AB0584 MANAGEMENT OF REFERRALS, TREATMENT STRATEGY, AND RESEARCH CHALLENGES IN POLYMYALGIA RHEUMATICA AMONGST RHEUMATOLOGISTS WORLDWIDE: A QUESTIONNAIRE BASED STUDY

Background

Polymyalgia rheumatica (PMR) is diagnosed and treated by both general practitioners (GP) and rheumatologists. How rheumatologists around the world manage the referral process of patients with PMR from GP’s has not been described. EULAR/ACR guidelines recommend initial prednisolone doses between 12.5 and 25 mg, but it is unknown if guidelines are followed in daily clinical practice1. In addition, the understanding of challenges for recruitment to clinical trials in PMR is currently limited.

Objectives

This study aims to describe the management of referrals, treatment strategy, and recruitment to clinical trials in PMR among rheumatologists worldwide.

Methods

An English language questionnaire was drafted by a working group of rheumatologists and GP’s from 6 different countries. Questions concerned: 1: respondent, 2: referrals, 3: prednisolone, and 4: barriers to research. Questionnaires were distributed to rheumatologists via members of the International PMR/GCA study group. Answers were collected via an online survey tool (Redcap), from 2nd of November 2021 to 27th of January 2022. Countries were grouped by income and geographical region based on the World bank classifications. Data were weighted by number of inhabitants in a country, based on the United Nations age specific population count, divided by number of respondents in a country. Countries with more than 20 respondents were included.

Results

Results from 27 countries were analysed including 1000 responders in total (Figure 1). There was large variation in time from referral to first assessment, initial dose of prednisolone was high, duration of treatment was relatively short, and a large proportion of patients with newly diagnosed PMR received prednisolone prior to rheumatological evaluation (Table 1). Concerning the 15% of respondents who performed research in PMR, 52% had participated in clinical trials and 56% of the responders experienced difficulties with recruitment.

Table 1.

Characteristics of reponders, referrals, and treatment.

Geographical regionIncomeThe worldEurope and Central AsiaNorth AmericaLatin AmericaEast Asia and PacificSouth AsiaMiddle East and AfricaHigh- income countriesLow- and middle- income countriesRespondersResponders (n), Completed questionnaire (total)875 (1000)294 (304)78 (81)136 (152)53 (53)53 (72)261 (338)446 (458)429 (542)Experience as rheumatologist (years)11 (6-20)12 (6-20)7 (4-20)11 (6-23)21 (10-30)7 (4-10)9 (5-18)11 (5-22)8 (5-12)ReferralsGP’s can discuss patients prior to referral, %647979575860677461Referred patients seen (%)100 (90-100)100 (90-100)100 (100-100)100 (100-100)100 (95-100)100 (100-100)100 (60-100)100 (100-100)100 (90-100)Evaluation > 2 weeks after referral, %26498060216185815PrednisoloneStarted prior to rheumatological evaluation (%)50 (20-50)60 (30-80)70 (50-80)50 (10-50)30 (20-50)50 (20-80)20 (0-50)50 (30-80)50 (10-70)Initial dose (mg)20 (15-40)20 (15-20)20 (15-20)20 (20-40)15 (15-15)20 (15-40)20 (15-40)15 (15-20)20 (15-40)Initial dose > 25 mg, %32964104143642Duration of treatment (months)12 (6-12)12 (12-18)12 (10-18)6 (3-12)18 (12-18)12 (6-12)6 (3-12)12 (12-18)9 (6-12)

Data presented as weighted median (interquartile range) unless otherwise stated.

GP: general practitioner

Conclusion

This is the first description of current practice in managing referrals and treatment of PMR by rheumatologists worldwide. In general, median treatment duration was according to EULAR/ACR guidelines, but initial dose of prednisolone was often higher than recommended in many parts of the world. PMR patients were often seen more than two weeks after referral, and treatment had started prior to first rheumatological evaluation.

References

[1]Dejaco C, Singh YP, Perel P, et al. 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Annals of the rheumatic diseases 2015; 74(10): 1799-807.

Acknowledgements

This study was endorsed by the international PMR/GCA study group.

Disclosure of Interests

Agnete Overgaard Donskov: None declared, Sarah Mackie: None declared, Ellen-Margrethe Hauge Speakers bureau: AbbVie, Sanofi, Sobi, MSD, UCB, Consultant of: AbbVie, Sanofi, Sobi, MSD, UCB, Grant/research support from: Novo Nordic Foundation, Danish Rheumatism Association, Danish Regions Medicine Grants, Roche, Novartis, Celgene, MSD, Pfizer, Roche, Sobi, CARLOS TORO GUTIÉRREZ: None declared, Ib Hansen: None declared, Andrea Hemmig: None declared, Aatke van der Maas: None declared, Tamer A Gheita: None declared, Berit Dalsgaard NIelsen Paid instructor for: Roche, Karen Douglas: None declared, Richard Conway Speakers bureau: Janssen, Roche, Sanofi, Abbvie,, Elena Rezus: None declared, Bhaskar Dasgupta: None declared, Sara Monti: None declared, Eric Matteson Consultant of: Boehringer-Ingelheim,, Grant/research support from: Boehringer Ingelheim,, Sebastian E. Sattui Grant/research support from: AstraZeneca, Mark Matza: None declared, Vanessa Ocampo Speakers bureau: Abbvie, Andrea Bran: None declared, Simone Appenzeller Grant/research support from: GSK, Annelise Goecke Speakers bureau: Abbvie, Boehringer Ingelheim, Recalcine. Consultant Abbvie, Boehringer Ingelheim, NELLY COLMAN MC LEOD Speakers bureau: Laboratorios FAPASA (Farmacéutica Paraguay), Helen Keen Speakers bureau: Roche, Abbvie, Masataka Kuwana: None declared, Latika Gupta: None declared, Babur Salim: None declared, Ghita Harifi Speakers bureau: Abvie, Johnson and johnson, Lilly, Novartis, Mariama Erraoui: None declared, Nelly Ziade Speakers bureau: Abbvie, Eli Lilly, Janssen, Pfizer, Pierre Fabre, Roche, Novartis, Sanofi-Aventis, Paid instructor for: Abbvie, Eli Lilly, Sanofi-Aventis, Pfizer, Janssen, Novartis., Consultant of: Abbvie, Eli Lilly, Janssen, Pfizer, Roche, Novartis, Sandoz, Grant/research support from: Abbvie, Celgene - Algorithm, Bristol-Myers Squibb - NewBridge, Pfizer, Nizar Abdulateef Al-Ani: None declared, Adeola Ajibade: None declared, Johannes Knitza: None declared, Line Frølund: None declared, Max Yates: None declared, Victor Pimentel-Quiroz: None declared, Andre Lyrio: None declared, Maria Sandovici: None declared, Kornelis van der Geest Speakers bureau: Roche, Toby Helliwell Grant/research support from: Valneva, Elisabeth Brouwer Speakers bureau: Roche, Christian Dejaco Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos and Sanofi, Consultant of: Abbvie, Eli Lilly, Janssen, Roche, Galapagos and Sanofi, Kresten Keller: None declared

POS1442 THE PREVALENCE OF RHEUMATOID ARTHRITIS IN WESTERN AUSTRALIA EXTRAPOLATED FROM HOSPITALISATION AND BIOLOGICAL THERAPY USAGE DATA

Background

Rheumatoid arthritis (RA) is a heterogeneous chronic autoimmune disease that affects the synovial joint lining and may result in permanent joint destruction, premature death, and socio-economic burden.1 Although RA is one of Australia’s national health priority areas and gathering information about the RA burden of disease was one of the national action plans2, no published epidemiological study adequately describes RA prevalence and risk factors for frequent hospitalisations in Western Australia (WA) to date. An accurate prevalence estimate of this disease offers a framework for predicting present and growing healthcare service requirements in the future.3

Objectives

We estimated RA period prevalence and identified risk factors of frequent RA hospitalisations, using linked administrative health and state-specific Australian Pharmaceutical Benefits Scheme (PBS) datasets in WA from 1995–2014.

Methods

RA prevalence was calculated per 1000 hospital separations and biological therapy users. RA patients were identified in the WA linked health dataset using ICD codes 714.0–714.9 and M05.00–M06.99. Dispensing data on biological therapy for RA were obtained from PBS records and converted to defined daily doses/1000 population/day. Multivariate logistic regression was used to analyse risk factors for frequent RA hospitalisations (>2/year), controlling for sex, age, and geographic locations.

Results

A total of 17,125 RA patients were admitted to WA hospitals between 1995–2014. The total number of RA hospital separations was 50,353, averaging three hospitalisations per patient over 20 years. The RA period prevalence was 3.4 per 1,000 separations (0.34%), while the RA period prevalence based on biological therapy use was 0.36%. The corrected RA prevalence based on biological therapy usage was 0.36% and 0.72% for the 2005–2009 and 2010–2014 periods, respectively (Table 1). Female gender, age 60–69 years, and living in rural areas were all risk factors for frequent RA hospitalisations.

Table 1.

Total number of Rheumatoid Arthritis patients in Western Australia taking a standard dose daily (DDD) of RA biological therapy from 1995 to 2014.

YearTotal RA bDMARDs utilisation (DDD/1000 population/day)WA general populationPrevalence of RA bDMARDs use in WA population (%)Number of RA patients use standard dose daily of bDMARDs at WA20030.011,952,7410.001420040.081,979,5420.0115820050.162,011,2070.0232920060.232,050,5810.0247620070.312,106,1390.0364320080.502,171,7000.051,09420090.602,240,2500.061,33820100.592,290,8450.061,36120110.632,353,4090.061,47520120.772,425,5070.081,85920130.662,486,9440.071,64920141.002,517,6080.102,510

Abbreviations: bDMARDs, biologic disease-modifying anti-rheumatic drugs included Abatacept, Adalimumab, Certolizumab, Etanercept, Golimumab, Infliximab, Rituximab, Tocilizumab; DDD, defined daily doses; RA, Rheumatoid arthritis; WA, Western Australia.

Conclusion

Based on hospital and biological therapy data, the minimal prevalence of RA in Western Australia is 0.34–0.36%, which falls within the literature range. Older female RA patients in rural areas were more likely to be hospitalised, suggesting unmet needs in primary care access.

References

[1] Guo Q, Wang Y, Xu D, Nossent J, Pavlos NJ, Xu J. (2018) Rheumatoid arthritis: pathological mechanisms and modern pharmacologic therapies. Bone Res. 6, 15.

[2] Australian Institute of Health and Welfare. (2006) National indicators for monitoring osteoarthritis, rheumatoid arthritis, and osteoporosis. pp. 55. AIHW, Canberra.

[3]Hanly JG, Thompson K, Skedgel C. (2015) The use of administrative health care databases to identify patients with rheumatoid arthritis. Open access rheumatology: research and reviews. 7(6), 69-75.

Acknowledgements

The authors thank the data custodians of Hospital Morbidity Data Collection, Emergency Department Data Collection, the Death Registrations and staff at the Western Australian Data Linkage Branch to assist in the provision of data. Special thanks to the University of Western Australia to support KA with an Australian Government Research Training Program PhD Scholarship and the Australian Rheumatology Association WA for Research Fellowship Award.

Disclosure of Interests

Khalid Almutairi: None declared, Charles Inderjeeth Speakers bureau: Eli Lilly, David Preen: None declared, Helen Keen Speakers bureau: Pfizer Australia, Abbvie Australia, Johannes Nossent Speakers bureau: Janssen

AB1274 ADULT-ONSET STILL’S DISEASE IN WESTERN AUSTRALIA: EPIDEMIOLOGY, COMORBIDITY AND LONG-TERM OUTCOME

Background

Adult-onset Stills disease (AOSD) is a rare, potentially life-threatening autoinflammatory condition for which the reported prevalence shows regional variation and where comparative long-term outcome data are scarce (1).

Objectives

To investigate annual incidence and point prevalence of AOSD in Western Australia (WA) and compare long-term health-related outcomes between AOSD patients and hospital-based controls.

Methods

Population-based cohort study using longitudinally linked administrative health data from all hospitals in WA between 1999 and 2013. ASD patients (ICD-10-AM code M06.1) were matched to controls for age and gender. Rate and odds ratios (RR/OR) with 95% confidence intervals (CI) were used to compare ASD patients and controls for serious infections (SI), osteoporosis, joint replacement and the modified Charlson Comorbidity (mCCI).

Results

In total 52 patients had incident AOSD for an average period incidence of 0.22/100,000 and a point prevalence of 2.4 /100.000 (per 30/12/2013). Compared to controls, ASD patients (median age 41.5 years, 59.6% females) had higher odds of prior liver disease (OR 2.67, 95%CI: 1.31-5.45), fever (OR 54.1, 95%CI: 6.6-43), rash (OR 15.7, 95%CI: 4.08-60.8) and SI (OR 4.36, 95%CI: 2.11-22.8). During 49 months of follow up, crude mortality (11.5% vs 7.5%; p=0.34), survival at one and five years (p=0.78) and m-CCI score at last observation (median 2 vs 2) were similar for ASD patients and controls. However, the odds for subsequent joint replacement (in 7 patients; 13.5%) (OR 45.5, 95%CI: 4.57-93), osteoporosis (OR 31.3, 95%CI: 3.43-97) and SI (RR 5.68, 95%CI: 6.61-8.74) were significantly higher in ASD patients.

Conclusion

The epidemiology and demographics of AOSD in Western Australia fall within the internationally reported range. Compared to controls, AOSD patients presented higher rates of liver disease, rash and SI before disease onset. Mortality following AOSD was not increased for five years despite high rates of chronic arthritis requiring joint replacement, SI, and osteoporosis.

References

[1]Tomaras, S.; Goetzke, C.C.; Kallinich, T.; Feist, E. Adult-Onset Still’s Disease: Clinical Aspects and Therapeutic Approach. J. Clin. Med.2021, 10, 733.

Acknowledgements

Supported by a grant from the Arthritis Foundation of Western Australia

Disclosure of Interests

None declared

OP0274 HOSPITALISATION FOR TUBERCULOSIS AND OTHER OPPORTUNISTIC INFECTIONS IN PATIENTS WITH INFLAMMATORY JOINT DISEASES BEFORE AND AFTER THE INTRODUCTION OF BIOLOGICAL THERAPY

Background

Over the last 20 years aggressive therapy for inflammatory joint diseases (IJD) has become standard of care following the acceptance of Methotrexate as anchor drug and extensive of use biologic therapy since 2003. Immunosuppression increases the risk for common and uncommon infections (1).

Objectives

To compare the temporal rates and associated mortality of hospitalisation with opportunistic infections (OI) (Table 1) for IJD patients in Western Australia between 1985 and 2015.

Methods

All patients hospitalized in Western Australia in the period 1980-2015 with ≥ 2 diagnostic codes for rheumatoid arthritis (RA, n=8490), psoriatic arthritis (PsA, n=601), axial spondylarthritis (AS, n=1419). Overall incidence rates (IR) with microbiologically confirmed OI (Mycobacterial, Fungal and viral infections)(Table 1) during 306.514 person years were expressed per 1000 person years and compared across IJD by incidence rate ratios (IRR) with 95% CI. IR trend rates across 5-year periods for each IJD were analyzed by least square regression (R2). Mortality rate ratio (MRR) was number of deaths per 1000 observation years in patients with OI compared to patients in same disease category hospitalized without OI.

Table 1.

Diagnostic codes applied to define conditions and opportunistic infections in hospital discharge database.

