Long-term effectiveness of a lifestyle intervention for rheumatoid arthritis and osteoarthritis: 1-year follow-up of the 'Plants for Joints' randomised clinical trial

OBJECTIVES

In two randomised controlled trials, the Plants for Joints (PFJ) multidisciplinary lifestyle intervention reduced signs and symptoms of rheumatoid arthritis (RA), or metabolic syndrome-associated hip or knee osteoarthritis (MSOA) compared with usual care. The current study investigated long-term outcomes.

METHODS

After completion of two 16-week trials in people with (1) RA or (2) MSOA, control groups switched to the active PFJ intervention. At the end of the intervention, all participants were followed up in a 1-year observational extension study. Primary outcomes were 28-joint Disease Activity Score (DAS28) (RA) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (MSOA). Secondary outcomes included body composition, metabolic outcomes, medication changes and intervention adherence. An intention-to-treat analysis with a linear mixed model was used to analyse within-group changes.

RESULTS

65 (84%) of 77 RA participants and 49 (77%) of 64 MSOA participants completed the extension study. The effects of the PFJ intervention were replicated in the original control groups and sustained within the RA group a year after intervention completion (mean DAS28 -0.9 points; p<0.001), while in the MSOA group mean WOMAC increased towards but remained well under the starting value (-7.8 points, p<0.001). Improvements in C-reactive protein, waist circumference (RA and MSOA); low-density lipoprotein cholesterol (RA); and weight, haemoglobin A1c, blood pressure (MSOA) were also sustained. Participants had a net decrease of medication, and intervention adherence was largely sustained.

CONCLUSIONS

A year after the PFJ lifestyle intervention, improvements of disease activity and metabolic outcomes within RA and MSOA groups were largely sustained and related to sustained adherence, with a net decrease of medication.

TRIAL REGISTRATION NUMBERS

NL7800, NL7801.

When it looks like Behçet's syndrome but is something else: differential diagnosis of Behçet's syndrome: a two-centre retrospective analysis

OBJECTIVE

To investigate the differential diagnostic spectrum in patients with suspected Behçet's syndrome (BS) in low prevalence regions. In addition, the number of patients fulfilling the ICBD criteria despite not having BS was evaluated.

METHODS

This retrospective analysis was performed in two referral centres for BS. Patients with confirmed BS (clinical diagnosis with fulfilment of ISG criteria or a score of ≥5 points in the ICBD criteria) were excluded. The remaining patients were divided into 11 differential diagnosis categories. If no definitive alternative diagnosis could be established, patients were termed 'probable BS' in case of (i) relapsing orogenital aphthosis in the absence of other causes and either HLA-B51 positivity, or origin from an endemic area or presence of an additional typical BS symptom that is not part of the classification criteria, or (ii) with 3-4 points scored in the ICBD criteria.

RESULTS

In total 202 patients were included and categorized as follows: 58 patients (28.7%) as 'probable BS', 57 (28.2%) skin disease, 26 (12.9%) chronic pain syndrome, 14 (6.9%) eye disease, 11 (5.4%) spondyloarthropathy, 9 (4.5%) gastrointestinal disease, 7 (3.5%) neurological disease, 4 (2%) arthritis, 3 (1.5%) auto-inflammation, 3 (1.5%) connective tissue disease and 10 (5.0%) miscellaneous disease. HLA-B51 was positive in 55/132 (41.7%); 75/202 (37.1%) of the patients fulfilled the ICBD criteria.

CONCLUSION

In a low disease prevalence setting, the straightforward application of the ICBD criteria may lead to overdiagnosis of BS. The differential diagnosis of BS is enormously broad. Clinicians should be aware that HLA-B51 positivity is still not considered as a diagnostic feature in BS.

EULAR study group on ‘MHC-I-opathy’: identifying disease-overarching mechanisms across disciplines and borders

The ‘MHC-I (major histocompatibility complex class I)-opathy’ concept describes a family of inflammatory conditions with overlapping clinical manifestations and a strong genetic link to the MHC-I antigen presentation pathway. Classical MHC-I-opathies such as spondyloarthritis, Behçet’s disease, psoriasis and birdshot uveitis are widely recognised for their strong association with certain MHC-I alleles and gene variants of the antigen processing aminopeptidases ERAP1 and ERAP2 that implicates altered MHC-I peptide presentation to CD8+T cells in the pathogenesis. Progress in understanding the cause and treatment of these disorders is hampered by patient phenotypic heterogeneity and lack of systematic investigation of the MHC-I pathway.

Here, we discuss new insights into the biology of MHC-I-opathies that strongly advocate for disease-overarching and integrated molecular and clinical investigation to decipher underlying disease mechanisms. Because this requires transformative multidisciplinary collaboration, we introduce the EULAR study group on MHC-I-opathies to unite clinical expertise in rheumatology, dermatology and ophthalmology, with fundamental and translational researchers from multiple disciplines such as immunology, genomics and proteomics, alongside patient partners. We prioritise standardisation of disease phenotypes and scientific nomenclature and propose interdisciplinary genetic and translational studies to exploit emerging therapeutic strategies to understand MHC-I-mediated disease mechanisms. These collaborative efforts are required to address outstanding questions in the etiopathogenesis of MHC-I-opathies towards improving patient treatment and prognostication.

A multidisciplinary lifestyle program for rheumatoid arthritis: the "Plants for Joints" randomized controlled trial

OBJECTIVE

To determine the effect of a multidisciplinary lifestyle program in patients with RA with low-moderate disease activity.

METHODS

In the "Plants for Joints" (PFJ) parallel-arm, assessor-blind randomized controlled trial, patients with RA and 28-joint Disease Activity Score [DAS28] ≥ 2.6 and ≤ 5.1 were randomized to the PFJ or control group. The PFJ group followed a 16-week lifestyle program based on a whole food plant-based diet, physical activity, and stress management. The control group received usual care. Medication was kept stable three months before and during the trial whenever possible. We hypothesized that PFJ would lower disease activity (DAS28). Secondary outcomes included anthropometric, metabolic, and patient-reported measures. An intention-to-treat analysis with a linear mixed model adjusted for baseline values was used to analyse between-group differences.

RESULTS

Of the 83 people randomized, 77 completed the study. Participants were 92% female with mean (SD) age of 55 (12), BMI of 26 (4) kg/m2 and mean DAS28 of 3.8 (0.7). After 16 weeks the PFJ group had a mean 0.9-point greater improvement of DAS28 vs the control group (95% CI 0.4-1.3; p < 0.0001). The PFJ intervention led to greater decreases in body weight (difference -3.9 kg), fat mass (-2.8 kg), waist circumference (-3 cm), HbA1c (-1.3 mmol/mol) and LDL (-0.32 mmol/l), whereas patient-reported outcome measures, blood pressure, glucose and other lipids did not change.

CONCLUSION

The 16-week PFJ multidisciplinary lifestyle program substantially decreased disease activity and improved metabolic status in people with RA with low-moderate disease activity.

TRIAL REGISTRATION

International Clinical Trials Registry Platform; https://www.who.int/clinical-trials-registry-platform; NL7800.

High-intensity versus low-intensity resistance training in patients with knee osteoarthritis: A randomized controlled trial

OBJECTIVES

To assess whether (i) high-intensity resistance training (RT) leads to increased muscle strength compared to low-intensity RT in patients with knee osteoarthritis (OA); and (ii) RT with vitamin D supplementation leads to increased muscle strength compared to placebo in a subgroup with vitamin D deficiency.

DESIGN

Randomized controlled trial.

SETTING

Outpatient rehabilitation centre.

SUBJECTS

Patients with knee OA.

INTERVENTIONS

12 weeks of RT at high-intensity RT (70-80% of 1-repetition maximum (1-RM)) or low-intensity RT (40-50% of 1-RM) and 24 weeks of vitamin D (1200 International units vitamin D3 per day) or placebo supplementation.

MAIN MEASURES

Primary outcome measure was isokinetic muscle strength. Other outcome measure for muscle strength was the estimated 1-RM. Secondary outcome measures were knee pain and physical functioning.

RESULTS

177 participants with a mean age of 67.6 ± 5.8 years were included, of whom 50 had vitamin D deficiency. Isokinetic muscle strength (in Newton metre per kilogram bodyweight) at start, end and 24 weeks after the RT was 0.98 ± 0.40, 1.11 ± 0.40, 1.09 ± 0.42 in the high-intensity group and 1.02 ± 0.41, 1.15 ± 0.42, 1.12 ± 0.40 in the low-intensity group, respectively. No differences were found between the groups, except for the estimated 1-RM in favour of the high-intensity group. In the subgroup with vitamin D deficiency, no difference on isokinetic muscle strength was found between the vitamin D and placebo group.

CONCLUSIONS

High-intensity RT did not result in greater improvements in isokinetic muscle strength, pain and physical functioning compared to low-intensity RT in knee OA, but was well tolerated. Therefore these results suggest that either intensity of resistance training could be utilised in exercise programmes for patients with knee osteoarthritis. No synergistic effect of vitamin D supplementation and RT was found, but this finding was based on underpowered data.

Neuropathic‐like pain symptoms in inflammatory hand osteoarthritis lower quality of life and may not decrease under prednisolone treatment

Background

Pain is common in hand osteoarthritis (OA) and multiple types may occur. We investigated the prevalence, associated patient characteristics, influence on health‐related quality of life (HR‐QoL) and response to anti‐inflammatory treatment of neuropathic‐like pain in inflammatory hand OA.

