

A total of 49 patients were included. ADA was used in 25 patients (40 eyes with CME), IFX in 15 (21 eyes with CME) and TCZ in 9 (11 eyes with CME). No statistically significant baseline differences were observed between the 3 groups (Table) except for previous anti-TNF therapy, which was used only in patients treated with TCZ (5 patients received ADA, 1 received IFX and 2 received both ADA and IFX, in different times). Most patients from all groups had received several conventional immunosuppressive drugs. Biological therapy was used in monotherapy or combined with azathioprine (n=10, 5 and 1 in ADA, IFX and TCZ group, respectively), cyclosporine A (n=10, 5 and 1) or methotrexate (n=4, 2 and 3). Macular thickness progressively decreased in the 3 groups, with no signs of CME after 1 year of treatment. Similarly, BCVA improvement and inflammatory ocular remission was reached in all groups (Figure).

Table 1.

Demographic and clinical characteristics of 49 patients with cystoid macular edema due to Behçet’s disease receiving ADA, IFX or TCZ.

ADA (n=25)IFX (n=15)TCZ (n=9)Eyes with cystoid macular edema, n402111Age, years41 ± 1138 ± 943 ± 16Sex, men/women12/137/85/4HLA–B51 +, n19106Duration of uveitis before anti-TNF/ anti-IL6R, months30 [12-82]15 [8-60]32 [24-144]Ocular features at start of anti-TNF/anti-IL6R Macular thickness, μm432 ± 118483 ± 126417 ± 113 Visual acuity, BCVA0.4 ± 0.20.3 ± 0.20.2 ± 0.2 Tyndall, inflammation grade2 [1-3]1 [0-1.5]1 [0-1.5] Vitritis, inflammation grade2.5 [1.5-3]1 [0-2]2 [1-2]Previous treatment, n Oral glucocorticoids // i.v. pulse methylprednisolone18 // 134 // 97 // 8 MTX //CsA //AZA13 // 22 // 148 // 13 // 88 // 6 // 2 ADA // IFX0 // 00 // 07 // 3Prednisone dosage at start of anti-TNF/anti-IL6R, mg/day45 [30-60]30 [20-60]30 [30-30]Combined treatment, n CsA // AZA // MTX10 // 10 // 45 // 5 // 21 // 1 // 3

Data are presented as mean ± SD or median [IQR] when data were not normally distributed. ADA, adalimumab; AZA, azathioprine; CsA, cyclosporine A; MTX, methotrexate; IFX, infliximab; TCZ, tocilizumab.

Figure 1.

Evolution of ocular parameters in 49 patients with cystoid macular edema due to Behçet’s disease receiving ADA, IFX or TCZ.

Conclusion:

Refractory CME associated to BD’s uveitis can be effectively treated with ADA, IFX or TCZ. Moreover, TCZ is effective in patients resistant to anti-TNF therapy.

References:

[1]Arthritis Rheumatol. 2019;71(12):2081-2089. doi: 10.1002/art.41026

[2]Ophthalmology. 2018;125(9):1444-1451. doi: 10.1016/j.ophtha.2018.02.020

[3]Rheumatology (Oxford). 2018;57(5):856-864. doi: 10.1093/rheumatology/kex480

[4]Am J Ophthalmol.2019;200:85-94. doi: 10.1016/j.ajo.2018.12.019

[5]Clin Exp Rheumatol. 2014;32(4 Suppl 84): S54-7. PMID: 25005576

[6]Clin Exp Rheumatol. 2016;34(6 Suppl 102): S34-S40. PMID:27054359

Disclosure of Interests:

None declared

A prospective study of lung disease in a cohort of early rheumatoid arthritis patients

Lung disease is common in patients with rheumatoid arthritis (RA). The onset of lung involvement in RA is not well known. The objective is to describe the features and evolution of lung involvement in early RA, its relationship with disease activity parameters, smoking and treatments. Consecutive patients with early RA without respiratory symptoms were included and tracked for 5 years. Lung assessment included clinical, radiological and pulmonary function tests at diagnosis and during follow-up. Peripheral blood parameters (erythrocyte sedimentation rate, C reactive protein, rheumatoid factor and anti-citrullinated peptide autoantibodies) and scales of articular involvement, such as DAS28-CRP, were evaluated. 40 patients were included and 32 completed the 5-year follow up. 13 patients presented lung involvement in the initial 5 years after RA diagnosis, 3 of them interstitial lung disease. Significant decrease of diffusion lung transfer capacity of carbon monoxide over time was observed in six patients, 2 of them developed interstitial lung disease. DLCO decrease was correlated with higher values of CRP and ESR at diagnosis. Methotrexate was not associated with DLCO deterioration or lung disease development. Subclinical progressive lung disease correlates with RA activity parameters. Smoking status and methotrexate were not associated with development or progression of lung disease.

AB0764 SAFETY OF SYSTEMIC CORTICOSTEROIDS IN A SHORT REGIMEN IN PATIENTS WITH PSORIATIC ARTHRITIS. RETROSPECTIVE ANALYSIS OF A LARGE OBSERVATIONAL COHORT

Background:

There is controversy surrounding the use of systemic corticosteroids in psoriatic arthritis (PsA). It’s an accepted fact that the use of systemic corticosteroids can trigger severe flare-up of erythroderma or pustular psoriasis. Nevertheless, corticosteroids have been used to achieve faster improvement of joint symptoms of PsA.

Objectives:

To analyze the use of systemic corticosteroids at intermediate doses in a short regimen in patients with PsA, as well as the serious complications of psoriasis upon withdrawal.

Methods:

Retrospective analysis of an observational cohort of 453 patients from a university hospital, following a specific protocol from 1992 to 2019. The following variables have been collected: corticosteroid treatment (methylprednisolone ≤16mg /day in a slow tapering regimen in 2 months), demographic and disease factors, comorbidities that could be associated (diabetes mellitus, high blood pressure, severe infections) and serious complications of psoriasis (erythroderma or pustular psoriasis). To assess the activity of psoriasis, physician global assessment is mostly used and occasionally to a lesser extent body surface area and psoriasis area severity index.

Statistical analysis (SPSS v.25): descriptive analysis, Chi-squared test for qualitative variables and t-student test for quantitative variables.

Results:

In our series, 35.98% (163/453) of patients have received short corticosteroid regimen at some point in follow-up care, of which 93.8% received concomitant treatment with disease modifying antirheumatic drugs (DMARD).

Only 6.2% of the patients who received short corticosteroid regimen presented a flare-up of psoriasis, most of them mildly. No patient developed an erythroderma or severe pustular psoriasis.

After analyzing the data, a greater use of this regimen of treatment has been observed in patients with dactylitis (44.6% with dactylitis vs 27.8% without dactylitis, p<0.001) and a lower use of corticosteroids in axial PsA (14% of axial PsA vs 41% of non-axial PsA, p<0.001).

There were no significant differences in the use of corticosteroids in respect to sex, age, age of onset of PsA, duration of PsA or high blood pressure. Nor in factors of poor radiographic prognosis: number of damaged joints, mutilating PsA and carpitis.

Conclusion:

In our series, no patient developed an erythroderma or severe pustular psoriasis and most of the flare-ups of psoriasis were mild. The use of systemic corticosteroids at intermediate doses in a slow tapering regimen concomitantly with DMARD can be safely used in patients with PsA.

References:

None

Disclosure of Interests:

None declared

AB0593 DOES REALLY EXIST MIXED CONNECTIVE TISSUE DISEASE?

Background:

Currently, most authors accept that mixed connective tissue disease (MCTD) is an independent entity, although there are those who argue that it is actually an overlap syndrome or an undifferentiated early phase of another systemic autoimmune disease (SAD).

Objectives:

To analyze the long term evolution of a serie of patients with MCTD.