ICD9CMICD10AMRA714.0-714.9M05.0-M06.9AS720.0M45, M08.10-M08.19PsA696.0M07.0-M07.3, L40.5 Tuberculosis010.x-018.xA15–A19 Non-tuberculous mycobacteria031.xA30-A31 Cryptococcosis117.5B45 Aspergillosis117.3B44 Histoplasmosis115B39 All mycosis114.0 - 118.9B35.0 - B49.9 Pneumocystosis136.3B59 Cytomegaloviral disease078.5B25 Influenza487.x, 488.xJ09, J10 Herpes zoster053.xB02 Varicella052.xB01

Results

The IR for all OI in RA patients (5.19, CI 4.8-5.6) was significantly higher than for PsA (IRR 0.56, CI 0.41-0.76 and AS (IRR 0.64, CI 0.53-0.79) with lower IRR observed especially for tuberculosis and H Zoster in PsA (0,49 and 0,47) and AS patients (0,43 and 0,49). H Zoster, TBC and other mycobacteria were the most frequent cause of OI with cryptococcal and pneumocystis only seen in RA. The IR for TBC decreased over time in RA (R2 0.51, p=0.08), and AS (R2 0.47, p=0.09) while the IR for H. zoster decreased in RA only (R2 0.46, p=0.09) (Figure 1). In-hospital mortality rate in patients with OI was 4.9 % for RA, 2.6 % for PsA and 2.2% for AS, but MRR for RA (1.15; 0.71-1.97), PsA (1.64; 0.82-3.57) and AS patients (1.35; 0.68-2.89) was not significantly increased.

Figure 1.

Incidence rate per 1000 personyears over time for hospitalisation with opportunistic infections in RA patients.

Conclusion

The IR for hospitalization with OI is twice as high for RA patients compared to AS and PsA patients. Admission rates for most OI including have decreased in RA patients over the two decades where more intensive treatment became standard of care. This suggests efficacy of preventative measures. Hospital admission with OI associated with a moderate risk of death, but did not incur a higher risk of death than admission for other medical complications in IJD patients

References

[1]Wang D, Yeo AL, Dendle C, Morton S, Morand E, Leech M. Severe infections remain common in a real-world rheumatoid arthritis cohort: A simple clinical model to predict infection risk. Eur J Rheumatol 2021; 8(3): 133-8.

Acknowledgements

Supported by an unrestricted grant from the Arthritis Foundation of Western Australia.

Disclosure of Interests

None declared

OP0168 DEVELOPMENT OF AN ULTRASOUND SCORING SYSTEM FOR CPPD EXTENT: RESULTS FROM A DELPHI PROCESS AND WEB-RELIABILITY EXERCISE BY THE OMERACT US WORKING GROUP

Background

Ultrasound (US) has proven to be an excellent imaging technique for detecting calcium pyrophosphate (CPP) deposition disease (CPPD); it is also widely available and inexpensive and can be performed during the clinic visit making it the preferred imaging modality for many rheumatologists. However, no validated grading systems have yet been developed allowing for a quantification of the extent of crystal deposition in CPPD.

Objectives

The aim of this study was to develop a scoring system for the quantification of CPP deposition at a patient level according to the OMERACT framework.

Methods

As part of the OMERACT methodology, we performed a systematic literature review (SLR) and meta-analysis aimed to estimate the prevalence of CPP deposition in peripheral joints by imaging, in order to identify relevant joints for CPPD monitoring. A preliminary survey was also circulated among the members of the OMERACT US – CPPD working group to collect their own suggestions according to their personal experience. Subsequently, a Delphi survey was prepared and circulated between members of the group, including statements that reflected both the results of the SLR and of the preliminary survey. In total, 32 statements were generated regarding the type of scoring for single structures, the sites to be included, the final scoring at patient level, and the scanning technique. Participants were asked to reply on a 5-point Likert scale (1, strongly disagree to 5, strongly agree) and agreement was achieved when 4 and 5 grades reached 75% or more of concordance. In case of disagreement, new statements were proposed according to the members’ suggestions and circulated for voting in a subsequent round. After agreement of a scoring system, the validation process began. Two rounds of a web-based exercise on static images were conducted on 120 images representing equally all sites under investigation and all degrees of crystal deposition, to assess the intra- and inter-reader reliability of the new scoring system. Representative images of the scoring system were visible throughout the entire exercise in order to facilitate the scoring of the lesions.

Results

Three Delphi rounds were needed to reach agreement on all items. 32/41 members of the OMERACT US-CPPD working group replied in the first round, 26/32 in the second, and 25/26 in the third round. Twenty statements were approved in the first round, 3 in the second, and 3 in the third round. Only the knees (menisci and hyaline cartilage) and the triangular fibrocartilage of the wrist were included in the final score, using a four-grade system (0-3). It was decided that each anatomical structure should be scored separately and then also summed in order to define the joint score. The sum of the assessed joints was the total score at patient level. The final scoring system with the definitions and the relative technical notes is represented in Figure 1. 33/41 members participated to the reliability exercise. The inter-reader reliability of the scoring was substantial (kappa of 0.72), and the intra-reader reliability was almost perfect (kappa of 0.82).

Conclusion

This is the first study for developing a scoring system for the extent of CPP crystal deposition in patients with CPPD. The scoring system demonstrated to be reliable in static images. The next step of the validation process is to assess the reliability of the scoring system in a patient-based exercise. This study represents a fundamental step in the OMERACT process of validating US as an outcome measure instrument, and above proposed scoring system will hopefully provide a useful tool for clinical practice and research.

Disclosure of Interests

None declared

POS0276 TRADITION VS INNOVATION! CONVENTIONAL RADIOGRAPHY AND ULTRASOUND IN THE DIAGNOSIS OF CPPD: INSTRUCTIONS FOR USE

Background

Conventional radiography (CR) is widely used as the first-line investigation for calcium pyrophosphate deposition (CPPD) disease, given its widespread use and the low cost. Next to it a series of advanced imaging techniques have been evaluated for accuracy and reliability. Among them, ultrasound (US) has been thoroughly tested and demonstrated to be accurate and reliable for CPPD diagnosis. However, even if there are data on the diagnostic accuracy of US and CR alone, it is not clear if performing both diagnostic tests and in which sequential order provides an added value for the diagnosis of CPPD.

Objectives

The aim of this study was to assess which diagnostic test performs better for the diagnosis of CPPD and if a combination of the two exams provides an additional value.

Methods

This is an ancillary study of the criterion validity of US in CPPD study1. Consecutive patients with knee osteoarthritis requiring total joint replacement were enrolled in 8 centres. Participants underwent US and CR of the affected knee prior to surgery. US was performed by experienced sonographers following the same scanning protocol described in the main study, while CR were performed in weight bearing AP and lateral views and were read by 2 experienced radiologists that reached a consensus on the presence/absence of CPPD. The evaluation of CPPD at the level of menisci and hyaline cartilage (HC) was based on the OMERACT definitions for US and on the new definitions developed by the ACR/EULAR CPPD classification criteria working group for CR [paper under submission]. Patients were classified as having CPPD considering histological examination as reference standard. Diagnostic indexes were calculated for US and CR alone and combined. Poisson models with robust estimation were used to estimate the best sequence of these diagnostic methods for a more accurate diagnosis of CPPD.

Results

51 pts were enrolled (63% F, mean age 74y ± 8). Diagnostic indexes of US and CR alone and combined are indicated in Table 1. Compared to histology, US demonstrated to be a sensitive tool for identification of CPPD at the knee, with a good sensitivity in all sites and in the overall evaluation. Instead, CR was less sensitive, but it was a highly specific exam for CPPD identification. Combining US and CR led to a higher sensitivity compared with CR alone, but a lower specificity compared to both CR and US alone, and it offered no additional increase in diagnostic accuracy. The Figure 1 shows the results of the appropriate sequence of use of US and CR in patients with suspected CPPD: in case of a positive CR at any of the 3 sites (menisci and HC) no additional exam is necessary, and the same in case of a positive US in at least two sites; however in case of a negative CR, US could help in a statistically significant way to identify CPPD patients, and further in case of a positive US in a single site CR can offer additional information.

Table 1.

diagnostic indexes of US, CR and US + CR in the identification of CPPD. MM: medial meniscus, LM: lateral meniscus, HC: hyaline cartilage, SN: sensitivity, SP: specificity, PPV: positive predictive value, NPV: negative predictive value, ACC: accuracy.

USSNSPPPVNPVACCMM0.880.810.820.880.84LM0.880.730.760.860.80HC0.780.860.820.830.82Overall0.920.640.730.890.78CRMM0.32110.610.67LM0.400.960.910.630.69HC0.480.930.850.680.73Overall0.540.920.880.660.73US + CRMM0.880.810.820.880.84LM0.920.690.740.900.80HC0.870.820.800.890.84Overall0.920.560.670.880.75Figure 1.

evaluation of sequence of US and CR

Conclusion

US confirmed a high diagnostic accuracy in identifying patients affected by CPPD at knee level, while CR demonstrated a high specificity but a low sensitivity. Performing both diagnostic tests could make sense in case of a negative CR or in case of an inconclusive US (only one positive site). To our knowledge, this is the first study that investigates the role of the combination of the two exams in CPPD. Further studies in a large number of patients and in different joints would be helpful to address this point.

References

[1]Filippou G. et al, Ann Rheum Dis, 2020

Disclosure of Interests

None declared

POS0751 TEMPORAL TREND IN HOSPITALISATION FOR OPPORTUNISTIC INFECTIONS IN PATIENTS WITH CONNECTIVE TISSUE DISEASES

Background

Patients with autoimmune connective tissue disease (CTD) and systemic vasculitis (SV) often require aggressive immune-modulating therapy to prevent organ damage. This however increases the risk for common and uncommon infections.

Objectives

To compare the temporal rates and associated mortality of hospitalisation with opportunistic infections (OI) for CTD and SV patients in Western Australia between 1985 and 2015.

Methods

All patients hospitalized in Western Australia in the period 1985-2015 with ≥ 2 ICD based diagnostic codes for SLE (n=1432), other CTD (o-CTD; incl DM/PM, systemic sclerosis, Sjogren’s syndrome; n=2161) and Systemic vasculitis (SV; n=1599) and a microbiologically confirmed OI (Mycobacterial, Fungal and viral infections) were included. Descriptive data are given as median (IQR) and frequency (%). Incidence rates per 1000 person years (IR) were calculated during 100.410 person years.

Results

OI occurred in 12.4 % of lupus, 11.5% of SV and 10.4% of o-CTD patients (p=0.72), but overall IR rates for OI were higher for lupus patients (9.87, CI 5 .49-15.76) than for SV (5.94, CI-2.81-10.24) and o-CTD patients (3.40, CI 1.62-7.23). However, whereas the IR for OI in lupus decreased over time, the IR increased for SV and o-CTD patients (Figure 1). Viral infections were the most frequent specific OI followed by tuberculosis and mycotic infections. Cryptococcal infections were observed in lupus patients only and the limited cases of pneumocystis occurred predominantly in SV patients with no cases observed after 2000 (Figure 2). In hospital mortality during OI admission was 11.5% for SV, 5.6 % for lupus and 3.5% for o-CTD patients (p=0.004).

Figure 1.Figure 2.

Conclusion

Hospitalization rates for OI have decreased for lupus patients especially since 2005, whereas viral and mycotic OI rates have increased for both SV and o-CTD patients. Hospitalization for OI associated with significant case fatality in especially SV patients, indicating a need for increased prevention of OI.

References

[1]Esposito S, Bosis S, Semino M, Rigante D. Infections and systemic lupus erythematosus. Eur J Clin Microbiol Infect Dis. 2014 Sep;33(9):1467-75

Acknowledgements

Supported by an unrestricted grant from The Arthritis Foundation of Western Australia

Disclosure of Interests

None declared

POS0769 CANCER DEVELOPMENT IN PATIENTS HOSPITALISED WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A LONGITUDINAL, POPULATION-LEVEL DATA LINKAGE STUDY

Background

The association between systemic lupus erythematosus (SLE) and cancer risk is unclear.

Objectives

Describe the association between systemic lupus erythematosus (SLE) and the risk of cancer development and subsequent 5-year mortality in Western Australia (WA).

Methods

Population-level cohort study of SLE patients (n=2,111) and general population comparators (n=21,110) hospitalised between 1980–2014. SLE patients (identified by ICD-9-CM: 695.4, 710.0, and ICD-10-AM: L93.0, M32.0) were nearest matched (10:1) for age, sex, Aboriginality, and temporality. Follow-up was from timezero (index SLE hospitalisation) to cancer development, death or 31/12/2014. Using longitudinal linked health data, we determined the risk of cancer development and subsequent 5-year mortality between SLE patients and comparators with Cox proportional hazards regression models.

Results

SLE patients had similar multivariate-adjusted risk (aHR 1.03, 95%CI 0.93, 1.15; P=0.583) of cancer development. Cancer development risk was higher in SLE patients <40 years old (aHR 1.51), and from 1980-1999 (aHR 1.28). SLE patients had higher risk of developing cancer of the oropharynx (aHR 2.13); vulvo-vagina (aHR 3.22); skin (aHR 1.20), and, lymphatic and haematopoietic tissues (aHR 1.78), all P<0.05. SLE patients had reduced risk of breast cancer (aHR 0.64). After cancer development, SLE patients had increased risk of 5-year mortality (aHR 1.16, 95%CI 1.01, 1.33); highest in 40-49 years old (aHR 1.89), and in those with skin (aHR 1.65) or prostate cancer (aHR 4.74).

Conclusion

Hospitalised SLE patients had increased risk of multiple cancers, but a reduced risk of breast cancer. Following cancer development, SLE patients had increased risk of 5-year mortality. Together there is scope to improve cancer prevention and surveillance in SLE patients.

Acknowledgements

The authors wish to thank the staff at the Western Australian Data Linkage Branch and Emergency Department Data Collection, Hospital Morbidity Data Collection, Western Australian Cancer Registry, and Death Registrations. The authors wish to thank the Australian Co-ordinating Registry, the Registries of Births, Deaths and Marriages, the Coroners, the National Coronial Information System and the Victorian Department of Justice and Community Safety for enabling COD URF data to be used for this publication.

Disclosure of Interests

None declared

POS0770 INCREASED RISK OF FRACTURE, RECURRENT FRACTURE AND POST-FRACTURE MORTALITY IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A POPULATION-LEVEL, LINKED DATA STUDY

Background

Systemic lupus erythematosus (SLE) patients have higher fracture risk, driven by primary (chronic inflammation) and secondary (glucocorticoids treatment) osteoporosis. However, there is limited data on fracture recurrence and post-fracture mortality in this vulnerable population.

Objectives

To describe the association between systemic lupus erythematosus (SLE) and the risk of fracture(s), 5- and 10-year recurrent fracture(s), and 5-year post-fracture mortality, compared to hospital-based controls in Western Australia (WA) from 1980 - 2014.

Methods

Population-level cohort study of SLE patients (n=2,440, 28,002 person-years) and general population comparators (controls) (n=10,220; 161,392 person-years) identified within the Western Australia (WA) Rheumatic Disease Epidemiological Registry (WARDER). SLE patients 18-80 years old (identified by ICD-9-CM: 695.4, 710.0, ICD-10-AM: L93.0, M32.0) and controls were nearest matched (5:1) for age, sex, Aboriginality, and temporality. Follow-up was from timezero (index SLE hospitalisation) to fracture-related hospitalisation, death or 31/12/2014. Using longitudinal linked health data we determined the relative risk of (low impact) fracture-related hospitalisations (after excluding for traumatic and external factors, such as, falls from more than standing height and transport accidents), 5- and 10-year recurrent fractures, and 5-year post-fracture mortality between SLE patients and controls with multivariate Cox proportional hazards regression models from 1980-2014.

