Regional anaesthesia via parasternal catheters inserted preoperatively and postoperative delirium after cardiac surgery: A prospective unrandomised clinical trial

VISUAL ABSTRACT

http://links.lww.com/EJA/A927.

Factors Associated with Fatigue in COVID-19 ICU Survivors

PURPOSE

Approximately 30% of people infected with COVID-19 require hospitalization and 20% of them are admitted to an intensive care unit (ICU). Most of these patients experience symptoms of fatigue weeks post-ICU, so understanding the factors associated with fatigue in this population is crucial.

METHODS

Fifty-nine patients [38-78 yr] hospitalized in ICU for COVID-19 infection for 32 [6-80] days including 23 [3-57] days of mechanical ventilation, visited the laboratory on two separate occasions. The first visit occurred 52 ± 15 days after discharge and was dedicated to questionnaires, blood sampling and cardiopulmonary exercise testing, while measurements of the knee extensors neuromuscular function and performance fatigability were performed in the second visit 7 ± 2 days later.

RESULTS

Using the FACIT-F questionnaire, 56% of patients were classified as fatigued. Fatigued patients had worse lung function score than non- fatigued (i.e. 2.9 ± 0.8 L vs 3.6 ± 0.8 L; 2.4 ± 0.7 l vs 3.0 ± 0.7 L for forced vital capacity and forced expiratory volume in one second, respectively) and forced vital capacity was identified as a predictor of being fatigued. Maximal voluntary activation was lower in fatigued patients than non-fatigued patients (82 ± 14% vs 91 ± 3%) and was the only neuromuscular variable that discriminated between fatigued and non-fatigued patients. Patient-reported outcomes also showed differences between fatigued and non-fatigued patients for sleep, physical activity, depression and quality of life (p < 0.05).

CONCLUSIONS

COVID-19 survivors showed altered respiratory function 4 to 8 weeks after discharge, that was further deteriorated in fatigued patients. Fatigue was also associated with lower voluntary activation and patient-reported impairments (i.e. sleep satisfaction, quality of life or depressive state). The present study reinforces the importance of exercise intervention and rehabilitation to counteract cardiorespiratory and neuromuscular impairments of COVID-19 patients admitted in ICU, especially individuals experiencing fatigue.

Dosing Regimen for Cefotaxime Should Be Adapted to the Stage of Renal Dysfunction in Critically Ill Adult Patients-A Retrospective Study

Cefotaxime administration is recommended in doses of 3-12 g/day in adults with a Glomerular Filtration Rate (GFR) > 5 mL/min. This study aimed to assess the impact of renal function and obesity on cefotaxime concentrations in intensive care unit (ICU) patients. A retrospective cohort study was conducted on consecutive ICU patients receiving continuous cefotaxime infusion between 2020 and 2022 [IRBN992021/CHUSTE]. Doses were not constant; consequently, a concentration-to-dose ratio (C/D) was considered. Statistical analysis was performed to assess the relationship between cefotaxime concentrations, renal function, and obesity. A total of 70 patients, median age 61 years, were included, with no significant difference in cefotaxime concentrations between obese and non-obese patients. However, concentrations varied significantly by GFR, with underdosing prevalent in patients with normal to increased renal function and overdosing in those with severely impaired renal function. Adjustment of cefotaxime dosing according to GFR was associated with improved target attainment. Cefotaxime dosing in critically ill patients should consider renal function, with higher initial doses required in patients with normal to increased GFR and lower doses in those with severely impaired renal function. Therapeutic drug monitoring may aid in optimising dosing regimens. Prospective studies are warranted to validate these findings and inform clinical practice.

Alteration of skeletal muscle energy metabolism assessed by phosphorus-31 magnetic resonance spectroscopy in clinical routine, part 1: Advanced quality control pipeline

Implementing a standardized phosphorus-31 magnetic resonance spectroscopy (31 P-MRS) dynamic acquisition protocol to evaluate skeletal muscle energy metabolism and monitor muscle fatigability, while being compatible with various longitudinal clinical studies on diversified patient cohorts, requires a high level of technicality and expertise. Furthermore, processing data to obtain reliable results also demands a great degree of expertise from the operator. In this two-part article, we present an advanced quality control approach for data acquired using a dynamic 31 P-MRS protocol. The aim is to provide decision support to the operator to assist in data processing and obtain reliable results based on objective criteria. We present here, in part 1, an advanced data quality control (QC) approach of a dynamic 31 P-MRS protocol. Part 2 is an impact study that will demonstrate the added value of the QC approach to explore data derived from two clinical populations that experience significant fatigue, patients with coronavirus disease 2019 and multiple sclerosis. In part 1, 31 P-MRS was performed using 3-T clinical MRI in 175 subjects from clinical and healthy control populations conducted in a University Hospital. An advanced data QC score (QCS) was developed using multiple objective criteria. The criteria were based on current recommendations from the literature enriched by new proposals based on clinical experience. The QCS was designed to indicate valid and corrupt data and guide necessary objective data editing to extract as much valid physiological data as possible. Dynamic acquisitions using an MR-compatible ergometer ran over a rest (40 s), exercise (2 min), and a recovery phase (6 min). Using QCS enabled rapid identification of subjects with data anomalies, allowing the user to correct the data series or reject them partially or entirely, as well as identify fully valid datasets. Overall, the use of the QCS resulted in the automatic classification of 45% of the subjects, including 58 participants who had data with no criterion violation and 21 participants with violations that resulted in the rejection of all dynamic data. The remaining datasets were inspected manually with guidance, allowing acceptance of full datasets from an additional 80 participants and recovery phase data from an additional 16 subjects. Overall, more anomalies occurred with patient data (35% of datasets) compared with healthy controls (15% of datasets). In conclusion, the QCS ensures a standardized data rejection procedure and rigorous objective analysis of dynamic 31 P-MRS data obtained from patients. This methodology contributes to efforts made to standardize 31 P-MRS practices that have been underway for a decade, with the goal of making it an empowered tool for clinical research.

Alteration of skeletal muscle energy metabolism assessed by 31 P MRS in clinical routine: Part 2. Clinical application

In this second part of a two-part paper, we intend to demonstrate the impact of the previously proposed advanced quality control pipeline. To understand its benefit and challenge the proposed methodology in a real scenario, we chose to compare the outcome when applying it to the analysis of two patient populations with significant but highly different types of fatigue: COVID-19 and multiple sclerosis (MS). 31 P-MRS was performed on a 3 T clinical MRI, in 19 COVID-19 patients, 38 MS patients, and 40 matched healthy controls. Dynamic acquisitions using an MR-compatible ergometer ran over a rest (40 s), exercise (2 min), and a recovery phase (6 min). Long and short TR acquisitions were also made at rest for T1 correction. The advanced data quality control pipeline presented in Part 1 is applied to the selected patient cohorts to investigate its impact on clinical outcomes. We first used power and sample size analysis to estimate objectively the impact of adding the quality control score (QCS). Then, comparisons between patients and healthy control groups using the validated QCS were performed using unpaired t tests or Mann-Whitney tests (p < 0.05). The application of the QCS resulted in increased statistical power, changed the values of several outcome measures, and reduced variability (standard deviation). A significant difference was found between the T1PCr and T1Pi values of MS patients and healthy controls. Furthermore, the use of a fixed correction factor led to systematically higher estimated concentrations of PCr and Pi than when using individually corrected factors. We observed significant differences between the two patient populations and healthy controls for resting [PCr]-MS only, [Pi ], [ADP], [H2 PO4 - ], and pH-COVID-19 only, and post-exercise [PCr], [Pi ], and [H2 PO4 - ]-MS only. The dynamic indicators τPCr , τPi , ViPCr , and Vmax were reduced for COVID-19 and MS patients compared with controls. Our results show that QCS in dynamic 31 P-MRS studies results in smaller data variability and therefore impacts study sample size and power. Although QCS resulted in discarded data and therefore reduced the acceptable data and subject numbers, this rigorous and unbiased approach allowed for proper assessment of muscle metabolites and metabolism in patient populations. The outcomes include an increased metabolite T1 , which directly affects the T1 correction factor applied to the amplitudes of the metabolite, and a prolonged τPCr , indicating reduced muscle oxidative capacity for patients with MS and COVID-19.

[Infections in primary Sjögren's syndrome patients: "Real-life" study of 109 patients from Montpellier university hospital]

INTRODUCTION

Infections are responsible for a part of the overall mortality in primary Sjögren's syndrome patients (pSS). Our retrospective monocentric study aimed at describing infections reported in a population of pSS hospitalized patients, along with the characteristics of their disease.

METHODS

Patients with SS have been randomly selected from our hospital database claim, between 2009 and 2018. After careful analysis of their medical chart, only patients with pSS and fulfilling ACR/EULAR 2016 diagnosis criteria were included. We collected main clinical, biological and pathological characteristics of SS, along with all the reported infections during the follow-up. The characteristics of the disease were compared according to the presence of an infection in hospitalization.

RESULTS

In total, 109 pSS patients were included (93% of women, mean age 53.6±14.3 years, mean follow-up 8.2±8.4 years). Fifty-one percent had been exposed to hydroxychloroquine (HCQ). Seventy-eight infections were recorded in 47 (43%) patients. Twenty-five infections were recorded in hospitalization (5 in critical care) in 20 (18%) patients, whom leading causes were urinary tract (28%), pulmonary (24%), ENT (16%), and intestinal (12%) infections. pSS patients with infections in hospitalization were older, exhibited more hypocomplementemia, and were less exposed to HCQ. We found no difference in immunosuppressive treatments exposure.

CONCLUSIONS

The impact of HCQ exposure on infectious risk needs further investigations. Broad vaccination campaign and tight control of sicca syndrome could lead to a better control of infection risk.

POS0700 IMPACT OF DELAYING INITIATION OF METHOTREXATE BY 1 MONTH ON THE OUTCOME OF RHEUMATOID ARTHRITIS AT 1 YEAR

Background

It is recommended that vaccinations should be performed prior to start methotrexate (MTX) knowing that delaying initiation of background therapy may have an impact on the progression of RA.

Objectives

To access the impact of delaying initiation of MTX by 1 month on the outcome of RA at 1 year.

Methods

The VACIMRA study is a prospective, randomized, parallel-group, multicenter trial comparing the vaccine protection obtained in patients with rheumatoid arthritis according to the 1-month delay between anti-pneumococcal vaccine PCV13 and methotrexate initiation in one arm, versus immediate introduction of MTX following vaccination in the other arm. We analyzed disease activity based on DAS28-ESR at baseline (M0), 1, 2, 3, 6 and 12 months between the 2 groups. For structural progression, we performed a radiographic analysis of 79 RA patients included in the Montpellier center at baseline, 6 and 12 months. This analysis was performed by the same physician two times, blinded to the patient’s group. Structural damage progression at 6 months and 1 year was assessed according to van-der-Heijde-modified Sharp score (vSHS) on radiographs performed at inclusion, at 6 and 12 months of follow-up. Comparisons of the means of activity scores and radiographic scores were made with the non-parametric Wilcoxon-Mann-Whitney test.

Results

Of the 276 patients randomized, 261 could be analyzed (131 in the IMMEDIATE group and 130 in the DELAY group). At inclusion, there were no significant differences in demographic, disease activity (DAS28-ESR), biological and radiographic characteristics between the 2 groups (Table 1).

Table 1.

Baseline characteristics

VariableModalityTotal populationGROUP IMMEDIATEGROUPE DELAYpGender, n(%)N=261n=131n=1300.97Man74 (28.35)37 (28.24)37 (28.46)Woman187 (71.65)94 (71.76)93 (71.54)Age (years)Mean (± SD)55.74 (± 14.68)55.31 (± 15.27)56.16 (± 14.11)0.76MTX true naive (n(% col))No13 (4.98)8 (6.11)5 (3.85)0.40yes248 (95.02)123 (93.89)125 (96.15)Age at diagnosis (years)Mean (± SD)N=205 55.86 (± 15.16)n=98 55.31 (± 16.07)n=107 56.37 (± 14.34)0.80Positive rheumatoid factorn(% col)166 (64.59)84 (65.12)82 (64.06)0.86Positive ACPAn(% col)174 (68.24)89 (68.99)85 (67.46)0.79CRP (mg/L)Mean (± SD)N=260 17.62 (± 24.87)n=131 15.36 (± 17.95)n=129 19.91 (± 30.23)0.65DAS28-ESRMean (± SD)N=249 5.01 (± 1.11)n=125 5.03 (± 1.13)n=12 4.98 (± 1.10)0.54Sharp modified VdH total radiographic scoreMean (± SD)N=93 1.53 (± 3.62)n=47 1.57 (± 3.68)n=46 1.48 (± 3.60)0.88

DAS 28-ESR evolution during 1 year of follow-up

There was a significant difference in the means of DAS28-ESR at 1 month between the DELAY and IMMEDIAT groups (3.96 ± 1.46 vs 3.41 ± 1.33; p<0.001, respectively). There was no significant difference in the means of DAS28-ESR between the 2 groups at 3 months (3.19± 1.46 in the 2 groups p<0.91), at 6 months (3.11 ± 1.42 vs 3.24 ± 1.43; p=0.46, respectively) and at 12 months (2.96 ± 1.34 vs 2.98 ± 1.26p=0.89) (Graphic). Similarly, there was no significant difference in mean radiographic scores at 6 months (2.00 ± 4.41 vs. 1.80 ± 4.03 p=0.81) or at 12 months (2.23 ± 4.86 vs. 2.00 ± 4.07 p=0.93).

There was no significant variation between radiographic scores at 6 months compared to baseline in either group (mean difference 0.21 ± 0.52 vs. 0.36 ± 1.01, p=0.90) nor at 12 months compared to baseline (mean difference 0.40 ± 1.06 vs. 0.62 ± 1.58, p=0.85).