Methods:

Observational, retrospective and multicenter study in patients with MCTD (diagnostic criteria of Alarcón-Segovia et al),followed for a minimun of 2 years.

Results:

Fifty-five patients (49 women) with a median age at diagnosis of 38±14 years and with a follow up time (median) of 101 months (range, 24-237 months with a total of 501.2 pacients-year) were identified.

At the end of the follow-up period, only 27% (15/55) of the patients kept on fulfilling MCTD criteria. In the remaining 73% (40), 40% (22) had been differentiated to systemic lupus erythematosus (SLE), 13% (7) to systemic sclerosis (SSc) and 20% (11) developed an overlap syndrome [SSc+SLE in 8 cases and SSc+rheumatoid arthritis (AR) in 3]. In 8% of these patients, a secondary Sjögren’s syndrome was diagnosed during the follow-up period. The average score in patients who met the EULAR/ACR 2013 criteria for SSc was 11 (minimum 9 - maximum 16) and the average time elapsed from the diagnosis of MCTD to meet SSc criteria was 64.4 months (interquartile range [IQR] 25-75%: 10-127 months).

Applying the 2012 SLICC criteria, only 24 patients of those initially diagnosed as MCTD ended up meeting SLE criteria. The average score in these patients was 5.6 (4-9) and the average time elapsed from the diagnosis of MCTD unltil fulfilling the SLICC criteria was 39 months (IQR 25-75%: 6-28). When we apply the new ACR/EULAR 2019 criteria, the percentage of patients who meet SLE criteria increased to 30%, with an average score of 17.3 (10-38). The average time elapsed since the diagnosis of MCTD until meeting the new SLE criteria was reduced to 17 months (IQR 25-75: 0-10).

In the multivariate study, the presence of sclerodactyly (OR: 2.91; IC 95% 1.90 - 4.1, p= 0.001) and esophageal involvement (OR: 2.05; IC 95% 1.14–3.66, p=0.016) were associated with the evolution to SSc. Any predictor of evolution to SLE was identified.

Conclusion:

Only slightly more than a quarter of patients initially diagnosed as MCTD maintain this diagnosis during the follow-up. The majority, ended up evolving towards to another SAD, fundamentally SLE and SSc. The new ACR/EULAR 2019 criteria seems to be more sensitive than the SLICC 2012 criteria for diagnose SLE in these patients.

Disclosure of Interests:

L Montolio-Chiva: None declared, J. Narváez: None declared, Maria Pascual: None declared, Hye Sang Park: None declared, Ana V Orenes Vera: None declared, Eduardo Flores: None declared, Juanjo J Alegre-Sancho Consultant of: UCB, Roche, Sanofi, Boehringer, Celltrion, Paid instructor for: GSK, Speakers bureau: MSD, GSK, Lilly, Sanofi, Roche, UCB, Actelion, Pfizer, Abbvie, Novartis, Iván Castellví: None declared, Joan Miquel Nolla: None declared

AB0163 ANTI-KU ANTIBODIES: MUCH MORE THAN SCLEROMYOSITIS

Background:

Initially, anti-Ku antibodies (Ab) were described in patients with overlap syndrome with systemic sclerosis (SSc) and inflammatory myophaty (scleromyositis), although later they have been linked to a wide variety of systemic autoimmune diseases (SAD) questioning its diagnostic value. Recently, the possible existence of 2 different clinical phenotypes associated with these Ab has been described: one with myositis and high risk of intersticial lung disease (ILD) and another with positive anti-dsDNA Ab and glomerulonephritis.

Objectives:

To analyze the clinical relevance and the main diagnosis of a serie of patients with positive anti-Ku Ab.

Methods:

Descriptive observational study of patients with anti-Ku Ab in two third level hospitals between 2011 and 2019. Their determination was made at the criteria of the requesting physician.

Results:

Twenty-three patients (20 women) with a median age of 59 ± 14 years (range, 24-83) and a follow up time (median) of 37 months (1-208) were identified. The main clinical and analytical characteristics, as well as the final clinical diagnosis of these patients are shown in Table 1. In the cluster analysis we could not identify clinical phenotypes, perhaps because of the small sample size. Only 50% of patients with myositis developed ILD. Regarding the final diagnosis, only 1 patient (5%) was diagnosed of scleromyositis. Besides detecting them in patients with SSc (39%) and idiopathic inflammatory myopathy (9%), anti-Ku Ab were detected in other SAD, the most frequent were systemic lupus erythematosus, rheumatoid arthritis (RA) and overlap syndrome of SSc + RA.

Table 1.

Main clinical-analytical manifestations and final diagnosis of pacientes with anti-Ku Ab.

FINAL CLINICAL DIAGNOSiSScleromyositis: 1Idiopahtic inflammatory myopathy: 1Systemic sclerosis (SSc): 6 (Pre-scleroderma: 3, limited SSc: 3).Systemic lupus erythematosus: 2Rheumatoid arthritis: 2Overlap syndrome RA + limited SSc: 2Primary Sjögren’s syndrome: 1 (Secondary Sjögren’s syndrome: 3)Mixed connective tissue disease: 1Polymyalgia rheumatica: 1Undifferentiated connective tissue disease: 1Acute hepatitis due to HEV: 1Autoimmune thrombocytopenia (ITP): 1Drug-induced fibrosing ILD: 1Systemic graft versus host disease (GVHD) in a patient with acute lymphoblastic leukemia who received and autologous haematopoietic progenitor transplant: 1Primary biliary cirrhosis: 1CLINICAL MANIFESTATIONS(patients could have more than one):Raynaud’s phenomenon: 61% (14/23).Inflammatory arthralgia/arthritis: 52% (12).Lung involvement: 30.5% (7: NSIP 3, UIP 2, other patterns 2).Serositis: 26% (6: pericarditis 4, pleuritis 1, pleuropericarditis 1).Cardiac involvement: 26% (6: PHT by echocardiogram 3, myocarditis 2, arrhytmia 1).Dry syndrome: 17% (4)Myositis: 17% (4).Esophageal involvement: 17% (4).Autoimmune cytopenias: leucolinfopenia: 17% (4) / thrombocytopenia: 13% (3).Telangiectasias: 13% (3).Photosensitivity: 13% (3).Other: non-androgenic alopecia: 9% (2); sensory-motor polyneuropathy: 4.5% (1);Puffy hands: 4.5% (1); fever: 4.5% (1); lymphadenitis: 4.5% (1); cold sores: 4.5% (1), and retinal hemorrhage: 4.5% (1).OTHER ASSOCIATED ANTIBODIES:ANA: 91% (21/23)anti Ro60/SSA Ab: 30.5% (7)Anti Ro52 Ab: 30.5% (7)Anti RNP Ab: 22% (5)Anti-dsDNA: 17% (4)Anti-La/SSB Ab: 17% (4)Anticentromer Ab: 17% (4)Anti Mi-2 Ab: 13% (3)Other: anti Sm Ab: 9% (2); anticardiolipin Ab(IgG): 4.5% (1); PM/Scl: 4.5% (1); nucleosomes: 4.5% (1); Scl70: 4.5% (1); PL12: 4.5% (1); anti-U1-RNP: 4.5% (1) and NOR90: 4.5% (1).

Conclusion:

Anti-Ku Ab are related to a great variety of SAD, without being a specific marker of any of them, nor being associated with any specific clinical manifestation. We couldn’t confirm the existence of clinical phenotypes associated with the presence of these antibodies.

