Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

122 Neurological manifestations of haemophagocytic lymphohistiocytosis

rachel

brown@ucl.ac.uk|ABN Bursary

86

OP0038 VITAMIN D AND MARINE n-3 FATTY ACID SUPPLEMENTATION FOR PREVENTION OF AUTOIMMUNE DISEASE IN THE VITAL RANDOMIZED CONTROLLED TRIAL: OUTCOMES OVER 7 YEARS

Background

Strong biologic rationale supports both vitamin D and marine omega-3 (n-3) fatty acids for prevention of autoimmune disease (AD). Within the randomized, double-blind, placebo-controlled VITamin D and OmegA-3 TriaL (VITAL), we tested the effects of these supplements on AD incidence. We previously reported results after 5.3 years of randomized follow-up showing overall protective effects for vitamin D on AD incidence (HR 0.78, 95% CI 0.61-0.99) and suggestive results for n-3 fatty acids (HR 0.85, 95%CI 0.67-1.08)1.

Objectives

We aimed to test effects of these supplements with two more years of post-intervention follow-up in VITAL.

Methods

VITAL enrolled and randomized men and women (age ≥50 and ≥55 years, respectively) in a 2-by-2 factorial design to vitamin D3 (2000 IU/d) and/or n-3 fatty acids (1000 mg/d) or placebo and followed for median 5.3 years. Here, we followed participants for another 2 years of observation to assess for sustained effects. Incident AD diagnoses were reported by participants annually and confirmed by medical record review by expert physicians using existing classification criteria. The primary endpoint was total incident AD, including rheumatoid arthritis (RA), polymyalgia rheumatica (PMR), autoimmune thyroid disease (AITD), psoriasis, and all others. Pre-specified secondary endpoints included individual common AD; and probable AD. Cox models calcuated hazard ratios (HR) for incident ADs.

Results

Of 25,871 participants randomized, 71% self-reported non-Hispanic Whites, 20% Black, 9% other racial/ethnic groups, 51% women, mean age was 67.1 years. During 7.5 years median follow-up, confirmed AD was diagnosed in 156 participants in vitamin D arm vs 198 in vitamin D placebo arm, HR 0.79 (0.64-0.97). Incident AD was confirmed in 167 participants in n-3 fatty acid arm and 187 in n-3 fatty acid placebo arm, HR 0.89 (0.72-1.10). For vitamin D, HRs trended toward reduction for RA 0.67 (0.37- 1.21), PMR 0.69 (0.46-1.03) and psoriasis 0.57 (0.33-0.99). For n-3 fatty acids, HRs trended toward reduction for RA 0.55 (0.30-1.10) and AITD 0.61 (0.33-1.12). Vitamin D’s effect on AD incidence was stronger in those with body mass index (BMI) < 25 (HR 0.65, 0.44-0.96) than ≥ 25 kg/m2 (p interaction 0.01).

Conclusion

Supplementation for 5.3 years with 2000 IU/day vitamin D (compared to placebo), followed by 2 years of observational follow-up, significantly reduced overall incident AD by 21% in older adults. HRs for RA, PMR and psoriasis trended toward reduction with vitamin D, with stronger effect in those with normal BMI. Supplementation with 1000 mg/day n-3 fatty acids did not significantly reduce total AD.

References

[1]Hahn J et al, BMJ, 2022 Jan 26;376: e066452.

Table 1.

Hazard Ratios for Primary and Secondary Endpoints, by Randomized Assignment to Vitamin D/Placebo (Left), N-3 Fatty Acids/Placebo (Right)a

EndpointVitamin D3(N=12,927)Placebo (N=12,944)Hazard Ratio (95% CI)pN-3 Fatty Acids (N=12,933)Placebo (N=12,938)Hazard Ratio (95% CI)pPrimary: Confirmed AD1561980.79 (0.64-0.97)0.031671870.89 (0.72-1.10)0.27Secondary:Confirmed + probable AD2653210.83 (0.70-0.97)0.022713150.86 (0.73-1.01)0.06Excluding subjects with any pre-randomization AD Confirmed AD1271620. 79 (0.62-0.99)0.041411480.95 (0.75-1.20)0.66 Confirmed + probable AD2112700. 78 (0.65-0.94)0.0072322490.93 (0.78-1.11)0.41Excluding first 2 years follow-up Confirmed AD861300.66 (0.50-0.87)0.0031041120.92 (0.71-1.21)0.56 Confirmed + probable AD1472050.72 (0.58-0.89)0.0021721800.95 (0.77-1.17)0.63Individual ADb RA18270.67 (0.37-1.21)0.1816290.55 (0.30-1.01)0.06 PMR39570.69 (0.46-1.03)0.0746500.92 (0.61-1.37)0.67 AITD27181.50 (0.82-2.71)0.1917280.61 (0.33-1.12)0.11 Psoriasis20350.57 (0.33-0.99)0.0534211.62 (0.94-2.79)0.08

aAnalyses from Cox regression models controlled for age, sex, race, and other (n-3 fatty acid or vitamin D) randomization group bConfirmed AD.

Figure 1.

Disclosure of Interests

Karen Costenbader Consultant of: Astra Zeneca, Glaxo Smith Kline, Neutrolis, Grant/research support from: Merck, Exagen, Gilead, Nancy Cook: None declared, I-min Lee: None declared, Jill Hahn: None declared, Joseph Walter: None declared, Vadim Bubes: None declared, Gregory Kotler: None declared, Nicole Yang: None declared, Sonia Friedman: None declared, Erik Alexander: None declared, JoAnn Manson: None declared.

