Lumbosacral pain in a patient with psoriatic arthritis: when the rheumatic disease is innocent

Lumbar pain is a very common symptom that derives from benign musculoskeletal conditions, rheumatic inflammatory diseases, neoplasms, and referred and/or nociplastic pain. A 70-year-old man with psoriatic arthritis presented with early-onset lumbosacral pain without evident red flags. Symptomatic treatment was unhelpful. Radiographic imaging showed subtle signs of a disease that could easily be missed. Magnetic resonance imaging revealed a massive prostatic malignancy with bone (sacral and iliopubic) metastasis. Awareness must be given not to disregard every lumbar pain as part of the preexisting rheumatic inflammatory disease (spondyloarthropathy in this case) or a common muscle/ligament/articular disarrangement. Persistence of pain, albeit not inflam-matory nor sharp in nature, despite adequate treatment might be just as important as an acute red flag and requires proper follow-up.

"A case of vanishing bone disease complicated by chylothorax- diagnosis and treatment"

A 16-year old girl with Gorham-Stout disease is presented. She had progressive replacement of the bones of her left arm and shoulder girdle by fibroadipose tissue and numerous proliferated, non-neoplastic, lymphatic channels. The clinico-pathologic features of this condition are discussed, as are its possible complications and available therapeutic modalities.

POS1290 EFFICACY AND SAFETY OF SODIUM THIOSULFATE IN CALCIFIC TENDINITIS OF THE ROTATOR CUFF – AN INTERIM ANALYSIS OF A RANDOMIZED CLINICAL TRIAL

Background

Calcific tendinitis of the rotator cuff is one of the most common causes of shoulder pain. (1) Ultrasound guided percutaneous lavage (UGPL) is indicated when conservative treatments have failed. (2) Recent reports have shown the interest of topical sodium thiosulfate (STS) in the treatment of other diseases characterizes by ectopic calcifications (3, 4, 5).

Objectives

To assess the efficacy and safety of UGPL with STS versus with saline solution (standard of care - SOC) in calcific tendinitis.

Methods

Double-blinded randomized clinical trial including adult patients with calcific tendinitis, shoulder pain for more than 3 months and at least one positive shoulder impingement test. Only dense type A calcifications (according to the Molé Classification) > 5 mm in diameter were included. Patients were randomized in two groups: STS and saline solution lavage. Informed consents were collected. Both groups were reevaluated at week 1, month 1 and month 3 after UGPL. Pain Visual Analogue Scale (VAS) at rest and during activities, shoulder range of motion and strength, impingement tests, Disabilities of the Arm, Shoulder and Hand (DASH), DASH-Work, EuroQol five-dimensional (EQ5D) and University of California at Los Angeles (UCLA) scores, ultrasound (US) and radiographic evaluations were performed on all follow up visits.

SPSS was used for statistical analysis and significance level was defined as 2-sided p<0.05.

Results

Twenty-six patients were included, where 76.9% (20) were women, with a mean age of 51.2 (SD=9.0) years old. The mean duration of pain before the procedure was 12.7 months (SD=11.3) (minimum of 3 months and a maximum of 48 months).

Fifteen patients (57.7%) were randomized to the control group (SOC) and performed a saline UGPL; the other 11 patients (42.3%) were randomized to the treatment group (STS). Demographic and baseline clinical characteristics are shown in Table 1. Since patient inclusion is dynamic, our sample met 23 patients at week 1 (SOC group = 13 and STS group = 10), 19 patients at month 1 (SOC group = 10 and STS group = 9) and 16 patients at month 3 (SOC group = 8 and STS group = 8).

Table 1.

Demographic and baseline clinical characteristics.

STS lavage(n=11)Saline solution lavage (n=15)p-valueAge (years), M (SD)52.3 (10.6)50.3 (8.0)NSSex, female % (n/N)72.7% (8/11)80% (12/15)NSDominant side, right % (n/N)100% (11/11)93.3% (14/15)NSNocturnal pain, yes % (n/N)100% (11/11)100% (15/15)NSVAS at rest (0–10), M (SD)5.7 (2.0)5.9 (2.1)NSVAS during activities (0–10), M (SD)7.1 (1.8)6.0 (2.5)NSDASH Score, M (SD)60.2 (14.0)52.6 (13.8)NSDASH-Work Score, M (SD73.4 (11.0)63.4 (22.6)NSEQ5D, M (SD)0.2897 (0.3)0.4070 (0.2)NSVAS EQ5D (0–100), M (SD)54 (15.9)58 (20.0)NSUCLA score, M (SD)18.7 (4.1)14.7 (3.3)0.014Bursitis, yes % (n/N)72.7% (8/11)66.7% (10/15)NSCalcification morphology, % (n/N)Acr-shaped18.2% (2/11)40% (6/15)0.039Fragmented18.2% (2/11)26.7% (4/15)Nodular and dense, well-defined63.6% (7/11)33.3% (5/15)Calcification size, median (IQR)12.6 (5.7)10.5 (6.3)NS

SD: Standard deviation; M: Mean; NS: non-significant; IQR: interquartile range

Overall, there were no differences between control (SOC) and treatment group (STS). Both procedures were effective improving pain at rest (p=0.024), EQ5D (p=0.019), DASH-Work (p=0.032) and UCLA scores (p=0.009) and calcification size measured by US (p=0.031) at month 3.

No adverse effects or complications were reported on both groups.

Conclusion

Although well tolerated with no side effects, STS UGPL has failed to show increased benefit for calcific tendinopathy local treatment. Further studies using STS will be needed to ascertain its interest in this disease. This on-going work will be reevaluated with a larger sample.

References

[1]Louwerens JK et al. J Shoulder Elbow Surg. 2015; 24:1588–93.

[2]De Witte PB et al. Am J Sports Med. 2013; 41:1665-73.

[3]Ossorio-García L et al. Actas Dermosifiliogr. 2016; 107:359-62. 21.