Disclosure of Interests:

L Montolio-Chiva: None declared, J. Narváez: None declared, Francisco Morandeira: None declared, Jordi Bas: None declared, Carla Marco: None declared, Xavier González: None declared, Juanjo J Alegre-Sancho Consultant of: UCB, Roche, Sanofi, Boehringer, Celltrion, Paid instructor for: GSK, Speakers bureau: MSD, GSK, Lilly, Sanofi, Roche, UCB, Actelion, Pfizer, Abbvie, Novartis, Eduardo Flores: None declared, I Vázquez-Gómez: None declared, Jose María López: None declared, Joan Miquel Nolla: None declared

SAT0567 USE OF THERMOGRAPHY OF HANDS AND MACHINE LEARNING TO DIFFERENTIATE PATIENTS WITH ARTHRITIS FROM HEALTHY SUBJECTS

Background:

The early diagnosis of rheumatic diseases improves their prognosis. However, patients take several months to reach the rheumatologist from the beginning of the first symptoms. Thermography is a safe and fast technique that captures the heat of an object through infrared photography. The inflammation of the joints causes an increase in temperature and, therefore, can be measured by thermography. Machine learning methods have shown that they are capable of analyzing medical images with an accuracy similar or superior to that of a healthcare professional.

Objectives:

Develop an algorithm that, based on thermographic images of hands and machine learning, differentiates healthy subjects from patients with rheumatoid arthritis (RA), psoriatic arthritis (PA), undifferentiated arthritis (UA) and arthritis of hands secondary to other diseases (SA).

Methods:

Multicenter observational study conducted in the rheumatology and radiology service of two hospitals. Patients with RA, PA, UA and SA who attended the followup visit and healthy subjects (companions and healthcare proffesionals) were recruited. In all cases, a thermal image of the hands was taken using a Flir One Pro or Thermal Expert TE-Q1 camera connected to the mobile and an ultrasound of both hands. The degree of synovial hypertrophy (SH) and power doppler (PD) was assessed for each joint (score from 0 to 3). Inflammation was defined as the presence of SH> 1 or PD> 0. Machine learning was used to classify patients with RA, PA, UA and SA with inflammation evidenced by ultrasound and healthy subjects from thermographic images. The evaluation of the classifier was performed by leave-one-out cross-validation and the area under the ROC curve (AUCROC) in those subjects whose thermal image was performed with the Thermal Expert TE-Q1 camera. The study was approved by the Clinical Ethics and Research Committee of the centers.

Results:

500 subjects were recruited from March 2018 to January 2020, of these 73 were excluded due to poor quality in the thermal image (moved or absence of temperature contrast between hand and background). Of the 427 subjects analyzed, 129 corresponded to healthy subjects, 138 to patients without evidence of inflammation and 160 to patients with inflammation evidenced by ultrasound (116 RA and 44 PA, UA or SA). Of these, 42% were taken using the Thermal Expert TE-Q1 camera. An AUCROC of 0.73 (p-value <0.01) was obtained for the healthy classifier vs RA and 0.72 (p-value <0.01) for the healthy classifier vs PA, UA and SA.

Conclusion:

A classification model has been developed capable of differentiating patients with RA, PA, UA and SA with evidence of inflammation from healthy subjects. These results open an opportunity to develop tools that facilitate early diagnosis.

References:

[1]Barhamain AS, Magliah RF, Shaheen MH, Munassar SF, Falemban AM, Alshareef MM, Almoallim HM. The journey of rheumatoid arthritis patients: a review of reported lag times from the onset of symptoms. Open Access Rheumatol. 2017 Jul 28;9:139-150. doi: 10.2147/OARRR.S138830. eCollection 2017. Review.

[2]Lynch CJ, Liston C. New machine-learning technologies for computer-aided diagnosis. Nat Med. 2018 Sep;24(9):1304-1305. doi: 10.1038/s41591-018-0178-4.

[3]Brenner M, Braun C, Oster M, Gulko PS. Thermal signature analysis as a novel method for evaluating inflammatory arthritis activity. Ann Rheum Dis. 2006 Mar;65(3):306-11.

Disclosure of Interests:

None declared

AB1219 ADHERENCE TO THE MEDITERRANEAN DIET IN PATIENTS WITH RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS, MULTICENTER STUDY

Background:

The Mediterranean diet (MD) has proven beneficial in a large number of chronic diseases. The relationship between the MD and rheumatic diseases is complex and there are few studies that have studied this relationship. These show that there could be a positive association between adherence to the Mediterranean diet (MD-A) and a lower prevalence of OA. In the case of RA, it has been proposed that the MD could reduce pain and improve functionality.

Objectives:

To determine the MD-A diet of patients with RA and OA, and compare it with that of healthy subjects.

Methods:

Multicenter, cross-sectional, observational study. Patients who attend the rheumatology outpatient and meet the ACR / EULAR 2010 criteria for RA and ACR for OA of hands, knees or hips are included in the study. The healthy are recruited among health personnel and companions of patients who do not live in the same address as the patient. The study is being carried out in the rheumatology consultations of two Hospitals and an outpatient center with specialized care. All participants have answered a survey of 14 questions (MEDAS-14), based on the Predimed study, which assesses MD-A. Fisher’s exact test and the Mann-Whitney U test have been used to assess statistical significance. The study was approved by the Clinical Ethics and Research Committee of the centers.

Results:

There have been 279 surveys (132 RA, 82 OA and 65 healthy). The MD-A in patients with RA is lower than in healthy (6.26 vs. 7.15, p <0.05). Patients with OA also have less adherence to the MD than healthy ones but this difference is not statistically significant (6.85 vs. 7.15, p> 0.05). The proportion of patients with RA and OA who consume 2 or more servings of vegetables daily is lower than that of healthy subjects (RA 20%; OA 13% and healthy 34%, p <0.05). The proportion of RA and OA that eats more than 3 weekly servings of nuts compared to healthy is also lower (RA 21%, OA 17%, healthy 35% p <0.05). The proportion of RA and OA that consume less than 1 serving of butter is lower than that of healthy (RA 86%; OA 82% and 98%, p <0.05). The proportion of RA that consumes 3 or more servings of legumes per week is lower than healthy (23% vs 40%, p <0.05). These differences between the OA group and healthy are not appreciated. The consumption of more than three pieces of fruit daily is more frequent in OA than in healthy ones (45% vs 26%, p <0.05).

Conclusion:

The MD-A diet quantified by MEDAS-14 in subjects with RA and OA is lower than in healthy subjects, being significant in RA. Patients with RA and OA eat less vegetables and nuts but the intake of butter is higher. The RA group consumes less legumes than healthy ones. Patients with OA eat more fruit than healthy ones, this is the only food in the MD valued by MEDAS-14 that is consumed in a lower proportion in healthy ones. Longitudinal intervention studies are necessary to assess whether the differences observed in this study have any causal relationship.

References:

[1]Estruch R, Ros E, Salas-Salvadó J, Covas M-I, Corella D, Arós F, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med. 2013;368(14):1279-90.

[2]Trichopoulou A, Martínez-González MA, Tong TY, Forouhi NG, Khandelwal S, Prabhakaran D, et al. Definitions and potential health benefits of the Mediterranean diet: views from experts around the world. BMC Med. 2014;12:112.

[3]Morales-Ivorra I, Romera-Baures M, Roman-Viñas B, Serra-Majem L. Osteoarthritis and the Mediterranean Diet: A Systematic Review. Nutrients. 2018;10(8) pii: E1030. doi: 10.3390/nu10081030.

[4]Forsyth C, Kouvari M, D’Cunha NM, Georgousopoulou EN, Panagiotakos DB, Mellor DD, et al. The effects of the Mediterranean diet on rheumatoid arthritis prevention and treatment: a systematic review of human prospective studies. Rheumatol Int. 2018 May;38(5):737–47.

Disclosure of Interests:

None declared

AB0594 EFFECTIVENESS OF RITUXIMAB IN CSDMARDS-RESISTANT ACTIVE MIXED CONNECTIVE TISSUE DISEASE

Background:

Objectives:

To evaluate rituximab (RTX) effectiveness and safety in treating patients with refractory mixed connective tissue disease (MCTD).