P054 Vascular Ehlers-Danlos syndrome: a life-altering diagnosis not to be missed

Background/Aims

A 41-year-old lady underwent a laparotomy and small bowel resection for small bowel obstruction due to adhesions after presenting with a three-day history of abdominal pain. The surgery was complicated by significant bleeding from multiple points of the mesentery and a laceration of the uterine fundus, the repair of which was complicated due to extremely friable tissue. Post-operative ileus, fever, tachycardia, and raised inflammatory markers led to antibiotic therapy and further investigation with computed tomograph angiography (CTA) abdomen which identified a retroperitoneal haematoma due to a herald bleed from an adrenal artery pseudoaneurysm and multiple further true aneurysms in the coeliac, splenic, and right posterior hepatic arteries. The right adrenal artery aneurysm was treated by right renal artery stent graft as targeted embolisation was not possible due to extremely friable arterial intima that dissected and bled on instrumentation. The rheumatology team was consulted to advise on the possibility of vasculitis and whether treatment with immunosuppressives was indicated.

Methods

Prior to this admission, she denied any fever, weight loss, rash or neuropathies. There was a history of spontaneous peri-renal haematoma and easy bruising. She had three successful pregnancies; two were Caesarean section deliveries, one of which was complicated by post-partum bleeding. There was no family history of connective tissue diseases, sudden deaths, aneurysms or visceral ruptures. There were no clinical features of connective tissue disease. She was noted to have acrogeria, small finger joint hypermobility, large eyes, a small nose, and absent earlobes. There were prominent veins on her lower back, chest, arms, and legs. She had a normal palate arch, normal appearances of previous surgical scars, and there was no skin hyperextensibility.

Results

Inflammatory markers prior to admission were normal, with no cytopenias or thrombocytosis. ANA, ENA, ANCA, HIV, Hepatitis B/C, treponemal antibody, and rheumatoid factor/anti-CCP were negative. CTA showed no thickening suggestive of vascular/perivascular inflammation. Histopathology of resected small bowel and mesentery showed no evidence of vasculitis. A diagnosis of probable vascular Ehlers-Danlos syndrome (EDS) was made. She was not treated with steroids. Genetic testing confirmed a heterozygous mutation for a pathogenic missense variant in the COL3A1 gene: c.574G&gt;C,p.(Gly192Arg), not previously reported to be associated with disease. Her inflammatory markers improved over time. She was discharged on celiprolol for blood pressure control and close surveillance of aneurysms. An extended screen for the presence of aneurysms elsewhere showed a left vertebral artery aneurysm and dissection at the C4/5 intervertebral foramen on CTA head. Genetic testing was offered to her family members, especially her three sons.

Conclusion

Vascular EDS is under-recognised and should be in the differential diagnosis of non-inflammatory vasculitis mimics in patients presenting with arterial ruptures, dissections or aneurysms to avoid potentially harmful treatment with immunosuppressive therapy.

Disclosure

S. Yeoh: Grants/research support; Versus Arthritis (unrelated to this work). C. von Stempel: None. C. Thornton: None. S. Yalamanchili: None. J. Manson: None.

P062 COVID-19 hyperinflammation can be predicted using routine clinical laboratory markers

Background/Aims

Since early in the COVID-19 pandemic, there has been interest in the concept that some morbidity and mortality may be due to excessive inflammation. Several definitions of COVID-19 hyperinflammation (COV-HI) have been proposed, including Manson criteria (C-reactive protein, CRP ≥150mg/L or doubling above 50mg/L in 24 hours and/or ferritin 1500ug/L); and Webb criteria (includes CRP ≥150mg/L or ferritin ≥750ug/L). A consistent finding has been worse outcomes. Little is known regarding the underlying pathologies separating these patients from others.

Aim

To investigate whether machine learning using standard laboratory features can identify a distinguishing ‘COV-HI signature’.

Methods

A database of daily clinical and laboratory features was collected from 611 patients admitted to hospital with confirmed COVID-19 during the first wave of community-acquired infection at University College London Hospitals, Sheffield Teaching Hospitals, Newcastle upon Tyne Hospitals and Royal Wolverhampton. All data prior to mechanical ventilation were interrogated. Patients were categorised as COV-HI based on Webb thresholds (CRP &gt;150 mg/L or ferritin ≥750ug/L). Laboratory features (peak or nadir depending on recognised predictors of illness severity) included: minimum lymphocyte count 10^9/L; minimum monocyte count 10^9/L; minimum haemoglobin g/dL, minimum albumin g/L; maximum neutrophils count 10^9/L; maximum alanine aminotransferase IU/L; maximum platelet count 10^9/L and maximum creatinine μmol/L. The data were analysed using unsupervised clustering and supervised machine learning models (logistic regression, support vector machine, decision trees, random forest classification (RF), naïve bayes and k-nearest neighbours) using Orange 3.29.1 software.

Results

463 patients had sufficient data to determine Cov-HI status: 361 met COV-Hi definition at any point pre- ventilation during admission (median age 71, 65.93% male), 102 patients did not (median age 73, 51% male). In keeping with our previous work, COV-HI was associated with increased mortality (p &lt; 0.0001), Odds ratio 3.506 (CI 1.871-6.916), relative risk 2.708 (CI 1.600-4.734). Multiple logistic regression revealed no significant relationship between sex and mortality (p 0.6673, Male Odds ratio 0.90). Unsupervised hierarchical clustering using laboratory features identified two clusters: Cluster-1, comprising 72.8% patients without hyperinflammation; and Cluster-2, comprising 73.3% COV-HI. Supervised machine learning models were tested using the same features. All models predicted COV-HI with good accuracy; the RF model performed best (area under the curve 0.818, classification accuracy 0.803, F1 0.79, Precision 0.85, Recall 0.74) and identified maximum neutrophil count and minimum albumin level as the most important features contributing to the classification.

Conclusion

Patients with hyperinflammation defined by CRP and ferritin thresholds share other global derangements in laboratory markers, suggesting shared pathology. Outcomes are less good in this patient group. The importance of neutrophils to the models is consistent with an association with COVID-19 disease severity and the possible contribution of neutrophil extracellular traps to pathology, while albumin is a known marker of inflammation.