Results

Compared to general population controls, SLE patients had higher multivariate-adjusted risk (aHR 2.44, 95%CI 2.08, 2.87; P<0.01) of fractures during follow-up. SLE patients had higher fracture risk regardless of sex, Aboriginality, age group (highest in those <50 years of age), or study period (2000-2014: aHR 1.83, 95%CI 1.32, 2.55; P<0.01). SLE patients had higher risk of hand, wrist and forearm fractures (aHR 1.95), vertebral fractures (aHR 5.73), hip fractures (aHR 1.83), and lower limb, ankle and foot fractures (aHR 2.14). Similarly, SLE patients had higher risk of both 5- (aHR 2.89) and 10-year (aHR 3.00) fracture recurrence, which held across sub-group analyses and remained high in the most recent 2000-2014 period (aHR 2.84 and aHR 3.04, respectively). SLE patients had higher (aHR 1.56, 95%CI 1.16, 2.09; P<0.01) risk of 5-year post-fracture mortality, which held for female SLE patients (aHR 1.45), those ≥70 years-old (aHR 1.72), and remained in the 2000-2014 period (aHR 1.57).

Conclusion

SLE patients have an increased risk of fractures, 5- and 10-year recurrent fractures, and 5-year mortality post-fracture compared to controls from the general population. After adjustment for conventional risk factors, these associations remained unchanged in the most recent period (2000-2014). This study highlights the need for improved primary prevention of a first fracture event in SLE patients.

Acknowledgements

The authors wish to thank the staff at the Western Australian Data Linkage Branch and Emergency Department Data Collection, Hospital Morbidity Data Collection, Western Australian Cancer Registry, and Death Registrations. The authors wish to thank the Australian Co-ordinating Registry, the Registries of Births, Deaths and Marriages, the Coroners, the National Coronial Information System and the Victorian Department of Justice and Community Safety for enabling COD URF data to be used for this publication.

Disclosure of Interests

None declared

OP0291 SCORING STRUCTURAL DAMAGE IN RHEUMATOID ARTHRITIS BY ULTRASOUND: RESULTS FROM A DELPHI PROCESS AND WEB-RELIABILITY EXERCISE BY THE OMERACT US WORKING GROUP

Background

Structural damage in rheumatoid arthritis (RA) includes bone erosion, cartilage change, and joint malalignment; historically evaluated with conventional radiography. Ultrasound (US) has been shown to be a valid tool for evaluating both cartilage change and bone erosion.

Objectives

To obtain agreement on definitions and develop semiquantitative scoring systems for assessing structural damage by US and to validate these in a web-based reliability exercise.

Methods

A Delphi survey of statements was prepared by an OMERACT US Working Group task force (USWG) based on a previously published systematic literature review (1) and circulated between group members, including definitions on normal US appearance of joint components, definitions of elementary lesions and scoring systems for bone erosions and joint malalignment. Definitions and a US scoring system for scoring cartilage change were recently developed and validated by the USWG (2) After agreement was achieved (≥75% of grades 4-5 on 1-5 Likert scale) on the statements, still images of metacarpophalangeal and proximal interphalangeal joints 2-5 in healthy controls and in RA patients with varying degrees of pathology were acquired by the USWG members. A dataset of 100 anonymized images, representing various grades of the 3 components of structural damage was created and utilized in 2 rounds of a web-based exercise. Intra- and inter-reader reliability of the scoring systems was assessed by kappa statistics.

Results

19 USWG members needed 4 Delphi rounds to reach agreement on a total of 9 statements. 4/12 statements were approved in the first, 2/6 in the second, 1/5 in the third and 2/2 in the fourth round. Final scoring systems and representative images are shown in Table 1 & Figure 1. 22 members participated in the web-based reliability exercise. The intra-reader reliability was almost perfect for bone erosion (kappa: 0.87) and cartilage change (kappa: 0.83) and substantial for malalignment (kappa of 0.72). The inter-reader reliability was almost perfect for bone erosion (kappa: 0.85), and substantial for cartilage change (kappa: 0.79) and malalignment (0.62).

Table 1.

Final definitions of scoring systems of elementary lesions of structural damage in rheumatoid arthritis

AgreementBone erosionA 4-grade semiquantitative scoring system can be used to score erosions as follows: grade 0. intact cortical bone; grade 1. single small erosion (diameter: ≤2mm); grade 2. single large erosion (diameter: >2mm) or 2 small erosions; grade 3. 2 large erosions or ≥3 erosions, regardless of size. Both longitudinal and transverse scans should be considered, and the largest measure chosen for each erosion.100%Cartilage changeA 3-grade semiquantitative scoring system can be used to grade hyaline cartilage change as follows: grade 0. normal cartilage; grade 1. minimal change: focal thinning or incomplete loss of cartilage; grade 2. severe change: diffuse thinning or complete loss of cartilage.80% (2)MalalignmentA 3-grade semiquantitative scoring system can be used to grade malalignment as follows: 0. normal alignment; 1. subluxation or partial dislocation, where the two bone endings are malaligned so that one bone ending is dislocated from its normal position, but still within the articulation; 2. luxation or total dislocation, where the luxated bone ending moves beyond the articulation and the opposing bone ending. Bone position may be compared with a contralateral or similar intact joint if available.94%Figure 1.

Representative images of the scoring systems for bone erosion (A), cartilage change (B) and malalignment (C)

Conclusion

This first attempt to create a composite US instrument based on scoring systems encompassing all aspects of structural damage, demonstrates that US is a reliable tool for evaluating and scoring bone erosion, cartilage change and malalignment in the finger joints of RA patients.

References

[1]Gessl I, et al. Semin Arthritis Rheum. 2021 Jun;51(3):627-39.

[2]Mandl P, et al. Rheumatology (Oxford). 2019 Oct 1;58(10):1802-11.

Disclosure of Interests

Peter Mandl Speakers bureau: AbbVie, Janssen, Lilly, Novartis, Consultant of: AbbVie, Janssen, Lilly, Novartis, Grant/research support from: AbbVie, BMS, Novartis, Janssen, Lilly, MSD, UCB, Irina Gessl: None declared, Georgios Filippou: None declared, Silvia Sirotti: None declared, Lene Terslev Speakers bureau: Novartis, Pfizer, UCB, Janssen, GE, Carlos Pineda: None declared, Helen Keen Speakers bureau: Roche, AbbVie, Janssen, Consultant of: Sanofi, Marina Backhaus: None declared, David Andrew Bong: None declared, Edoardo Cipolletta: None declared, PAZ COLLADO: None declared, Christian Dejaco Speakers bureau: Roche, AbbVie, Sanofi, Lilly, Pfizer, Novartis, Janssen, Galapagos, Consultant of: Roche, AbbVie, Sanofi, Lilly, Pfizer, Novartis, Janssen, Galapagos, Andrea Delle Sedie Speakers bureau: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Paid instructor for: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Consultant of: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Christina Duftner: None declared, Hilde Berner Hammer: None declared, Annamaria Iagnocco: None declared, Zunaid Karim: None declared, Ingrid Möller Speakers bureau: Bristol-Myers Squibb, Ibsa, Pfizer, Galapagos, Esperanza Naredo Speakers bureau: Abbvie, Pfizer, Lilly, Novartis, Janssen, Celgene GmbH, Paid instructor for: Novartis, Consultant of: Novartis, Lilly, Grant/research support from: Lilly, Pfizer, Wolfgang A. Schmidt: None declared, Marcin Szkudlarek: None declared, Giorgio Tamborrini: None declared, Priscilla C Wong: None declared, Emilio Filippucci Speakers bureau: AbbVie, Amgen, Bristol -Myers Squibb, Janssen-Cilag, Lilly, Novartis, Pfizer, Roche, Union Chimique Belge Pharma, Peter Balint Speakers bureau: Abbvie, Janssen, Lilly, Novartis, Maria-Antonietta D’Agostino: None declared

OP0227 WEIGHT LOSS IS ASSOCIATED WITH REDUCED INCIDENCE AND PROGRESSION OF STRUCTURAL DEFECTS IN KNEE OSTEOARTHRITIS, AS ASSESSED BY RADIOGRAPHY OVER 4 TO 5 YEARS: A PROSPECTIVE MULTI-COHORT STUDY

Background

Overweight and obesity are associated with greater incidence and progression of the structural defects of knee osteoarthritis, but it is unknown if weight loss is of benefit.

Objectives

To describe the association between change in body mass index (BMI) and the incidence and progression of structural defects in knee osteoarthritis.

Methods

Scores from radiographic analyses of knees at baseline and at 4 to 5 years’ follow up were obtained from three independent data sets (the OAI and MOST data sets from the United States from America, and the CHECK data set from the Netherlands). The exposure of interest was change in BMI from baseline to 4 to 5 years’ follow up. To investigate the incidence of structural defects of knee osteoarthritis, we selected a total of 9732 knees (from 5802 participants) that had a Kellgren-Lawrence (KL) grade of knee osteoarthritis at baseline of ‘none’ (0) or ‘doubtful’ (1) (the ‘incidence cohort’), and determined the odds of having a KL grade at follow-up of ‘minimal’ (2), ‘moderate’ (3), or ‘severe’ (4). To investigate progression, we selected a total of 6084 knees (from 3996 participants) that had a KL grade at baseline of ‘minimal’ (2), ‘moderate’ (3), or ‘severe’ (4) (the ‘progression cohort’), and determined the odds of increasing by 1 or more KL grades by follow up. The degradation of three individual structural features of knee osteoarthritis (i.e., joint space narrowing, osteophytes on the femoral surface, and osteophytes on the tibial surface), on both the medial and lateral sides of the knee, were also investigated in both the incidence and progression cohorts. Here, degradation was defined as an increase by 1 or more Osteoarthritis Research Society International (OARSI) grades.

Results

Change in BMI was positively associated with both the incidence and progression of knee osteoarthritis, as defined by KL grade. Specifically, for each one-unit change in BMI, the adjusted odds ratio for incidence was 1.05 (95% confidence interval [CI] 1.02 to 1.09), and for progression, the same adjusted odds ratio and 95% CI was also observed. Change in BMI was also positively associated with degradation (i.e., narrowing) of joint space on the medial but not the lateral side of the knee, with an adjusted odds ratio of 1.08 (95% CI 1.04 to 1.12) in the ‘incidence cohort’ and 1.08 (95% CI 1.03 to 1.12) in the ‘progression cohort’. Degradation of the tibial and femoral surfaces (i.e., osteophytes) was also seen on the medial but not the lateral side of the knee, but only in one of the two cohorts investigated (the ‘incidence cohort’), with an adjusted odds ratio of 1.07 (95% CI 1.03 to 1.12) for osteophytes on the femoral surface, and 1.05 (95% CI 1.01 to 1.09) for osteophytes on the tibial surface.

Conclusion

Each one-unit reduction in BMI is associated with a 5 to 8% decrease in the odds of the incidence and progression of the structural defects of knee osteoarthritis, with lower odds of structural degradation specific to the medial – not lateral – side of the knee.

Acknowledgements

We acknowledge the provision of datasets and/or research tools from three studies: the Osteoarthritis Initiative (OAI) Study; the Multicenter Osteoarthritis Study (MOST); and the Cohort Hip and Cohort Knee (CHECK) Study.

OAI is a collaborative informatics system created by the National Institute of Mental Health and the National Institute of Arthritis, Musculoskeletal and Skin Diseases (NIAMS) to provide a worldwide resource to quicken the pace of biomarker identification, scientific investigation and OA drug development. The OAI data repository is housed within the National Institute of Mental Health (NIMH) Data Archive (NDA).

For the MOST data set, we wish to acknowledge the contributions of the study participants, investigators and research staff involved. MOST is comprised of four (4) cooperative grants: U01 AG18820 David T. Felson (Boston University); U01 AG18832 James Torner (University of Iowa); U01 AG18947 Cora E. Lewis (University of Alabama at Birmingham); U01 AG19069 Michael C. Nevitt (University of California, San Francisco), funded by the National Institutes of Health, a branch of the Department of Health and Human Services, and conducted by MOST investigators. This manuscript was prepared using MOST data and does not claim, infer, or imply endorsement by MOST, by the MOST investigators and their respective institutions or by the University of California of the Data Recipients’ use of the Data, of the entity or personnel conducting the research, or of any results of the research.

The CHECK study is funded by the Dutch Arthritis Foundation. Involved are: Erasmus Medical Center Rotterdam; Kennemer Gasthuis Haarlem; Leiden University Medical Center; Maastricht University Medical Center; Martini Hospital Groningen /Allied Health Care Center for Rheumatology and Rehabilitation Groningen; Medical Spectrum Twente Enschede /Ziekenhuisgroep Twente Almelo; Reade Center for Rehabilitation and Rheumatology; St.Maartens-kliniek Nijmegen; University Medical Center Utrecht and Wilhelmina Hospital Assen.

Disclosure of Interests

Zubeyir Salis: None declared, Helen Keen: None declared, Blanca Gallego: None declared, Tuan van Nguyen: None declared, Amanda Sainsbury Speakers bureau: ZS and AS own 50% each of the shares in Zuman International, which receives royalties for books AS has written and payments for presentations, and provides paid training for higher degree students. AS additionally reports receiving presentation fees and travel reimbursements from Eli Lilly and Co, the Pharmacy Guild of Australia, Novo Nordisk, the Dietitians Association of Australia, Shoalhaven Family Medical Centres, the Pharmaceutical Society of Australia, and Metagenics, and serving on the Nestlé Health Science Optifast VLCD advisory board from 2016 to 2018., Consultant of: ZS and AS own 50% each of the shares in Zuman International, which receives royalties for books AS has written and payments for presentations, and provides paid training for higher degree students. AS additionally reports receiving presentation fees and travel reimbursements from Eli Lilly and Co, the Pharmacy Guild of Australia, Novo Nordisk, the Dietitians Association of Australia, Shoalhaven Family Medical Centres, the Pharmaceutical Society of Australia, and Metagenics, and serving on the Nestlé Health Science Optifast VLCD advisory board from 2016 to 2018.

POS0297 HOSPITAL ADMISSIONS FOR PATIENTS WITH RHEUMATOID ARTHRITIS IN WESTERN AUSTRALIA HOSPITALS HAVE DECLINED OVER TIME

Background:

Rheumatoid arthritis (RA) represents a substantial burden on patients and society in terms of morbidity, enduring disability, and medical expenses (1). RA prevalence is poorly described in Australia, and linked health datasets can provide a more meaningful picture for RA epidemiology in the Australian population.

Objectives:

To describe the period prevalence rate of RA patients per 1000 hospital separations coded as RA primary or secondary diagnosis in Western Australia (WA) hospitals between 1995 and 2014.

Methods:

We extracted data on all patients identified in the WA Hospital Morbidity Data Collection between 1995 and 2014, with the International Classification of Diseases (ICD) codes for RA (ICD 10 M05.00–M06.99, and the corresponding ICD 9 codes). We estimated period prevalence rates per 1000 hospital separations and annual average percentage changes, with the total number of hospital separations each year.