Conclusion

In patients with rheumatoid arthritis, initiation of methotrexate 1 month after PCV13 vaccination has no significant impact on RA activity and structural outcome at 1 year. Performing vaccinations 1 month before starting MTX can be proposed without significant impact on RA outcome at 1 year.

Figure 1.

Disclosure of Interests

None declared

AB0899 A 24-month Prospective Psoriatic Arthritis Observational Study of Persistence of Treatment (PRO-SPIRIT) - Interim Analysis of Baseline Characteristics

Background

Ixekizumab (ixe), a highly selective interleukin (IL)-17A monoclonal antibody, has been approved for treatment of psoriatic arthritis (PsA). However, there is limited real-world evidence (RWE) available for ixe. PRO-SPIRIT is the first large-sample prospective observational study to provide RWE for ixe in patients (pts) with PsA.

Objectives

PRO-SPIRIT’s primary objective is to describe treatment persistence at 24 months (M) among pts with PsA who initiate or switch to a new biologic Disease Modifying Arthritis Rheumatic Drugs (bDMARDs) or targeted synthetic (tsDMARDs), including ixe. This abstract describes the interim baseline (BL) characteristics.

Methods

PRO-SPIRIT is a prospective observational study, conducted in FR, ES, IT, DE, UK, and CA, enrolling adults with PsA (≥6M) to be initiated or switched to a new b/tsDMARD, locally approved for PsA. Treatment groups include ixe, secukinumab, IL-12/IL-23 inhibitors (i) (ustekinumab) or IL-23i (guselkumab), tumour necrosis factor (TNFi) (adalimumab, etanercept, infliximab or biosimilar), Janus kinase (JAKi) (tofacitinib or upadacitinib). Pt demographic, disease activity and therapy characteristics are collected at BL; clinical and patient-reported outcomes measures are collected at BL and at a routine post-BL visit. BL descriptive statistics are reported.

Results

From December 2019 until this interim data cut (June 2021), a total of 477 pts (305 female; mean age 52) were enrolled. Mean age ranged from 48 (IL-12/23i and IL-23i) to 55 (JAKi), with a majority of female pts in each group (Table 1). Pts in the IL-12/23i and IL-23i and TNFi groups showed the shortest time since PsA diagnosis (5.2±4.5; 6.5±7.9), while pts in the JAKi group showed the longest time (10.6±9.4). The lowest proportion of pts with a prior b/tsDMARDs use was observed in the TNFi group (31%), the highest in the IL-12/23i and IL-23i group (71%). Pts in the ixe and IL-12/23i and IL-23i groups were more likely to be on monotherapy. Tender Joint Count (9.1-11.3) and Swollen Joint Count (3.3-5.8) were comparable across groups, with the highest values in the ixe and JAKi groups, respectively. Pt proportion with enthesitis and dactylitis was higher in the ixe, secukinumab and JAKi groups. Percentage of Body Surface Area affected by psoriasis was higher in the ixe, secukinumab and IL-12/23i and IL-23i groups. Pt proportion with nail psoriasis was higher in the ixe and secukinumab groups. Physician’s Global Assessment Visual Analog Scale (VAS), Patient’s Global Assessment VAS and Patient’s Assessment of Joint Pain VAS reflected a high burden of illness.

Table 1.

Baseline characteristics

bDMARDstsDMARDsIxekizumabSecukinumabIL-12/23 and IL-23 inhibitorsTNF inhibitorsJAK InhibitorsN=137N=46N=24N=211N=40Age52.8±12.252.8±13.147.6±13.450.3±11.755.3±9.9Female, n (%)86 (62.8)31 (67.4)16 (66.7)135 (64.0)25 (62.5)Years since diagnosis8.4±7.57.6±8.05.2±4.56.5±7.910.6±9.4Prior b/tsDMARD, n (%)87 (63.5)27 (58.7)17 (70.8)66 (31.3)26 (65.0)Concomitant csDMARD, n (%)47 (34.3)19 (41.3)5 (20.8)108 (51.2)19 (47.5)Tender Joint Count11.3±10.29.1±10.89.1±9.310.9±10.611.1±8.8Swollen Joint Count5.7±6.63.3±3.83.4±6.44.8±5.65.8±6.6Body Surface Area % affected by psoriasis6.1±10.57.6±14.27.0±9.74.6±11.02.2±3.1Presence of enthesitis, n (%)58 (42.3)16 (34.8)4 (16.7)67 (31.8)16 (40.0)Presence of dactylitis, n (%)33 (24.1)10 (21.7)3 (12.5)26 (12.3)10 (25.0)Presence of nail psoriasis, n (%)57 (41.6)20 (43.5)7 (29.2)71 (33.6)11 (27.5)Physician’s Global assessment VAS62.6±18.159.5±20.555.7±24.661.7±18.063.0±20.5Patient’s Global Assessment VAS60.5±20.456.8±25.156.2±25.757.5±22.955.4±22.5Patient’s Assessment of Joint Pain VAS62.7±21.358.4±27.155.7±28.359.4±22.957.5±24.0

Mean±SD, unless otherwise stated

Conclusion

The reported BL characteristics offer preliminary information about which pts initiate or switch to a b/tsDMARD in a real life-setting. Future disclosures (at 12 and 24M) will provide RWE regarding persistence, effectiveness, and health care resource use of available treatments for PsA, which will help pts and physicians to make better informed treatment decisions.

Disclosure of Interests

Jacques Morel Speakers bureau: Abbvie, Amgen, Biogen, Biogen, Bristol Myer Squib, Fresenius, Galapagos, Eli Lilly and Company, Médac, Novartis, Sandoz, Sanofi, Consultant of: Abbvie, Galapagos, Eli Lilly and Company, Médac, Novartis, Glaxo Smith Kline, Grant/research support from: Bristol Myer Squib, Biogen, Eli Lilly and Company, Novartis, Pfizer, Lorenzo Dagna Speakers bureau: Abbvie, Amgen, BMS, Eli Lilly and Company, Galapagos, GSK, Pfizer, Sobi, Consultant of: Abbvie, Amgen, Astra Zeneca, Biogen, BMS, Celltrion, Eli Lilly and Company, Galapagos, GSK, Janssen, Kiniksa, Pfizer, Roche, Sobi, Sanofi, Beatriz Joven-Ibáñez Speakers bureau: Eli Lilly and Company, Grant/research support from: (institutional grant) Eli Lilly and Company, Thorsten Holzkaemper Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Celine El Baou Consultant of: Eli Lilly and Company, Leonore Unger Speakers bureau: Eli Lilly and Company, Angelo Semeraro: None declared, Nicola Gullick Speakers bureau: AbbVie, Celgene, Janssen, Eli Lilly and Company, Novartis, UCB, Consultant of: AbbVie, Janssen, Eli Lilly and Company, Novartis, UCB, Grant/research support from: (institutional grants) Eli Lilly and Company, AbbVie, Astra Zeneca, Izana, Novartis, Tamas Treuer Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company

POS1264 LONGITUDINAL FOLLOW-UP OF HUMORAL RESPONSE AGAINST SARS-CoV-2 AND VIRAL PERSISTENCE IN 96 DMARDs-TREATED PATIENTS WITH PREVIOUS COVID-19 INFECTION

Background

Although it prevents severe forms of the disease, vaccination does not completely protect against the occurrence of COVID19 disease. If, DMARDs used have been associated with variable humoral response to SARS-CoV-2 vaccination, the impact of their use after SARS-CoV-2 natural infection have been poorly studied.

Objectives

To characterize humoral response after SARS-CoV-2 infection and viral persistence in the nasopharyngeal sphere (NP), stools and blood of patients with rheumatic disease under DMARDs, and compared to healthy controls.

Methods

Prospective monocentric longitudinal study including patients with rheumatoid arthritis or spondyloarthritis under DMARDs and with a confirmed SARS-CoV-2 infection (positive NP PCR and/or positive serology and/or pathognomonic thoracic tomography (CT)) during the first or second wave of the COVID pandemic. Patients were followed up until one year after infection and humoral response was assessed before vaccination. Serum IgG and IgA antibodies against spike (S) and nucleocapsid (N) proteins were measured at every visit. Viral persistence was assessed at the early visit in the NP and stools using conventional RT-PCR and in the blood using a high sensitive technique (droplet digital PCR).

Results

Between June 2020 and July 2021, we include 96 patients (50 SpA and 46 RA) with a mean age of 53 +/- 14 years and 20 healthy controls (mean age 49 ± 16 years) corresponding to relatives of patients (spouses, children) living together and infected at the same time. The immune responses were analyzed according to 6 treatment groups: methotrexate (MTX)/salazopyrine (SLZ) monotherapy (n=17/2); anti-TNF monotherapy (n=24), anti-TNF + MTX (n=23); rituximab (RTX) (n=11); anti-IL17 or -23 (n=8); others (n=11). Visits were made at 1 month (29 ±13 days; n=18), 3 months (110 ±23 days; n=67), 6 months (231 ±35 days; n=48) and 12 months (368 ± 19 days; n=19) after infection. The anti-S and anti-N IgG Ab titers were not significantly different in the 6 treatment groups and the control population at 3 months. A significant decrease in anti-S IgA Ab titers was noted in the group treated with RTX (p=0.007) and with molecules targeting the IL17/23 pathway (p=0.007). A similar but non-significant trend was observed in these same treatment groups for anti-N IgA Ab (p=0.07). The titers of anti-SARS-CoV-2 antibodies at M3, was not associated with a severe COVID disease. Detection of SARS-Cov-2 RNA in stools and serum was negative for all samples taken at 1 month or 3 months. 4 patients (2 RA treated with abatacept/RTX and 2 SpA treated with anti-TNF/secukinumab) had a positive RT-PCR NP with low to very low viral load at the 1-month visit (mean Ct 36). None of these 4 patients had had a severe form of COVID19 infection.

Conclusion

DMARDs - treated patients with previous proven COVID-19 did not seem to alter IgG Ab response but RTX and anti-IL17/-IL-23 might alter IgA humoral response. This lower immune response was not associated with a more severe disease. In these patients, new infection may not be considered as a full boost for the immune system. DMARDs did not induce viral persistence in the serum, the NP or in the stool.

Acknowledgements

financial support from Société Française de Rhumatologie and ANR RA COVID

Disclosure of Interests

None declared

Impact of prolonged requirement for insulin on 90-day mortality in critically ill patients without previous diabetic treatments: a post hoc analysis of the CONTROLING randomized control trial

BACKGROUND

Stress hyperglycemia can persist during an intensive care unit (ICU) stay and result in prolonged requirement for insulin (PRI). The impact of PRI on ICU patient outcomes is not known. We evaluated the relationship between PRI and Day 90 mortality in ICU patients without previous diabetic treatments.

METHODS

This is a post hoc analysis of the CONTROLING trial, involving 12 French ICUs. Patients in the personalized glucose control arm with an ICU length of stay ≥ 5 days and who had never previously received diabetic treatments (oral drugs or insulin) were included. Personalized blood glucose targets were estimated on their preadmission usual glycemia as estimated by their glycated A1c hemoglobin (HbA1C). PRI was defined by insulin requirement. The relationship between PRI on Day 5 and 90-day mortality was assessed by Cox survival models with inverse probability of treatment weighting (IPTW). Glycemic control was defined as at least one blood glucose value below the blood glucose target value on Day 5.

RESULTS

A total of 476 patients were included, of whom 62.4% were male, with a median age of 66 (54-76) years. Median values for SAPS II and HbA1C were 50 (37.5-64) and 5.7 (5.4-6.1)%, respectively. PRI was observed in 364/476 (72.5%) patients on Day 5. 90-day mortality was 23.1% in the whole cohort, 25.3% in the PRI group and 16.1% in the non-PRI group (p < 0.01). IPTW analysis showed that PRI on Day 5 was not associated with Day 90 mortality (_IPTWHR = 1.22; CI 95% 0.84-1.75; p = 0.29), whereas PRI without glycemic control was associated with an increased risk of death at Day 90 (_IPTWHR = 3.34; CI 95% 1.26-8.83; p < 0.01).

CONCLUSION

In ICU patients without previous diabetic treatments, only PRI without glycemic control on Day 5 was associated with an increased risk of death. Additional studies are required to determine the factors contributing to these results.

Prevalence of self-reported fatigue in intensive care unit survivors 6 months-5 years after discharge

Prolonged stays in intensive care units (ICU) are responsible for long-lasting consequences, fatigue being one of the more debilitating. Yet, fatigue prevalence for patients that have experienced ICU stays remains poorly investigated. This study aimed to evaluate fatigue prevalence and the level of physical activity in ICU survivors from 6 months to 5 years after ICU discharge using the Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F) and Godin questionnaires, respectively. Data from 351 ICU survivors (out of 1583 contacted) showed that 199 (57%) and 152 (43%) were considered as fatigued and non-fatigued, respectively. The median FACIT-F scores for fatigued versus non-fatigued ICU survivors were 21 (14–27) and 45 (41–48), respectively (p < 0.001). Time from discharge had no significant effect on fatigue prevalence (p = 0.30) and fatigued ICU survivors are less active (p < 0.001). In multivariate analysis, the only risk factor of being fatigued that was identified was being female. We reported a high prevalence of fatigue among ICU survivors. Sex was the only independent risk factor of being fatigued, with females being more prone to this symptom. Further studies should consider experimental approaches that help us understand the objective causes of fatigue, and to build targeted fatigue management interventions.

Slope analysis for the prediction of fluid responsiveness by a stepwise PEEP elevation recruitment maneuver in mechanically ventilated patients

Objective

Assessment of fluid responsiveness is problematic in intensive care unit patients. Lung recruitment maneuvers (LRM) can be used as a functional test to predict fluid responsiveness. We propose a new test to predict fluid responsiveness in mechanically ventilated patients by analyzing the variations in central venous pressure (CVP) and systemic arterial parameters during a prolonged sigh breath LRM without the use of a cardiac output measuring device.

Design

Prospective observational cohort study.

Setting

Intensive Care Unit, Saint-Etienne University Central Hospital.