Methods:

Open observational study including patients with refractory MCTD (active disease despite treatment with glucocorticoids and csDMARDs) from two third-level hospitals who had been treated with RTX (off-label use) from January 2001 to December 2019.

Results:

Thirteen patients (all women) were included, with a mean age of 32 years (SD: 10, range 17-50) and a median time of evolution of the disease of 55 months (SD: 34.3; range 5-98 months). The main indication for initiating treatment with RTX was refractory arthritis (100%), most of the times accompanied by other features of the disease including shrinking lung syndrome (2), fibrosing progressive non-specific interstitial pneumonia (FP-NSIP) (1), recurrent serositis (2), glomerulonephritis (GMN) (2), lymphadenitis (1) and immune thrombocytopenic purpura (ITP) (1). All patients were treated with RTX at rheumatoid arthritis dosage while the baseline immunosuppressive treatment (methotrexate, azathioprine, mycophenolate, leflunomide or tacrolimus) remained unchanged. Hydroxychloroquine was also associated in 8 of the patients. The follow-up time (median) after starting RTX was 118 months (range, 65-177 months, with a total of 132.6 patient-years of follow-up) and the mean number of cycles of treatment was 4.2 (range, 1-15), with a variable interval (from 6 to 12 months). After the first RTX cycle, a partial or complete response was achieved in 92% of the patients. A significant improvement in the mean DAS28-ESR was observed (initial: 4.56 ± 1.6 / final: 2.21 ± 0.85; p=0.008). In all but one patient, who had previously failed to 2 anti-TNFα DAS28-ESR clinical remission or low activity was achieved, generally from week 16 to 20, although relapses were frequent and all cases need retreatment after 6-9 months. In 4 patients, RTX retreatment dosage was optimized to 1 g/cycle. The 3 patients with pulmonary involvement showed stabilization (2 cases) or improvement (1) of the lung function(as defined by the American Thoracic Society). In patients with GMN, renal response to RTX treatment was complete in a patient and partial in the other. The patient with ITP entered remission after the first RTX cycle and no more cycles were needed. Response in patients with serositis and lymphadenitis was also complete and maintained. Moreover, the glucocorticoid doses were reduced to less than half of the initial dose in all cases. At the end of the follow-up, 7 out of the 13 patients (54%) were still being treated with RTX. For the remaining 6 patients, RTX was withdrawn because of primary failure (1), recurrent bacterial infections (2), gestational desire (2) sustained remission (1).

Conclusion:

According to our preliminary results, RTX seems to be effective and relatively safe in patients with csDMARDs-resistant active MCTD.

Disclosure of Interests:

L Montolio-Chiva: None declared, J. Narváez: None declared, Juanjo J Alegre-Sancho Consultant of: UCB, Roche, Sanofi, Boehringer, Celltrion, Paid instructor for: GSK, Speakers bureau: MSD, GSK, Lilly, Sanofi, Roche, UCB, Actelion, Pfizer, Abbvie, Novartis, J Lluch Pons: None declared, Ana V Orenes Vera: None declared, I Vázquez-Gómez: None declared, Maribel Mora: None declared, Xavier González: None declared, Carla Marco: None declared, Jesús Rodriguez: None declared, Montserrat Romera: None declared, Joan Miquel Nolla: None declared

Spanish consensus on treat to target for osteoporosis

To reach a Spanish expert consensus on a treat-to-target strategy in osteoporosis, a Delphi Consensus Study has been developed. Most of the experts (59.8%) were rheumatologist with a mean clinical experience of 21.3 years (SD 8.5). Consensus was achieved for 70% of the items. Therapeutic objectives, patient follow-up scheme, treatment failure criteria, and appropriate treatment choice for use in T2T strategy in Spain have been defined.

INTRODUCTION

The paper aims to achieve a Spanish expert consensus on a treat-to-target (T2T) strategy in osteoporosis.

METHODS

A scientific committee led the project and was involved in expert panel identification and Delphi questionnaire development. Two Delphi rounds were completed. The first-round questionnaire included 24 items and assessed, using a seven-point Likert scale, the experts' wish (W) and prognosis (P) in 5 years for each topic (applicability, therapeutic objectives, patient follow-up, and possible treatment to be prescribed). Items for which there was no consensus in the first round were included in the second round. Consensus was defined as ≥75% agreement (somewhat/mostly/entirely agree) or disagreement (somewhat/mostly/entirely disagree) responses.

RESULTS

Of the experts, 112 and 106 completed the first and second rounds, respectively. 59.8% were rheumatologists with a mean clinical experience of 21.3 years (SD 8.5). Consensus was achieved for 70% of the items, and was established regarding the utility of a T2T strategy to define therapeutic objectives, optimal follow-up, and therapeutic algorithm. Participants agreed on the utility of the bone mineral density (BMD) value (T-score >-2.5 SD for spine and >-2.5/-2.0 SD for femoral neck), lack of fractures, and fracture risk (FRAX) as therapeutic objectives. For measuring BMD changes, consensus was achieved on the suitability of hip and femoral neck locations. Experts agreed to consider treatment failure as when a significant BMD gain could not be achieved, or when a new fracture occurs within 2-3 years. There was consensus that all proposed therapies should achieve a therapeutic target through T2T strategy (treatments with the highest consensus scores were denosumab and teriparatide).

CONCLUSION

The therapeutic objectives, patient follow-up scheme, treatment failure criteria, and appropriate treatment choice for use in T2T strategy in Spain have been established by a panel of experts. Some aspects nevertheless still require further analysis.

Early changes in biochemical markers of bone formation during teriparatide therapy correlate with improvements in vertebral strength in men with glucocorticoid-induced osteoporosis

Changes of the bone formation marker PINP correlated positively with improvements in vertebral strength in men with glucocorticoid-induced osteoporosis (GIO) who received 18-month treatment with teriparatide, but not with risedronate. These results support the use of PINP as a surrogate marker of bone strength in GIO patients treated with teriparatide.

INTRODUCTION

To investigate the correlations between biochemical markers of bone turnover and vertebral strength estimated by finite element analysis (FEA) in men with GIO.

METHODS

A total of 92 men with GIO were included in an 18-month, randomized, open-label trial of teriparatide (20 μg/day, n = 45) and risedronate (35 mg/week, n = 47). High-resolution quantitative computed tomography images of the 12th thoracic vertebra obtained at baseline, 6 and 18 months were converted into digital nonlinear FE models and subjected to anterior bending, axial compression and torsion. Stiffness and strength were computed for each model and loading mode. Serum biochemical markers of bone formation (amino-terminal-propeptide of type I collagen [PINP]) and bone resorption (type I collagen cross-linked C-telopeptide degradation fragments [CTx]) were measured at baseline, 3 months, 6 months and 18 months. A mixed-model of repeated measures analysed changes from baseline and between-group differences. Spearman correlations assessed the relationship between changes from baseline of bone markers with FEA variables.

RESULTS

PINP and CTx levels increased in the teriparatide group and decreased in the risedronate group. FEA-derived parameters increased in both groups, but were significantly higher at 18 months in the teriparatide group. Significant positive correlations were found between changes from baseline of PINP at 3, 6 and 18 months with changes in FE strength in the teriparatide-treated group, but not in the risedronate group.

CONCLUSIONS

Positive correlations between changes in a biochemical marker of bone formation and improvement of biomechanical properties support the use of PINP as a surrogate marker of bone strength in teriparatide-treated GIO patients.

Adult onset Still's disease: review of 41 cases

OBJECTIVES

To describe the clinical, laboratory and radiological features, treatment and prognosis of patients with adult onset Still's disease (AOSD).

METHODS

Specific clinical features were retrospectively recorded in 41 patients fulfilling the Yamaguchi criteria. Patients were reviewed in two academic hospitals with a referral area of 700,000-1,000,000 inhabitants. Laboratory tests including haemogram, ferritin, biochemistry and autoimmunity were reviewed. Radiological studies, treatment and ACR functional class were determined.