Disclosure

M. Hutchinson: None. R. Tattersall: None. E.C. Jury: None. E. Hawkins: None. J. Manson: None.

A validation study of the identification of haemophagocytic lymphohistiocytosis in England using population-based health data

We assessed the validity of coded healthcare data to identify cases of haemophagocytic lymphohistiocytosis (HLH). Hospital Episode Statistics (HES) identified 127 cases within five hospital Trusts 2013-2018 using ICD-10 codes D76.1, D76.2 and D76.3. Hospital records were reviewed to validate diagnoses. Out of 74 patients, 73 were coded D76.1 or D76.2 (positive predictive value 89·0% [95% Confidence Interval {CI} 80·2-94·9%]) with confirmed/probable HLH. For cases considered not HLH, 44/53 were coded D76.3 (negative predictive value 97·8% [95% CI 88·2-99·9%]). D76.1 or D76.2 had 68% sensitivity in detecting HLH compared to an established active case-finding HLH register in Sheffield. Office for National Statistics (ONS) mortality data (2003-2018) identified 698 patients coded D76.1, D76.2 and D76.3 on death certificates. Five hundred and forty-one were coded D76.1 or D76.2 of whom 524 (96·9%) had HLH in the free-text cause of death. Of 157 coded D76.3, 66 (42·0%) had HLH in free text. D76.1 and D76.2 codes reliably identify HLH cases, and provide a lower bound on incidence. Non-concordance between D76.3 and HLH excludes D76.3 as an ascertainment source from HES. Our results suggest electronic healthcare data in England can enable population-wide registration and analysis of HLH for future research.

P062 How do our patients feel about face-to-face review in rheumatology clinics since COVID-19? A single tertiary care centre experience

Background/Aims 

The COVID-19 pandemic has had a significant impact on the management of outpatients. During the first wave of the pandemic, and in common with other departments, almost all our patient consultations happened over the phone. As the rate of infection fell, we felt it was crucial that the patient voice was heard as we re-organised clinical areas and re-opened services. In view of this, we conducted an online survey to better understand patient concerns around visiting our hospital for appointments and how we can adapt the way we work to ensure patient safety and satisfaction.

Methods 

Using our electronic patient record, we identified patients from the clinic lists of 2 adult rheumatology consultants over a 6-week period between June and August 2020. This timeframe was selected as it was towards the end of the UK nationwide shielding period and our department was returning to deliver an increasing proportion of outpatient care face-to-face. Included patients had to have been treated with an immunosuppressive drug and only those on monotherapy hydroxychloroquine, sulfasalazine or prednisolone under 5mg were excluded. We consented each patient via telephone before sending them an email link to an online anonymised survey. This included a combination of 9 multiple choice and white space questions.

Results 

65 patients were identified of which 16 were excluded as we were unable to contact them or they declined consent. 49 patients were sent the survey of which 31 responses were received. 21/31 (67%) of patients had been shielding. The survey revealed six themes of concern. These include: lack of social distancing in common hospital areas, lack of personal protective equipment compliance amongst staff, prolonged time spent in waiting rooms, lack of knowledge on new hospital policies, logistics of using public transport to come to the hospital, and the importance of retaining virtual consultations going forward. 55% of patients stated they would feel safe in returning to the hospital for face-to-face appointments over the next few months.

Conclusion 

Important themes have emerged from this project that we have presented to our rheumatology multi-disciplinary team, Director of Innovation and Head of Patient Experience. This has reinforced adaptations in our hospital environment such as installing safe distance seating in waiting rooms and scheduled phlebotomy slots. Further, where possible we call patients before face-to-face appointments to inform them of our safety measures and try to schedule these patients for outside peak travel hours. We acknowledge that using an online survey may limit responses from older individuals or those with English as a second language. Despite this, our project has shown the importance of recognising the unique concerns of rheumatology patients and the value in using their opinions to create a “new normal” for our outpatient environment.

Disclosure 

R. Amarnani: None. B. Goulden: None. J. Manson: None. V. Morris: None.

P144 What is the role of musculoskeletal ultrasound in assessing disease activity of RA in pregnancy?

Background/Aims 

In rheumatoid arthritis (RA), musculoskeletal ultrasound (MSK-US) has greater sensitivity for the detection of active disease than clinical assessment using the DAS28 score, which is prone to false elevation by a spuriously high tender joint count (TJC) and/or visual analogue score (VAS) from non-RA causes. Thus, DAS28 may correlate poorly with MSK-US findings. In pregnancy, standardised disease activity of RA comprises calculation of the modified DAS28(3)CRP score, with removal of the VAS and ESR, both of which are confounded by pregnancy, and replacement with CRP; however, it is unknown whether non-specific musculoskeletal pain and/or peripheral oedema in (especially late) pregnancy might contribute to the TJC or swollen joint count (SJC) respectively and thus render this adapted score less reliable. Therefore, we conducted this study of pregnant RA patients and controls to assess the ability of the DAS28(3)CRP to detect disease activity compared with MSK-US.

Methods 

Pregnant RA patients were recruited from the UCLH obstetric rheumatology clinic from September 2018 to March 2020. Patients underwent clinical assessment with DAS28(3)CRP and MSK-US longitudinally through pregnancy/post-partum. A control group of age-matched non-pregnant female RA patients was recruited from general rheumatology clinics and had equivalent assessments. MSK-US was undertaken using a Logiq S8. The standard protocol comprised 22-joint assessment of hands (dorsal longitudinal and transverse views of wrists, metacarpophalangeal and proximal interphalangeal joints). Quantification of Power Doppler (PD) signal was made as per the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) US definitions. PD scores were calculated as mean scores of all joints scanned. Statistical correlations were performed in SPSS using Spearman’s rank coefficient as data were non-normally distributed.

