AB1114 HANDWORK VS MACHINE; A COMPARISON OF RHEUMATOID ARTHRITIS PATIENT POPULATIONS AS IDENTIFIED BY MACHINE-LEARNING AND CRITERIA-BASED CHART REVIEW

Background:

Electronic Medical Records (EMRs) offer a magnitude of observational data which is currently often manually reviewed to identify patient cases. Machine-Learning (ML) methods are highly efficient tools for data extraction, being able to process the information-rich free-text physician notes from EMRs. [1]

We postulate that incorporating this data into an ML pipeline, will enable the high-throughput identification of RA case cohorts qualitatively equal to conventional EULAR/ACR criteria based chart review.

Objectives:

To investigate the comparability of Rheumatoid arthritis (RA) cases identified through EMR free-text enriched machine-learning algorithms to the field’s gold-standard (GS) of criteria based chart-review.

Methods:

We developed a classification algorithm using a Support Vector Machine (SVM) trained on 1000 manually reviewed patient EMRs and validated on a separate 1000 records. [2]

The SVM assigns a probability of being an RA case to each patient at a speed of >5000 records per second. The probability cutoff for case identification can be tailored to studies’ needs, optimizing on sensitivity, specificity, etc. We optimized on PPV, resulting in a cutoff of 0.48 with a PPV of 0.96.

We used the 1987 and 2010 EULAR/ACR criteria based diagnoses of RA at one year after inclusion in a prospective arthritis cohort as GSs and compared the baseline characteristics of ML identified RA cases with both GSs separately and for those fulfilling at least one set of criteria using Pearson chi-squared and Mann-Whitney U tests (α = 0.05).

Results:

At the 0.48 cutoff the ML model performs very well on the annotated set and when compared to criteria based GSs. (Table 1)

Since patients diagnosed with RA do not necessarily meet classification criteria, it is not surprising that the ML cases and GSs do not completely overlap. The ML cases overlap to a larger degree with the 1987 GS than with the 2010 GS. Clinically, the ML identified cases do not differ from the 2010 and 1987 GS cohorts except for a slightly higher CCP2 positivity compared to the 1987 GS (65 vs 51%) and the combined criteria (65 vs 56%). (Table 1 & 2)

Table 1.

Performance of ML-model in the annotated data†(N = 1000) predicting cases and 1987, 2010 or either criteria based data * (N = 1235, 1218 & 1244 respectively) predicting cases (prob. ≥ 0.48). TP; True Positive, FP; False Positive, TN; True Negative, FN; False Negative, PPV; Positive Predictive Value, NPV; Negative Predictive Value, Spec; Specificity, Sens; Sensitivity

AccuracyPPVNPVSpecSensAnnotated Cases†0.980.960.981.000.74Criteria Definite Cases 1987*0.820.790.830.920.61Criteria Definite Cases 2010*0.780.810.770.930.55Either Criteria Cases*0.760.900.720.950.51

Conclusion:

ML algorithms processing clinician notes enable fast and efficient selection of cases that are clinically similar to cases selected by criteria based chart review. This allows a significant reduction of time and effort required to construct high quality research cohorts.

Table 2.

Comparison of baseline characteristics between 3 ML defined cohorts and a criteria based gold standard.†Not statistically tested; * significantly different to the ML selected cases at α = 0.05, Pearson Chi-Squared for proportions, Mann-Whitney U for medians

Predicted Definite Case1987 Criteria Based Case2010 Criteria Based CaseEither Criteria Based CaseN†335399609666Proportion Women0.670.630.650.65Proportion CCP2 Positive0.650.51*0.610.56*Proportion RF positive0.670.600.690.64Median BMI26.025.525.625.6Median BSE28292626Median CRP9.61199Median Age at Inclusion57.758.757.258.3Median Symptom Duration at Diagnosis (in Days)95.5909189Median Number of Swollen Joints5665

References:

[1]Maarseveen et al. ARD 2019;78

[2]https://github.com/levrex/DiagnosisExtraction_ML

Acknowledgments:

T. Maarseveen and M. Maurits contributed equally.

Disclosure of Interests:

Tjardo Maarseveen: None declared, Marc Maurits: None declared, Ellis Niemantsverdriet: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Annette van der Helm - van Mil: None declared, Rachel Knevel: None declared

SAT0310 ANTI-CENTROMERE ANTIBODY ISOTYPE LEVELS AS BIOMARKER FOR DISEASE PROGRESSION IN SUBJECTS AT RISK TO DEVELOP SYSTEMIC SCLEROSIS

Background:

Presence of anti-centromere antibodies (ACA) generally associates with a better prognosis than many other systemic sclerosis (SSc) associated autoantibodies. However, presentation of the disease can be very heterogeneous and prediction of the disease course is challenging. Some older studies suggest a possible association between clinical characteristics and isotypes of ACA in patients with SSc. It is unknown whether ACA can serve as biomarker for future SSc development.

Objectives:

To evaluate the clinical course of very early SSc and to assess whether ACA isotype levels can identify subjects that will progress to definite SSc.