RESULTS

Forty-one patients with AOSD were identified, 25 of whom were female. Mean age at diagnosis: 38.19 years (range 17-68). Feverish polyarthritis was the most common clinical presentation. Acute phase reactants were invariably high in all patients. Serum ferritin levels were elevated in 86% of patients. Anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies) were negative in all patients except one. The course of the disease was monocyclic in 44% of the patients, polycyclic in 26%, and chronic articular in 30%. ACR class was as follows: 29 (72.5%) class I, 7 (17.5%) class II, 2 (5%) class III and 2 (5%) class IV. As for the treatment received, aspirin or NSAIDs controlled the disease in eight patients (19.5%) and high-dose corticosteroids (0.5-1 mg/kg/day) in 32 (78%). Almost half of the patients (49%) required an additional diseasemodifying agent, usually methotrexate. Finally, in seven of them (17%) a biological treatment with TNF-α or specially anti-IL-1 had to be added to control the disease.

CONCLUSIONS

The clinical and laboratory findings were similar to previous studies. Anti-CCP antibodies were almost always negative. A monocyclic course was associated with a good prognosis. Most of the patients were in ACR functional class I and II. Biological agents were required in 7 patients (17%).

Cervical spine involvement in rheumatoid arthritis: correlation between neurological manifestations and magnetic resonance imaging findings

OBJECTIVE

To evaluate the correlation between neurological deficits indicative of compressive myelopathy and MRI findings in a series of patients with RA and symptomatic involvement of the cervical spine.

METHODS

Forty-one consecutive patients with RA were studied using cervical spine MRI. Unconditional logistic regression analysis was used to identify MRI parameters of cervical spine involvement associated with the development of neurological dysfunction.

RESULTS

The mean age of the 41 patients (33 women and 8 men) was 59 yrs (range 23-82 yrs), while the median disease duration was 18 +/- 9 yrs (range 4-40 yrs). According to Ranawat's classification, 17 (42%) patients were in Class I, 21 (51%) in Class II and 3 (7%) in Class III. Thus, patients with clinical manifestations of compressive myelopathy (Ranawat's Class II + III) represented 58% (24/41) of all cases. Among the different MRI parameters of cervical spine involvement analysed, only the presence of atlantoaxial spinal canal stenosis [odds ratio (OR) 4.55; 95% CI 1.14-18.15], atlantoaxial cervical cord compression (OR 9.6; 95% CI 1.08-85.16) and subaxial myelopathy changes (OR 11.43; 95% CI 1.3-100.81) were associated with a significantly increased risk for neurological dysfunction (Ranawat's Class II or III).

CONCLUSION

In RA patients with symptomatic cervical spine involvement, there is a strong correlation between the development of neurological dysfunction and MRI identification of atlantoaxial spinal canal stenosis, especially in those cases with evidence of upper cervical cord or brainstem compression and subaxial myelopathy changes.

High HDL-cholesterol in women with rheumatoid arthritis on low-dose glucocorticoid therapy

BACKGROUND

Dyslipidaemia has been described in non-treated rheumatoid arthritis (RA), and improves after therapy with disease modifying anti-rheumatic drugs or glucocorticoids; however, it has generally been perceived that glucocorticoids adversely affect lipid metabolism. The association of low dose glucocorticoid therapy with plasma lipid levels was evaluated in female RA patients.

MATERIALS AND METHODS

A cross-sectional study was conducted in 78 female RA patients [mean age: 60 (12) years; mean disease duration: 13 (9) years]. Sixty-five (83%) were on glucocorticoid therapy [total equivalent mean prednisone dose: 5.1 (1.7) mg d(-1)]. Each patient was assessed through a self-reported questionnaire, structured interview and physical examination. Blood samples were obtained for routine biochemistry, lipid profile and haematological tests. Lipid profiles of RA patients who were and were not on glucocorticoid therapy were compared.

RESULTS

Clinical and laboratory features of the two groups of patients were similar, except for the Health Assessment Questionnaire and body mass index, which were significantly higher in the patients on glucocorticoid therapy. These patients had 14.7% higher serum high-density lipoprotein cholesterol (HDL-c) levels than untreated patients (P = 0.043), mainly at the expense of HDL2 subfraction, which was 24.4% higher (P < 0.039), whereas HDL3-c was only 7.4% higher (P = 0.219). Serum levels of glucose and total cholesterol, triglyceride, low-density lipoprotein cholesterol (LDL -c), very low-density lipoprotein cholesterol, apolipoproteins A-I and B were not increased in patients on glucocorticoid therapy.

CONCLUSIONS

Low dose glucocorticoid therapy in RA patients is associated with an increase in HDL-c, without increasing LDL-c or triglyceride. These lipid changes may overall be considered favourable.

Impact of antiplatelet therapy in the development of severe ischemic complications and in the outcome of patients with giant cell arteritis

OBJECTIVE

To evaluate whether concomitant treatment with low-dose aspirin or other antiplatelet agents have an impact on the risk of severe ischemic complications and in the outcome of patients with giant cell arteritis (GCA).

METHODS

A retrospective follow-up study of an unselected population of 121 patients with GCA.

RESULTS

Thirty-seven patients (30.5%) received antiplatelet therapy before the onset of GCA symptoms and continued taking it during the corticosteroid treatment (30 received aspirin and 7 other antiplatelet agents). No statistically significant reduction in the incidence of ischemic manifestations (including jaw claudication, visual manifestations, cerebrovascular accidents, ischemic heart disease, and limb claudication due to large artery stenosis) was observed in this group compared with the remaining patients. When we analyzed follow-up data, we found no significant differences between groups in terms of frequency of relapses and percentage of patients recovered from GCA. Corticosteroid requirements among patients in long-lasting remission were lower in those under antiplatelet therapy, but this reduction was fairly modest, statistically non significant and thus of uncertain clinical significance. Similar results were found when only aspirin exposed patients (n=30) were compared to non-exposed patients. Logistic regression analysis showed that antiplatelet therapy (p=0.54, OR 1.31; 95% CI: 0.54-3.19) had not an independent protective effect against ischemic events when adjusted for age, sex, and the presence of atherosclerotic risk factors.

CONCLUSION

We did not observe a significant benefit derived from the use of antiplatelet therapy in either the incidence of severe ischemic events or the disease outcome. Although our results do not discard a potential therapeutic effect of high-dose aspirin, they do not confirm its suggested protective effect in preventing ischemic complications when used at antiplatelet doses.

Giant cell arteritis and polymyalgia rheumatica: usefulness of vascular magnetic resonance imaging studies in the diagnosis of aortitis

OBJECTIVES

One of the unresolved challenges posed in giant cell (temporal) arteritis (GCA) is the detection and monitoring of large-artery complications, particularly aortitis. Recent investigations support vascular magnetic resonance imaging (MRI) studies in this issue. We report our preliminary experience with this imaging technique in the study of the aorta and its proximal branches in patients with GCA and/or polymyalgia rheumatica (PMR).

METHODS

Between 2000 and 2003, six patients with GCA and/or PMR seen in our department were diagnosed with aortitis using vascular MRI studies. In all cases, the study was performed according to a specifically designed protocol that included MRI and MR angiography (MRA).

RESULTS

MRI was a hepful non-invasive method for diagnosis of aortitis in all cases, providing accurate information about its extent. In particular, MRI had a higher ability to detect earlier stages of vasculitis disclosing subclinical aortitis in five of the six patients. The main signs of early vascular inflammation observed were vessel wall thickness and oedema (six cases) and increased mural enhancement on postcontrast T1-weighted images (four cases). MRA disclosed lumen changes (stenosis) in two patients. On follow-up studies, whereas vascular stenosis and vessel wall thickness remained invariable, vascular wall oedema and contrast enhancement improved significantly when disease activity decreased.