[4]Jost J et al. J Clin Endocrinol Metab. 2016; 101:2810-5. 22.

[5]Guigonis V et al. Ann Endocrinol (Paris). 2015; 76:183-4.

Disclosure of Interests

None declared

Portuguese validation of the Adult Carer Quality of Life Questionnaire (AC-QoL)

Background

Assuring informal carers' quality of life (QoL) must be a priority for public health policies and practices. The Adult Carer Quality of Life Questionnaire (AC-QoL) is a recent and valid instrument, overpassing limitations of previous tools, and being already used among informal stroke carers. This study aimed to assess the feasibility, reliability and validity of the AC-QoL among Portuguese informal carers of stroke survivors.

Methods

The linguistic adaptation of the AC-QoL was performed. Informal carers (n = 212) of stroke survivors hospitalized between September 2018 and August 2019 in all Stroke Units of the North of Portugal (n = 12) were invited to participate, 18 to 24 months post-stroke. Data on sociodemographic characteristics, psychological profile, burden and QoL were collected using a structured questionnaire. The psychometric properties of the AC-QoL were investigated through exploratory and confirmatory factor analyses. Cronbach's alpha was used to measure internal consistency. Construct validity was assessed through the association of the overall score of AC-QoL with anxiety and depressive symptoms, burden and sociodemographic characteristics.

Results

Exploratory factor analysis supported the original eight-factor structure of the AC-QoL, revealing an adequate goodness of fit to the study sample (X2(674)=1145.926; CFI=0.916; TLI=0.908; RMSEA=0.058). The AC-QoL showed a high degree of reliability, with Cronbach's scores for the subscales ranging from 0.64 to 0.97 and a Cronbach's alpha of 0.91 for the overall score. Anxiety symptoms (p &lt; 0.001), depression symptoms (p &lt; 0.001) and burden (p &lt; 0.001) were inversely associated with the overall score of AC-QoL. Younger (p = 0.032) and employed (p = 0.021) informal carers presented more frequently higher scores of overall QoL, than those older and unemployed.

Conclusions

The Portuguese version of the AC-QoL is a comprehensive, simple, reliable and valid instrument to assess informal stroke carers' QoL.

Key messages

The Portuguese version of the AC-QoL is a comprehensive and valid instrument with a high degree of reliability, that can be briefly and easily applied to informal carers of stroke survivors. A comprehensive and brief assessment of informal carers’ QoL will contribute to devise strategies to promote well-being and social integration of stroke survivors and their informal carers.

POS0162 PREDICTIVE FACTORS OF A NEW FRAGILITY FRACTURE AFTER WRIST FRAGILITY FRACTURE

Background:

Fragility fractures (FF) are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or ‘low energy’) trauma.1 Studies have shown that history of wrist fracture increases the risk for subsequent FF.2

Objectives:

To assess predictive factors of FF occurring after a wrist fracture.

Methods:

Retrospective monocentric study that included patients with a wrist FF observed at the emergency department (ED) in a tertiary center, between 1st January 2017 and 31st December 2018. Wrist fractures were identified through the 10th International Classification of Diseases and FF were identified after revision of the clinical record. Patients with relevant missing data were excluded. Seven hundred thirty-three wrist FF were identified. After calculating a representative sample (90% confidence interval), 188 patients were included. Their clinical records until 31th December 2020 (2 to 3 years after FF) were reviewed. SPSS was used for statistical analysis and significance level was defined as 2-sided p<0.05. In multivariate analysis we included variables with a significant association in univariate analysis and those with clinical relevance (reported in others studies).

Results:

Wrist fractures represented 44.3% of the FF observed at the ED.

Most patients were woman (83.5%) with a mean age of 70.7 (SD=11.2) years-old at the time of their wrist fracture. A previous FF was seen in 22.9% of patients and 13.3% had a new FF during the follow-up period.

We found an association between the occurrence of a new FF and the number of comorbidities (p=0.012), number of visits to the ED due to falls (p<0.001), previous diagnosis of chronic pulmonary disease (p=0.029) and hematologic pathologies (p=0.047), and the need for hospitalization at time of the wrist FF (p=0.018).

No associations were found between the age at the wrist fracture time, number of drugs taken daily nor its type (anxiolytics, antiepileptics, corticoids), previous fractures (and localization), overweight/obesity and other cardiovascular risk factors, endocrinopathies, psychiatric or neurologic disease or other comorbidities.

After adjustment for age, gender, anti-osteoporotic treatment and comorbidities, the main predictors of a new FF were visits to the ED for falls (p=0.005), chronic pulmonary disease (p=0.040), hematologic pathologies (p=0.004) and need for hospitalization (p=0.040) (table 1).

Table 1.

Multivariate analyses: linear multiple regression for predictive factors of new fragility fracture.

DeterminantsUnstandardized CoefficientsBStandardized Coefficients Beta95.0% CIp-valueAge-0.0250.9750.924 – 1.030NSGender2.0657.8890.757 – 82.165NSNumber of comorbidities0.1861.2040.846 – 1.713NSVisits to the emergency service for falls-2.1360.1180.026 – 0.5290.005Chronic pulmonary disease-1.3260.2660.075 – 0.9400.040Hematologic pathologies-4.2960.0140.001 – 0.2550.004Need for hospitalization-2.7640.0630.004 – 0.8870.040Anti-osteoporotic treatment0.1571.1700.227 – 6.017NS

CI: Confidence Interval; NS: non-significant;

Conclusion:

Certain comorbidities seem to be associated with new FF. Patients with visits to the emergency service after falls and those who needed hospitalization due to the wrist fracture were more prone to have a new FF. There might be a substantial missed opportunity for intervention in these patients.

References:

[1]Osteoporosis: assessing the risk of fragility fracture. London: National Institute for Health and Care Excellence (UK); 2017 Feb. PMID: 32186835.