Methods

Data were analysed from a 6‐week, randomized, double‐blind, placebo‐controlled trial investigating prednisolone treatment in 92 patients with painful inflammatory hand OA. Neuropathic‐like pain was measured with the painDETECT questionnaire. Associations between baseline characteristics and baseline neuropathic‐like pain were analysed with ordinal logistic regression, association of baseline neuropathic‐like pain symptoms with baseline HR‐QoL with linear regression, painDETECT and visual analogue scale (VAS) change from baseline to week 6 and interaction of painDETECT with prednisolone efficacy on VAS pain change from baseline to week 6 with generalized estimating equations (GEE).

Results

Of 91 patients (79% female, mean age 64) with complete painDETECT data at baseline, 53% were unlikely to have neuropathic‐like pain, 31% were indeterminate and 16% were likely to have neuropathic‐like pain. Neuropathic‐like pain was associated with female sex, less radiographic damage and more comorbidities. Patients with neuropathic‐like pain had lower HR‐QoL (PCS‐6.5 [95% CI −10.4 to −2.6]) than those without. Neuropathic‐like pain symptoms remained under prednisolone treatment and no interaction was seen between painDETECT and prednisolone efficacy on VAS pain.

Conclusions

In this study, 16% of inflammatory hand OA patients had neuropathic‐like pain. They were more often female, had more comorbidities and had lower QoL than those without. Neuropathic‐like pain symptoms remained despite prednisolone treatment and did not seem to affect the outcome of prednisolone treatment.

Significance

Pain is the dominant symptom in hand OA, with an unclear aetiology. In this study, we found that neuropathic‐like pain may play a role in hand OA, that it showed associations with female sex, younger age and more comorbidities and that it lowered health‐related quality of life in hand OA. Neuropathic‐like pain in hand OA seems resistant to prednisolone therapy but did not seem to interfere with the treatment of inflammatory pain with prednisolone.

AB0384 THE EFFECT OF A LIFESTYLE PROGRAM ON PATIENTS AT RISK FOR RHEUMATOID ARTHRITIS:THE “PLANTS FOR JOINTS” PILOT RANDOMIZED CLINICAL TRIAL

Background

An unhealthy lifestyle increases the risk of developing rheumatoid arthritis (RA). Interventions including plant-based diets, physical activity, and stress management have shown benefits for RA patients but have not yet been evaluated in a program for patients at risk for RA.

Objectives

To investigate preliminary effectiveness of a multidisciplinary lifestyle program on RA risk in patients at risk for RA, in comparison to usual care.

Methods

In the “Plants for Joints” (PFJ) pilot RCT, patients with anti-citrullinated protein antibody (ACPA) positive arthralgia were randomized to the PFJ or control group. Both groups received usual care while the PFJ group additionally followed a 16-week lifestyle program based on a whole food plant-based diet, physical activity, and stress management.1 The primary outcome was risk of developing RA as quantified by the RA risk score (including family history, symmetry, stiffness, pain level, RF/ACPA level).2 The maximum score (13 points) was given to participants who developed RA. Secondary outcomes included self-reported pain intensity, inflammatory, anthropometric, and metabolic markers, and serum levels of ACPA and rheumatoid factor (RF). A linear mixed model for between group analysis was used, adjusted for baseline values.

Results

14 out of 17 included patients completed the study (all female, mean age 47 years). Three patients (n = 2 PFJ group, n = 1 control group) were diagnosed with RA after mean 9.6 weeks and remained in the study. After 16 weeks there was no significant difference in RA risk score between PFJ and control groups (Figure 1). Compared to the control group, the PFJ group had significantly lower fat mass and LDL-cholesterol after 16 weeks (Table 1). After the intervention the PFJ group had an average weight loss of 4.9 kg, of which 2.7 kg was fat mass.

Table 1.

Results reported as mean (SD) when normally distributed and median [Q1 – Q3] when skewed. P-value <0.05 = significant. RA = rheumatoid arthritis, ACPA = anti-citrullinated protein antibody, RF = Rheumatoid factor, ESR = erythrocyte sedimentation rate, CRP = C-reactive protein.

Plants for Joints group (n = 7)Control group (n = 7)BaselineWeek 16BaselineWeek 16p-valueRA risk and related outcomesRA risk score6.1 (1.4)8.6 (3.4)7.1 (1.4)8.3 (2.3)0.56Pain intensity4.9 (2.6)3.8 (1.9)5.7 (2.6)4.0 (2.1)0.74ACPA, kU/l330 [94 - 530]225 [116 - 550]256 [79 - 462]202 [94 - 403]0.86RF, kU/l13 [3 - 68]11 [3 - 56]12 [3 - 21]5 [4 - 12]0.96RA diagnosis, N0201-InflammationESR, mmol/hour9 [6 - 15]7 [6 - 9]7 [6 - 12]12 [8 -17]0.79CRP, mg/l0.7 [0.6 - 2.5]0.6 [0.6 - 1.2]3.0 [1.1 - 3.6]3.3 [1.3 - 6.7]0.58AnthropometricWeight, kg78.4 (18.6)73.5 (16.4)77.4 (16.2)77.0 (16.3)0.28BMI, kgm-226.8 (5.3)25.1 (4.5)28.2 (6.2)28.0 (6.0)0.23Fat mass, kg30.6 (14.3)27.9 (12.3)31.2 (12.8)29.8 (13.0)<0.01Waist circumference, cm87.9 (13.3)86.6 (11.6)91.6 (15.5)90.6 (16.1)0.33MetabolicLDL-cholesterol, mmol/l3.1 (0.87)2.83 (0.75)3.07 (0.36)3.05 (0.36)<0.01HbA1C, mmol/mol34.9 (3.2)34.4 (3.1)35.1 (3.0)36.9 (3.6)0.97

Conclusion

The results of this pilot study do not suggest the PFJ lifestyle program influenced RA risk score, pain, or autoantibody levels, although possible effects cannot be excluded due to the small sample size. However, metabolic health clearly improved in the PFJ group.

References

[1]Walrabenstein, Trials 2021

[2]van de Stadt, Ann Rheum Dis 2013

Acknowledgements

C. W. was funded by ZonMW (The Netherlands Organization for Health Research and Development) grant number 555003210.

Disclosure of Interests

Carlijn Wagenaar: None declared, Wendy Walrabenstein: None declared, Marieke van der Leeden: None declared, Franktien Turkstra: None declared, Jos Twisk: None declared, Maarten Boers Consultant of: Consultant for Novartis, Henriët van Middendorp: None declared, Peter Weijs: None declared, Dirkjan van Schaardenburg: None declared

AB0396 EFFECT OF A MULTIDISCIPLINARY LIFESTYLE PROGRAM IN PATIENTS WITH RHEUMATOID ARTHRITIS: THE PLANTS FOR JOINTS RANDOMIZED CONTROLLED TRIAL

Background

Lifestyle factors have been associated with the development and progression of rheumatoid arthritis (RA). Interventions involving whole food plant-based diets (WFPDs), physical activity or stress management have shown promising results for people with RA but were not yet evaluated in an integrated program.

Objectives

To determine the effect of a 16-week multidisciplinary lifestyle program on disease activity in patients with RA.

Methods

In the “Plants for Joints” (PFJ) parallel-arm, assessor-blind randomized clinical trial, patients with RA and a 28-joint Disease Activity Score [DAS28] score ≥ 2.6 and ≤ 5.1, were assigned to the PFJ group or the control group. The PFJ group followed a lifestyle program based on a WFPD, physical activity, and stress management in addition to usual care. The control group received usual care. Medication was kept stable three months before and during the trial. Secondary outcomes included anthropometric, and metabolic markers. An intention-to-treat analysis with a linear mixed model, adjusted for baseline values was used to analyze between-group differences of continuous outcomes.

Results

Of 115 people screened, 85 were randomized and 79 completed the study. Participants were 91% female with a mean (SD) age of 55 (12) and body mass index of 26 (4) kg/m2. After 16 weeks the PFJ group had a mean 0.85-point greater improvement of the DAS28 versus the control group (95% CI 0.40 to 1.30; p < 0.001) (Figure 1). Subgroup analyses showed significant improvements in the seropositive as well as the seronegative subgroup, although the effect was more profound in the seronegative group. Weight, fat mass, HbA1c, LDL and triglycerides also showed significant improvements in the PFJ versus control group, while blood glucose and HDL remained unchanged (Table 1). No serious adverse events occurred.

Conclusion

The 16-week PFJ lifestyle program substantially decreased disease activity in people with RA with low-moderate disease activity.

Disclosure of Interests

Wendy Walrabenstein: None declared, Carlijn Wagenaar: None declared, Marike van der Leeden: None declared, Franktien Turkstra: None declared, Jos Twisk: None declared, Maarten Boers Consultant of: Consultant for Novartis, Henriët van Middendorp: None declared, Peter Weijs: None declared, Dirkjan van Schaardenburg: None declared

POS0123 NEUROPATHIC PAIN SYMPTOMS IN INFLAMMATORY HAND OSTEOARTHRITIS(OA) LOWERS HEALTH RELATED PHYSICAL QUALITY OF LIFE AND MAY REQUIRE ANOTHER APPROACH THAN ANTI-INFLAMMATORY TREATMENT

Background:

Pain is a common, difficult to manage symptom in hand osteoarthritis (OA). Multiple pain mechanisms may play a role in hand OA.