Methods:

ACA IgG+ patients with very early SSc (defined as presence of ACA IgG AND Raynaud and/or puffy fingers and/or abnormal nailfold capillaroscopy but not fulfilling ACR 2013 criteria) from five prospective SSc cohorts (Leiden, Zurich, Oslo, Bordeaux, Ghent) were included. Presence and levels of ACA IgG, IgM and IgA were determined at first clinical assessment and clinical course was evaluated annually. Disease progression to definite SSc, which was defined as fulfillment of the ACR 2013 criteria for SSc, and included any development of: digital ulcers (DU), interstitial lung disease (ILD) assessed by high resolution chest tomography, pulmonary arterial hypertension assessed by right heart catheterization, gastro-intestinal involvement, renal crisis or myocardial involvement was determined. ACA response characteristics were compared between very early SSc patients that progressed to definite SSc and those who did not. Logistic regression was performed to determine whether ACA response characteristics can predict progression to definite SSc, with adjustment for age and follow-up duration.

Results:

In total 92 subjects were included with median follow-up (FU) of 3 years (table 1); 39% progressed to definite SSc, mostly based on the development of skin involvement (77%). Twenty-three percent of patients developed lung involvement, 11% DU, 17% gastro-intestinal involvement and 4% myocardial involvement. Progression on more than one organ system was present in 31% of the very early SSc patients. In the multivariable logistic regression, with adjustment for age and follow-up duration, ACA IgG levels at baseline were significantly associated with progression to definite SSc (OR 3.0 (1.1-8.8)). Likewise, a trend was observed for higher ACA IgM levels (OR 1.8 (0.9-3.5)) in the very early SSc patients progressing to definite SSc (figure 1).

Table 1.

Baseline characteristics and ACA isotype levels in patients with very early SSc, and between progressors and non-progressors. * p value < 0.05.

Progressors(n=35)Non-progressors(n=57)Female, n(%)32 (91)50 (91)Age, mean (SD)56 (14)53 (13)Disease duration since non Raynaud phenomenon, median(IQR) in years3 (0.8-10)2 (0.6-7)Follow-up duration in years, median (IQR)4 (2-6)2 (1-3)*Abnormal Nailfold videocapillaroscopy, n(%)17 (65)27 (60)IgA level [aU/mL], median (IQR)63 (34-120)75 (35-144)IgM level [aU/mL], median (IQR)131 (32-585)79 (18-391)IgG level [U/mL], median (IQR)342 (162-720)195 (93-488)*

Conclusion:

In this study we illustrate that 39% of the ACA positive very early SSc subjects progress to definite SSc within median 4 years. We identified higher ACA IgG level as a predictive biomarker for progression to definite SSc indicating that it might be a useful biomarker for risk stratification in clinical practice.

Disclosure of Interests:

Nina van Leeuwen: None declared, Jaap Bakker: None declared, Annette Grummels: None declared, Corrie Wortel: None declared, Suzana Jordan: None declared, Sophie Liem: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche, Karin Melsens: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Marie-Elise Truchetet: None declared, Hans Ulrich Scherer Grant/research support from: Bristol Myers Squibb, Sanofi, Pfizer, Speakers bureau: Pfizer, Lilly, Roche, Abbvie, Rene Toes: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Jeska de Vries-Bouwstra: None declared

AB0383 EXTREME FATIGUE IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND NEUROPSYCHIATRIC SYMPTOMS

Background:

Fatigue is commonly described in chronic illnesses, especially auto-immune disorders such as systemic lupus erythematosus (SLE).

Objectives:

We aim to study the prevalence of fatigue in SLE patients with NP symptoms and compare fatigue in SLE patients with NP symptoms attributed to major organ involvement due to SLE (NPSLE) with SLE patients with NP symptoms not caused by major nervous system involvement (non-NPSLE).

Methods:

All patients visiting the tertiary referral center for NPSLE in the LUMC between 2007-2019 with the clinical diagnosis of SLE and age >18 years that signed informed consent were included in this study. Patients underwent a standardized multidisciplinary assessment, including two questionnaires: SF-36 (2007-2019) and multidimensional fatigue index (MFI, 2011-2019). Patients were classified as NPSLE in this study if NP symptoms were attributed to SLE and immunosuppressive or anticoagulant therapy was initiated, otherwise patients were classified as non-NPSLE. The vitality (VT) domain of the SF-36 domain was used to assess fatigue, which generates a score from 0-100, 100 representing the complete absence of fatigue. Patients with a score more than 1 standard deviation (SD) removed from age-related controls of the Dutch general population were classified as fatigued; patients more than 2 SD removed were classified as extremely fatigued1. The MFI was also used, which consists of 5 subdomain scores between 0-20, leading to a total score between 0-100, 100 representing the most extreme fatigue. All scores are presented as mean and standard deviation.

Results:

373 patients fulfilled the inclusion criteria and SF-36 questionnaires of 328 patients were available (88%). The majority of these patients was female (87%) and 98 were classified as NPSLE (30%). In NPSLE patients, average age was 41 ± 13 years and in non-NPSLE the average age was 45 ± 14 years. The average score of the SF-36 vitality domain was 36.0 ± 20.7 in NPSLE vs 33.9 ± 18.8. in non-NPSLE. Overall, 73.5% of the patients were fatigued and 46.9% extremely fatigued in NPSLE vs 77.8% fatigued and 45.7% extremely fatigued in non-NPSLE.

The MFI questionnaire and VAS score were available for 222 patients, of which 65 patients were classified as NPSLE (29.3%). Table 1 depicts the scores of NPSLE and non-NPSLE patients on the MFI subdomains and the VAS score.

Table.

Patient characteristics at registry entry.