Patients

Patients under mechanical ventilation, equipped with invasive arterial blood pressure, CVP, pulse contour analysis (PICCO™), requiring volume expansion, with no right ventricular dysfunction.

Interventions.

None.

Measurements and main results

CVP, systemic arterial parameters and stroke volume (SV) were recorded during prolonged LRM followed by a 500 mL fluid expansion to asses fluid responsiveness. 25 patients were screened and 18 patients analyzed. 9 patients were responders to volume expansion and 9 were not. Evaluation of hemodynamic parameters suggested the use of a linear regression model. Slopes for systolic arterial pressure, pulse pressure (PP), CVP and SV were all significantly different between responders and non-responders during the pressure increase phase of LRM (STEP-UP) (p = 0.022, p = 0.014, p = 0.006 and p = 0.038, respectively). PP and CVP slopes during STEP-UP were strongly predictive of fluid responsiveness with an AUC of 0.926 (95% CI, 0.78 to 1.00), sensitivity = 100%, specificity = 89% and an AUC = 0.901 (95% CI, 0.76 to 1.00), sensibility = 78%, specificity = 100%, respectively. Combining sensitivity of PP and specificity of CVP, prediction of fluid responsiveness can be achieved with 100% sensitivity and 100% specificity (AUC = 0.96; 95% CI, 0.90 to 1.00). One patient showed inconclusive values using the grey zone approach (5.5%).

Conclusions

In patients under mechanical ventilation with no right heart dysfunction, the association of PP and CVP slope analysis during a prolonged sigh breath LRM seems to offer a very promising method for prediction of fluid responsiveness without the use and associated cost of a cardiac output measurement device.

Trial registration

NCT04304521, IRBN902018/CHUSTE. Registered 11 March 2020, Fluid responsiveness predicted by a stepwise PEEP elevation recruitment maneuver in mechanically ventilated patients (STEP-PEEP)

Prevention of cardiac surgery-associated acute kidney injury by risk stratification using (TIMP-2)*(IGFBP7)

Aim: The purpose of this study was to assess urinary (TIMP-2)*(IGFBP7) for prevention of acute kidney injury (AKI) in patients undergoing elective cardiac surgery. Materials & methods: Two retrospective cohorts were analyzed before and after the implementation of urinary (TIMP-2)*(IGFBP7). The control cohort had a standard supportive care. For the (TIMP-2)*(IGFBP7) cohort, patients with the (TIMP-2)*(IGFBP7) >0.3 received renal supportive measures. Results: A total of 382 patients were included, 197 in the control cohort and 185 in intervention cohort. The incidence of AKI was significantly reduced in the (TIMP-2)*(IGFBP7) cohort (20.5 vs 29.9%, p < 0.05). In multivariate analysis, patients of the (TIMP-2)*(IGFBP7) cohort had a lower risk of developing AKI (p = 0.029). Conclusion: In conclusion, renal supporting care based on AKI risk stratification using urinary (TIMP-2)*(IGFBP7) may reduce AKI incidence.

Evaluation of effectiveness and compliance with the mupirocin nasal ointment part of Staphylococcus aureus decolonization in real life using UPLC-MS/MS mupirocin quantification

BACKGROUND

Preoperative decolonization is recommended in Staphylococcus aureus nasal carriers scheduled for cardiac surgery. We aimed to evaluate the effectiveness of and compliance with mupirocin use in nasal S. aureus carriers in a real-life setting.

METHODS

Prospective study including consecutive patients scheduled for cardiac surgery screened for S. aureus nasal carriage at preoperative consultation. Carriers were prescribed mupirocin nasal ointment, chlorhexidine shower and mouthwash. Effectiveness of decolonization was evaluated with a postoperative nasal sample. Compliance was evaluated objectively by determination of nasal mupirocin concentration using UPLC-MS/MS and self-reported by questionnaire.

RESULTS

Over 10 months, 361 patients were included, 286 had preoperative screening, 75 (26.2%) were S. aureus nasal carriers and 19 of them (25.3%) failed to be effectively decolonized. No resistance to mupirocin was documented. Preoperative and postoperative strains were identical in all cases. Declared good compliance was associated with decolonization success (OR = 24; 95% CI 4-143, P < 0.0001). Mupirocin detection was significantly associated with the level of compliance. Mupirocin was detected in 52.2% (24/46) of patients effectively decolonized and in 12.5% (2/16) of patients with decolonization failure (P < 0.01). In 2/19 patients, failure of decolonization was not associated with a compliance issue. Postoperative carriage was associated with an increased risk of S. aureus infection (OR = 9.8; 95% CI 1.8-53, P < 0.01).

CONCLUSIONS

In real life, decolonization is not always effective, hence there is a persisting risk of S. aureus endogenous infection. Mupirocin concentration measurement may help to understand compliance issues and failures in decolonization.

AB0493 WHAT IS THE DIAGNOSTIC VALUE OF IMPAIRED SPINAL MOBILITY MEASUREMENTS IN INFLAMMATORY BACK PAIN PATIENTS? DATA FROM THE DESIR COHORT

Background:

The diagnostic process in a patient with early inflammatory back pain suggestive of axial spondyloarthritis (ax-SpA) requires assessment and integration of multiple aspects, including clinical examination, biological measurements and radiologic assessments. Among the physical examination features, alteration of spinal mobility is often observed in ax-SpA. However, whether mobility impairment might really increase diagnostic likelihood, and which of the measurements made have relevant diagnostic value remains unknown.

Objectives:

To describe the frequency and severity of mobility impairment in multiple traditional measurements in patients suspect of early ax-SpA at initial assessment time, and to analyze their individual diagnostic performances in reference to usual classification criteria applied after 2 years of follow-up.

Methods:

Data from the DESIR cohort, which included patients aged 18-50 with inflammatory back pain lasting for 3 months to 3 years and a clinical suspicion of ax-SpA diagnosis were used. Baseline measurements of Schober’s test (Schober), chest expansion (CEx), lateral spinal flexion (LatSpiFlex), cervical rotation (CervRot) and intermalleolar distance (IntMalDist) collected at baseline were classified according to reference data from the general population adjusted for age and -when appropriate- for height. Cutoffs were defined as above 2.5th, 5th, 10th and 25th percentiles. With ASAS classification for ax-SpA applied at 2 years follow-up visit as external reference, diagnostic performances (Sensitivity [Se], Specificity [Sp], Positive [PPV] and Negative [NPV] Predictive Values) were calculated.

Results:

Complete data were available for 575 patients (of whom 377 (66%) fulfilled the ASAS criteria at 2 years). Schober, CEx, LatSpiFlex, CervRot and IntMalDist were above 5th percentile in respectively 278 (48%), 82 (14%), 220 (38%) and 93 (16%) patients. None of the measurements showed a clinically relevant compromise between both Se and Sp, but Sp was highest for CEx-most impaired cutoffs (Figure 1). The highest PPV (73.6%) and NPV (39.4%) were observed for LatSpiFlex.

Conclusion:

Measures of mobility and their levels of impairment do not show sufficient individual diagnostic value for ax-SpA among patients with early inflammatory back pain. However, highest degrees of impairment when compared to general population are more specifically observed in patients finally classified with ax-SpA for CEx, which was –consistently- 1 of the 2 mobility measures that was retained in the modified New York criteria for ankylosing spondylitis.

Disclosure of Interests:

Cédric Lukas Speakers bureau: AbbVie; Lilly; Merck; Novartis; Pfizer; Roche-Chugai;, Consultant of: AbbVie; Bristol-Myers Squibb; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; UCB; Sanofi;, Grant/research support from: Pfizer: Novartis, Gisèle Khoury Grant/research support from: Pfizer, Maria-Antonietta d’Agostino: None declared., Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Jacques Morel Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai.

POS1082 CATASTROPHIZING IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Catastrophizing is a negative cognitivo-affective response to an anxiety-provoking stimulus, especially anticipated or actual pain. It can be quickly assessed using a validated questionnaire: the Pain Catastrophizing Scale (PCS)1. Catastrophizing plays a role in maintaining chronic pain and is associated with several pain-related outcomes in osteoarthritis and low back pain. To our knowledge, there are no data on catastrophizing in patients with psoriatic arthritis (PsA).

Objectives:

To assess the prevalence of catastrophizing and associated factors in PsA.

Methods:

We performed a bi-centric observational, prospective study. All patients aged 18 or over with PsA fulfilling the 2006 CASPAR criteria were consecutively included. Sociodemographic data, information on the disease and its treatments were collected as well as questionnaires for disease activity (BASDAI), function (HAQ, BASFI), quality of life (SF12, EQ5D), anxiety and depression (HADS, GAD7), fibromyalgia (FiRST), insomnia (ISI) and catastrophizing scores (PCS). Statistical analysis included samples T-test, one-way variance analysis, Spearman’s correlation coefficient, Chi2 test, Fisher’s exact test, Wilcoxon test, multivariate linear regression (considering catastrophizing as a continuous variable) and multivariate logistics regression (considering catastrophizing as a categorical variable: PCS ≥ 20 = high level catastrophizing).

Results:

From September 2019 to March 2020, 85 PsA patients were included: 54.1% were women, the median age was 54.0 years and 33 patients (39.8%) were professionally active. The majority of patients (88.2%) had a disease lasting for more than 2 years. Axial involvement was found for 39 patients (45.9%), almost all patients (98.8%) had peripheral involvement, 32 patients (37.7%) had enthesitic involvement and 14 patients (16.7%) had erosions. Median DAS28 CRP was 3.12 [2.13-4.46] and the median BASDAI score was 5.50 [4.30-6.70]. The prevalence of a PCS score ≥20 was 45.9% [35.3;56.5]. The median PCS score was 16 [6-29]. In multivariate logistics regression, high-level catastrophizing was significantly associated with the HADS anxiety score (OR=1.35 [1.15-1.61]) and pain VAS (OR=1.04 [1.02-1.06]). In multivariate linear regression, catastrophizing was significantly associated with the HADS anxiety score (p= 0.004), pain VAS (p=0.001), HADS depression score (p=0.018) and insomnia score (p=0.034).

Conclusion:

Almost half the patients with PsA were high catastrophizers. Catastrophizing is related to anxiety, pain, depression and insomnia. It may be interesting to detect catastrophizing in order to improve the care of our patients.

References:

[1]Sullivan MJL. et al. Psychological Assessment. 1995;7(4):524–32

Disclosure of Interests:

None declared.

POS1239 POSITIVE IMPACT OF THE FIRST LOCKDOWN IN PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATISM

Background:

Since the beginning of 2020, the COVID-19 pandemic has caused a considerable amount of fear, worry and concern in the general population and among certain groups such as the elderly, healthcare providers and people with pre-existing conditions in particular. Our patients suffering from chronic inflammatory rheumatism (CIR), a group of autoimmune pathologies treated by immunosuppressant medication, are particularly concerned. Actions taken – particularly quarantine and its effects on the normal activities, habits or livelihoods of many people – also have a significant impact. There is little information on the impact of the lockdown in patients with CIR with data measured prospectively, in a standardized way, before and during the first lockdown period.

Objectives:

The objective of this ancillary study was to evaluate the psychological impact of the first lockdown period (anxiety, depression, sleep disorders, catastrophizing...) as well as the evolution of disease activity in patients suffering from CIR.

Methods:

At two French university hospitals, adult patients with rheumatoid arthritis (RA) according to the ACR-EULAR 2010 criteria, spondyloarthritis (SpA) fulfilling the ASAS 2009 criteria and psoriatic arthritis (PsA) according to the Caspar 2006 criteria were consecutively included in the Catastrophism in Chronic Inflammatory Rheumatism (CRIC) study from September 2019. Sociodemographic data, information on the disease and its treatments were collected as well as questionnaires on disease activity (DAS28, CDAI, BASDAI), function (HAQ), quality of life (SF12, EQ5D), anxiety and depression (HADS, GAD7), insomnia (ISI) and catastrophizing scores (PCS). These data were collected prospectively at baseline, 3, 6 and 12 months.

In this ancillary study, data from patients with an assessment before and during lockdown were analyzed. Statistical analyses were descriptive with a paired Student’s T-test.

Results:

In all, 140 patients (49 RA, 69 SpA and 22 PsA) were evaluated before and during lockdown. The median age was 53.5 [44-63] years and 60.7% were women; 74 patients (53.2%) were professionally active and 102 (72.9%) were living as couples. The majority of patients (92.9 %) had a disease lasting more than 2 years. Concerning treatments, 63 (45%) were treated by bDMARD monotherapy, 40 (28.5%) by bDMARD+ csDMARD, 17 (12.1%) by csDMARD monotherapy and 2 patients by tsDMARD; 90.7% were not taking any corticosteroids and 8.6% were taking ≤5 mg/d; 30% were on NSAIDs.

When comparing before and during lockdown, pain, tender joint count, swollen joint count, disease activity (CDAI, BASDAI) and function (HAQ, SF12 physical component) were similar. However, there was a significant improvement in psychological status, anxiety (HADS, GAD7), the mental component of SF12, catastrophizing and overall quality of life (EQ5D) (see Table 1 below).

Conclusion:

There are very few prospective, standardized data on the impact of lockdown in patients with CIR with an assessment before and during the first lockdown period. In patients with CIR, the first lockdown period had no impact on the activity of the disease and was well experienced psychologically with less anxiety and an improvement in quality of life.