Objectives:

To investigate presence of neuropathic pain symptoms in patients with inflammatory hand OA, characteristics of those patients, their impact on health related quality of life (HR-QoL), and the influence of anti-inflammatory treatment on neuropathic pain symptoms.

Methods:

Data from a randomised, double-blind, placebo-controlled trial of prednisolone including 92 patients with hand OA fulfilling ACR criteria were used. At baseline patients had signs of synovial inflammation, a VAS finger pain of ≥30 mm and who flared ≥20 mm upon NSAID washout. The primary endpoint was VAS finger pain (0-100) at week 6.

Neuropathic pain symptoms were measured at baseline and week 6 using the validated painDETECT questionnaire, consisting of questions on pain quality, pain intensity over time and radiating pain. Scores range -1 to 38 and patients are classified as having unlikely (<13), indeterminate (13-18) and likely (>18) neuropathic pain. HR-QoL was measured with physical component scale (PCS) of Short-Form 36 (SF36; 0-100), comorbidities with the Self-administered Comorbidities Questionnaire (SCQ; 0-45), radiographic severity with Kellgren-Lawrence (KL) sum score (0-120), and treatment response with OMERACT-OARSI responder criteria.

Association of patient characteristics with neuropathic pain symptoms was analysed with univariate and multivariate ordinal logistic regression, with painDETECT as dependent variable. Association of neuropathic pain symptoms with HR-QoL was analysed with multivariate linear regression, adjusted for age, sex, BMI, VAS finger pain, SCQ score and KL sum score, with PCS as dependent variable. Response of neuropathic pain symptoms and VAS pain to prednisolone was analysed with generalised estimating equations. Association of neuropathic pain symptoms at baseline with response to treatment was analysed using χ2-tests and GEE.

Results:

91 patients had complete painDETECT data at baseline (mean painDETECT score 12.8 [SD 5.9]). Scores were <13 in 53%, 13-18 in 31% and >18 in 16%. Higher painDETECT score categories were associated with less radiographic damage, more comorbidities, female sex and higher VAS finger pain in multivariate analysis. (table 1)

Table 1.

Ordinal logistic regression with painDETECT categories as dependent variable

VariablesMean (SD) N=91 (100%)Odds ratio (95% CI)Age64 (9)0.96 (0.90 to 1.02)Female sex; N (%)72 (79%)3.84 (1.19 to 12.39)*BMI; median (SD)27 (24 to 29)0.97 (0.89 to 1.06)SCQ score; median (SD)2 (1 to 5)1.04 (1.04 to 1.36)*VAS finger pain53.8 (2.1)1.02 (1.00 to 1.04)*KL sum score37 (16)0.96 (0.93 to 1.00)*

*p<0.05. BMI = body mass index. SCQ = Self-administered comorbidities questionnaire. VAS = visual analog scale. KL= Kellgren-Lawrence.

Patients with painDETECT scores >18 had a lower HR-QoL (PCS -6.5 [95%CI -10.4 to -2.6]) than those with painDETECT scores <13.

PainDETECT scores remained unchanged throughout the trial in both prednisolone-treated and placebo-treated patients, and there was no between-group difference at week 6. VAS pain improved more in the prednisolone group than in the placebo group (mean between-group difference -16.5 [95%CI -26.1 to -6.9]) (figure 1). No association between the presence of neuropathic pain symptoms at baseline and OMERACT-OARSI response to treatment was found.

Conclusion:

Patients with inflammatory hand OA and additional neuropathic pain symptoms are more often female and have more comorbidities, and report a lower QoL, than those without. Neuropathic pain symptoms seem unresponsive to anti-inflammatory therapy. Clinicians should be aware of neuropathic pain symptoms in their patients as they might benefit from additional, specific treatment.

Acknowledgements:

The authors thank all patients for their participation in the HOPE study, and participating rheumatologists for inclusion of patients in the HOPE study. We also thank research nurses B.A.M.J. van Schie-Geyer and S. Wongsodihardjo, and technicians J.C. Kwekkeboom and E.I.H. van der Voort, for their contributions.

Disclosure of Interests:

Coen van der Meulen: None declared, Lotte van de Stadt: None declared, Féline Kroon: None declared, Marion Kortekaas: None declared, Annelies Boonen Speakers bureau: Lecture for UCB; paid to department., Consultant of: Yes. Advisory board meetings at Galapagos, Eli Lilly and Abvvie; paid to department., Grant/research support from: Yes. Grants by Celgene and Abbvie; paid to department., Stefan Böhringer: None declared, Marieke Niesters: None declared, Monique Reijnierse: None declared, Frits Rosendaal: None declared, Naghmeh Riyazi: None declared, M. Starmans: None declared, Franktien Turkstra: None declared, Jende van Zeben: None declared, Cornelia Allaart: None declared, Margreet Kloppenburg Consultant of: For Abbvie, Pfizer, Levicept, GlaxoSmithKline, Merck-Serono, Kiniksa, Flexìon, Galapagos, Jansen, CHDR and local investigator of industry-driven trial (Abbvie). All fees were paid to the institution., Grant/research support from: Grant by the Dutch Arthritis Society

POS1361 EVALUATION OF PATIENTS WITH (SUSPECTED) BEHÇET SYNDROME; DIAGNOSTIC VALUE OF PATHERGY TESTING AND OPHTHALMOLOGIC EXAMINATION

Background:

Behçet syndrome (BS) is a multisystem vasculitis of unknown etiology. A positive pathergy test (PT) is part of the ISG criteria for the classification of BS [1]. The added value of PT in the diagnostic workup is unknown. Also, it is unknown whether real time assessment of the pathergy reaction after 48 hours by a physician can be replaced by patient assessment.

The diagnostic value of routine eye examination in patients with suspected BS is unclear.

Objectives:

Assess the diagnostic value of PT and ophthalmologic examination in (suspected) BS patients. Examine the correlation between physician and patient assessment of PT results.

Methods:

This prospective cohort study in (suspected) BS patients was conducted from 2009 to 2020.

At baseline, patients were classified as “true” (≥3 criteria), “probable” (2 criteria) or “no” (0-1 criteria) BS according to ISG criteria and were referred to a dermatologist and/or ophthalmologist for PT and/or eye examination. The percentage of positive PT and eye examination in each group was assessed and the percentage of patients with a changed classification (probable to true BS) was determined.

PT results were scored by both patients and physicians.

Results:

Baseline characteristics are reported in Table 1. Figure 1 displays the flowchart of diagnostic value of PT.

Figure 1.

Flowchart of the results of PT in (suspected) BS patients

In 22 patients with two ISG criteria, grade I uveitis was diagnosed in 1 patient (4.5%, 95% CI [0.8,21.8]) and retinal vasculitis in 1 patient (4.5%, 95% CI [0.8,21.8]). He had shortly experienced photophobia 3 months earlier. Both patients (9%, 95% CI [2.5,27.8]) changed from “probable” to “true” BS, the latter also had a positive PT.

47 patients assessed the results of their own PT. The dermatologist scored PT as positive in one patient. This patient scored the results as unsure on all six PT points. In 46 patients, the dermatologist scored PT as negative, a total of 26 patients (56.5%, 95% CI [42.2,69.7]) scored their results negative as well.

Conclusion:

The added diagnostic value of PT in patients fulfilling 2 features of the ISG criteria was limited in our study, i.e. 5.7% 95% CI [1.6,18.6]. Furthermore, half of patients scored their true negative PT result as negative. The added diagnostic value of routine eye examination in probable BS patients was limited in our study.

References:

[1]Criteria for diagnosis of Behcet’s disease. International Study Group for Behcet’s Disease. Lancet 1990;335(8697):1078–8

Table 1.

Baseline characteristics of (suspected) BS patients.

All patientsn=153ISG +1n=59ISG+ after FU2 n=11ISG –3n=83P-value (+ vs -)Age (mean ± SD4 years)39.5 (12)41.8 (11.6)33.6 (7.5)38.5 (12.6)0.294Male n (%)47 (30.7)16 (27.1)4 (36.4)27 (32.5)0.360HLA-B51+ n/n (%)8/18 (44.4)5/7 (71.4)1/3 (33.3)2/8 (25)0.070Ethnicity: endemic5 n (%)82 (53.6)38 (64.4)6 (54.5)38 (45.8)0.114Oral aphthae n (%)145 (94.8)59 (100)11 (100)75 (90.4)0.008Genital ulcers n (%)82 (53.6)50 (84.7)8 (72.7)24 (28.9)0.000Skin n (%)71 (46.4)51 (86.4)1 (9.1)19 (22.9)0.000Pathergy + n/n (%) 23/58 (39.7)17/33 (51.5) 2/3 (66.7)4/22 (18.1)0.000Eye n (%) 28 (18.3)17 (28.8)1 (9.1)10 (12)0.035Superficial thrombophlebitis n (%)15 (9.8)11 (18.6)1 (9.1)3 (3.6)0.018Vascular n (%)11 (7.2)5 (8.5)1 (9.1)5 (6)0.360Venous n (%)10 (6.5)5 (8.5)1 (9.1)4 (4.8)Arterial n (%)2 (1.3)1 (1.7)01 (1.2)Neurological n (%)5 (3.3)3 (5.2)02 (2.4)0.433Arthritis n (%)40 (26.1)20 (33.9)2 (18.2)18 (21.7)0.197Gastro- intestinal n (%)6 (3.9)3 (5.1)03 (3.6)1.00Epididymitis n (% of males)5 (10.6)5 (31.3)000.002

1.patients fulfilling the ISG criteria at enrollment

2.patients who fulfilled the ISG criteria during FU

3.patients did not fulfill the ISG criteria after FU

4.standard deviation

5.Turkey, Asia, Middle and Far Eastern, Arabic countries and Northern Africa

Disclosure of Interests:

None declared

Feasibility of Self-Monitoring Rheumatoid Arthritis With a Smartphone App: Results of Two Mixed-Methods Pilot Studies

Background

Several mobile apps that monitor symptoms of rheumatoid arthritis (RA) exist, but a recent systematic review indicated that high-quality apps are lacking. When patients self-monitor their own disease with patient-reported outcomes (PROs) and self-initiate care at the right moment, it may be possible to reduce the frequency of their clinic visits, which would reduce health care burden and costs. We developed an app, that is, the MijnReuma Reade app, for this purpose and performed 2 pilot tests with weekly self-monitoring.

