Clinical presentation and outcomes in patients with antiphospholipid syndrome-associated adrenal hemorrhage. A multicenter cohort study and systematic literature review

BACKGROUND

Adrenal hemorrhage (AH) can occur in patients with antiphospholipid Syndrome (APS). We aimed to characterize the clinical manifestations, treatments, and outcomes of patients presenting with APS-associated AH (APS-AH) through a retrospective cohort and a systematic literature review (SLR).

METHODS

We performed a mixed-source approach combining a multicenter cohort with an SLR of patients with incident APS-AH. We included patients from Mayo Clinic and published cases with persistent positivity for antiphospholipid antibodies and presenting with AH, demonstrated by imaging or biopsy. We extracted demographics, clinical characteristics, laboratory findings, treatment strategies, and outcomes (primary adrenal insufficiency and mortality). We used Kaplan-Meier and Cox models for survival analysis.

RESULTS

We included 256 patients in total, 61 (24%) from Mayo Clinic and 195 (76%) from the SLR. The mean age was 46.8 (SD 15.2) years, and 45% were female. 69% of patients had bilateral adrenal involvement and 64% presented adrenal insufficiency. The most common symptoms at presentation were abdominal pain in 79%, and nausea and vomiting 46%. Hyponatremia (77%) was the most common electrolyte abnormality. Factors associated with primary adrenal insufficiency were bilateral adrenal involvement at initial imaging (OR 3.73, CI; 95%, 1.47-9.46) and anticardiolipin IgG positivity (OR 3.80, CI; 95%, 1.30-11.09). The survival rate at five years was 82%. History of stroke was associated with 3.6-fold increase in mortality (HR 3.62, 95% CI; 1.33-9.85).

CONCLUSION

AH is a severe manifestation of APS with increased mortality. Most patients developed permanent primary adrenal insufficiency, particularly those positive for anticardiolipin IgG and bilateral adrenal involvement.

Clinical features of patients with hands arthralgia referred from primary care physicians to rheumatologists: A cohort study

PURPOSE

Early referral of patients with suspicious of rheumatoid arthritis (RA) has an impact on prognosis. Our study aimed to evaluate the clinical characteristics of patients with hands arthralgia who were referred from primary care physicians (PCP) to the rheumatologist.

METHODS

A descriptive, observational, prospective cohort study was performed. We included patients who visited a PCP for the first time for hands arthralgia. Demographics and the European Alliance of Associations for Rheumatology criteria for arthralgia suspicious for progression to RA plus seven complementary questions, the time to referral, the pressure needed to provoke pain with an automatic squeeze test machine in the metacarpophalangeal joints of both hands, and the diagnoses established at the last review of medical charts from patients on follow-up were documented. The primary outcome was the referral to a rheumatologist.

RESULTS

A total of 109 patients were included. The mean age was 49.9 years, 81.6% were women. 30.3% were referred to the rheumatologist. The time to referral was a median of 38 days. The main clinical characteristics associated with referral to the rheumatologist were the "most severe symptoms are present after midnight" (OR=6.29) and the "difficulty with making a fist" (OR=3.67). An isolated "positive squeeze test of metacarpophalangeal joints" was not associated with a referral to the rheumatologist.

CONCLUSIONS

Among patients with hands arthralgia who attended PCP, those with most severe symptoms after midnight and difficulty making a fist were more likely to be referred to the rheumatology clinic. Isolated positive squeeze tests are not a parameter for referral, it should only be performed if arthralgia is clinically suspected.

Calprotectin Impairs Platelet Survival in Patients With Primary Antiphospholipid Syndrome

OBJECTIVE

While thrombosis and pregnancy loss are the best-known clinical features of antiphospholipid syndrome (APS), many patients also exhibit "extra-criteria" manifestations, such as thrombocytopenia. The mechanisms that drive APS thrombocytopenia are not completely understood, and no clinical biomarkers are available for predicting antiphospholipid antibody (aPL)-mediated thrombocytopenia. Calprotectin is a heterodimer of S100A8 and S100A9 that is abundant in the neutrophil cytoplasm and released upon proinflammatory neutrophil activation. Here, we sought to evaluate the presence, clinical associations, and potential mechanistic roles of circulating calprotectin in a cohort of primary APS and aPL-positive patients.

METHODS

Levels of circulating calprotectin were determined in plasma by the QUANTA Flash chemiluminescent assay. A viability dye-based platelet assay was used to assess the potential impact of calprotectin on aPL-mediated thrombocytopenia.

RESULTS

Circulating calprotectin was measured in 112 patients with primary APS and 30 aPL-positive (without APS criteria manifestations or lupus) patients as compared to patients with lupus (without APS), patients with unprovoked venous thrombosis (without aPL), and healthy controls. Levels of calprotectin were higher in patients with primary APS and aPL-positive patients compared to healthy controls. After adjustment for age and sex, calprotectin level correlated positively with absolute neutrophil count (r = 0.41, P < 0.001), positively with C-reactive protein level (r = 0.34, P = 0.002), and negatively with platelet count (r = -0.24, P = 0.004). Mechanistically, we found that calprotectin provoked aPL-mediated thrombocytopenia by engaging platelet surface toll-like receptor 4 and activating the NLRP3-inflammasome, thereby reducing platelet viability in a caspase-1-dependent manner.

CONCLUSION

These data suggest that calprotectin has the potential to be a functional biomarker and a new therapeutic target for APS thrombocytopenia.

Fragility of randomised controlled trials for systemic lupus erythematosus and lupus nephritis therapies

OBJECTIVE

We aimed to evaluate the robustness of phase III randomised controlled trials (RCTs) for SLE and lupus nephritis (LN) using the fragility index (FI), the reverse FI (RFI) and the fragility quotient (FQ).

METHODS

We searched for phase III RCTs that included patients with active SLE or LN. Data on primary endpoints, total participants and the number of events for each arm were obtained. We calculated the FI score for RCTs with statistically significant results (number of patients required to change from event to non-event to make the study lose statistical significance), the RFI for RCTs without statistically significant results (number of patients required to change from non-event to event to make study gain statistical significance) and the FQ score for both (FI or RFI score divided by the sample size).

RESULTS

We evaluated 20 RCTs (16 SLE, four LN). The mean FI/RFI score was 13.6 (SD 6.6). There were nine RCTs with statistically significant results (seven SLE, two LN), and the mean FI score was 10.2 (SD 6.2). The lowest FI was for the ILLUMINATE-2 trial (FI=2), and the highest FI was for the BLISS-52 trial (FI=17).Twelve studies had non-statistically significant results (10 SLE, two LN) with a mean RFI score of 15.6 (SD 6.1). The lowest RFI was for the ILLUMINATE-1 trial (RFI=4), and the highest RFI was for the TULIP-1 trial (RFI=27). The lowest FQ scores were found in the ILLUMINATE trials and the highest in the Rituximab trials (EXPLORER and LUNAR), meaning that the last ones were the most robust results after accounting for sample size.

CONCLUSIONS

The evidence of therapies for patients with SLE and LN is derived mostly from fragile RCTs. Clinicians and trialists must be aware of the fragility of these RCTs for clinical decision-making and designing trials for novel therapeutics.

Multimorbidity in systemic lupus erythematosus in a population-based cohort: the lupus Midwest network

OBJECTIVES

To assess the prevalence and incidence of multimorbidity and the association with the SLICC/ACR damage index (SDI) among patients with systemic lupus erythematosus (SLE).

METHODS

Using prevalent and incident population-based cohorts of patients with SLE and their matched comparators, we assessed 57 chronic conditions. Chronic conditions were categorized as SDI-related or SDI-unrelated. Multimorbidity was defined as the presence of 2+ chronic conditions. Multimorbidity at prevalence and incidence/index was compared between cohorts using logistic regression. Cox models were used to examine development of multimorbidity after SLE incidence.

RESULTS

The prevalent cohort included 449 patients with established SLE on January 1, 2015. They were three times more likely to have multimorbidity compared with non-SLE comparators (OR 2.98, 95% CI 2.18-4.11). The incident cohort included 270 patients with new-onset SLE. At SLE incidence, patients with SLE were more likely to have multimorbidity than comparators (OR 2.27, 95% CI 1.59-3.27). After incidence, the risk of developing multimorbidity was 2-fold higher among patients with SLE than comparators (hazard ratio (HR) 2.11, 95% CI 1.59-2.80). Development of multimorbidity was higher in patients with SLE based on SDI-related (HR 2.91, 95% CI 2.17-3.88) and SDI-unrelated conditions (HR 1.73, 95% CI, 1.32-2.26).

CONCLUSION

Patients with SLE have a higher burden of multimorbidity, even before the onset of the disease. The risk disparity continues after SLE classification and is also seen in a prevalent SLE cohort. Multimorbidity is driven both by SDI-related and unrelated conditions.

Utilisation of cardiovascular preventive services in a rheumatoid arthritis population-based cohort

OBJECTIVES

The objective is to examine utilisation of cardiovascular preventive services in patients with rheumatoid arthritis (RA), compared with a non-RA population, and to examine cardiovascular disease (CVD) screening rates among RA patients without diabetes mellitus (DM), hypertension or hyperlipidaemia to non-RA patients with one of these diagnoses.

METHODS

All ≥18-year-old patients with an RA diagnosis living in one of eight Minnesota counties on 1 January 2015 were included and matched (1:1) by sex, age and county to non-RA comparators. Rates of screening for CVD risk factors, including DM (ie, glucose), hypertension (ie, blood pressure) and hyperlipidaemia (ie, lipids), were compared between groups using Cox models.

RESULTS

The study included 1614 patients with RA and 1599 non-RA comparators. DM screening was more common among patients with RA (HR: 1.10, 95% CI: 1.01 to 1.19), as was hypertension screening (HR: 1.37, 95% CI: 1.24 to 1.52). Hyperlipidaemia screening in RA was similar to comparators (HR: 0.99, 95% CI: 0.89 to 1.10). Conversely, patients with RA and no CVD risk factors had a lower probability of undergoing diabetes (HR: 0.67, 95% CI: 0.57 to 0.78) and hyperlipidaemia screening (HR: 0.65, 95% CI: 0.54 to 0.79) than non-RA patients with only one CVD risk factor diagnosis. Hypertension screening was similar between both groups.

CONCLUSIONS

RA patients undergo CVD preventive screening at rates at least comparable to the general population. However, patients with RA as their sole CVD risk factor were less likely to undergo screenings, despite an equivalent-to-higher risk as the traditional CVD risk factors. These findings demonstrate opportunities for improvement of RA patient care.

Clinical features, risk factors, and outcomes of diffuse alveolar hemorrhage in antiphospholipid syndrome: A mixed-method approach combining a multicenter cohort with a systematic literature review

BACKGROUND

Antiphospholipid syndrome (APS) is a systemic autoimmune disease clinically associated with thrombotic and obstetric events. Additional manifestations have been associated with APS, like diffuse alveolar hemorrhage (DAH). We aimed to summarize all the evidence available to describe the presenting clinical features, their prognostic factors, and short- and long-term outcomes.

METHODS

We performed a mixed-method approach combining a multicenter cohort with a systematic literature review (SLR) of patients with incident APS-associated DAH. We described their clinical features, treatments, prognostic factors, and outcomes (relapse, mortality, and requirement of mechanical ventilation [MV]). Kaplan-Meier methods were used to estimate relapse and mortality rates, and Cox and logistic regression models were used to assess the factors associated as appropriate.

RESULTS

We included 219 patients with incident APS-associated DAH (61 from Mayo Clinic and 158 from SLR). The median age was 39.5 years, 51% were female, 29% had systemic lupus erythematosus, and 34% presented with catastrophic APS (CAPS). 74% of patients had a history of thrombotic events, and 26% of women had a history of pregnancy morbidity; half of the patients had a history of thrombocytopenia, and a third had valvulopathy. Before DAH, 55% of the patients were anticoagulated. At DAH onset, 65% of patients presented hemoptysis. The relapse rate was 47% at six months and 52% at one year. Triple positivity (HR 4.22, 95% CI 1.14-15.59) was associated with relapse at six months. The estimated mortality at one and five years was 30.3% and 45.8%. Factors associated with mortality were severe thrombocytopenia (< 50 K/μL) (HR 3.10, 95% CI 1.39-6.92), valve vegetations (HR 3.22, 95% CI 1.14-9.07), CAPS (HR 3.80, 95% CI 1.84-7.87), and requirement of MV (HR 2.22, 95% CI 1.03-4.80). Forty-two percent of patients required MV on the incident DAH episode. Patients presenting with severe thrombocytopenia (OR 6.42, 95% CI 1.77-23.30) or CAPS (OR 4.30, 95% CI 1.65-11.16) were more likely to require MV.

CONCLUSION

APS-associated DAH is associated with high morbidity and mortality, particularly when presenting with triple positivity, thrombocytopenia, valvular involvement, and CAPS.

Immune responses and disease biomarker long-term changes following COVID-19 mRNA vaccination in a cohort of rheumatic disease patients

Introduction

The longitudinal responses towards multiple doses of COVID-19 mRNA vaccines in patients with systemic autoimmune diseases remain incompletely understood. While observational studies suggested the safety of COVID-19 mRNA vaccines in rheumatic disease patients, laboratory evidence is lacking.

Methods

Here we evaluated seroreactivity, clinical manifestions, and multiple disease biomarkers after 2 or 3 doses of COVID-19 mRNA vaccines in a cohort of patients with rheumatic diseases.

Results

Most patients generated high SARS-CoV-2 spike-specific neutralizing antibodies comparable to those in healthy controls after 2 doses of mRNA vaccines. The antibody level declined over time but recovered after the third dose of the vaccine. Patients with systemic lupus erythematosus (SLE) or psoriatic arthritis (PsA) remained without significant flares post-vaccination. The changes in anti-dsDNA antibody concentration and expression of type I interferon (IFN) signature genes were highly variable but did not show consistent or significant increases. Frequency of double negative 2 (DN2) B cells remained largely stable.

Discussion

Our data provide experimental evidences indicating the efficacy and safety of repeated COVID-19 mRNA vaccination in rheumatic disease patients.

Long-Term Opioid Therapy Among Patients With Systemic Lupus Erythematosus in the Community: A Lupus Midwest Network (LUMEN) Study

OBJECTIVE

There is little information about the epidemiology and factors associated with opioid therapy in systemic lupus erythematosus (SLE). We aimed to assess the prevalence of opioid therapy and explore factors associated with long-term opioid therapy (LTOT) in patients with SLE.

METHODS

Patients with SLE were matched with controls without SLE in a population-based cohort on January 1, 2015. We captured demographics, manifestations of SLE, comorbidities (ie, fibromyalgia, mood disorders, osteoarthritis, chronic low back pain [CLBP], chronic kidney disease (CKD), avascular necrosis, osteoporosis, fragility fractures, and cancer), and the Area Deprivation Index (ADI). Opioid prescription data were used to assess the prevalence of LTOT, defined as contiguous prescriptions (gaps of < 30 days between prescriptions) and receiving opioid therapy for ≥ 90 days or ≥ 10 prescriptions before the index date.

