AB0696 Prevalence and clinical associations of different autoantibodies in the Reuma.pt systemic sclerosis cohort: is it all really set in stone?

Background

Different autoantibodies (Ab) have been associated with distinct systemic sclerosis (SSc) phenotypes. Most of these associations have not been confirmed in Portuguese patients.

Objectives

To evaluate SSc immuno-clinical associations in the Rheumatic Diseases Portuguese Register (Reuma.pt) cohort.

Methods

Multicentre open cohort study including adult SSc patients registered in Reuma.pt up to February 2021. The associations between Ab expression and clinical data were established using Chi-Square, Fischer’s Exact or Mann-Whitney U tests. The Bonferroni correction for multiple comparisons was applied to get α≤0.05. Definite associations were defined by p≤0.002, and likely associations by p≤0.05.

Results

1080 patients were included, with a mean age and disease duration of 60.2±14.6 and 12.4±10.0 years, respectively. Most were females (87.5%) and had white European ancestry (WEA, 93.2%). The most common disease subtypes were limited cutaneous (lcSSc, 57.4%), diffuse cutaneous (dcSSc, 17.7%), and very early diagnosis of SSc (VEDOSS, 12.3%). Most patients expressed antinuclear Ab (ANA, 93.4%), and the most frequent were anti-centromere (ACA, 54.6%), anti-topoisomerase I (Scl70, 21.8%), and anti-Pm/Scl Ab (PmScl, 4.7%).

ACA had definite positive associations with female sex, older age at diagnosis, lcSSc, lower modified Rodnan skin score (mRSS, median 0 vs 4), and isolated sclerodactyly, and likely associations with a higher diagnosis delay, WEA and VEDOSS. ACA had definite inverse associations with flexion contractures (FC), myositis, digital ulcers (DU), and interstitial lung disease (ILD), and likely inverse associations with pitting scars (PS) and oesophageal involvement (OI).

Scl70 had definite positive associations with male sex, dcSSc, higher mRSS, FC, DU, PS, ILD, and OI, and likely associations with younger age at diagnosis, tendon friction rubs, active scleroderma pattern in capillaroscopy, and heart involvement.

PmScl had a definite association with myositis and likely associations with male sex, calcinosis, joints involvement, and ILD. Anti-U1RNP Ab had definite associations with younger age at diagnosis, MCTD and myositis, and likely associations with a lower diagnosis delay, African ancestry and joint involvement. Anti-RNA polymerase III Ab (RP3) had likely associations with higher mRSS and renal involvement. Anti-U3RNP Ab had a definite association with dcSSc and likely associations with calcinosis and renal involvement. Anti-Th/To Ab had likely associations with male sex and myositis. Anti-Ku Ab had likely associations with systemic lupus erythematosus and mixed connective tissue disease (MCTD) overlap syndromes.

Conclusion

There was a higher prevalence of ACA and PmScl compared to other cohorts, most likely due to the high proportion of WEA patients. Most immuno-clinical associations described in the literature apply, including ACA with lcSSc and Scl70 with dcSSc, DU, PS and ILD. However, Scl70+ patients did not have an increased risk of renal involvement, and ACA+ patients did not have an increased risk for calcinosis, PAH or OI, contrary to what was described in the literature. New findings included the association of PmScl with ILD and Scl70 with an active pattern in capillaroscopy. Also, anti-U3RNP+ and Th/To+ patients did not have an increased risk of ILD or PAH, contrarily to what was previously reported. These nuances may be specific to the Portuguese SSc population or signal previously reported associations as geographically specific.

Disclosure of Interests

None declared

AB1357 THE BEST CUT-OFF POINT FOR MEDIAN NERVE CROSS SECTIONAL AREA AT THE LEVEL OF PISIFORM BONE

Background

Carpal tunnel syndrome (CTS) is a focal neuropathy caused by compression of the median nerve (MN) at the wrist. Electromyography (EMG) is the gold standard for the diagnosis of CTS. Currently, the ultrasound (US) is frequently used as an initial screening exam by measuring the cross-sectional area (CSA) of the MN. The cut-off point of the CSA at the pisiform bone level to define CTS remains controversial with previous studies reporting values between 6.5mm2 and 15mm2 (1).

Objectives

The aim of this study is to determine the best cut-off point of the CSA for the diagnosis of CTS.

Methods

Cross-sectional study at a Tertiary Rheumatology Department including patients aged ≥ 18 years with symptoms compatible with CTS. Sociodemographic and clinical data, visual analogue scale for pain (VAS), Boston Questionnaire (BQ), and the results of EMG and US performed in each patient were collected. The EMG was performed according to the standardized protocol (sensory conduction velocity, sensory amplitude, distal sensory and motor latency), and the patients were categorized in 4 groups: normal, mild, moderate, and severe. A rheumatologist with expertise in imaging performed all the US evaluations by means of a 6–18-MHz (Siemens ACUSON S 2000) linear array transducer. The largest CSA of the MN was measured at the level of the pisiform bone. Receiver operating characteristic (ROC) curve was used to determine optimal cut-off values of the CSA taking the EMG result as the gold-standard. One-way ANOVA test was used to compare CSA between the 4 EMG groups.

Results

Fifty patients were included, 90% were female, mean age was 52.1 ± 10.8 years and median duration of symptoms was 28.0 (IQR 23.0-31.0) months. The mean VAS was 4.2 ± 2.9. In the BQ there was a mean symptom severity score of 2.4 ± 0.6 and a mean functional status score of 2.0 ± 0.9. One-way ANOVA showed that mean CSA values were significantly different in the 4 groups of patients. The Ryan-Einot-Gabriel-Welsch post hoc analysis showed that only the mean CSA of patients with severe STC is different from the remaining groups defined by EMG results. The best cut-off point for CSA at the pisiforme bone level for CTS diagnosis was 6.6 mm2 with a sensitivity and specificity of 92.9% and 75.0% (AUC=0.9, P<0.001). The positive and negative predictive values were 95.1% and 66.7%, respectively. For severe CTS diagnosis the best cut-off point for CSA was 12.3mm2 with a sensitivity of 82.4% and a specificity of 72.7% (AUC=0.8, P<0.001). The positive and negative predictive values were 60.9% and 88.9%, respectively.

Conclusion

In our study we found that the best cut-off point of the CSA was 6.6mm2 for distinguishing patients with/without CTS based on EMG alterations, with a high sensitivity and moderate specificity. This is a lower cut-off value than usually used in clinical practice and could be explained by small sample and the greater number of patients with mild and moderate STC on EMG.

References

[1]McDonagh C, Alexander M, Kane D. The role of ultrasound in the diagnosis and management of carpal tunnel syndrome: A new paradigm. Rheumatology (Oxford, England). 2014;54.

Disclosure of Interests

None declared

POS0861 ANTI-Ku ANTIBODY SYNDROME: IS IT A DISTINCT CLINICAL ENTITY? A CLUSTER ANALYSIS OF 75 PATIENTS

Background

Anti-Ku antibodies are rare among patients with Connective Tissue Diseases (CTD) (1). Their potential role as a disease biomarker is not well established.

Objectives

To identify subgroups of anti-Ku positive patients according to their spectrum of anti-nuclear antibody (ANA) specificities and analyze their clinical and analytical features.

Methods

Multicenter, cross-sectional study of anti-Ku positive patients, irrespective of their diagnosis, followed at eight Rheumatology outpatient clinics. Patients were spontaneously identified according to the local work-out for suspected autoimmune diseases. Anti-Ku and other ANA specificities were determined at each hospital’s Immunology lab according to the local methodology and strategy to decide on which auto-antibodies to check when faced with a positive ANA immunofluorescence. Clinical, analytical and treatment cumulative features were identified following a dedicated structured questionnaire. Hierarchical cluster analysis (method: between-groups linkage, squared Euclidian distance) for ANA specificity variables was performed to identify subgroups.

Results

Seventy-five anti-Ku positive patients were included (female: 73.3%, mean age at diagnosis: 50.5±17.9 years, mean disease duration: 4.7±5.4 years). Their clinical diagnosis were undifferentiated connective tissue disease (UCTD) (21.3%), systemic lupus erythematosus (17.3%), Sjögren’s syndrome (16.0%), inflammatory myositis (14.7%), systemic sclerosis (10.7%), overlap CTD syndrome (8.0%), other connective tissue diseases (17.3%), healthy anti-Ku carrier (17.3%).