Results:

A total of 17,125 patients were admitted to WA hospitals with a diagnostic code for RA over the study period (1995-2014). The total number of hospital separations for RA patients was 50,353, indicating an average of three hospital separations per patient over twenty years. The RA prevalence was 3.4 per 1000 separations over the study period, with a -2.89% annual average decrease since 1995.

Conclusion:

These data demonstrate that hospitalisation for RA has decreased considerably in WA over the last two decades. As this decrease roughly coincides with the introduction of biological drug treatment for RA, the reduced need for hospital admission is likely due to improvements in RA management.

References:

[1]Uhlig T, Moe RH, Kvien TK (2014) The burden of disease in rheumatoid arthritis. Pharmacoeconomics 32:841-851. doi:10.1007/s40273-014-0174-6

Acknowledgements:

Khalid Almutairi was supported by an Australian Government Research Training Program PhD Scholarship at the University of Western Australia.

Disclosure of Interests:

Khalid Almutairi: None declared, Johannes Nossent Speakers bureau: Janssen, David Preen: None declared, Helen Keen Speakers bureau: Pfizer Australia, Abbvie Australia, Charles Inderjeeth Speakers bureau: Eli Lilly

AB0103 THE ACCURACY OF ADMINISTRATIVE HEALTH DATA FOR IDENTIFYING PATIENTS WITH RHEUMATOID ARTHRITIS: A VALIDATION STUDY USING MEDICAL RECORDS IN WESTERN AUSTRALIA

Background:

The use of large administrative health datasets is increasingly important in Rheumatology for disease trends and outcome research (1). We established the West Australian Rheumatic Disease Epidemiological Registry containing longitudinal health data for over 10000 patients with Rheumatoid Arthritis (RA) in Western Australia (WA). Accuracy of coding for RA is essential to validity of the datasets.

Objectives:

Investigate the diagnostic accuracy of International Classification of Diseases (ICD) based discharge codes for RA at WA’s largest tertiary hospital.

Methods:

Medical records for RA patients randomly selected from the hospital discharge database with ICD 10 codes (M05.00–M06.99) from 2008–2020 were retrospectively reviewed. Rheumatologist reported diagnosis and ACR/EULAR classification were used as gold standards to determine positive predictive value (PPV) with 95% Confidence Interval (CI) for RA primary diagnostic codes.

Results:

Medical chart review was completed for 87 patients (mean age 64.7 years, 67% female). Total of 80 (92%) patients had specialist confirmed RA diagnoses, while seven patients (8%) had alternate clinical diagnoses providing a PPV of 93.5% (95%CI: 89.9 to 95.86). Overall, 69 out 87 patients (79.3%) fulfilled ACR/EULAR classification criteria based on RA primary diagnostic codes with a PPV of 80.5% (95%CI: 76.81 to 83.7). A combination of a diagnostic RA code with biologic infusion codes in two or more codes increased the PPV to 97.9%.

Conclusion:

Hospital discharge diagnostic codes in WA identify RA patients with a high degree of accuracy. Combining a primary diagnostic code for RA with biological infusion codes can further increase the PPV.

References:

[1]Hanly et al. The use of administrative health care databases to identify patients with rheumatoid arthritis. Open Access Rheumatol 2015; 7: 69–75.

Table 1.

Accuracy measures of different algorithms for random sample of rheumatoid arthritis (RA) patients with one or more RA codes.

Rheumatologist-reported diagnosisACR/EULAR classification criteriaAdministrative dataSNSPPPVNPVSNSPPPVNPVOne or more RA primary codes90%28.5%93.5%7.6%89.8%16.6%80.5%30%One or more RA biological infusion codes25%71.4%90.9%7.7%20.3%55.5%63.6%15.3%Two or more RA codes including biological codes60%85.7%97.9%15.8%56.5%44.4%79.6%21%

RA=Rheumatoid Arthritis, SN=Sensitivity, SP=Specificity, PPV= Positive predictive value, NPV= Negative predictive value.

Acknowledgements:

Khalid Almutairi was supported by an Australian Government research training Program PhD Scholarship at the University of Western Australia.

Disclosure of Interests:

Khalid Almutairi: None declared, Johannes Nossent Speakers bureau: Janssen, David Preen: None declared, Helen Keen Speakers bureau: Pfizer Australia, Abbvie Australia, Katrina Roger: None declared, Charles Inderjeeth Speakers bureau: Eli Lilly

POS1147 COSTS AND FACTORS AFFECTING HEALTH SERVICE UTILISATION IN PATIENTS WITH GOUT: A LONGITUDINAL, POPULATION-LEVEL LINKED DATA STUDY IN WESTERN AUSTRALIA

Background:

Evidence suggests that gout is associated with high health care costs and that many inpatient admissions are preventable (1). Understanding the driver of health care costs will allow more targeted intervention.

Objectives:

To examine factors associated with high health service utilisation and cost in patients admitted to hospital with gout, using whole-population linked hospital, WA cancer registration, Emergency Department (ED) and death data (2).

Methods:

The study included patients (18 to 84 years) who had been admitted to hospital with a primary or co-diagnosis of gout for the first time between 1 Jan 02 and 31 Dec 09 Hospital costs were calculated per patient using DRG codes and ED costs were calculated from URG codes. Costs are presented in Australian dollars. Follow-up was completed at five years post their initial gout hospitalisation, at death, or at the 31th of December 2014. Both univariable and multivariable analysis was conducted for each patient characteristic. Independent variables were assessed for collinearity. Collinearity was assumed present where the correlation co-efficient was greater than 0.7.

Results:

4,379 individuals were included. In the following five years, there was 22,222 ED attendances (median cost, $1826 per patient (IQR: $433 - $4,414)), and 58,920 hospital admissions, (median cost, $25,009 per patient (IQR: $6,844 - $60,535)). 4,059 (18.3%) ED attendances and 3,834 (6.5%) hospital admissions were potentially preventable. Gout was not a major driver of events, with 341 (1.5%) ED attendances and 620 (1.1%) hospital admissions coded with a primary diagnosis of gout. In the univariable analysis (Table 1), Aboriginality and smoking were associated with an increased number of both ED attendances and hospital admissions. Increased socio-economic status was associated with a reduction in ED attendances, however, this was not reflected in hospital admissions.

Conclusion:

Patients admitted to hospital with gout are highly likely to be re-admitted or attend ED in the following 5 years. Many of these contacts are preventable, but are usually driven by comorbidities rather than gout.

References:

[1]Loh K, . Intern Med J. 2020 Mar;50(3):386.

[2]https://www.datalinkage-wa.org.au.

Acknowledgements:

The authors wish to thank the staff at the Western Australian Data Linkage Branch and the Hospital Morbidity Data Collection, and the Death Registrations and the Emergency Department Data Collection.

Disclosure of Interests:

None declared.

AB0629 ACCURACY OF SYNOVIAL FLUID ANALYSIS FOR THE IDENTIFICATION OF CALCIUM PYROPHOSPHATE CRYSTALS: AN ANCILLARY STUDY OF OMERACT CRITERION VALIDITY STUDY FOR ULTRASOUND IN CPPD

Background:

Synovial fluid analysis (SFA) via compensated polarized light microscopy is still considered the gold standard for the identification and diagnosis of Calcium Pyrophosphate Deposition disease (CPPD)-related arthropathies[1], but very few studies have been published about its diagnostic accuracy.

Objectives:

The aim of this study was to evaluate the accuracy of SFA in the identification of calcium pyrophosphate dihydrate (CPP) crystals compared to microscopic analysis of joint tissues as the reference standard.

Methods:

This is an ancillary study of an international, multicentre cross-sectional study performed by the CPPD subgroup of the OMERACT Ultrasound working group[2]. Consecutive patients with knee osteoarthritis (OA) waiting for total knee replacement surgery were enrolled in the study from 2 participating centres, Mexico and Romania. During surgical procedures synovial fluid (SF), menisci and hyaline cartilage were collected and analysed within 48 hours after surgery under transmitted light microscopy and compensated polarised light microscopy for the presence/absence of CPP crystals. All slides were analysed by expert examiners on site, blinded to other findings. A dichotomic score (absence/presence) was used for scoring both SF and tissues. Microscopic analysis of knee tissues was considered the gold standard. Sensitivity, specificity, accuracy, positive and negative predictive values (PPV and NPV) of SFA in the identification of CPP crystals were calculated.

Results:

15 patients (53% female, mean age 68yo ± 8.4) with OA of grade 3 or 4 according to Kellgren-Lawrence scoring were enrolled. 12 patients (80%) were positive for CPP crystals at SFA and 14 (93%) at tissues microscopic analysis. Among 12 SFA positive patients, all were positive for CPP crystals in either medial or lateral meniscus, and 11 were positive in both; 10 patients were positive at the hyaline cartilage, and all 10 were also positive for at least one meniscus. Regarding the 3 SFA negative patients, only one had no crystals in the examined tissues, while the other 2 patients had CPP crystals in both menisci and hyaline cartilage. The overall diagnostic accuracy of SFA compared to histology analysis for CPPD was 87%, with a sensitivity of 86% and a specificity of 100%, the PPV was 100% and the NPV was 33% (Table 1).

Table 1.

sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of synovial fluid analysis compared to the reference standard. CI: Confidential Interval. SF: synovial fluid, in parentheses: numerators and denominators for all percentages provided.

SensitivitySpecificityPPVNPVAccuracySF analysis86% (12/14)100% (1/1)100% (12/12)33% (1/3)87% (13/15)(0.65-0.99) CI 95%(0.0-0.25) CI 95%(0.65-0.99) CI 95%(0.0-0.25) CI 95%

Conclusion:

SFA demonstrated to be an accurate test for the identification of CPP crystals in patients with advanced OA. However, is not always feasible and carries some risks for the patient. Considering the availability of validated imaging techniques for the detection of CPPD, such as US, SFA could be used in those patients where imaging and clinical data are not definitely confirmatory of the disease.

References:

[1]W. Zhang et al., ‘European League Against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: terminology and diagnosis’, Ann Rheum Dis, vol. 70, no. 4, pp. 563–570, Apr. 2011, doi: 10.1136/ard.2010.139105.

[2]G. Filippou et al., ‘Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study’, Ann Rheum Dis, p. annrheumdis-2020-217998, Sep. 2020, doi: 10.1136/annrheumdis-2020-217998.

Disclosure of Interests:

None declared.

POS0632 THE LONGITUDINAL ASSOCIATIONS OF METHOTREXATE AND BIOLOGIC USE ON HOSPITAL ADMISSION FOR RHEUMATOID ARTHRITIS PATIENTS IN WESTERN AUSTRALIA POPULATION (1995- 2014)

Background:

Rheumatoid arthritis (RA) carries a substantial burden for patients and society in terms of morbidity, enduring disability, and costs [1]. The Australian Pharmaceutical Benefits Scheme (PBS) has subsidised biological disease-modifying anti-rheumatic drugs (B-DMARDs) since 2003 [2].

Objectives:

We examined the impact of B-DMARDs availability on RA hospitalisation rate in the Western Australia (WA) population pre- and post- B-DMARDs introduction to the PBS (1995-2002 and 2003-2014).

Methods:

Population PBS dispensing data for WA of DMARD were obtained and converted to defined daily doses (DDD)/1000 population/day using the WA population census. RA inpatient records were extracted from the WA Hospital Morbidity Data Collection using ICD-9 codes 714 and ICD-10 codes M05.00–M06.99). Principal component analysis (PCA) was applied to determine the relationship between DMARDs use and RA hospital admission rates.

Results:

There was a total of 17,125 patients who had 50,353 admissions with a diagnostic code for RA during the study period. DMARD use for RA rose from 1.45 to 3.19 DDD/1000 population/day over 1995-2014 (Figure 1). In 1995-2002, the number of RA admissions fell from 7.9 to 2.6 per 1000 hospital separations, then dropped further from 2.9 to 1.9 per 1000 hospital separations in 2003-2014. Based on PCA analysis, conventional DMARDs (methotrexate) and B-DMARDs dispensing had an inverse association with hospital admissions for RA.

Conclusion:

The increased availability of conventional and biological DMARDs for RA was associated with a significant decline in hospital admissions for RA patients in WA.

References:

[1]Boonen A, Severens JL (2011) The burden of illness of rheumatoid arthritis. Clin Rheumatol 30:3-8.

[2]Medicare Australia (2020) Pharmaceutical Benefits Schedule statistics. http://medicarestatistics.humanservices.gov.au/statistics/pbs_item.jsp.

Figure 1.

The hospital separations and total drugs use patterns of RA in 1995-2014 in Western Australia.

Acknowledgements:

Supported by an Australian Government Research Training Program PhD Scholarship at the University of Western Australia.

Disclosure of Interests:

Khalid Almutairi: None declared, Johannes Nossent Speakers bureau: Janssen, David Preen: None declared, Helen Keen Speakers bureau: Pfizer Australia, Abbvie Australia, Charles Inderjeeth Speakers bureau: bureau: Eli Lilly

POS1132 DIAGNOSTIC ACCURACY OF CONVENTIONAL RADIOGRAPHY OF THE KNEE FOR CALCIUM PYROPHOSPHATE DEPOSITION DISEASE: AN ANCILLARY STUDY OF THE OMERACT ULTRASOUND – CPPD GROUP

Background:

Conventional Radiography (CR) has been widely used in the assessment of knee chondrocalcinosis (CC) and is still considered one of the most important diagnostic methods for the diagnosis. However, there are very few studies that examine the diagnostic accuracy of CR compared to histology of the knee tissues.

Objectives:

To assess the diagnostic accuracy of CR of the knee in Calcium Pyrophosphate Deposition Disease (CPPD) by using the recently created definitions for CPPD in CR of the ACR/EULAR taskforce for the new classification criteria for CPPD.

Methods:

This is an ancillary study of the Criterion Validity of Ultrasound in CPPD study [1]. Consecutive patients with osteoarthritis (OA) awaiting total knee replacement were enrolled in 4 centres from Romania, Italy, USA and Mexico. All patients underwent CR of the knees taken maximum 6 months before surgery, in posterior-anterior weight baring and lateral projections. DICOM files of the radiographs were anonymised and read independently by two musculoskeletal radiologists with experience in microcrystalline arthropathies. For each patient, a dichotomic score was used (absence/presence of CC) at the level of the menisci and tibiofemoral hyaline cartilage by each reader. The definitions of the ACR/EULAR taskforce for identification of CPPD in CR were used in this study [paper in preparation]. According to these definitions CPPD in CR appears as “linear or punctate opacities in the region of fibro- or hyaline articular cartilage/synovial membrane or joint capsule/within tendons or entheses that are distinct from denser, nummular radio-opaque deposits due to basic calcium phosphate deposition”. In case of disagreement a consensus decision was taken by both radiologists after discussion of the case. Menisci and the hyaline cartilage were analysed using compensated polarized light microscopy as described previously [1], patients were considered positive for CPPD if at least one of their tissue specimens revealed the presence of calcium pyrophosphate crystals. All examiners were blind to each other’s findings.

Results:

We enrolled 33 patients with OA (61% female, mean age 69yo). The accuracy values of CR in the various sites of the knee are indicated in Table 1. CR demonstrated to be a specific exam for identification of CPPD at the knee, but sensitivity remains low in all sites and in the overall evaluation. Identification of CPPD appears challenging and this could be due to the advanced grade of OA in our cohort of patients. Advanced degeneration, dislocation of the menisci and thinning of the hyaline cartilage in these patients is frequent and the eventual presence of calcific deposits in one of these structures could overlap with other anatomical structures making the exact localisation difficult. According to the results of the predictive values, the presence of typical deposition on CR allows a definite confirmation of the diagnosis, but a negative radiography does not exclude CPPD as testified by the low negative predictive value.