[2]Crandall CJ, Hovey KM, Cauley JA, Andrews CA, Curtis JR, Wactawski-Wende J, Wright NC, Li W, LeBoff MS. Wrist Fracture and Risk of Subsequent Fracture: Findings from the Women’s Health Initiative Study. Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research. 2015;30(11):2086–2095. doi: 10.1002/jbmr.2559.

Disclosure of Interests:

None declared

AB0799 DO WE OVERDIAGNOSE SERONEGATIVE RHEUMATOID ARTHRITIS? – THE ROLE OF MUSCULOSKELETAL ULTRASOUND IN CLARIFYING SERONEGATIVE INFLAMMATORY ARTHRITIS

Background:

Several data indicate that seronegative rheumatoid arthritis (RA-) and seropositive RA (RA+) may have different mechanisms and prognosis, being well established that rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA) have diagnostic and prognostic value. Several conditions, like peripheral spondyloarthritis (SpA), psoriatic arthritis or crystal-related arthropathies may mimic the presentation of RA. Mechanisms and treatment of each of these conditions differ significantly. The authors speculate that RA- may be overdiagnosed in the setting of seronegative chronic inflammatory arthritis and that musculoskeletal ultrasound (US) may help us to better classify these patients through the identification of characteristic lesions of the mentioned diseases.

Objectives:

To compare the frequency of US lesions found in joints and entheses between RA- and RA+ patients.

Methods:

Cross-sectional study: systematic US evaluation of ten joints, twelve entheses and both flexor and extensor tendons of four fingers (Table 1) in consecutive RA- patients. RA+ patients matched for sex and age were recruited. RA- patients included met every of the following criteria: history of chronic polyarthritis, RF and ACPA negativity, no extra-articular features of SpA or RA nor family history of SpA, no suspected crystal-related arthritis.

Results:

Twenty-one RA- patients were included and twenty RA+ patients were recruited as controls. No differences between groups were found in sex, age, body mass index, time of disease evolution or use of biological therapy.

RA- patients had a significantly higher number of entheseal structural and/or inflammatory lesions than RA+ patients (median 2.0 vs. 0.5, U 111.5, p=.008**), with triceps enthesitis being significantly more frequent in RA- patients (p=.036*). In total, 18.7% of RA- entheses had enthesitis lesions vs. only 8.3% of RA+ entheses. One RA- patient had ultrasonographic features of dactylitis which was not clinically evident.

As expected, considering the role of RF and ACPA in erosive RA, RA- patients had a significantly lower number of joints with erosions compared to RA+ patients (median 0.0 vs. 3.0, U 64.5, p<.001***), with significant differences in every considered joint. Erosions were found in 6.7% of RA- joints vs. 32.0% RA+ joints.

Additionally, two RA- patients had hyperechogenic foci in knee cartilage or carpal fibrocartilage suggestive of calcium pyrophosphate deposition.

Table 1.

Comparative frequency of ultrasound lesions found in joints and entheses of RA- and RA+ patients.

RA-(n=21)RA+(n=20)p-valueMdn number of ENTHESES with any lesion per patient ± IQR2.0 ± 3.00.5 ± 2.0.008**Triceps – n (%)8 (38.1%)2 (10.0%).036*Quadriceps – n (%)9 (42.9%)6 (30.0%).393Superior patellar – n (%)4 (19.0%)1 (5.0%).169Inferior patellar – n (%)---Achilles – n (%)9 (42.8%)4 (20.0%).116Plantar fascia – n (%)5 (23.8%)1 (5.0%).089DACTYLITIS – 2nd + 5th finger – n (%)1 (4.8%)--Mdn number of joints with EROSIONS per patient ± IQR0.0 ± 1.03.0 ± 3.0<.001***Ulnar styloid process – n (%)5 (23.8%)11 (55.0%).041*Metacarpophalangeal 2 – n (%)3 (14.3%)11 (55.0%).006**Metacarpophalangeal 5 – n (%)1 (4.8%)10 (50.0%).001**Metatarsophalangeal 1 – n (%)-3 (15.0%)-Metatarsophalangeal 5 – n (%)3 (14.3%)11 (55.0%).006**CHONDROCALCINOSIS – triangular fibrocartilage + knee – n (%)2 (9.5%)--DOUBLE CONTOUR – any joint – n (%)---

RA- – seronegative rheumatoid arthritis; RA+ – seropositive rheumatoid arthritis Mdn – median; IQR – interquartile range; n (%) – absolute number (percentage) of patients with the indicated lesion.

Conclusion:

We found that some patients diagnosed with RA- had, in fact, ultrasonographic features of different diseases, namely enthesitis/dactylitis and crystal deposition. These data suggest that RA- may be overdiagnosed in clinical practice. Systematic US evaluation of joints and entheses may provide valuable diagnostic information in patients with chronic inflammatory seronegative arthritis and improve patient care.

Disclosure of Interests:

None declared

FRI0388 ARE WE OVERLOOKING OSTEOARTHRITIS? – A COMPARATIVE STUDY OF PAIN, FUNCTION AND QUALIFY OF LIFE IN PATIENTS WITH HAND OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS

Background:

Osteoarthritis (OA) is frequently regarded by patients and health care providers as a normal consequence of ageing (1). On the other hand, it is well established that rheumatoid arthritis (RA) is a pathological condition requiring prompt and efficacious treatment and in which remarkable progresses have been achieved in the last decades. Pain and physical limitations are hallmarks of both conditions. Some previous studies suggest that OA and RA may have a similar burden (2,3).

Objectives:

To compare levels of pain, physical disability and health-related quality of life in patients with primary hand osteoarthritis (hOA) and with RA: active disease (aRA) or in remission (rRA).

Methods:

Observational cross-sectional study including patients of two clinical centres with hOA and RA, either in remission or with active disease (at least two swollen and/or tender hand joints). Matching for sex and age was performed. Patients were asked to complete a survey consisting of visual analogic scale (VAS) for pain, Health Assessment Questionnaire (HAQ) and Short Form 36 (SF36). Mean values for each domain were compared between the three groups using one-way ANOVA test with significance accepted for p<.05.