CONCLUSION

MRI may be a useful technique for diagnosing patients with occult major artery involvement in GCA, whether presenting with classic symptoms of temporal arteritis or PMR. Its utility for monitoring the course of the disease and response to treatment requires further confirmation.

Usefulness of bone densitometry in postmenopausal women with clinically diagnosed vertebral fractures

OBJECTIVE

To analyse whether bone mineral density (BMD) assessment is required in postmenopausal women presenting with low trauma vertebral fracture.

METHODS

Women with vertebral fracture diagnosed over a 10 year period were recruited from our database. The following were excluded: (a) patients with high energy trauma; (b) patients with malignancies; (c) patients with a metabolic bone disease other than osteoporosis. All postmenopausal women were included in whom BMD had been evaluated at both the lumbar spine and femoral neck by dual energy x ray absorptiometry during the six months after the diagnosis. Patients with a potential cause of osteoporosis other than age and menopause were not considered. A total of 215 patients were identified.

RESULTS

The mean (SD) age of the patients was 65.9 (6.9) years. BMD at the lumbar spine was 0.725 (0.128) g/cm(2) and the T score was -2.94 (1.22); BMD at the femoral neck was 0.598 (0.095) g/cm(2) and the T score was -2.22 (0.89). The BMD of the patients was significantly lower than that of the general population at both the lumbar spine and femoral neck. When the lowest value of the two analysed zones was considered, six patients (3%) showed a normal BMD, 51 (23.5%) osteopenia, and 158 (73.5%) osteoporosis. The prevalence of osteoporosis at the femoral neck increased with age; it was 25% in patients under 60, 35% in patients aged 60-70, and 60% in patients over 70.

CONCLUSION

These results indicate that bone densitometry is not required in postmenopausal women with clinically diagnosed vertebral fractures if it is performed only to confirm the existence of a low BMD.

Salivary testosterone is associated with higher lumbar bone mass in premenopausal healthy women with normal levels of serum testosterone

The relationships among lumbar and femoral bone mineral density (BMD) and different forms of testosterone--total, salivary testosterone and free testosterone index (FTI) calculated with the sex hormone binding globulin (SHBG)--, body mass index (BMI) and body fat distribution (waist-to-hip ratio and breast-to-hip ratio) were analysed in a cross-sectional study with 66 Spanish premenopausal healthy women aged 42 years and with normal levels of serum testosterone. BMD was measured using dual-energy X-ray absorptiometry (Hologic QDR 1000), and salivary and blood samples were obtained during early follicular phase. In a multiple stepwise regression analysis, lumbar BMD was positively predicted by salivary testosterone and negatively by SHBG adjusted by BMI (R2 = 0.20; p < 0.02). The most femoral BMDs were negatively predicted by SHBG and positively by breast-to-hip ratio (R2 = 0.22-0.33, according to the site measured), but neck BMD was not predicted by any variable. When FTI was entered into the regression model instead of SHBG, it was not an independent predictor of BMD. The waist-to-hip ratio was positively correlated with several femoral BMD sites, but breast-to-hip ratio was better predictor. After adjusting by SHBG, the BMI was only predictor for intertrochanter BMD. All women with elevated salivary testosterone (n = 12) had higher lumbar BMD than those with normal value (1.120 +/- 0.112 vs. 1.026 +/- 0.118; p < 0.01) without differences in other confounding variables. As a conclusion, in premenopausal healthy women of the same age with normal levels of serum testosterone, low levels of SHBG and high levels of salivary testosterone are associated with higher lumbar BMD, whereas low levels of SHBG together with higher breast-to-hip ratio are associated with higher femoral BMD.

Nutritional status in patients with rheumatoid arthritis

BACKGROUND

Some chronic diseases have been associated to an impairment of nutritional status.

OBJECTIVE

To analyze nutritional status and its relation to dietary intake, disease activity and treatment in rheumatoid arthritis.

PATIENTS AND METHODS

We have included 93 patients (43 men and 50 women) and 93 age- and sex-matched healthy controls. The assessment of nutritional status included anthropometric (body mass index, tricipital skin fold and midarm muscular circumference) and biochemical (serum albumin, prealbumin and retinol binding protein) parameters. Dietary intake was calculated from a food frequency questionnaire. As a measure of disease activity, we used the Health Assessment Questionnaire, Ritchie index, tender and swollen joint count and C-reactive protein. Statistical analysis was performed in the whole series and in every functional class.

RESULTS

In the whole series, midarm muscular circumference and serum albumin were significantly lower in patients than in controls. All anthropometric parameters and serum albumin were significantly lower in patients in functional class IV than in their respective controls. The dietary intake of energy, carbohydrates, vegetal proteins and lipids was higher in patients than in controls. Midarm muscular circumference and serum albumin had a significant inverse relation with disease activity parameters; body mass index, midarm muscular circumference and serum albumin correlated inversely with the cumulative dose of glucocorticoids.

CONCLUSIONS

Patients with rheumatoid arthritis in functional class IV have an impairment of nutritional status without a deficient dietary intake. The differences found in other functional classes are explained by rheumatoid arthritis itself. Nutritional parameters are related to disease activity and glucocorticoid treatment.

Osteoporotic vertebral fracture in clinical practice. 669 Patients diagnosed over a 10 year period

OBJECTIVE

Few data are available on clinically diagnosed vertebral fracture. Information about osteoporotic vertebral fracture has mainly been obtained via inferences from epidemiological studies of vertebral deformity. We evaluated the characteristics of patients with osteoporotic vertebral fracture diagnosed in a rheumatology department over a 10 year period.

METHODS

Patients with back pain and vertebral fracture diagnosed between January 1990 and December 1999 were recruited from our data base. Patients with high energy trauma, malignancies, and metabolic bone diseases other than osteoporosis were excluded. These variables were analyzed: sex, age at diagnosis, type of osteoporosis (primary vs secondary), number of fractures at diagnosis (single vs multiple), and percentage of admissions and length of stay.

RESULTS

Of the 669 patients, 534 (80%) were women and 135 (20%) were men. Age at diagnosis ranged from 30 to 91 yrs, mean 67.1 +/- 9.1. Secondary osteoporosis was diagnosed in 177 (26%) patients and the frequency was significantly higher in men than women (55% vs 19%; p < 0.001); the most common associations for secondary osteoporosis were oral corticosteroids, chronic obstructive airway disease, and rheumatoid arthritis. At diagnosis, half of the patients presented with multiple fractures. One hundred twenty (18%) patients were admitted; length of stay ranged from 5 to 56 days, mean 15.9 +/- 7.7. The frequency of admissions was higher in men than women (27% vs 16%; p < 0.001), higher in patients with secondary osteoporosis than in those with primary osteoporosis (33% vs 12%; p < 0.001), and higher in patients with multiple fractures than in those with single fractures (27% vs 8%; p < 0.001).

CONCLUSION

Characteristics of patients recruited from a clinical setting differ significantly from those of subjects included in the epidemiological studies. In a rheumatology practice, frequency of secondary osteoporosis, mainly associated with corticosteroid treatment, is notably high. Admission is by no means a rare event.

Value of clinical factors in selecting postmenopausal women with rheumatoid arthritis for bone densitometry

OBJECTIVE

Criteria to decide which patients with rheumatoid arthritis (RA) should be examined by dual energy x ray absorptiometry (DXA) are currently not available. The rheumatologists from Amsterdam have proposed preliminary criteria based on clinical risk factors (age, disease activity, and functional status). These criteria are preliminary and not widely accepted but might be helpful in practice. The value of the proposal in a group of Spanish postmenopausal women with RA is analysed.

METHODS

DXA (lumbar spine and femoral neck) was performed in 128 patients recruited from a clinical setting, and the proposed criteria were applied. T and Z scores were established for a Spanish reference population.