RESULTS

A total of 465 patients with SLE and 465 controls without SLE were included. In total, 13% of patients with SLE and 3% of controls without SLE were receiving opioid therapy (P < 0.001), and 11% of patients with SLE were on LTOT vs 1% of controls without SLE. Among patients with SLE, acute pericarditis (odds ratio [OR] 3.92, 95% CI 1.78-8.66), fibromyalgia (OR 7.78, 95% CI 3.89-15.55), fragility fractures (OR 3.72, 95% CI 1.25-11.07), CLBP (OR 4.00, 95% CI 2.13-7.51), and mood disorders (OR 2.76, 95% CI 1.47-5.16) were associated with LTOT. We did not find an association between opioid therapy and ADI.

CONCLUSION

Patients with SLE are more likely to receive LTOT than controls. Among patients with SLE, LTOT was associated with pericarditis and several comorbidities. However, LTOT was not associated with CKD despite the limited pain control options among these patients.

Immune responses and disease biomarker long-term changes following COVID-19 mRNA vaccination in a cohort of rheumatic disease patients

Objective

To evaluate seroreactivity and disease biomarkers after 2 or 3 doses of COVID-19 mRNA vaccines in a cohort of patients with rheumatic diseases.

Methods

We collected biological samples longitudinally before and after 2-3 doses of COVID-19 mRNA vaccines from a cohort of patients with systemic lupus erythematosus (SLE), psoriatic arthritis, Sjogren's syndrome, ankylosing spondylitis, and inflammatory myositis. Anti-SARS-CoV-2 spike IgG and IgA and anti-dsDNA concentration were measured by ELISA. A surrogate neutralization assay was utilized to measure antibody neutralization ability. Lupus disease activity was measured by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Expression of type I interferon signature was measured by real-time PCR. The frequency of extrafollicular double negative 2 (DN2) B cells was measured by flow cytometry.

Results

Most of the patients generated high SARS-CoV-2 spike-specific neutralizing antibodies comparable to those in healthy controls after 2 doses of mRNA vaccines. The antibody level declined over time but recovered after the third dose of the vaccine. Rituximab treatment substantially reduced antibody level and neutralization ability. Among SLE patients, no consistent increase in SLEDAI scores was observed post-vaccination. The changes in anti-dsDNA antibody concentration and expression of type I IFN signature genes were highly variable but did not show consistent or significant increases. Frequency of DN2 B cells remained largely stable.

Conclusion

Rheumatic disease patients without rituximab treatment have robust antibody responses toward COVID-19 mRNA vaccination. Disease activity and disease-associated biomarkers remain largely stable over 3 doses of vaccines, suggesting that COVID-19 mRNA vaccines may not exacerbate rheumatic diseases.

KEY MESSAGES

Patients with rheumatic diseases mount robust humoral immunity towards 3 doses of COVID-19 mRNA vaccines.Disease activity and biomarkers remain stable following 3 doses of COVID-19 mRNA vaccines.

Health Care Utilization in Systemic Lupus Erythematosus in the Community: The Lupus Midwest Network

OBJECTIVE

The aim of this study was to determine inpatient health care utilization in an incident cohort of patients with systemic lupus erythematosus (SLE) compared with the general population.

METHODS

This was a population-based cohort study in the upper Midwest, United States. We included patients fulfilling the European League Against Rheumatism/American College of Rheumatology SLE classification criteria between 1995 and 2018. They were 1:1 age-, sex-, county-matched with individuals without SLE. All hospital admissions and emergency department (ED) visits were electronically retrieved for 1995-2020. Rates for hospital admission, length of stay, readmission, ED visits, and discharge destination were compared between groups.

RESULTS

Three hundred forty-one patients with SLE and 341 comparators without SLE were included (mean age, 48.6 years at diagnosis; 79.2% female). Rates of hospitalization for patients with SLE and comparators were 29.8 and 9.9 per 100 person-years, respectively. These differences were present across sexes and age groups. Hospitalization rates were higher in patients with SLE after diagnosis and remained higher than comparators for the first 15 years of the disease. Patients with SLE were more likely than comparators to visit the ED (hazard ratio, 2.71; 95% confidence interval, 2.05-3.59). Readmission rates (32% vs. 21%, p = 0.017) were higher in patients with SLE. Length of stay and discharge destination were similar between both groups.

CONCLUSION

Patients with SLE were more likely to be hospitalized and to visit the ED than individuals without SLE, highlighting important inpatient care needs. Increased hospitalization rates were observed in both male and female patients and all age groups.

Soluble LILRA3 is aberrantly expressed in antiphospholipid syndrome (APS) and is a potential marker of thrombotic APS

OBJECTIVE

Leucocyte immunoglobulin-like receptor A3 (LILRA3) belongs to a family of leucocyte receptors. Our previous study reported LILRA3 transcripts were markedly upregulated in neutrophils from patients with APS. We undertook this study to investigate clinical implications of LILRA3 in APS and its potential role in APS-associated thrombosis.

METHODS

Two independent cohorts were studied. The first consisted of 294 APS patients, 48 asymptomatic aPL carriers and 150 healthy controls (HCs) from Peking University People's Hospital. The second included 99 APS patients, 25 aPL carriers and 40 HCs from United States APS centres. Serum or plasma concentrations of LILRA3 and MPO-DNA complexes were measured. Additionally, 35 patients with thrombotic APS (tAPS) were evaluated to determine potential effects of immunosuppressive therapy on serum concentrations of LILRA3 and MPO-DNA complexes.

RESULTS

Both positivity and serum concentration of LILRA3 were significantly increased in APS patients, especially in those with tAPS. LILRA3-positive tAPS patients displayed more severe thrombotic manifestations. Serum LILRA3 was positively correlated with MPO-DNA complexes in LILRA3-positive tAPS. After immunosuppressive treatment, LILRA3 and MPO-DNA complexes were consistently decreased in tAPS patients. Key findings from the Peking cohort were confirmed in the United States cohort.

CONCLUSION

Our study provides first evidence that LILRA3 is aberrantly expressed in APS, especially in patients with tAPS. Serum LILRA3 correlated with MPO-DNA complexes, and the two indices were consistently decreased in tAPS patients after treatment. LILRA3 may play a role in thrombosis of APS and may serve as a biomarker and/or therapeutic target in tAPS.

COVID-19 Vaccine Uptake Among Patients With Systemic Lupus Erythematosus in the American Midwest: The Lupus Midwest Network (LUMEN)

OBJECTIVE

Patients with systemic lupus erythematosus (SLE) are at higher risk of poor outcomes from coronavirus disease 2019 (COVID-19). The vaccination rate among such patients is unknown. We aimed to assess COVID-19 vaccine uptake among patients with SLE.

METHODS

We included 342 patients with SLE from the Lupus Midwest Network (LUMEN) and 350 age-, sex-, race-, and county-matched comparators. Vaccination uptake for influenza, pneumococcal, and zoster vaccines before pandemic restrictions began (up to February 29, 2020) was assessed. First-dose COVID-19 vaccine uptake was electronically retrieved and manually ascertained (December 15, 2020, to July 31, 2021). Time to COVID-19 vaccination, demographics, SLE manifestations, medications, Charlson Comorbidity Index, Area Deprivation Index, and Rural-Urban Commuting Area codes were compared.

RESULTS

On July 31, 2021, 83.3% of patients with SLE and 85.5% of comparators were vaccinated against COVID-19. The COVID-19 vaccination rates were similar among SLE and comparators (hazard ratio 0.93, 95% CI 0.79-1.10). Unvaccinated patients with SLE were more likely than vaccinated patients to be men (27.3% vs 14.1%), younger (mean age 54.1 vs 58.8 yrs), have a shorter SLE duration (median 7.3 vs 10.7 yrs), and be less frequently vaccinated with influenza and pneumococcal vaccines.

CONCLUSION

Patients with SLE in the Lupus Midwest Network had similar COVID-19 vaccination uptake as matched comparators, most of whom were vaccinated early when the vaccine became available. One in 6 patients with SLE remain unvaccinated.

Risk of severe COVID-19 outcomes associated with rheumatoid arthritis and phenotypic subgroups: a retrospective, comparative, multicentre cohort study

Background

Rheumatoid arthritis has been associated with severe COVID-19, but few studies have investigated how phenotypes of rheumatoid arthritis affect these associations. We aimed to investigate the associations between rheumatoid arthritis and phenotypes of interstitial lung disease, serostatus, and bone erosions with COVID-19 severity.

Methods

We did a retrospective, comparative, multicentre cohort study at two large health-care systems (Mayo Clinic [19 hospitals and affiliated outpatient centres] and Mass General Brigham [14 hospitals and affiliated outpatient centres]) in the USA. Consecutive patients with rheumatoid arthritis meeting the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria and who had COVID-19 between March 1, 2020, and June 6, 2021, were matched 1:5 on age, sex, and calendar date with patients without rheumatoid arthritis (comparators). Data were received from electronic health records from Mayo Clinic and Mass General Brigham. We examined subgroups of patients with rheumatoid arthritis by phenotypic features: rheumatoid arthritis-associated interstitial lung disease, seropositivity (for anti-cyclic citrullinated peptide, rheumatoid factor, or both), and bone erosions. Severe COVID-19 was a composite of hospitalisation or death. We used Cox regression to estimate hazard ratios (HR) for severe COVID-19, comparing rheumatoid arthritis and subgroups to the comparator group.

Findings

We identified 582 patients with rheumatoid arthritis and 2875 matched comparators, all of whom had COVID-19 within the study dates. The mean age of those with rheumatoid arthritis was 62 [SD 14] years, 421 (72%) of 582 were women and 161 (28%) were men, 457 (79%) were White, 65 (11%) were Hispanic or Latino, and 41 (7%) were Black. Among patients with rheumatoid arthritis, 50 (9%) of 582 had interstitial lung disease, 388 (68%) of 568 were seropositive, and 159 (27%) of 582 had bone erosions. Severe COVID-19 occurred in 126 (22%) of 582 patients with rheumatoid arthritis versus 363 (13%) 2875 in the comparator group. Patients with rheumatoid arthritis had an HR of 1·75 (95% CI 1·45-2·10) for severe COVID-19 versus the comparator group. Patients with rheumatoid arthritis-associated interstitial lung disease had an HR of 2·50 (1·66-3·77) versus the comparator group for severe COVID-19. The risk for severe COVID-19 was also higher in patients with rheumatoid arthritis who were seropositive (HR 1·97 [95% CI 1·58-2·46]) or had erosive disease (1·93 [1·41-2·63]) than for those in the comparator group.

Interpretation

Patients with rheumatoid arthritis have an increased risk of severe COVID-19 across phenotypic subgroups, especially among patients with interstitial lung disease. These findings suggest that rheumatoid arthritis with interstitial lung disease, or its treatment, might be a substantial contributor to severe COVID-19 outcomes for patients with rheumatoid arthritis.

Funding

None.

Utilization of preventive services in a systemic lupus erythematosus population-based cohort: a Lupus Midwest Network (LUMEN) study

BACKGROUND

Systemic lupus erythematosus (SLE) is a disease that can lead to damage of multiple organs and, along with certain treatments, increase the risk of developing cancer, cardiovascular disease, diabetes, osteoporosis, and infections. Preventive services are particularly important in patients with SLE to mitigate the aforementioned risks. We aimed to evaluate the trends of preventive services utilization in patients with systemic lupus erythematosus, compared with non-SLE population.

METHODS

All ≥19-year-old patients in the Lupus Midwest Network (LUMEN) registry, a population-based cohort, with SLE on January 1, 2015, were included and matched (1:1) by sex, age, race, and county to non-SLE comparators. Among both groups, we compared the rates of screenings for breast and cervical cancer, hypertension, hyperlipidemia, diabetes mellitus, and osteoporosis as well as immunizations.

RESULTS

We included 440 SLE patients and 430 non-SLE comparators. The probability of breast cancer screening among women with SLE was similar to comparators (hazard ratio [HR] 1.09, 95% CI 0.85-1.39), while cervical cancer screening was lower (HR 0.75, 95% CI 0.58-0.96). Hypertension screening was higher among patients with SLE (HR 1.35, 95% CI 1.13-1.62); however, hyperlipidemia screening was similar to comparators (HR 1.16, 95% CI 0.96-1.41). Diabetes and osteoporosis screenings were more likely to be performed for SLE patients than for comparators (HR 2.46, 95% CI 2.11-2.87; and HR 3.19, 95% CI 2.31-4.41; respectively). Influenza and pneumococcal immunizations were higher among SLE patients (HR 1.31, 95% CI 1.12-1.54; and HR 2.06, 95% CI 1.38-3.09; respectively), while zoster vaccination was similar (HR 1.17, 95% CI 0.81-1.69).

CONCLUSIONS

The trends of utilization of preventive services by SLE patients vary according to screening or vaccine compared with the general population. Considering these differences, we demonstrate an opportunity for improvement, particularly in cervical cancer, hyperlipidemia, and osteoporosis screenings and vaccinations.

OP0251 IMPACT OF INTERSTITIAL LUNG DISEASE ON SEVERE COVID-19 OUTCOMES FOR PATIENTS WITH RHEUMATOID ARTHRITIS: A MULTICENTER STUDY

Background

RA has been associated with poor COVID-19 outcomes, but few studies have investigated outcomes in RA features such as interstitial lung disease.

Objectives

To assess COVID-19 outcomes in patients with RA overall, and those with and without ILD, compared to general population comparators.

Methods

A multicenter, retrospective cohort study was conducted at Mayo Clinic (19 hospitals and affiliated outpatient centers in 4 states) and Mass General Brigham (14 hospitals and affiliated outpatient centers in New England). Consecutive patients with RA meeting ACR/EULAR criteria and a positive COVID-19 test from March 1, 2020 through June 6, 2021 were matched 1:5 on age, sex, race, and COVID-19 test date with general population comparators without RA. RA features assessed included: RA-ILD per Bongartz criteria [1], duration, rheumatoid factor (RF), cyclic citrullinated peptide antibody (CCP), bone erosions, and treatments. The primary outcome was a composite of hospitalization or death following COVID-19 diagnosis. We used multivariable Cox regression to investigate the association of RA, and features such as ILD, with COVID-19 outcomes compared to matched comparators.

Results

We analyzed 582 patients with RA and 2892 comparators without RA, all with COVID-19. Mean age was 62 years, 51% were female, and 79% were White. Mean RA duration was 11 years, 67% were seropositive (52% RF+ and 54% CCP+), 27% had bone erosions, 28% were on steroids, and 79% were on DMARDs. 50/582 (9%) patients with RA had ILD.

The COVID-19 hospitalization or death rate for RA patients was higher than comparators (3.0 per 1,000 days [95% CI 2.5-3.6] vs. 1.9 per 1,000 days [95% CI 1.7-2.1], respectively). Overall, RA patients had a 53% higher risk of hospitalization or death than comparators after adjustment (95% CI 1.20-1.94).