Results 

A total of 45 MSK-US scans of pregnant/postpartum RA patients (N = 24, mean age 34.5+-3.6) were performed and compared to a control group of non-pregnant RA patients, who were scanned once each (N = 18, mean age 32.3+-5.2; p = 0.12). In the second (T2) and third trimester (T3) and the postpartum (PP), there was a significant positive correlation between DAS28(3)CRP and PD score (T2, ρ = 0.87 (p &lt; 0.01); T3, ρ = 0.76 (p &lt; 0.01); PP, ρ = 0.68 (p = 0.03)). Interestingly, each of these were stronger correlations than the equivalent comparison in non-pregnant RA patients (ρ = 0.51 (p = 0.03)). TJC also significantly positively correlated with PD score in each trimester of pregnancy and postpartum, but not in non-pregnant patients; difference between correlation coefficients was statistically significant for each trimester (T1, p &lt; 0.01; T2, p = 0.05; T3, p = 0.05).

Conclusion 

Interestingly, we found that that DAS28(3)CRP correlates better with PD signal on MSK-US in pregnancy than in non-pregnancy. Specifically, there was significantly better correlation of the TJC with PD score. It is unclear why non-inflammatory contributors to the TJC may be less prominent in pregnancy and further investigation is warranted.

Disclosure 

C. Raine: Grants/research support; C.R. has received research funding from UCB. J. Manson: None. C. Ciurtin: None. I. Giles: Grants/research support; IG has received an unrestricted educational grant, speaker's fees and travel fees from UCB.

P018 Multi-disciplinary team management of haemophagocytic lymphohistiocytosis: improving patient outcomes in a central London teaching hospital

Background/Aims 

Haemophagocytic lymphohistiocytosis (HLH) is a syndrome characterised by the presence of severe uncontrolled systemic inflammation due the overproduction of inflammatory cytokines and macrophage activation. The majority of adult patients have secondary HLH, triggered by either infection, haematological malignancy or rheumatic disease. Early recognition and initiation of definitive treatment is of vital importance as HLH leads to multi-organ failure and death if left untreated, with mortality of up to 80% in some cohorts.

Methods 

Under-recognition of the disease and vast differences in the management of patients with HLH between specialities have been common problems. To address this, a Rheumatology-led HLH multi-disciplinary team (MDT) meeting was established at University College London Hospital (UCLH) in 2018. The MDT includes physicians from Rheumatology, Infectious Disease, Haematology, Intensive Care, Nephrology and Neurology and feeds into the national HLH group HASC - HLH Across Specialty Collaboration. The MDT is now held bimonthly, discussing between 2 and 4 cases each meeting. The MDT functions as a decision-making tool, while providing consensus on patient management, including collaboration on how to access urgent HLH-directed treatments such as Anakinra for secondary care centres without access. It also serves as a unique learning opportunity for trainees from different disciplines.

Results 

Since the introduction of the MDT the number of patients diagnosed with HLH at ULCH has increased from an average of 6 per year in 2014-2016 to 12 per year in 2018-2020. In the last two years we have seen improved survival from years 2017/18 to 2019/20 (Table 1); survival was approximately 30% in 2017 and 75% in 2019. P018 Table 1:Outcomes of patients diagnosed with HLH (using ICD codes D761 and D762) at University College London Hospital since 2005.YEARALIVEDECEASED200511200601201021201111201220201334201442201525201641201737201839201993202095

Conclusion 

We believe that the HLH MDT has directly contributed to these improvements by encouraging earlier recognition and subspeciality collaboration. We encourage other sites to adopt a multi-disciplinary approach to managing patients with HLH to promote awareness of the condition and improve patient outcomes.

Disclosure 

D.R. Ludwig: None. J. Manson: None. A. Jones: None. S. Mackenzie: None. N. Mccann: None.

Laboratory biomarkers associated with COVID-19 severity and management

The heterogeneous disease course of COVID-19 is unpredictable, ranging from mild self-limiting symptoms to cytokine storms, acute respiratory distress syndrome (ARDS), multi-organ failure and death. Identification of high-risk cases will enable appropriate intervention and escalation. This study investigates the routine laboratory tests and cytokines implicated in COVID-19 for their potential application as biomarkers of disease severity, respiratory failure and need of higher-level care.

From analysis of 203 samples, CRP, IL-6, IL-10 and LDH were most strongly correlated with the WHO ordinal scale of illness severity, the fraction of inspired oxygen delivery, radiological evidence of ARDS and level of respiratory support (p ≤ 0.001). IL-6 levels of ≥3.27 pg/ml provide a sensitivity of 0.87 and specificity of 0.64 for a requirement of ventilation, and a CRP of ≥37 mg/l of 0.91 and 0.66.

Reliable stratification of high-risk cases has significant implications on patient triage, resource management and potentially the initiation of novel therapies in severe patients.

Clinicogenomic factors of biotherapy immunogenicity in autoimmune disease: A prospective multicohort study of the ABIRISK consortium

BACKGROUND

Biopharmaceutical products (BPs) are widely used to treat autoimmune diseases, but immunogenicity limits their efficacy for an important proportion of patients. Our knowledge of patient-related factors influencing the occurrence of antidrug antibodies (ADAs) is still limited.