Six autoantibody clusters were identified and included most patients (Figure 1): Cluster 1 - anti-Ku without any other ANA specificities (36.0%); cluster 2 - Anti-nor90 and anti-fibrillarin (8.0%); cluster 3 - anti-Jo1, PL-7, PL-12, and PM-Scl100 (9.3%); cluster 4 - anti-Scl70 (4.0%); cluster 5 - anti-Sm, anti-ribosome, and anti-dsDNA (13.3%); cluster 6 - anti-centromere, Th/To, PM-Scl75 (8.0%). The remaining patients were outliers (21.3%) not fitting in any cluster.

Figure 1.

Hierarchical cluster analysis of ANA specificities in anti-Ku+ patients

Detailed clinical analysis of patients in cluster 1, the most numerous, presenting anti-Ku antibodies without any other ANA specificities, the most frequent clinical manifestations were: Raynaud’s phenomenon (40.7%), arthritis (25.9%), sicca syndrome (25.9%), myositis (14.8%), and interstitial lung disease (ILD) (14.8%); 25.9% were healthy anti-Ku carriers. Patients from cluster 1 were most frequently treated with low dose glucocorticoids (51.9%), hydroxychloroquine (37.0%), or methotrexate (18.5%).

Among the whole study population (n=75), major organ involvement was present in 18.7%, with ILD in 10.7% and renal involvement in 8.0%. None of the patients in cluster 1 presented nephritis.

Conclusion

Anti-Ku positive patients without any other ANA specificities is the largest subset and may represent a distinct entity among the differentiated CTD (2). Patients with this anti-Ku syndrome may develop ILD. In addition, anti-Ku antibodies can be found in patients with a diversity of other ANA specificities and heterogeneous CTD diagnosis.

References

[1]Lakota K, et al. International cohort study of 73 anti-Ku-positive patients: association of p70/p80 anti-Ku antibodies with joint/bone features and differentiation of disease populations by using principal-components analysis. Arthritis Res Ther. 2012 Jan 6;14(1):R2. doi: 10.1186/ar3550. PMID: 22226402; PMCID: PMC3392788.

[2]Spielmann L, et al. Anti-Ku syndrome with elevated CK and anti-Ku syndrome with anti-dsDNA are two distinct entities with different outcomes. Ann Rheum Dis. 2019 Aug;78(8):1101-1106. doi: 10.1136/annrheumdis-2018-214439. Epub 2019 May 24. PMID: 31126956.

Disclosure of Interests

None declared

Profil évolutif clinique des patients adultes infectés à SARS-CoV-2 et hospitalisés à partir du service des urgences de Strasbourg

Introduction : La prise en charge de l’épidémie de Covid-19 dans un service d’urgences (SU) requiert une évaluation de ses critères de gravité. La Covid-19 est évolutive et l’aggravation respiratoire détermine le pronostic. Notre objectif était de rechercher les facteurs prédictifs de gravité en fonction du délai d’initiation d’une oxygénothérapie dans une population française atteinte de Covid-19 au sein d’un SU.

Matériels et méthode : L’étude observationnelle rétrospective aux Hôpitaux Universitaires de Strasbourg, durant la première vague de la pandémie, incluait les patients hospitalisés depuis le SU en 2020 pour infection au SARS-CoV-2. Elle évaluait les délais entre le début des symptômes (J0) et l’initiation d’une oxygénothérapie, et entre J0 et l’apparition des complications hospitalières. L’analyse multivariée recherchait les facteurs associés à l’oxygénothérapie précoce et à la mortalité intra-hospitalière.

Résultats : 699 patients ont été inclus. L’oxygénothérapie était initiée le 7 ± 4e jour, la ventilation mécanique le 9 ± 4e jour. L’initiation précoce d’oxygénothérapie (avant le 6e jour) était significativement et indépendamment associée à l’immunosuppression, à l’âge ≥ 75 ans, à l’hypertension artérielle, et au sexe féminin. La mortalité intra-hospitalière était significativement et indépendamment associée à un âge ≥ 75 ans, une immunosuppression, une cardiopathie ischémique, et une oxygénothérapie précoce.

Conclusion : Parmi les patients hospitalisés pour la Covid-19 durant la première vague, le jour moyen d’initiation d’oxygénothérapie était le septie jour. Une oxygénothérapie précoce, un âge ≥ 75 ans, une immunosuppression et une cardiopathie ischémique étaient associés à une forme grave de la Covid-19.

POS0496 YOUNG VERSUS LATE-ONSET RHEUMATOID ARTHRITIS: A PROSPECTIVE 12 MONTH-FOLLOW-UP COHORT STUDY IN AN EARLY ARTHRITIS COHORT

Background:

Rheumatoid Arthritis (RA) is a chronic inflammatory arthropathy that can present at any age. Data regarding differences in the clinical course and outcome in Late-Onset Rheumatoid Arthritis (LORA) comparing to Young-Onset RA (YORA) are conflicting. Some studies suggested that LORA may represent a more benign form of RA (1), while others have shown a poorer prognosis in these patients (2,3). Only a few publications have included patients with early disease (3).

Objectives:

To compare demographic and clinical features between LORA and YORA patients, and clinical activity at baseline and after 12 months of initial therapy, in patients with early disease.

Methods:

We conducted a prospective cohort study of 12 months of follow-up based on an early arthritis clinic. Consecutive patients with early RA – less than 12 months duration – fulfilling ACR/EULAR 2010 and/or ACR 1987 RA classification criteria, were included and classified in LORA (disease onset ≥60 years) and YORA groups. Variables were collected from patients’ registries at first appointment after symptoms onset and after 12 months of treatment, according to a treat-to-target strategy. Independent t-test and chi-square test were performed to compare variables between groups.

Results:

We included 72 patients (40 (55.6%) YORA; 32 (44.4%) LORA), mean age at diagnosis 44.9±1.78 and 72.5± 1.34 years, respectively. In LORA group, the symptoms duration at first observation was shorter (17.0±2.26 vs. 23.8±2.45 weeks; p=0.046) and rheumatoid factor (RF)/ anti-citrullinated protein antibodies (ACPA) positivity was lower (28.1% vs 65.0%; p= 0.002; 31.3% vs 72.5%; p<0.001). At baseline, LORA had higher mean number of tender joints (9.76±1.29 vs 6.50±0.67; p=0.021), erythrocyte sedimentation rate (ESR) (45.7±4.98 vs. 29.3±3.74; p=0.011), C-reactive protein (CRP) (4.63±0.91 vs 2.22±0.46; p=0.022) and disease activity using DAS28-3V (5.11±0.28 vs 4.42±0.19; p=0.046), CDAI (33.7±3.39 vs 23.6±2.18; p=0.015) and SDAI (37.4±3.43 vs 26.3±2.57; p=0.015). At the end of follow-up, there were no statistically significant differences between LORA and YORA groups regarding treatment, disease activity and patient-reported outcomes at 12 months (Table 1).

Table 1.

Clinical variables assessment at 12 months of follow-up.

EORAYORAp-valueTreatment, % users Corticosteroids93.397.4p= 0.576 Methotrexate76.774.4p=0.825 Hydroxychloroquine43.346.2p= 0.815 Sulfasalazine10.015.4p=0.722 Leflunomide3.305.10p=1.000 TNF blockers3.305.10p=0.717DAS28-3V, mean (SD)1.99±0.152.22±0.15p=0.286SDAI, mean (SD)4.64±1.357.68±1.39p=0.128CDAI, mean (SD)4.15±1.176.56±1.32p=0.180Swollen joints, mean (SD)1.29±0.491.03±0.25p=0.613Tender joints, mean (SD)0.32±0.131.28±0.53p=0.084ESR, mean (SD)10.6±1.799.43±1.14p=0.585CRP, mean (SD)0.44±0.090.50±0.15p=0.730PtGA, mean (SD)21.8±5.9029.2±6.11p=0.387PhGA, mean (SD)10.6±3.2613.1±3.11p= 0.593Pain intensity (VAS), mean (SD)20.7±5.8232.7±6.30p=0.169HAQ, mean (SD)0.23±0.0890.54±0.13p=0.060

Legend: DMARD- disease-modifying anti-rheumatic drug; TNF- tumoral necrosis factor; SDAI-simplified disease activity score; CDAI- clinical disease activity score; PtGA/ PhGA – patient’s/ physician’s global assessment of general health; VAS- visual analogic scale; HAQ- health assessment questionnaire.