Table 1.Outcome (N)140 CIR: 49 RA, 69 SpA, 22 PsABefore lockdownMean (SD)During lockdownMean (SD)Mean change(SD)PPain VAS (138)39.4 (25.3)39.4 (25.0)-0.28 (27.1)NSTJC (57)4.0 (6.8)4.7 (4.4)0.7 (5.9)NSSJC (56)1.0 (2.6)1.6 (1.7)0.5 (2.4)NSCDAI (36)11.7 (1.4)12.3 (7.5)1.2 (8.7)NSBASDAI (84)4.7 (1.9)4.9 (2.0)0.14 (1.4)NSHAQ (135)0.72 (0.57)0.72 (0.53)0.03 (0.33)NSSF12 mental(136)32.7 (8.7)36.2 (8.4)3.46 (8.01)<0.0001GAD-7 (anxiety) (135)7.7 (5.5)5.0 (5.3)-1.73 (0.40)<0.0001HADS anxiety(137)8.5 (3.9)7.8 (3.9)-0.64 (2.91)0.0113EQ5D(139)0.55 (0.31)0.61 (0.29)0.06 (0.24)0.0078PCS (catastrophizing) (137)18.9 (13.3)15.9 (11.1)-3.10 (9.60)0.0003

Disclosure of Interests:

None declared

OP0214 IMPACT OF A MULTI-MORBIDITY SCREENING AND PREVENTION PROGRAM IN CHRONIC INFLAMMATORY RHEUMATIC DISEASES ON THE ONE-YEAR HOSPITALIZATION RATE BASED ON AN ANALYSIS OF THE FRENCH NATIONAL HEALTH DATABASE

Background:

A screening program for multimorbidities started in 2014 at the Montpellier University Hospital for primary prevention in patients with chronic inflammatory rheumatic diseases (IRD).

Objectives:

The objective of this work was to assess the impact of this program on morbidity by comparing the hospitalization rate of those patients in the year following the screening to the one of patients with IRD who did not benefit from this program.

Methods:

Patients with IRD who benefit from the screening program in 2015, 2016 and 2017 were identified in the French national health database PMSI and matched to 3 controls living in the same area on age, sex, type of IRD, use of intravenous (IV) biologic (b) DMARDs and index date. The exclusion criteria were subjects in secondary prevention identified as history of myocardial infarction in the previous 5 years or use of antiplatelet therapy. The primary outcome was the rate of all-cause hospitalization in the following year. The secondary endpoints were hospitalizations for another reason than IRD (“non-IRD”) including those for cardiovascular [CV] events and major fractures. Hospitalization rates were compared between the two groups in the year after screening (or index date) and also between the year preceding screening and the year after for each group. Univariate and multivariate odds ratios (CI95%) were calculated, taking into account the medical history (hypertension, diabetes, heart failure, CV disease, COPD, major fractures in the 5 years preceding the index date) and hospitalizations in the previous year.

Results:

486 patients were identified and matched with 1458 controls. 67.08% had rheumatoid arthritis and 21.81% spondyloarthritis; 7% of them had IV bDMARDs. Unscreened patients had more hypertension (19% vs 10.1%), diabetes (9% vs 4.9%), heart failure (2.3% vs 0.4%) and “non-IRD” hospitalizations (78.5% vs 72.2%) in the 5 years preceding the index date. In the year following the index date, the percentages of “all causes” and “non-IRD” hospitalizations were significantly higher in non-screened than in screened patients (n = 1944, 64.8% versus 51%, Chi2 test, p <0.001; and 47.1% versus 37.9%, p <0.001 respectively). 17 (1.17%) cardiovascular events occurred in non-screened versus 2 (0.41%) in screened patients (n = 1944, Chi2 test, p = 0.14). There was no difference in the occurrence of CV events or major fractures between the 2 groups. In multivariate analysis, screening was associated with a 49% (0.51 [0.41-0.64]) reduction in “all causes” hospitalization and a 27% (0, 73 [0.58-0.91]) decrease in “non-IRD” hospitalization, with no difference for CV or fracture cardiological events. The risk factors associated with “non-IRD” hospitalization were: history of “non-IRD” hospitalization in the previous year (2.26 [1.63-3.13]), IV bDMARDs (1.69 [1, 14-2.53]) and age> 70 years (1.44 [1.02-2.03] vs <50 years). Hospitalization in the previous year for “all causes” or “non-IRD” was associated with rehospitalization in the following year in the non-screened group (p <0.001), but not in the screened group (p = 0.750 and p = 0.066 respectively).

Conclusion:

Our screening and prevention program was associated with a reduction in hospitalizations in the following year and a decrease in the risk of re-hospitalization compared to unscreened patients with IRD. This suggests a positive impact of performing systematic screening for multi-morbidities in IRD patients.

Acknowledgements:

We thank Pfizer for their financial support

Disclosure of Interests:

guillaume decarriere: None declared, Jenica PASTOR: None declared, David DEMOULIN: None declared, Gael Mouterde Speakers bureau: Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Pfizer, Cédric Lukas Speakers bureau: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Consultant of: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Pfizer, Novartis and Roche-Chugai, Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Grégoire Mercier: None declared, Jacques Morel Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Claire Daien Speakers bureau: Pfizer, Roche-Chugai, Fresenius, BMS, MSD, Lilly, Novartis, Galapagos, Consultant of: Abivax, Abbbvie, BMS, Roche-Chugai, Grant/research support from: Pfizer, roche-chugai, fresenius, MSD

OP0053 IMPACT OF CORRECTING CRP THRESHOLD ACCORDING TO BMI ON DIAGNOSIS, DISEASE ACTIVITY, INDICATION OF BIOLOGICAL TREATMENT AND PREDICTION OF THERAPEUTIC RESPONSE, IN PATIENTS SUSPECTED OF AXIAL SPONDYLOARTHRITIS. RESULTS FROM DESIR COHORT

Background:

Acute phase reactants are crucial parameters to consider for management of chronic inflammatory back pain (IBP) patients suspect of axial spondyloarthritis (ax-SpA). Indeed, C-reactive protein (CRP) is part of ASAS classification criteria for SpA, impacts on assessment of disease activity by ASDAS-CRP score, and should be elevated when a bDMARD is discussed in patients without radiological sacroiliac lesions. Moreover, elevated CRP is regarded predictive of favorable therapeutic response. Obesity in otherwise healthy people is associated with high CRP values. An adjusted definition of normal CRP threshold based on gender and BMI has been proposed.

Objectives:

The aim of this study was to assess whether correcting CRP threshold with patient’s BMI would change classification according to ASAS criteria for ax-SpA, presence of clinically relevant activity according to ASDAS-CRP, indication for TNF inhibitor (TNFi) and, as primary endpoint, improve prediction of therapeutic response to first TNFi.

Methods:

The study was conducted in DESIR cohort, which included 708 patients with early IBP suspect of ax-SpA. We included all patients with available data on BMI and CRP. High CRP level was defined either according to usual threshold (5 mg/L) or to the formula using BMI for adjustment. With this formula, CRP could be considered “normal” or due to obesity if: ≤ 1 + (BMI-25)/25 for men and ≤ 1 + (BMI-25)/12.5 for women (with CRP in mg/dL). We reported distribution of CRP levels in patients with high level according to usual threshold but below BMI adjusted threshold, as it is potentially suggestive of false-positive CRP due to overweight/obesity. Among them, we identified those who had no objective sign of disease activity (defined as arthritis, dactylitis, active uveitis or inflammatory bowel disease). To evaluate the impact on classification/diagnosis, we examined HLAB27-positive patients with only 2 ASAS criteria, including high CRP (the second being IBP, since it was mandatory for inclusion in DESIR cohort). Then, we calculated ASDAS-CRP score. We presented proportions of patients with ASDAS- high or very high disease activity but high CRP level possibly due to BMI only, and among those, the number concerned by a change of disease activity level when adjusting ASDAS-CRP score with minimal value for CRP (2mg/l). Among patients treated by TNFi during first 24-month follow-up, we excluded those with sacro-iliitis, and studied in others, CRP levels at last visit before treatment initiation using both thresholds. We compared proportion of ASAS40 responders using logistic regression analysis, with abnormal CRP defined after correction for BMI in patients without any sign of activity, beside other classical predictive factor of therapeutic response (age, gender, sacro-iliitis, HLAB27, psoriasis, arthritis, smoking).

Results:

Data were available for 634 patients. 205 had a high CRP level using usual threshold, of which 73 (35.6%) had a high CRP possibly due to BMI alone as they had no objective sign of disease activity. There were no differences in diagnosis as no patient had as only ASAS criteria: HLAB27 associated with high CRP and IBP. ASDAS-CRP score could be calculated in 626 patients. By correcting ASDAS score for patients with high CRP possibly due to BMI, 95.3% remained with same activity level (kappa for the ASDAS levels was 0.93). For impact of CRP on indication of bDMARD, 178 patients were treated by TNFi during first 24 months of follow-up: 61% of patients had an indication of TNFi according to EMA, with usual CRP threshold, and 56% with the adjusted one. Regarding response to TNFi, there were no association between any of the 2 CRP thresholds and ASAS40 response. Only sacro-iliitis on MRI was associated with ASAS40 response.

Conclusion:

Adjustment of CRP threshold according to BMI has a very limited impact on diagnosis, evaluation of disease activity of SpA, indication of TNFi initiation and prediction of TNFi response.

Disclosure of Interests:

Odile Facorat: None declared, Jacques Morel Speakers bureau: Abbvie, Biogen, BMS, Fresenius Kabi, Lilly, Mylan, Novartis, Pfizer, Sanofi, Consultant of: Abbvie, BMS, Boerhinger Ingelheim, Galpaagos, GSK, Lilly, Novartis, Sanofi, Grant/research support from: Biogen, BMS, Lilly, Novartis, Pfizer, Sanofi, Servier, Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Pascal Richette Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Janssen-Cilag, Lilly, Medac, MSD, NORDIC Pharma, Novartis, Pfizer, Roche, SanofiAventis, UCB, Cédric Lukas Speakers bureau: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Consultant of: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Pfizer, Novartis and Roche-Chugai

AB0247 ANALYSIS OF THE IMPACT OF TOFACITINIB TREATMENT ON WEIGHT IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

A prior post hoc analysis of tofacitinib clinical trial data reported improvements in rheumatoid arthritis (RA) outcomes with tofacitinib vs placebo (PBO) through Month (M)6, regardless of baseline (BL) body mass index (BMI).1

Objectives:

To assess change from BL (Δ) in BMI, and disease activity by BL BMI status, in patients (pts) with moderate/severe RA receiving tofacitinib through M12.

Methods:

This post hoc analysis included data pooled from Phase 3 and 3b/4 studies of pts who were methotrexate-naïve (NCT01039688) or inadequate responders to conventional synthetic (cs) or biologic DMARDs (NCT00960440; NCT00847613; NCT00814307; NCT00856544; NCT00853385; NCT02187055; NCT02831855). Pts received ≥1 dose of tofacitinib 5 or 10 mg twice daily (BID) or 11 mg once daily (QD), ± csDMARDs, or PBO. Least squares (LS) mean ΔBMI (linear mixed model repeated measures; observed cases) was summarised for all treatment groups at M3/6/12 (M3/6 only for tofacitinib 11 mg QD and PBO). Other assessments at M3/6/12 included ΔBMI ± BL concomitant glucocorticoids (GCs) or antidepressants (descriptive statistics), LS mean ΔDAS28-4(ESR) stratified by BL BMI status (<25, ≥25–<30, ≥30), and correlations between LS mean ΔBMI and ΔDAS28-4(ESR).

Results:

In total, 2349, 1611, 694 and 681 pts received tofacitinib 5 mg BID, 10 mg BID, 11 mg QD or PBO, respectively. Demographics/baseline characteristics were generally similar across treatments, except for some numerical differences in the tofacitinib 11 mg QD group, eg fewer female pts, more White pts and fewer pts receiving concomitant GCs, compared with other treatment groups. At M3/6, LS mean BMI significantly increased from BL with all tofacitinib doses vs PBO (all p<0.05); LS mean ΔBMI was greatest with 10 mg BID and lowest with 11 mg QD (Figure 1a). LS mean ΔBMI was greater in pts receiving tofacitinib as monotherapy vs combination therapy at M3/6/12 (Figure 1b). ΔBMI was generally similar in pts receiving treatment ± concomitant GCs or antidepressants (data not shown). Improvements in DAS28-4(ESR) were observed in each BL BMI status group at M3/6/12 and were greatest with all tofacitinib doses vs PBO. LS mean ΔDAS28-4(ESR) was generally numerically highest for pts with BMI <25 and numerically lowest for pts with BMI >30, for all tofacitinib doses. LS mean ΔDAS28-4(ESR) was generally greatest with tofacitinib 10 mg BID and 11 mg QD vs 5 mg BID across BL BMI status groups (Figure 1c). Across treatments, model-adjusted associations between LS mean ΔDAS28-4(ESR) and ΔBMI were weak (correlation coefficients all <0.3; Table 1).

Table 1.

Correlations between LS mean ΔDAS28-4(ESR) and ΔBMI through M12

Tofacitinib5 mg BIDTofacitinib10 mg BIDTofacitinib11 mg QDPBONCorrelation coefficientNCorrelation coefficientNCorrelation coefficientNCorrelation coefficientM320210.116913480.12406410.09075540.0783M619180.130512700.13976110.04381500.1556M1214550.12138740.1826----

Slopes for associations between LS mean ΔBMI and ΔDAS28-4(ESR) were significantly different from 0 at M3/6/12 with tofacitinib 5 and 10 mg BID (all p<0.05). Correlations were analysed by a general linear model method, which included BL age, gender, race and RA duration. For pts receiving tofacitinib 11 mg QD in ORAL Shift (NCT02831855), only data to M6 were included. Pts who advanced from PBO to tofacitinib were not analysed post-advancement

DAS28-4(ESR), Disease Activity Score in 28 joints, erythrocyte sedimentation rate; N, number of pts analysed

Conclusion:

LS mean ΔBMI was greater with tofacitinib (all doses) vs PBO at M3/6, and with tofacitinib monotherapy vs combination therapy at M3/6/12. Improvements in DAS28-4(ESR) were seen across all BL BMI status groups. BMI increases with tofacitinib were only weakly associated with DAS28-4(ESR) improvements. The relationship between disease activity and ΔBMI requires further investigation.