Objective

The primary objective of this study was to design, develop, and evaluate the usability, satisfaction, and usage of the MijnReuma Reade app—an app that allows patients with RA to monitor their own disease. The secondary objective was to review the patients’ perspectives on app usage and its intended purpose.

Methods

This app was designed in collaboration with patients with RA, rheumatologists, and information technology experts. Two 1-month pilot studies were performed, after which satisfaction (0-10 scale), usability (system usability scale, 0-100), and usage (proportion of completed questionnaires) of this app were assessed. After the second pilot study, semistructured interviews were performed to determine patients’ perspectives and the promoters and barriers of app usage.

Results

In the first and second pilot study, 42 and 27 patients were included, respectively. Overall, the patients were satisfied (medians, 8 and 7) and found the app usable (mean system usability scores, 76 and 71) in pilot studies 1 and 2, respectively. App usage declined over time in both the pilot studies; 61% (17/28) and 37% (10/27) of the patients who disclosed their usage statistics completed the final weekly questionnaire in pilot study 1 and pilot study 2, respectively. Approximately 81% (25/31) of the patients indicated they would like to skip hospital visits if the self-monitored disease activity is low. In the semistructured interviews, technical problems, internal resistance (respondent fatigue, the app reminded them of their disease), and a lack of symptoms were identified as barriers for usage. Patients reported that “experiencing more grip on their disease” and “improved communication with their physician” were promoters for usage. Patients reported that pain positively mediated usage, that is, more pain promoted and less pain discouraged app usage.

Conclusions

This study illustrates the feasibility of the MijnReuma Reade app that enables self-monitoring of the disease activity in patients with RA with the overarching aim to allocate clinical consultations according to need. Satisfaction with the app and usability of the app were found to be high; however, app usage declined over time. Patients acknowledged the potential of the app to self-monitor their own disease and would like to be able to skip clinic visits if the monitored disease activity is low. To evaluate this strategy, a randomized controlled trial is underway.

AB0536 EFFECT OF HYDROXYCHLOROQUINE TREATMENT IN MUCOCUTANEOUS MANIFESTATIONS IN PATIENTS WITH BEHÇET’S SYNDROME

Background:

Behçet syndrome (BS) is a rare multisystemic vasculitis, most commonly seen in regions along the ancient Silk Road. It runs a relapsing and remitting course. Mucocutaneous disease, consisting of oral ulcers, genital ulcers and skin lesions is often reported. EULAR recommendations advise colchicine and topical agents for the treatment of these lesions.1Not all patients respond adequately, thus, it is important to explore alternative treatment options.

Objectives:

To study the efficacy of hydroxychloroquine (HCQ) 400 mg daily in patients with mucocutaneous BS.

Methods:

Data on all patients who presented at the outpatient Behçet clinic in New York were recorded. Patients with a first prescription with HCQ and a follow-up of 3 months (range: 2.75-41.2 months) were included. Patient reported outcomes BSAS and RAPID3 were used to evaluate the effect of HCQ. Results of all patients and of International Study Group (ISG) positive patients were analyzed separately using Wilcoxon rank tests.

Results:

We included 94 patients with a first prescription of HCQ. 72 patients (76.6%) fulfilled ISG criteria. Mean age was 36.1 years (SD 12.5), 76 patients (80.9%) were female and 11 patients (11.7%) were from Silk Road countries.

Mean duration until follow-up was 6.5 months (SD 5.7). Median BSAS scores in ISG+ patients at baseline did not differ significantly from ISG- patients, except for skin lesions (5.0 in ISG+ vs. 0.5 in ISG- p=0.005). BSAS scores at follow-up did not differ significantly (ISG+ vs. ISG-).

Median BSAS scores were significantly lower at follow-up compared to baseline for oral ulcers (p=0.010), skin lesions (p=0.018) and overall activity (p=0.019). Regarding genital ulcers there was no significant result, due to only 37 patients reporting complaints of genital ulcers. Performing these analyses in ISG+ patients only did not change these results, except for BSAS overall activity, which lost significance (p=0.057).

RAPID3 scores were not statistically different between baseline and follow-up (9.67 vs. 8.75, p=0.145), nor were its separate components function (p=0.67 vs. 0.67, 0.713), pain (4.0 vs. 4.0, p=0.157) and patient global (5.0 vs. 4.5, p=0.095).

The majority of patients used prednisone at baseline (58.5%) and at follow-up (57.4%). In 15 patients, prednisone was stopped at follow up, in 13 patients it was started.

Table 1.

Median BSAS scores of patients treated with HCQ.

Baseline(median, IQR)Follow-up 3 months(median, IQR)P-valuesAll patients (n=94)Oral ulcers5.0 (2.00-7.88)3.0 (1.00-6.00)0.010Genital ulcers0.0 (0.00-3.88)0.0 (0.00-3.00)0.371Skin lesions5.0 (1.25-7.00)2.5 (0.00-7.00)0.018Overall activity5.5 (4.00-8.00)5.0 (2.00-7.25)0.019ISG+ patients (n=72)Oral ulcers5.25 (2.00-7.63)3.25 (1.00-6.00)0.007Genital ulcers0.5 (0.00-4.00)0.0 (0.00-3.00)0.684Skin lesions5.0 (2.00-7.13)3.0 (0.00-7.00)0.015Overall activity6.0 (4.00-8.00)5.0 (2.00-7.50)0.057

Conclusion:

HCQ improves median BSAS scores for oral ulcers, skin lesions and overall activity at 3 months follow-up compared to baseline. These results were similar in ISG+ patients (except for overall activity). Additional research is needed to assess the effect of HCQ in more patients and over multiple time points.

References:

[1]Hatemi G et al. 2018 update of the EULAR recommendations for the management of Behçet’s syndrome. Ann Rheum Dis 2019;77:808-818

Disclosure of Interests:

Floor Kerstens: None declared, Shreen Mohamed: None declared, Ingrid Visman: None declared, Franktien Turkstra: None declared, Christopher Swearingen: None declared, Yusuf Yazici Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant, Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant

A Smartphone App for Self-Monitoring of Rheumatoid Arthritis Disease Activity to Assist Patient-Initiated Care: Protocol for a Randomized Controlled Trial

Background

Telemedicine based on self-measurement of disease activity could be one of the key components to create the health care system of the future. Previous publications in various medical fields have shown that it is possible to safely telemonitor patients while reducing the number of outpatient clinic visits. For this purpose, we developed a mobile phone app for patients with rheumatoid arthritis (RA), which allows them to self-monitor their disease.

Objective

The objective of this study is to assess the safety and efficacy of self-initiated care assisted by a smartphone app in patients with RA.

Methods

This is a randomized controlled trial that will be performed for 1 year. A total of 176 patients with RA will be randomized to either self-initiated care with only one scheduled follow-up consultation assisted by our app or usual care. The coprimary outcome measures are the number of outpatient clinic consultations with a rheumatologist taking place during the trial period and the mean disease activity score as measured by the disease activity score 28 (DAS28) at 12 months. The secondary outcomes are patient satisfaction, adherence, patient empowerment, and cost evaluation of health care assisted by the app.

Results

Recruitment started in May 2019, and up to 18 months will be required for completion of recruitment. Thus far, 78 patients have been randomized, and thus far, experiences with the app have been positive. The study results are expected to be published by the end of 2021.

Conclusions

The completion of this study will provide important data regarding the following: (1) safety of self-initiated care supported by a smartphone app in terms of DAS28 and (2) efficacy of lowering health care usage with this new strategy of providing health care.

Trial Registration

Netherlands Trial Register NL7715; https://www.trialregister.nl/trial/7715

International Registered Report Identifier (IRRID)

DERR1-10.2196/15105

Results of a 6-week treatment with 10 mg prednisolone in patients with hand osteoarthritis (HOPE): a double-blind, randomised, placebo-controlled trial

BACKGROUND

Hand osteoarthritis is a prevalent joint condition that has a high burden of disease and an unmet medical need for effective therapeutic options. Since local inflammation is recognised as contributing to osteoarthritic complaints, the Hand Osteoarthritis Prednisolone Efficacy (HOPE) study aimed to investigate the efficacy and safety of short-term prednisolone in patients with painful hand osteoarthritis and synovial inflammation.