METHODS AND FINDINGS

The European consortium ABIRISK (Anti-Biopharmaceutical Immunization: prediction and analysis of clinical relevance to minimize the RISK) conducted a clinical and genomic multicohort prospective study of 560 patients with multiple sclerosis (MS, n = 147), rheumatoid arthritis (RA, n = 229), Crohn's disease (n = 148), or ulcerative colitis (n = 36) treated with 8 different biopharmaceuticals (etanercept, n = 84; infliximab, n = 101; adalimumab, n = 153; interferon [IFN]-beta-1a intramuscularly [IM], n = 38; IFN-beta-1a subcutaneously [SC], n = 68; IFN-beta-1b SC, n = 41; rituximab, n = 31; tocilizumab, n = 44) and followed during the first 12 months of therapy for time to ADA development. From the bioclinical data collected, we explored the relationships between patient-related factors and the occurrence of ADAs. Both baseline and time-dependent factors such as concomitant medications were analyzed using Cox proportional hazard regression models. Mean age and disease duration were 35.1 and 0.85 years, respectively, for MS; 54.2 and 3.17 years for RA; and 36.9 and 3.69 years for inflammatory bowel diseases (IBDs). In a multivariate Cox regression model including each of the clinical and genetic factors mentioned hereafter, among the clinical factors, immunosuppressants (adjusted hazard ratio [aHR] = 0.408 [95% confidence interval (CI) 0.253-0.657], p < 0.001) and antibiotics (aHR = 0.121 [0.0437-0.333], p < 0.0001) were independently negatively associated with time to ADA development, whereas infections during the study (aHR = 2.757 [1.616-4.704], p < 0.001) and tobacco smoking (aHR = 2.150 [1.319-3.503], p < 0.01) were positively associated. 351,824 Single-Nucleotide Polymorphisms (SNPs) and 38 imputed Human Leukocyte Antigen (HLA) alleles were analyzed through a genome-wide association study. We found that the HLA-DQA1*05 allele significantly increased the rate of immunogenicity (aHR = 3.9 [1.923-5.976], p < 0.0001 for the homozygotes). Among the 6 genetic variants selected at a 20% false discovery rate (FDR) threshold, the minor allele of rs10508884, which is situated in an intron of the CXCL12 gene, increased the rate of immunogenicity (aHR = 3.804 [2.139-6.764], p < 1 × 10-5 for patients homozygous for the minor allele) and was chosen for validation through a CXCL12 protein enzyme-linked immunosorbent assay (ELISA) on patient serum at baseline before therapy start. CXCL12 protein levels were higher for patients homozygous for the minor allele carrying higher ADA risk (mean: 2,693 pg/ml) than for the other genotypes (mean: 2,317 pg/ml; p = 0.014), and patients with CXCL12 levels above the median in serum were more prone to develop ADAs (aHR = 2.329 [1.106-4.90], p = 0.026). A limitation of the study is the lack of replication; therefore, other studies are required to confirm our findings.

CONCLUSION

In our study, we found that immunosuppressants and antibiotics were associated with decreased risk of ADA development, whereas tobacco smoking and infections during the study were associated with increased risk. We found that the HLA-DQA1*05 allele was associated with an increased rate of immunogenicity. Moreover, our results suggest a relationship between CXCL12 production and ADA development independent of the disease, which is consistent with its known function in affinity maturation of antibodies and plasma cell survival. Our findings may help physicians in the management of patients receiving biotherapies.

O01 Adult onset PIMS-TS with secondary haemophagocytic lymphistiocytosis: into the eye of the cytokine storm

Case report - Introduction

A small sub-group of COVID-19 patients develop secondary haemophagocytic lymphohistiocytosis (sHLH), a multisystem progressive hyperinflammatory syndrome characterised by fever, hepatosplenomegaly, hyperferritinaemia, cytopenia, and multiple-organ failure, which if not identified and promptly treated may be fatal. There have been isolated reports of adults developing PIMS-TS, a rare inflammatory multisystem syndrome seen in children with COVID-19 which shares common features with Kawasaki disease, toxic shock syndrome and macrophage activation syndrome / sHLH. Here we present a case of COVID-19-associated PIMS-TS in an adult complicated by frank sHLH (COV-HLH) which, after a protracted course, responded to combination immunotherapy including the IL-1 antagonist anakinra.

Case report - Case description

A 22-year-old female of Nigerian-descent with sickle cell trait presented with fever, headache, sore throat, arthralgia, abdominal pain, diarrhoea/vomiting, swollen feet/legs, and macular rash on hands/forearms. A 3-day flu-like illness occurred 8 weeks earlier. Persistent pyrexia, tachycardia and hypotension required ICU admission for inotropic support. Although she briefly required oxygen, hypoxaemia was not a prominent feature. Bloods revealed CRP&gt;200mg/L, ferritin&gt;14,000ng/mL, raised D-Dimer, procalcitonin, Troponin-T and ALT, anaemia, lymphopenia, and neutrophilia. Computed-tomography showed mild bibasilar subpleural ground-glass changes, pelvic free fluid, and peritoneal enhancement. 

As treatment for suspected COV-HLH, or connective tissue disorder, intra-venous hydrocortisone 100mg QDS was given; fever resolved and blood parameters transiently improved. Second nasopharyngeal SARS-CoV-2 RT-PCR was positive and screen for other infection and autoimmune disease negative. Echocardiography and CTA excluded coronary aneurysms although Troponin-T peak was 330ng/L.

Rapidly rising ferritin and triglycerides, falling cell counts and fibrinogen, led to a diagnosis of COV-HLH. Intra-venous anakinra 70mg (1mg/kg) BD was initiated. When pyrexia remained &gt;40 °C, inotrope requirement persisted, cell counts fell and ferritin rose to 45,861ng/ml, anakinra was increased over 48h to 200mg BD with intra-venous methylprednisolone 1g OD x2. After 7 days anakinra was weaned to 100mg subcutaneous BD enabling discharge. Outpatient bone marrow aspirate/trephine showed reactive hyperplasia, no leukaemia or haemophagocytosis. Genomic testing showed no primary genetic cause. A week later she was readmitted with fatigue, arthralgia, pyrexia, tachycardia, haematuria, and ferritin of 23,000ng/mL (nadir 4,000ng/mL). FDG-PET showed hepatosplenomegaly with no lymphoma. Anakinra was increased to 200mg IV BD with IVIG 1mg/kg OD x2 and methylprednisolone 1g IV OD x3, then cyclosporine 1mg/kg IV BD. Fevers and haemoproteinuria resolved within 1 week and inflammatory markers fell allowing discharge on a reducing regime of subcutaneous anakinra, oral prednisolone and cyclosporine. She remained well; ferritin and FBC finally normalised &gt;2 months after presentation.

Case report - Discussion

Through the UK HLH across speciality collaboration (HASC) we are aware of only a handful of UK cases of adult presentation PIMS-TS and even fewer with frank sHLH. Our patient’s ethnic background and presentation were typical for paediatric PIMS-TS. Hence, we actively excluded coronary artery aneurysms, a key feature of the Kawasaki-type variant of PIMS-TS.