References:

[1]Dikranian et al. Arthritis Rheumatol 2018; 69 (S10): Abs 2371.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Anthony G McCluskey, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

Jürgen Wollenhaupt Speakers bureau: Pfizer Inc, Consultant of: Pfizer Inc, Jacques Morel Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Novartis, Pfizer Inc, Sanofi Genzyme, Grant/research support from: Bristol-Myers Squibb, Pfizer Inc, Claire Daien Consultant of: Abivax, Grant/research support from: AbbVie, Bristol-Myers Squibb, Chugai, Eli Lilly, MSD, Novartis, Pfizer Inc, Sandoz, Adeline Ruyssen-Witrand Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Mylan, Novartis, Pfizer Inc, Sanofi Genzyme, Grant/research support from: AbbVie, Amgen, Mylan, Pfizer Inc, Cédric Lukas Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer Inc, Sanofi Genzyme, UCB, Grant/research support from: Novartis, Pfizer Inc, Christophe Richez Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Mylan, Pfizer Inc, Grant/research support from: Biogen, Eli Lilly, Glenmark, Nordic Pharma, Roche, Andrea Shapiro Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Douglass Chapman Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Magali CROS Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose Luis Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Gustavo Citera Consultant of: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis, Pfizer Inc, Sanofi Genzyme, Grant/research support from: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis, Pfizer Inc, Sanofi Genzyme

POS0641 INCIDENCE OF GASTRO-INTESTINAL COMPLICATIONS IN RHEUMATOID ARTHRITIS PATIENTS RECEIVING BIOLOGICAL DMARDS IN OBSERVATIONAL COHORT STUDIES: A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS

Background:

Rheumatoid arthritis (RA) patients are at increased risk of gastro-intestinal (GI) perforations compared with non-RA patients, resulting in increased mortality. Clinical trials, post-marketing studies and registries have reported an increased risk of GI perforations in RA patients treated with tocilizumab.

Objectives:

The aim of our study was to assess the incidence of GI complications among RA patients receiving bDMARDs in observational cohort studies

Methods:

A systematic literature review was carried out through September 2020 on the Pubmed, Embase and international congress databases, selecting observational cohort studies assessing the incidence of GI complications, including perforations and diverticulitis, in RA patients receiving bDMARDS. Keywords were “gastrointestinal perforation”, “gastrointestinal disease”, “diverticulitis”, “biological DMARDs” and “rheumatoid arthritis” with no publication date limit. Studies were selected independently by two readers. Data were extracted by one investigator and independently checked by another. A meta-analysis was performed with Review Manager Software, with random-effects models, whenever methodologically possible and relevant.

Results:

The literature search revealed 232 articles and abstracts of potential interest, and further examination resulted in 7 studies fulfilling required criteria. Among bDMARDs, Tocilizumab was associated with an increased incidence of GI perforations, with an overall incidence of 2.40 per 1000 person-years (95% confidence interval [95% CI] 1.45-3.35). The overall incidences of GI perforations were 1.01 per 1000 PY [0.75-1.27] for TNF inhibitors, 1.07 per 1000 PY [0.53-1.62] for abatacept and 1.12 per 1000 PY [0.16-2.08] for rituximab (Figure 1). In RA patients treated with tocilizumab, most of the perforations were located in the lower GI tract, with an incidence of 2.24 per 1000 PY [1.24-3.52]. The incidences of upper GI perforations were similar across the different bDMARDs. The incidences of diverticulitis were 4.99 per 1000 PY [4.08-5.99] in RA patients receiving tocilizumab and 1.81 per 1000 PY [1.47-2.19] in those receiving TNF inhibitors.

Figure 1.

Meta-analysis of the incidences of gastro-intestinal perforations in RA patients receiving bDMARDs in observational cohort studies

Conclusion:

In our meta-analysis, focused in RA patients receiving bDMARDs in observational cohort studies, tocilizumab was associated with an increased incidence of GI perforations, mainly located in the lower GI tract. An history of diverticulitis and long-term corticosteroid therapy were associated with an increased risk of GI perforations.

Acknowledgements:

We cannot express enough thanks to PhD Constantin and PhD Morel for their support and encouragement.

We would like to address a special word of thanks to PhD Lukas for his accuracy.

Special Thanks to Claire Rempenault for her precious advices. You have been a role model for us.

Disclosure of Interests:

None declared

POS1003 CATASTROPHIZING IN PATIENTS WITH SPONDYLOARTHRITIS

Background:

Catastrophizing is a negative cognitivo-affective response to an anxiety-provoking stimulus, especially anticipated or actual pain. It can be assessed quickly using a validated questionnaire: the Pain Catastrophizing Scale (PCS)1. Catastrophizing plays a role in maintaining chronic pain and is associated with several pain-related outcomes in osteoarthritis and low back pain. There is a lack of knowledge about catastrophizing in axial spondyloarthritis (AS) with only one study2 so far.

Objectives:

To assess the prevalence of catastrophizing and associated factors in spondyloarthritis.

Methods:

We performed an observational, prospective, bi-centric study. All patients aged 18 or over with AS fulfilling the 2009 Assessment in Spondyloarthritis International Society (ASAS) criteria were consecutively included. Sociodemographic data, information on the disease and its treatments were collected as well as questionnaires regarding disease activity (BASDAI), function (HAQ, BASFI), quality of life (SF12, EQ5D), anxiety and depression (HADS, GAD7), fibromyalgia (FiRST), insomnia (ISI) and catastrophizing scores (PCS). Statistical analysis included a samples t-test, one-way variance analysis, Spearman’s correlation coefficient, the Chi2 test, Fisher’s exact test, the Wilcoxon test, multivariate linear regression (considering catastrophizing as a continuous variable) and multivariate logistics regression (considering catastrophizing as a categorical variable: PCS ≥ 20 = high level catastrophizing).

Results:

From September 2019 to March 2020, 168 AS patients were included: 48.5% were women, the median age was 48.5 years and 100 patients (60.2%) were professionally active. Almost all patients (95.8%) had a disease lasting for more than 2 years; 110 (72%) were HLA-B27+; 84 (50%) had MRI sacroiliitis and 62 (37.6%) radiographic sacroiliitis. In all, 166 (98.8%) had axial involvement, 99 (58.9%) had peripheral involvement and 44 (26.2%) had enthesitic involvement. The median BASDAI score was 6.30 [Q1-Q3 4.65-6.30].

The prevalence of a PCS score ≥20 was 45.5% [38.0;53.0]. The median PCS score was 18 [7-27]. In multivariate logistics regression, high-level catastrophizing was significantly associated with the HADS anxiety score (OR=1.54 [1.22-2.0]), HADS depression score (OR=1.25 [1.10-1.43]) and disease activity (BASDAI OR=1.14 [1.01-1.26]). In multivariate linear regression, catastrophizing was also significantly associated with anxiety (p<0.0001), depression (p<0.0001) and disease activity (p=0.0008).

Conclusion:

Almost half the patients with AS were high catastrophizers. Catastrophizing is linked to anxiety, depression, and disease activity. It may be interesting to detect catastrophizing in order to improve the management of our patients.

References:

[1]Sullivan MJL. et al. Psychological Assessment. 1995;7(4):524–32

[2]Penhoat M. et al. Joint Bone Spine. 2014;81(3):235–9

Disclosure of Interests:

None declared.

OP0035 ASSESSMENT OF THE INTESTINAL PERMEABILITY IN PATIENTS WITH RHEUMATOID ARTHRITIS USING COLONIC TISSUES AND SERA

Background:

Patients with rheumatoid arthritis (RA) have an altered gut microbiota (dysbiosis) (1-3). This microbiota interacts with intestinal epithelium which can lead to an increased intestinal permeability, responsible for the passage of antigens and inflammatory molecules, and can therefore promote systemic inflammation. Gut microbiota tends to normalize with disease control (2), suggesting that systemic inflammation may directly influence the composition of microbiota and the gut barrier. It was shown in many inflammatory diseases that intestinal permeability is impaired, but to date there is very little data in RA.

Objectives:

In the present study, we evaluate the intestinal permeability in RA patients by analyzing tight junctions in colonic biopsies and serum markers.

Methods:

Colonic biopsies from 20 RA patients who underwent coloscopy for screening with normal histology were compared with those from 20 age and sex matched controls. ZO-1, occludin and claudin 2 junction proteins were evaluated by immunohistochemistry. The staining intensity was assessed by two blinded independent readers. The serum concentrations of LPS-binding protein (LBP), CD14s and zonulin were evaluated by ELISA in 25 patients naive of DMARDs, 41 patients before and after introduction of a DMARDs and 21 controls. Elevated zonulin in serum indicates an increase in intestinal permeability while LBP and CD14s indicate bacterial translocation.

Results:

ZO-1 expression was significantly lower in biopsies from patients with RA than controls (mean score ± SD of 1.6 ± 0.56 vs 2.0 ± 0.43; p = 0.01). Age, sex, disease duration and immunological status did not significantly influence the expression of colonic junction proteins. LBP and CD14s were higher in serum from RA patients naive of DMARDs than controls (p = 0.002 and p = 0.003). LBP, CD14s and zonulin levels significantly correlated with DAS28 (r = 0.61, p = 0.005; r = 0.51, p = 0.030 and r = 0.46, p = 0.049, respectively). After treatment, unlike non-responders, LBP and CD14s were significantly reduced in DMARD responders and variations in LBP and CD14s significantly correlated with changes in DAS28 (r = 0.46, p = 0.002 and r = 0, 33 and p = 0.030, respectively).

Conclusion:

This work is one of the first to explore intestinal permeability in RA and to show altered tight junction in colonic tissue from RA. This increased intestinal permeability appears to be related to the systemic inflammation. Improving the gut microbiota through food or probiotics could enhance the effect of treatments by limiting this amplification loop of inflammation.

References:

[1]Horta-Baas G, Romero-Figueroa MDS, Montiel-Jarquin AJ, Pizano-Zarate ML, Garcia-Mena J, Ramirez-Duran N. Intestinal Dysbiosis and Rheumatoid Arthritis: A Link between Gut Microbiota and the Pathogenesis of Rheumatoid Arthritis. J Immunol Res. 2017;2017:4835189.

[2]Zhang X, Zhang D, Jia H, Feng Q, Wang D, Liang D, et al. The oral and gut microbiomes are perturbed in rheumatoid arthritis and partly normalized after treatment. Nat Med. 2015;21(8):895-905.

[3]Maeda Y, Kurakawa T, Umemoto E, Motooka D, Ito Y, Gotoh K, et al. Dysbiosis Contributes to Arthritis Development via Activation of Autoreactive T Cells in the Intestine. Arthritis Rheumatol. 2016;68(11):2646-61.

Disclosure of Interests:

Rachel Audo: None declared, Pauline Sanchez: None declared, Julie Mielle: None declared, Laurence Macia: None declared, Benjamin Rivière: None declared, Cédric Lukas: None declared, Bernard Combe: None declared, Jacques Morel: None declared, Claire Daien Speakers bureau: Pfizer roche chugai fresenius BMS msd Novartis galapagos, Consultant of: Abivax abbbvie BMS roche chugai, Grant/research support from: Pfizer, roche-chugai, fresenius, msd

POS0566 CATASTROPHIZING IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Catastrophizing is conceptualized as a negative cognitive–affective response to an anxiety-provoking stimulus, especially anticipated or actual pain. Catastrophizing can be assessed quickly using a validated questionnaire: the Pain Catastrophizing Scale (PCS)1. Catastrophizing plays a role in maintaining chronic pain and is associated with several pain-related outcomes in osteoarthritis and low back pain.

Objectives:

To assess the prevalence of catastrophizing and associated factors in rheumatoid arthritis (RA).

Methods:

We performed an observational, prospective, bi-centric study. All patients aged 18 or over with RA and fulfilling the ACR-EULAR 2010 criteria were consecutively included. Sociodemographic data, information on the disease and its treatments were collected as well as questionnaires for disease activity (DAS28), function (HAQ), quality of life (SF12, EQ5D), anxiety and depression (HADS, GAD7), fibromyalgia (FiRST), insomnia (ISI) and catastrophizing scores (PCS). Statistical analysis included the samples t-test, one-way variance analysis, the Spearman’s correlation test, the Chi2 test, Fisher’s exact test, the Wilcoxon test, multivariate linear regression (considering catastrophizing as a continuous variable) and multivariate logistics regression (considering catastrophizing as a categorical variable: PCS ≥ 20 = high level catastrophizing).

Results:

From September 2019 to March 2020, 201 patients with RA were included: 78.1% were women and the median age was 63.0 years. In all, 64.1% of patients were RF+, 65.7% ACPA+, and 46% had erosive disease. Median DAS28 CRP was 2.9 [2.1-4.0]. with 45% of patients in remission, 14.8% with low, 31.2% moderate and 9 % high activity. The majority of patients (92 %) had a disease lasting for more than 2 years.

The prevalence of a PCS score ≥20 was 48.0% [41.0;54.9]. The median PCS score was 18 [7-28]. In multivariate logistics regression, high-level catastrophizing was significantly associated with DAS28-CRP (OR= 1.61 [1.18-2.20]), HADS anxiety score (OR=1.25 [1.11-1.40]) and the HADS depression score (OR=1.19 [1.07-1.33]). In multivariate linear regression, catastrophizing was significantly associated with the HADS anxiety score (p< 0.0001), HADS depression score (p=0.0055), HAQ (p=0.0015) and the ISI insomnia score (p=0.005).

Conclusion:

Almost half the patients with RA were high catastrophizers. Catastrophizing is linked to anxiety, depression, disease activity, function impairment and insomnia. It may be interesting to detect catastrophizing in order to improve the management of our patients.