Table 1.

Sensitivity, specificity, PPV, NPV, accuracy and AUC of CR for identification of CPPD by using the new ACR/EULAR taskforce definitions.

Medial meniscusLateral meniscusHyaline cartilageOverallSensitivity22%33%31%42%Specificity100%100%85%90%Positive predictive value100%100%67%80%Negative predictive value56%60%55%61%Accuracy61%68%58%66%AUC0.60.70.60.7

Conclusion:

CR has been extensively used for the diagnosis of OA and CPPD and has been tested previously for diagnostic accuracy. The results of our study confirm that the presence of typical CPPD calcifications, as defined by the ACR/EULAR task force, are highly specific but have low sensitivity for disease identification when using CR. Absence of CPPD on CR does not exclude the diagnosis.

References:

[1]Filippou G, et al. Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study. Ann Rheum Dis 2020. doi:10.1136/annrheumdis-2020-217998

Disclosure of Interests:

None declared.

OP0100-HPR THE INFLUENCE OF COMORBIDITY ON MORTALITY IN PATIENTS WITH RHEUMATOID ARTHRITIS 1980-2015: A LONGITUDINAL POPULATION-BASED STUDY IN WESTERN AUSTRALIA

Background:

Rheumatoid arthritis (RA) contributes to excess morbidity and mortality in RA patients compared with the general population (1). In Australia, there is a paucity of published literature on the mortality and morbidity rates in RA patients, despite the significant morbidity and mortality burden on health care costs due to RA. Linked data is the preferred method to estimate morbidity and mortality outcomes as they provide the best case-ascertainment.

Objectives:

To describe temporal changes in mortality rates for patients with RA in relation to comorbidity accrual from 1980-2015 in Western Australia (WA).

Methods:

Using population-level linked data from WA health administrative datasets (hospital morbidity, emergency department and death data) we followed 17,125 RA patients (ICD-10-AM M05.00–M06.99, ICD-9-CM 714) from 1980- 2015. Comorbidity was ascertained using the Charlson Comorbidity Index (CCI). Mortality rate ratios (MRR) were calculated per decade between the RA cohort and the WA general population by direct age standardisation method, while temporal trends of comorbidities and in-hospital mortality were estimated per 1000 hospital separations in three consecutive decades.

Results:

During 356,069 patient-years, a total of 8955 (52%) deaths occurred in the RA cohort. The leading causes of deaths were cardiovascular diseases 2386 (26.6%), cancer 1511 (16.8%), rheumatic diseases 519 (5.8%), chronic pulmonary disease 491 (5.5%), dementia 269 (3.0%) and diabetes 235 (2.6%). The highest prevalence of comorbidity (688.6 per 1000 separations) was in the period 1991-2000 following a 1.3% average annual increase since 1980. In-hospital mortality rate was also highest (26.7 deaths per 1000 separations) in the same period. After 2001, both RA comorbidity and mortality rates decreased annually by -0.5% and -4.8%, respectively, with annual changes of -4.4% to -2% and from 2011- 2015, respectively. The overall mortality rate in RA patients after age adjustment was 2.5-times (95%CI: 2.52-2.65) higher than the general population between 1980- 2015 and 1.5-times (95%CI: 1.39-1.81) for the period 2011-2015.

Conclusion:

The annual comorbidity prevalence and mortality rates in WA have decreased significantly since 2001 reflecting improvements in the management of RA and comorbidity. Nonetheless, the mortality rate in RA patients in WA remains 1.5-times higher than their community counterparts suggesting that there is room to achieve further improvements.

References:

[1]Meune C, Touze E, Trinquart L, Allanore Y (2009) Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies. Rheumatology (Oxford) 48:1309-1313. doi:10.1093/rheumatology/kep252

Table 1.

Mortality rates observed among patients with rheumatoid arthritis, based on Charlson Comorbidity Index, per 1000 hospital separations, Western Australia hospitals (1980-2015).

Time period1980-19901991-20002001-20102011-2015Total number of hospital separations8209910773118539880410Number of deaths1620287531831277CCI score0481 (29.7%)1024 (35.6%)1197 (37.6%)565 (44.2%)1838 (51.7%)1271 (44.2%)1358 (42.6%)467 (36.6%)2273 (16.8%)518 (18%)581 (18.3%)232 (18.2%)31 (0.1%)4 (0.2%)2 (0.1%)0 (0%)627 (1.7%)58 (2%)45 (1.4%)13 (1%)In-hospital RA mortality per 1000 hospital separation19.726.717.215.9Parentage of average annual change per annum in the period03.8-4.8-2.6Parentage of average annual change since 198001.5-1.4-0.2

CCI= Charlson Comorbidity Index.

Acknowledgements:

Khalid Almutairi was supported by an Australian Government Research Training Program PhD Scholarship at the University of Western Australia.

Disclosure of Interests:

Khalid Almutairi: None declared, Johannes Nossent Speakers bureau: Janssen, David Preen: None declared, Helen Keen Speakers bureau: Pfizer Australia, Abbvie Australia, Charles Inderjeeth Speakers bureau: Eli Lilly.

POS1141 ASSESSING RELEVANT JOINTS FOR MONITORING CPPD DISEASE: A SYSTEMATIC LITERATURE REVIEW OF IMAGING TECHNIQUES BY THE OMERACT ULTRASOUND – CPPD SUBGROUP

Background:

Imaging has been extensively used for the Calcium Pyrophosphate Deposition Disease (CPPD) diagnosis but the prevalence of joint calcifications at imaging in CPPD patients has not been thoroughly assessed.

Objectives:

This systematic literature review (SLR) is aimed to estimate the prevalence of calcium crystal deposition in peripheral joints by imaging in suspected or definite CPPD patients to establish relevant joints for CPPD monitoring

Methods:

After defining PICOs, Pubmed and Embase were searched from inception to October 2020 for identifying studies that evaluated the use of Conventional Radiography (CR), Ultrasound (US), Computed Tomography (CT) and Dual Energy Computed Tomography (DECT) in detecting calcifications at peripheral joints in patients with defined or probable CPPD. Search strategies based on MeSH terms and free text were applied. Six reviewers independently screened titles and abstracts, eligible article full texts were evaluated for inclusion and data extraction.

Results:

The SLR identified 1149 manuscripts. 524 papers entered in the full text evaluation and 181 articles were finally included. Considering excluded abstracts and full texts, 23 and 17 were excluded as duplicate, 156 and 9 for language, 171 and 48 for population, 171 and 20 for intervention, 57 and 117 for outcome, 47 and 70 for study type and 76 for full text unavailability. Among included, 41 papers considered patients with definite CPPD with a total population of 1239 patients, 908 cases and 331 controls and 140 papers referred to patients with suspected CPPD with a total population of 26785 patients, 2896 affected by CPPD and 23889 controls. The results about all joints are summarized in the Table 1. In patients with definite diagnosis, knee and wrist are the joints with the highest prevalence of calcifications at all imaging types, followed by hip and acromion-clavicular joint while in patients with suspected CPPD, the knee is the most prevalent followed by the wrist, hip and ankle (only sites with more than 50 patients assessed considered). The hand joints are characterized by CPPD lowest prevalence at imaging. Bilateral imaging findings varies depending on the technique used, the site and the patient’s type.

Table 1.

Definite CPPD Diagnosis

KNEEWRISTHANDELBOWSHOULDERACHIPANKLEFOOTTMXRImaging positive cases/all cases330/584 57%214/409 52%43/158 27%54/212 25%65/249 26%37/84 44%140/293 48%30/255 12%15/59 25%0Cases positivebilaterally99/146 68%30/79 38%0/104/12 33%2/2 100%9/17 53%7/10 70%7/10 70%00USImaging positive cases/all cases155/252 62%86/118 75%4/42 9%2/2 100%0/304/30 13%47/80 59%30/255 12%15/59 25%0Cases positivebilaterally83/96 86%33/47 70%1/ 4 25%003/ 4 75%29/47 62%7/10 70%00CTImaging positive cases/all cases41/50 82%22/28 78%00000000Cases positivebilaterally27/30 90%000000000DECTImaging positive cases/all cases8/10 80%9/10 90%1/1 100%0000000Cases positivebilaterally001/1 100%0000000Suspected CPPD diagnosisKNEEWRISTHANDELBOWSHOULDERACHIPANKLEFOOTTMXRImaging positive cases/all cases1989/2442 81%549/1024 54%98/602 16%29/72 40%75/185 41%27/31 87%322/887 36%56/116 48%24/42 57%0Cases positive bilaterally611/1068 57%209/334 63%64/85 75%22/23 96%41/46 89%0/294/196 48%44/53 83%18/19 95%0USImaging positive cases/all cases241/261 93%125/185 68%2/39 5%1/1 100%4/12 33%02/2 100%27/78 35%8/37 22%0Cases positivebilaterally4/9 44%74/93 80%00000000CTImaging positive cases/all cases019/23 83%002/2 100%02/2 100%001/1 100%Cases positivebilaterally0000000001/1 100%DECTImaging positive cases/all cases1/1 100%2/2 100%00000000Cases positivebilaterally1/1 100%000000000

Table 1 For each joint, are summarized the ratio between positive joints and overall evaluated joints and the ratio between the joints positive bilaterally and overall joints evaluated bilaterally.

AC Acromion Clavicular, TM temporo mandibular

Conclusion:

According to the results of this SLR, knees and wrists could be the sentinel joints for CPPD detection by imaging.

Disclosure of Interests:

None declared.

OP0095 NON-GONOCOCCAL PYOGENIC ARTHRITIS OF NATIVE JOINTS IN WESTERN AUSTRALIA. A LONGITUDINAL POPULATION-BASED STUDY OF FREQUENCY, RISK FACTORS AND OUTCOME

Background:

The worldwide incidence of PyA is reportedly rising due to a combination of increased longevity, multi- comorbidity, iatrogenic complications and increasing use of immunomodulating therapies, while there is limited data on longterm outcomes of PyA.

Objectives:

To describe the recent incidence, risk factors and long-term outcomes in adults hospitalised with non-gonococcal pyogenic arthritis (PyA) of native joints in Western Australia (WA).

Methods:

We extracted population-based longitudinally linked administrative health data for patients 16 years or older with a first diagnostic code of 711.xx (ICD9-CM) and M00.xx (ICD10-AM) in WA in the period 1990-2010. Annual incidence rates (IR), risk factors during 14.5 years lookback and outcomes including standardized mortality rates (SMR) during 10.1 years follow-up are reported.

Results:

A total of 2,777 patients (67% male, mean age 49.8 ± 20.5) received a first diagnostic code for PyA. The AIR increased from 4.5 to 11.8 /100,000 over time as did age at onset (45.1 to 55.4 years) and proportion of female patients (23 to 36%). There was no seasonal variation in PyA incidence but a higher rate of predisposing comorbidities in female patients. Knees (33.6%) and hands (22%) were most frequently affected with 28.4 % of positive cultures not due to Gr+ cocci. Mean hospital stay was 8 days, 30-day readmittance and mortality rate was 12 .8% and 3.1% respectively. During ten years follow-up serious infections (43%), new diagnosis of osteoarthrosis (20%), joint replacement (10.8%), osteomyelitis (6%), and crystal arthropathy (6.3%) were the most common morbidities. SMR were increased across all age and gender categories (Table) but highest in females aged 16-40 (SMR 25.9).

Table 1.

Mortality rates (MR) per 1000 person years in patients with pyogenic arthritis compared with age (at death) and gender matched categories from the general population by standardised mortality rate (SMR)

GenderAgeDeathsPerson years MR PyAMR Gen pop * SMRMale16-402740156.720.8927.5340-5980710611.252.9723.78>60331736644.9321.552.08All4381848723.695.8204.07Female16-4011102610.720.4125.9540-5940276914.441.758.21>60208408850.8824.202.10All259788332.855.505.96

* Based on WA death data from Australian Bureau of statistics in 2011

Conclusion:

The incidence of PyA has increased significantly between 1990 and 2010 in WA. PyA associates with a 3% in-hospital mortality rate and significant late bone and joint morbidity including osteomyelitis. PyA associated with excess mortality across age and gender categories, most markedly in younger female patients.

References:

[1]Ross JJ. Septic arthritis of native joints. Infect Dis Clin North Am 2017;31:203-18

Acknowledgements:

The authors would like to acknowledge the support of the Western Australian Data Linkage Branch, the Western Australian Department of Health, and the data custodians of, the Hospital and Morbidity Data Collection, the Emergency Department Data Collection the WA Cancer Register and the WA Death Register for their assistance with the study

Disclosure of Interests:

None declared

AB0393 PRE-EXISTING MORBIDITY AS A RISK FACTORS FOR MORTALITY IN IgA VASCULITIS

Background:

IgA vasculitis is generally considered to be a self-limiting condition, but this is at odds with the increased mortality observed in adult patients with IgA vasculitis (1).

Objectives:

With sparse data on prognostic factors in IgAV, we investigated whether pre-existing conditions are risk factors for mortality in adult IgAV patients.

Methods:

Observational population-based cohort study using state-wide linked longitudinal health data for adults with IgAV (n=267) and matched controls (n=1080) between 1980-2015. Charlson comorbidity index (CCI) and serious infections (SI) were recorded over an extensive lookback period prior to diagnosis. Date and causes of death were extracted from the WA Death Registry. Mortality rate (deaths/1000 person-years) ratios (MRR) and time dependent survival analysis assessed the risk of death. Age and gender specific mortality rate data were obtained from the Australian Bureau of Statistics.

Results:

During 9.9 (±9.8) years lookback IgAV patients accrued higher CCI scores (2.60 vs1.50 p<0.001) and had higher risk of SI (OR 8.4, p<0.001), not fully explained by CCI scores. During 19 years follow-up, the risk of death in IgAV patients (n=137) was higher than in controls (n=397) (MRR 2.06, CI 1.70-2.50, p<0.01) and the general population (SMRR 5.64, CI 4.25, 7.53, p<0.001). Survival in IgAV was reduced at five (72.7 vs. 89.7 %) and twenty years (45.2% vs. 65.6 %) (both p<0.05). CCI (HR1.88, CI:1.25 - 2.73, p=0.001), renal failure (HR 1.48, CI: 1.04 - 2.22, p=0.03) and prior SI (HR 1.48, CI:1.01 – 2.16, p=0.04) were independent risk factors. Death from infections (5.8 vs 1.8%, p=0.02) was significantly more frequent in IgAV patients.

Conclusion:

Premorbid accrual of comorbidity is increased and predicts premature death in IgAV patients. However, comorbidity does not fully explain the increased risk of serious infections prior to diagnosis or the increased mortality due to infections in IgAV.

References:

[1]Villatoro-Villar M, Crowson CS, Warrington KJ, Makol A, Ytterberg SR, Koster MJ. Clinical Characteristics of Biopsy-Proven IgA Vasculitis in Children and Adults: A Retrospective Cohort Study. Mayo Clin Proc. 2019;94(9):1769-80.

Acknowledgements:

The authors would like to acknowledge the support of the Arthritis Foundation of WA and acknowledge the Western Australian Data Linkage Branch, the Western Australian Department of Health, and the data custodians of, the Hospital and Morbidity Data Collection, the Emergency Department Data Collection the WA Cancer Register and the WA Death Register for their assistance with the study.