Conclusion:

LORA patients presented with higher disease activity manifested by higher joint counts and laboratory inflammatory markers but lower RF and ACPA positivity proportion. Despite the more aggressive clinical presentation, the clinical and functional outcomes at 12 months were similar between LORA and YORA patients.

References:

[1]Deal et al. Arthritis Rheum 1985;28(9):987-94.

[2]Arnold et al. Rheumatology (Oxford) 2014; 53:10751086.

[3]Romão et al. Semin Arthritis Rheum 2020;0(4):735-743.

Disclosure of Interests:

None declared

POS0872 CLINICAL FEATURES AND OUTCOME OF 1054 PATIENTS WITH SYSTEMIC SCLEROSIS: AN ANALYSIS OF THE PORTUGUESE REUMA.PT REGISTRY FOR SCLERODERMA (REUMA.PT/SSC)

Background:

Systemic sclerosis (SSc) may present distinctive manifestations and survival in different ethnic and geographic groups.

Objectives:

To describe the clinical features, treatments, and survival of adult SSc patients registered in Reuma.pt/SSc.

Methods:

Demographic features, SSc subsets, fulfilment of classification criteria, clinical and immunologic characteristics, comorbidities, medication and deaths were reviewed. Survival was calculated for patients included in the registry within the first 2 years of diagnosis.

Results:

In total, 1054 patients were included, 87.5% female, mean age at diagnosis 52.7 ± 14.8 years. The most common subset was limited cutaneous (lc)SSc (56.3%), followed by diffuse cutaneous (dc)SSc (17.5%), preclinical SSc (13%), overlap syndrome (9.8%) and SSc sine scleroderma (3.3%). Raynaud’s phenomenon (93.4%) and skin thickening (76.9%) were the most observed manifestations. Gastrointestinal (62.8% vs 47.8%), pulmonary (59.5% vs 23%) and cardiac (12.8% vs 6.9%) involvement were significantly more prevalent in dcSSc compared to lcSSc (Table 1). 52.5% of patients were ACA positive and 21% anti-topoisomerase positive, with significant differences between lcSSc and dcSSc. One third of patients was treated with immunomodulators, 53.6% with vasodilators, 23% received glucocorticoids and 2.3% biologics.

During the median follow-up 12.4 years, 83 deaths (7.9%) were verified. The overall 1, 2 and 5 years survival was 98.0%, 96.8% and 92.6% respectively, without significant differences between lcSSc and dcSSc (Figure 1).

Conclusion:

Reuma.pt/SSc register is useful in routine patient monitoring and contributes to improve knowledge about this rare and complex disease. Clinical features of Portuguese SSc patients are similar to what has been described in other populations although the overall 5-year survival in recently diagnosed patients appears to be higher than previously reported.

Table 1.

Cumulative clinical and immunologic characteristics of Portuguese SSc patients

Clinical and immunologic featuresTotalN=1054Limited cutaneous SScN= 576 (56.3%)Diffuse cutaneous SScN=180 (17.5%)P valueSkin involvement – N(%) N=987688 (90.6)525 (90.7)180 (100)<0.01Skin thickening * – N (%) N= 962680 (76.9)512 (88.9)180 (100)<0.01Digital ulcers – N (%) N=970325(33.5)186 (34.7)4 (51.5)<0.01Raynaud’s Phenomenon – N (%) N=1010943 (93.4)539 (95.7)157 (92.4)0.06Musculoskeletal involvement – N(%) N=972346 (45.6)247 (42.7)99 (55)<0.01Cardiac involvement –N(%) – N=92471 (7.7)36 (6.9)19 (12.8)0.02Renal involvement –N(%) – N= 91717 (1.9)8!1.5)6 (4.1)0.07Gastrointestinal involvement - N(%) N=933508 (48.2)277 (47.8)113 (62.8)<0.01Pulmonary involvement – N(%) N=915261 (28.5)119 (23)88 (59.5)<0.01PAH – N(%) N= 87114 (1.6)10 (2)1 (0.7)0.23Intersticial lung disease – N(%) N=765218 (28.5)100 (22.7)75 (57.7)<0.01Antinuclear antibodies - N(%) N=1040934 (89.8)522 (90.2)154 (88.5)0.57Anti-centromere – N(%) N= 1027540 (52.6)383 (67.1)16 (9.5)<0.01Anti-Scl70 – N(%) N=1020214 (21)12 (3.3)104 (60.1)<0.01Anti-RNA polymerase III – N(%) N=71025 (3.5)12 (3.3)7 (5.6)0.38ComorbiditiesHypertension – N(%) N=431117 (27.1)76 (29.7)67 (20.7)0.1Hyperlipidemia – N(%) N=43171 (13.4)72 (12.2)24 (15.9)0.08Neoplasia – N(%) N=105429 (2.8)12 (2.1)7 (3.9)0.14

PDE-5 (phosdiasterase-5); PPIs (proton pump inhibitors); PAH-Pulmonary arterial hypertension confirmed by right heart catheterization. Immunomodulators includes Metothrexate, Leflunomide, Hydroxycloroquine; Azathioprine, Mycophenolate Mofetil and Cyclophosphamide; * Does not include sclerodactyly.

Figure 1.

Panel A - Survival in years from diagnosis of patients with SSc included in Reuma.pt in the first 2 years of disease (N=472). Panel B - survival according to SSc subset (lcSSc and dcSSC).

Disclosure of Interests:

None declared

AB0147 OLDER AGE AT ONSET AND NOT DISEASE ACTIVITY IS ASSOCIATED WITH FUNCTIONAL DISABILITY AT RA DIAGNOSIS: RESULTS FROM AN EARLY ARTHRITIS COHORT

Background:

Rheumatoid Arthritis (RA) is a chronic inflammatory arthropathy that potentially leads to loss of function and disability early in the disease course. (1) Optimizing physical function is one of the primary goals of RA treatment (2). Several demographic, psychosocial and clinical factors may influence the impact of RA upon physical capacity, and understanding their relative contribution to disability at disease diagnosis is key to an effective treatment approach.

Objectives:

To evaluate functional disability at the time of disease diagnosis and identify its demographic and clinical correlates in an early RA cohort.

Methods:

We conducted a cross-sectional study based on a Rheumatology centre early arthritis cohort. Consecutive patients with early RA – less than 12 months duration– fulfilling ACR/EULAR 2010 and/or ACR 1987 RA classification criteria, were included. Variables were collected from patients’ registries at the first rheumatology appointment after symptom’s onset. Functional disability was assessed using the Health Assessment Questionnaire- Disability Index (HAQ-DI) (range 0 to 3, higher values indicating greater disability). Independent t-test, one way-ANOVA and Pearson’s correlation coefficient were performed to evaluate differences between groups. Variables with p<0.1 were included in a stepwise multiple linear regression analysis to assess the independent association of variables with the HAQ-DI at baseline.

Results:

We included 71 patients (63.4% female, mean age 57.2 ±2.01 years). Mean HAQ-DI score was 1.42±0.08. Sociodemographic and clinical variables are described in Table 1. There was a significant difference in HAQ-DI scores between rheumatoid factor (RF) positive (mean 1.24±0.11) and RF negative (1.61±0.113) patients. HAQ-DI was positively weakly correlated with age (r=0.48; p<0.001), CDAI (r=0.43; p=0.038), SDAI (r=0.49; p=0.015), and moderately with DAS28-3V (r=0.60; p<0.001) and DAS28-3V-CRP (r=0.60; p<0.001). The number of tender (r=0.35; p=0.024) and swollen joints (r=0.42; p= 0.005), ESR (r=0.46; p=0.001), CRP (r=0.35; p=0.018), HADS-depression (r=0.46; p=0.023) and educational level (r= -0.48; p=0.002) were also associated with HAQ-DI in univariate analyses. After multivariate regression analysis, age at disease diagnosis (β= 0.022 [95 CI 0.010 to 0.034]; p= 0.001) was the only independent predictor of HAQ-DI (R2= 0.46, p=0.001).

Table 1.

Patients’ baseline sociodemographic and clinical characteristics.