Initial COVID-19 swabs were negative as was extensive investigation for other sepsis triggers. A high clinical suspicion of COVID-19 led to the second positive swab and early recognition of sHLH. Diagnosis of HLH can be challenging due to its non-specific features and was even more difficult in critically ill patients during the peak of the pandemic, where bone marrow biopsy and cross-sectional imaging (key components of diagnostic scoring systems such as the HScore) were difficult to obtain. Persistent pyrexia, hyperferritinaemia and recognition of worsening trends in all relevant domains raised suspicion of sHLH. On initiation of anakinra, her HScore was only 118, although her illness peak was 162, well above the HASC agreed threshold of 132 for HLH diagnosis during the pandemic. She subsequently had a negative bone marrow biopsy in line with &gt;50% of critical care patients with sHLH; a demonstration that biopsy proven haemophagocytosis is not necessary for a clinical diagnosis of sHLH. No other sHLH trigger was found.

Early recognition and intensive treatment may have contributed to the positive outcome; sHLH mortality in ICU patients can reach nearly 70%. These decisions were facilitated by early discussion with MDT members of HASC. The initial dose of 70mg IV BD and speed of wean after an effective dose was achieved were insufficient. A longer period on 400mg anakinra daily, a slower wean, plus addition of methylprednisolone, IVIG and cyclosporin appeared to aid the resolution of her relapse. 

Case report - Key learning points  COVID-19 infection is complicated by hyperinflammatory syndromes (cytokine storm, PIMS-TS, sHLH) in a significant minority of patients. In the absence of a treatment for COVID-19, early recognition of treatable complications should be a clinical priority.Adult clinicians should be aware of PIMS-TS which may rarely occur in young adults, especially those of African descent. The CDC definition extends to those aged up to 21. Cardiac aneurysms should be actively excluded in this group.The challenges associated with sHLH diagnosis became more apparent during the peak of the COVID-19 pandemic where key tests were difficult to obtain. Current scoring systems are insensitive for evolving sHLH. A high index of clinical suspicion and a multidisciplinary team approach, in which rheumatologists are key, is important for early recognition and treatment. Although no other sHLH trigger was found in this case, we have seen COV-HLH patients with underlying connective tissue disorder, haematological malignancy or a primary genetic defect, which should be considered if COV-HLH patients do not respond to treatment.Optimal treatment for sHLH and the hyperinflammatory syndromes associated with COVID-19 is not supported by randomised controlled trials but there is accumulating evidence for anakinra. Whilst its use in sHLH remains off-license, UK guidelines have been developed, with an emphasis on early and high dose treatment. Careful anakinra weaning regimens should be considered and patient progress regularly reviewed to avoid relapse of sHLH and subsequent readmission. Our patient also appeared to have a favourable response to corticosteroid and other combined immunosuppressive treatments including IVIG and cyclosporine. It remains to be seen if the incidence of adult-onset PIMS-TS and COV-HLH will reduce now that Dexamethasone is standard of care in adult patients with COVID-19. 

AB0310 TROUGH CONCENTRATION AND ESTIMATED CLEARANCE CAN DETECT IMMUNOGENICITY TO ADALIMUMAB IN RA PATIENTS: A PROSPECTIVE LONGITUDINAL MULTICENTRE STUDY

Background:

Anti-Drug Antibodies (ADA) to adalimumab increase drug clearance in rheumatoid arthritis (RA).

Objectives:

To study the ability of drug concentration or estimating clearance to identify ADA to adalimumab.

Methods:

Adalimumab concentration was measured with a validated ELISA. ADA was measured using a capture ELISA (Theradiag®) and the Meso scale discovery (MSD) platform. Using a bayesian PK model, adalimumab clearance was estimated at 1, 3, 6 and 12 months. Predictions for ADA presence were calculated, and the correlation between ADA and adalimumab clearance was analysed.

Results:

We analyzed 108 samples from 53 RA patients. Serum concentrations and clearance estimates showed good prediction performance for ADA presence (Table 1). There was a correlation between adalimumab clearance and ADA (Figure 1).

Table 1.

Immunogenicity prediction of adalimumab, using trough concentration or estimated clearance

Time of visitADA methodAdalimumab trough concentrationAdalimumab estimated clearanceAUC ROCp-valueAUC ROCp-valueMonth 1THER.55.6411.52.8358MSD.65.0821.61.1872Month 3THER.89.0006.91.0003MSD.73.0096.72.0131Month 6THER.95.0035.95.0035MSD.85.0004.84.0006Month 12THER.87.0045.86.0057MSD.88.0002.88.0002Figure 1.

correlation between adalimumab estimated clearance and ADA as provided by the Meso scale discovery (MSD) plateform

Conclusion:

Adalimumab concentration and clearance should be considered as reliable predictors for ADA presence in RA patients.

Acknowledgments:

Measurement of adalimumab serum concentrations was performed within the ‘Centre pilote de suivi biologique des anticorps thérapeutiques’ (CePiBAc)– Pilot centre for therapeutic antibodies monitoring platform of Tours University Hospital, which was cofinanced by the European Regional Development Fund (ERDF). We thank Oscar Knight, Delphine Delord and Fabien Giannoni (ABIRISK lab technician), Caroline Brochon and Anne Claire Duveau (CePIBAc), Aliette Decock-Giraudaud (Centre de ressource-Biobank), Sophie Tourdot (ABRISIK Project manager), Aline Doublet (Assistance Publique Hopitaux de Paris, Agnès Hincelin-Méry (Sanofi, Chilly-Mazarin, France). This work has received support from the Innovative Medicines Initiative Joint Undertaking (IMI JU) under grant agreement no. 115303, the resources of which are composed of financial contributions from the European Union’s Seventh Framework Programme (FP7/2007-2013) and European Federation of Pharmaceutical Industries and Associations (EFPIA) companies’ in-kind contributions.