Disclosure of Interests:

None declared

POS1133 RELIABILITY OF CONVENTIONAL RADIOGRAPHY OF THE KNEE FOR THE ASSESSMENT OF CHONDROCALCINOSIS: AN ANCILLARY STUDY OF THE OMERACT ULTRASOUND – CPPD GROUP

Background:

Conventional Radiography (CR) has been widely used in the assessment of knee chondrocalcinosis (CC) and is still considered one of the most important diagnostic methods for the diagnosis. However, there are no studies on the reliability of CR for CC.

Objectives:

To assess the reliability of CR of the knee in the assessment of chondrocalcinosis (CC).

Methods:

This is an ancillary study of the Criterion Validity of Ultrasound in Calcium Pyrophosphate Deposition Disease (CPPD) study [1]. Consecutive patients with knee osteoarthritis (OA) that were planned for total knee replacement surgery were enrolled in 4 centres from Romania, Italy, USA and Mexico. All patients underwent CR of the knees taken maximum 6 months before surgery, in posterior-anterior weight baring and lateral projections. DICOM files of the radiographs were retrieved, anonymised and read independently by two musculoskeletal radiologists with experience in microcrystalline arthropathies. Each reader performed a second evaluation 3 weeks after the first one to calculate the inter- and intra-reader agreement. For each patient a dichotomic score was assigned (absence/presence of CC) at the level of the medial and lateral menisci, tibiofemoral hyaline cartilage, quadriceps and patella tendons, synovial membrane/joint capsule. The definitions of the ACR/EULAR taskforce for identification of CPPD in conventional radiography were used in this study [paper in preparation]. According to these definitions CPPD in CR appears as “linear or punctate opacities in the region of fibro- or hyaline articular cartilage/synovial membrane or joint capsule/within tendons or entheses that are distinct from denser, nummular radio-opaque deposits due to basic calcium phosphate deposition”. Cohen’s kappa was used to calculate the agreement between the two readers.

Results:

We enrolled 33 patients with knee OA (60.6% female, mean age 69yo ± 8). The kappa values of the inter-reader and intra-reader agreement in the various sites of the knee are indicated in Table 1. Inter-reader agreement was substantial at the level of both menisci but only moderate or fair at the other sites of assessment. This had a negative impact on the overall evaluation of the knee joint that proved to be unreliable (k of 0.16 – none to slight agreement) if all anatomical structures are included for assessment, and moderately reliable (kappa 0.41) when both menisci and hyaline cartilage are considered. On the other hand, intra-reader kappa values were substantial or higher in all sites (except for synovial membrane/joint capsule for one reader). The striking difference of the intra-reader compared to the inter-reader kappa values, highlight a different interpretation and application of the definitions used for most of the sites with the exception of the menisci.

Table 1.

kappa values for intra- and inter-reader agreement. Values from 0.01–0.20 are considered as none to slight agreement, 0.21–0.40 as fair, 0.41– 0.60 as moderate, 0.61–0.80 as substantial, and 0.81–1.00 as almost perfect agreement.

Medial meniscusLateral meniscusHyaline cartilageQuadriceps tendonPatellar tendonCapsule/ synoviaMenisci + cartilageEntire jointInter-reader0.670.710.340.47NA0.370.400.17Intra-reader 1st assessor0.670.900.840.65NA(insufficient number of categories)0.530.710.76Intra-reader 2nd assessor10.801110.910.860.94

Conclusion:

CR has been extensively used for diagnosis of OA and CPPD. The results of our study raise some concerns on the reliability of CR in identification of CPPD. Assessment of calcium crystals at the menisci level should be used for identification of CC as other sites of the knee seem to present low reliability.

References:

[1]Filippou G et al. Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study. Ann Rheum Dis 2020. doi:10.1136/annrheumdis-2020-217998

Disclosure of Interests:

None declared.

POS0276 EFFICACY OF KRILL OIL IN THE TREATMENT OF KNEE OSTEOARTHRITIS: A 24-WEEK MULTICENTRE RANDOMISED DOUBLE-BLIND CONTROLLED TRIAL

Background:

Elevated levels of systemic inflammation are common in people with osteoarthritis and predict both pain and structural outcomes. Krill oil has anti-inflammatory properties and reduces severity of inflammatory arthritis in mice by 50% compared to controls.1 In humans, krill oil reduced knee pain and function in two short, moderate quality randomised controlled trials (RCTs) in people with osteoarthritis. However, evidence from longer trials with imaging data is lacking.

Objectives:

The aim of this study was to compare the efficacy of krill oil (2g / day) vs. placebo for treating knee pain in patient with clinical knee osteoarthritis who have significant knee pain and effusion-synovitis.

Methods:

KARAOKE was a 24-week multicentre, randomised, double-blind, placebo-controlled trial conducted at five Australian sites. Participants aged ≥40 years with symptomatic knee OA (according to ACR criteria), significant knee pain (pain score ≥40mm on a 100mm visual analogue scale [VAS]), and effusion-synovitis present on MRI (grade ≥1 according to modified Whole-Organ Magnetic Resonance Imaging Score (WORMS) scoring) were eligible. The study protocol has been published previously.2

Participants were randomised to receive 2g/day of krill oil, (350 mg/g omega-3 content, 12 mg/g total omega-6 content) or inert placebo (vegetable oil, no EPA or DHA, <5 mg/g (0.05%) other omega-3s).

The primary outcome was absolute change in knee pain assessed using a VAS [0-100mm] after 24 weeks. Secondary outcomes were: change in knee pain and function assessed using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score [0-500mm]), change in back and hand pain assessed using a VAS [0-100mm], change in lower limb leg strength assessed using a dynamometer, and change in blood parameters (including CRP, triglycerides, fasting glucose and total, HDL, LDL cholesterol), after 24 weeks.

Linear mixed-models were used, using patient identification as random intercepts and trial centre and treatment month as random effect to adjust for correlated data within trial centres and repeated measures and to allow different treatment effects among patients over time, respectively.

Results:

262 participants were randomised (mean age 61.5 years, 53% females) to receive krill oil (n=130) or placebo (n=132). A total of 85% completed the trial.

Knee pain improved in both groups over 24 weeks, but with no between-group difference (krill oil, -20.1mm; placebo, -19.3mm, p=0.81). Secondary outcomes: knee pain and function score improved in both groups, but with no between-group difference (WOMAC pain: krill oil, -86.7; placebo, -82.5mm, p=0.81; WOMAC function: krill oil, -245.3; placebo, -184.3, p=0.14 at 24 weeks). The same applies for hand pain and back pain. No significant changes were seen in leg strength or any of the blood parameters at 24 weeks). Incidence of one or more adverse events was 50% in the krill oil group (n=66) and 55% in the placebo group (n=71). There were 8 serious adverse events in the krill oil group 6 in the placebo group, all considered unrelated to treatment.

Conclusion:

Krill oil was safe and well tolerated, but did not significantly reduce knee pain in patients with clinical knee osteoarthritis, significant knee pain and effusion-synovitis after 24 weeks compared to placebo. These findings do not support use of krill oil for alleviating knee pain in clinical knee osteoarthritis.

References:

[1]Ierna M, et al. BMC Musculoskelet Disord 2010;11:136.

[2]Laslett L, et al. Trials 2020;21:79

OutcomesAbsolute between group difference at 24 weeksP valuePrimaryKnee pain0.8 (-5.6 to 7.2)0.81SecondaryKnee pain (WOMAC)4.2 (-29.1 to 37.5)0.81Knee function (WOMAC)61 (-19.2 to 141.3)0.14Hand pain2.8 (-2.6 to 8.3)0.31Back pain1.9 (-3.9 to 7.8)0.46Leg strength-2.59 (-9.41 to 4.23)0.52Metabolic factorsTotal Cholesterol0.09 (-0.1 to 0.29)0.34HDL Cholesterol-0.03 (-0.1 to 0.03)0.35LDL Cholesterol0.05 (-0.12 to 0.22)0.57Triglycerides0.12 (-0.09 to 0.33)0.27Fasting glucose0.01 (-0.26 to 0.29)0.93hsCRP0.64 (-0.56 to 1.84)0.30

Disclosure of Interests:

Laura Laslett Speakers bureau: once, several years ago, and unrelated to this topic, Grant/research support from: Yes, received funding from Aker Biomarine to conduct this trial, Lieke Scheepers Shareholder of: AstraZeneca, Grant/research support from: Pfizer, unrelated to this topic, Employee of: Previously employed by AstraZeneca, Benny Antony Speakers bureau: Zydus, Grant/research support from: Grant support for investigator-initiated trial from NR Ltd for unrelated research, Anita Wluka: None declared, Catherine Hill: None declared, Lyn March Speakers bureau: Speaker fees from Pfizer Australia Ltd, Bristol Myer Squibb Australia, Abbvie Australia, Grant/research support from: Grant support for my institution from Janssen for unrelated research, Helen Keen: None declared, Petr Otahal: None declared, Flavia Cicuttini: None declared, Graeme Jones: None declared

POS0084 SEPTIC ARTHRITIS IN CHILDREN. A LONGITUDINAL POPULATION-BASED STUDY IN WESTERN AUSTRALIA

Background:

The incidence of Septic arthritis (SA) in adults is rising, but few data are available for children (1). SA symptomatology in young children is often atypical and delayed diagnosis can cause significant morbidity.

Objectives:

To describe the incidence, risk factors and long-term outcomes in children hospitalised with septic arthritis (SA) in Western Australia (WA).

Methods:

We extracted population-based longitudinally linked administrative health data for patients under 16 years with a first inpatient primary or secondary code of 711.xx (ICD9-CM) and M00.xx (ICD10-AM) in WA for the study period 1990-2010 (to allow a minimum 5 year followup). We report annual incidence rates per 100.000 (AIR), prior conditions during lookback (median 15 months, IQR 5-45) as well as joint and other comorbidities including Charlson comorbidity index (CCI) and standardised mortality rates (SMR) during a median follow-up of 10 years. Age and gender speficic population and mortality rate data were obtained from the Australian Bureau of Statistics.

Results:

A total of 891 patients (62% male, median age 6.4 (IQR 1.9-10.6) years with 34% <3 years of age) had a first admission for SA. AIR was 9.85 (CI 4.79-14.41) overall with higher rates in males (11.9 vs 7, p<0.01) and no apparent period (Figure 1) or seasonal variation. Knees (43.9%), hips (34.6%), and ankles (13.3%) were most frequently affected with Staphylococci (49%) the predominant organism in patients with positive cultures (41.5%). Prior infections (40.4%) and respiratory disease (7 %) were the main preexisting morbidities. Mean hospital stay was 5.78 (± 6.4) days with ICU admission required in 1.9%, while 30-day readmittance rate was 10.4%. During follow-up 25 patients (3%) had recurrent/persistent osteomyelitis, nine patients were diagnosed with osteoarthrosis (1.1%) and five patients (0.6%) underwent joint replacement. More female patients developed new comorbidity (CCI>0, 34.6 vs 27.2%, p=0.02) including diabetes (4.2% vs 0%, p=0.001), cardiovascular events (4.2 vs 1.4%, p=0.002) and chronic arthritis (1% vs 0, p=0.05). While the crude mortality rate was low (0.3%) SMR was significantly increased for female patients (10.52, CI 1.59-41.6).

Conclusion:

The statewide incidence of septic arthritis in children in WA is similar to a recent report (1) and did not change over a 20-year period. In this large population based study, subsequent bone/joint disease occured in 4.6 %, while a third of patients developed other comorbidity before the age of 18. Such (subclinical) comorbidity may thus be a contributing factor to SA development and to the increased mortality risk in female SA patients.

References:

[1]Cohen E, Katz T, Rahamim E, Bulkowstein S, Weisel Y, Leibovitz R, Fruchtman Y, Leibovitz E. Septic arthritis in children: Updated epidemiologic, microbiologic, clinical and therapeutic correlations. Pediatr Neonatol. 2020 Jun;61(3):325-330. doi: 10.1016/j.pedneo.2020.02.006

Figure 1.

Annual incidence of septic arthritis per 100,000 population <16 years in Western Australia over period 1990-2010 by gender.

Acknowledgements:

The authors wish to thank the Arthritis Foundation of WA for their support and would like to acknowledge the support of the Western Australian Data Linkage Branch, the Western Australian Department of Health, and the data custodians of, the Hospital and Morbidity Data Collection, the Emergency Department Data Collection the WA Cancer Register and the WA Death Register for their assistance with data collection.

Disclosure of Interests:

None declared.

SAT0576 THE PREVALENCE OF RHEUMATOID ARTHRITIS: A SYSTEMATIC REVIEW OF POPULATION-BASED STUDIES

Background:

Rheumatoid arthritis (RA) is a heterogeneous disease with unknown aetiology (1). The reported worldwide RA prevalence varies widely (2, 3), and it is unclear whether this is due to inconsistencies in defining populations or methodologies used to identify RA patients (3, 4). Accurate RA prevalence data are required to plan preventative, diagnostic, and management strategies to address raising health care service demands and costs associated with improved lifespan and level of disability (5, 6).

Objectives:

To estimate the prevalence of RA from international population-based studies and investigate the influence of prevalence definition, data sources, classification criteria and geographical area on RA prevalence.

Methods:

A systematic review of existing literature was performed using the Joanna Briggs Institute approach for the systematic review and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search of ProQuest, MEDLINE, Web of Science, and EMBASE was undertaken to include population-based studies investigating RA prevalence between 1980 and 2019.

Results:

Sixty published population-based studies met the inclusion criteria over the study period. The mean point-prevalence of RA was 0.56% (range 0.00% to 2.70%) between 1986 and 2014. The period-prevalence was 0.51% (range 0.05% to 1.9%) between 1955 and 2015. RA point- and period-prevalence was higher in urban settings than rural settings, (0.69% vs 0.48%) and (0.54% vs 0.25%), respectively. The mean point- and period-prevalence were 0.56% (SD=0.52) and 0.57% (SD=0.41) and were lower in sampling population studies than in larger population databases studies (0.60% (SD=0.27) and 0.44% (SD= 0.26)). The highest period-prevalence of RA was observed in linked databases (0.80%, SD=0.1) where RA diagnosis was validated by rheumatologists.

Conclusion:

The average point- and period-prevalence of RA were 51/10,000 and 56/10,000 respectively. The RA prevalence was higher in urban areas than rural areas, suggesting an impact of environmental differences. Population database studies were more consistent than sampling studies, and linked databases appeared to provide the best estimate of RA period-prevalence when rheumatologists clinically verified RA.

Table 1.

The top five countries for the highest and lowest prevalence of RA in recent global estimate between 1980 and 2019.

Global prevalence of RATop five countriesPrevalence (%)Highest1-Cuba2.702-Finland1.903-Lesotho1.804-USA1.075-Lebanon1.00Lowest1-Nigeria0.002-Taiwan0.05Taiwan0.10Taiwan0.123-Thailand0.124-India0.155-Philippines0.17

References:

[1]Smolen JS, Aletaha D, Barton A, Burmester GR, Emery P, Firestein GS, et al. Rheumatoid arthritis. Nat Rev Dis Primers 2018;4:1-23.

[2]Tobon GJ, Youinou P, Saraux A. The environment, geo-epidemiology, and autoimmune disease: Rheumatoid arthritis. Journal of Autoimmunity 2010;35:10-4.

[3]Shapira Y, Agmon-Levin N, Shoenfeld Y. Geoepidemiology of autoimmune rheumatic diseases. Nature reviews Rheumatology 2010;6:468-76.