Age at diagnosis (years), mean (SD)57.2±2.01Educational level (years), mean (SD)7.37±0.59Employment: full-time, %42.4Employment: partial-time, %3.00Employment: retired, %48.4Employment: absenteeism in the last month, %1.50Unemployed, %4.50Disease duration at presentation (weeks), mean (SD)20.4±1.70Morning stiffness >30 minutes, %83.0RF positivity, %47.9ACPA positivity, %53.5Fibromyalgia, %6.60DAS28-3V, mean (SD)4.72±0.17CDAI, mean (SD)29.2±2.28SDAI, mean (SD)32.4±2.42PtGA, mean (SD)66.8±3.73PhGA, mean (SD)54.7±3.08Pain intensity (VAS), mean (SD)67.7±3.75EQ-5D score, mean (SD)0.26±0.039HADS-depression, mean (SD)7.17±0.87

Legend: ACPA- anti-citrullinated protein antibodies; ESR- erythrocyte sedimentation rate; CRP- c-reactive protein; DAS- disease activity score; CDAI- clinical disease activity score; SDAI-simplified disease activity score; PtGA/ PhGA – patient’s/physician’s global assessment of general health; VAS- visual analogic scale; EQ-5D- EuroQoL 5-Dimensional Descriptive System; HADS-Hospital Anxiety and Depression Scale.

Conclusion:

Older age at disease onset is associated with greater functional impairment at diagnosis, assessed by HAQ-DI, in this cohort of early RA patients, irrespective of disease activity and other clinical variables. This result suggests that older newly diagnosed RA patients may deserve special attention regarding physical function.

References:

[1]Wolfe F et al. Arthritis Res Ther. 2010; 12(2): R35.

[2]Smolen JS et al. Ann Rheum Dis. 2010; 69:631-637.

Disclosure of Interests:

None declared

POS0878 ULTRASOUND ASSESSMENT OF DERMAL THICKNESS AND SKIN STIFFNESS IN UNDIFFERENTIATED CONNECTIVE TISSUE DISEASE AT RISK FOR SYSTEMIC SCLEROSIS

Background:

High-frequency ultrasound (HFUS) and shear-wave elastography (SWE) allow an objective assessment of skin involvement in systemic sclerosis (SSc) patients.1 Till now it has been applied to patients with established diagnosis.2,3 However, there is no data concerning its application in Undifferentiated Connective Tissue Disease at risk for SSc (UCTD-risk-SSc), i.e., patients with Raynaud’s phenomenon and either SSc marker autoantibodies or typical capillaroscopic findings or both, not satisfying classification criteria for SSc.4

Objectives:

To compare ultrasound-dermal thickness (DT) and skin stiffness, using high-frequency ultrasound and shear-wave elastography, in UCTD-risk-SSc and healthy controls.

Methods:

Forty UCTD-risk-SSc patients and 40 age- and gender-matched healthy controls were included. Ultrasound-DT was measured using an 18MHz probe, and skin stiffness (i.e. shear-wave velocity values, SWV) using the VTIQ software with a 9MHz probe, at the 17 Rodnan skin sites. The mRSS score was, by definition, zero in all sites, both in cases and controls. Continuous data were expressed as the mean (SD), and Mann-Whitney U test was performed to compare differences between the groups, as variables were not normally distributed. Associations between variables were analysed using the Spearman’s correlation.

Results:

SWV values were significantly higher in patients with UCTD-risk-SSc compared with controls at the right and left hands, and in the right and left fingers (table 1). Higher values of ultrasound dermal-thickness were found in the fingers and hands bilaterally, although differences were only significantly at the hands, compared with healthy controls (table 1). There were no significant differences in the other Rodnan skin sites. There was no significant correlation between ultrasound-dermal thickness and stiffness at the same skin site.

Conclusion:

This study provides the first evidence suggesting that ultrasound-DT and stiffness can discriminate patients with UCTD-risk-SSc from healthy controls. Prospective studies including a larger number of patients with different subsets of UCTD-risk-SSc are needed to investigate diagnostic and prognostic value of the ultrasound parameters in this group.

References:

[1]Santiago T, et al. Arthritis Care Res (Hoboken). 2019;71:563-574.

[2]Hesselstrand R, et al. Rheumatology (Oxford). 2008;47:84-7.

[3]Flower V et al. jrheum.200234.

[4]Valentini, G., et al. Arthritis Care Res, 66: 1520-1527.

Table 1.

Clinical and ultrasound parameters in UCTD-risk-SSc and healthy control groups.

UCTD-risk-SSc (n=40)Healthy controls (n=40)p valueAge, mean (SD)51.4 (14.9)49.8 (13.9)NsFemale, n (%)36 (90.0)36 (90.0)Raynaud phenomenon, %100.0%-ANAs100.0-Anti-centromere, %60.0Anti-Scl70+, %11.5Scleroderma/non-scleroderma pattern in capillaroscopy, %5.0/95.0--Ultrasound parametersDermal thickness (mm) Dorsal hand right0.77 (0.32)0.62 (0.12)0.02 Dorsal hand left0.79 (0.39)0.62 (9.13)0.02 Proximal phalanx right0.64 (0.14)0.61 (0.11)Ns Proximal phalanx left0.66 (0.16)0.60 (0.09)NsSWV values (m/s) Dorsal hand right1.94 (0.40)1.61 (0.24)0.0001 Dorsal hand left1.82 (0.36)1.65 (0.25)0.025 Proximal phalanx right2.09 (0.60)1.68 (0.24)0.001 Proximal phalanx left2.13 (0.82)1.66 (0.27)0.004

Legend: ANA: Antinuclear antibodies; Ns: Non-significant; UCTD: Undifferentiated Connective Tissue Disease; SD: Standard Deviation

Disclosure of Interests:

None declared

Patients’ and rheumatologists’ perspectives on the efficacy and safety of low-dose glucocorticoids in rheumatoid arthritis—an international survey within the GLORIA study

Objective

To evaluate the current perspectives of patients and health professionals regarding the efficacy and safety of low-dose glucocorticoids (GCs) in RA.

Methods

Two online surveys were disseminated to patients and health professionals, in their native language, through national patient organizations and national rheumatology medical societies, respectively. SurveyMonkey®, MediGuard.org and the Glucocorticoid Low-dose Outcome in RA Study (GLORIA) website were used to offer and deliver these surveys.

Results

A total of 1221 RA patients with exposure to GCs, and 414 rheumatologists completed the surveys. Patients and rheumatologists reported high levels of agreement regarding the efficacy of low-dose GCs: at least 70% considered that they are very rapid and effective in the control of signs and symptoms of RA. However, half of the patients also reported having suffered serious adverse events with GCs, and 83% described concerns about safety. The majority of rheumatologists estimated that endocrine, ophthalmologic and cutaneous adverse events affect &gt;4% of all patients treated with low-dose GCs for 2 years, based on a heat map.

Conclusions

RA patients with self-reported exposure to GCs express high levels of satisfaction with low-dose GCs efficacy, as do rheumatologists. However, both expressed excessive concerns regarding the safety of GCs (greatly exceeding the published evidence data), which may compromise the optimal use of this medication. This study indicates that there is an unmet need for appropriately designed prospective trials that shed light on the real risk associated with low-dose GCs, as well as a need for renovated educational programs on the real benefits and harms of low-dose GCs, for both patients and physicians.

THU0090 AGREEMENT BETWEEN REFERRING PHYSICIANS AND RHEUMATOLOGISTS AND PREDICTORS OF INFLAMMATORY ARTHRITIS: ANALYSIS BASED ON 8 YEARS OF EXPERIENCE IN AN EARLY ARTHRITIS CLINIC

Background:

Early recognition of patients with arthritis is a crucial opportunity for optimal outcome. The Early Arthritis Clinic (EAC) of our department was created in 2012 to ensure a prompt access of these patients to efficient medical care. Patients may be referred based on a set of clinical criteria with less than 12 months duration and laboratory parameters: arthritis, inflammatory arthralgias, squeeze test, morning stiffness > 30 minutes, rheumatoid factor (RF), erythrocyte sedimentation rate (ESR)>30mm/h and C-reactive-protein>0.5mg/dL (CRP).

Objectives:

To assess the level of agreement between the referring physician and the rheumatologist, regarding the presence of each of the six referral criteria and to identify predictors of inflammatory arthritis.

Methods:

Cross sectional study including patients aged ≥ 18-year-old observed in the EAC between January 2012 and October 2019. Subjects who were referred to the EAC by a rheumatologist and those without available referral letter/medical records from the first visit to the EAC were excluded. Demographic data, provenience, referral criteria (presence/absence) and the final diagnosis [presence or not of an inflammatory rheumatic disease (IRD)] were collected from medical records. For the six referral criteria, the agreement between the referring physician and the rheumatologist was assessed using the Cohen’s Kappa. The presence of each referral criteria was compared between patients with and without an IRD using χ2 tests. Variables with p<0.1 or clinically relevant were included in forward stepwise multivariable logistic regression analysis to identify possible predictors for IRD. The statistical analysis was performed using SPSS® v21 andp<0.05 was considered statistically significant.