Among those with RA-ILD, the hospitalization or death rate was significantly higher than comparators (10.9 [95% CI 6.7-15.2] vs. 2.5 per 1,000 days [1.8-3.2], respectively). RA-ILD was associated with nearly 3-fold higher risk for hospitalization or death than comparators (multivariable HR 2.84 [95% CI 1.64-4.91], Table 1). There was a significant interaction between RA/comparator status and presence/absence of ILD for risk of severe COVID-19 (p<0.001, Figure 1). The elevated risk for severe COVID-19 was similar for RA subgroups defined by serostatus or bone erosions.

Table 1.

Frequencies, proportions, and hazard ratios for COVID-19 outcomes, comparing all RA patients, and subgroups with or without RA-ILD, to matched comparators.

COVID-19 OutcomesAll RA Patients (n=582)RA-ILD (n=50)RA Patients without ILD (n=532)Comparators (n=2,892)Hospitalization, n (%)121 (21)24 (48)97 (18)402 (14)Unadjusted HR (95% CI)1.58 (1.27, 1.96)2.65 (1.71, 4.09)1.43 (1.12, 1.82)Ref.Adjusted* HR (95% CI)1.45 (1.14, 1.83)2.35 (1.38, 4.00)1.31 (1.00, 1.70)Ref.Death, n (%)26 (4)9 (18)17 (3)63 (2)Unadjusted HR (95% CI)1.72 (0.98, 3.01)5.88 (2.07, 16.71)1.13 (0.56, 2.29)Ref.Adjusted* HR (95% CI)1.24 (0.66, 2.32)13.94 (4.30, 45.18)0.75 (0.35, 1.63)Ref.Hospitalization or death, n (%)126 (22)25 (50)101 (19)419 (14)Unadjusted HR (95% CI)1.66 (1.33, 2.07)3.01 (1.93, 4.70)1.47 (1.14, 1.89)Ref.Adjusted* HR (95% CI)1.53 (1.20, 1.94)2.84 (1.64, 4.91)1.34 (1.02, 1.77)Ref.

*Adjusted for age, sex, race, and smoking

Figure 1.

Multivariable hazard ratios for the composite outcome of hospitalization or death from COVID-19, comparing all RA and subgroups by serostatus, bone erosions, and ILD to matched comparators without RA.

Conclusion

We confirmed that RA was associated with severe COVID-19 outcomes compared to the general population. We found evidence that ILD may be an effect modifier for the relationship between RA and severe COVID-19 outcomes, but RA subgroups defined by serostatus and bone erosions had similarly elevated risk. These findings suggest that ILD or its treatment may be a major contributor to severe COVID-19 outcomes in RA.

References

[1]Bongartz, T, et al, Arthritis Rheum. 2010 Jun;62(6):1583-91.

Disclosure of Interests

None declared

Evolution of clinical, histological and serological features in a Primary Sjὄgren´s Syndrome cohort and the limitations of the current classification criteria

OBJECTIVE

The classification and/or diagnosis of Primary Sjögren's Syndrome (PSS) requires a multidimensional approach. Although age and the duration of sicca symptoms can affect the clinical, serological and histological features found at initial evaluation, these are not considered when using classification criteria as a guide for PSS diagnosis. Our study aimed to explore if there is any relationship between the duration of symptoms and clinical, histopathological and serological findings.

METHODS

An observational, retrospective study was performed. All the evaluated subjects were part of the "sicca cohort". Patients' clinical, serological and histological characteristics were assessed according to the duration of symptoms. A Receiving Operator Characteristic (ROC) curve was performed to establish the duration of symptoms (months) that predicted a PSS diagnosis. Binary regression models and odds ratios were used to evaluate the association between the duration of symptoms and the clinical, serological, and histopathological profiles.

RESULTS

One hundred and sixteen patients were included; 97(83.62%) fulfilled PSS criteria. Of the 116 patients, thirty-six (31.03%) had < 15 months presenting with sicca symptoms when receiving a diagnostic approach. A duration of symptoms >15 months was associated with an altered Schirmer test (OR 2.76; 95% CI 1.15-6.61, P=0.02), low salivary flow rate (OR 3.5; 95% CI 1.34-9.13, P=0.01), ≥1 foci score (OR 1.21; 95% CI 1-1.45, P=0.04), ocular (OR 7.8; 95% CI 1.49-40.81, P=0.02) and severe oral symptoms (OR 2.61; 95% CI 1.16-5.87, P=0.02).

CONCLUSION

The time of evolution of symptoms plays a fundamental role in the clinical, histological and serological profiles in PSS.

AB0624 COMPARISON OF DIFFERENT FRAX SCORES WITHOUT BONE MINERAL DENSITY FOR THE EVALUATION OF RISK FRACTURE IN MEXICAN PATIENTS WITH RHEUMATIC DISEASES

Background:

Osteoporosis (OP) is characterized by compromised bone strength and deterioration of quality, often leading to fragility fractures(1). Dual-energy x-ray absorptiometry (DXA) is the recommended test for OP screening(1). However, there are limitations to perform DXA on all patients, and the clinicians use screening tools to identify those patients with higher risk, like the FRAX score(2). Nevertheless, these scores have showed low to moderate correlation with DXA in RD patients(3).

Objectives:

To evaluate the fracture risk in RD patients, using different versions of FRAX scores without a bone mineral density (BMD) measure.

Methods:

An observational prospective study was performed at the Rheumatology Clinic in the University Hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico, between August and October 2020. Consecutive patients with a RD were evaluated as part of a “Bone Health Program”(3). Demographics and the risk factors included in FRAX tool was collected from ≥40 years-old patients; FRAX score was calculated online at https://www.sheffield.ac.uk/FRAX/ (algorithm for Mexicans). Four versions were calculated: 1) FRAX score without (w/o) BMD; 2) FRAX score with a T-score of -1.0 (w/Op); 3) FRAX score with a T-score of -2.5 (w/OP) and a FRAX score with positive previous fracture (Fx+). Then were classified as low (<10% for OP or <1% for hip), intermediate (10%-19% for OP or 1%-<3% for hip) and high risk (≥20% for OP or ≥3% for hip). Results are shown in means (SD) or frequency (%). A chi-square test was used to compare groups. Spearman’s correlation test (rho) was done between OP risk and Hip risk in each version of FRAX. P<0.05 was considered statistically significant.

Results:

One hundred and three patients were included, 93.2% were woman. The most frequent diagnosis was RA in 51.5% of patients, followed by osteoarthritis in 7.8%. 62.1% of patients had a previous BMD measured by DXA. 21.4% had history of previous fracture. 61.2% of patients were taking glucocorticoids. (Table 1). According to FRAX risk w/o BMD, 82 (79.6%) had low risk, 13 (12.6%) had intermediate risk, and 8 (7.8%) had high risk for OP. According to FRAX risk w/o BMD, 59 (57.3%) had low risk, 24 (23.3%) had intermediate risk, and 20 (19.4%) had high risk for hip fracture (Table 2). The correlations between OP risk and Hip risk in each version were as follow: FRAX w/o BMD (rho= .734, P= <.001) FRAX w/Op (rho= .308, P= .002); FRAX w/OP (rho= .476, P= <.001); FRAX with Fx+ (rho= .634, P= <.001).

Conclusion:

There is a wide variability among the different FRAX risk scores evaluated, and moderate to high correlation between the OP and Hip risk in patients with RD.

References:

[1]Ann Intern Med. 2017;166(11):818-839. doi:10.7326/M15-1361

[2]Arthritis Rheumatol. 2019;71(suppl 10):3924-3925

[3]Ann Rheum Dis. 2020;79:1190-1191

Table 1.

FRAX score risk factors

N= 10395% C.I.Age, years, mean (SD)57.0 (9.56)55.1 – 58.9Female, n (%)96 (93.2)86.4 – 96.9Weight, kg, mean (SD)68.2 (14.88)65.3 – 71.2Height, cm, mean (SD)154.6 (6.73)153.3 – 155.9Previous Fracture, n (%)22 (21.4)14.5 – 30.3Parent Fractured Hip, n (%)12 (11.7)6.7 – 19.4Current Smoking, n (%)12 (11.7)6.7 – 19.4Glucocorticoids, n (%),63 (61.2)51.5 – 70.0Rheumatoid arthritis, n (%)53 (51.5)41.9 – 60.9Secondary osteoporosis, n (%)1 (1.0)0.0 – 5.8Alcohol use, n (%)1 (1.0)0.0 – 5.8Previous DXA, n (%)64 (62.1)52.5 – 70.9

Disclosure of Interests:

None declared.

AB0301 CRITERIA FULLFILLMENT OF PRIMARY SJÖGREN’s SYNDROME ACCORDING TO TIME OF EVOLUTION OF SICCA SYMPTOMS

Background:

Primary SjÖgren´s Syndrome (PSS) is an autoimmune disease characterized by sicca symptoms, autoantibodies and lymphocytic infiltrate in exocrine glands.

Classification and diagnosis of PSS is performed by applying 2002 AECG, 2012 ACR or 2016 ACR-EULAR criteria.

Time of evolution of symptoms has been associated with different clinical, serological and pathology findings.

Objectives:

Document sicca profiles and compare findings according to time of evolution of symptoms.

Methods:

A descriptive retrospective observational study was performed in 116 patients with sicca symptoms in a Rheumatology center in México.

Patients were separated according to time of evolution of sicca symptoms in ≤1 year, ≤2 years, ≤3 years, and ≥3 years. Clinical, serological, and histopathology features were assessed at each established time.

Time from symptom onset to diagnosis was reported in median and interquartil range (IQR); age at symptom onset and age at diagnosis was expressed in mean and standard deviation (SD).

Patients were classified as PSS if they fullfilled the 2002 AECG or 2016 ACR-EULAR criteria. Serology of Rheumatoid factor (RF), ANA, Anti-Ro, and Anti-La were documented.

Description of MSGB was performed reporting presence of foci, lobules, atrophy, adipose tissue infiltration and ductal dilatation.

Results:

One hundred and sixteen sicca patients had a complete profile and 97 (83.62%) fulfilled AECG 2002 SSP criteria. Eighty-two (70.6%) patients with an ocular staining score were able to classify as PSS using the 2016 ACR-EULAR criteria.

Of the sicca cohort, 112 (96.6%) were female. The mean age of symptom onset was 48.4 (SD 13.11) years, and the mean age at diagnosis was 53.33 (SD 12.43) years. The median time from symptom onset to diagnosis was 36 (IQR 12-84) months.

Fullfilment the 2002 AECG PSS classification criteria according to duration of sicca symptoms is described in Table 1.

Table 1.

Classification PSS criteria according to time of evolution of sicca symptoms

<12 months<24 months<36 months>37 monthsOral symptoms28%40%48%89%Ocular symptoms26%39%47%93%Altered Salivary flow rate test21%32%41%81%Altered Schirmer test19%28%38%75%Positive Anti Ro13%19%26%47%Positive Anti La3%6%10%16%≥1 foci score/4mm214%24%34%67%2002 AECG Criteria*22%34%44%84%*AECG-American European Consensus Group0%25%50%75%100%

Extra-classification criteria such as severe oral symptoms (choking, cracker cookie) were more common with prolonged symptom duration. Figure 1

Figure 1.

Clinical, serologic and histopathologic findings according to sicca symptom duration

Conclusion:

The probability and capability of fulfilling PSS criteria is time dependent, this should be taken into consideration when evaluating patients referring sicca symptoms. Longer symptom duration was associated with more severe clinical, serological and histopathology profiles.

References:

[1]Shiboski CH, Baer AN, Shiboski SC, et al (2018) Natural History and Predictors of Progression to Sjögren’s Syndrome Among Participants of the Sjögren’s International Collaborative Clinical Alliance Registry. Arthritis Care Res (Hoboken) 70:284–294. https://doi.org/10.1002/acr.23264

Acknowledgements:

We thank Dr. Jazzia Emily Díaz Angulo and Dr. Gabriela Luna Limón for their help in data compilation.

Disclosure of Interests:

None declared

POS1494-HPR THE COLLABORATION OF RHEUMATOLOGY-DERMATOLOGY IN THE EVALUATION OF RHEUMATIC DISEASES PATIENTS: EXPERIENCE IN A UNIVERSITY HOSPITAL

Background:

Dermatological manifestations are not rare in patients with rheumatic diseases (RD). Multidisciplinary management and direct interaction between these disciplines are essential. According to Dermatology-Rheumatology clinics, most diagnoses evaluated are systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), with dermatitis being the most common manifestation. It is important to be aware that skin problems in RD patients are not always related to the underlying condition(1). Nowadays, there is significant evidence to support the manifold advantages of the joint dermatology-rheumatology clinics, including improved quality of care for patients and multidisciplinary training for new physicians(2). This ongoing trend is intended to highlight the important interaction between specialties that treat overlapping conditions, and it has been incorporated in academic health centers to give a comprehensive approach to patients.

Objectives:

Our purpose was to describe the collaboration between the Rheumatology and Dermatology services during the evaluation of RD patients.

Methods:

An observational, retrospective study was performed in the Rheumatology Service of the University Hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico, between March 2019 and February 2020. All the patients with a Rheumatology or Dermatology consultation requested were included (hospitalized and outpatients). Demographic (age, gender, baseline diagnosis), the reason for consultation, specialty requested, type of treatment, final diagnoses, and agreement in final diagnosis were registered. Results are shown in descriptive statistics.

Results:

One hundred and seventy-four patients were included, 142 (81.6%) patients from the outpatient clinic and 32 (18.4%) patients hospitalized. The mean age was 45.1 (SD±15.8) years, 135 (77.6%) were females, 54 (31%) patients were under initial diagnosis evaluation, 30 (17.2%) had RA, 25 (14.4%) patients had SLE, 15 (8.6%) patients had psoriatic arthritis, 12 (6.9%) patients had systemic sclerosis, 6 (3.4%) patients had dermatomyositis. The main reasons for consultation in hospitalized patients were acute lupus (15.6%), subacute lupus (12.5%), purpura (12.5%), cutaneous vasculitis (9.4%), urticarial dermatitis (9.4%), dermatomyositis (6.3%) and others (34.3%). The consultation requested was: 156 (89.7%) to Dermatology and 18 (10.3%) to Rheumatology. The type of treatment prescribed was topic/local in 37 (21.3%) patients, systemic in 25 (14.4%) and both in 92 (52.9%) patients. The final diagnoses were related to the underlying disease in 102 (77%) patients and unrelated in 40 (23%) patients. The agreement between initial clinical suspicion and final diagnoses reached 75.9% between Rheumatology and Dermatology services. Figure 1.

Conclusion:

The collaboration between Rheumatology and Dermatology services are very important. Most of the patients were under initial evaluation. All the rheumatologists and dermatologists should be aware of the interdependence from both specialties to give the best quality of care to the patients.

References:

[1]Samycia M, McCourt C, Shojania K, Au S. Experiences From a Combined Dermatology and Rheumatology Clinic: A Retrospective Review. J Cutan Med Surg. 2016;20(5):486-489. doi:10.1177/1203475416649138.