Results:

Thirty patients with hOA and 93 with RA (33 with aRA and 60 with rRA) were included. All patients were caucasian females with no significant differences in age between groups. Patients with hOA reported higher levels of pain in comparison with aRA patients (mean VAS 57.3vs49.3mm, respectively, p=.265) and with rRA patients (57.3vs28.6mm, respectively, p<.001) [F(2.120)=25.907, p<.001]. Regarding physical function, patients with hOA reported levels of disability similar to rRA patients, but significantly lower disability than patients with aRA [F(2.120)=6.962, p=.001]. Patients with hOA evaluated their quality of life significantly better than patients with aRA and in similar levels to patients with rRA, as measured by mental health and general health status domains of SF36.

Conclusion:

Our results show that hOA may have similar or even higher burden of pain than RA; this is in line with previous studies, although most of them did not consider the level of inflammatory activity of RA. On the other hand, patients with hOA seem to preserve function and have better health-related quality of life despite the higher levels of pain. These results highlight OA as a cause of severe pain, which should lead us to try an optimal symptom control for these patients. These findings should also encourage rheumatologists to endeavor efforts to perform more studies in the field of OA, to better understand its pathogenesis and to eventually find disease modifying drugs.

References:

[1]Gignac MAM, Davis AM, Hawker G, Wright JG, Mahomed N, Fortin PR, et al. “What do you expect? You’re just getting older”: A comparison of perceived osteoarthritis-related and aging-related health experiences in middle- and older-age adults. Arthritis Rheum. 2006 Dec 15;55(6):905–12.

[2]El-Haddad C, Castrejon I, Gibson KA, Yazici Y, Bergman MJ, Pincus T. MDHAQ/RAPID3 scores in patients with osteoarthritis are similar to or higher than in patients with rheumatoid arthritis: a cross-sectional study from current routine rheumatology care at four sites. RMD Open. 2017 Jul;3(1):e000391.

[3]Slatkowsky-Christensen B, Mowinckel P, Kvien T. Health status and perception of pain: a comparative study between female patients with hand osteoarthritis and rheumatoid arthritis. Scand J Rheumatol. 2009 Jan;38(5):342–8.

Disclosure of Interests:

None declared

AB0192 RHEUMATOID ARTHRITIS: IS IT WORTH IT TO ADD LEFLUNOMIDE TO METHOTREXATE IN REFRACTORY DISEASE?

Background:

In refractory rheumatoid arthritis (RA), adding other classic synthetic disease-modifying antirheumatic drug (csDMARD) such as leflunomide (LFN) to methotrexate (MTX) is one suitable option [1,2]. Yet, there are safety issues to consider which may limit this strategy, but also regarding its true effectiveness in avoiding exposure to biological DMARDs (bDMARD) or target synthetic DMARDs (tsDMARD).

Objectives:

To assess the effectiveness and safety of adding LFN to MTX and to evaluate the predictors of drug retention, toxicity and inefficacy.

Methods:

A retrospective clinical record review of adult RA patients followed on our rheumatology department in whom LFN was added to MTX was done. Sociodemographic information, comorbidities, disease related information, adverse reactions and disease activity according to Disease Activity Score 28 – C reactive protein (DAS28) were recorded at baseline and after 3, 6 and 12 months of combination therapy (3_DAS28; 6_DAS28; 12_DAS28, respectively). Information regarding toxicity (need to dose adjustment/suspension) and inefficacy (add/switch to bDMARD/tsDMARD) were recorded. Follow-up was considered until last medical record available. SPSS was used for statistical analysis. Kaplan Meier and Cox-regression were used for univariate and multivariate analysis, respectively, significant level was 2-sidedp<.05.

Results:

In total, 77 patients were included, 66.20% females, with a mean age of 56±11 years old. There was a significant reduction of DAS28 only after 3 months of therapy (4.01±1.01 to 2.57±1.52,p=.003; ΔDAS28 = 1.58±1.17). However, during a median follow up time of 64 (IQR 39-83) months, 58.44% of patients needed to change treatment strategy, 66.67% due to toxicity (median time to toxicity 13 months, IQR 2-16) and 33.33% due to inefficacy (median time to inefficacy of 10 months, IQR 5.84-17.64). Gastrointestinal intolerance was the main reported toxicity (46.15%). In univariate analysis, anti-citrullinated protein antibodies (ACPA) positivity, alcohol consumption, lack of comorbidities, hepatic toxicity, higher 6_DAS28, swollen joint count and tender joint count on the 6thmonth were associated to lower retention rates.

In multivariate analysis, lack of comorbidities (HR=3.3, CI 95% 1.4-7.8,p=.006) and higher 6_DAS28 (HR=0.32, CI 95% 0.14-0.72,p=.006) were independent predictors of suspension of combination therapy. Moreover, both male gender (HR=2.87, 95%CI 1.2-6.56,p=.016) and positivity to ACPA (HR=0.1, 95%CI 0.01-0.73,p=.024) were independent predictors of toxicity. There was also higher tendency to toxicity, but without statistical significance, in alcohol consumers (p=.08). Regarding inefficacy, smoking habits (HR=0.15, 95%CI 0.04-0.52) and 3_DAS28 (HR=0.15, 95%CI 0.04-0.53) were independent predictors.

Conclusion:

Addition of LFN to MTX showed an early positive response. However, it was frequently associated to toxicity, and less than half of the patients continued with this therapeutic strategy after 5 years of follow up. Male gender, smoking habits and positivity to ACPA were predictors of worse outcome, as already reported in literature [1]. Lack of comorbidities was an independent predictor of suspension. This can be explained by the fact that physicians tend to adopt a more aggressive strategy on patients without comorbidities, switching earlier to bDMARDs/tsDMARDs.