[4]Carmona L, Cross M, Williams B, Lassere M, March L. Rheumatoid arthritis. Best Pract Res Clin Rheumatol 2010;24:733-45.

[5]Kvien TK. Epidemiology and burden of illness of rheumatoid arthritis. Pharmacoeconomics 2004;22:1-12.

[6]Uhlig T, Moe RH, Kvien TK. The burden of disease in rheumatoid arthritis. Pharmacoeconomics 2014;32:841-51.

Acknowledgments:

Khalid Almutairi was supported by an Australian Government Research Training Program PhD Scholarship at the University of Western Australia (UWA).

We acknowledge senior librarian Samantha Blake (SB) for her help within the scope of UWA library support services for systematic reviewers.

Disclosure of Interests:

Khalid Almutairi: None declared, Johannes (“Hans”) Nossent Speakers bureau: Janssen, David Preen: None declared, Helen Keen Speakers bureau: Pfizer Austrlaia, Abbvie Australia, Charles Inderjeeth Grant/research support from: UCB Australia, Speakers bureau: Eli Lilly

OP0145 MALIGNANCY IN ANCA-ASSOCIATED VASCULITIS AND POLYARTERITIS NODOSA: AN AUSTRALIAN POPULATION-BASED STUDY

Background:

The increased risk of malignancy in patients with ANCA-associated vasculitis (AAV) and polyarteritis nodosa (PAN) has been attributed to late treatment related effects, with non-melanoma skin and genitourinary cancers most frequently reported in European studies1,2,3. Malignancy has not been examined in patients with AAV/PAN in Australia, where environmental factors may influence risk.

Objectives:

To determine the risk and timing of incident cancer in Western Australian (WA) AAV/PAN patients compared to controls.

Methods:

Patients and controls were ascertained through the WA Hospital Morbidity Data collection System (HMDS). Administrative hospitalisation data were linked with the WA cancer and death registries. Data was available between 1980-2015. Patients were classified into two sub-groups using International Classification of Disease (ICD) -9 and/or -10 codes: (1) GPA/MPA- granulomatosis with polyangiitis (GPA)/microscopic polyangiitis (MPA), and (2) other-AAV/PAN- eosinophilic granulomatosis with polyangiitis (EGPA), PAN, and other patients with any AAV or PAN where more specific ICD-10 coding was not available. Controls were age, sex and temporally matched (at patient diagnosis date) and had no rheumatological diagnosis. Patients and controls with prior cancer were excluded from the analysis.

Spline-based estimation of time-varying hazard ratios (HR) for incident cancer in patientsvscontrols was performed using the Stata library stpm2cr4. Results for cause-specific models, which treated deaths in patients without cancer as censored, were confirmed using models treating death as a competing risk. The risk of specific cancers was analysed by Cox regression.

Results:

The analysis included 391 patients (165 GPA/MPA, 217 other-AAV/PAN) and 4913 controls, with 86 incident cancers (over 3556.7 person-years) observed in patients and 1119 (over 64997.0 person-years) in controls. Patients and controls were well matched for age (mean ± standard deviation GPA/MPA: 55 ± 18 years, other AAV/PAN: 59 ± 17 years, controls 57 ± 16 years), and sex (female: GPA/MPA 48%, other AAV/PAN 46%, controls 46%).

Incident cancer risk and timing differed between the two patient subgroups (Figure 1). The risk of incident cancer in GPA/MPA patients, compared to controls, increased with disease duration, whilst other-AAV/PAN patients had a greater risk within the first two years of diagnosis, but a similar risk to controls in the longer term.

By specific cancers, GPA/MPA patients had an increased risk of skin cancers (excluding squamous and basal cell carcinomas): hazard radio (HR) 2.71 95% confidence interval (CI) 1.55 – 4.74, and genitourinary cancers: HR 3.64, 95% CI 1.58, 8.39, which was not observed in other-AAV/PAN patients. While there was trend for an overall increase in haematological cancers, this was inconclusive.

Conclusion:

Incident cancer risk, driven by skin and genitourinary cancers, increased with disease duration in GPA/MPA patients, consistent with previous studies, suggestive of a treatment related effect. In contrast, cancer was more frequently observed early after diagnosis in other-AAV/PAN patients. Our findings suggest that vigilance for incident cancers is required for all patients with AAV and PAN after diagnosis and in long term management, considering distinct periods of greater risk by disease subgroup.

References:

[1]Heijl C et al. Ann Rheum Dis 2011;70:1415-1421

[2]Lafarge A et al. Ann Rheum Dis 2019;0:1-2

[3]Farschou M et al. Rheumatology 2015;54:1345-1350

[4]Mozumder S et al. Stata J. 2017;17(2):462-489

Disclosure of Interests:

Joanna Tieu: None declared, Susan Lester: None declared, Warren Raymond: None declared, Helen Keen Speakers bureau: Pfizer Austrlaia, Abbvie Australia, Catherine Hill: None declared, Johannes (“Hans”) Nossent Speakers bureau: Janssen

FRI0192 MORTALITY IN IGA VASCULITIS: A LONGITUDINAL POPULATION-BASED STUDY

Background:

There is sparse population-level data on outcome in patients with Immunoglobulin-A vasculitis (IgAV) and none from Australia

Objectives:

We compared long-term mortality for paediatric and adult IgAV patients with age- and gender-matched controls.

Methods:

Linked health data for pediatric (<20 years=473) and adult (20+ years, n=267) IgAV patients were obtained from state-wide hospital and deaths registries in Western Australia for the period 1980-2015. All-cause mortality rates (MR) (deaths/1000 person-years) were compared with controls using mortality rate ratios (MRR) and with the general population of Western Australia by standardised mortality rate ratios (SMRR) with Poisson derived 95% confidence intervals (CI). We used Kaplan-Meier survival estimates and multivariate Cox regression derived hazard ratios (HR) for time dependent analyses.

Results:

In pediatric patients (mean age 7.2 years, 60 % male) MRR was 1.27 (CI: 0.34-4.08, p=0.68) and SMRR was 2.31 (CI: 0.72-5.7, p=0.47) (Table 1) with a 20-year survival rate (>99%) similar to controls. Despite higher rates of renal failure (1.5% vs 0.2%, p=0.002) deaths in pediatric IgAV patients were mainly from unrelated causes. In adult IgAV patients (mean age 55.8 years, 48% males) MMR was 2.06 (CI 1.70-2.50, p<0.01) and SMRR 6.16 (3.04 -14.3, p<0.01) (Table) during a mean of 19.5 years follow-up with significantly reduced survival at five (72.7 vs. 89.7 %) and twenty years (45.2% vs. 65.6 %) (p<0.05). Renal disease (HR: 1.47, CI 1.04 - 2.06), the presence of any comorbidity (HR:1.30, CI 1.23 - 1.37) and male gender (HR:1.23; CI 1.04 - 1.47) were independent predictors of death. While cardiovascular events (34.2%) and malignancy (19.4%) were the most frequent causes of death, only death from infections (5.8 vs 1.8%, p=0.02) and renal disease (3.6 vs 1.8%, p=0.03) were more frequent in adult IgAV patients than controls.

Mortality data for childhood and adult-onset IgAV patients and controls. Figures indicate mean (±SD), numbers (%) or rate/1000 patient months (95% CI)

PediatricAdultIgAVControlsP valueIgAVControlsPMean follow-up (yrs)22.71 (±5.2)23.75 (±3.17)0.00111.9 (±9.04)15.94 (±8.30)0.001Non-survivors (%)<5 (0.8)9 (0.9)0.5137 (51.3)394 (33.4)<0.001Person-years1027529520317818815MR0.39 (0.1, 0.9)0.30 (0.1, 0.5)43.11 (36,1,50.9)20.94 (18.9, 23.1)MRR1.27 (0.34, 4.08)0.672.06 (1.70, 2.50)<0.001SMRR2.31 (0.71, 5.71)0.716.16 (3.04, 14.3)<0.001

Conclusion:

Compared to controls and general population, mortality risk was not increased in paediatric IgAV patients for at least 20 years following diagnosis despite a higher rate of end stage renal failure. However, in adult IgAV patients, all-cause mortality risk was six times higher than in the general population leading to significantly reduced five-year survival, especially for male patients with comorbidity including renal disease.

Acknowledgments:

The authors thank the Data Custodians of the Hospital Morbidity Data Collection (HMDC), Emergency Department Data Collection (EDDC), the Western Australian Cancer Registry (WACR), the State Registry of Births, Deaths and Marriages, the WA Electoral Commission, and the NCIS for use of the CODURF dataset, and the staff at Data Linkage Branch at the Western Australian Department of Health for their assistance in provision of data. This work was supported by an unrestricted grant from the Arthritis Foundation of Western Australia. Author WDR received a PhD Scholarship in Memory of John Donald Stewart from the Arthritis Foundation of Western Australia.

Disclosure of Interests:

Johannes (“Hans”) Nossent Speakers bureau: Janssen, Milica Ognjenovic: None declared, warren raymond: None declared, Helen Keen Speakers bureau: Pfizer Austrlaia, Abbvie Australia, Charles Inderjeeth Consultant of: Linear Research Perth, David Preen: None declared

AB1221 POPULATION WIDE STUDY OF MORTALITY IN ANCA-ASSOCIATED VASCULITIS IN WESTERN AUSTRALIA FROM 2000 TO 2014

Background:

Survival in ANCA-associated vasculitis (AAV) has improved substantially in the last fifty years, but Australian data and studies with a control population are scarce.

Objectives:

The aim of this study was to compare the all-cause mortality rate between patients with AAV and matched controls in Western Australia.

Methods:

A retrospective population-based cohort study conducted using the Western Australia Health Data Linkage System (WADLS) for patients with a diagnostic code for AAV (International Classification of Diseases (ICD)-10-AM M30.1, M31.3 and M31.7). We included 240 patients with AAV (mean age 57.37 ± 16.69, 48.8% males) who had a hospital admission or emergency department visit between 1 January 2000 and 31 December 2014 and 4406 controls matched for age and sex. Death details were obtained from the WA Death registry. Mortality rates per 1000 person-years (MR) for AAV patients and controls were compared by mortality rate ratios (MRRs) with 95% CI. Kaplan Meijer survival estimates were analyzed by log-rank test.

Results:

During a mean follow-up of 6.58 years (3.37, 11.25) 83 incident AAV patients (34.6%) died, giving a mortality rate of 48.13 per 1000 person-years (95% CI 38.33, 59.66). This was 82% higher overall than in controls (MRR 1.82, 95% CI 1.46, 2.26, P < 0.0001), while the MRR for males with AAV was 2.28 (95% CI 1.46, 2.26; P < 0.0001) and for females 1.43 (95% CI 1.01, 2.02; P = 0.0267). Survival estimates at one (90.5%) and five years (75%) were significantly lower in AAV patients than controls.

Conclusion:

Over the last fifteen years, the mortality risk for AAV patients remains significantly increased compared with matched controls and more so for male than female AAV patients. Together with the reduced one- and five-year survival rate, this indicates the need for further improvements in initial disease management in order to reduce the risk of death in AAV.

Table

Mortality rates (MR) per 100 patient years and Mortality rate ratio (MRR) with 95% CI in patients with AAV and controls

AAVControlDeathsPersonyearsMR(95% CI)DeathsPersonyearsMR(95% CI)MRR(95% CI)All83172448.1(38.3, 59.6)12194606926.4(25.0, 27.9)1.82 (1.46, 2.26)Male4978962.1(45.9 82.0)6902529528.2(25.2, 29.3)2.28 (1.72, 3.02)Female3493536.3(25.1, 50.7)5292077325.4 (23.3, 27.7)1.43 (1.01, 2.02)Figure.

Kaplan Meyer Survival curves for AAV patients and controls

Acknowledgments:

The authors thank the Data Custodians of the Hospital Morbidity Data Collection (HMDC), Emergency Department Data Collection (EDDC), the State Registry of Births, Deaths and Marriages, the WA Electoral Commission, and the staff at Data Linkage Branch at the Western Australian Department of Health for their assistance in provision of data. This work was supported by an unrestricted grant from the Arthritis Foundation of Western Australia. Author WDR received a PhD Scholarship in Memory of John Donald Stewart from the Arthritis Foundation of Western Australia

Disclosure of Interests:

Wade Taylor: None declared, warren raymond: None declared, Helen Keen Speakers bureau: Pfizer Austrlaia, Abbvie Australia, Charles Inderjeeth Consultant of: Linear Research Perth, David Preen: None declared, Johannes (“Hans”) Nossent Speakers bureau: Janssen

SAT0594 LONG-TERM MORBIDITY FOLLOWING IGA VASCULITIS IN CHILDHOOD

Background:

IgA vasculitis (IgAV) in children is considered a mostly self-limiting disease. However, patients may require aggressive initial treatment, are prone to disease relapses and conceivably have a sustained abnormality in mucosal and /or circulating IgA responsiveness, that can predispose to the development of other conditions.

Objectives:

To determine whether childhood IgAV predisposes to comorbidity later in life.

Methods:

Observational cohort study examining rates of hospitalization, ED visits, procedures and accrual of comorbidity (by Charlson comorbidity index; CCI) comparing 494 IgAV patients <20 years at diagnosis with 1385 non-exposed matched controls over a 20-year period. Maximum likelihood estimates were used to obtain Odds (OR) and Rate ratios per 1000 person-years (RR).

Results:

Hospitalization was increased proportionally (73.5 vs 51.5%) and by rate (21.7 vs 18.9; rate ratio 1.15) (both p<0.01) for IgAV patients, who underwent more diagnostic and medical procedures whereas controls had higher rates of surgical interventions. IgAV patients had an higher overall ED attendance (25 vs 16%) and visit rate (10.8 vs 8.43, RR 1.29) (each p<0.01)) and accrued more often peptic ulcer and renal disease and developed severe comorbidity (CCI ≥3) at a higher rate (OR 2.9, 95% CI 0.79-11.6) than controls.

Conclusion:

A diagnosis of IgAV in childhood associates with increased risk and rate of subsequent hospital admission, ED attendance and severe comorbidity. The occurrence of childhood IgAV thus signifies the presence of a sustained predisposition to illness.

Acknowledgments:

Supported by an unrestricted grant from the Arthritis Foundation of Western Australia

Disclosure of Interests:

Johannes (“Hans”) Nossent Speakers bureau: Janssen, warren raymond: None declared, milica ognjenivic: None declared, Helen Keen Speakers bureau: Pfizer Austrlaia, Abbvie Australia, David Preen: None declared, Charles Inderjeeth Grant/research support from: UCB Australia, Speakers bureau: Eli Lilly

3'-Deoxy-3'-[18F]Fluorothymidine Uptake Is Related to Thymidine Phosphorylase Expression in Various Experimental Tumor Models

PURPOSE

We recently reported that high thymidine phosphorylase (TP) expression is accompanied by low tumor thymidine concentration and high 3'-deoxy-3'-[18F]fluorothymidine ([18F]FLT) uptake in four untreated lung cancer xenografts. Here, we investigated whether this relationship also holds true for a broader range of tumor models.

PROCEDURES

Lysates from n = 15 different tumor models originating from n = 6 institutions were tested for TP and thymidylate synthase (TS) expression using western blots. Results were correlated to [18F]FLT accumulation in the tumors as determined by positron emission tomography (PET) measurements in the different institutions and to previously published thymidine concentrations.

RESULTS

Expression of TP correlated positively with [18F]FLT SUVmax (ρ = 0.549, P < 0.05). Furthermore, tumors with high TP levels possessed lower levels of thymidine (ρ = - 0.939, P < 0.001).