NPSLE(N = 65)Non-NPSLE (N = 157)MFI(mean, sd)General Fatigue10.8 (1.8)11.1 (1.5)Physical Fatigue11.4 (2.4)12.3 (1.9)Reduced Activity9.6 (2.9)10.7 (2.2)Reduced Motivation10.7 (2.6)11.1 (1.9)Mental Fatigue9.5 (3.0)9.8 (2.7)Total score51.8 (9.9)54.9 (6.9)SF-36 Vitality (mean, sd)35 (20.7)32.7 (18.2)

Conclusion:

Nearly half of patients with SLE and NP symptoms are as extremely fatigued as only 2.5% of the general Dutch population. Extreme fatigue is not influenced by major nervous system involvement.

References:

[1]Aaronsonet al.J Clin Epidemiol. Vol. 51, No. 11, pp. 1055–1068, 1998

Disclosure of Interests:

Rory Monahan: None declared, Rolf Fronczek: None declared, Jeroen Eikenboom: None declared, Huub Middelkoop: None declared, L.J.J. Beaart- van de Voorde: None declared, Gisela Terwindt: None declared, Nic van der Wee: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Margreet Kloppenburg: None declared, G.M. Steup-Beekman: None declared

FRI0585 HIGH-THROUGHPUT METHODOLOGY FOR EMR-BASED IDENTIFICATION OF CLINICAL SUB-PHENOTYPES IN COMPLEX PATIENT POPULATIONS

Background:

Heterogeneity in disease populations complicates discovery of risk factors. To identify risk factors for subpopulations of diseases, we need analytical methods that can deal with unidentified disease subgroups.

Objectives:

Inspired by successful approaches from the Big Data field, we developed a high-throughput approach to identify subpopulations within patients with heterogeneous, complex diseases using the wealth of information available in Electronic Medical Records (EMRs).

Methods:

We extracted longitudinal healthcare-interaction records coded by 1,853 PheCodes[1] of the 64,819 patients from the Boston’s Partners-Biobank. Through dimensionality reduction using t-SNE[2] we created a 2D embedding of 32,424 of these patients (set A). We then identified distinct clusters post-t-SNE using DBscan[3] and visualized the relative importance of individual PheCodes within them using specialized spectrographs. We replicated this procedure in the remaining 32,395 records (set B).

Results:

Summary statistics of both sets were comparable (Table 1).

Table 1.

Summary statistics of the total Partners Biobank dataset and the 2 partitions.

Set-Aset-BTotalEntries12,200,31112,177,13124,377,442Patients32,42432,39564,819Patientyears369,546.33368,597.92738,144.2unique ICD codes25,05624,95326,305unique Phecodes1,8511,8531,853

We found 284 clusters in set A and 295 in set B, of which 63.4% from set A could be mapped to a cluster in set B with a median (range) correlation of 0.24 (0.03 – 0.58).

Clusters represented similar yet distinct clinical phenotypes; e.g. patients diagnosed with “other headache syndrome” were separated into four distinct clusters characterized by migraines, neurofibromatosis, epilepsy or brain cancer, all resulting in patients presenting with headaches (Fig. 1 & 2). Though EMR databases tend to be noisy, our method was also able to differentiate misclassification from true cases; SLE patients with RA codes clustered separately from true RA cases.

Figure 1.

Two dimensional representation of Set A generated using dimensionality reduction (tSNE) and clustering (DBScan).

Figure 2.

Phenotype Spectrographs (PheSpecs) of four clusters characterized by “Other headache syndromes”, driven by codes relating to migraine, epilepsy, neurofibromatosis or brain cancer.

Conclusion:

We have shown that EMR data can be used to identify and visualize latent structure in patient categorizations, using an approach based on dimension reduction and clustering machine learning techniques. Our method can identify misclassified patients as well as separate patients with similar problems into subsets with different associated medical problems. Our approach adds a new and powerful tool to aid in the discovery of novel risk factors in complex, heterogeneous diseases.

References:

[1] Denny, J.C. et al. Bioinformatics (2010)

[2]van der Maaten et al. Journal of Machine Learning Research (2008)

[3] Ester, M. et al. Proceedings of the Second International Conference on Knowledge Discovery and Data Mining. (1996)

Disclosure of Interests:

Marc Maurits: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Marcel Reinders: None declared, Soumya Raychaudhuri: None declared, Elizabeth Karlson: None declared, Erik van den Akker: None declared, Rachel Knevel: None declared

P1473 Detection of cardiac sources of cerebrovascular events in patient with systemic lupus erythematosus with neuropsychiatric manifestations

Introduction

Systemic lupus erythematosus (SLE) is an idiopathic connective tissue disease, characterized with multiorgan involvement. Central nervous system (CNS) involvement is one of the most frequent manifestation of SLE and is termed as neuropsychiatric SLE (NPSLE) Prevalence of NPSLE varies between 12% and 95% among SLE patients. cerebrovascular accidents (CVA) and/or transient ischemic attack (TIA) represents one of the most frequent neuropsychiatric manifestation in SLE patients. Cerebral embolism may have cardioembolic source. Purpose: we described one case of SLE patient with NPSLE diagnosis and concomitant nonsignificant size of ASD II and tried to find its possible association with cerebrovascular accident. Method: We performed retrospective analysis of SLE (NPSLE) patient who had undergone echocardiographic and brain MRI evaluation. Case-Results: A 63 years old women was diagnosed with SLE in 1996 based on positive ANF, positive anti-cardiolipin IGg , arthritis, discoid lupus, positive coombs test and neurological manifestations (hemiplegia and aphasia). Echocardiographic evaluation showed pericarditis and nonsignificant ASD II (&lt;3mm). Ischemic changes were observed on Brain MRI study. Two years later in 1998 brain MRI showed a white matter defect (suspected vascular nature). Patient received 6 standard course of treatment with Cyclophosphamide ,Prednisone (from 60 mg gradually decreased to 10 mg) and oral anticoagulation drugs. After 9 years from the first diagnosis of SLE patient achieved complete remission, but soon in 2006 patient developed TIA and in 2013 developed lacunar infarct. Cardiac source of embolism was excluded according to performed analysis. In addition myocardial infarction was excluded based on Single-photon emission computed tomography (SPECT) perfusion scan. Since then patient remained under the observation of multidisciplinary team. Conclusion: We demonstrated one case of SLE patient with life threating neurological manifestations developed several times. Transthoracic echocardiographic examination showed small ASD II which was not considered as source of embolism, but we believe that in SLE patients with PFO/ASD, even though the size of defect is not large, cerebrovascular accidents may develop due to underlying inflammatory mechanism predisposing possible thromboembolism and early diagnosis, follow-up and management can be paramount to avoid future complications.