Results:

376 patients (70% female; mean age (±SD) 56.3±16.2 years) were included. Most patients were referred from primary care (84%); the remaining 16% include those referred from emergency department and other hospital specialties. We diagnosed an inflammatory arthritis in 62% (n = 232) of the patients. Table 1 shows the level of agreement between the referring physician and the rheumatologist, regarding the presence of the referral criteria.

Table 1.

Agreement between the referring physician and the rheumatologist, regarding the presence of the referral criteria.

Referral criteriaKappapArthritis0.230.05Squeeze test0.090.04Inflammatory arthralgias0.110.04Morning stiffness0.180.04RF0.270.04ESR0.260.04CRP0.250.04ANA0.020.47

ANA- antinuclear antibodies; CRP- C-reactive-protein; ESR-erythrocyte sedimentation rate; RF-Rheumatoid factor

In univariable analysis (IRD Vs non-IRD), inflammatory arthralgias (74% Vs 93%, p=0.01), squeeze test (24% Vs 55%, p=0.01), morning stiffness (49% Vs 63%, p=0.05), ESR (63% Vs 46%, p=0.01), CRP (62% Vs 48%, p=0.04) were associated to IRD. In multivariable analysis, only ESR (OR 5.0 [95% CI 1.9-13.0], p < 0.05) and inflammatory arthralgias (OR 0.15 [95% CI 0.04-0.52], p < 0.05) remained as predictors of IRD.

Conclusion:

Agreement between the referring physicians and the rheumatologist regarding then presence/absence of the referral criteria was poor in all clinical criteria and fair in laboratory criteria. Elevated ESR was an independent predictor of IRD and the description of inflammatory arthralgias was negatively correlated with IRD. These findings suggest the need to clarify the referral criteria used and to improve education among the physicians referring patients to the EAC.

Disclosure of Interests:

Luisa Brites: None declared, LILIANA SARAIVA: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Tânia Santiago: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

THU0632-HPR DETERMINANTS OF HAPPINESS AND QUALITY OF LIFE IN PEOPLE WITH SYSTEMIC SCLEROSIS: A STRUCTURAL EQUATION MODELLING APPROACH

Background:

In recent years more attention has been given to patients reported outcomes (PROs). Systemic sclerosis (SSc) is no exception. As there is no effective treatment or cure to SSc, it is important to recognize the relevance to patients of the different features of the disease to improve quality and enjoyment of life: the ultimate targets of therapy. Remarkably lacking in PROs is the evaluation of the overall perspective of subjective well being, equivalent to ‘happiness’ or “positive psychological dimensions”.

Objectives:

To examine the determinants of happiness and quality of life (QoL) in patients with SSc with emphasis on disease activity, disease impact and personality traits.

Methods:

This is an observational, cross-sectional and multicenter study from six rheumatology clinics in Portugal. A total of 113 patients with SSc with a complete set of data on disease activity, disease impact, personality, quality of life and happiness were included.

Structural equation modelling (latent variable structural model) was used to estimate the association between the variables using a maximum likelihood estimation with Satorra-Bentler’s correction and performed with STATA® 15.0. Two hypotheses were pursued: H1 – Disease activity and impact of disease are negatively associated to overall QoL and happiness; H2 – ‘Positive’ personality traits are related to happiness both directly and indirectly through perceived disease impact.

Results:

Results obtained in the structural equation measurement model indicated a good fit [χ2/df=1.44; CFI=0.93; TLI=0.90; RMSEA=0.06] and supported all driving hypotheses (Figure 1). Happiness was positively related to ‘positive’ personality (β=0.45, p=0.01) and, to a lesser extent, negatively related with impact of disease (β=-0.32; p=0.01). This impact, in turn, was positively related to EUSTAR activity score (β=0.37; p<0.001) and mitigated by ‘positive’ personality traits (β=-0.57; p<0.001). Impact of disease had a much stronger relation with QoL than with happiness (β=-0.78, p<0.001). Quality of life and happiness had no statistically significant relationship.

Conclusion:

Optimization of Qol and happiness in people with SSc requires effective control of the disease process. Personality and its effects upon the patient´s perception of the disease impact, seems to play a pivotal mediating role in these relations and should deserve paramount attention if happiness and enjoyment of life is taken as the ultimate goal of health care.

Disclosure of Interests:

Tânia Santiago: None declared, Eduardo Santos: None declared, Ana Catarina Duarte: None declared, Patrícia Martins: None declared, Marlene Sousa: None declared, Franscisca Guimarães: None declared, Soraia Azevedo: None declared, Raquel Ferreira: None declared, Miguel Guerra: None declared, Ana Cordeiro Consultant of: Ana Cordeiro has acted as a consultant for Roche, Speakers bureau: Ana Cordeiro has received speaker fees from Boehringer Ingelheim, Lilly, and Vitoria, Inês Cordeiro: None declared, Sofia Pimenta: None declared, Patrícia Pinto: None declared, Maria Joao Salvador: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis

SAT0593 ANA TESTING IN THE (VERY) ELDERLY: EXPECTATION VERSUS REALITY

Background:

Antinuclear antibodies (ANA) are frequently used as a screening tool for systemic autoimmune rheumatic diseases (SARD), although they are also present in 10-15% of the adult healthy population. SARD have their peak incidence in the young/ middle-aged adult. As age progresses, the incidence of SARD decreases while the prevalence of ANA tends to increase, with some series reporting up to 30% prevalence in older ages1.

Objectives:

To determine the clinical significance and utility of ANA testing in a population over 85 years of age.

Methods:

We conducted a retrospective study of patients over the age of 85 who underwent ANA testing due to a SARD suspicion at our hospital autoimmunity laboratory, from 2011 to 2018. Justification for ANA request was collected from patient’s clinical records. Patients with pre-established diagnosis of SARD and patients with no justification given for ANA request were excluded from the analysis. ANA titer (positive ≥ 1:160) and cellular staining patterns were assessed by indirect immunofluorescence (Hep-2 cells).

Results:

Ages ranged from 85 to 98 years, with 58.8% being females. The prevalence of ANA in this population was 61.5%, mostly in lower titers (1:160 in 45.0%, 1:320 in 31.9%, 1:640 in 20.3% and 1:1280 in 2.7%). Dense fine speckled pattern was by far the most common cellular staining pattern (79.1%). A suspicion of SARD was the reported reason for ANA testing in 34,5% (n=296) of the 854 patients submitted to this test. The main clinical clues justifying SARD suspicion were: arthralgia/arthritis (11.9%), thrombocytopenia (10.0%), pancytopenia (10.0%), spotless fever (8.2%), interstitial lung disease (4.8%), pleural (6.1%) and pericardial (4.1%) effusion. Over a median follow-up of 1.0 year, 10 patients (3.4%) were diagnosed with a SARD, only one being an ANA-related disease: 5 cases of polymyalgia rheumatica, 2 cases of rheumatoid arthritis, 1 case of giant cell arteritis, 1 case of Sjogren syndrome and 1 case of sarcoidosis. In 60% of patients with a confirmed SARD, the main reason for suspicion was the presence of arthralgia/ arthritis. Positive ANA testing showed a 90.0% sensitivity and a 39.6% specificity for SARD. This translates into a positive predictive value of 5.0%.

Conclusion:

ANA are highly prevalent in elderly patients under SARD suspicion, while the incidence of SARD is very low, which explains the low positive predictive value of ANA testing. Interestingly, only one among the ten cases of SARD confirmed was indeed an ANA-related disease (Sjogren syndrome).

References:

[1]Selmi C, Ceribelli A, Generali E, et al. Serum antinuclear and extractable nuclear antigen antibody prevalence and associated morbidity and mortality in the general population over 15 years.Autoimmun Rev. 2016;15(2):162–166. doi:10.1016/j.autrev.2015.10.007

Disclosure of Interests:

Mariana Luis: None declared, Anália Carmo: None declared, Rosário Cunha: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Tânia Santiago: None declared

FRI0229 THE IMPACT OF SYSTEMIC SCLEROSIS ON BODY IMAGE PATIENTS

Background:

Satisfaction with body image has a major impact in quality of life. Systemic sclerosis (SSc) is a can result in disfiguring physical changes.