METHODS

The HOPE study is a double-blind, randomised, placebo-controlled trial. We recruited eligible adults from rheumatology outpatient clinics at two sites in the Netherlands. Patients were considered eligible if they had symptomatic hand osteoarthritis and signs of inflammation in their distal and proximal interphalangeal (DIP/PIP) joints. For inclusion, patients were required to have four or more DIP/PIP joints with osteoarthritic nodes; at least one DIP/PIP joint with soft swelling or erythema; at least one DIP/PIP joint with a positive power Doppler signal or synovial thickening of at least grade 2 on ultrasound; and finger pain of at least 30 mm on a 100-mm visual analogue scale (VAS) that flared up during a 48-h non-steroidal anti-inflammatory drug (NSAID) washout (defined as worsening of finger pain by at least 20 mm on the VAS). Eligible patients were randomly assigned (1:1) to receive 10 mg prednisolone or placebo orally once daily for 6 weeks, followed by a 2-week tapering scheme, and a 6-week follow-up without study medication. The patients and study team were masked to treatment assignment. The primary endpoint was finger pain, assessed on a VAS, at 6 weeks in participants who had been randomly assigned to groups and attended the baseline visit. This study is registered with the Netherlands Trial Registry, number NTR5263.

FINDINGS

We screened patients for enrolment between Dec 3, 2015, and May 31, 2018. Patients completed baseline visits and started treatment between Dec 14, 2015, and July 2, 2018, and the last study visit of the last patient was Oct 4, 2018. Of 149 patients assessed for eligibility, 57 (38%) patients were excluded (predominantly because they did not meet one or several inclusion criteria, most often because of an absence of synovial inflammation or of flare-ups after NSAID washout) and 92 (62%) patients were eligible for inclusion. We randomly assigned 46 (50%) patients to receive prednisolone and 46 (50%) patients to receive placebo, all of whom were included in the modified intention-to-treat analysis of the primary endpoint. 42 (91%) patients in the prednisolone group and 42 (91%) in the placebo group completed the 14-week study. The mean change between baseline and week 6 on VAS-reported finger pain was -21·5 (SD 21·7) in the prednisolone group and -5·2 (24·3) in the placebo group, with a mean between-group difference (of prednisolone vs placebo) of -16·5 (95% CI -26·1 to -6·9; p=0·0007). The number of non-serious adverse events was similar between the groups. Five serious adverse events were reported during our study: one serious adverse event in the prednisolone group (a myocardial infarction) and four serious adverse events in the placebo group (an infected traumatic leg haematoma that required surgery, bowel surgery, atrial fibrillation that required a pacemaker implantation, and symptomatic uterine myomas that required a hysterectomy). Four (4%) patients discontinued the study because of an adverse event: one (2%) patient receiving prednisolone (for a myocardial infarction) and three (7%) patients receiving placebo (for surgery of the bowel and for an infected leg haematoma and for Lyme disease arthritis of the knee).

INTERPRETATION

Treatment with 10 mg prednisolone for 6 weeks is efficacious and safe for the treatment of patients with painful hand osteoarthritis and signs of inflammation. The results of our study provide clinicians with a new short-term treatment option for patients with hand osteoarthritis who report a flare-up of their disease.

FUNDING

Dutch Arthritis Society.

The value of joint ultrasonography in predicting arthritis in seropositive patients with arthralgia: a prospective cohort study

BACKGROUND

The value of joint ultrasonography (US) in the prediction of clinical arthritis in individuals at risk of developing rheumatoid arthritis (RA) is still a point of debate, due to varying scanning protocols and different populations. We investigated whether US abnormalities assessed with a standard joint protocol can predict development of arthritis in seropositive patients with arthralgia.

METHODS

Anti-citrullinated protein antibodies and/or rheumatoid factor positive patients with arthralgia, but without clinical arthritis were included. US was performed at baseline in 16 joints: bilateral metacarpophalangeal 2-3, proximal interphalangeal 2-3, wrist and metatarsophalangeal (MTP) joints 2-3 and 5. Images were scored semi-quantitatively for synovial thickening and for positive signs on power Doppler (PD). Association between US abnormalities and arthritis development at the joint and at the patient level was evaluated. Also, we investigated the added value of US over clinical parameters.

RESULTS

Out of 163 patients who underwent US examination, 51 (31%) developed clinical arthritis after a median follow-up time of 12 (interquartile range 5-24) months, of which 44 (86%) satisfied the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for RA. US revealed synovial thickening and PD in at least one joint in 49 patients (30%) and 7 patients (4%), respectively. Synovial thickening was associated with both development and timing of clinical arthritis in any joint (patient level) when MTP joints were excluded from the US assessment (odds ratio 6.6, confidence interval (CI) 1.9-22), and hazard ratio 3.4, CI 1.6-6.8, respectively, with a mean time to arthritis of 23 versus 45 months when synovial thickening was present versus not present). There was no association between US and arthritis development at the joint level. Predictive capacity was highest in the groups with an intermediate and high risk of developing arthritis based on a prediction rule with clinical parameters.

CONCLUSIONS

Synovial thickening on US predicted clinical arthritis development at the patient level in seropositive patients with arthralgia when MTPs were excluded from the US assessment. Positive PD signs were infrequently seen in these at-risk individuals and was not predictive. In patients at intermediate risk of RA, US may help to identify those at higher risk of developing arthritis.

Reliable Rapid Blood Test for the Exclusion of Venous Thromboembolism in Symptomatic Outpatients

In this study we assessed the reliability of a rapid bed-side whole blood D-dimer assay prospectively in patients with clinically suspected venous thromboembolism, referred to the Academic Medical Centre, Amsterdam. In consecutive outpatients with clinically suspected deep vein thrombosis or pulmonary embolism we measured the sensitivity, specificity and negative predictive value of the assay compared to the outcome of standard diagnostic tests and 3-month follow-up. A total of 234 patients were included; the prevalence of venous thromboembolism was 29%. A sensitivity, specificity and negative predictive value of 100% (95% Cl: 95% -100%), 58% (95% Cl: 50% - 65%) and 100% (95% Cl: 96% -100%), respectively, were obtained. The exclusion rate was 41% of all referred patients. Conclusion: The SimpliRED whole blood D-dimer assay appears to be a simple and reliable method for the exclusion of venous thromboembolism in symptomatic outpatients.

Value of Chest X-ray Combined with Perfusion Scan versus Ventilation/Perfusion Scan in Acute Pulmonary Embolism

BackgroundThe main purpose of ventilation scanning, as adjunct to perfusion lung scintigraphy, in acute pulmonary embolism is to allow for the classification of segmental perfusion defects as mismatched, which is generally accepted as proof for the presence of pulmonary embolism. We examined whether this function of the ventilation scan could be replaced by the chest X-ray.MethodsIn 389 consecutive patients with suspected pulmonary embolism and at least one segmental perfusion defect we classified the ventilation/perfusion (V/Q) scan and chest X-ray/perfusion (X/Q) scan as either mismatched or matched. Furthermore we analyzed whether this comparison was different in subgroups of patients with concomitant congestive heart failure or chronic obstructive pulmonary disease.Results Overall agreement between the X/Q and V/Q scan diagnostic category was found in 341 of 389 patients (88%; 95% CI 84-92%). The positive predictive value for obtaining a mismatched V/Q scan result in case of a mismatched X/Q scan result was 86% (95% CI 81-90%). If the X/Q scan yielded only matched defects the V/Q scan resulted in the same classification in 90% (95% CI 85-95%). Analysis of the small subgroup of patients with chronic obstructive pulmonary disease showed that a mismatched X/Q scan was confirmed by V/Q scanning in 21 of 34 cases (62%; 95% CI 45-78%).ConclusionThis study shows that in the great majority of patients with clinically suspected acute pulmonary embolism combination of chest X-ray with perfusion scintigraphy reliably replaced ventilation/perfusion scintigraphy in defining (mis)-matching of segmental perfusion defects. These results need confirmation before the chest X-ray can fully obviate the use of ventilation scintigraphy.

Comparison of a Clinical Probability Estimate and Two Clinical Models in Patients with Suspected Pulmonary Embolism

Recent studies have suggested that both the subjective judgement of a physician and standardized clinical models can be helpful in the estimation of the probability of the disease in patients with suspected pulmonary embolism (PE). We performed a multi-center study in consecutive in- and outpatients with suspected PE to compare the potential diagnostic utility of these methods. Of the 517 study patients, 160 (31%) were classified as having PE. Of these patients, 14% had a low probability as estimated by the treating physician, while 25 to 36% were categorized as having a low clinical probability with the use of two previously described clinical models. The objectively confirmed prevalence of PE in these three low probability categories was 19%, 28% and 28%, respectively. The three methods yielded comparable predictive values for PE in the other probability categories. We conclude that a physician’s clinical judgement alone and two standardized clinical models, although comparable, perform disappointingly in categorizing the pre-test probability in patients with suspected PE.

Is the Prevalence of the Factor V Leiden Mutation in Patients with Pulmonary Embolism and Deep Vein Thrombosis Really Different?