P4440Assessment of left atrial function in patients with systemic lupus erythematosus with and without neuropsychiatric manifestations: association with cardiovascular events

Introduction

Cardiac involvement in Systemic Lupus Erythematosus (SLE) may lead to left ventricular (LV) hypertrophy with possible impairment of LV diastolic function and left atrial (LA) function, particularly in patients with severe forms of SLE with neuropsychiatric manifestations (NPSLE) and can also be associated with cardiovascular outcome.

Purpose

We evaluated the prevalence of LV diastolic dysfunction and LA dysfunction in a large cohort of SLE patients including also NPSLE patients, and their association with the occurrence of cardiovascular events (cerebrovascular accidents, lung-embolism, coronary revascularisation, heart failure hospitalisations and development of supraventricular arrhythmias).

Methods

A total of 102 SLE patients (87% female, 42±15 years) were included, of which 43 (42%) with NPSLE according to a multidisciplinary team assessment. All patients fulfilled the American College of Rheumatology (ACR 1997) and Systemic Lupus Erythematosus International Collaborating Clinics (SLICC 2012) classification criteria for SLE. Echocardiography was performed at the first visit: LV diastolic function was assessed according to current recommendations and including Tissue Doppler Imaging measures; LA volume (LAVI) was also measured and LA function was assessed by LA reservoir strain using 2D speckle tracking imaging.

Results

In the SLE patients, mean LV mass index was 82±32 g/m2, 29% of patients showed an e'septal <10, 7% an E/e'>14, 16% a LAVI>34 ml/m2 and 5% a tricuspid velocity >2.8m/s. When applying the currently recommended multiparametric approach, only 4% of SLE patients showed LV diastolic dysfunction. In NPSLE patients, the prevalence of LV diastolic dysfunction was not significantly higher (5%). However, an impaired LA reservoir strain (based on the median value of 25%) was observed in 54% of the total SLE population and in 77% of NPSLE patients suggesting higher sensitivity of this parameter to detect impaired LA function and LV diastolic function. During a median follow up of 11 years (Interquartile range: 4–19 years), 43 (42%) patients developed a cardiovascular event. Kaplan-Meier curve analysis showed that SLE patients with impaired LA strain <25% experienced higher cumulative rates of cardiovascular events, as compared to SLE patients with LA strain≥25% (Chi-square 4.350; Log rank p=0.037). At the uni- and multivariate Cox-regression models, LA strain showed significant association with cardiovascular events (hazard ratio [HR]:0.944; 95% confidence interval [CI]: 0.893–0.997; p=0.039) together with age (HR: 1.030; 95% CI: 1.002–1.059; p=0.039) after correcting for LV mass index and LV diastolic dysfunction.

LA reservoir strain

Conclusions

LA dysfunction as assessed by LA reservoir strain is significantly impaired in SLE and particularly in NPSLE patients and improve detection of myocardial involvement in these patients. Furthermore, LA reservoir strain is independently associated with the development of cardiovascular events.

4312Left ventricular systolic function in patients with systemic lupus erythematosus and its association with cardiovascular events

Introduction

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that may involve the cardiovascular system. Diagnosis of cardiac involvement, particularly at an early stage, represents challenge since symptoms in SLE patients are often atypical and current diagnostic tools are characterized by a low sensitivity to detect myocardial dysfunction. Purpose of this study was to assess left ventricular (LV) systolic function in a large cohort of SLE patients in comparison with a control group of healthy subjects and using standard echocardiographic measures and global longitudinal strain (GLS) by 2D speckle tracking analysis. Furthermore, the association between echocardiographic parameters and the occurrence of cardiovascular events was tested.

Methods

A total of 102 patients (87% female, 42±15 years) were analysed including echocardiography at the time of their first visit. All patients fulfilled the American College of Rheumatology (ACR 1997) and The Systemic Lupus Erythematosus International Collaborating Clinics (SLICC 2012) classification criteria for SLE. During follow-up, cardiovascular events included cerebrovascular accident or transient ischemic attack, pulmonary embolism, coronary artery interventions, hospitalisations for heart failure and development of supraventricular arrhythmias. The control group consisted of 50 age- and gender-matched healthy subjects.