CONCLUSIONS

In a broad range of tumors, [18F]FLT uptake as measured by PET is substantially influenced by TP expression and tumor thymidine concentrations. These data strengthen the role of TP as factor confounding [18F]FLT uptake.

Correction to: The relationship between endogenous thymidine concentrations and [18F]FLT uptake in a range of preclinical tumour models

CORRECTION

Unfortunately, the original version of Figs. 4, 5 and 6b in the article [1] contained errors in the n numbers as indicated on the columns. Please note that column heights and error bars in the original figures and data in the ESM tables are correct and statistical tests are valid. These corrections do not affect any results or conclusions in this article.

Prevalence and associations of gout and hyperuricaemia: results from an Australian population-based study

BACKGROUND

Despite gout and hyperuricaemia being major comorbid health issues worldwide, there is a knowledge gap regarding their impact in the Australian community.

AIMS

To determine the prevalence and associations of self-reported medically diagnosed gout and hyperuricaemia in an Australian population-based cohort.

METHODS

The North West Adelaide Health Study is a longitudinal cohort study consisting of three stages of data collection. Each stage comprised a self-complete questionnaire, clinic assessment and computer-assisted telephone interview. In Stage 3 (2008-2010), participants were asked if a doctor had ever diagnosed them with gout. Additional data included demographics, comorbidities, laboratory data and Short Form 36 (SF-36). Participants were defined as having gout if they had self-reported medically diagnosed gout or were taking any gout-specific medication (allopurinol, colchicine, probenecid). Hyperuricaemia was defined as a serum uric acid (SUA) level >0.42 mmol/L in men and >0.34 mmol/L in women.

RESULTS

The overall prevalence of gout was 5.2%. Males were significantly more likely to have gout than females (8.5 vs 2.1%, P < 0.001). The overall prevalence of hyperuricaemia was 16.6%, with being male again identified as a significant risk factor (17.8 vs 15.4%, P < 0.01). Both gout and hyperuricaemia were associated with male sex, body mass index and renal disease after multivariable adjustment. There was no significant difference reported in quality of life (mean SF-36) scores in participants with gout compared to unaffected individuals.

CONCLUSION

The prevalence of gout and hyperuricaemia is high in the South Australian population. This study emphasises the need for optimal diagnosis and management of gout in Australia.

The relationship between endogenous thymidine concentrations and [(18)F]FLT uptake in a range of preclinical tumour models

BACKGROUND

Recent studies have shown that 3'-deoxy-3'-[(18)F] fluorothymidine ([(18)F]FLT)) uptake depends on endogenous tumour thymidine concentration. The purpose of this study was to investigate tumour thymidine concentrations and whether they correlated with [(18)F]FLT uptake across a broad spectrum of murine cancer models. A modified liquid chromatography-mass spectrometry (LC-MS/MS) method was used to determine endogenous thymidine concentrations in plasma and tissues of tumour-bearing and non-tumour bearing mice and rats. Thymidine concentrations were determined in 22 tumour models, including xenografts, syngeneic and spontaneous tumours, from six research centres, and a subset was compared for [(18)F]FLT uptake, described by the maximum and mean tumour-to-liver uptake ratio (TTL) and SUV.

RESULTS

The LC-MS/MS method used to measure thymidine in plasma and tissue was modified to improve sensitivity and reproducibility. Thymidine concentrations determined in the plasma of 7 murine strains and one rat strain were between 0.61 ± 0.12 μM and 2.04 ± 0.64 μM, while the concentrations in 22 tumour models ranged from 0.54 ± 0.17 μM to 20.65 ± 3.65 μM. TTL at 60 min after [(18)F]FLT injection, determined in 14 of the 22 tumour models, ranged from 1.07 ± 0.16 to 5.22 ± 0.83 for the maximum and 0.67 ± 0.17 to 2.10 ± 0.18 for the mean uptake. TTL did not correlate with tumour thymidine concentrations.

CONCLUSIONS

Endogenous tumour thymidine concentrations alone are not predictive of [(18)F]FLT uptake in murine cancer models.

The concomitants of raised blood sugar: studies in newly-detected hyperglycaemics: II. Urinary albumin excretion, blood pressure and their relation to blood sugar levels

The albumin excretion rate following an oral glucose load was measured, using a sensitive radio-immunoassay method, in three groups drawn from the population of Bedford. The three groups – normal,borderline diabetic and diabetic – were classified by the level of the blood sugar 2 hours after the 50 -g glucose load. The degree of albumin excretion was positively correlated with the 2-hour blood sugar level, suggesting that hyperglycaemia may cause renal functional abnormality, which may be present at or before the time of diagnosis. In the diabetic group, only, the degree of albumin excretion was also positively correlated with the height of the blood pressure.

Abstract 1030: Use of 18F-FDG-PET as a biomarker to demonstrate activity of the novel AKT inhibitor AZD5363 in a xenograft model

Introduction: The PI3K/Akt/PTEN network is the most frequently de-regulated pathway in human cancer. The protein kinase Akt, a key node on this pathway, has been shown to drive proliferation and survival of tumour cells, and also plays a key role in glucose metabolism. Therefore, it is hypothesized that Akt inhibition can be assessed using 18F-flurodeoxyglucose (18F-FDG) positron emission tomography (PET).

The aim of this study was to determine tumour uptake of 18F-FDG 4 hours after an acute dose of AZD5363 or vehicle using a range of doses in the U87-MG xenograft model, the overall goal being to correlate 18F-FDG changes with tumour pharmacodynamics in the absence of any systemic glucose changes.

Materials & Methods: AZD5363 was administered orally at 75, 130, 200 and 300mg/kg. Prior to dosing blood glucose concentration was measured and mice were dosed with either vehicle or AZD5363 4 hours prior to imaging. 18F-FDG was administered as an i.v. bolus under anaesthesia; followed by a 45-minute wash-out period and a 20 minute PET scan. Mice were then sacrificed and blood samples taken for pharmacokinetic (PK) analysis and blood glucose concentration. Tumours were removed and snap frozen for pharmacodynamic analysis and background tissues taken for biodistribution analysis. Image analysis was carried out using Inveon Reconstruction Workplace (IRW) software. Biodistribution data were derived from gamma counting. Decay correction and uptake values were calculated using Microsoft Excel and statistical analysis performed using Graph Pad Prism.

Results: Mean tumour volumes were not statistically different amongst the five groups. There was significantly decreased 18F-FDG uptake (p&lt;0.05) in the tumour in all of the AZD5363 treated groups as a group average compared to vehicle; maxSUV = 4.06 ± 0.41 (SEM) in the vehicle; 3.42 ± 0.23; 3.16 ± 0.16; 3.12 ± 0.18 and 2.66 ± 0.06 (SEM) in the 75, 130, 200 and 300mg/kg groups respectively. There was a significant increase in blood glucose concentration at only the higher doses of 200 and 300mg/kg compared to the vehicle group post-dose (p&lt; 0.05). There was significantly increased 18F-FDG uptake in the blood, lung and liver from biodistribution data at the 300mg/kg treated dose compared to vehicle (p&lt;0.05). Ex-vivo tumour biomarker analyses demonstrated dose-dependent inhibition of PRAS40, GSK3β and S6 phosphorylation in response to AZD5363. Furthermore, AZD5363 resulted in dose-dependent inhibition of tumour growth in this xenograft model.

Conclusions: AZD5363 significantly reduced tumour 18F-FDG uptake at all four doses investigated in U87-MG human glioma xenografts 4 hours after drug administration. This correlated with inhibition of AKT substrate and downstream biomarker phosphorylation in the tumours and was seen at doses that did not cause systemic blood glucose changes. Therefore, 18F-FDG PET has potential as a biomarker for AZD5363 activity in the clinic.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 1030. doi:10.1158/1538-7445.AM2011-1030

The insulin dilemma in resource-limited countries. A way forward?

The International Insulin Foundation (IIF) has developed and validated a needs-assessment instrument called the Rapid Assessment Protocol for Insulin Access (RAPIA) which has been used in seven countries in four continents to analyse the constraints to delivering effective continuing care for people with diabetes. One major contributor to the difficulties in availability of insulin is a failure to use the least costly sources and types of insulin and other effective drugs for diabetes. The purchase of insulins can consume as much as 10% of government expenditure on drugs, this being highly sensitive to the selection of newer analogue insulins as first-choice options, which cost between three and 13 times more than biosynthetic human insulin. Insulin cartridges for use with injection pens further add to costs. Similar considerations apply to most of the newer treatments for people with type 2 diabetes, which may cost up to 40 times more than metformin and sulfonylureas, still considered first-line drugs by European and US guidelines. Both biosynthetic human insulin and the first-line oral hypoglycaemic drugs are available from generic manufacturers. With the present price differentials, there is thus a growing need for countries involved in tendering for sourcing insulin to be provided with the guarantees of Good Manufacturing Practice, quality and bioequivalence, which would come from a WHO Pre-Qualification Scheme as currently exists for a variety of drugs for chronic diseases, both communicable and non-communicable. The IIF has developed a position statement on the provision and choice of diabetes treatments in resource-limited settings which should be applicable wherever consideration of resources is a component of therapeutic decision making.

Abstract A225: The mTOR kinase inhibitor AZD8055 modulates 18F-FDG uptake in vivo in the human glioma xenograft model U87-MG

Introduction: mTOR is a a sensor of mitogen, energy and nutrient levels and a central controller of cell growth. mTOR is present in two multi-protein complexes: mTORC1, rapamycin sensitive and containing raptor, and mTORC2, rapamycin-insensitive. AZD8055 is a small molecule ATP competitive inhibitor of mTOR kinase, thus inhibiting both mTORC1 and mTORC2. This results in a greater reduction of mTORC1 substrates pS6 on Ser235/236 and p4EBP1 on T37/46 compared to rapamycin. AZD8055 also reduces the mTORC2 substrate pAKT on Ser473. The PI3K-AKT-mTOR pathway is involved in glucose uptake/metabolism. 18F-Flurodeoxyglucose (18F-FDG) is a biomarker for glucose metabolism detectable by positron emission tomography (PET). It is used in clinical oncology for tumor diagnosis and is currently under evaluation for therapy monitoring. The aim of this study was to assess the impact of a single and 4 daily dosing of AZD8055 on 18F-FDG uptake in U87-MG human glioma xenografts implanted subcutaneously in nude mice.

Methods: AZD8055 was administered orally at a dose of 20 mg/kg qd for 1 or 4 days. Animals received either vehicle or AZD8055 1 hour prior to imaging. Mice were anaesthetised and then injected with approximately 15 MBq 18F-FDG i.v. via the tail vein. Forty-five minutes later, mice underwent PET scanning (20 minute scan, 3D histogramming and OSEM2D reconstruction) followed by biodistribution analysis. Image analysis was carried out using Inveon Research Workplace (IRW) software. Biodistribution data were derived from gamma counting.

Results: Plasma drug concentrations were not modified significantly by anesthesia and the imaging procedure. In the vehicle and AZD8055-treated groups, tumor volumes were comparable after single dose, but differed significantly following 4 days of treatment due to drug effect. Image analysis of 18F-FDG uptake after single and multiple doses showed that there was a significant difference (p&lt;0.05) in meanSUV, maxSUV and the percentage of injected dose per gram of tissue (%ID/g) between vehicle and drug treated tumors. Biodistribution analysis showed that the average 18F-FDG %ID/g in vehicle-treated tumors was significantly higher than in AZD8055-treated tumors (p&lt;0.05).

The changes in glucose uptake after 1 and 4 administrations were consistent with the pharmacodynamic effects of AZD8055 on pS6 and pAKT biomarkers in U87-MG tumors collected at the same time-points.

Conclusions: AZD8055 reduces significantly 18F-FDG uptake in U87-MG human glioma xenografts, as early as 1 hour after a single dose. This data suggests that 18F-FDG uptake could be used as an early sign of metabolic response to AZD8055.

Citation Information: Mol Cancer Ther 2009;8(12 Suppl):A225.

Functional comparison of annexin V analogues labeled indirectly and directly with iodine-124

We are interested in imaging cell death in vivo using annexin V radiolabeled with (124)I. In this study, [(124)I]4IB-annexin V and [(124)I]4IB-ovalbumin were made using [(124)I]N-hydroxysuccinimidyl-4-iodobenzoate prepared by iododestannylation of N-hydroxysuccinimidyl-4-(tributylstannyl)benzoate. [(124)I]4IB-annexin V binds to phosphatidylserine-coated microtiter plates and apoptotic Jurkat cells and accumulates in hepatic apoptotic lesions in mice treated with anti-Fas antibody, while [(124)I]4IB-ovalbumin does not. In comparison with (124)I-annexin V, [(124)I]4IB-annexin V has a higher rate of binding to phosphatidylserine in vitro, a higher kidney and urine uptake, a lower thyroid and stomach content uptake, greater plasma stability and a lower rate of plasma clearance. Binding of radioactivity to apoptotic cells relative to normal cells in vitro and in vivo appears to be lower for [(124)I]4IB-annexin V than for (124)I-annexin V.

MBP-annexin V radiolabeled directly with iodine-124 can be used to image apoptosis in vivo using PET

A noninvasive method of measuring programmed cell death in the tumors of cancer patients using positron-emission tomography (PET) would provide valuable information regarding their response to therapeutic intervention. Our strategy is to radiolabel annexin V, a protein that binds to phosphatidylserine moieties that are translocated to the external leaflet of plasma membranes during apoptosis. We developed a phosphatidylserine-ELISA capable of distinguishing wild type from point mutant annexin V that is known to have a lower phosphatidylserine binding affinity. A maltose-binding protein/annexin V chimera was synthesized and purified with high yield using amylose resin. We showed that it bound to phosphatidylserine in the ELISA as well as to that exposed on apoptotic Jurkat cells; therefore, it was used in the development of a method for radiolabeling annexin V using iodine radionuclides. MBP-annexin V retained its phosphatidylserine binding properties on direct iodination, but at high levels of oxidizing agents (iodogen and chloramine T), its specificity for phosphatidylserine was compromised. (124)I-MBP-annexin V was successfully used to image Fas-mediated hepatic cell death in BDF-1 mice using PET. In conclusion, we have shown that MBP-annexin V and the phosphatidylserine ELISA are useful tools for the development of methods for radiolabeling annexin V for PET imaging.

Cancer incidence and mortality in patients with insulin-treated diabetes: a UK cohort study

Raised risks of several cancers have been found in patients with type II diabetes, but there are few data on cancer risk in type I diabetes. We conducted a cohort study of 28 900 UK patients with insulin-treated diabetes followed for 520 517 person-years, and compared their cancer incidence and mortality with national expectations. To analyse by diabetes type, we examined risks separately in 23 834 patients diagnosed with diabetes under the age of 30 years, who will almost all have had type I diabetes, and 5066 patients diagnosed at ages 30–49 years, who probably mainly had type II. Relative risks of cancer overall were close to unity, but ovarian cancer risk was highly significantly raised in patients with diabetes diagnosed under age 30 years (standardised incidence ratio (SIR)=2.14; 95% confidence interval (CI) 1.22–3.48; standardised mortality ratio (SMR)=2.90; 95% CI 1.45–5.19), with greatest risks for those with diabetes diagnosed at ages 10–19 years. Risks of cancer at other major sites were not substantially raised for type I patients. The excesses of obesity- and alcohol-related cancers in type II diabetes may be due to confounding rather than diabetes per se.