Introduction. Previous investigations have suggested a lower prevalence of the factor V Leiden mutation in patients with pulmonary embolism, as compared to patients with deep leg vein thrombosis. Methods. We studied unselected patients with pulmonary embolism, in whom we also assessed the presence of deep vein thrombosis by ultra-sonography. We assessed the prevalence of heterozygosity for the factor V Leiden mutation and compared the outcome of patients with a normal ultrasound (primary pulmonary embolism) to those with an abnormal ultrasound (combined form of venous thromboembolism). Furthermore, we performed a literature search to identify all articles regarding the prevalence of heterozygous factor V Leiden mutation in patients with primary deep vein thrombosis, primary pulmonary embolism and a combined form of venous thromboembolism. We calculated a (common) odds ratio for these 3 manifestations of venous thromboembolism, including the current findings. Results. In 92 patients with proven pulmonary embolism, 25 (27%) had also an abnormal ultrasound. In these patients, the prevalence of the factor V Leiden mutation was 24% (95% CI 9%-45%), whereas the mutation was present in 5 of 67 patients with primary pulmonary embolism (7%; 95% CI 2%-16%). The literature analysis indicated the common odds ratio for the presence of heterozygous factor V Leiden mutation in patients with primary deep vein thrombosis, primary pulmonary embolism and the combined form of venous thromboembolism to be 7.9 (95% CI 5-12), 3.5 (95% CI 2-6) and 6.8 (95% CI 3-14), respectively. Conclusion. In patients with primary pulmonary embolism the prevalence of the factor V Leiden mutation appears to be half of that reported in patients with primary deep vein thrombosis. The mechanism remains unclear.

Observer and Biological Variation of a Rapid Whole Blood D-Dimer Test

In consecutive patients with suspected venous thromboembolism the interobserver variability of the SimpliRED D-dimer test was evaluated by two observers who independently scored one plate, the between assay variation was performed simultaneously by a third independent observer, who assessed a second plate. The biological variation was studied, 1-4 hours later by an independent evaluation.

A total of 155 patients entered the study, venous thromboembolism was present in 42 patients (28%). The interobserver variability was 2/83 samples, with a kappa of 0.95 (95% confidence interval 0.88-1.0). The between assay variation was 2/98, with a kappa value of 0.96 (95% confidence interval 0.90-1.0). When testing the biological variation the observers disagreed in 2 of 69 patients (3%).

The SimpliRED D-dimer assay has a good to excellent interobserver variability, between assay variation and reproducibility.

Adherence to guidelines for the treatment of Behçet's syndrome in New York and Amsterdam

OBJECTIVES

To assess adherence to published guidelines for the treatment of Behçet's syndrome (BS) in two geographic areas.

METHODS

We extracted guideline statements from the 2008 EULAR recommendations. Adherence to these statements was evaluated retrospectively in both New York (USA) and Amsterdam (The Netherlands), by reviewing records from patients fulfilling the ISG criteria. We analysed data per statement and event, and divided data according to the year in which an event occurred. We compared events prior to 2009 to those after publication of the EULAR recommendations (2009 and later).

RESULTS

474 patients were evaluated, 24 of whom were from Amsterdam. Treatment adherence varied substantially across various Behçet's manifestations, ranging from 21% vs. 31% in posterior uveitis, 50% vs. 25% in arterial disease, 29% vs. 29% in arthritis and 38% vs. 55% in erythema nodosum to 65% vs. 67% in deep venous thrombosis (DVT), before and after publication of the guidelines respectively. Topical treatment of mucocutaneous disease was only 2% vs. 8%, whereas adherence in neuro-Behçet was ≥ 94% and 100% in gastrointestinal disease.

CONCLUSIONS

Adherence to treatment guidelines varies substantially by Behçet's manifestation. Lack of adherence in manifestations such as eye disease and arthritis suggests that current recommendations are not sufficient or other concurrent manifestations require more aggressive treatment. The extensive use of anti-TNF agents might indicate a shift towards more aggressive treatment. Thus, our results suggest the 2008 guidelines were not in line with treatment in clinical practice over the past years and the recent revision of the recommendations was indeed needed.

Detection of Subclinical Synovitis with Macrophage Targeting and Positron Emission Tomography in Patients with Rheumatoid Arthritis without Clinical Arthritis

Objective.

To determine whether macrophage targeting by (R)-11C-PK11195 positron emission tomography (PET) can visualize subclinical joint inflammation in patients with rheumatoid arthritis (RA) without clinical arthritis during or after treatment, with flare as clinical outcome measure.

Methods.

(R)-11C-PK11195 PET and contrast-enhanced magnetic resonance imaging (MRI) of hands/wrists were performed in 29 patients with RA without clinical arthritis. (R)-11C-PK11195 PET uptake (semiquantitative score 0–3) in metacarpophalangeal, proximal interphalangeal, and wrist joints (i.e., 22 joints per patient) was scored and summed to obtain a cumulative PET score (range 0–66). Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS) was performed on similar joints. Synovitis and bone marrow edema scores (> 1) were summed to obtain a cumulative MRI score (range 0–288). Occurrence of flare was determined during 3-year followup.

Results.

Flare was observed in 17/29 patients (59%). (R)-11C-PK11195 PET showed enhanced tracer uptake in 16/29 patients (55%), of which 11 (69%) developed a flare. Highest cumulative PET scores (> 6, n = 3) corresponded with highest cumulative MRI scores (> 39) and were related to development of flare in hands/wrists within 6 months. Cumulative PET scores of patients developing a flare were higher than those of patients without a flare [median (interquartile range) 2 (0–4.5) vs 0 (0–1), p < 0.05]. In contrast, no significant differences were found between cumulative MRI scores of patients with and without a flare.

Conclusion.

(R)-11C-PK11195 PET showed enhanced uptake, pointing to presence of subclinical synovitis in over half of patients without clinical arthritis. (R)-11C-PK11195 PET may be of value for prediction of exacerbation of RA, since cumulative PET scores > 1 were associated with development of flare within 3 years.

Results of a questionnaire on the treatment of patients with Behçet's syndrome: a trend for more intensive treatment

OBJECTIVES

To determine the preferred treatment for patients with Behçet's syndrome.

METHODS

A questionnaire was given to all participants of the 2010 meeting of the International Society for Behçet's Disease.

RESULTS

Forty-one respondents from 6 different subspecialties. In the case of a patient with (severe) posterior uveitis or parenchymal central nervous system (CNS) disease no consensus was seen. A diffuse spectrum of different schedules were given. In both uveitis and CNS disease the majority of respondents preferred treatment options consisting of combination systemic therapy and systemic corticosteroids. TNF was preferred as first line drug in uveitis in 7.5% and in severe uveitis in 32.5% of respondents. In parenchymal CNS disease TNF blockage was given by 17% of the respondents. EULAR guidelines regarding uveitis were followed by 12/40 physicians. In patients with a new deep vein thrombosis, 90% of respondents would intensify immunosuppression. More than half would also anticoagulate.

CONCLUSIONS

Although consensus about how to treat patients with Behçet syndrome in different clinical situations is far from present, treatment has become more intensive when compared to 10-20 years ago. More uniformity should be sought for in the decision process in individual patients with Behçet's syndrome, regarding their treatment, as well as adhering to evidence, as presented in the EULAR guidelines, when present.

Venous and arterial thromboembolic events in adalimumab-treated patients with antiadalimumab antibodies: a case series and cohort study

OBJECTIVE

We observed 3 patients who developed severe venous and arterial thromboembolic events during treatment with adalimumab, 2 of whom had rheumatoid arthritis (RA) and 1 of whom had psoriatic arthritis. Antiadalimumab antibodies were detected in all 3 patients. We undertook this study to determine whether the development of antiadalimumab antibodies was associated with thromboembolic events during adalimumab treatment.

METHODS

A retrospective search (with blinding with regard to antiadalimumab antibody status) for thromboembolic events was performed in a prospective cohort of 272 consecutively included adalimumab-treated RA patients. Incidence rates were calculated and hazard ratios (HRs) were estimated using Cox regression. None of the index patients were part of the cohort.

RESULTS

Antiadalimumab antibodies were detected in 76 of 272 patients (28%). Eight thromboembolic events were found, 4 of which had occurred in patients with antiadalimumab antibodies. The incidence rate was 26.9/1,000 person-years for patients with antiadalimumab antibodies and 8.4/1,000 person-years for patients without those antibodies (HR 3.8 [95% confidence interval 0.9-15.3], P = 0.064). After adjustment for duration of followup, age, body mass index, erythrocyte sedimentation rate, and prior thromboembolic events, the HR was 7.6 (95% confidence interval 1.3-45.1) (P = 0.025).

CONCLUSION

These findings suggest that the occurrence of venous and arterial thromboembolic events during adalimumab treatment is higher in patients with antiadalimumab antibodies than in those without antiadalimumab antibodies. Patient numbers were relatively small; therefore, validation in other cohorts is mandatory.

The value of ultrasonography in predicting arthritis in auto-antibody positive arthralgia patients: a prospective cohort study

Introduction

Ultrasonography (US) has better sensitivity than clinical evaluation for the detection of synovitis in early rheumatoid arthritis (RA). Patients presenting with arthralgia and a positive anti-citrullinated protein antibodies (ACPA) and/or Rheumatoid Factor (IgM-RF) status are at risk for developing RA. In the present study, US utility and predictive properties in arthralgia patients at risk for the development of arthritis were studied.