Objectives:

Our aim was to determine the impact of systemic sclerosis on body image using the Satisfaction with Appearance Scale (SWAP). (1)

Methods:

Cross-sectional study including patients satisfying the 2013 American College of Rheumatology criteria for SSc diagnosis, aged ≥ 18 years, treated in a tertiary Rheumatology Department. Demographic and clinical data were collected from Reuma.pt and clinical records. All patients provided informed consent and fulfilled SWAP questionnaire, which consists of 14 questions in 4 subscales: satisfaction with facial appearance, satisfaction with non-facial appearance, social discomfort due to appearance and perceived social impact of appearance. Patients rate each item on a numerical rating scale from 1 (strongly disagree) to 7 (strongly agree). Scores for the facial and non-facial appearance range from 0-24 and scores for the social discomfort and perceived social impact subscales range from 0-18. Total SWAP score can range from 0-84 and higher values indicate greater dissatisfaction with appearance and poorer body image. A descriptive analysis was used to summarize demographic and clinical data; categorical variables were described using frequencies; and continuous data using mean and standard deviation. Correlation between variables [Rodnan, age, disease duration, Hospital Anxiety and Depression Scale (HADS) and Short Form Health Survey (SF36)] and SWAP score was tested with Pearson or Spearman coefficient, as appropriated. Scores of SWAP and its subscales in preclinical, limited and diffuse forms of SSc were compared using ANOVA test. Analyses were performed with SPSS Statistics, V.21 andp<0.05 was considered statistically significant.

Results:

We enrolled 38 patients, 84.2% (n=32) female, with mean age 60.3±14.5 years and mean disease duration 13.3±6.5 years. All but one were caucasian. Fifty percent (n=19) had a limited form, 26.3% (n=10) had preclinical scleroderma and 23.7% (n=9) had a diffuse form of SSc. Regarding the autoantibody profile: 63.2% (n=24) had anti-centromere antibodies, 28.9% (n=11) had anti-Scl-70 antibodies, 5.3% (n=2) had anti-PM antibodies and 2.6% (n=1) had no positive antibodies. The median of Rodnan scores was 4 (IQR 0-9). The total mean SWAP score was 44.8±12.5 with worse results at “Satisfaction with facial appearance” subscale (mean score 14.4±6.1). There is no statistically significant difference in the SWAP score (or its subscales) between the three diagnosis subtypes. No statistically significant correlation was found between the total and subscale SWAP scores and any of the continuous variables considered and no statistically significant difference was found between the different forms of SSc.

Conclusion:

We found no significant differences between preclinical, limited or diffused SS. SWAP scores were not significantly correlated with the total Rodnan score, age or disease duration. Contrary to our expectations SWAP did not show any relationship with depression, anxiety (HADS) or quality of Life (SF-36) However, our sample is too small to support definite conclusions. Further studies assessing body image in SSc and its impact in quality of life are warranted to support the holistic care of these patients.

References:

[1]doi:10.3899/jrheum.141482.;

[2]10.1037/0278-6133.22.2.130;

[3]10.3899/jrheum.141482.

Disclosure of Interests:

Luisa Brites: None declared, Flavio Costa: None declared, LILIANA SARAIVA: None declared, Ana Rita Cunha: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Tânia Santiago: None declared, Maria Joao Salvador: None declared

PARE0004 PATIENT PERSPECTIVE ON THE EFFICACY AND RISKS OF GLUCOCORTICOIDS IN RHEUMATOID ARTHRITIS – AN INTERNATIONAL SURVEY OF 1344 PATIENTS

Background:

The Glucocorticoid Low-dose Outcome in Rheumatoid Arthritis Study (GLORIA) is an international investigator-initiated pragmatic randomized trial designed to study the effects of low-dose glucocorticoids (GCs) in elderly patients with Rheumatoid Arthritis (RA).

The research team is also committed to promote a better understanding of the risks and benefits of these drugs among health professionals and patients. In order to achieve these goals, it is important to assess the current ideas and concerns of patients regarding GCs.

Objectives:

To evaluate the current patient perspective on the efficacy and risks of GCs in RA patients who are or have been treated with GCs.

Methods:

Patients with RA completed an online survey (with 5 closed questions regarding efficacy and safety) presented in their native language. RA patients were recruited through a variety of patient organizations representing three continents. Patients were invited to participate through national patient organizations. In the USA, patients were also invited to participate through MediGuard.org. Participants were asked for their level of agreement on a 5-point Likert scale.

Results:

1344 RA patients with exposure to GCs, from Brazil, USA, UK, Portugal, Netherlands, Germany and 24 other countries** participated: 89% female, mean age (SD) 52 (14) years and mean disease duration 13 (11) years. The majority of participants (84%) had ≥10 years of education. The duration of GCs exposure was 1.6 (4.2) years. The majority of participants had read articles or pamphlets on the benefits or harms of GC therapy.

Regarding GCs efficacy (table 1), high levels of endorsement were found: about 2/3 of patients considered that GCs as very useful in their case, more than half considered that GCs were effective even at low doses, and agreed that GC improved RA symptoms within days.

Regarding safety (table 1), 1/3 of the participants reported having suffered some form of serious adverse events (AEs) due to GCs, and 9% perceived this as “life-threatening. Adverse events had a serious impact on quality of life, according to about 1/3 of the respondents.

Conclusion:

Patients with RA exposed to GC report a strong conviction that GCs are very useful and effective for the treatment of their RA, even at low doses. This is accompanied by an important prevalence of serious AEs. Understanding the patient perspective can improve shared decision-making between patient and rheumatologist.

References:

Funding statement:This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 634886.

Disclosure of Interests:

Tânia Santiago: None declared, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Maarten de Wit Grant/research support from: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Consultant of: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Speakers bureau: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Pedro Carvalho: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi., Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha, Maarten Boers: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis

AB1335-HPR HEALTH PROFESSIONALS’ PERSPECTIVE ON THE BENEFITS AND RISKS OF LOW-DOSE GLUCOCORTICOIDS IN RHEUMATOID ARTHRITIS – AN INTERNATIONAL SURVEY OF 444 HEALTH PROFESSIONALS

Background:

The Glucocorticoid Low-dose Outcome in Rheumatoid Arthritis Study (GLORIA) is an international investigator-initiated pragmatic randomized trial designed to study the effects of low-dose glucocorticoids (GCs) in elderly patients with Rheumatoid Arthritis (RA).

The research team is also committed to promote a better understanding of the risks and benefits of these drugs among health professionals and patients. In order to achieve these goals, it is important to assess the current ideas and concerns of patients regarding GCs.

Objectives:

To evaluate the current patient perspective on the efficacy and risks of GCs in RA patients who are or have been treated with GCs.

Methods:

Patients with RA completed an online survey (with 5 closed questions regarding efficacy and safety) presented in their native language. RA patients were recruited through a variety of patient organizations representing three continents. Patients were invited to participate through national patient organizations. In the USA, patients were also invited to participate through MediGuard.org. Participants were asked for their level of agreement on a 5-point Likert scale.

Results:

1344 RA patients with exposure to GCs, from Brazil, USA, UK, Portugal, Netherlands, Germany and 24 other countries** participated: 89% female, mean age (SD) 52 (14) years and mean disease duration 13 (11) years. The majority of participants (84%) had ≥10 years of education. The duration of GCs exposure was 1.6 (4.2) years. The majority of participants had read articles or pamphlets on the benefits or harms of GC therapy.

Regarding GCs efficacy (table 1), high levels of endorsement were found: about 2/3 of patients considered that GCs as very useful in their case, more than half considered that GCs were effective even at low doses, and agreed that GC improved RA symptoms within days.

Regarding safety (table 1), 1/3 of the participants reported having suffered some form of serious adverse events (AEs) due to GCs, and 9% perceived this as “life-threatening. Adverse events had a serious impact on quality of life, according to about 1/3 of the respondents.

Conclusion:

Patients with RA exposed to GC report a strong conviction that GCs are very useful and effective for the treatment of their RA, even at low doses. This is accompanied by an important prevalence of serious AEs. Understanding the patient perspective can improve shared decision-making between patient and rheumatologist.

Funding statement:

This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 634886.