References:

[1]Sullivan MJL. et al. Psychological Assessment. 1995;7(4):524–32

Disclosure of Interests:

None declared

OP0138 FEASIBILITY OF PROGRESSIVE ANTI-TNF TAPERING IN AXIAL SPONDYLOARTHRITIS PATIENTS IN LOW DISEASE ACTIVITY: RESULTS FROM THE MULTICENTER NON-INFERIORITY PROSPECTIVE RANDOMIZED CONTROLLED TRIAL SPACING

Background:

Anti-TNF treatments (TNFi) have shown high efficacy in axial spondyloarthritis (ax-SpA) with inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs). However their effect remains predominantly symptomatic, and their long-term tolerance as well as significant societal cost justify investigation about a potential reduction in drug dosage, or –most feasible and comfortable for the patient– increase in intervals between doses.

Objectives:

To assess if a progressive and monitored reduction of administered TNFi by increase of intervals between injections results in a comparable proportion of patients remaining after 12 months (m) in low disease activity state despite a decreased cumulative treatment dose received.

Methods:

Non-inferiority randomized controlled trial, having included adult patients with ax-SpA fulfilling ASAS criteria, already treated by anti-TNF, and in stable low disease activity for at least 6 m (current and at least 6 m old BASDAI<4/10), who were randomized into 2 groups: either keeping on their usual treatment with stable doses (“unchanged” group), or progressive spacing of injections of their treatment (“spacing” group). Follow-up was done every 3 m during 12 m, with regular monitoring of disease activity and, in patients from the group “spacing”, modification of the rhythm of injections according to disease activity and predefined standardized protocol (either increase or decrease (step-back) of intervals between injections). The primary endpoint was the difference of proportions of patients having a low disease activity state (BASDAI<4/10) after 12 m of follow-up between the 2 groups. It was estimated on the ITT population after multiple imputation. The 90% confidence interval associated was calculated using the Farrington-Manning method and the lower bound was compared to the non-inferiority margin of -20%. With an expected proportion of 85% patients remaining in low disease activity in the unchanged group, and α and β risks at respectively 5% and 90%, the required number of patients was calculated at 358, and thus 398 had to be included with a 10% expected proportion of patients with unavailable data.

Results:

398 patients were randomized in 23 French rheumatology units (197 and 201 in the spacing and unchanged groups respectively), and 389 included in analyses (9 did not receive the allocated treatment). Mean (SD) age was 44.3 (12.4) years, 71.2% were males. Mean (SD) BASDAI at inclusion was 1.45 (1.02). TNFi used were etanercept (35.7%), adalimumab (33.9%), infliximab (20.6%), golimumab (9.3%) and certolizumab (0.5%). For the 373 patients with complete follow-up (93.7%), 162/184 (88.0%) had a low disease activity in the “spacing” group vs. 173/189 (91.5%) in the “unchanged” group at 12 m. After multiple imputation for the 16 patients with missing data, the difference of proportion between the two groups was estimated to -4.18% [CI90% -10.0; 1.7], thus confirming the non-inferiority of the “spacing” procedure. In the “spacing” group at 12 m, 134/162 (82.7%) patients in low disease activity were still receiving a lowered TNFi dose.

Conclusion:

In ax-SpA patients with BASDAI<4 for at least 6 months under TNFi, it is possible to increase intervals between injections while maintaining a low disease activity by adjusting treatment with quarterly monitoring of SpA activity.

Disclosure of Interests:

Cédric Lukas Speakers bureau: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Consultant of: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Pfizer, Novartis and Roche-Chugai, Anne Tournadre Speakers bureau: Abbvie, Fresenius, Janssen, MSD, Pfizer, Roche Chugai, Sanofi, Paid instructor for: Fresenius, Consultant of: Abbvie, Fresenius, Lilly, Novartis, Sanofi, Grant/research support from: Fresenius, Novartis, Pfizer, UCB, Marie Christine Picot: None declared, Erika Nogué: None declared, Emmanuelle Dernis Speakers bureau: Roche chugai, UCB, BMS, Novartis, Lilly, Mylan, Pfizer, Celgène, Consultant of: UCB, MSD, BMS, Lilly, Novartis, Philippe Goupille Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Jacques Morel Speakers bureau: Abbvie, Biogen, BMS, Fresenius Kabi, Lilly, Mylan, Novartis, Pfizer, Sanofi, Consultant of: Abbvie, BMS, Boerhinger Ingelheim, Galpaagos, GSK, Lilly, Novartis, Sanofi

Mechanical ventilation preserves diaphragm mitochondrial function in a rat sepsis model

BACKGROUND

To describe the effect of mechanical ventilation on diaphragm mitochondrial oxygen consumption, ATP production, reactive oxygen species (ROS) generation, and cytochrome c oxidase activity and content, and their relationship to diaphragm strength in an experimental model of sepsis.

METHODS

A cecal ligation and puncture (CLP) protocol was performed in 12 rats while 12 controls underwent sham operation. Half of the rats in each group were paralyzed and mechanically ventilated. We performed blood gas analysis and lactic acid assays 6 h after surgery. Afterwards, we measured diaphragm strength and mitochondrial oxygen consumption, ATP and ROS generation, and cytochrome c oxidase activity. We also measured malondialdehyde (MDA) content as an index of lipid peroxidation, and mRNA expression of the proinflammatory interleukin-1β (IL-1β) in diaphragms.

RESULTS

CLP rats showed severe hypotension, metabolic acidosis, and upregulation of diaphragm IL-1β mRNA expression. Compared to sham controls, spontaneously breathing CLP rats showed lower diaphragm force and increased susceptibility to fatigue, along with depressed mitochondrial oxygen consumption and ATP production and cytochrome c oxidase activity. These rats also showed increased mitochondrial ROS generation and MDA content. Mechanical ventilation markedly restored mitochondrial oxygen consumption and ATP production in CLP rats; lowered mitochondrial ROS production by the complex 3; and preserved cytochrome c oxidase activity.

CONCLUSION

In an experimental model of sepsis, early initiation of mechanical ventilation restores diaphragm mitochondrial function.

A longitudinal study of SARS-CoV-2-infected patients reveals a high correlation between neutralizing antibodies and COVID-19 severity

Understanding the immune responses elicited by SARS-CoV-2 infection is critical in terms of protection against reinfection and, thus, for public health policy and vaccine development for COVID-19. In this study, using either live SARS-CoV-2 particles or retroviruses pseudotyped with the SARS-CoV-2 S viral surface protein (Spike), we studied the neutralizing antibody (nAb) response in serum samples from a cohort of 140 SARS-CoV-2 qPCR-confirmed infections, including patients with mild symptoms and also more severe forms, including those that required intensive care. We show that nAb titers correlated strongly with disease severity and with anti-spike IgG levels. Indeed, patients from intensive care units exhibited high nAb titers; conversely, patients with milder disease symptoms had heterogeneous nAb titers, and asymptomatic or exclusive outpatient-care patients had no or low nAbs. We found that nAb activity in SARS-CoV-2-infected patients displayed a relatively rapid decline after recovery compared to individuals infected with other coronaviruses. Moreover, we found an absence of cross-neutralization between endemic coronaviruses and SARS-CoV-2, indicating that previous infection by human coronaviruses may not generate protective nAbs against SARS-CoV-2. Finally, we found that the D614G mutation in the spike protein, which has recently been identified as the current major variant in Europe, does not allow neutralization escape. Altogether, our results contribute to our understanding of the immune correlates of SARS-CoV-2-induced disease, and rapid evaluation of the role of the humoral response in the pathogenesis of SARS-CoV-2 is warranted.

Relationship between intensive care unit-acquired weakness, fatigability and fatigue: What role for the central nervous system?

PURPOSE

To provide a comprehensive review of studies that have investigated fatigue in intensive care unit (ICU) survivors and questions the potential link between intensive care unit-acquired weakness (ICUAW), fatigability and fatigue. We also question whether the central nervous system (CNS) may be the link between these entities.

MATERIAL AND METHODS

A narrative review of the literature that investigated fatigue in ICU survivors and review of clinical trials enabling understanding of CNS alterations in response to ICU stays.

RESULTS

Fatigue is a pervasive and debilitating symptom in ICU survivors that can interfere with rehabilitation. Due to the complex pathophysiology of fatigue, more work is required to understand the roles of ICUAW and/or fatigability in fatigue to provide a more holistic understanding of this symptom. While muscle alterations have been well documented in ICU survivors, we believe that CNS alterations developing early during the ICU stay may play a role in fatigue.

CONCLUSIONS

Fatigue should be considered and treated in ICU survivors. The causes of fatigue are likely to be specific to the individual. Understanding the role that ICUAW and fatigability may have in fatigue would allow to tailor individual treatment to prevent this persistent symptom and improve quality of life.

FRI0353 FACTORS ASSOCIATED WITH DISCORDANCE BETWEEN PATIENT AND RHEUMATOLOGIST ASSESSMENT OF DISEASE ACTIVITY IN PSORIATIC ARTHRITIS CONSIDERED IN REMISSION

Background:

Assessment of disease activity in psoriatic arthritis (PsA) requires evaluation of multiple aspects. Perception of disease activity by patient and physician is frequently discordant.

Objectives:

The aim of our study was to evaluate factors associated with persistence of disease activity evaluated by patients yet considered in remission by their rheumatologist.

Methods:

We performed a transversal monocentric study. PsA patients were included if they met the CASPAR criteria and if they were considered in remission. Disease activity was evaluated by scores: Disease Activity Score (DAS28-CRP), Simple Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), Disease Activity in Psoriatic Arthritis (DAPSA), Minimal Disease Activity (MDA), modified Boolean remission criteria for PsA. We collected multiple Patient’s Reported Outcomes (PROs): Psoriatic Arthritis Impact of Disease (PsAID), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Health Assessment Questionnaire (HAQ), Dermatology Life Quality Index (DLQI), Beck Depression Inventory (BDI), Fibromyalgia Rapid Screening Tool (FiRST), Pain Catastrophizing Scale (PCS). Discordance was defined by a difference between patient’s and rheumatologist’s global assessment ≥30/100 on a Visual Analogue Scale (VAS). Univariate and multivariate analyses were performed to evaluate factors associated with the presence of discordance.

Results:

62 PsA patients were included. 40.3 % were women and the mean (SD) age was 55 (14) years. 61% patients were in remission (rheumatologist definition) for more than 12 months and 19% for less than 3 months. 50% met MDA, 63% DAS28-CRP < 2,6, 39% SDAI and CDAI remission, 27% DAPSA remission. 39% had a discordant disease activity assessment from their rheumatologist. In univariate analysis, factors associated with discordance were a history of depression, an associated fibromyalgia, a history of clinical enthesitis and a history of corticosteroid use (Table 1). All disease activity scores and PROs were higher in discordant group and were associated with discordance in univariate analysis. In multivariate analysis, discordance was associated with no previous corticosteroid use (OR 24.5 (95%CI 2.9-203.7), p=0.003), a higher BDI scale (OR 1.4 (95%CI 1.1-1.8) by supplementary point, p=0.017) and a higher DAPSA score (OR 1.5 (95%CI 1.2-2), p<0.001) by supplementary point.

Conclusion:

In this PsA cohort, discordance between patient and rheumatologist is very common. Discordance in assessment of disease activity was associated with no previous corticosteroid use, probably reflecting a less severe disease, presence of depressive symptoms and an increase of DAPSA, reflecting a more active disease.

Disclosure of Interests:

Marie Moly: None declared, Cédric Lukas: None declared, Jacques Morel: None declared, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Gael Mouterde: None declared

Table 1.

Factors associated with discordance: Univariate analysis

Discordant group n=24Concordant group n=38OR (95%CI)PHistory of depression, n (%)9 (37.5)1 (2,6)22 (2.58-190.84)<0.001Fibromyalgia (ACR criteria), n (%)5 (20.8)1 (2.6)9.74 (1.06-89.4)0.028At least one enthesitis on the Leeds Enthesitis Index, n (%)14 (58.3)34 (89.5)0.17 (0.04-0.61)0.006TreatmentsPrevious corticosteroid use, n (%)8 (33.3%)26 (68.4%)0.23 (0.08-0.69)0.007Disease activity scores et Patients Reported Outcomes PROsDAS28-CRP > median (2.3), n (%)19 (79.2)12 (31.6)8.23 (2.48-27.32)<0.001SDAI > median (5.09), n (%)21 (87.5)10 (26.3)19.6 (4.79-80.18)<0.001DAPSA > median (7.97), n (%)22 (91.7)9 (23.7)35.4 (6.9-180.8)<0.001BDI > median (3), n (%)14 (58.3)10 (26.3)3.92 (1.32-11.62)0.012FiRST > median (2), n (%)17 (70.8)11 (28.9)5.95 (1.94-18.37)0.001BASDAI > median (2.45), n (%)19 (79.2)12 (31.6)8.23 (2.48-27.32)<0.001HAQ> median (0.1), n (%)16 (66.7)11 (28.9)4.91 (1.63-14.76)0.004PCS > median (9), n (%)18 (75)11 (28.9)7.36 (2.3-23.5)<0.001PsAID > median (2.1), n (%)18 (75)13 (34.2)5.77 (1.84-18.06)0.002

THU0282 EPIDEMIOLOGY OF CUTANEOUS INVOLVEMENT IN SJÖGREN’S SYNDROME: DATA FROM THREE FRENCH POPULATIONS OF PSS (TEARS, ASSESS, DIAPSS)

Background:

Cutaneous involvement is common during primary Sjogren’s Syndrome (pSS) but prevalence and characteristics are difficult to establish precisely because of the limited number of patients studied in most cohorts, the variability of the disorders evaluated in each cohort, the rarity of some of them, and the heterogeneity of evaluations from previous studies (1).

Objectives:

To determine the prevalence and significance of dermatological disorders in primary Sjogren Syndrome.

Methods:

We use 2 French cohorts (ASSESS, in which prevalence of skin disorders in 395 pSS patients was evaluated, and diapSS in which 91 consecutive pSS patients had an examination by a dermatologist) and baseline data of the TEARS randomized trial (110 patients with recent or active pSS, treated with rituximab or placebo, and evaluated for skin dryness using a visual analogue scale out of 100).