This study also showed that early response to combination therapy is an independent predictor on drug retention, suggesting that decisions on treatment strategy should be made early after the beginning of MTX/LFN.

References:

[1]Smolen JS, et al. Ann Rheum Dis 2020;0:1–15. doi:10.1136/annrheumdis-2019-216655

[2]Kremer J, et al. J Rheumatol. 2004 Aug;31(8):1521-31. PMID: 15290730

Disclosure of Interests:

None declared

AB0236 DIFFERENCES AND DETERMINANTS OF PHYSICIAN’S AND PATIENT’S PERCEPTION IN GLOBAL ASSESSMENT OF RHEUMATOID ARTHRITIS

Background:

Patient’s Global Assessment of Disease Activity (PtGA) and Physician’s Global Assessment of Disease Activity (PhGA) are assessed as part of commonly used measures of disease activity in RA.1Both are important measures in treat-to-target strategies in Rheumatoid Arthritis (RA), but often provide discordant results.2,3This can provide an erroneous assessment of disease activity in patients under Biologic treatment and mislead treatment decisions, namely switches.

Objectives:

To assess differences and determinants of PtGA and PhGA in RA patients under biologic treatment.

Methods:

Cross-sectional study, including 46 patients with RA diagnosed according to the ACR/EULAR criteria, under biologic treatment, consecutively evaluated in day-care unit. Participants completed patient-reported outcomes (PROs), including PtGA, and sociodemographic characteristics. Physicians collected comorbidities and parameters of inflammatory activity (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) and completed PhGA and disease activity score 28 with ESR (DAS28). SPSS was used for statistical analysis and significance level was defined as 2-sided p<0.05.

Results:

Clinical and laboratory characteristics of patients are shown in table 1. PtGA and PhGA were significantly different (36.1±27.6 mmvs8.7±14.2 mm, p< 0.001) and a positive discordance (PtGA>PhGA, more than 25mm in visual analogue scale [VAS]) was found in 54.3% of cases.

PtGA had a correlation with PROs (Pain VAS, 36-Item Short Form Health Survey [SF-36], Health Assessment Questionnaire [HAQ], Functional Assessment of Chronic Illness Therapy [FACIT], EuroQol [EQ5D] and Hospital Anxiety and Depression Scale [HADS]), CRP, tender and swollen joint counts and an association with comorbidities like fibromyalgia or osteoarthritis (OA). No association was found between PtGA and age, sex, education level, profession, employment status, extra-articular manifestations, positivity of rheumatoid factor, ESR, years of disease evolution or number of biologic treatments. In multivariable analyse including SF-36, CRP, tender joints count and OA (R2adjusted= 0.672), the main predictors of PtGA were lower SF36, concomitant OA and higher CRP level.

PhGA had a correlation with PtGA, pain VAS, CRP, tender and swollen joints. No association was found between PhGA and patient or physician age, patient or physician sex, extra-articular manifestations, positivity of rheumatoid factor, ESR level, years of disease evolution or number of biologic treatments. In multivariable analysis including ESR, tender and swollen joints count and CRP (R2adjusted= .800), the main predictors of PhGA were swollen joint count and higher CRP level.

Conclusion:

This study showed the variability implied on global assessment of RA activity. Overall PtGA is based on function and also in subjective and emotional experience of pain, whereas the PhGA is based on more objective measures, more related to disease activity.

References:

[1]Kanekoa Y. et al, Determinants of Patient’s Global Assessment of Disease Activity and Physician’s Global Assessment of Disease Activity in patients with rheumatoid arthritis: A post hoc analysis of overall and Japanese results from phase 3 clinical trials.Modern Rheumatology2018; 28(6):960–967

[2]Furu M. et al. Discordance and accordance between patient’s and physician’s assessments in rheumatoid arthritis.Scand J Rheumatol.2014; 43(4):291-5.

Ann Rheum Dis. 2016 Sep;75(9):1661-6. doi: 10.1136/annrheumdis-2015-208251. Epub 2015 Oct 22.

[3]Portier A. et al, Patient-perceived flares in rheumatoid arthritis: A sub-analysis of the STRASS treatment tapering strategy trial.Joint Bone Spine. 2017; 84(5):577-581

Disclosure of Interests:

None declared

AB1350-HPR SOCIOECONOMIC BURDEN OF NON-ATTENDANCE IN RHEUMATOLOGY CONSULTATION

Background:

Outpatient non-attendance refers to the phenomenon of patients who have a medical appointment but do not show up at the specified date, time, and location without giving previous notice.1In addition to affecting the efficiency and thereby increasing the healthcare total costs, nonattendance might also delay access to care for users on waiting lists.1Nonattendance at health appointments is costly to services, and can risk patient health.2There is very little data on the nonattendance prevalence and impact in Portugal. This knowledge might be fundamental to improve effectiveness of outpatient care in Portugal.

Objectives:

1) describe patient’s non-attendance rate; 2) assess and characterize the sociodemographic and clinical characteristics among non-attending patients; 3) estimate the economic burden of non-attendance.

Methods:

Retrospective, cross-sectional and analytical study. We reviewed a one-month Rheumatology consultation period regarding performed medical consultations and non-attended consultations without previous notification from patients. Direct economic costs of non-attended appointments were calculated based on the “Amending Agreement to the ULSAM, EPE Program Agreement”.

Results:

982 consultations within January 2018 were included. Appointments episodes for therapeutic prescription, medical reports or programmed admissions were excluded. Fifty-seven (5.8%) of scheduled outpatient appointments were non-attended. Subsequent consultations represented 85.2% of attended appointments and 80.7% of non-attended appointments. Female gender was the most prevalent in both groups – 620 (67.0%) among attended consultations and 37 (65.0%) among non-attended consultations. Mean age was 57±15 years in the first group and 54±16 years in the second one. Among attended appointments, mean education level was 8±5 years versus 9±6 years among non-attended appointments. There were no differences between both groups in gender, age, education level, diagnosis, disease duration and activity or appointment type (first or subsequent consultation). A cost of 2,438 euros was estimated regarding non-attended appointments for this period, what could represent a burden of more than 29,000 euros yearly, in direct costs, only.