Results

Prevalence of comorbidities, such as hypertension (8%), hypercholesterolemia (4%) and diabetes mellitus (2%) was relatively low in SLE patients. In comparison with the control group, SLE patients were characterized by worse LV systolic function as measured by LV ejection fraction (51±6% vs 62±6%, p<0.001) and by LV GLS (−15±3% vs −19±2%, p<0.001), as well as worse LV diastolic function (e' septal: SLE 9±2 cm/s vs 10±2 cm/s healthy controls, p=0.020; E/e': SLE 8±3 vs 7±2 healthy controls, p<0.001; TR velocity: SLE 2±0.6 m/s vs 1.6±0.5 m/s healthy controls, p=0.020). During a median follow up of 11 years (Interquartile range: 4–19 years), 43 (42%) patients developed cardiovascular events. Kaplan-Meier curves show that SLE patients with more impaired GLS (based on the median value of −15%) experienced higher cumulative rates of cardiovascular events as compared to patients with GLS ≤−15% (Chi-square 7.197; Log rank p=0.007). On uni- and multivariate Cox-regression models, LV GLS demonstrated significant association with cardiovascular events (HR: 2.229; 95% CI: 1.024–4.853; p=0.043), together with age (HR: 1.043; 95% CI: 1.017–1.069; p=0.014) after correcting for LV mass index and e'; in turn, LV ejection fraction was not significantly associated with cardiovascular events.

LV GLS in SLE patients

Conclusions

In SLE patients, LV systolic function as measured by GLS is significantly impaired and independently associated with cardiovascular events. Incorporation of LV GLS in the early assessment of these patients may significantly improve risk-stratification for cardiovascular events.

Complex medical history of a patient with a compound heterozygous mutation in C1QC

Introduction

C1q is an essential part of the classical pathway of complement activation. Genetic deficiencies, caused by homozygous mutations in one of the C1q genes, are rare and are strongly associated with development of systemic lupus erythematosus (SLE). Here we describe a C1q-deficient patient with a compound heterozygous mutation.

Material and methods

Serum was analysed with enzyme-linked immunosorbent assay (ELISA) and Western blot for the presence of C1q, and DNA and RNA sequencing was performed to identify the mutations and confirm that these were located on different chromosomes.

Results

The medical history of the patient includes SLE diagnosis at age 11 years with cerebral involvement at age 13, various infections, osteonecrosis and hemophagocytic syndrome. Using ELISA and Western blot, we confirmed the absence of C1q in the serum of the patient. Using DNA sequencing, two mutations in the C1QC gene were identified: c.100G > A p.(Gly34Arg) and c.205C > T p.(Arg69X). With RNA sequencing we confirmed that the mutations are located on different chromosomes.

Discussion

The patient described in this case report has a compound heterozygous mutation in C1QC resulting in C1q deficiency.

Does treatment strategy influence the ability to achieve and sustain DMARD-free remission in patients with RA? Results of an observational study comparing an intensified DAS-steered treatment strategy with treat to target in routine care

OBJECTIVES

To study the impact of treatment strategy on achieving and sustaining disease-modifying antirheumatic drug (DMARD)-free remission in patients with rheumatoid arthritis (RA).

METHODS

Two hundred seventy-nine RA patients (median follow-up 7.8 years) were studied. Of these, 155 patients participated in a disease activity score (DAS) < 1.6 steered trial aimed at DMARD-free remission. Initial treatment comprised methotrexate with high-dose prednisone (60 mg/day) and a possibility to start biologicals after 4 months. In the same period and hospital, 124 patients were treated according to routine care, comprising DAS < 2.4 steered treatment. Percentages of DMARD-free remission (absence of synovitis for ≥ 1 year after DMARD cessation), late flares (recurrence of clinical synovitis ≥ 1 year after DMARD cessation), and DMARD-free sustained remission (DMARD-free remission sustained during complete follow-up) were compared between both treatment strategies.

RESULTS

Patients receiving intensive treatment were younger and more often ACPA-positive. On a group level, there was no significant association between intensive treatment and DMARD-free remission (35% vs 29%, corrected hazard ratio (HR) 1.4, 95%CI 0.9-2.2), nor in ACPA-negative RA (49% versus 44%). In ACPA-positive RA intensive treatment resulted in more DMARD-free remission (25% vs 6%, corrected HR 4.9, 95%CI 1.4-17). Intensive treatment was associated with more late flares (20% versus 8%, HR 2.3, 95%CI 0.6-8.3). Subsequently, there was no difference in DMARD-free sustained remission on a group level (28% versus 27%), nor in the ACPA-negative (43% versus 42%) or ACPA-positive stratum (17% versus 6%, corrected HR 3.1, 95%CI 0.9-11).

CONCLUSIONS

Intensive treatment did not result in more DMARD-free sustained remission, compared to routine up-to-date care. The data showed a tendency towards an effect of intensive treatment in ACPA-positive RA; this needs further investigation.

Outcomes of neuropsychiatric events in systemic lupus erythematosus based on clinical phenotypes; prospective data from the Leiden NP SLE cohort

Objective

The objective of this study was to assess whether clinical and patient’s reported outcomes are associated with a different pathophysiological origin of neuropsychiatric events presenting in systemic lupus erythematosus.

Methods

A total of 232 neuropsychiatric events presenting in 131 systemic lupus erythematosus patients were included. Neuropsychiatric systemic lupus erythematosus diagnosis was established per event by multidisciplinary evaluation. All neuropsychiatric events were divided according to a suspected underlying pathophysiological process into one of the following: non-neuropsychiatric systemic lupus erythematosus related, inflammatory and ischaemic neuropsychiatric systemic lupus erythematosus. The clinical outcome of all neuropsychiatric events was determined by a physician-completed four-point Likert scale. Health-related quality of life was measured with the subscales of the patient-generated Short Form 36 (SF-36) health survey questionnaire. The change between scores at paired visits of all domain scores, mental component summary (SF-36 MCS) and physical component summary (SF-36 PCS) scores were retrospectively calculated and used as patient-reported outcome. The association among these outcomes and the different origin of neuropsychiatric events was obtained using multiple logistic regression analysis.