Disclosure of Interests:

David Ternant Consultant of: Sanofi and Amgen., Jamal Elhasnaoui: None declared, Natacha Szely: None declared, Salima Hacein-Bey: None declared, Aude Gleizes: None declared, Christophe Richez Consultant of: Abbvie, Amgen, Mylan, Pfizer, Sandoz and UCB., Jessica Manson: None declared, Martin SOUBRIER: None declared, Olilvier Brocq: None declared, Jérôme Avouac: None declared, Anna Fogdell-Hahn Grant/research support from: Biogen Idec and Pfizer., Consultant of: Pfizer, Biogen, Merck-Serono, and Sanofi-Genzyme., Pierre Dönnes: None declared, Gilles Paintaud Grant/research support from: Amgen, Genzyme (Sanofi), Lilly, Merck, Novartis, and Roche Pharma., Consultant of: Chugai, Novartis and Shire (Takeda), with remunerations received by his institution., Céline Desvignes: None declared, Florian Deisenhammer: None declared, Sebastian Spindeldreher Employee of: Novartis, Marc Pallardy: None declared, Xavier Mariette Consultant of: BMS, Gilead, Medimmune, Novartis, Pfizer, Servier, UCB, Denis Mulleman Grant/research support from: Non-governmental organisation Lions Club Tours Val de France, French Society for Rheumatology., Consultant of: Pfizer, Novartis.

P82 Multi-centre cross-specialty recommendations for the investigation of suspected adult onset secondary haemophagocytic lymphohistiocytosis (HLH)

Background

Secondary HLH (sHLH) in adults is a paradigm of a disorder with multiple challenges. It is rare and under-recognised, clinical features are non-specific and heterogeneous, it may present to a broad range of specialties and there is no single test which can unambiguously diagnose the condition. The investigation of such patients often occurs in a piecemeal fashion, which causes delays in establishing diagnosis leading to missed opportunities to start treatment early. Treatment protocols are extrapolated from mostly paediatric data from the primary, genetic form of HLH with insufficient clinical trials in adults to provide robust evidence-based management approaches. There is a resultant wide range in clinical practice and sHLH has a high mortality rate. Addressing these issues and improving knowledge about the disorder therefore requires cross-speciality, multi-centre working. Within the UK, these challenges have begun to be addressed over the past 24 months, resulting in the creation of local and regional HLH MDTs, the formation of a national network of interested specialists (HASC: the HLH across-specialty collaboration) as well as the creation of a national HLH registry as part of the UK Histiocytosis Registry (UKHR).

Methods

The aim of this project was to create a national guideline for the diagnosis and investigation of adult patients with suspected sHLH in order to start to standardise practice across the UK. Over 30 clinicians from a broad range of specialties, from both paediatric and adult practice, were consulted. These included sub-specialist input from rheumatology, haematology, infectious diseases, virology, nephrology, intensive care and immunology with collaborations from 15 centres around the UK. The HASC meetings were used as a forum to collaborate and develop the guidance.

Results

We created an investigation algorithm dividing tests for work-up into 3 sections: 1. Routine initial work 2. HLH-specific testing, comprehensive infection work-up, guidance on tissue biopsy 3. Identification and work-up of suspected adult cases of familial/genetic HLH (fHLH).

The guidance also uses HASC multi-professional expertise to provide approaches to controversial areas including ferritin and sCD25 thresholds in adults, deep skin biopsies for suspected intravascular lymphoma and specific scenarios such as neurological presentations and CAR-T therapy. Clinicians from different specialties across the UK and specialist laboratories with an interest in HLH have been identified in order to make the HLH network more accessible. The aim is to have the guideline hosted by Histio UK, and freely available on their website.

Conclusion

This guideline is based on cross-specialty consensus expert opinion with reference to published literature in order to develop best practice. The coordinated investigation of patients with sHLH is key to improving early diagnosis and treatment and is just one part of the collaborative multi-faceted approach that is required to improve overall outcomes for patients with sHLH.

Disclosures

S. Mackenzie None. R. Low None. M. Brown None. E. Sanchez None. K. Gilmour None. T. Youngstein None. R. Tatersall None. B. Carpenter None. A. Patel None. C. Mcnamara None. J. Manson None.

EP31 Musculoskeletal ultrasound of rheumatoid arthritis pregnancy: a single centre experience

Background

The utility of musculoskeletal ultrasound (MSK-US) in the measurement of disease activity of rheumatoid arthritis (RA) is well established. However, it has not been formally studied in pregnancy, with the literature limited to a single case report. Standard disease activity assessment in RA pregnancy comprises measurement of the DAS28(3) CRP score, which removes the visual analogue score (VAS) and replaces ESR with CRP, as both of these components may be confounded by pregnancy. Use of this modified score remains problematic as the tender joint count may be affected by non-specific musculoskeletal pain in pregnancy, and the swollen joint count may be obscured by peripheral oedema, especially late in pregnancy. No study of RA in pregnancy has used MSK-US to measure disease activity. Our objective was to conduct a pilot study of MSK-US in RA pregnancy, and compare findings with clinical assessment using the DAS28(3)CRP score.

Methods

We offered MSK-US to pregnant RA patients attending the UCLH obstetric rheumatology clinic from September 2018 to September 2019. Patients were assessed longitudinally through pregnancy/post-partum where possible. Examination was undertaken using a Logiq S8 US machine. The standard protocol comprised 22-joint assessment of hands (dorsal longitudinal and transverse views of wrists, metacarpophalangeal and proximal interphalangeal joints). In the feet, bilateral MTP joints were scanned with longitudinal views. Quantification of Power Doppler (PD) signal and grey scale (GS) synovitis was made as per the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) US definitions. PD and GS scores were calculated as mean scores of all joints scanned.