Disclosure of Interests:

Tânia Santiago: None declared, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Maarten de Wit Grant/research support from: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Consultant of: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Speakers bureau: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Pedro Carvalho: None declared, Maarten Boers: None declared, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi., José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis

How much of skin improvement over time in systemic sclerosis is due to normal ageing? A prospective study with shear-wave elastography

Background

Measurement of skin involvement is essential for the diagnosis and assessment of prognosis and disease progression in systemic sclerosis (SSc). The modified Rodnan skin score (mRSS) is the gold standard measure of skin thickness, but it has been criticised for the lack of objectivity, poor inter-observer reproducibility and lack of sensitivity to change. Recently, shear-wave elastography (SWE) emerged as a promising tool for the objective and quantitative assessment of the skin in SSc patients. However, no studies have evaluated its sensitivity to change over time.

Objective

To assess changes in skin stiffness in SSc patients using SWE during a 5-year follow-up.

Methods

Skin stiffness [i.e. shear-wave velocity values (SWV) in metres per second] was assessed by SWE ultrasound (using virtual touch image quantification) at the 17 sites of the mRSS, in each participant, at baseline and follow-up. mRSS was performed at both time points. Differences between groups were analysed using the related-samples Wilcoxon signed-rank test and the Mann–Whitney U test.

Results

We included 21 patients [85.7% females; mean age 56.3 (10.4) years at baseline, 57.1% with limited SSc] and 15 healthy controls [73.3% females; mean age 53.6 (14.1) years)]. The median follow-up was 4.9 (0.4) years.

Skin stiffness decreased significantly at all Rodnan sites (p ≤ 0.001) (except in the fingers), in SSc patients, over time. The same phenomenon occurred in controls, but to a lesser degree, in terms of percentage change.

The percentage reduction in skin stiffness varied in the different Rodnan sites and in different phases of the disease. In addition, SWV values also decreased significantly in 15/16 skin sites with local normal Rodnan at baseline, whereas local Rodnan skin score only changed significantly in the upper arm (p = 0.046) and forearm (p = 0.026).

Conclusion

This study provides first-time evidence suggesting that skin SWV values are more sensitive to change over time than mRSS and reduce significantly over time in SSc and normal controls.

Psychological factors associated with response to treatment in rheumatoid arthritis

This paper presents a comprehensive review of research relating psychological domains with response to therapy in patients with rheumatoid arthritis. A holistic approach to the disease was adopted by incorporating not only disease activity but also dimensions of the impact of disease on patients' lives. Psychological distress, including depression and anxiety, is common among patients with rheumatoid arthritis and has a significant negative impact on response to therapy and on patients' abilities to cope with chronic illness. Evidence regarding the influence of positive psychological dimensions such as acceptance, optimism, and adaptive coping strategies is scarce. The mechanisms involved in these interactions are incompletely understood, although changes in neuro-endocrine-immune pathways, which are common to depression and rheumatoid arthritis, seem to play a central role. Indirect psychological influences on therapeutic efficacy and long-term effectiveness include a myriad of factors such as adherence, placebo effects, cognition, coping strategies, and family and social support. Data suggest that recognition and appropriate management of psychological distress may improve response to treatment and significantly reduce disease burden.

Balancing the benefits and risks of low-dose glucocorticoid in rheumatoid arthritis

Glucocorticoids have potent anti-inflammatory and immunomodulatory effects and are widely use in the management of rheumatoid arthritis in combination with other synthetic and with biological disease-modifying anti-rheumatic drugs. Concerns about the risk of adverse effects of glucocorticoids, especially if they are given at higher dosages and for a longer time, hamper their use despite the clear symptomatic and disease modifying benefits. However, the evidence base for these concerns for low dose glucocorticoid therapy is quite limited due to the scarcity of quality literature on its safety in rheumatoid arthritis. This review discusses the current understanding about their disease-modifying effects, toxicity data from recent trials and observational studies, recommendations for their management and the current efforts to improve the therapeutic ratio of glucocorticoid through the development of new formulations, such as modified-release prednisone.

Sieving wastewater--cellulose recovery, economic and energy evaluation

Application of fine-mesh sieves (<0.35 mm) as pretreatment for municipal biological wastewater treatment gives an opportunity to recover resources and increase sustainability of wastewater treatment processes. Sieves are traditionally used for single stage mechanical treatment (typical mesh of 0.35 mm) or in combination with an MBR (typical mesh >0.7 mm). When sieves with a mesh of 0.35 mm are used on raw sewage we observed that cellulose fibres mainly originating from toilet paper are removed efficiently from the influent with a high recovery and purity. The application of sieves as pretreatment for conventional activated sludge processes has been evaluated based on pilot plant research at three WWTPs in the Netherlands. With sieving applied to the dry weather flow only the overall energy usage of the WWTP including sludge treatment can be decreased by at least 40% with a payback time of 7 years.

[Osteoarticular brucellosis: an analysis of the past decade]

OBJECTIVES

Characterize Osteoarticular Brucellosis in the University Hospital of Coimbra (HUC) in the past decade.

MATERIAL AND METHODS

A retrospective study of the cases diagnosed between January/2000 and December/2009 in the HUC.

RESULTS

Ninety patients were admitted with the dia-gnosis of brucellosis in our hospital, of whom 44 (49%; 18 men; 26 women, mean 49.5 years) had osteoarticular complications. Twenty-five (45%) patients had a positive epidemiological context. The most frequent clinical manifestation was local pain (73%) followed by polyarthralgias and constitutional symptoms. The C-reactive protein was the inflammatory marker most often increased (82%). The Rose Bengala test was positive in 42 patients, and a Wright's sero-aglutination above than 1/160 was detected in 28 patients. An etiologic agent was isolated in 28 (64%) patients, with 70% of positive blood cultures. The imaging procedure of choice was magnetic resonance imaging (MRI) (46%). The osteo-articular manifestation most frequent was spondylodiscitis (57%) with a lumbosacral involvement in 40%. All patients completed antibiotic therapy. One patient underwent surgery to drain the abscess. Patients had an average length of admission of 28.3 days, with a good outcome in 60%, and a reasonable outcome in 20%, despite 20% of the patients lost follow-up.

CONCLUSIONS

Brucellosis is a disease of obligatory declaration not eradicated in Portugal, with a great impact on socio-economic and public health. So, this epidemiological knowledge of brucellosis cases, allows an early intervention and therapy.

Enterophages, a group of phages infecting Enterococcus faecalis, and their potential as alternate indicators of human faecal contamination

We have developed a method for the detection of viruses in environmental samples that we have called enterophages, that specifically infect Enterococcus faecalis. This method has allowed us to determine the prevalence and to study the ecology of this group of phages. The enterophages replicate at 37 degrees C, and at 41 degrees C. The presence of NaN(3) in the media inhibits the growth of background microbiota and allows an accurate, specific and rapid detection of these viruses. Enterophages were present in raw domestic sewage at lower concentrations (average 1.8 x 10(2) PFU/100 mL) than those of coliphages (average 1.7 x 10(5) PFU/100 mL). Phages were characterised by transmission electron microscopy showing icosahedral capsids, some with non-contractile tails as well as icosahedral non-tailed capsids. Different isolates had capsid sizes ranging from 20 nm to about 75 nm in diameter. These data describe a new group of phages that may serve as alternate indicators of human faecal pollution, especially in recreational waters. The ecology of these enterophages indicates that these may be strictly of human origin.

Processing of ovine cardiac valve allografts: 3. Implantation following antimicrobial treatment and preservation

It is known that a satisfactory clinical outcome can follow the implantation of cardiac valve allografts in spite of the loss of living cells in the tissue. If viable cells are not required for long term graft function, then effective disinfection of the tissue might become possible. In an earlier paper in this series we reported that peracetic acid (PAA) is an effective antimicrobial agent for the treatment of valve allografts; it was lethal to the cells but at a concentration of 0.21% had little effect on the mechanical properties or extracellular morphology of the valve leaflets. It was also found that PAA-treatment could be combined with storage in 85% glycerol at 4 degrees C, or cryopreservation with 10% Me(2)SO, without substantial further impairment of microscopic structure or mechanical properties. In this paper we describe the implantation of processed ovine aortic valves in the descending thoracic aorta of sheep. The experimental groups included control untreated valves and valves that had been treated with antibiotics or PAA and either cryopreserved, or stored in 85% glycerol. The recipient sheep showed good clinical appearances until the experiment was terminated at six months. The explanted grafts were examined by standard morphological and mechanical testing methods. The PAA-treated valves were clearly recognisable as valves: the leaflets had fair to medium morphology in both the unpreserved and the cryopreserved groups. All leaflets had a superficial overgrowth of cells. Microsatellite analysis for allelic differences were performed on samples of donor and recipient tissues using three markers of tissue source. Only one valve, which had been treated with PAA, revealed allelic differences between donor and recipient. It is suggested that DNA-fragments may have remained after the destruction of donor cells and six months of implantation: the overgrowing cells were almost certainly of recipient origin. We conclude that our experiments, in which PAA-treatment was combined with preservation, are sufficiently encouraging to justify further studies to refine the technique, but in our opinion they are not sufficient to justify a clinical trial at this time.