[2]Theodorakopoulou E, Dalamaga M, Katsimbri P, Boumpas DT, Papadavid E. How does the joint dermatology-rheumatology clinic benefit both patients and dermatologists?. Dermatol Ther. 2020;33(3):e13283. doi:10.1111/dth.13283

Figure 1.

Disclosure of Interests:

None declared

AB0281 MORTALITY PREDICTORS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A SINGLE TERTIARY CENTER REFERRAL EXPERIENCE

Background:

Systemic Lupus Erythematosus (SLE) is a heterogeneous chronic multisystemic disease that has an increased risk of requiring inpatient management with higher morbidity and mortality rates.

The most frequent causes of mortality are a high disease activity, infections, and cardiovascular diseases.

Objectives:

To determine the predictors of mortality in patients diagnosed with SLE.

Methods:

A longitudinal, descriptive, observational study was performed from March 2017-March 2020 at the University Hospital of the Autonomous University of Nuevo León, México, including patients with a diagnosis of SLE according to the ACR-EULAR 2012/2019 criteria.

Descriptive statistics were used for demographic variables. Associations between mortality and clinical variables were determined using binary logistic regression analysis; a p <0.05 was considered statistically significant. The SPSS program version 20 was used.

Results:

One-hundred and eighty-six patients with SLE diagnosis who fulfilled ACR-EULAR 2012/2019 criteria were included, 161 (86.6%) were women; the mean age was 35.8 (SD 15.41) years. The main chief complaints were dyspnea 31 (16.7%), fever in 28 (15.1%), renal involvement in 21 (11.29%), and arthritis in 19 (10.22%) patients.

Of the 186 patients, 34 (18.3%) had a readmission, 13 (7%) required intensive care unit management, 68 (36.6%) had some type of infection and 22 (11.8%) died. Factors associated with mortality are shown in table 1.

Patients receiving steroids and immunosuppression previous to hospitalization were 73 (39.2%) and 92 (49.5%) respectively.

Conclusion:

Infections remain the leading cause of death in SLE patients. Factors that predispose to infections are a chronic use of steroids and immunosuppression as well as high activity of disease.

References:

[1]Wu X-Y, Yang M, Xie Y-S, Xiao W-G, Lin J, Zhou B, et al. Causes of death in hospitalized patients with systemic lupus erythematosus: a 10-year multicenter nationwide Chinese cohort. Clin Rheumatol. enero de 2019;38(1):107-15.

Table 1.

Association between clinical and therapeutic factors with mortality in SLE patients.

Factors associated with mortalityUnivariadoMultivariadoβ (95 % IC)β (95 % IC)□Age0.93 (0.96-1.02)0.98 (0.96-1.02)Use of mechanical ventilation3.83 (1.07-13.4)*3.07 (0.59-16.04)Previous use of steroids3.92 (1.51-10.15)*2.04 (0.58-7.35)Previous use of immunosupression4.04 (1.42-11.45)*2.85 (0.71-11.48)Infection3.57 (1.41-9.01)*3.25 (1.19-8.86)*

p <0.05 *

Disclosure of Interests:

None declared

AB0866-HPR INPATIENT RHEUMATOLOGY HEALTHCARE IN A TERTIARY REFERRAL ACADEMIC HOSPITAL

Background:

Diagnosis of autoimmune diseases (AD) has been increasing in recent years, with a prevalence of 3- 5% worldwide. The causes that lead to an inpatient approach in patients with suspicion or a confirmed rheumatic disease (RD) vary widely.

RD are at higher risk of infectious, cardiovascular and other comorbidities due to immunosuppression, a continuous inflammatory state and an altered immune response, increasing morbidity and mortality rates.

Objectives:

Describe hospitalized patients who required a rheumatology consultation due to a preexistent or a new RD.

Methods:

A descriptive, observational study was performed during a three year follow up (March 2017 -February 2020) in a University Hospital in Mexico. We included patients with definite or suspicion of a RD who received a rheumatologic evaluation. Demographic and clinical characteristics, length of stay and complications such as infection, readmission, use of mechanical ventilation and mortality were registered. Descriptive statistics were used. Binary regression models were applied to find association between clinical factors and infection/mortality in RD hospitalized patients, SPSS v20 was used to perform statistical analysis. A P< 0.05 was considered statistically significant.

Results:

A total of 642 hospitalized patients received a rheumatologic evaluation. Of the evaluated patients, 315 (49.1%) had a history of a confirmed RD, of these, 237 (75.2%) were hospitalized due to a complication associated to the underlying RD and 78 were hospitalized for other non-rheumatic nor related disorder and were omitted for the rest of the analysis; 327 (50.9 %) patients were evaluated for the first time, 147 (45.0%) of them being diagnosed with a new RD; Systemic Lupus Erythematosus (SLE) 55 (37.4%) was the most frequent diagnosis. Figure 1

Of the 642 evaluated patients, 384 (59.81%) patients with a previous (237) or new (147) rheumatic cause of hospitalization were studied. Table 1A

Factors associated to infection and mortality in the 384 patients are shown in Table 1B.

Conclusion:

Inpatient rheumatologic evaluation is a major concern of healthcare due to the severity and prognosis of these diseases. SLE was found to be the most common diagnosis in patients evaluated for the first time. Infection is an important cause of hospitalization and mortality, being the use of steroids and immunosuppression some of the main risk factors of these outcomes.

References:

[1]O’Sullivan O, Bateman J, Jobanputra P. 172 Acute Rheumatology Referrals are Increasing: A Service Evaluation of more than 1000 Consecutive Acute Inpatient Referrals from a Tertiary Centre. Rheumatology. 1 de abril de 2016;55(suppl_1):i131-2.

Table 1A.

Descriptive analysis of patients receiving a Rheumatology evaluation

Total evaluated patientsRheumatic cause of hospitalizationNew rheumatic diseasen=642n=384n=147Age (SD) Mean39 (25-53)40 (25-53)40.56 (16-89)SexFemale462 (72%)285 (74.2%)94 (63.9%)Median days of follow up6 (4-11)6 (3-11)7 (2-11)Previous immunosupression225 (35%)156 (40.6%)16 (10.9%)Previous steroid use197 (30.7%)132 (34.4%)12 (8.2%)Mechanical ventilation60 (9.3%)26 (6.8%)11 (7.5%)Infection248 (38.6%)148 (38.5%)51 (34.7%)Mortality59 (9.2%)39 (10.2%)13 (8.8%)Readmission106 (16.5%)89 (23.2%)14 (9.5%)Table 1B.

Association between clinical factors and infection/mortality

InfectionUnivariateMultivariateβ (95 % CI)β (95 % CI)Age1.02 (1-1.02)1.02 (1.01-1.03)Use of mechanical ventilation4.82 (1.97-11.77)4.28 (1.67-10.97)Previous use of steroids1.55 (1.01-2.39)1.33 (0.74-2.4)Previous use of immunosupression1.37 (0.9-2.07)1.16 (0.65-2.04)Readmission1.76 (1.02-3.02)1.4 (0.76-2.56)MortalityAge0.71 (0.99-1.02)0.99 (0.98-1.02)Use of mechanical ventilation7.09 (2.95-17.04)8.54 (2.89-25.23)Previous use of steroids1.95 (1-3.8)0.97 (0.39-2.39)Previous use of immunosupression2.58 (1.31-5.1)3.06 (1.21-7.72)Infection3.66 (1.81-7.37)2.96 (1.41-6.23)Readmission1.33 (0.58-3.05)0.42 (0.14-1.24)

p <0.05 *

Disclosure of Interests:

None declared

POS0434 CLINICAL UTILITY OF SCREENING TOOLS IN REFERRAL OF PATIENTS WITH HAND ARTHRALGIA TO RHEUMATOLOGISTS

Background:

Clinically Suspect Arthralgia (CSA) was defined by European League Against Rheumatism to identify a combination of clinical features that best characterise patients with arthralgia who are at risk of progression to rheumatoid arthritis (RA) (1). A specificity >90% is obtained with the presence of ≥4 parameters. Another clinical feature useful to identify patients at risk is the squeeze test (ST). Recently, we have identified the necessary strength to screen the patient with arthralgia through ST, with a median squeeze force of 3 kg and 2.78 kg to evoke pain in the right and left hand of the RA patient, respectively (2). Primary care physicians (PCP), the first contact of patients at risk, could benefit from these screening tools, prompting early referral, diagnosis, and treatment of these individuals.

Objectives:

To identify the clinical utility of CSA and ST in the referral of patients with hand arthralgia from PCP to rheumatologists.

Methods:

We conducted a cohort study from October 2018 to December 2020 in 110 patients who attended a Family Medicine clinic at University Hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico. We recruited patients with hand arthralgia with no history of previous trauma or autoimmune rheumatic diseases. A questionnaire assessing CSA criteria was employed, and an ST maneuver was performed through an automated compressor with quantitative measures of applied force. Patients were grouped based on referral to Rheumatology consultation and variables categorized according to clinically relevant thresholds. Chi square test was performed in categorical variables, t-student test was performed in normal, continuous variables and Spearman’s rho correlation was utilized between CSA number of criteria and quantitative ST force using SPSS v25.

Results:

Out of 110 patients, 49 (44.5%) were referred to a rheumatologist. A non-significant association was found across assessed variables in referred and non-referred patients as seen in Table 1. Spearman’s rho found a moderate correlation between the number of CSA criteria and quantitative force in right (r=-.445) and left (r=-.382) hand as seen in Figure 1. Evaluation of CSA cutoffs other than ≥4 did not yield a significant association in referral of patients to the rheumatologist (data not shown).

Conclusion:

The clinical utility of CSA criteria and ST in referral of patients with hand arthralgia from PCP to rheumatologists is currently limited. More research is needed to elucidate the clinical utility of these screening tools.

References:

[1]van Steenbergen HW, et al. EULAR definition of arthralgia suspicious for progression to rheumatoid arthritis. Ann Rheum Dis. 2017;76(3):491-496.

[2]Vega-Morales D, et al. Automated squeeze test (Gaenslen’s manoeuvre) to identify patients with arthralgia suspicious for progression to RA: improving time delay to rheumatology consultation. Ann Rheum Dis. 2017;76(10):e40.

Table 1.

Demographic characteristics and clinical performance of CSA and ST in referral of patients with hand arthralgia from PCP to rheumatologists.

Referred patients,n = 49Non-referred patients, n = 61pFemale, n (%)40 (81.6)50 (82.0)0.964Age in years, mean ± SD46.76 ± 14.4352.05 ± 15.000.064Patients with ≥4 CSA criteria, n (%)23 (46.9)19 (31.1)0.090Right hand positive ST patients, n (%)21 (42.9)22 (36.1)0.468Left hand positive ST patients, n (%)26 (53.1)28 (45.9)0.455Force in right hand ST, mean kg ± SD4.19 ± 2.923.86 ± 3.070.571Force in left hand ST, mean kg ± SD4.25 ± 3.043.54 ± 2.740.198

CSA, Clinically Suspect Arthralgia; ST, Squeeze Test; SD, Standard Deviation.

Disclosure of Interests:

None declared

POS1220 PREGNANT AND POSTPARTUM WOMEN WITH AUTOIMMUNE RHEUMATIC DISEASES AND COVID-19: A CASE SERIES

Background:

Pregnant women represent a high-risk population during the COVID-19 pandemic. The main cause of maternal deaths in Mexico during 2020 was COVID-19 with 191 (21.2%) deaths registered until December 2020. The age group most affected was 30 to 34 years. Women during their third trimester and during puerperium were the most affected. Information regarding pregnant and postpartum women with autoimmune rheumatic diseases remains scarce.

Objectives:

The aim of this study was to describe a COVID-19 case series from a clinic of pregnancy and rheumatic diseases.

Methods:

We conducted a descriptive, retrospective study in patients from the clinic of pregnancy and rheumatic diseases of the University Hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico. Pregnant patients with RD and documented COVID-19 between March and November 2020 were included. Demographic and clinical features were obtained. Results are shown in descriptive statistics.

Results:

From the 18 women with autoimmune rheumatic disease in follow-up during this period, 2 (11.1%) pregnant women, 2 (11.1%) postpartum women, and 1(5.5%) post-miscarriage woman developed COVID-19. The mean age was 28 ± 6.3 years, 3 (60%) had systemic lupus erythematosus, 1 (20%) had rheumatoid arthritis, and 1 (20%) had the antiphospholipid syndrome. Clinical features and treatments are shown in Graphic 1 and Table 1. The most frequent symptoms were fever (80%), cough (60%) and anosmia (60%). Four (80%) had mild symptoms, and 1 (20%) had severe symptoms requiring intensive care unit admission and mechanical ventilation. Three (60%) referred history of contact with a person who had COVID-19. All the patients were using hydroxychloroquine and prednisone. No patient in our study died.

Conclusion:

From our population, a total of 27.8% presented COVID-19. Most of our patients had a mild course of SARS-CoV-2 infection consistent with data from the general population. Additionally, none of our patients had risk factors such as hypertension, diabetes, chronic kidney disease or lung disease. Nonetheless, pregnant women remain a vulnerable population. Prevention measures must continue worldwide to avoid additional COVID-19 morbidity and mortality.

References:

[1]Gob.mx. 2021. INFORME SEMANAL DE NOTIFICACIÓN INMEDIATA DE MUERTE MATERNA. [online] Available at: <https://www.gob.mx/cms/uploads/attachment/file/601780/MM_2020_SE51.pdf> [Accessed 10 January 2021].

[2]Arentz M, Yim E, Klaff L, et al. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. 2020;323(16):1612–1614. doi:10.1001/jama.2020.4326

Graphic 1.

Diagnosis, severity disease and clinical symptoms of pregnant rheumatic disease patients with COVID-19

Table 1.

Features, preventive measures, and treatments of pregnant rheumatic disease patients with COVID-19

N=5Age, years, mean (SD)28 (6.36)Obesity, n (%)2 (40)Current occupation, n (%) Employee3 (60) Student1 (20) Housewife1 (20)  Positive PCR test, n (%)5 (100)Prevention measures, n (%) Social Distancing2 (40) Quarantine3 (60) Contact with a person who had COVID-193 (60)Treatments used before disease, n (%) Prednisone5 (100) Hydroxychloroquine5 (100) Sulfasalazine2 (40) Azathioprine1 (20) Methotrexate*1 (20)Rheumatic treatment during disease, n (%) Continued3 (60) Suspended2 (40)

PCR: polymerase chain reaction, *Methotrexate was used during conception and suspended immediately after the pregnancy detection.

Disclosure of Interests:

None declared

AB0843 OBSTETRIC AND PERINATAL OUTCOMES IN MEXICAN WOMEN WITH RHEUMATIC DISEASES

Background:

Rheumatic diseases (RD) are more frequent among women of childbearing age. Adverse events during pregnancy in RDs have been frequently reported, leading some women to avoid pregnancy. “CEER” is an outpatient clinic in Monterrey, Nuevo Leon, Mexico, that was created for pregnant women with RD.

Objectives:

The objective is to describe pregnancy outcomes in patients with RD surveilled at a rheumatology outpatient clinic.