Results

The clinical status of 26.8% non-neuropsychiatric systemic lupus erythematosus events, 15.8% ischaemic neuropsychiatric systemic lupus erythematosus and 51.6% inflammatory neuropsychiatric systemic lupus erythematosus improved after re-assessment. Almost all SF-36 domains had a positive change at re-assessment in all groups independently of the origin of neuropsychiatric events. Neuropsychiatric systemic lupus erythematosus ( B = 0.502; p < 0.001) and especially inflammatory neuropsychiatric systemic lupus erythematosus ( B = 0.827; p < 0.001) had better clinical outcome, with change in disease activity being the only important predictor. The change in SF-36 MCS was also independently associated with neuropsychiatric systemic lupus erythematosus ( B = 5.783; p < 0.05) and inflammatory neuropsychiatric systemic lupus erythematosus ( B = 11.133; p < 0.001). Disease duration and change in disease activity were the only predictors in both cases. The change in SF-36 PCS was only negatively associated with age.

Conclusion

Inflammatory neuropsychiatric systemic lupus erythematosus events have better clinical outcome and meaningful improvement in SF-36 MCS than ischaemic neuropsychiatric systemic lupus erythematosus or non-neuropsychiatric systemic lupus erythematosus.

Phase 1b randomized, double-blind study of namilumab, an anti-granulocyte macrophage colony-stimulating factor monoclonal antibody, in mild-to-moderate rheumatoid arthritis

Background

Namilumab (AMG203) is an immunoglobulin G1 monoclonal antibody that binds with high affinity to the GM-CSF ligand. This was a phase 1b, randomized, double-blind study (PRIORA) to assess namilumab in active, mild-to-moderate rheumatoid arthritis (RA). The primary outcome was the safety and tolerability of repeated subcutaneous injections of namilumab in patients with mild-to-moderate RA.

Methods

Adults with mild-to-moderate RA on stable methotrexate doses for ≥12 weeks were eligible. Patients received three subcutaneous injections of namilumab 150 or 300 mg, or placebo on days 1, 15, and 29, with 12 weeks’ follow-up. Primary objective was safety/tolerability.

Results

Patients in cohort 1 were randomized to namilumab 150 mg (n = 8) or placebo (n = 5). In cohort 2, patients were randomized to namilumab 300 mg (n = 7) or placebo (n = 4). Incidence of treatment-emergent adverse events (TEAEs) was similar across the three groups (namilumab 150 mg: 63%; namilumab 300 mg: 57%; placebo: 56%). TEAEs in ≥10% of patients were nasopharyngitis (17%) and exacerbation/worsening of RA (13%). No anti-namilumab antibodies were detected. The pharmacokinetics of namilumab were linear and typical of a monoclonal antibody with subcutaneous administration. In a post hoc efficacy, per protocol analysis (n = 21), patients randomized to namilumab showed greater improvement in Disease Activity Score 28 (erythrocyte sedimentation rate and C-reactive protein [CRP]), swelling joint counts and tender joint counts compared with placebo. Difference in mean DAS28-CRP changes from baseline between namilumab and placebo favored namilumab at both doses and at all time points. In addition area under the curve for DAS28-CRP was analyzed as time-adjusted mean change from baseline. A significant improvement in DAS28-CRP was shown with namilumab (150 and 300 mg groups combined) compared with placebo at day 43 (p = 0.0117) and also 8 weeks after last dosing at day 99 (p = 0.0154).

Conclusions

Subcutaneous namilumab was generally well tolerated. Although namilumab demonstrated preliminary evidence of efficacy, patient numbers were small; phase 2 studies are ongoing.

Trial registration

ClinicalTrials.gov, NCT01317797. Registered 18 February 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1267-3) contains supplementary material, which is available to authorized users.

Neuropsychiatric symptoms in systemic lupus erythematosus: impact on quality of life

Objective

Assess quality of life in patients with systemic lupus erythematosus (SLE) presenting with neuropsychiatric symptoms (neuropsychiatric SLE, NPSLE).

Methods

Quality of life was assessed using the Short-Form 36 item Health Survey (SF-36) in patients visiting the Leiden NPSLE clinic at baseline and at follow-up. SF-36 subscales and summary scores were calculated and compared with quality of life of the general Dutch population and patients with other chronic diseases.

Results

At baseline, quality of life was assessed in 248 SLE patients, of whom 98 had NPSLE (39.7%). Follow-up data were available for 104 patients (42%), of whom 64 had NPSLE (61.5%). SLE patients presenting neuropsychiatric symptoms showed a significantly reduced quality of life in all subscales of the SF-36. Quality of life at follow-up showed a significant improvement in physical functioning role (p = 0.001), social functioning (p = 0.007), vitality (p = 0.023), mental health (p = 0.014) and mental component score (p = 0.042) in patients with neuropsychiatric symptoms not attributed to SLE, but no significant improvement was seen in patients with NPSLE.

Conclusion

Quality of life is significantly reduced in patients with SLE presenting neuropsychiatric symptoms compared with the general population and patients with other chronic diseases. Quality of life remains considerably impaired at follow-up. Our results illustrate the need for biopsychosocial care in patients with SLE and neuropsychiatric symptoms.