Processing of ovine cardiac valve allografts: 1. Effects of preservation method on structure and mechanical properties

It is essential to have some method of preservation of allograft valves during the time between procurement and implantation. Cryopreservation is the most commonly-used storage method today but it has the major disadvantage of high cost, and because its aim is to preserve living cells only relatively gentle antimicrobial treatments are used. This study addresses two interrelated questions: Is it necessary to maintain living donor cells in the tissue graft? Can more effective measures be used to reduce the risk of transmission of diseases, especially viral diseases, via human tissue grafts. In this paper, we report an investigation of four preservation methods that could be combined with more effective disinfection: cryopreservation with dimethyl sulphoxide, storage at approximately 4 degrees C in a high concentration of glycerol as used for the preservation of skin, snap-freezing by immersion in liquid nitrogen and vitrification. Snap freezing was mechanically damaging and vitrification proved to be impracticable but two methods, cryopreservation and storage in 85% glycerol, were judged worthy of further study. Cryopreservation was shown to maintain cellular viability and excellent microscopic structure with unchanged mechanical properties. The glycerol-preserved valves did not contain any living cells but the connective tissue matrix and mechanical properties were well preserved. The importance of living cells in allograft valves is uncertain. If living cells are unimportant then either method could be combined with more effective disinfection methods: in that case the simplicity and economy of the glycerol method would be advantageous. These questions are addressed in the two later papers in this series.

Processing of cardiac valve allografts: 2. Effects of antimicrobial treatment on sterility, structure and mechanical properties

This is the second in a series of papers that report experiments to investigate the properties required for effective tissue valve implants. This paper is concerned with investigations into alternative antimicrobial treatments and the effect these treatments produce on the structural and biomechanical properties of ovine aortic valves. Six treatments were studied: heat, peracetic acid (at two concentrations), chlorine dioxide, a surfactant cleaning agent and a solvent/detergent treatment. Samples of myocardial tissue were exposed to a mixed bacterial culture or one of three virus cultures and then decontaminated. Two of the six treatments (0.35% peracetic acid and heat) were effective in removing both bacterial and viral contamination, reducing levels of contamination by 2.5 to 3 logs, whilst a third (chlorine dioxide) was effective against viruses ( approximately 3 log reduction). Valves subjected to these treatments were examined by microscopy and measurements of mechanical properties were made. All three treatments seriously damaged endothelial cells and leaflet fibroblasts. Heat treatment also damaged connective tissue components (collagen and elastin) but these changes were not seen after chemical treatment. Mechanical testing confirmed severe damage following heat treatment but chemical treatment showed only minor effects on the elasticity of the leaflets and none on extensibility. These minor effects could be mitigated by exposure to a lower dose of peracetic acid and this treatment could be safely combined with cryopreservation or storage in 85% glycerol. Peracetic acid was the preferred disinfection method for use in the subsequent in vivo studies in sheep.

Endocardial and epicardial radiofrequency ablation in the treatment of atrial fibrillation with a new intra-operative device

OBJECTIVE

Atrial fibrillation has been a difficult problem to solve in many surgical patients, especially in those with mitral valve pathology. This study evaluates the results of endocardial and epicardial radiofrequency ablation with a new intra-operative device in the treatment of atrial fibrillation.

METHODS

We operated on 65 patients with atrial fibrillation, 58 of which had concomitant mitral surgery. Atrial fibrillation was chronic (over 1 year) in 46 patients (group A) and paroxysmal or recent onset in 12 (group B). Group C had lone atrial fibrillation (two), concomitant coronary artery disease (four) or a sarcoma (one). Bilateral pulmonary vein isolation with a new intra-operative device was performed through multiple dry lesions in all patients. Groups A and B had endocardial applications at 70 degrees C during 60 s and group C had epicardial applications at 75 degrees C. Three group C patients had epicardial applications off pump. Atrial wall biopsies were performed in nine patients from groups A and B.

RESULTS

There were no serious post-operative complications. At 1 month follow-up 54% of all patients were out of atrial fibrillation and 34% were in normal sinus rhythm with bilateral atrial contraction (Santa Crus Score 4). At 6 months follow-up, in spite of some crossover of patients among groups, similar results were obtained. The success of the procedure was 69% (Santa Crus scores 3 and 4) in mitral patients with a left atrial volume smaller than 200 cm(3). Preliminary data on the transmurality of the lesions is presented. The patients submitted to epicardial radiofrequency ablation (group C) have satisfactory results at 1 month (six out of seven were out of AF).

CONCLUSIONS

Both endocardial and epicardial RF applications are simple and quick to perform and do not pose an additional risk for most patients. Furthermore we believe that it is possible to perform bilateral epicardial radiofrequency ablation of the pulmonary veins without cardiopulmonary bypass. Further refinements of the technique are needed to assure transmurality of all lesions and better results.

No evidence of chaos in the heart rate variability of normal and cardiac transplant human subjects

INTRODUCTION

The variability observed in the heart rate may reflect fundamental aspects of cardiac activity. It has been under discussion whether heart rate variability (HRV) is due to noise or chaos, which is irregular behavior occurring in deterministic nonlinear systems.

METHODS AND RESULTS

Using chaos analysis techniques, we analyzed HRV of five normal and five human cardiac transplant subjects at rest. HRV is studied using the beat-to-beat RR interval time series extracted from the ECG. The cardiac transplant subjects exhibited a much smaller HRV than the normal subjects because of heart denervation. We present the map and correlation dimension estimation for the RR time series. To test for nonlinear correlations in the dynamics, we built surrogate time series that have the same power spectra as the experimental time series, but also have randomized phases. The experimental and the surrogate data were compared using the correlation integral. No correlation dimension was found for the RR time series of either the normal or the cardiac transplant subjects. Nevertheless, nonlinear correlations were detected in the HRV of the normal subjects but not in HRV of the cardiac transplant subjects. For the latter, no significant changes were observed in the correlation integral as a function of time after transplantation.

CONCLUSION

We found no evidence of low-dimensional chaos in the HRV of normal and cardiac transplant subjects. However, some nonlinear correlations were detected in the HRV of the normal subjects, which may be associated with autonomic nervous system influence.

Modelling a parasystolic rhythm in a heart-transplant patient

A parasystole from a heart-transplant patient is analysed using a beat-to-beat RR interval time series obtained from an electrocardiogram (ECG). The dysrhythmia, resulting from the co-existence of two pacemakers, the sinus node and an ectopic focus, presents distinctive regular patterns, with transitions from one pattern to another occurring abruptly. It is shown that the parasystolic rhythm can be simulated by a model involving two oscillators firing at fixed rates, under the restriction that neither is allowed to fire during the other's refractory period. It is found that the structure of the generated RR time series is essentially determined by the ratio of the periods of the two oscillators. In the case of a heart-transplant patient with a small heart-rate variability as a result of heart denervation, the model predicts the RR intervals with an error of less than 6% for an 80-beat sequence. From a physiological point of view, the results imply that the interaction between the two pacemakers in the heart is fairly weak, and hence the parasystole observed in the heart-transplant patient can be modelled as pure parasystole.

Nitroglycerin-induced hypotension, bradycardia, and asystole: report of a case and review of the literature

A 36-year-old man presented with a prolonged history of chest pain, and was given two sublingual nitroglycerin tablets. Subsequently, the patient became hypotensive, bradycardiac, apneic, and lost consciousness. The bradycardia resolved spontaneously. No evidence for acute myocardial infarction or ischemic disease was found. Thirty-four cases reported to date are reviewed, demonstrating that this response appears to be an independent effect of nitroglycerin taken in any form, in patients with and without myocardial infarction and to be unpredictable, especially without evidence of inferior or right ventricular infarction. Careful monitoring is warranted when administering nitroglycerin.