Methods:

A single-center retrospective study of women with RD at CEER between 2017 and 2020 was conducted. Clinical features and maternal, fetal and neonatal outcomes were retrospectively collected. The rate of adverse perinatal outcomes (APO) was compared with the tertiary referral center´s general obstetric population (GOP). All data was retrieved from clinical files.

Results:

Overall, 62 pregnancies in women with RD were recorded. The median maternal age at conception was significantly higher in pregnancies with RD than GOP (29 [24-35] years old vs 23 [19-28] years old, p<0.001).The odds of preterm delivery were increased among pregnancies with RD (OR 1.85, 95% CI 1.03-3.30, p=0.038). Other APO are summarized in Table 1. Rheumatoid arthritis (RA) was the leading diagnosis followed by systemic erythematosus lupus (SLE) and antiphospholipid syndrome (APS).

Cesarean sections were recorded in 41 pregnancies in RD group, more frequent than in GOP (66.1% vs 50.8%, p=0.016). Figure 1 shows the distribution of indications for cesarean sections, the two leading indications were previous cesarean section (43.9%) and Nonreassuring fetal heart rate pattern (19.5%) Pregnancies with RD appeared to have frequent, emergency cesarean sections and preterm deliveries compared with GOP (12.9% vs 15.9%, p=0.02 and 23.7% vs 12.2%, p=0.006, respectively).

Conclusion:

Pregnancies with RD were at increased risk for APO. Women of this population should be made aware of these risks and be closely monitored by a multidisciplinary team as a high-risk pregnancy.

References:

[1]Aljary H, Czuzoj-Shulman N, Spence AR, Abenhaim HA. Pregnancy outcomes in women with rheumatoid arthritis: a retrospective population-based cohort study. J Matern Fetal Neonatal Med. 2020;33(4):618-24.

[2]Alvarez-Nemegyei J, Cervantes-Díaz MT, Avila-Zapata F, Marín-Ordóñez J. [Pregnancy outcomes before and after the onset of rheumatoid arthritis]. Rev Med Inst Mex Seguro Soc. 2011;49(6):599-604.

[3]Davutoğlu EA, Ozel A, Yilmaz N, Madazli R. Pregnancy outcome in 162 women with rheumatic diseases: experience of a university hospital in Turkey. Arch Gynecol Obstet. 2017;296(6):1079-84.

[4]Harris N, Eudy A, Clowse M. Patient-Reported Disease Activity and Adverse Pregnancy Outcomes in Systemic Lupus Erythematosus and Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2019;71(3):390-7.

[5]Ideguchi H, Ohno S, Uehara T, Ishigatsubo Y. Pregnancy outcomes in Japanese patients with SLE: retrospective review of 55 pregnancies at a university hospital. Clin Rev Allergy Immunol. 2013;44(1):57-64.

Table 1.

Pregnant outcome, maternal, fetal and neonatal adverse events

RD (n=62)GOP (n=31254)OR (CI 95%)pPregnancy outcomePregnancy lossa6 (9.68)1560 (4.99)1.94 (0.84-4.49)0.122Live birthsa60 (90.9)29694 (95)0.96 (0.67-1.35)0.8Gestational age,median (IQR) (weeks)b37.6 (37-39)39 (38-40.2)-<0.001Birth weight,mean (CI) (Kg)c2831.6(2677.4-2985.8)3022.2(2986.8-3057.6)-0.007Maternal adverse eventsPreterm deliveries(<37 weeks)a14 (23.7)3821 (12.2)1.85 (1.03-3.3)0.038<34 weeksa3 (5.1)1065 (3.4)1.42 (0.45-4.53)0.553Gestational diabetesa4 (6.5)1406 (4.5)1.43 (0.52-3.95)0.485Preeclampsiaa5 (8.1)2471 (7.89)1.02 (0.41-2.54)0.97Postpartum hemorrhagea0930 (2.97)0.27 (0.017-4.35)0.355Emergency cesarean sectiona8 (12.9)1844 (5.9)2.19 (1.05-4.57)0.037Fetal adverse eventsMiscarriagesa3 (4.8)663 (2.12)2.28 (0.71-7.29)0.164Stillbirthsa3 (4.8)897 (2.87)1.69 (0.53-5.38)0.377Congenital abnormalitiesa4 (6.5)1094 (3.5)1.84 (0.67-5.08)0.237

an,%

bIQR, interquartile range (25th–75th percentile)

cCI, confidence interval (95%)

Disclosure of Interests:

None declared

AB0830 ADVERSE PERINATAL OUTCOMES AND CONGENITAL DEFECTS IN MEXICAN WOMEN WITH AUTOIMMUNE RHEUMATIC DISEASES

Background:

Pregnancy in women with autoimmune rheumatic diseases (ARD) is associated with an increase in the risk of adverse perinatal outcomes and birth defects. Many factors have been attributed to these including medication employed and maternal autoantibodies. The national prevalence of congenital anomalies in newborns in Mexico is estimated to be 73.9 per 10,000 births but the rate of these in Mexican women with ARD is unknown.

Objectives:

This study aims to describe the frequency of adverse perinatal outcomes and congenital defects in Mexican women with ARD.

Methods:

We performed a descriptive and prospective study that included all pregnant patients with ARDs from the clinic of pregnancy and rheumatic diseases in the University Hospital “Dr. José Eleuterio González” who gave birth between February 2019 to November 2020. Demographic information, pregnancy outcome, and congenital defects were prospectively evaluated. Congenital defects were clinically confirmed by a clinical geneticist.

Results:

A total of 40 women were taken in the final analyses. The ARD diagnosis is shown in graphic 1. Rheumatoid arthritis was the most frequent diagnosis that had an adverse perinatal outcome with 4 (40%) and congenital defects in 2 (40%). No complications or birth defects were reported in 25 (62.5%). The adverse perinatal outcome was reported in 10 (25%) women and congenital defects in 5 (12.5%). The most frequent adverse perinatal outcomes were preterm birth 6 (15%) and the second most frequent miscarriage 3 (7.5%) (Table 1 below).

Conclusion:

We found a high frequency (12.5%) of adverse perinatal outcomes and congenital defects in Mexican women with ARD. Multidisciplinary groups and clinics are needed to adequately serve this complex population and reduce morbidity and mortality. A multidisciplinary approach before, during, and after pregnancy in patients with ARD may improve morbidity and mortality.

References:

[1]Vinet, E., Bernatsky, S. (2017). Outcomes in Children Born to Women with Rheumatic Diseases. Rheum Dis Clin N Am. http://dx.doi.org/10.1016/j.rdc.2016.12.006.

[2]Krishnan AN, Sable CA, Donofrio MT.(2008). Spectrum of fetal echocardiographic findings in fetuses of women with clinical or serologic evidence of systemic lupus erythematosus. J Matern Fetal Neonatal Med. 21(11):776–82.

[3]NAVARRETE HERNANDEZ, Eduardo et al. Prevalencia de malformaciones congénitas registradas en el certificado de nacimiento y de muerte fetal: México, 2009-2010. Bol. Med. Hosp. Infant. Mex. [online]. 2013, vol.70, n.6, pp.499-505.

Graphic 1.

Percentage of adverse perinatal outcomes and congenital defects due to rheumatic disease.

Table 1.

Frequency and percentages of adverse perinatal outcomes and congenital defects.

Adverse perinatal outcome (n=10) 25%Congenital defects (n=5) 12.5%Preterm birth6 (15%)-Miscarriage3 (7.5%)-Stillbirth1 (2.5%)-Congenital heart disease*-1 (2.5%)Congenital cardiac block with pacemaker placement-1 (2.5%)Krabbe´s disease-1 (2.5%)Preauricular appendix-1 (2.5%)Diabetic fetopathy-1 (2.5%)

*Tetralogy of Fallot

Disclosure of Interests:

None declared

AB0801 TIME FOR REFERRAL AND DEFINITIVE DIAGNOSIS IN PATIENTS WITH HAND ARTHRALGIA

Background:

Early referral of patients with suspicion of progression to rheumatoid arthritis (RA) is of paramount importance in disease prognosis. We had previously described a time delay of 28 months between symptom onset and evaluation by a rheumatologist, and a mean wait time of 9.5 weeks for referral to a secondary-level public hospital (1). The availability of specialized interdisciplinary evaluation of patients in a third-level of care raises the possibility of shortening this time gap, as well as describing patient and physician decisions amidst the referral to a Rheumatology center.

Objectives:

Describe the diagnosis profile of patients with hand arthralgia and time of referral to Rheumatology in a Family Medicine clinic.

Methods:

A cohort study was conducted in 110 patients from October 2018 to December 2020 in a Family Medicine clinic within the tertiary-care University Hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico. Patients with hand arthralgia as their chief complaint were recruited. An observational, descriptive compilation of patient history was retrieved prospectively through medical records. Variables included time of inclusion, number of medical visits until referral and definitive diagnosis. Descriptive statistics, Kaplan-Meier curves and log-rank tests were used to test the association between time of diagnosis and clinical variables of interest.

Results:

Assessed variables are shown in Table 1. Out of 110 patients with hand arthralgia, a quarter received a final diagnosis within 3 medical visits. Less than half of patients were referred, and only a third attended the referral indication. It takes 39.3 days from the first medical visit to be referred, and 69 days and 2.89 consultations to receive a definitive diagnosis. Around half of patients will have a definitive diagnosis, osteoarthritis being the most common. The log-rank test for categoric variables including a positive squeeze test or ≥4 criteria of clinically suspect arthralgia did not show a significant association for time of referral and definitive diagnosis (data not shown).

Table 1.

Diagnostic and referral characteristics of patients with hand arthralgia attending a Family medicine clinic

Patients recruited in a Family Medicine clinicn = 110Female, n (%)90 (81.8)Age in years, mean ± SD49.69 ± 14.90RF, ACPA, or hand radiography request, n (%)100 (90.9)Diagnosis in Family MedicineDiagnosed patients after 1 medical visit, cumulative n (%)5 (4.6)Diagnosed patients after 2 medical visits, cumulative n (%)22 (20.0)Diagnosed patients after 3 medical visits, cumulative n (%)26 (23.6)Referral to Rheumatology for diagnostic doubt or clinical follow-upPatients referred to a Rheumatology clinic, n (%)49 (44.5)Patients attending Rheumatology referral, n (%)34 (30.9)Time for referral, days ± SD39.37 ± 38.64Global definitive diagnosisPatients with a definitive diagnosis, n (%)51 (46.4)Osteoarthritis diagnosis, n (%)23 (20.9)Rheumatoid arthritis diagnosis, n (%)13 (11.8)Overlap syndrome diagnosis, n (%)5 (4.5)Time for definitive diagnosis, days ± SD68.96 ± 106.57Number of consultations for definitive diagnosis, mean ± SD2.86 ± 1.05

RF, rheumatoid factor; ACPA, anticitrullinated protein antibodies; SD, standard deviation.

Conclusion:

Patients with hand arthralgia evaluated in a tertiary-care Rheumatology center receive a timely referral in one month and a definitive diagnosis after 3 medical visits in around two months.

References:

[1]Vega-Morales, D., Covarrubias-Castañeda, Y., Arana-Guajardo, A. C., & Esquivel-Valerio, J. A. (2016). Time Delay to Rheumatology Consultation: Rheumatoid Arthritis Diagnostic Concordance Between Primary Care Physician and Rheumatologist. American journal of medical quality: the official journal of the American College of Medical Quality, 31(6), 603.

Graphs:

Disclosure of Interests:

None declared

Knowledge and attitudes about influenza vaccination in rheumatic diseases patients

Patients with rheumatic diseases (RD) have a higher risk of morbidity and mortality from vaccine-preventable infections attributed to disease activity, comorbidities, immunosuppressive therapy, and other factors. Vaccines are one of the safest and most effective public health interventions. The aim of this study was to investigate knowledge and attitudes about influenza vaccination as factors influencing vaccine uptake and hesitancy in a population with RD. A descriptive cross-sectional study was designed. A self-administered questionnaire surveyed age, RD diagnosis, ten questions about the uptake, safety and efficacy of influenza vaccine, knowledge of cost-free availability, and the relationship between influenza vaccination and RD. A total of 223 questionnaires were filled; 79.8% of patients were vaccinated for influenza at least once. Uptake by diagnosis was 80.3% in rheumatoid arthritis, 76.2% in osteoarthritis, 86.7% in lupus, 73.9% in other auto-immune diseases (AID), and 60% in other non-AID; 83.9% of patients considered influenza vaccine as safe and effective. From those who had never been vaccinated, 26.7% of patients did not consider influenza vaccine safe and effective vs. 13.5% among patients who had been vaccinated (P = .032). Only 7.6% considered that RD patients could not be vaccinated; 11.7% thought that influenza vaccine would worsen their RD symptoms. This study showed that concerns about safety, efficacy, side effects, fear of the vaccine, and knowledge of cost diminished vaccine uptake. These are factors related to confidence, complacency, and convenience as components of vaccine hesitancy that affect influenza vaccination in RD patients.

Knowledge and attitudes about influenza vaccination in rheumatic diseases patients

Patients with rheumatic diseases (RD) have a higher risk of morbidity and mortality from vaccine-preventable infections attributed to disease activity, comorbidities, immunosuppressive therapy, and other factors. Vaccines are one of the safest and most effective public health interventions. The aim of this study was to investigate knowledge and attitudes about influenza vaccination as factors influencing vaccine uptake and hesitancy in a population with RD. A descriptive cross-sectional study was designed. A self-administered questionnaire surveyed age, RD diagnosis, ten questions about the uptake, safety and efficacy of influenza vaccine, knowledge of cost-free availability, and the relationship between influenza vaccination and RD. A total of 223 questionnaires were filled; 79.8% of patients were vaccinated for influenza at least once. Uptake by diagnosis was 80.3% in rheumatoid arthritis, 76.2% in osteoarthritis, 86.7% in lupus, 73.9% in other auto-immune diseases (AID), and 60% in other non-AID; 83.9% of patients considered influenza vaccine as safe and effective. From those who had never been vaccinated, 26.7% of patients did not consider influenza vaccine safe and effective vs. 13.5% among patients who had been vaccinated (P = .032). Only 7.6% considered that RD patients could not be vaccinated; 11.7% thought that influenza vaccine would worsen their RD symptoms. This study showed that concerns about safety, efficacy, side effects, fear of the vaccine, and knowledge of cost diminished vaccine uptake. These are factors related to confidence, complacency, and convenience as components of vaccine hesitancy that affect influenza vaccination in RD patients.

Reproductive health counseling and contraceptive use in Mexican women with rheumatic diseases: a cross-sectional study

BACKGROUND

There is an overall increased risk of adverse pregnancy outcomes and maternal morbidity in patients with most autoimmune rheumatic diseases (ARD); outcomes are generally improved when the pregnancy is planned and the disease is in control.

OBJECTIVE

The objective of the present study was to describe the sexual and reproductive health characteristics and contraceptive use of Mexican women in childbearing age with ARD.

METHODS

We conducted an observational, cross-sectional, and descriptive study. All non-pregnant childbearing age women with an ARD were invited to participate. A self-administered questionnaire of ten items that included questions about sexuality, use of contraceptive methods, pregnancy desire, and contraceptional counseling was applied.