RESULTS

The mean (SD) age of the patients was 61.3 (10.7) and mean duration of the postmenopausal period 14.5 (10.1) years. Mean duration of RA was 13.7 (7.7) years. Mean C reactive protein was 22 (21) mg/l; mean erythrocyte sedimentation rate 26 (18) mm/1st h; and mean Health Assessment Questionnaire score 1.25 (0.79). Ninety (70%) patients fulfilled the proposed criteria. Their sensitivity for the diagnosis of osteoporosis (T score < or =-2.5 SD) was 86% and their specificity, 43%. Positive predictive value was 54% and negative predictive value, 79%.

CONCLUSIONS

The proposed criteria seem a good screening method for the selection of those patients with RA whose bone mineral density should be assessed as the sensitivity and negative predictive value are acceptable.

Bone mineral density in patients with type 1 diabetes mellitus

Although osteopenia is often reported as a complication of type 1 diabetes mellitus, its frequency and severity remain unclear, and studies of bone mineral density in type 1 diabetics have yielded conflicting results. We measured bone mineral density at the lumbar spine and femoral neck in 88 Spanish adults with type 1 diabetes mellitus responsible for moderately severe complications. Mean age (+/- SD) was 28.9 +/- 8.8 years, and mean disease duration was 11.2 +/- 6.4 years. As compared to normal Spanish adults, bone mineral density was decreased in the patients at the lumbar spine (Z-score, -0.32 +/- 1.08; P < 0.001) but not at the femoral neck (Z-score, -0.21 +/- 1.03; P non-significant). The magnitude of bone loss in the diabetics was small (T-score, -0.38 +/- 1.13 at the lumbar spine and -0.37 +/- 1.08 at the femoral neck). Only three patients met WHO criteria for osteoporosis at one or both measurement sites. Patients with retinopathy (n = 37) had lower lumbar spine bone mineral density values than patients without retinopathy; however, this difference was no longer present after adjustment for age and disease duration. Bone mineral density values were similar in patients with (n = 13) and without microalbuminuria. Our findings suggest that bone loss is not a major problem in younger type 1 diabetics with short disease durations and no severe diabetic complications.

Weak androgen levels, glucocorticoid therapy, and bone mineral density in postmenopausal women with rheumatoid arthritis

OBJECTIVE

To study dehydroepiandrosterone sulfate (DHEAS) and androstenedione (AND) status in postmenopausal women with rheumatoid arthritis (RA), the effects of glucocorticoid therapy on DHEAS and AND levels, and their relationship with bone mineral density (BMD).

METHODS

Forty-six postmenopausal women with RA were separated into two groups based on whether they had a negative history for glucocorticoid therapy (n = 24) or were currently on glucocorticoid therapy (n = 22). The control group was composed of 39 postmenopausal women who had never received hormone replacement therapy. Serum DHEAS and AND levels were measured using a radioimmunoassay. BMD was determined at the lumbar spine (L2-L4) and femoral neck using a DEXA Hologic QDR-1000 densitometer. Results. RA patients and controls were similar in age, weight, body mass index, and years since menopause. DHEAS and AND levels were lower in the glucocorticoid-treated RA group than in the other two groups. The glucocorticoid-treated RA group also had a significantly lower femoral BMD value than the nonglucocorticoid-treated RA group. Lumbar BMD was similar in the two RA groups and in the controls.

CONCLUSION

Decreases in DHEAS and AND levels in postmenopausal women with RA are probably related to glucocorticoid therapy rather than to the disease itself.

A comparative study of computed digital absorptiometry and conventional dual-energy X-ray absorptiometry in postmenopausal women

The aim of the study was to evaluate whether computed digital absorptiometry (CDA) of the hand might be a useful screening technique for identifying patients with postmenopausal osteoporosis and to compare the results of CDA with those of dual-energy X-ray absorptiometry (DXA) of the lumbar spine and femoral neck. We studied 230 postmenopausal women (mean age 58.4 + 7.9 years). For CDA, bone mineral density (BMD) was measured with an AccuDEXA Schick densitometer in the third middle phalanx of the nondominant hand. For DXA, BMD of the lumbar spine and upper femur was assessed using a DXA Hologic QDR-1000 densitometer. We did a comparative analysis (ANOVA) and linear correlation tests. Sensitivity and specificity of CDA and receiver operating characteristic (ROC) curves for the diagnosis of osteoporosis were calculated. The mean BMD with CDA was 0.445 +/- 0.084 (T-score: -1.27 +/- 1.29). The mean BMD (g/cm2) with DXA at the lumbar spine was 0.877 +/- 0.166 (T-score: -1.52 +/- 1.59) and 0.708 +/- 0.127 at the femoral neck (T-score: -1.12 +/- 1.25). BMD at the lumbar spine and femoral neck correlated positively with CDA of the hand (r = 0.66 and r = 0.65 respectively, p<0.001). When using as cut-off a T-score of -2.5, according to WHO criteria, 76 women (33%) had osteoporosis of the lumbar spine and/or femoral neck with DXA and 42 (18%) with CDA (p<0.001). The kappa score for osteoporosis was 0.33 for CDA versus spinal DXA and 0.35 for CDA versus femoral DXA. With the cut-off level used, sensitivity and specificity of CDA in detecting osteoporosis at the lumbar spine were 0.39 and 0.90, respectively; sensitivity and specificity of CDA in identifying osteoporosis at the femoral neck were 0.58 and 0.87, respectively. The positive predictive value of CDA for osteoporosis was 69% and the negative predictive value was 75%. The area under the ROC curve for osteoporosis was 0.822 +/- 0.028. We conclude that: (a) CDA assessment has a moderate correlation with BMD measured by DXA at the lumbar spine and femoral neck; (b) CDA has a low sensitivity for the diagnosis of osteoporosis compared with spinal and femoral DXA; and (c) predictive values for osteoporosis at both the lumbar spine and femoral neck are acceptable.

Pyarthrosis in patients with rheumatoid arthritis: a detailed analysis of 10 cases and literature review

OBJECTIVES

1) To analyze the clinical features and outcome of patients with rheumatoid arthritis and pyarthrosis seen in a rheumatology department during a 9-year period; 2) To review the available literature about this association in the last decade.

METHODS

From the database of our department, we collected all hospitalized cases of infectious arthritis in native joints between January 1990 and December 1998. In 10 cases (27%), pyarthrosis occurred in patients with rheumatoid arthritis. A detailed analysis of each patient was performed. The literature was reviewed by using MEDLINE from 1990 to 1999.

RESULTS

The mean age of patients was 63.2 years; six were female. Most patients had long-standing disease and poor functional class, and all received glucocorticoid treatment. Mean diagnostic delay was 7.3 days. Causative organisms were Staphylococcus aureus (4 cases), gram-negative bacilli (3 cases), anaerobic bacteria (2 cases), and Streptococcus pneumoniae (n = 1). Two patients died. In all but two patients who survived, joint function worsened.

CONCLUSIONS

Rheumatoid arthritis is a relevant host-related risk factor for septic arthritis. Pyarthrosis in these patients is associated with considerable morbidity and mortality.

Bone mineral density in women with ankylosing spondylitis

OBJECTIVE

To determine bone mineral density (BMD) in premenopausal women with early ankylosing spondylitis (AS).

METHODS

Eighteen premenopausal women with AS without syndesmophytes, interapophysiary arthritis, and/or coxofemoral joint destruction were studied. BMD was analyzed at lumbar spine and femoral neck by dual energy x-ray absorptiometry (Hologic QDR 1000). Z scores and T scores related to the general Spanish population were recorded. Comparisons were performed using the Student t test. Pearson's correlation coefficients were used to study the correlation between BMD and the variables. Following the WHO classification, osteopenia was diagnosed in patients with T score between -1 and -2.5 and osteoporosis in those with T score < -2.5 at lumbar spine or femoral neck.