Methods

192 arthralgia patients with ACPA and/or IgM-RF were included. Absence of clinical arthritis was confirmed by two physicians. US was performed by one of two trained radiologists of any painful joint, and of adjacent and contralateral joints. Joint effusion, synovitis and power Doppler (PD) signal in the synovial membrane of the joints and tenosynovitis adjacent to the joint were evaluated and classified on a 4-grade semi-quantitative scale. Grade 2-3 joint effusion, synovitis, tenosynovitis and grade 1-3 Power Doppler signal were classified as abnormal.

Results

Forty-five patients (23%) developed arthritis after a mean of 11 months. Inter-observer reliability for synovitis and PD was moderate (kappa 0.46, and 0.56, respectively) and for joint effusion low (kappa 0.23). The prevalence of tenosynovitis was too low to calculate representative kappa values. At joint level, a significant association was found between US abnormalities and arthritis development in that joint for joint effusion, synovitis and PD. At patient level, a trend was seen towards more arthritis development in patients who had US abnormalities for joint effusion, synovitis, PD and tenosynovitis.

Conclusions

US abnormalities were associated with arthritis development at joint level, although this association did not reach statistical significance at patient level. US could potentially be used as a diagnostic tool for subclinical arthritis in seropositive arthralgia patients. However, further research is necessary to improve test characteristics.

High prevalence of unemployment in patients with systemic lupus erythematosus: association with organ damage and health-related quality of life

OBJECTIVE

To evaluate employment status in relation to organ damage, demographic factors, and health-related quality of life (HRQOL) in patients with systemic lupus erythematosus (SLE).

METHODS

One hundred forty-seven patients with SLE, aged 18 to 64 years, were included. Examination of self-reported HRQOL was performed using the Medical Outcome Study Short Form-36 (SF-36). Demographic factors, disease characteristics, and HRQOL were compared between patients with and without paid employment using nonparametric tests.

RESULTS

In 147 patients with SLE (mean age 38.4 +/- 11 yrs, mean disease duration 6.3 +/- 6.5 yrs), we found a high rate of unemployment (59%), whereas 93% of patients had previously worked. In patients who had stopped or reduced working, 75% attributed their withdrawal from work at least in part to disease-related factors. Unemployed patients had a significantly higher median age at disease onset, a higher frequency of neuropsychiatric organ damage and diabetes mellitus, and lower HRQOL than employed patients.

CONCLUSION

We found a high rate of unemployment (59%) in patients with SLE. Higher age at disease onset, neuropsychiatric organ damage, diabetes mellitus, and reduced HRQOL were associated with unemployment in patients with SLE. Our findings highlight the need to develop strategies to reduce work loss in patients with SLE, for both individual and socioeconomic reasons.

Tracheobronchomalacia due to amyloidosis in a patient with rheumatoid arthritis

In this case report, we describe a patient with longstanding rheumatoid arthritis who developed tracheobronchomalacia with fatal outcome. Despite negative antemortem biopsies of abdominal fat and tongue, amyloid was found postmortem in the trachea and appeared to be associated with tracheobronchomalacia.

Prevalence of and risk factors for the metabolic syndrome in women with systemic lupus erythematosus

OBJECTIVE

To examine the prevalence of the metabolic syndrome and the relationship between metabolic syndrome score (MetS score) and disease characteristics and cardiovascular events (CVEs) in women with SLE.

METHODS

Demographic and clinical data were collected in 141 female SLE patients. The prevalence of the metabolic syndrome was defined by a modified National Cholesterol Education Program (NCEP/ATP III) definition. Metabolic syndrome was defined as MetS score >or= 3.

RESULTS

Twenty-three (16%) of the 141 SLE patients (mean age 39+/-12 years, mean disease duration 6.2+/-6.6 years) fulfilled the criteria of the metabolic syndrome. The mean MetS score was significantly higher in patients with SLE and a history of cardiovascular events (CVEs) than in those without a previous CVE. In linear multiple regression analysis, a high MetS score was significantly associated with previous intravenous methylprednisolone use, older age, higher ESR, higher C3 levels and higher serum creatinine levels.

CONCLUSIONS

In our female SLE patients, a high prevalence of the metabolic syndrome was found as compared to healthy women in the Amsterdam Growth and Health Longitudinal Study. Independent risk factors for high MetS score in patients with SLE are previous treatment with intravenous methylprednisolone, renal insufficiency, older age, higher ESR and higher C3 levels. These results suggest that assessment of the metabolic syndrome in patients with SLE might be important to identify subgroups of patients that are at disproportional high risk of developing cardiovascular disease and diabetes mellitus.

Survey of the management of deep vein thrombosis in general practice in the Netherlands

BACKGROUND

To investigate the management of (suspected) deep vein thrombosis in general practice.

METHODS

Self completing postal questionnaire among a random sample of 692 general practitioners in the Netherlands.

RESULTS

The overall response rate was 58%. Eighty-nine percent of the respondents initiated objective evaluation. Less than 3% usually make the diagnosis on clinical grounds only. Ninety-two percent initiated adequate treatment for the last patient with deep vein thrombosis. No more than 4% usually treat patients with acenocoumarol alone. Respondents frequently referred a patient to a specialist, 41% to confirm the diagnosis and 85% for treatment. Already 44% feel that management of deep vein thrombosis is a mandate of the general practitioner. For those who do not, the availability of diagnostic and therapeutic facilities are the main obstacles.

CONCLUSION

In general practice objective diagnostic methods to evaluate suspected deep vein thrombosis are routinely used and patients receive adequate treatment. Although patients are frequently referred to the hospital many general practitioners feel that they should be able to take care of these patients themselves. (See Editorial p. 133)

Postthrombotic syndrome after hip or knee arthroplasty: a cross-sectional study

BACKGROUND

Although the incidence of the postthrombotic syndrome (PTS) has been addressed in patients with symptomatic deep vein thrombosis (DVT), less information is available on the incidence in patients who develop asymptomatic DVT after major hip or knee arthroplasty.

OBJECTIVES

To determine whether symptomatic PTS occurs more frequently in patients who develop DVT after hip or knee arthroplasty than those who are free of DVT and to provide an estimate of the incidence of PTS in patients who had undergone major hip or knee arthroplasty and had proximal DVT, distal (calf) DVT, or no DVT.

DESIGN AND SETTING

A cross-sectional study conducted at the Hamilton Health Sciences Corporation, Hamilton, Ontario, and the Academic Medical Centre, Amsterdam, the Netherlands.

SUBJECTS AND METHODS

Two hundred fifty-five subjects who had undergone major hip or knee arthroplasty 2 to 7 years previously and had routine predischarge venography showing proximal DVT (n = 25), distal DVT (n = 66), or no DVT (n = 164) were enrolled from March 1993 through December 1998. The presence of symptomatic PTS confirmed by the presence of objectively confirmed venous valvular incompetence was ascertained.

RESULTS

The rates of PTS were low and not significantly different among the 3 subgroups: 1 (4.0%, 95% confidence interval [CI] = 0.1%-20.4%) of 25 patients with proximal DVT, 4 (6.1%, 95% CI = 1.7%-14.8%) of 66 patients with distal DVT, and 7 (4.3%, 95% CI = 1.7%-8.6%) of 164 patients with no DVT.

CONCLUSIONS

Symptomatic PTS is an uncommon complaint after major hip or knee arthroplasty. Patients who develop postoperative proximal or distal DVT and who receive 6 to 12 weeks of anticoagulant therapy are not predisposed to PTS.

Value of chest X-ray combined with perfusion scan versus ventilation/perfusion scan in acute pulmonary embolism

BACKGROUND

The main purpose of ventilation scanning, as adjunct to perfusion lung scintigraphy, in acute pulmonary embolism is to allow for the classification of segmental perfusion defects as mismatched, which is generally accepted as proof for the presence of pulmonary embolism. We examined whether this function of the ventilation scan could be replaced by the chest X-ray.

METHODS

In 389 consecutive patients with suspected pulmonary embolism and at least one segmental perfusion defect we classified the ventilation/perfusion (V/Q) scan and chest X-ray/perfusion (X/Q) scan as either mismatched or matched. Furthermore we analyzed whether this comparison was different in subgroups of patients with concomitant congestive heart failure or chronic obstructive pulmonary disease.

RESULTS

Overall agreement between the X/Q and V/Q scan diagnostic category was found in 341 of 389 patients (88%; 95% CI 84-92%). The positive predictive value for obtaining a mismatched V/Q scan result in case of a mismatched X/Q scan result was 86% (95% CI 81-90%). If the X/Q scan yielded only matched defects the V/Q scan resulted in the same classification in 90% (95% CI 85-95%). Analysis of the small subgroup of patients with chronic obstructive pulmonary disease showed that a mismatched X/Q scan was confirmed by V/Q scanning in 21 of 34 cases (62%; 95% CI 45-78%).

CONCLUSION

This study shows that in the great majority of patients with clinically suspected acute pulmonary embolism combination of chest X-ray with perfusion scintigraphy reliably replaced ventilation/perfusion scintigraphy in defining (mis)-matching of segmental perfusion defects. These results need confirmation before the chest X-ray can fully obviate the use of ventilation scintigraphy.

Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group

Recent studies have suggested that both the subjective judgement of a physician and standardized clinical models can be helpful in the estimation of the probability of the disease in patients with suspected pulmonary embolism (PE). We performed a multi-center study in consecutive in- and outpatients with suspected PE to compare the potential diagnostic utility of these methods. Of the 517 study patients, 160 (31%) were classified as having PE. Of these patients, 14% had a low probability as estimated by the treating physician, while 25 to 36% were categorized as having a low clinical probability with the use of two previously described clinical models. The objectively confirmed prevalence of PE in these three low probability categories was 19%, 28% and 28%, respectively. The three methods yielded comparable predictive values for PE in the other probability categories. We conclude that a physician's clinical judgement alone and two standardized clinical models, although comparable, perform disappointingly in categorizing the pre-test probability in patients with suspected PE.

Is the prevalence of the factor V Leiden mutation in patients with pulmonary embolism and deep vein thrombosis really different?

INTRODUCTION

Previous investigations have suggested a lower prevalence of the factor V Leiden mutation in patients with pulmonary embolism, as compared to patients with deep leg vein thrombosis.

METHODS

We studied unselected patients with pulmonary embolism, in whom we also assessed the presence of deep vein thrombosis by ultrasonography. We assessed the prevalence of heterozygosity for the factor V Leiden mutation and compared the outcome of patients with a normal ultrasound (primary pulmonary embolism) to those with an abnormal ultrasound (combined form of venous thromboembolism). Furthermore, we performed a literature search to identify all articles regarding the prevalence of heterozygous factor V Leiden mutation in patients with primary deep vein thrombosis, primary pulmonary embolism and a combined form of venous thromboembolism. We calculated a (common) odds ratio for these 3 manifestations of venous thromboembolism, including the current findings.

RESULTS

In 92 patients with proven pulmonary embolism, 25 (27%) had also an abnormal ultrasound. In these patients, the prevalence of the factor V Leiden mutation was 24% (95% CI 9%-45%), whereas the mutation was present in 5 of 67 patients with primary pulmonary embolism (7%; 95% CI 2%-16%). The literature analysis indicated the common odds ratio for the presence of heterozygous factor V Leiden mutation in patients with primary deep vein thrombosis, primary pulmonary embolism and the combined form of venous thromboembolism to be 7.9 (95% CI 5-12), 3.5 (95% CI 2-6) and 6.8 (95% CI 3-14), respectively.

CONCLUSION

In patients with primary pulmonary embolism the prevalence of the factor V Leiden mutation appears to be half of that reported in patients with primary deep vein thrombosis. The mechanism remains unclear.

[Recombinant factor VIIa (eptacog alfa): a new therapeutic option for patients with severe bleeding disorder due to inhibitory antibodies against a coagulation factor]

In 2 patients with severe haemorrhage (a 63-year-old man with haemophilia A (the factor VIII level was 29%) and a 44-year-old woman), of an inhibitory antibody against factor VIII was diagnosed. The development of recombinant factor VIIa (eptacog alpha) has made available a new therapeutic option for patients with an inhibitory antibody against a coagulation factor. Both patients were treated successfully with the new factor after other forms of treatment had failed. The new concept of the coagulation cascade on which the treatment with eptacog alpha is based assumes that the lack of an amplifying loop in the coagulation which takes place via factor IX (in combination with factor VIII) can be compensated by extra stimulation of the principal route (tissue factor-factor VIIa --> factor X) by pharmacological amounts of factor VIIa.

Observer and biological variation of a rapid whole blood D-dimer test

In consecutive patients with suspected venous thromboembolism the interobserver variability of the SimpliRED D-dimer test was evaluated by two observers who independently scored one plate, the between assay variation was performed simultaneously by a third independent observer, who assessed a second plate. The biological variation was studied, 1-4 hours later by an independent evaluation. A total of 155 patients entered the study, venous thromboembolism was present in 42 patients (28%). The interobserver variability was 2/83 samples, with a kappa of 0.95 (95% confidence interval 0.88-1.0). The between assay variation was 2/98, with a kappa value of 0.96 (95% confidence interval 0.90-1.0). When testing the biological variation the observers disagreed in 2 of 69 patients (3%). The SimpliRED D-dimer assay has a good to excellent interobserver variability, between assay variation and reproducibility.

The treatment of deep vein thrombosis and pulmonary embolism

Deep vein thrombosis and pulmonary embolism can be considered as one clinical entity, termed venous thromboembolism, because of their comparable pathogenesis, treatment and prognosis. In this clinical spectrum of venous thromboembolism a gradient in severity of the disease can be recognized. Therapeutic strategies should be adapted to the extent of the thrombotic disease, varying from surgical or thrombolytic therapy in life-threatening disease to a watchful waiting diagnostic follow-up approach in minimal disease. In patients with established venous thromboembolism (low molecular weight) (LMWH), heparin should be initiated. An overview will be given of the safety and efficacy of the different therapeutic modalities such as thrombectomy, thrombolytic therapy, a watchful waiting diagnostic approach and unfractionated heparin. Furthermore, clinical studies comparing LMWH with unfractionated heparin in the initial treatment of venous thromboembolism will be reviewed.

A survey of the diagnostic and therapeutic management of patients with suspected pulmonary embolism in the Netherlands

BACKGROUND

Pulmonary embolism (PE) remains a complex diagnostic problem. Many diagnostic modalities are available. Several published guidelines have failed to yield a uniform approach. We have assessed the current diagnostic and therapeutic management of patients with clinically suspected PE in the Netherlands.

METHODS

A questionnaire was sent to internists and pulmonologists, who were then asked to detail their diagnostic and therapeutic management in their last patient seen with suspected PE.

RESULTS

1571 questionnaires were sent out (response rate 64%). 95% of the patients with suspected PE underwent a perfusion scan (in 91% within 24 h). 1.6% of the respondents had no available perfusion scan facility. Of those who underwent a perfusion scan, 62% had ventilation scan (66% with segmental defects, 80% with subsegmental defects, 27% with a normal perfusion scan). Tests for deep vein thrombosis were performed in 58% of the patients and pulmonary angiography was carried out in 6.1%. Anticoagulant treatment was instituted in 73.2% of all patients.

CONCLUSIONS

The perfusion lung scan is appropriately used as the initial step in the diagnostic workup of patients with suspected PE. Ventilation scanning is overused in patients with subsegmental perfusion defects and normal scan results, whereas it is underused in patients with segmental defects. Additional ventilation scan results had a limited influence on treatment decisions. There is still considerable overtreatment of patients with suspected PE.

Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism

BACKGROUND

The standard diagnostic approach in patients suspected of having pulmonary embolism starts with perfusion-ventilation lung scanning. If the resulting scan is not diagnostic, pulmonary angiography should be done. The use of tests for deep venous thrombosis has been advocated as an adjunct to establishing the diagnosis of pulmonary embolism, but no prospective studies have provided adequate information about the value of these tests.

OBJECTIVE

To determine the accuracy and potential clinical utility of compression ultrasonography in the diagnosis of pulmonary embolism.

DESIGN

Prospective cohort study with blinded assessment of ultrasonographic results.

SETTING

Teaching hospital.

PATIENTS

397 consecutive inpatients and outpatients in whom pulmonary embolism was clinically suspected.

MEASUREMENTS

Sensitivity and specificity of compression ultrasonography. Perfusion-ventilation scanning and angiography were the conjoint gold standard for determining the presence or absence of pulmonary embolism. Also calculated were the number of angiograms and lung scans avoided and the number of patients unnecessarily treated when compression ultrasonography was included in the diagnostic strategy.

RESULTS

The overall sensitivity of compression ultrasonography for deep venous thrombosis in patients with pulmonary embolism was 29% (95% CI 22% to 37%); the specificity was 97% (CI, 94% to 99%). Adding ultrasonography to the diagnostic approach before lung scanning would avoid approximately 14% of lung scans and 9% of angiograms but would lead to unnecessary treatment of 13% of patients who have an abnormal ultrasonographic result (2% to 4% of all those receiving anticoagulation). When compression ultrasonography is done only in patients with a nondiagnostic lung scan, 9% of angiographies are prevented at the cost of unnecessarily treating 26% of patients who have an abnormal ultrasonographic result (2% of all patients receiving anticoagulation).

CONCLUSION

The diagnostic value of compression ultrasonography for the detection of deep venous thrombosis in patients suspected of having pulmonary embolism is limited; the gain in diagnostic efficiency obtained through the use of ultrasonography may be offset by a loss in diagnostic accuracy.

Reliable rapid blood test for the exclusion of venous thromboembolism in symptomatic outpatients

In this study we assessed the reliability of a rapid bed-side whole blood D-dimer assay prospectively in patients with clinically suspected venous thromboembolism, referred to the Academic Medical Centre, Amsterdam. In consecutive outpatients with clinically suspected deep vein thrombosis or pulmonary embolism we measured the sensitivity, specificity and negative predictive value of the assay compared to the outcome of standard diagnostic tests and 3-month follow-up. A total of 234 patients were included; the prevalence of venous thromboembolism was 29%. A sensitivity, specificity and negative predictive value of 100% (95% CI: 95% - 100%), 58% (95% CI: 50%-65%) and 100% (95% CI:96% - 100%), respectively, were obtained. The exclusion rate was 41% of all referred patients.

CONCLUSION

The SimpliRED whole blood D-dimer assay appears to be a simple and reliable method for the exclusion of venous thromboembolism in symptomatic outpatients.