Presence of anticitrullinated protein antibodies in a large population-based cohort from the Netherlands

OBJECTIVES

To determine the prevalence of anticitrullinated protein antibodies (ACPAs) and their association with known rheumatoid arthritis (RA) risk factors in the general population.

METHODS

Lifelines is a multidisciplinary prospective population-based cohort study in the Netherlands. Cross-sectional data from 40 136 participants were used. The detection of ACPA was performed by measuring anti-CCP2 on the Phadia-250 analyser with levels ≥6.2 U/mL considered positive. An extensive questionnaire was taken on demographic and clinical information, including smoking, periodontal health and early symptoms of musculoskeletal disorders. RA was defined by a combination of self-reported RA, medication use for the indication of rheumatism and visiting a medical specialist within the last year.

RESULTS

Of the total 40 136 unselected individuals, 401 (1.0%) had ACPA level ≥6.2 U/mL. ACPA positivity was significantly associated with older age, female gender, smoking, joint complaints, RA and first degree relatives with rheumatism. Of the ACPA-positive participants, 22.4% had RA (15.2% had defined RA according to our criteria and 7.2% self-reported RA only). In participants without RA, 311 (0.8%) were ACPA-positive. In the non-RA group, older age, smoking and joint complaints remained significantly more frequently present in ACPA-positive compared with ACPA-negative participants.

CONCLUSIONS

In this large population-based study, the prevalence of ACPA levels ≥6.2 U/mL was 1.0% for the total group and 0.8% when excluding patients with RA. Older age, smoking and joint complaints were more frequently present in ACPA-positive Lifelines participants. To our knowledge, this study is the largest study to date on ACPA positivity in the general, mostly Caucasian population.

Age affects joint space narrowing in patients with early active rheumatoid arthritis

BACKGROUND

Joint space narrowing (JSN) in rheumatoid arthritis (RA) may be a manifestation of (primary) osteoarthritis becoming more prominent with age. We investigated the severity and predictors of JSN progression among different age groups.

METHODS

10-year follow-up data of the BeSt study, a randomised controlled treat-to-target trial in early RA were used. Annual X-rays of hands and feet were scored using the Sharp/van der Heijde score (SHS). Subgroups were defined by age at baseline: ≥55, ≥40<55 and <40 years. JSN progression predictors were assessed by Poisson regression.

RESULTS

Baseline JSN scores (median (IQR)) were higher in patients ≥55 (2.0 (0.0-6.0)) compared with the other age groups: 1.0 (0.0-3.0) ≥40<55 and 0.3 (0.0-3.0) <40, p<0.001. After 10 years, total JSN and SHS were similar in all age groups. In patients ≥55 the mean erythrocyte sedimentation rate (ESR) over time (relative risk 1.02 (95% CI 1.00 to 1.03)) and the combined presence of rheumatoid factor and anticitrullinated protein antibodies (RF+/ACPA+) (3.27 (1.25-8.53)) were significantly correlated with JSN progression. In patients <40 the baseline swollen joint count (SJC; 1.09 (1.01-1.18)) and ESR over time (1.04 (1.02-1.06)) were significantly associated.

CONCLUSIONS

At baseline, patients with RA ≥55 years had more JSN than younger patients but after 10 years JSN scores were similar between age groups. Independent risk factors for JSN progression were baseline SJC and ESR over time in patients <40, RF+/ACPA+ and ESR over time in patients ≥55 years. This suggests that mechanisms leading to JSN progression are related to (residual) rheumatoid inflammation and vary between age groups. These mechanisms remain to be elucidated.

TRIAL REGISTRATION NUMBERS

NTR262, NTR265.

Rheumatoid arthritis phenotype at presentation differs depending on the number of autoantibodies present

Objectives

In rheumatoid arthritis (RA), seropositive and seronegative disease may be two entities with different underlying pathophysiological mechanisms, long-term outcomes and disease presentations. However, the effect of the conjoint presence of multiple autoantibodies, as proxy for a more pronounced humoral autoimmune response, on clinical phenotype remains unclear. Therefore, this study investigates the association between the number of autoantibodies and initial clinical presentation in two independent cohorts of patients with early RA.

Methods

Autoantibody status (rheumatoid factor, anticitrullinated protein antibodies and anticarbamylated protein antibodies) was determined at baseline in the Leiden Early Arthritis Cohort (n=828) and the Swedish BARFOT (Better Anti-Rheumatic Farmaco-Therapy, n=802) study. The association between the number of autoantibodies and baseline clinical characteristics was investigated using univariable and multivariable ordinal regression.

Results

In both cohorts, the following independent associations were found in multivariable analysis: patients with a higher number of RA-associated antibodies were younger, more often smokers, had a longer symptom duration and a higher erythrocyte sedimentation rate at presentation compared with patients with few autoantibodies.

Conclusions

The number of autoantibodies, reflecting the breadth of the humoral autoimmune response, is associated with the clinical presentation of RA. Predisease pathophysiology is thus reflected by the initial clinical phenotype.

Complement levels and anti-C1q autoantibodies in patients with neuropsychiatric systemic lupus erythematosus

Objective

The objective of this paper is to analyse serum levels of anti-C1q, C1q circulating immune complexes (CIC), complement activation and complement components in systemic lupus erythematosus (SLE) patients during the first central nervous system neuropsychiatric (NP) event and to define the possible association between these results and clinical and laboratory characteristics.