Conclusion:

Non-attendance at scheduled appointments in public hospitals seems to be influenced by other factors besides gender, age and education level. The burden of non-attended appointments is undeniable. In addition to the costs estimated in this study, further indirect costs such as poorer patients outcomes, impaired access to medical care and hospital penalties should be taken into account. Implementation of awareness strategies aiming the optimization and effectiveness of healthcare system are required.

References:

[1]Blæhr EE, Kristensen T, Væggemose U, Søgaard R. The effect of fines on nonattendance in public hospital outpatient clinics: study protocol for a randomized controlled trial.Trials. 2016;17(1):288. doi:10.1186/s13063-016-1420-3

[2]Akter S. A qualitative study of staff perspectives of patient non-attendance in a regional primary healthcare setting.Australas Med J. 2014;7(5):218-226. doi:10.4066/AMJ.2014.2056

Disclosure of Interests:

None declared

Cross-Talk between Inflammation, Coagulation/Fibrinolysis and Vascular access in Hemodialysis Patients

This work aimed to study the association between fibrinolytic/endothelial cell function and inflammatory markers in chronic kidney disease (CKD) patients undergoing hemodialysis (HD) and recombinant human erythropoietin (rhEPO) therapies, and its relationship with the type of vascular access (VA) used for the HD procedure. As fibrinolytic/endothelial cell function markers we evaluated plasminogen activator inhibitor type-1 (PAI-1), tissue plasminogen activator (tPA) and D-dimers, and as inflammatory markers; C-reactive protein (CRP), soluble interleukin (IL)-2 receptor (s-IL2R), IL-6 and serum albumin levels. The study was performed in 50 CKD patients undergoing regular HD, 11 with a central venous dialysis catheter (CVC) and 39 with an arteriovenous fistula (AVF), and in 25 healthy controls. Compared to controls, CKD patients presented with significantly higher levels of CRP, s-IL2R, IL-6 and D-dimers, and significantly lower levels of PAI-1. The tPA/PAI-1 ratio was significantly higher in CKD patients. We also found statistical significant correlations in CKD patients between D-dimers levels and inflammatory markers: CRP, albumin, s-IL2R and IL-6. When comparing the two groups of CKD patients, we found that those with a CVC presented statistically significant lower levels of hemoglobin concentration and albumin, and higher levels of CRP, IL-6, D-dimers and tPA. Our results showed an association between fibrinolytic/endothelial cell function and increased inflammatory markers in CKD patients. The increased levels of D-dimer, tPA and inflammatory markers in CKD patients using a CVC, led us to propose a relationship between the type of VA chosen for HD, and the risk of thrombogenesis.

Titration with automatic continuous positive airway pressure in obstructive sleep apnea

BACKGROUND AND OBJECTIVE

Autotitrating positive airway pressure (APAP) is an accepted titration method to determine the optimal positive airway pressure (PAP), for the treatment of obstructive sleep apnea (OSA). The required duration of APAP monitoring to determine a fixed continuous positive airway pressure level still remains to be established. We aimed to evaluate the variation in PAP level, delivered by APAP devices, at different periods of treatment, to determine the APAP treatment duration required to reach an effective and stable PAP level.

METHODS

A cross-sectional study of 62 patients newly diagnosed with OSA were evaluated after 3 months of APAP therapy. APAP data corresponding to the first day (D1), first week (W1), seventh week (W7) and twelfth week (W12) under APAP therapy was collected. For the analysis of the pressure behaviour, the difference of P95th pressure level between W12 and W7 (P W12-W7), W12 and W1 (P W12-W1) and W12 and D1 (P W12-D1) was calculated.

RESULTS

There was a high correlation in P95th pressure level between D1 and W12 (r=0.771; p>0.0001), W1 and W12 (r=0.817; p>0.0001), and W7 and W12 (r=0.926; p>0.0001). This correlation progressively increased with APAP use. A significance difference was found in concordance between P W12-W7 and P W12-D1 (p=0.046) within the pressure range ±2cmH₂O. However there was no significant difference in concordance between P W12-W7 and P W12-W1.

CONCLUSIONS

One week of APAP therapy seems sufficient to determine an effective and stable PAP level, within the pressure range ±2cmH₂O.

Abdominal wall reconstruction after desmoid type fibromatosis radical resection: Case series from a single institution and review of the literature

BACKGROUND

Abdominal wall desmoid type fibromatosis management has been changing over recent years, from an aggressive approach towards a more conservative one. When radical resection is indicated, the surgical team faces the challenge of abdominal wall reconstruction, for which optimal technique is still debated. The present study reports the experience from a single center with abdominal closures after desmoid type fibromatosis resection.

MATERIAL AND METHODS

Retrospective analysis of patients who underwent abdominal wall closure after sporadic abdominal desmoid type fibromatosis radical resection from 1982 to 2013.

RESULTS

Twenty-seven patients were included, mean tumor diameter was 10 + 5.3 cm, and the main choice of abdominal wall reconstruction was midline closure with anterior rectus sheath relaxing incisions and polypropylene onlay mesh (74% of the cases). Only 7% of the cases required more complex procedures for skin closure. Mean follow-up was 5 years and 89% remained disease-free. No grade 4 or 5 complications were observed.

CONCLUSION

High midline fascial closure rate can be achieved after resection of abdominal wall desmoid tumor using relaxing incisions and mesh, with low complication rate.