RESULTS

A total of 135 women were evaluated. The median age was 33 (25-39) years. Contraceptive use was referred by 49 (71%) of the patients that had sexual activity the last month, while 20 (28.9%) patients denied use. From the patients who had initiated sexual activity (N = 112), 41 (36.6%) did not use any contraceptive method, and 16 (14%) used a method classified as ineffective. The question about contraceptive counseling was answered by 112 patients. Eighty (70.4%) said they had received counseling from health-professional and 64 (57.1%) from their rheumatologist. A total of 57% of the women with teratogenic drugs did not employ a contraception method.

CONCLUSION

Contraceptive use and reproductive health counseling are suboptimal in Mexican women with ARD. A high proportion of women taking teratogenic drugs did not employ a highly effective contraceptive method. Strategies to improve reproductive and sexual health are necessary.

AB1361-HPR PRIMARY CARE PHARMACOLOGICAL TREATMENT FOR PATIENTS WITH HAND ARTHRALGIA

Background:

Primary care physicians (PCP) are the first point of contact for patients with a new-onset inflammatory rheumatic disease, like rheumatoid arthritis (RA). Consequently, primary care is crucial to the early diagnosis and prompt treatment of such individuals. The first three months following the onset of RA symptoms represent an important therapeutic window. Historically, patients with inflammatory arthritis received first-line treatment with non-steroidal anti-inflammatory drugs (NSAIDs), moving to synthetic disease-modifying anti-rheumatic drugs (DMARDs) relatively late in the disease process. As synthetic DMARDs are usually initiated in secondary care by rheumatologists, PCP focus on alleviation of patient’s discomfort. Documented problems in primary care practice include accuracy of diagnosis, test ordering, medication use and delays in referral.

There is no evidence of which is the pharmacological treatment more commonly used for hand arthralgia in Family Medicine patients of a university hospital on their first or second visit.

Objectives:

To examine the primary care physicians’ pharmacological treatment prescribed for hand arthralgia in a Family Medicine Consultation.

Methods:

In a period of a year and two months, eligible patients were recruited on their first or second visit to the Family Medicine Consultation of the Hospital Universitario “Dr. José Eleuterio González” in Monterrey, Nuevo León, México. Eligible patients were adults (aged≥18 years) with hand arthralgia as their chief complaint, who had not rheumatologic diagnosis and wasn’t caused by trauma. Ninety patients were recruited, data were collected by capturing the prescription made by PCP.

Results:

In this cohort of 90 patients, 71 (78.9%) were women. Of the 90 patients, 19 (21.1%) had no pharmacological prescription at all. Forty-nine patients (54.4%) had one prescribed drug, 17 (18.9%) had two drugs and 5 (5.6%) had three drugs. Prescribed drugs and their frequencies are reported in Table 1.

Table 1.

Prescribed drugs and frequencies.

Drugn (%)No treatment19 (21.1)Celecoxib26 (28.9)Oxicams22 (24.4)Propionic acid derivatives6 (6.7)Phenyl Acetic acids5 (5.6)Acetaminophen15 (16.7)Tramadol12 (13.3)Steroids11 (12.2)Methotrexate1 (1.1)

Conclusion:

The most common group of drugs used for hand arthralgia in this cohort of patients was NSAID, and the most used of this group was celecoxib. Only in one patient, PCP prescribed disease-modifying anti-rheumatic drugs (DMARD) therapy, in this case was methotrexate. Almost 80% of the patients were prescribed with at least one drug without knowing the final diagnosis.

References:

[1]Warburton L, Hider SL, Mallen CD, Scott IC. Suspected very early inflammatory rheumatic diseases in primary care. Best Pract Res Clin Rheumatol. 2019;33(4):101419

[2]Calabrese L. Rheumatoid arthritis and primary care: The case for early diagnosis and treatment. The Journal of the American Osteopathic Association. 1999;99(6):313.

Disclosure of Interests:

None declared

SAT0577 USE OF CONTRACEPTIVE METHODS IN MEXICAN WOMEN WITH RHEUMATIC DISEASES

Background:

The importance of safe and effective contraception for women with rheumatic diseases has been increasing.1Several studies have demostrated that carefully planned pregnancies are related with better outcomes making the use of contraceptive methods (CM) more significant.

Objectives:

To describe the use of methods of contraception among Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE).

Methods:

A Cross-sectional study where women aged 18-45 followed in our CEER outpatient clinic, at Monterrey, Mexico, were questioned about the use of CM. Sociodemographic data was collected from the medical record.

CM were classified as Ineffective (10-25% pregnant each year), effective (6-9% pregnant each year) and highly effective (<1% pregnant each year). Methotrexate, Mycophenolate, Cyclophosphamide, Thalidomide and Leflunomide were considered as teratogenic drugs.

The statistical analysis was performed using SPSS 24.0. Ap<0.05was taken to indicate statistical significance.

Results:

A total of 91 patients were included, 35 (38.5%) SLE patients with a median age of 30 years (22-39) and 56 (61.5%) RA patients with a median age of 34.5 years (27.25-40). From the total population, 58 (63.7%) reported the use of teratogenic drugs, with a higher use in RA patients (p <.001). Socio-demographic characteristics are listed inTable 1.

Table 1.

Socio-demographic characteristics.

RA(n=56)SLE(n=35)pAge,years, median (IQR)34.5 (27.25-40)30(22-39)Disease duration,years, median (IQR)3.5 (1.25-7.75)4 (1-7)Onset of Sexual activity,n (%)46 (82.1)24 (68.6).135Onset of Sexual activity age, median (IQR)18 (17-20)14 (17-20)Sexually Active,n (%)*34 (60.7)18 (51.4).384Use of teratogenic drugs,n (%)44 (78.6%)14 (40%)<.001

RA, Rheumatoid Arthritis; SLE, Systemic Lupus Erythematosus. *Sexual activity in the last month.

Among the patients that had started sexual activity (SLE=24, RA=46), the most common CM was tubal ligation 26 (28.6%)Graphic 1. In this group, 49 (70%) patients received contraceptive counseling, however, 21 (42%) patients were using innefective CM.Table 2.

According to effectiveness, highly efective were the most frequent method used in patients that had started sexual activity (n=39, 55.7%)Graphic 2.

Conclusion:

Despite highly effective CM were more frequent in patients that had started sexual activity, 42% of patients that received contraceptive counseling reported the use of inneffective methods. It is neccesary to promote the counseling and use of contraception and provide a multidisciplinary support among rheumatoid patients.

Table 2.

Methods according to effectiveness in patients that received contraception counseling.

GRADE OF EFFECTIVENESSn (%)PatientsThat receive Contraceptive counselingInneffectiveEffectiveHigly effectiveRA= 4630 (65.21)12 (40)1(3.3)17 (56.6)SLE= 2419 (79.16)9 (47.3)1 (5.2)9 (47.36)Total = 70 *49 (70)21 (42)2 (4.08)26 (53.06)

RA= Rheumatoid Arthritis; SLE= Systemic Lupus Erythematosus. * Total of patients that have started sexual activity.

References:

[1]Sammaritano, L. R. (2014). Contraception in Rheumatic Disease Patients. InContraception and Pregnancy in Patients with Rheumatic Disease(pp. 201-227). Springer, New York, NY.

Figure 1.

Graphic 1. This graphic shows the frequence in percentage % of contraceptive methods used by Rheumatoid Arthritis (RA) n=56 and Systemic Lupus Erythematosus (SLE) n=35 patients, which are categorized by the grade of effectiveness. Only were included patients that had started sexual activity.

Figure 2.

Graphic 2. This graphic shows the percentage of use according to the effectiveness of contracetive methods. RA, Rheumatoid Arthritis; SLE, Systemic Lupus Erythematosus. Only were included patients that had started sexual activity.

Disclosure of Interests:

None declared

AB1280-HPR REQUIRED FORCE TO OBTAIN A POSITIVE SQUEEZE TEST AUTOMATIZED IN PATIENTS WITH HAND ARTHRALGIA

Background:

Primary care physicians (PCP) are usually the first contact of people with inflammatory rheumatic diseases, and find the early symptoms of Rheumatoid Arthritis (RA) difficult to distinguish from those of other rheumatic diseases. A time-delay in the reference to Rheumatology is a health issue in several countries. The clinical aspects that general practitioner took into account in hand arthralgia patients are important to make the reference. In particular the Squeeze Test (ST) - which is simple to perform and rapidly done, ST is useful for identifying progression to RA in patients with undifferentiated arthritis. The ST has been described as not reliable because is clinician-dependent.

Objectives:

To identify the required force that needs to be applied in order to obtain a positive Automatized Squeeze Test (AST) in a cohort of patients with hand arthralgia.

Methods:

Ninety-seven patients were recruited in Family Medicine Consultation and in Rheumatology Consultation of the Hospital Universitario “Dr. José Eleuterio González” in Monterrey, Nuevo León, México. Eligible patients were adults (aged≥18 years) with hand arthralgia (that wasn’t caused by trauma) as their chief complaint. After obtaining informed consent and after a questionnaire application, patients were submitted to AST maneuver, using an automated compressor with different forces already predetermined in the interface of the software used for compression.

Results:

In this cohort of 98 patients, 79 (80.6%) were women. The mean age was 51.14 years (SD 14.66). Ninety-six (97.9%) patients were right handed. The diagnoses were Osteoarthritis (OA) (16.3%), RA (5.1%), Undifferentiated arthritis (1.2%), Psoriatic arthritis (1.2%) and Fibromyalgia (2%). Force measures according to diagnoses are reported in Table 1.

Table 1.

Diagnoses and mean forces

Diagnosisn (%)Right hand force mean (kg/s2) (SD)Left hand force mean (kg/s2) (SD)OA16 (16.3)3.53 (2.74)3.18(2.73)RA5 (5.1)3.60 (2.53)3.16(1.36)UA1 (1.2)7.60(0)8.70(0)PsA1 (1.2)7.60(0)7.80(0)FM2 (2.0)4.11(4.40)1.75(1.06)

OA, Osteoarthritis;RA, Rheumatoid Arthritis;UA, Undifferentiated Arthritis;PsA, Psoriatic Arthritis;FM, Fibromyalgia;SD, Standard Deviation

Conclusion:

In the cases of RA and OA, the means of force to obtain a positive AST was lower than in the rest of the diagnoses.

References:

[1]Stack R, Nightingale P, Jinks C, Shaw K, Herron-Marx S, Horne R et al. Delays between the onset of symptoms and first rheumatology consultation in patients with rheumatoid arthritis in the UK: an observational study. BMJ Open. 2019;9(3):e024361.

Disclosure of Interests:

None declared

SAT0206 MINOR SALIVARY GLAND BIOPSY AND SEROLOGICAL PROFILE IN PRIMARY SJÖGREN’S SYNDROME: A SINGLE TERTIARY REFERRAL CENTER EXPERIENCE

Background:

Minor salivary gland biopsy (MSGB) portrays an important role as part of the diagnostic criteria of primary Sjögren’s syndrome (pSS) in the ACR/EULAR 2016 classification. Autoantibodies anti-Ro/SSA and anti-La/SSB embody part of these criteria. Patients with negative serology have been classified as pSS using MSGB outcomes in up to 40% of cases.

Objectives:

Compare MSGB and serological characteristics between pSS positive biopsy versus pSS negative biopsy and sicca groups.

Methods:

174 subjects with sicca symptoms and MSGB biopsy were studied. Patients who fulfilled the ACR/EULAR 2016 criteria were classified as pSS. Serological profile: Rheumatoid factor (RF) (IgA, IgG and IgM), Anti La/SSB and Anti-Ro/SSA, available in 148 and 161 patients respectively, as well as histopathological characteristics of MSGB were recollected (Table 2).

Table 1.

Comparison between serological and histopathological characteristics in pSS and sicca groups

GroupsPositive biopsyn=95Negative biopsyn=47Siccan=32p1p2Age (years) mean, (SD)54.59 (11.69)50.17 (12.35)49.18 (12.74)0.42(0.43-0.45)0.78Female, n (%)92 (96.8)46 (97.87)32 (100)0.7790.58Serological profileRheumatoid factorIgA (%)26 (27.4)12 (25.5)4 (12.5)0.35(0.47-0.49)0.23IgM (%)47 (49.5)25 (53.19)7 (21.9)0.34(0.41-0.43)0.015IgG (%)13 (13.7)7 (14.8)1 (3.1)0.35(0.45-0.47)0.25Positivity Anti-Ro/SSA, n (%)47 (52.8)12 (30)2 (6.3)0.015(0.013-0.018)<0.05Positivity Anti-La/SSB, n (%)17 (19.77)3 (9.09)0(0)0.003(0.002-0.004)0.019

1pof the comparison between pSS positive biopsy group vs pSS negative biopsy group

2pof the comparison of the 3 groups

Anti-Ro/SSA: available in pSS biopsy positive group n=89, pSS negative biopsy group n=40

Anti-La/SSB: available in pSS biopsy positive group n=86, pSS negative biopsy group n=33

Table 2.

Histopathologic characteristics and comparison in pSS and sicca groups.

CharacteristicsPositive biopsyn=95Negative biopsyn=47Siccan=32p1p2Lobules, n (SD)12.45 (7.24)15.2 (9.95)11.84 (9.84)0.19 (0.13 0.15)0.43Foci, n (SD)3.23 (3.16)0(0)0(0)<0.05<0.05Atrophy, n (%)27 (28.4)9 (9.5)7 (21.9)0.0070.57Adipose infiltration, n (%)22 (23.2)12 (12.6)6 (18.8)0.12NADuctal dilatation, n (%)22 (23.2)8 (8.4)6(18.8)0.050.73

1pof the comparison between pSS positive biopsy group vs pSS negative biopsy group

2pof the comparison of the 3 groups

Comparison between subgroups according to biopsy status was performed. Differences between serology and MSGB were reported using Chi square, a p<0.05 was considered statistically significant

Results:

95(54.59%) pSS patients with positive biopsy, 47 (27. 02%) pSS with a negative biopsy and 32 (18.39%) sicca patients were included.

A positive serology profile (RF, Anti-Ro/SSA, Anti-La/SSB) was found more frequently in the pSS positive biopsy cohort when compared to the pSS negative biopsy and sicca groups (Table 1).

Histopathological characteristics of MSGB are described in Table 2. Sicca group had more alterations when compared to pSS negative biopsy group.

Conclusion:

Histopathological alterations in MSGB (atrophy, adipose infiltration and ductal dilatation) can act as confounding data at biopsy interpretation since they were found in close prevalence in the pSS positive biopsy group and sicca group and should be carefully taken into account at diagnosis. A positive serologic profile was associated with more histopathological alterations in the positive biopsy group.

References:

[1]Wicheta S, Van der Groen T, Faquin W, August M. Minor Salivary Gland Biopsy—An Important Contributor to the Diagnosis of Sjögren Syndrome. Journal of Oral and Maxillofacial Surgery. 2017;75(12):2573-2578.