Methods

A total of 280 patients suspected of having NP involvement due to SLE were recruited in the Leiden NPSLE-clinic. All SLE patients were classified according to the ACR 1982 revised criteria for the classification of SLE. The clinical disease activity was measured by the SLE Disease Activity Index 2000 (SLEDAI-2K) and NP diagnoses were classified according to the 1999 ACR case definitions for NPSLE. We measured in serum of all patients anti-C1q and C1q CIC levels, the activation capacity of complement (CH50 and AP50) and different complement components (C1q, C3, C4).

Results

In 92 patients the symptoms were attributed to SLE. NPSLE patients consisted of 63 patients with focal NPSLE and 34 patients with diffuse NPSLE. Anti-C1q antibodies were significantly higher and CH50, AP50 and C3 were significantly lower in NPSLE patients compared with SLE patients without NPSLE. This association was specially marked for diffuse NPSLE while no differences were found for focal NPSLE. After using potential predictors, decreased C4 remained significantly associated with focal NPSLE, but only when antiphospholipid antibodies (aPL) were included in the model. C3 and AP50 were independently associated with diffuse NPSLE. When SLEDAI-2K was included in the model these two associations were lost. When individual NPSLE syndromes were analysed, psychosis and cognitive dysfunction showed significantly lower values of complement activation capacity and all complement components. No significant associations were seen for other individual NPSLE syndromes.

Conclusion

The associations between diffuse NPSLE and anti-C1q, C3/AP50 and focal NPSLE and C4 may be explained by disease activity and the presence of aPL, respectively. The role of complement activation and complement components in lupus psychosis and cognitive dysfunction merits further research.

The association between anti-carbamylated protein (anti-CarP) antibodies and radiographic progression in early rheumatoid arthritis: a study exploring replication and the added value to ACPA and rheumatoid factor

Objective

Anti-carbamylated protein (anti-CarP) antibodies are reported to associate with more radiographic progression within the total rheumatoid arthritis (RA) population and anti-citrullinated peptide antibody (ACPA)-negative subgroup. We explored the association of anti-CarP with radiographic progression in RA and aimed to replicate the association and evaluate the added value of anti-CarP antibodies in relation to ACPA and rheumatoid factor (RF).

Methods

576 Swedish and 628 Dutch patients with RA (2394 and 3247 sets of radiographs, respectively) were longitudinally studied. Replication was restricted to the Swedish patients. In both cohorts, the association of anti-CarP with radiographic progression was determined in strata of patients with similar ACPA and RF status; results of both cohorts were combined in fixed-effect meta-analyses. The net percentage of patients for whom the radiographic progression in 5 years was additionally correctly classified when adding anti-CarP to a model including ACPA and RF was evaluated.

Results

Anti-CarP associated with radiographic progression in the total Swedish RA population (beta=1.11 per year, p=8.75×10−13) and in the ACPA-negative subgroup (beta=1.14 per year, p=0.034). Anti-CarP associated with more radiographic progression in the strata of ACPA-positive/RF-negative, ACPA-negative/RF-positive and ACPA-positive/RF-positive patients with RA (respective p values 0.014, 0.019 and 0.0056). A model including ACPA and RF correctly classified 54% and 57% of the patients; adding anti-CarP to this model did not increase these percentages (54% and 56% were correctly classified).

Conclusions

Anti-CarP antibodies associated with more severe radiographic progression in the total and ACPA-negative RA population. Anti-CarP-positivity had a statistically significant additive value to ACPA and RF, but did not improve correct classification of patients.

Efficacy of etanercept in combination with methotrexate in moderate-to-severe rheumatoid arthritis is not dependent on methotrexate dosage

Objective

To evaluate the impact of methotrexate (MTX) dosage on clinical, functional and quality of life outcomes in patients with rheumatoid arthritis (RA) from two previous etanercept (ETN) trials after 24 months of treatment.

Methods

Patients with active RA in the ETN+MTX combination treatment arms of the Trial of Etanercept and Methotrexate with Radiographic Patient Outcomes (TEMPO) and COmbination of Methotrexate and ETanercept in Active Early Rheumatoid Arthritis (COMET) studies were pooled in this post hoc analysis and stratified by MTX dosage at 24 months, having MTX monotherapy groups as control: low dose, <10.0 mg/week; medium dose, 10.0–17.5 mg/week; and high dose, >17.5 mg/week. Data from these patient subgroups were included in descriptive summaries of demographic and disease characteristics at baseline. The following outcomes at 24 months were also evaluated for each subgroup: Disease Activity Score in 28 joints (DAS28) low disease activity (LDA) and remission; American College of Rheumatology 20%, 50% and 70% improvement criteria (ACR20, 50 and 70) responses; and changes from baseline in DAS28, Health Assessment Questionnaire Disease Index (HAQ-DI) and EuroQol 5-dimensions visual analogue scale (EQ-5D VAS).

Results

Baseline demographics were similar between the low, medium and high MTX dose groups in the ETN+MTX combination and MTX monotherapy arms, with the exception of disease duration (ETN+MTX low 5.5; medium 5.1; high 0.8 years vs MTX low 8.3; medium 4.7; high 0.8 years). Responses to ETN+MTX combination therapy at 24 months were consistently high across MTX dosage groups, with very similar rates of DAS28 LDA/remission and ACR20/50/70. Improvements in DAS28, HAQ-DI and EQ-5D VAS were also not dependent on MTX dosage in the combination treatment arm.

Conclusions

Patients with RA in the TEMPO and COMET trials who received ETN+MTX showed similar efficacy outcomes at 24 months, regardless of MTX dosage.

Trial registration numbers

NCT00195494 (COMET) and NCT00393471 (TEMPO).