Rheumatoid arthritis and associated large granular lymphocytic leukemia--successful treatment with rituximab

Large granular lymphocytic (LGL) leukemia is an uncommon, usually indolent, lymphoproliferative disorder strongly associated with various autoimmune diseases. The authors report a case of a 67-year-old woman with a long-standing rheumatoid arthritis, who developed neutropenia and associated recurrent infections, diagnosed with LGL leukemia. We describe the treatment approach and the response to an anti-TNF and the rituximab.

Cyclosporine A-induced nephrotoxicity is ameliorated by dose reduction and conversion to sirolimus in the rat

Side-effect minimization strategies to avoid serious side-effects of cyclosporine A (CsA), such as nephrotoxicity, have been mainly based on dose reduction and conversion to other putatively less nephrotoxic drugs, such as sirolimus (SRL), an inhibitor of the mammalian target of rapamycin. This study intended to evaluate the impact of protocols based on CsA dose reduction and further conversion to SRL on kidney function and lesions, based on serum, urine and renal tissue markers. The following 3 groups (n=6) were tested during a 9-week protocol: control (vehicle); CsA (5 mg/kg/day) and Red + Conv (CsA 30 mg/kg/day during 3 weeks + 3 weeks with CsA 5 mg/kg/day + SRL 1 mg/kg/day during the last 3 weeks). The following parameters were analysed: blood pressure, heart rate and biochemical data; serum and urine contents and clearances of creatinine, urea and neutrophil gelatinase-associated lipocalin (NGAL), as well as, glomerular filtration rate; kidney lipid peroxidation and clearance; kidney lesions were evaluated and protein expression was performed by immunohistochemistry. After the first 3 weeks of CsA (30 mg/kg/day) treatment animals showed body weight loss, hypertension, tachycardia, as well as, increased serum levels of non-HDL cholesterol, glucose, triglycerides, creatinine and urea, accompanied by decreased GFR and insulin levels. In addition, a significant increase in the expression of connective tissue growth factor, kidney injury molecule-1 (KIM-1), mammalian target of rapamycin, nuclear factor-κβ1 and transforming growth factor-β was found in the kidney, accompanied by extensive renal damage. The following 3 weeks with CsA dose reduction revealed amelioration of vascular and glomerular lesions, but without significant tubular improvement. The last 3 weeks with the conversion to sirolimus revealed high serum and urine NGAL contents but the CsA-evoked renal damage was substantially ameliorated, by reduced of connective tissue growth factor, mammalian target of rapamycin, nuclear factor-κβ1 protein expression. In conclusion, CsA nephrotoxicity is dose dependent and moderate dysfunction could be ameliorated/prevented by SRL conversion, which could be pivotal for the preservation of kidney function and structure.

Validation of a Portuguese version of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea: Analysis in a sleep clinic

INTRODUCTION

Screening methods have become increasingly important owing to the growing number of patients suspected of obstructive sleep apnea (OSA) being referred for sleep consultation. The STOP-Bang questionnaire has been validated as a screening tool for OSA in surgical patients.

OBJECTIVES

To evaluate the performance of a Portuguese version of the STOP-Bang questionnaire for the diagnosis of OSA in a sleep clinic.

METHODS

Prospectively, for 2 months, all patients referred to our clinic for clinical evaluation completed a translated version of the STOP-Bang questionnaire in Portuguese and underwent a sleep study.

RESULTS

We observed 216 patients and 215 (99.5%) were included. Age was 53.63±13.10 years, 63.3% were male patients, neck circumference was 40.4±44.11 cm and BMI was 29.41 [26.85; 33.06] kg/m(2). OSA was present in 78% of the patients, of whom, 33% had moderate and 37% had severe OSA. A STOP-Bang score ≥3 had a sensitivity and positive predictive value (PPV) for OSA of 93.4% and 86.6%, respectively. Each increase in the STOP-Bang score was associated with an increase in the probability of OSA and severe OSA; reaching a 95% OSA probability, for a score of 6, and a 73% severe OSA probability, for a score of 8. A score of 3 and 2 had a negative predictive value for moderate/severe OSA of 85.3% and 91.7%, respectively.

CONCLUSIONS

The STOP-Bang questionnaire showed high sensitivity and PPV for OSA with the probability of severe OSA steadily increasing, the higher the scores. Furthermore, a low score showed high predictive value for the exclusion of moderate/severe OSA. The STOP-Bang questionnaire can be a powerful tool for stratifying patients in the diagnosis of OSA.

WITHDRAWN: Validation of a Portuguese version of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea: Analysis in a sleep clinic

This article has been withdrawn for editorial reasons because the journal will be published only in English. In order to avoid duplicated records, this article can be found at http://dx.doi.org/10.1016/j.rppnen.2014.04.009. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Recurrent Focal myositis: a rare inflammatory myopathy

Focal myositis is an acute and localized muscle inflammation of unknown aetiology. The clinical diagnosis is often difficult to obtain, since it can be confused with infections, vascular thrombosis or muscle tumours such as sarcomas. This leads to a significant delay in the diagnosis, resulting in the administration of inappropriate and potentially harmful treatments.  We report here a case of recurrent focal myositis in a woman where the diagnosis was only obtained after 6 years, despite multiple hospital admissions. This case reinforces the importance of clinical knowledge and experience to tackle challenging medical scenarios.

Portuguese recommendations for the diagnosis and management of gout

OBJECTIVE

To develop Portuguese evidence-based recommendations for the Diagnosis and Management of Gout.

METHODS

As part of the 3e Initiative (Evidence, Expertise and Exchange), a panel of 78 international rheumatologists developed 10 relevant clinical questions which were investigated with systematic literature reviews. MEDLINE, EMBASE, Cochrane CENTRAL and abstracts from 2010-2011 EULAR and ACR meetings were searched. Based on the evidence found in the published literature, rheumatologists from 14 countries developed national recommendations that were merged and voted into multinational recommendations. We present the Portuguese recommendations for the Diagnosis and Management of Gout which were formulated and voted by Delphi method in April 2012, in Lisbon. The level of agreement and potential impact in clinical practice was also assessed.