Disclosure of Interests:

None declared

AB1300-HPR MALNUTRITION SCREENING AND ASSESSMENT TOOLS IN RHEUMATIC DISEASES

Background:

Inflammatory disorders have been associated with an increased risk of malnutrition, defined as an abnormal physiologic condition caused by an insufficient, unbalanced or excessive intake of nutrients due to exacerbated metabolic states.1

Mini Nutritional Assessment (MNA) and Nutritional Risk Screening Tool 2002 (NRS-2002) have been used to evaluate nutritional status in patients with rheumatic diseases.

Objectives:

Compare MNA and NRS-2002 as tools for nutritional screening in rheumatic patients.

Methods:

152 patients with rheumatic diseases were evaluated in a Rheumatology center of México. Anthropometrical measurements were performed using Bioelectrical Impedance Analysis (BIA) TANITA. MNA and NRS-2002 were applied at the same date.

MNA is comprised of a dietary questionnaire, subjective and objective global assessment and anthropometrical measurements, classified as adequate (MNA 24-30), risk for malnutrition (MNA 17–23.5) and malnutrition (MNA<17).

NRS-2002 consists of nutritional and severity disease score and an age adjustment for patients >70 years (+1); classified as normal (0-3) and risk of malnutrition/established malnutrition (3 or more).

For statistical analysis the SPSS v24 was used. A p <0.05 was considered statistically significant.

Results:

A total of 152 patients with different rheumatic diseases were included, Table 1. The results according to each tool are represented inGraphic 1.A significant difference was found by the Chi-Square-test when comparing both tools, (p<0.004).

Table 1.

Socio-demographic characteristics of rheumatic patients

DISEASES, n (%)Rheumatoid Arthritis70 (46.1)Systemic Lupus Erythematosus19 (12.5)Ostearthrosis18 (11.8)Sjögren´s Syndrome5 (3.3)Fibromyalgia4 (2.6)Ankylosing Spondylitis2 (1.3)Systemic Sclerosis6 (3.9)Others27 (17.8)SOCIO-DEMOGRAPHICSAge, mean years (SD)51.98 (13.56)BMI,mean (SD)28.14 (5.8)Brachial Circumference, cm, (SD)32.57 (4.19)Calf Circumference, cm, (SD)37.08 (4.17)

A subanalysis in 70 Rheumatoid Arthritis patients was done with a mean age of 50.94 years (SD±12.11) and a mean BMI 28.53 kg/m2 (SD 5.48). The results according to each tool are represented in Table 2. When NRS-2002 was reclassified in 3 parameters (normal <2, risk of malnutrition 2 and malnutrition 3 or more), a significant difference persisted (p. 05) with a low correlation (.43).

Table 2.

Descriptive data of MNA and NRS-2002 in rheumatic diseases.

NUTRITIONAL SCREENING TOOLSMNANRS-2002NRS-2002*RhopAll Rheumatic DiseasesTotal Score, n(SD)24.31 (3.48)______.23.004Malnutrition,n(%)4 (2.6)5 (3.3)5 (3.3)Risk,n(%)55 (36.2)147 (96.7)41(27)Normal,n(%)93 (61.2)106 (69.7)Rheumatoid ArthritisTotal Score, n(SD)24.43 (3.23)______.43.05Malnutrition,n(%)1 (1.4)2 (2.9)2 (2.9)Risk,n(%)22 (31.4)68 (97.1)15 (21.4)Normal,n(%)47 (67.1)53 (75.7)

Conclusion:

MNA was a more sensible tool for detecting risk of malnutrition when compared to NRS-2002. Screening tools play an important role at nutritional evaluation and should be complemented with objective methods such as BIA.1Rheumatologists must be aware that nutritional disorders affect the state of rheumatic diseases; and selecting an appropriate tool to detect malnutrition is of vital importance.

References:

[1]Elkan, A. C., Engvall, I. L., Tengstrand, B., Cederholm, T., & Hafström, I. (2008). Malnutrition in women with rheumatoid arthritis is not revealed by clinical anthropometrical measurements or nutritional evaluation tools.European journal of clinical nutrition,62(10), 1239-1247.

Figure 1.

Graphic 1. Nutritional screening tools in rhematic disorders.Total N=152 patients.MNA=Mini Nutritional AssessmentNRS-2002=Nutritional Risk Screening Tool-2002.NRS-2002*=Nutritional Risk Screening Modified with 3 parameters.

Disclosure of Interests:

None declared

AB1157 SEASONAL INFLUENZA VACCINATION: KNOWLEDGE AND ATTITUDES IN RHEUMATIC PATIENTS

Background:

Vaccines are one of the safest and effective public health interventions (1). Patients with rheumatic diseases (RD) have a higher risk of morbidity and mortality from vaccine-preventable infections (2). Seasonal Influenza vaccination (SIV) had shown to reduce the incidence, complications, admissions, and mortality from Influenza in patients with RD (3). Vaccine hesitancy is one of the threats to global health established by the WHO.

Objectives:

To assess the knowledge and attitudes of rheumatic patients about SIV.

Methods:

A self-questionnaire was applied during a community speech for rheumatic patients in October 2019 and also was applied in the rheumatology clinic of the university hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico, between November and December 2019. The questionnaire asks age, rheumatic diagnosis, and ten questions. Results are shown in descriptive statistics, the Chi-square and Mann-Whitney U tests were performed to compare groups. A P-value ≤0.05 was considered statistically significant. Analyses were performed using SPSS version 22.0.

Results:

A total of 205 self-questionnaires were applied. 122 (59.5%) in the community speech and 83 (40.5%) in the clinic. The median age was 55 (45.75-62.25) years in the community population and 44 (28-59) years in the clinic, also the diagnosis distribution was different (Table 1). Most patients considered that rheumatic patients can be vaccinated. About 80% of patients have ever been vaccinated for seasonal influenza. 87.7% and 77.1% considered that SIV is safe and effective. About 85% of patients considered SIV the best way to avoid complications of Influenza. About 40% considered not safe to be vaccinated for influenza and other vaccine at the same time. 23.8% and 48.2% considered that SIV weakens the immune system and renders it susceptible to infections. Most of the patients know that SIV is free. 23.0% and 42.2% consider other measures better than SIV. 17.2% and 33.7% considered that SIV will get them worse instead of helping them, and 9.0% and 14.5% think that his RD will get worst with SIV.

Table 1.

Population Characteristics

CommunityN= 95ClinicN= 83PAge, years, median (IQR)55 (45.75-62.25)44 (28-59)0.001*Diagnosis, n (%)-RA67 (70.5)46 (55.4)0.037*-OA14 (14.7)7 (8.4)0.194-SLE3 (3.2)11 (13.3)0.013*-Other AID8 (8.4)8 (9.6)0.780-Other NAID3 (3.1)11 (13.2)0.012*

Conclusion:

Misinformation about SIV is patent among rheumatic patients. It is a big challenge to clarify these myths to gain confidence about his safety and effectiveness and provide his benefits.

References:

[1]Hum Vaccin Immunother. 2013;9(8):1774-1778.

[2]Hum Vaccin Immunother. 2018;14(6):1311-1322.

[3]Ann Rheum Dis. 2020;79:39-52

Table 2.

Questionnaire

CommunityN= 122 (%)ClinicN= 83 (%)P1. Can rheumatology patients be vaccinated?Yes114 (93.4)75 (90.4)0.420No8 (6.6)8 (9.6)2. Have you ever been vaccinated for Influenza?Yes97 (79.5)68 (81.9)0.668No25 (20.5)15 (18.1)3. Influenza vaccine is safe and effective:Yes107 (87.7)64 (77.1)0.045*No15 (12.3)19 (22.9)4. The best way to avoid compilations of influenza is by using SIV:Yes104 (85.2)71 (85.5)0.953No18 (14.8)12 (14.5)5. It is safe to be vaccinated for Influenza and other vaccines at the same time:Yes73 (59.8)48 (57.8)0.774No49 (40.2)35 (42.2)6. SIV weakens the immune system and renders it susceptible to infectionsYes29 (23.8)40 (48.2)<0.001*No93 (76.2)43 (51.8)7. Do you know that SIV is freely provided?Yes115 (94.3)76 (91.6)0.453No7 (5.7)7 (8.4)8. Herbal medications, traditional medicine and some food (like orange) are better than SIV:Yes28 (23.0)35 (42.2)0.003*No94 (77.0)48 (57.8)9. SIV instead of helping me will get me worst:Yes21 (17.2)28 (33.7)0.006*No101 (82.8)55 (66.3)10. SIV will worst my rheumatic disease:Yes11 (9.0)12 (14.5)0.226No111 (91.0)71 (85.5)

Disclosure of Interests:

None declared

AB1158 VACCINATION BARRIERS IN PATIENTS WITH RHEUMATIC DISEASES

Background:

Patients with rheumatic diseases (RD) are at increased risk of infections, attributed to the underlying RD, comorbidities and immunosuppressive therapy, including glucocorticoids, disease-modifying antirheumatic drugs, etc. (1). While many infectious diseases can generally be prevented by vaccines, immunization rates in this specific patient population remain suboptimal (2). Despite being recognized as one of the most successful public health measures, vaccination is perceived as unsafe and unnecessary by a growing number of individuals. Lack of confidence in vaccines is now considered a threat to the success of vaccination programs (3).

Objectives:

To describe the main causes of non-vaccination in patients with RD.

Methods:

A self-questionnaire was applied to a sample of patients with RD in the rheumatology clinic of the university hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico between September and December 2019. The questionnaire evaluated demographic characteristics (age, gender, diagnosis) and the vaccination status for Influenza (last year), pneumococcal (last 5 years), Herpes zoster (ever), Human papillomavirus (any dose) and Hepatitis B (any dose). It also includes a question asking: If you didn’t receive any of the previous vaccines, what was the reason? (multiple-choice are shown in Table 2). Results are shown in frequencies and percentages.

Table 2.

Vaccination barriers

N=82If you didn’t receive any of the previous vaccines,what was the reason? n (%)1)Did not was recommended22 (26.8)2) Lack of availability21 (25.6)3) Vaccines don’t work13 (15.8)4) Fear of adverse events8 (9.7)5) Previous adverse event3 (3.6)6) Other reason- Own decision8 (9.7)- Disinformation7 (8.5)

Results:

102 patients were evaluated: Mean age was 51.27 (SD 14.68) years; 84 (82.4%) were females; 71 (69.6%) had rheumatoid arthritis, 13 (12.7%) had systemic lupus erythematosus, 6 (5.8%) had other autoimmune diseases and 12 (11.8%) had osteoarthritis. The rate of vaccination for Influenza was 49 (48%), for pneumococcal 25 (24.5%), for Herpes zoster 5 (4.9%), for Human papillomavirus 9 (8.8%), for Hepatitis B 14 (13.7%) (Table 1). 82 (80.3%) patients reported some barriers in vaccination, from these: 22 (26.8%) did not get the recommendation from the rheumatologist, 21 (25.6%) did not found available the vaccine, 13 (15.8%) believes that vaccines don’t work, 8 (9.7%) had fear of adverse events, 3 (3.6%) reported previous adverse events, and 15 (18.2%) reported other reasons, that we classified as own decision 8 (9.7%) and disinformation 7 (8.5%) (Table 2).

Table 1.

Demographic characteristics

N= 102Age, years, mean (SD)51.27 (14.68)Female, n (%)84 (82.4)Diagnosis, n (%)-RA71 (69.6)-SLE13 (12.7)-OA12 (11.8)-Other AID6 (5.8)

Conclusion:

The main barriers in vaccination of rheumatic patients reported were the lack of availability of the indicated vaccines and the medical and patient disinformation. This problem must be combated to ensure the complete vaccination of rheumatic patients.

References:

[1]Ann Rheum Dis. 2020;79:39-52.

[2]J Rheumatol. 2019;46(7):751-754

[3]Hum Vaccin Immunother. 2013;9(8):1763-73.

Disclosure of Interests:

None declared

AB1295-HPR PREGNANCY RISK IN CHILDBEARING AGE WOMEN WITH RHEUMATIC DISEASES

Background:

Rheumatic diseases (RD) are more frequent in women, affecting them during childbearing age. Medications used to treat can interfere with fertility or increase the risk of miscarriages and congenital abnormalities; Disease control and therapy should be discussed with patients before and during pregnancy, in order to minimize adverse outcome (1). Barriers to adequate communication and counseling of women regarding reproductive health and family planning still exist among rheumatologists and increases the risk of complications(2).

Objectives:

To identify childbearing age women with RD and a high risk of pregnancy.

Methods:

A cross-sectional study was performed in the rheumatology clinic of the university hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico between October 2019 and January 2020. All non-pregnant childbearing age (18 to 45 years old) women any were included. A self-questionnaire of 10-items was applied. Demographic, data were collected from the electronic medical record. Results are shown in descriptive statistics. Analyses were performed with SPSS 22. A p< 0.05 was considered statistically significant.

Results:

135 women were evaluated, median age was 33 (25-39) years. Patients characteristics are shown in table 1. 115 (85.1%) had initiated sexual activity earlier in life (median age 18 years). Regarding the question, did you have sex last month? 115 answered it, 69 (60%) said they had, 49 (42.6%) used a contraceptive and 20 (28.9%) did not. 135 patients, 68 (50.3%) had a desire for pregnancy, 12 (17.6%) in the next 12 months and 56 (82.3%) in more than one year, of which 37 (66%) were using a family planning method and 19 (34%) were not (Table 2). For the question about receiving contraceptional counselling 112 answered it, 80 (70.4%) say they had. When they were asked if they received family planning and reproductive health counseling by their rheumatologist, just 64 (57.1%) affirmed they did; There was no differences in the use of contraceptive methods among those who received contraceptive counselling and those who did not (p>0.05). Among the 67 (49.6%) patients who did not want to be pregnancy 16 (23.8%) did not use a contraceptive method.

Table 1.

Chracteristics

n=135Age,years, median (IQR)33 (25-39)Marital statusn (%)Single58(42.9)Unmarried19 (14.1)Married49 (36.3)Divorced9 (6.7)Educationn (%)None12 (8.9)Elementary school17 (12.6)High school77 (57.0)University28 (20.7)Diagnosisn (%)Rheumatoid arthritis63 (46.7)Systemic lupus erythematosus39 (28.9)Other autoimmune diseases32 (24.3)Onset of Sexual activity age, median (IQR)18 (16-20)Onset of Sexual activity?, n (%)Yes115 (85.1)Table 2.

Tool questions

n=135 (%Did you have sex last month? (n= 115, %)69 (60)YesDid you use any contraceptive method?(n=115, %)Yes49(42.6)Did you receive family planning and reproductive health counseling by the rheumatologist? (n= 112, %)Yes64 (57.1)Do you want to get pregnant after the next 12 months?Yes56 (41.1)Do you want to get pregnant in the next 12 months?Yes12 (8.9)Contraceptional counselling(n=112, %)Yes80 (71.4)Current treatment (n= 107, %)Pregnancy Risk65 (60.7)

Conclusion:

Using this short questionnaire, we identified that 35 (25.9%) of the patients had a risk of unintended pregnancy and that only 80 (70.4%) received reproductive health counseling from their rheumatologist. It is necessary to design and systematically apply questionnaires capable of detecting and evaluating risks in this population.