Results:

Skin manifestations included in the ESSDAI were rare in the ASSESS cohort (n=16/395, 4.1%, mainly purpuras; only 3 had high activity) but associated with activity in the other ESSDAI domains (peripheral neurological (p<0.001), muscular (p=0.01), hematological (p=0.017) and biological (p=0.017)), history of arthritis (p=0.008), splenomegaly (p=0.024) and higher gamma globulin level (p=0.008)) (Table). Compared to pSS patients not receiving a dermatological consultation, the pSS patients who had a dermatological consultation had significantly more dermatological involvement outside ESSDAI score [42% (29/69) versus 19.6% (11/56); p=0.008]. The TEARS study showed a high prevalence of cutaneous dryness (VAS>50; 48.2%) and that these dry skin patients had higher pain VAS (61.5+/-28.2 vs 46.8+/-27.0; p=0.003) and drought (79.4+/-15.2 vs 62.5+/-21.7; p<0.0001).

Cutaneous involvementNo Cutaneous involvementTotalp values*Muscular3/16 (18.8)10/373 (2.7)13/389 (3.3)0.001Peripheral nervous system PNS4/16 (25)34/373 (9.1)38/389 (9.8)0.00001Biological8/16 (50)138/371 (37.2)146/387 (37.7)0.017Hematologic7/16 (43.8)55/373 (14.7)62/389 (15.9)0.017History of arthritis12/16 (75)154/374 (41.2)166/390 (42.6)0.008History of splenomegaly2/16 (12.5)10/3762.7)12/392 (3.1)0.024History of lymphoma0/16 (0)18/379 (4.7)18/395 (4.6)0.372Mean (SD) ESSDAI score14.5 (6.8)4.4 (5.1)0.00001Mean (SD) ESSDAI score after excluding the points awarded by skin manifestations8.1 (6.2)4.4 (5.1)0.014Gammaglobulin levels (mean +/- SD)23.1 +/-7.318.5 +/-8.1-0.006

Conclusion:

The most common skin disorder is dryness, which is associated with a higher level of pain and overall subjective dryness. ESSDAI skin activity is rare, associated with hypergammaglobulinemia and ESSDAI activity. Systematic dermatological examination is informative for non-specific pSS lesions

References:

[1]Orgeolet L, Foulquier N, Misery L, Redou P, Pers J-O, Devauchelle-Pensec V, et al. Can artificial intelligence replace manual search for systematic literature? Review on cutaneous manifestations in primary Sjögren’s syndrome. Rheumatol Oxf Engl. 2019 Aug 31;

Disclosure of Interests:

Camille Villon: None declared, Laure Orgeolet: None declared, Anne-Marie Roguedas-Contios: None declared, Laurent Misery: None declared, Jacques-Eric Gottenberg Grant/research support from: BMS, Pfizer, Consultant of: BMS, Sanofi-Genzyme, UCB, Speakers bureau: Abbvie, Eli Lilly and Co., Roche, Sanofi-Genzyme, UCB, Divi Cornec: None declared, Sandrine Jousse-Joulin: None declared, Raphaèle Seror Consultant of: BMS UCB Pfizer Roche, Jean-Marie Berthelot: None declared, Philippe Dieudé: None declared, Jean-Jacques Dubost: None declared, anne-laure Fauchais: None declared, Vincent Goeb: None declared, Eric Hachlla: None declared, Pierre-Yves Hatron: None declared, Claire Larroche: None declared, Gilles Hayem: None declared, Véronique LE GUERN Grant/research support from: UCB for GR2 study (to our institution), Aleth Perdriger: None declared, Jacques Morel: None declared, Olivier VITTECOQ: None declared, Xavier Mariette Consultant of: BMS, Gilead, Medimmune, Novartis, Pfizer, Servier, UCB, Valerie Devauchelle-Pensec: None declared, alain saraux: None declared

THU0050 CXCL13 IS A KEY DRIVER FOR MIGRATION AND DIFFERENTIATION OF REGULATORY B CELLS

Background:

Regulatory B cells in human still need to be characterized. Given the absence of a phenotypical definition of these cells, a functional definition based on their ability to secrete IL-10 is often used (corresponding to B10+ cells). Chemokine receptors (CKR) profiles are useful to characterize some populations of T cells but have never been explored among B10+cells. Moreover, very little is known about B10+cell migration. Chemokines (CK) have also been implicated in the differentiation of naïve T cells towards regulatory T cells.

Objectives:

Therefore, the aims of our study were to first characterize the profile of CKR on B10+cells, and second to investigate CK implicated in their migration and differentiation, this, both in control (CTL) and in patients with rheumatoid arthritis (RA).

Methods:

B cells were isolated with Rosette Sep Human B cells enrichment followed by Ficoll separation. B cells were then activated 24 hours with CpG and CD40L to generate B10+cells. IL-10 secretion from B cells was assessed by FACs and ELISA. We compared the expression of several CKR between B10+and IL-10negB cells (B10neg) from CTL and RA patients by flow cytometry. For migration assay, B10+and B10negcells were sorted by FACSaria. Their ability to migrate, in response to ligand of CKR found differentially expressed in the first part (CCL21, CCL22, CXCL11, CXCL12 or CXCL13) or synovial fluid (SF) from RA patients, were evaluated by migration assay in 5μM Transwell chambers and expressed as fold increase compare to basal migration towards control media.

Results:

B10+cells expressed a different profile of CKR compared to B10negboth in CTL and RA patients and these profiles differed between B10+cells of CTL and RA patients. However, no CKR profile could phenotypically define B10+cells. Of note, CXCR5 was under-expressed on B10+cell surface compared to B10negin CTL (75% [IQR 72.9-81.4] positive cells among B10+vs 99.2% [98.4-99.4] positive cells among B10neg, p=0.006, n=10) and also in RA patients (78.3% [70.8-82.3] vs 98.2% [96.9-99.54, p=0.008, n=8). Nevertheless, mRNA expression of CXCR5 was higher among B10+versus B10negcells in CTL and RA patients. As CpG-stimulated cells over-expressed CXCL13, ligand of CXCR5, we hypothesized that the binding of its ligand induced the internalisation of CXCR5. Indeed, among all CK tested, only CXCL13, attracted significantly more B10+than B10negfrom CTL (9.1[5.6-14.6] fold increase migration of B10+vs 5.2 [3.1-7.5] fold increase migration of B10neg, p<0.0001, n=21). This was also true in RA patients (10.9 [3.6-29.9] fold increase migration of B10+vs 4.8[2.1-7.7] fold increase migration of B10neg, p=0.009, n=12). SF from RA patients induced a significant migration of B10+cells in CTL (7.3-fold increase [4.1-21.7], p=0.004, n=9) and RA patients (5.7-fold increase [2.3-7.9], p=0.008, n=10). This migration was correlated with the levels of CXCL13 in these SF, in CTL (r=0.7, p=0.05, n=9) but not in RA patients (n=10). Lastly, CXCL13 was also found to increase IL-10 secretion in B cells stimulated with CpG in CTL (1.5-fold increase [1.3-1.5], p=0.0002, n=13) and in RA patients (1.2-fold increase [1.1-1.3], p=0.005, n=12).

Conclusion:

We showed that CXCL13 is a key driver for migration and differentiation of B10+ cells in CTL and in RA patients. However, the migration of B10+cells in RA patients was not correlated with the level of CXCL13 in SF from RA patients, suggesting the implication of other CK in the migration of B10+cells in RA.

Disclosure of Interests:

None declared

OP0022 RISK OF DIVERTICULITIS AND GASTRO-INTESTINAL PERFORATION IN RHEUMATOID ARTHRITIS TREATED WITH TOCILIZUMAB COMPARED TO RITUXIMAB AND ABATACEPT: A PROSPECTIVE PROPENSITY-MATCHED COHORT STUDY

Background:

There are discordant results regarding a potential increased risk of gastro-intestinal perforation (GIP) in rheumatoid arthritis (RA) patients treated with tocilizumab (TCZ) compared to conventional synthetic disease modifying anti rheumatic drugs (csDMARDs) or TNF inhibitors (TNFis) (1–3).

Objectives:

The aim of our study was to compare the risk of diverticulitis and GIP in RA patients treated with TCZ compared to rituximab (RTX) and abatacept (ABA).

Methods:

We conducted a multicentric study of patients with RA, prospectively followed in 3 observational French registries evaluating the effectiveness and safety of RTX (Autoimmunity and Rituximab (AIR)), ABA (Orencia and Rheumatoid Arthritis (ORA)), and TCZ (REGistry–RoAcTEmra (REGATE)). Using a propensity score approach, we compared the risk of diverticulitis or GIP during treatment with TCZ vs RTX and ABA. The following covariates were included in the propensity score: age, sex, history of diabetes and neoplasia, Charlson Comorbidity Index, number of previous csDMARDs and TNFi, history of TNFi, daily dose of glucocorticoids (GCs) at baseline, co-treatment with a csDMARDs, average DAS28 during follow-up, duration of RA, and exposure time to the considered bDMARDs.

Results:

4501 patients (1496 treated by TCZ, 1986 by RTX and 1019 by ABA) were included. 21 and 9 GIP occurred in the TCZ treated patients, compared to 10 and 8 in the RTX treated patients and 10 and 2 in the ABA treated patients (corresponding incidence rate (IR) are shown in table 1). Two deaths occurred in patients experiencing GIP: 1 (12.5%) due to undetermined rectal perforation among a RTX treated patient, and 1 (11.1%) due to a perforated ulcer among a TCZ treated patient. Based on inverse probability weighting (IPW), there was an increased risk of diverticulitis and GIP in the TCZ treated patients compared with RTX or ABA (table 1). In a subgroup analysis, we confirmed an increased risk of GIP due to diverticulitis but not to any other etiology. Older age (p=0.05), GCs at baseline (p=0.10) and average daily dose of GCs during follow-up (p=0.08) seemed associated with GIP only in univariate analysis. Compared to RTX and ABA, diverticulitis and GIP among TCZ patients occurred earlier after the last perfusion (p=0.01), with atypical clinical presentation (slow transit in 30%, p=0.04) and lower acute phase reactants when the event occurred (C-reactive protein: 31.2±58.4 vs 88.2±89.6 mg/L, p=0.005). Perforated diverticulitis seemed to have higher dose of GCs at the time of the event compared to diverticulitis without perforation in univariate analysis (p=0.06).

Table 1.

Incidence (/1000 PY) and risk of diverticulitis or GIP

AE (n)IRAE (n)IRAE (n)IRIPW analysisOR[95 CI]pOR[95 CI]pExposition (PY)TCZ (ref)3 990RTX6 322ABA2 389TCZ vs RTXTCZ vs ABADiverticulitis215.3101.6104.24.5[2.6-7.6]<0.00013.4[1.7-6.5]<0.0001GIP92.381.320.82.8[1.5-5.1]0.0015.4[1.4-19.9]0.01*Diverticular GIP61.530.520.83.8[1.7-8.5]0,0016.9[1.9-25.4]0.004*Due to another etiology30.750.8001.4[0.5-3.9]0.5--

AE=adverse events; PY=person-years

Conclusion:

TCZ was associated with an increased risk of diverticulitis, and GIP due to diverticulitis, compared to RTX and ABA. Our study confirms an increased risk of GIP in RA patients treated with TCZ, which might be explained by an increased risk of diverticulitis with misleading clinical presentation.

References:

[1]Strangfeld A et al. Ann Rheum Dis. 2016 Jul 12

[2]Xie F, Yun H et al. Arthritis Rheumatol. 2016 May 1

[3]Barbulescu A et al. OP0231, Ann Rheum Dis. 2018 Jun 1;77(Suppl 2):164–5.

Disclosure of Interests:

Claire Rempenault: None declared, Cédric Lukas: None declared, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Thierry Schaeverbeke: None declared, Daniel Wendling: None declared, Thao Pham Speakers bureau: Novartis, Janssen, Lilly, Xavier Mariette Consultant of: BMS, Gilead, Medimmune, Novartis, Pfizer, Servier, UCB, Jacques-Eric Gottenberg Grant/research support from: BMS, Pfizer, Consultant of: BMS, Sanofi-Genzyme, UCB, Speakers bureau: Abbvie, Eli Lilly and Co., Roche, Sanofi-Genzyme, UCB, Jacques Morel: None declared

FRI0101 EFFECTS OF IL6 INHIBITORS ON THE INCIDENCE OF MAJOR ADVERSE CARDIOVASCULAR EVENTS IN RHEUMATOID ARTHRITIS PATIENTS: A SYSTEMATIC REVIEW WITH META ANALYSIS

Background:

Rheumatoid arthritis (RA) is associated with a 2 fold increased risk of cardiovascular events (CVE) and mortality when compared to the general population. The systemic inflammation in RA seems to play a pivotal role by creating endothelial dysfunction and thus accelerating atherosclerosis. This long lasting inflammatory process potentiates the effects of additional classical cardiovascular risk factors. Since the 2000s, numerous therapeutic advances, in particular biologics, allow better control of this inflammation. Among these, IL6 inhibitors (IL6i) are known to provide rapid and sustained improvements in clinical, biological and radiographic outcomes. However, an increase in circulating lipid concentrations in patients treated with IL6i is usual. This raises the question of the risk -to -benefit ratio of IL6i.

Objectives:

The purpose of this systematic literature review and meta-analysis was to evaluate the impact of IL6i on the incidence of major adverse cardiovascular events in RA patients in comparison with TNFalpha inhibitors (TNFi), non TNFi bDMARDs or csDMARDS.

Methods:

A systematic literature search of MEDLINE (via PubMed), EMBASE and the Cochrane Library databases until February 2019 was performed. Included studies were observational studies or randomized controlled trials having reported relevant confirmed CVEs (death from CVE, myocardial infarction, heart failure and stroke) in patients with RA treated with IL6i, and a suitable control group. A meta-analysis of the relative risk for each CVE in RA patients treated with IL6i compared to patients in the control groups was performed. A random effect model was applied in case of substantial heterogeneity.