RESULTS

The mean Z score for spine BMD was -0.19+/-0.7, and -0.03+/-0.85 for femoral neck BMD. There were no significant differences of Z score values compared to the general population. No significant correlation was found between BMD and disease duration, radiology sacroiliac score, and spine mobility. Densitometry showed osteopenia in 2 patients and osteoporosis in none.

CONCLUSION

We found a slight reduction in BMD in premenopausal women with early AS, but the difference was not statistically significant. We discuss the factors related to its pathogenesis.

[Study of bone mineral density in postmenopausal women with rheumatoid arthritis treated with low dose glucocorticoids]

BACKGROUND

To study bone mineral density (BMD) in a group of postmenopausal women with rheumatoid arthritis (RA) treated with low doses of corticosteroids.

PATIENTS AND METHODS

One hundred and eleven patients were included. Mean age (SD) was 63.8 (8.8) years, mean duration of postmenopausal period was 16.4 (10.1) years and the mean disease duration was 12.5 (8.2) years.

RESULTS

A significant reduction of lumbar BMD (p < 0.05) and femoral BMD (p < 0.0001) was observed. The prevalence of osteoporosis was of 47%.

CONCLUSIONS

The study supports, in the Spanish population, that postmenopausal women with RA treated with low doses of corticosteroids, have low BMD. We consider that the prevalence of osteoporosis in these patients is high.

Suitability of the T-score for establishing bone mineral density categories

The use of different reference ranges may give rise to different T-score values for the same bone mineral density (BMD) value. This study was designed to quantify the differences in the classification of a particular population on the basis of normal ranges obtained from other reference databases. The T-scores obtained in a sample of 148 women by applying the Spanish normal range were compared with the normal range obtained in NHANES III for femoral neck. Significant differences were found when T-scores were compared, but there were no differences in categorizations using the WHO criteria. The application of these reference ranges to a female population aged older than 45 years with known BMD showed significant differences in classification. In conclusion, the T-score can vary according to the normal range used as reference, but it has little influence on the categorization of individual patients. However, it may be important when applied to a general population.

Influence of the vitamin D receptor gene polymorphism on bone loss in men after liver transplantation

BACKGROUND

Bone loss is a frequent complication after liver transplantation.

OBJECTIVE

To investigate whether vitamin D receptor gene polymorphism influences bone loss in men after liver transplantation.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PATIENTS

55 male candidates for liver transplantation.

MEASUREMENTS

Lumbar spine bone mineral density was measured before and 3, 6, 12, and 24 months after liver transplantation. Vitamin D receptor genotype was determined by restriction endonuclease Bsml.

RESULTS

Vitamin D receptor genotypes were significantly associated with post-transplantation changes in bone mineral density (P = 0.028). Within 3 months after transplantation, patients with the genotypes Bb or BB showed a vertebral bone loss substantially greater than that in patients with the bb genotype (between-group difference in the percentage change with respect to baseline bone mineral density, 3.7% [95% CI, 0.6% to 6.9%1). In 3 to 24 months after transplantation, bone mineral density increased steadily in the three allelic groups.

CONCLUSIONS

Vitamin D receptor gene polymorphism influences bone loss after liver transplantation. Patients with the bb genotype are, to some extent, protected against post-transplantation bone loss.

Bone mineral density in patients with peripheral psoriatic arthritis

BACKGROUND

Little information is available on the occurrence of generalized osteopenia in psoriatic arthritis. The only two published studies of bone mass in psoriatic arthritis produced conflicting results.

METHODS

We compared bone mineral density measured at the lumbar spine and femoral neck using dual-energy X-ray absorptiometry in 52 patients with active peripheral psoriatic arthritis and in 52 controls. The psoriatic arthritis group included 19 males, 14 premenopausal women, and 19 post-menopausal women. Controls were matched to the patients on sex, age, and menopausal status.

RESULTS

In the overall study population no significant differences were found between psoriatic arthritis patients and controls. Postmenopausal psoriatic arthritis patients had a lower femoral neck bone mineral density than the relevant subgroup of controls. No significant differences in lumbar spine bone mineral density were found in the analyses of the male, premenopausal female, and postmenopausal female subgroups. Neither was femoral neck density significantly different between male or premenopausal female psoriatic arthritis patients and controls.

CONCLUSION

These results suggest that peripheral psoriatic arthritis is not associated with significant generalized bone loss.

High serum prolactin levels in men with rheumatoid arthritis

OBJECTIVE

High prolactin (PRL) levels have been reported in systemic lupus erythematosus, Reiter's syndrome, and psoriatic arthritis. However, results of PRL investigations in rheumatoid arthritis (RA) are contradictory. We evaluated the PRL status in men with RA and the possible effect on bone mineral density (BMD).

METHODS

We studied 91 men with RA and 68 controls. PRL serum levels were analyzed under standardized conditions. Sex hormones (testosterone, androstenedione, and DHEAS) were also studied. BMD was analyzed at L2-L4 and the femoral neck by Hologic QDR1000. Comparative tests, linear correlations, and multiple regression analysis were performed.

RESULTS

Serum PRL levels were significantly higher in men with RA (249+/-162 mU/l) than in controls (189+/-85 mU/l) (p=0.0015). High PRL levels were significantly correlated with the duration of RA (r=0.23; p=0.01) and with functional stage according to the Steinbrocker classification (r=0.24; p=0.01). High PRL concentrations were not correlated with the low levels of androgens observed in males with RA. Femoral BMD showed a negative correlation with PRL concentrations (r=0.20; p=0.04). Nevertheless, PRL was not a significant determinant of BMD.

CONCLUSION

Men with RA have high serum PRL levels and concentrations increase with longer disease evolution and worse functional stage. Prolactin levels do not have a direct effect on BMD.

Salivary testosterone in postmenopausal women with rheumatoid arthritis

OBJECTIVE

To study changes in testosterone concentrations in saliva and total testosterone, free testosterone, and sex hormone binding globulin (SHBG) concentrations in serum in 2 groups of postmenopausal women with rheumatoid arthritis (RA), one group with glucocorticoid treatment and the other without it.

METHODS

The above mentioned hormonal levels were measured in 20 postmenopausal women with RA undergoing glucocorticoid treatment, in 24 postmenopausal women with RA without treatment, and in 36 postmenopausal women without RA.

RESULTS

We observed significantly lower levels of total testosterone in serum, SHBG in serum, testosterone in saliva, and the free testosterone index in the group of patients with RA undergoing glucocorticoid treatment compared to the group without treatment. We did not observe changes in free testosterone concentrations in serum of the groups studied, which is believed due to its lower specificity.

CONCLUSION

Testosterone in saliva is a useful indicator for monitoring androgenic status in women with RA.

Evaluation of circulating type I procollagen propeptides in patients with Paget's disease of bone

We evaluated circulating aminoterminal and carboxyterminal propeptides of type I procollagen and total alkaline phosphatase levels in eighty consecutive patients affected by Paget's disease of bone. We compared the biochemical data with the extent of bone disease calculated on the basis of the bone scintigraphic indices. Serum aminoterminal propeptide of type I procollagen levels were high in 77% of patients, serum carboxyterminal propeptide of type I procollagen levels in 22% and serum total alkaline phosphatase levels in 76%. We found significant correlations between the three markers studied. The three biochemical markers correlated significantly with the bone scintigraphic activity indices, but the highest correlation coefficient was between the aminoterminal propeptide and total alkaline phosphatase. We conclude that there is a discrepancy between serum levels of the propeptides studied in relation to Paget's disease of bone. The sensitivity of the carboxyterminal propeptide of type I procollagen in this disease is low. In contrast the aminoterminal propeptide may be as sensitive a marker for the evaluation of this disorder as total alkaline phosphatase, and in addition may be more specific.