References:

[1]Gayed, M., & Gordon, C. (2007). Pregnancy and rheumatic diseases. Rheumatology, 46(11), 1634-1640.

[2]Birru Talabi, M., Clowse, M. E., Blalock, S. J., Hamm, M., & Borrero, S. (2019). Perspectives of Adult Rheumatologists Regarding Family Planning Counseling and Care: A Qualitative Study. Arthritis Care & Research.

Figure 1.

Graphs 1.

Graphs 2.

Disclosure of Interests:

None declared

AB1327-HPR SELF-ASSESSMENT OF ORAL HEALTH STATUS IN RHEUMATOID ARTHRITIS, SYSTEMIC LUPUS ERYTHEMATOSUS AND CONTROLS

Background:

Different periodontal disorders have been associated with the development of multiple rheumatic diseases, encouraging the production of citrullinated proteins and creating a proinflammatory state with an increase in oral and systemic symptomatology.

The Geriatric/General Oral Health Assessment Index (GOHAI) survey has been used as a self-assessment tool where studies have found a diminished quality of oral health in Rheumatoid Arthritis (RA).1

Objectives:

Compare the behavior of GOHAI survey in RA, Systemic lupus erythematosus (SLE), and controls in a Rheumatology center at Northeast Mexico.

Methods:

We performed a descriptive study of patients with RA and LES who answered the Spanish version of GOHAI survey. A control group was also included.

GOHAI survey consists of 12 Questions with Likert answers evaluating problems related to periodontal disease in the last 3 months.

Questions 1-4 evaluate physical function, 6, 7, 9-11 psychosocial status and 5, 8 and 12 pain.

Results:

Sixty RA patients, 32 SLE patients and 46 controls were included. Groups were adjusted by sex and age.

GOHAI survey presented a total mean of 23.4 in RA, 22.06 in SLE and 21.54 in controls with a maximum score of 60 points.

When analyzing the survey in physical function and psychosocial status a statistical significant difference was found when comparing RA group to controls.

Table 1.

Comparison between GOHAI index scores in RA, SLE and control groups

RA n= 60SLE n= 32Controls n=46Median (SD)Median (SD)Median (SD)RA vs SLERA and controlsThree groupsAge51.27 (15.84)37.03 (14.14)41.07(11.25)0.17Sex58 (96.67%)29 (90.62%)42 (91.3 %)1. Limit the kinds of food consumed1.87 (1.14)1.78 (1.15)1.78 (0.81)2. Trouble biting or chewing1.96 (1.2)1.91 (1.27)1.78 (1)3. Able to swallow comfortably2.2 (1)1.81 (1.47)1.41(1.15)4. Unable to speak clearly1.63 (1)1.13 (0.42)1.24(0.57)5. Able to eat without discomfort1.9 (1.17)1.59 (0.98)1.76 (0.79)6. Limit contact with people1.45 (0.9)1.34 (0.75)1.3 (0.73)7. Pleased with appearance of teeth2.85 (1.65)3.2 (1.79)2.22(1.25)8. Use medication to relieve pain1.83 (1.08)1.94 (1.13)1.87 (0.88)9. Worried about teeth, gum or dentures2.56 (1.39)2.06 (1.54)2.54(1.15)10. Self-conscious about teeth, gum or dentures1.66 (0.94)1.59 (1.02)2.02 (1.06)11. Uncomfortable eating in front of others1.54 (0.82)1.53 (0.8)1.39(0.8)12. Sensitive to hot,cold or sweet food2.07 (1.06)2.19 (1.31)2.22(0.94)Total score (12-60)23.4 (6.94)22.06 (7.05)21.54 (5.6)0.270.120.19Physical function7.6 (3.32)6.63 (2.6)6.22 (2.26)0.150.060.05Psychosocial function10.07(3.23)9.72 (3.74)9.48 (3.5)0.350.0030.02Pain discomfort5.78 (2.19)5.72 (2.48)5.85 (1.48)0.690.150.1

RA: Rheumatoid Arthritis, SLE: Systemic Lupus Erythematosus

Conclusion:

RA patients presented an increased alteration in oral health perspective when compared to SLE and controls. This association demonstrates the relationship between RA and periodontitis pathogenesis.

Importance in diagnosing periodontal disorders in rheumatic diseases should be performed due to its influence in quality of life and perpetuation of an inflammatory state and oral symptoms.

References:

[1]Blaizot, A., Monsarrat, P., Constantin, A., Vergnes, J. N., de Grado, G. F., Nabet, C., ... & Sixou, M. (2013). Oral health-related quality of life among outpatients with rheumatoid arthritis. International dental journal, 63(3), 145-153.

Disclosure of Interests:

None declared

AB0432 CLINICAL AND SEROLOGICAL CHARACTERISTICS OF “RHUPUS SYNDROME”

Background:

Systemic lupus erythematosus (SLE) is a multisystemic and chronic autoimmune disorder that typically affects (1). Arthritis is one of the most frequent manifestations in SLE with an incidence reported from 69% to 95% (2). Rheumatoid arthritis (RA) is an articular, inflammatory, chronic disease of autoimmune nature (3). Rhupus syndrome is defined as a patient that meets the classification criteria for RA of the American College of Rheumatology (ACR) of 1987 and for SLE of the ACR of 1982, in addition, necessarily erosive arthropathy with antibodies specific for positive SLE (anti-Sm or anti-DNAdc) (4). With the development of more recent classification criteria for both RA and SLE, which allow us to detect both diseases earlier, they create even more heterogeneity in the definition of rhupus, being a rare entity, the analysis of the clinical and serological characteristics of this population in our clinic would provide data to the few existing.

Objectives:

To describe the clinical and serological characteristics of patients with Rhupus.

Methods:

An observational, retrospective study was done in the rheumatology clinic of the university hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico. The electronic medical record (EMR) was reviewed. In search of the term “rhupus”. All the patients were analyzed individually to verify the rhupus diagnosis. The main clinical and serological characteristics were evaluated. The results are shown in descriptive statistics.

Results:

30 patients were obtained from the search in the EMR, 22 patients were included, 8 patients were excluded (5 non-SLE, 3 non-RA) (Figure 1). The mean age was 40.14 (SD 10.86); 20 (90.9%) were females; the onset diagnosis was SLE in 5 (22.7%), RA in 14 (63.6%) and both 3 (13.6%). 17 (77.3%) had general symptoms, 12 (54.5%) had cutaneous manifestations, 14 (66.6%) had renal manifestations, 6 (27.3%) had serositis, 19 (86.3%) had hematologic manifestations, 3 (13.6%) had neuropsychiatric manifestations, 1 (4.5%) had diffuse alveolar hemorrhage. 12 (60%) had anti-dsDNA positive, 4 (23.5%) had anti-Sm positive, 16 (84.2%) had anti-CCP positive (Table 1). The articular manifestations (swollen and tender joints at onset and at last visit) are detailed in Table 2. The treatments were different at the onset of the disease compared with the last visit, except for methotrexate (Table 2).

Table 1.

Clinical and serological characteristics.

N=22Female, n (%)20 (90.9)Age, mean (SD)40.14 (10.86)Onset diagnosisSLE, n (%)5 (22.7)RA, n (%)14 (63.6)Both, n (%)3 (13.6)ManifestationsGeneral, n (%)17 (77.3)Cutaneous, n (%)12 (54.5)Renal, n (%)14 (66.6)Serositis, n (%)6 (27.3)Hematological, n (%)19 (86.3)Neuropsychiatric, n (%)3 (13.6)Diffuse alveolar hemorrhage, n (%)1 (4.5)SerologyAnti-dsDNA (N=20), n (%)12 (60)Anti-Sm (N=17), n (%)4 (23.5)Anti-CCP (N=19), n (%)16 (84.2)Table 2.

Disease activity and treatment.

At onset N=22Last visit N=22Swollen joints, mean (SD)9.3 (6.6)3.0 (4.8)Tender joints, mean (SD)8.5 (7.1)1.59 (3.8)VAS, mean (SD)42 (33.6)17.2 (21.1)PGA, mean (SD)38 (32.3)16.6 (20.3)Activity scalesSLEDAI-2k, mean (SD)8.38 (4.5)2.9 (3.2)DAS28-VSG, mean (SD)5.26 (1.51)2.89 (0.83)TreatmentGlucocorticoid, n (%)21 (95.4)15 (68.2)Antimalarials, n (%)17 (77.2)11 (50)Immunosuppressants, n (%)8 (36.3)2 (9.1)Methotrexate, n (%)16 (72.7)16 (72.7)Leflunomide, n (%)4 (18.2)5 (22.7)Sulfasalazine, n (%)5 (22.7)0 (0)Figure 1.

Conclusion:

In our cohort, rhupus affects more frequently females, the hematologic manifestations are very frequent and the neuropsychiatric and diffuse alveolar hemorrhage was rare.

References:

[1]Nat Rev Dis Primers. 2016;2(1):1-21.

[2]Best Practice & Research Clinical Rheumatology. 2009;23(4):495-506.

[3]Nat Rev Dis Primers. 2018;4(1):1-23.

[4]Lupus. 2002;11(5):287-292.

Disclosure of Interests:

None declared

SAT0466 FRAX RISK OF FRACTURE AND ITS CORRELATION WITH BONE MINERAL DENSITY IN MEXICAN PATIENTS WITH RHEUMATIC DISEASES

Background:

Osteoporosis (OP) is characterized by compromised bone strength and deterioration of quality, often leading to fragility fractures (1). Dual-energy x-ray absorptiometry (DXA) is the recommended test for OP screening among patients with rheumatoid arthritis (RA) and other RD (2). However, there are limitations to perform DXA on every patient, and the clinicians use screening tools to identify those patients with higher risk. The opportune identification of the patients at increased risk and early treatment can prevent the loss of bone mineral density (BMD) and reduce the risk of fractures(3).

Objectives:

To evaluate the FRAX risk and its correlation with the spine and femoral neck T-score in patients with RD.

Methods:

An observational retrospective study was done in the rheumatology clinic of the university hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico, between March and November 2019. Patients who had reported DXA from the spine and hip in the medical record were included. The risk factors included in FRAX tool was collected; FRAX tool was used online athttps://www.sheffield.ac.uk/FRAX/(algorithm for Mexicans) and classified as low (<10% for OP or <1% for hip), intermediate (10%-19% for OP or 1%-<3% for hip) and high risk (≥20% for OP or ≥3% for hip); results of DXA of the spine and hip were collected. Results are shown in means or frequency. A chi-square test or one-way analysis of variance was used to compare groups. Pearson’s correlation test (r) was done between spine T-score and FRAX risk for OP and between femoral neck T-score and FRAX risk for hip. P<0.05 was considered statistically significant.

Results:

141 patients were included, Patients with OP was older (mean 62.6 years), weight and height were higher in those with normal BMD. There was no difference between the use of glucocorticoids or other risk factors (Table 1). According to FRAX risk for OP, 122 (86.5%) had low risk, 14 (9.9%) had intermediate risk and only 5 (3.5%) had high risk. According to FRAX risk for hip, 81 (57.4%) had low risk, 38 (27.0%) had intermediate risk and only 22 (15.6%) had high risk (Table 2). There was a low negative correlation between spine T-score and FRAX risk for OP (r= -0.396, P=<0.001) (Figure 1), there was a moderate negative correlation between femoral neck T-score and FRAX risk for hip (r= -0.614, P=<0.001) (Figure 2).

Table 1.

FRAX score risk factors

Normal BMDN= 27Low BMDN= 66OsteoporosisN= 48PAge, years, mean (SD)46.8 (10.6)56.5 (11.7)62.6 (9.1)<0.001*Female, n (%)24 (88.8%)61 (92.4)43 (89.5)0.814Weight, kg, mean (SD)76.6 (14.6)66.4 (12.1)64.8 (10.6)0.001*Height, cm, mean (SD)156.7 (7.5)152.3 (6.8)153.3 (7.1)0.034*Previous Fracture, n (%)----Parent Fractured Hip, n (%)----Current Smoking, n (%)-2 (3.0%)4 (8.3%)0.060Glucocorticoids, n (%),15 (55.5%)30 (45.4%)19 (39.6%)0.411Rheumatoid arthritis, n (%)18 (66.6%)40 (60.6%)21 (43.7%)0.040*Secondary osteoporosis, n (%)----Alcohol use, n (%)1 (3.7%)2 (3.0%)1 (2.0%)0.631Osteoporosis treatment, n (%)-16 (24.2%)42 (87.5%)<0.001*Table 2.

BMD and FRAX risk

Normal BMDN= 27Low BMDN= 66OsteoporosisN= 48PFRAX risk for OP, n (%)Low risk, (n=122)27 (100%)63 (95.4%)32 (66.6%)<0.001*Intermediate risk, (n=14)-3 (4.5%)11 (22.9%)0.001*High risk, (n=5)--5 (10.4%)0.007*FRAX risk for hip, n(%)Low risk, (n=81)26 (96.3%)45 (68.1%)10 (20.8%)<0.001*Intermediate risk, (n=38)1 (3.7%)18 (25.7%)20 (41.6%)0.001*High risk, (n=22)-4 (6.0%)18 (37.5%)<0.001*

Conclusion:

Most of the patients were classified as low risk for OP and hip, including a high amount of those with OP showing a low and moderate correlation with DXA respectively.

References:

[1]Ann Intern Med. 2017;166(11):818-839

[2]Osteoporos Int. 2014; 25(10): 2359-81

[3]Arthritis Rheumatol. 2019;71(Suppl 10):3924-3925

Disclosure of Interests:

None declared

DNA vaccine encoding human papillomavirus antigens flanked by a signal peptide and a KDEL sequence induces a potent therapeutic antitumor effect

Cellular immune responses play a critical role in the eradication of intracellular infections and malignant cells through the recognition and subsequent removal of the infection or malignant cells. Effective antigen presentation is crucial for stimulating the immune system against malignant cells. Calreticulin (CRT) has been used to improve antigen presentation. However, CRT overexpression has been previously associated with the development of pancreatic and breast cancer. The import and retention signals of CRT in the endoplasmic reticulum (ER) can be used to overcome CRT overexpression. The present study describes the potent antitumor effect of a DNA vaccine encoding human papillomavirus type 16 E6 and E7 antigens flanked by ER import and retention signals (SP-E6E7m-KDEL). The effect of this vaccine was compared with that of E6 and E7 antigens fused to human full-length CRT (hCRT-E6E7m). In the present study, the effectiveness of SP-E6E7m-KDEL for inducing an interferon-γ antigen-specific, response and its therapeutic effect against tumors was demonstrated, which was as effective as immunization against those antigens fused to CRT. This simplified strategy, using ER import and retention signal peptides to direct antigens to this organelle, provides an efficient alternative to traditional vaccines and, more importantly, a safe and potent system to induce a therapeutic antitumor response.