Results:

Of 6869 studies, 23 randomized controlled trials and 6 controlled cohorts could be included. IL6i were significantly associated with a reduction in the risk of myocardial infarction in comparison with TNFi (OR, 0.73; 95% CI [0.56 to 0.96]). No other significant effects were observed with regard to the risks of stroke, heart failure (HF), and death from CVE in comparison with csDMARDs, TNFi, or non-TNFi bDMARDs (table 1).

Table 1.

Pooled relative risks of cardiovascular events in RA patients treated with IL-6 inhibitors and respective control groups

Cs DMARDSTNFiNon TNFi bDMARDSMyocardial infarction1.44 [0.50;4.17]0.73 [0.56; 0.96]0.81 [0.48; 1.36]Stroke1.08 [0.40; 2.91]1.20 [0.82; 1.77]0.73 [0.39; 1.37]Heart failure0.17 [0.01; 4.08]1.51 [0.61; 3.70]1.19 [0.71; 1.98]Cardiovascular death1.59 [0.62; 4.11]1.13 [0.72; 1.78]NA

Our findings of a potentially protective effect of IL6i use on the risk of MI are reassuring. Although several beneficial effects might be involved, like the effective control of systemic inflammation, the anti-arrhythmia effect or the improvement of endothelial and left ventricle dysfunction, a potential indication bias with a decreased likelihood to prescribe these drugs in patients with high cardiovascular risk cannot be excluded.

Conclusion:

This review of the literature with meta-analysis provides reassuring results about the association between use of IL6i and CVE in RA patients. Data from long-term observational studies is however needful to confirm and ascertain this result.

Disclosure of Interests:

None declared

THU0538 IN PSORIATIC ARTHRITIS PATIENTS CONSIDERED IN REMISSION BY THEIR RHEUMATOLOGIST, CAN DISCORDANCE IN DISEASE ACTIVITY ASSESSMENT BETWEEN PATIENT AND RHEUMATOLOGIST BE EXPLAINED BY RESIDUAL INFLAMMATION AS MEASURED BY ULTRASONOGRAPHIC EXAMINATION?

Background:

Psoriatic arthritis (PsA) is a heterogeneous disease and its assessment is sometimes difficult. Perception of disease activity by patient and physician is frequently discordant in patients in clinical remission. Ultrasound (US) is an imaging technique, which can detect inflammation in PsA.

Objectives:

The aim of our study was to assess whether persistence of disease activity evaluated by the patient, considered in remission by his rheumatologist, was associated with inflammation measured by US.

Methods:

We performed a transversal monocentric study. PsA patients were included if they met the CASPAR criteria and were considered in remission by their rheumatologist. Demographic data, characteristics of the disease and treatments were collected. Discordance was defined by a difference between patient’s and rheumatologist’s global assessment ≥30/100 on a Visual Analogic Scale. An US examination was performed on 50 joints, 28 tendons and 14 entheses by an independent investigator. Synovial or tendon sheath hypertrophy and PD signal were evaluated on a semi-quantitative scale, B Mode and PD signal abnormalities on entheses were searched, according to the EULAR-OMERACT scoring system. US remission was defined by no power Doppler (PD) signal on joints, tendons and entheses and minimal US activity by maximum one PD signal on the same sites. Univariate and multivariate analyses were performed to evaluate factors associated with US abnormalities.

Results:

Sixty-two PsA patients were included. 40.3% were women, the mean (SD) age was 55 (14) years, 42% were in US remission and 71% in minimal US activity (Table 1), 19.4% had ≥1 PD synovitis and 88.7% had a B mode synovitis, 95.2% had a B mode abnormality on entheses and 51.6% had ≥1 PD signal on entheses. Thirty nine percent had a discordant disease activity assessment with their rheumatologist. In univariate analysis, discordance was not associated with US remission (OR=1.71 (95%CI 0.61-4.83), p=0.224) or US minimal disease activity (OR=0.99 (95%CI 0.32-3.05), p=0.602). In multivariate analysis, US remission was independently associated with female gender (OR=3.94 (95%CI 1.20-12.9), p=0.024) and younger age (OR=0.95 (95%CI 0.91-0.99), p=0.027). Minimal US activity was associated with history of enthesis lesion (OR=11.26 (95%CI 1.34-94.93), p=0.026) and age (OR=0.95 (95%CI 0.90-1), p=0.044).

Table 1.

Ultrasound characteristics of the 62 PsA patients.

N (%)Ultrasound remission26 (41.9)Ultrasound minimal disease activity44 (71)Patients with ≥1 grey scale synovitis55 (88.7)Patients with ≥1 Power Doppler synovitis12 (19.4)Patients with ≥1 grey scale tenosynovitis15 (24.2)Patients with ≥1 Power Doppler tenosynovitis1 (1.6)Patients with ≥1 grey scale enthesitis lesion (thickness, hypo echogenicity, calcification, enthesophyte, erosion, bursitis)59 (95.2)Patients with ≥1 Power Doppler enthesitis32 (51.6)

Conclusion:

Our study showed persistent inflammation evaluated by US in PsA patients considered in remission by their rheumatologist. However, prevalence of residual inflammation evaluated by US was not higher in patients with self-assessment of their disease discordant from their rheumatologist.

Disclosure of Interests:

Marie Moly: None declared, Cédric Lukas: None declared, Jacques Morel: None declared, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Gael Mouterde: None declared

Interplay of nasal and rectal carriage of Staphylococcus aureus in intensive care unit patients

The aim of this study was to investigate the relationship between nasal and rectal Staphylococcus aureus carriage in intensive care unit (ICU) patients and the occurrence of ICU-acquired infections related to S. aureus carriage. Three hundred and ninety-five patients admitted in ICU were screened for S. aureus nasal and rectal carriages and followed to record S. aureus infections during their stay. S. aureus strains were genotyped by arbitrarily primed PCR, spa-typing, microarray and whole genome sequencing. At ICU admission, 112 of 363 (30.9%) patients carried S. aureus including 61 (16.8%) exclusive nasal carriers, 40 (11.0%) combined nasal and rectal carriers and 11 (3.0%) exclusive rectal carriers. The 152 S. aureus isolates from nasal and rectal swabs belonged to 19 clonal complexes (CCs). Patients colonized in both nose and rectum harboured different strains in at least 40% of cases according to arbitrarily primed PCR data. Nasal carriers of CC5 S. aureus had an increased risk of rectal carriage (RR = 1.85, P < .05). S. aureus nasal and rectal carriage was a risk factor of S. aureus ICU-acquired infection (RR = 4.04; 95%CI [1.38-11.76]). Incidence rates of endogenous ICU-acquired infections in exclusive nasal carriers, exclusive rectal carriers and in both nasal and rectal carriers were 0.08 (5/61), 0.09 (1/11) and 0.03 (1/40), respectively (p = 0.47). Rectal swabbing increased the detection of S. aureus carriage and revealed an important diversity of S. aureus strains in ICU patients. Further studies are needed to understand how S. aureus rectal carriage increases the risk of endogenous ICU-acquired infections.

An audit of mammographic screen detected lesions of uncertain malignant potential (B3) diagnosed on initial image guided needle biopsy: how has our practice changed over 10 years?

AIM

To review all cases of B3 lesion diagnosed at initial image-guided needle biopsy over two 5-year cohorts to identify upgrade rates to malignancy and the effect of changing guidance on the management of such lesions.

MATERIALS AND METHODS

Data was collected retrospectively. Mammographic features, biopsy type and management were recorded for each lesion. Upgrade rates for each B3 histological category were quantified. Statistical analysis was performed using SPSS.

RESULTS

There were 224 cases in 2005-2010 and 240 cases in 2010-2015. Mammographically 211 lesions were microcalcifications, 182 masses, 65 distortions and six asymmetric densities with no difference in the mammographic features in the two cohorts. Two hundred and eight 14 G core biopsies and 256 initial vacuum-assisted biopsies were performed. There was a statistically significant reduction in benign surgical biopsies and an increase in second-line vacuum biopsy/excision in the latter cohort, with no significant change in the upgrade rate. There was an overall 6% upgrade to invasive malignancy and 13% upgrade to ductal carcinoma in situ (DCIS). The upgrade rates for the following histological categories were atypical intraductal epithelial proliferation (AIDEP) 33.2% (21/63); classical (not pleomorphic) in situ lobular neoplasia (ISLN) 18.2% (6/33); flat epithelial hyperplasia (FEA) 21.7% (20/92); papilloma with atypia 53.8% (7/13), without atypia 12.1% (8/66); and radial scar/complex sclerosing lesion with atypia 16.7% (2/12), and without atypia 7.9% (6/76).

CONCLUSION

Upgrade rates remain high for some histological categories even with first-line use of vacuum biopsy. Management of borderline lesions should be considered carefully in a multidisciplinary meeting. In many cases, the need for diagnostic surgical excision has been replaced by image-guided vacuum sampling.

Venous leiomyosarcoma arising from the radiocephalic vein

Vascular leiomyosarcoma is a very rare soft tissue neoplasma. We are reporting a vascular leiomyosarcoma case arising from an unusual site: the radiocephalic vein. Despite a poor prognosis, after surgery and radiotherapy, the patient was alive without signs of recurrence two years later.

Risk of fracture and low bone mineral density in adults with inflammatory bowel diseases. A systematic literature review with meta-analysis

Inflammatory bowel diseases (IBDs) are associated with a decreased bone mineral density, but the impact on fractures is unknown. In our study, global risk of fracture is increased for patients with IBDs versus controls. This result will help to determine the appropriate assessment with early screening and management of osteoporosis. Inflammatory bowel diseases (IBDs), such as Crohn's disease (CD) and ulcerative colitis (UC), are associated with a decreased bone mineral density (BMD). However, the impact on fracture risk is unknown and data are contradictory across studies. In this systematic review and meta-analysis, we aimed to assess the risk of fracture and presence of low BMD in patients with IBDs compared to healthy controls. A systematic search of literature was conducted of MEDLINE, EMBASE, the Cochrane library and abstracts from appropriate scientific congresses. Studies were selected if they compared the incidence of fractures and/or BMD measurement by dual-energy X-ray absorptiometry in patients with IBDs and healthy sex- and age-matched controls. Data were extracted by two independent investigators. Meta-analysis was performed with the inverse variance approach to estimate pooled odds ratios (ORs) and risk ratios (RRs) with their 95% confidence intervals (CIs). Twenty-four studies met the inclusion criteria. On the basis of nine studies, global risk of fracture was increased for patients with IBDs versus controls (RR = 1.38, 95% CI 1.11-1.73; p = 0.005). Fracture risk with IBDs was significantly increased for vertebral fractures (OR = 2.26, 95% CI 1.04-4.90; p < 0.001), but not for any other site. The analysis of 16 studies evaluating BMD showed a significant decrease in mean BMD and Z-scores for IBD patients versus controls at all sites. In our meta-analysis, patients with IBDs have an increased risk of fractures, especially in the spine, and significant decreased BMD at all sites, which suggests the need for identifying high-risk individuals among this population.

Performance of Doppler-based resistive index and semi-quantitative renal perfusion in predicting persistent AKI: results of a prospective multicenter study

PURPOSE

The Doppler-based resistive index (RI) and semi-quantitative evaluation of renal perfusion using color Doppler (SQP) have shown promising results for predicting persistent acute kidney injury (AKI) in preliminary studies. This study aimed at evaluating the performance of RI and SQP to predict short-term renal prognosis in critically ill patients.

METHODS

Prospective multicenter cohort study including unselected critically ill patients. Renal Doppler was performed at admission to the intensive care unit. The diagnostic performance of RI and SQP to predict persistent AKI at day 3 was evaluated.

RESULTS

Overall, 371 patients were included, of whom 351 could be assessed for short-term renal recovery. Two thirds of the included patients had AKI (n = 233; 66.3%), of whom 136 had persistent AKI (58.4%). Doppler-based RI was higher and SQP lower in AKI patients and according to AKI recovery. Overall performance in predicting persistent AKI was however poor with area under ROC curve of respectively 0.58 (95% CI 0.52-0.64) and 0.59 (95% CI 0.54-0.65) for RI and SQP. Optimal cutoff was respectively 0.71 and 2 for RI and SQP. At optimal cutoff, sensitivity and specificity were 50% (95% CI 41-58%) and 68% (62-74%) for RI and 39% (32-45%) and 75% (66-82%) for SQP.

CONCLUSION

Although statistically associated with AKI occurrence, RI and SQP perform poorly in predicting persistent AKI at day 3. Further studies are needed to adequately describe factors influencing Doppler-based assessment of renal perfusion and to delineate whether these indicators may be useful at the bedside. CLINICALTRIAL.GOV: NCT02355314.

MACVIA-LR (Fighting Chronic Diseases for Active and Healthy Ageing in Languedoc-Roussillon): A Success Story of the European Innovation Partnership on Active and Healthy Ageing

The Région Languedoc Roussillon is the umbrella organisation for an interconnected and integrated project on active and healthy ageing (AHA). It covers the 3 pillars of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA): (A) Prevention and health promotion, (B) Care and cure, (C) and (D) Active and independent living of elderly people. All sub-activities (poly-pharmacy, falls prevention initiative, prevention of frailty, chronic respiratory diseases, chronic diseases with multimorbidities, chronic infectious diseases, active and independent living and disability) have been included in MACVIA-LR which has a strong political commitment and involves all stakeholders (public, private, patients, policy makers) including CARSAT-LR and the Eurobiomed cluster. It is a Reference Site of the EIP on AHA. The framework of MACVIA-LR has the vision that the prevention and management of chronic diseases is essential for the promotion of AHA and for the reduction of handicap. The main objectives of MACVIA-LR are: (i) to develop innovative solutions for a network of Living labs in order to reduce avoidable hospitalisations and loss of autonomy while improving quality of life, (ii) to disseminate the innovation. The three years of MACVIA-LR activities are reported in this paper.