RESULTS

Twelve national recommendations were elaborated from 10 international and 2 national questions. These recommendations addressed the diagnosis of gout; the treatment of acute flares and urate-lowering therapy; monitoring of gout and comorbidity screening; the influence of comorbidities in drug choice; lifestyle; flare prophylaxis; management of tophi and asymptomatic hyperuricaemia; the role of urine alkalinization; and the burden of gout. The level of agreement with the recommendations ranged from 6.8 to 9.0 (mean 7.7) on a 1-10 point visual analogue scale, in which 10 stands for full agreement.

CONCLUSION

The 12 Portuguese recommendations for the Diagnosis and Management of Gout were formulated according to the best evidence and endorsed by a panel of 42 rheumatologists, enhancing their validity and practical use in daily clinical practice.

Immunization with the Leishmania infantum recombinant cyclophilin protein 1 confers partial protection to subsequent parasite infection and generates specific memory T cells

Control of zoonotic visceral leishmaniosis can be achieved using several available drugs. These drugs present high toxicity and require longer treatment regimens which complicate compliance to the treatment. Other control measures directed to the vector or the reservoirs are useful tools to restrain the spreading of this disease but the effects are transitory. A safe, affordable and efficient vaccine conferring long lasting immunity should be the most cost effective way of controlling zoonotic visceral leishmaniosis. The present study aims at characterizing a cyclophilin protein 1 of Leishmania infantum (LiCyP1) and investigating whether recombinant LiCyP1 (LirCyP1) is able to confer protection against infection by evaluating viable parasite load and the generation of specific CD4(+) and CD8(+) effector and central memory T cells in rodent model. LiCyP1 is present in the cytoplasm of L. infantum amastigotes and promastigotes. Immunization of BALB/c mice with LirCyP1 confers high protection to L. infantum infection, causing a marked reduction in parasite replication in the liver and spleen. Furthermore, helper and cytotoxic memory T cell subsets able to specifically recognize parasite antigens expanded in immunized and in challenged mice. CD4(+) T cell subpopulation of intermediate phenotype (CD62L(high)CD127(low)) of challenging mice also presented an accentuated expansion after the recall. This study demonstrated that LirCyP1 confers partial protection to L. infantum infection, promoting the generation of a desired long lasting immunity. LirCyP1 can be considered a potential candidate for the design of a vaccine against zoonotic visceral leishmaniosis.

Pharmacology of biosimilar candidate drugs in rheumatology: a literature review

OBJECTIVE

To review current evidence concerning pharmacology of biosimilar candidates to be used in rheumatology.

METHODS

A PubMed search up to August 2013 was performed using relevant search terms to include all studies assessing pharmacological properties of biosimilar candidates to be used in rheumatology. Data on study characteristics, type of intervention, pharmacokinetics (PK), pharmacodynamics (PD) and bioequivalence ratios was extracted.

RESULTS

Of 280 articles screened, 5 fulfilled our inclusion criteria. Two trials, PLANETAS and PLANETRA, compared CT-P13 and infliximab in patients with active ankylosing spondylitis and rheumatoid arthritis, respectively. PK bioequivalence was demonstrated in the phase 1 PLANETAS trial by highly comparable area under the curve (AUC) and maximum drug concentrations (Cmax), whose geometric mean ratios fell between the accepted bioequivalence range of 80-125%. Equivalence in efficacy and safety was demonstrated in the phase 3 PLANETRA trial. Two phase 1 trials comparing etanercept biosimilar candidates TuNEX and HD203 in healthy volunteers showed a high degree of similarity in AUC and Cmax, with respective geometric mean ratios between PK bioequivalence range. The last included trial referred to GP2013, a rituximab biosimilar candidate, which demonstrated PK and PD bioequivalence to reference product in three different dosing regimens in cynomolgus monkeys.

CONCLUSION

Infliximab, etanercept and rituximab biosimilar candidates have demonstrated PK bioequivalence in the trials included in this review. CT-P13 has recently been approved for use in the European market and the remaining biosimilar candidates are currently being tested in patients with rheumatoid arthritis.

Cardiac antiapoptotic and proproliferative effect of recombinant human erythropoietin in a moderate stage of chronic renal failure in the rat

Objective:

Recombinant human erythropoietin (rhEPO) therapy under circumstances of moderate chronic renal failure (CRF), with yet lower kidney and heart lesion, may have a protective cardiac effect beyond the correction of anemia, whose mechanism deserves better elucidation, namely by clarifying the impact on gene expression profile of markers of apoptosis, inflammation, proliferation, angiogenesis, and lesion/stress in the heart.

Materials and Methods:

Four groups of rats were studied over a period of 15 weeks (n=7 each): control—without surgery and without drug treatment; rhEPO—treated with 50 IU/kg/week of rhEPO—beta; CRF—submitted to partial nephrectomy (3/4); CRF + rhEPO—CRF with rhEPO treatment after the 3rd week of surgery. The heart was collected in order to evaluate the gene expression, by real-time qPCR, of markers of apoptotic machinery, inflammation/immunology, proliferation/angiogenesis, and lesion/stress.

Results:

The main findings obtained were (a) CRF rats have demonstrated overexpression of EPO-R in the heart without changes on EPO expression, together with overexpression of Bax/Bcl2 ratio, PCNA, and IL-2; (b) rhEPO therapy on the heart of the rats with CRF induced by partial 3/4 nephrectomy promoted nonhematopoietic protection, demonstrated by the apoptosis prevention, viewed by the Bax/Bcl2 balance, by the promotion of proliferation, due to PCNA increment, and by the immunomodulatory action, expressed by a trend to prevent the IL-2 increment.

Conclusion:

In this model of moderate CRF, rhEPO treatment showed important cardiac nonhematopoietic effects, expressed mainly by the antiapoptotic and the proproliferative action, suggesting that early rhEPO therapy in moderate stages of CRF might have further therapeutic benefits.