Results

To date, 17 pregnant RA patients have undergone a total of 35 MSK-US studies. Disease activity assessments showed 10/17 patients with persistent low activity through pregnancy, 5/17 with moderate or good response, 1/17 with no response and 1/17 with a moderate flare. Overall, PD scores correlated well with DAS28(3) CRP assessment (R2 = 0.68). All patients at moderate or high disease activity by DAS28(3) CRP had ≥1 joint with detectable PD signal, but 2/21 patients clinically in ‘remission’ and 3/7 patients in ‘low disease activity’ had detectable PD. One patient with only 2 tender and 1 swollen joints (and normal CRP; DAS28 3.17) had very extensive PD signal and contributed to the decision to recommence anti-TNF treatment in the 3rd trimester. It was noted that increased vascularity in pregnancy can complicate the assessment of synovial PD signal. MSK-US was particularly helpful in distinguishing true joint synovitis from subcutaneous oedema in the feet.

Conclusion

This is the first series of MSK-US in pregnant RA patients. The detection of active joint synovitis (by PD signal) in clinical remission/low disease activity states suggests a potential role for MSK-US in confirming apparent low disease activity in pregnancy, and thus guiding stratification of treatment.

Disclosures

C. Raine None. J. Manson None. C. Ciurtin None. I. Giles None.

Real benefits of ultrasound evaluation of hand and foot synovitis for better characterisation of the disease activity in rheumatoid arthritis

Objectives

Optimal management of rheumatoid arthritis (RA) depends on accurate evaluation of disease activity. Foot synovitis is not included in the most used RA outcome measure (DAS-28 score). The aim of this study was to investigate how musculoskeletal ultrasound (MSK-US) examination of hand and feet correlate with the disease activity score (DAS-28 score). We also explored whether performing MSK-US assessments of hands alone compared with hands and feet underestimates the disease activity in RA.

Methods

This is a real-life cross-sectional study of 101 patients (51 with RA and 50 with other musculoskeletal conditions) with inflammatory small joint pain, who underwent MSK-US examination of hands and feet.

Results

MSK-US-detected hand synovitis was found in 18/51 (35.3%) RA patients and 16/50 (32%) of those with other musculoskeletal conditions (p = 0.96), while foot synovitis was detected in 18/51 (35.3%) and 12/50 (24%) patients, respectively (p = 0.78). DAS-28 did not correlate with any of the US outcome measures in patients with RA. Six out of 13 (46.1%) RA patients in remission, 7/14 (50%) with low disease activity and 18/32 (56.2%) with moderate disease activity (according to DAS-28 definition) had active synovitis as assessed by the MSK-US examination of their hands and feet. MSK-US-detected synovitis led to treatment escalation in 26/51 (51%) RA patients.

Conclusion

This study emphasises that MSK-US examination of hands and feet has led to optimised management of the majority of RA patients, which would have not been possible otherwise, because of the lack of correlation between DAS-28 assessment and MSK-US outcomes.

Key Points

• The most used disease activity score in rheumatoid arthritis (DAS-28) did not correlate with US outcome measures derived from hands and feet examination.

• DAS-28 did not differentiate between RA patients with subclinical active synovitis versus well-controlled disease on US.

• As a result of US examination of the hands and feet, 51% RA patients had their immunosuppressive treatment optimised.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06187-8) contains supplementary material, which is available to authorized users.

Abstract 14: Secular Trends in Racial and Socioeconomic Status Disparities in the Rate of Coronary Revascularization Among Post-Menopausal Women Before and After 2005 for Acute Coronary Syndrome: The Women Health Initiative

Background: We looked at a large multi-racial, geographically diverse cohort of post-menopausal women to determine whether revascularization for either acute coronary syndrome (ACS) or coronary disease (CHD) differed by race and socioeconomic status when 2002 ACC/AHA guidelines secular trends are considered.

Methods: Using data from the WHI, we evaluated the rate of revascularization among 20,262 post-menopausal women (2,181 were Black, 572 Hispanic, and 17,509 white). We chose 2005 as the cut-point for the secular trend as it usually takes 2-3 years for guidelines to be implemented. We used a Cox proportional hazards models with unadjusted, age-adjusted, and fully adjusted hazards ratios to examine revascularization disparities by race and SES.

Results: Revascularization rates increased over the two decades studied but the racial disparities did not narrow. Black women with either ACS or CHD had significantly lower rates of revascularization pre and post 2005. Hispanic women with acute coronary syndrome or CHD had significantly lower rates of revascularization pre-2005 and a trend for lower rates post-2005. Black women with STEMI had trend towards lower rates of revascularization pre and post 2005 compared to their white counterparts. Hispanic women with STEMI have similar rates of revascularization pre-2005 and a trend towards lower rates of revascularization post-2005. Black women with NSTEMI trend towards a higher rate of revascularization pre-2005 and a trend towards a lower rate of revascularization post-2005. Hispanics with NSTEMI had a trend for higher revascularization pre-2005, and similar rates of revascularization post-2005. Low SES women with acute coronary syndrome or coronary heart disease had no difference in the rate of revascularization pre-2005 and significantly lower revascularization post-2005. Low SES with STEMI and NSTEMI had comparable rates of revascularization for both time periods when compared to their high SES counterparts.

Conclusions: Black women with ACS or CHD had lower rates of revascularization, regardless of timing, compared to their white counterpart. Despite having similar rates of coronary events, low SES women had lower rates of revascularization in the post 2005 period when compared to their high SES counterpart.

Phthalate Metabolites and Postmenopausal Breast Cancer Risk

Mounting laboratory and animal model evidence supports the potentially carcinogenic effects of phthalates, chemicals used as plasticizers in a wide variety of consumer products (e.g., cosmetics, medications, vinyl flooring). Phthalate metabolites (PMs) are measurable in nearly 100% of the U.S. population, though levels vary widely, and also have been reported in human breast milk. However, prospective data on whether phthalates affect human breast cancer risk is lacking. Methods We conducted a nested case-control study within the Women's Health Initiative (WHI) prospective cohort (N = 419 invasive cases and 838 matched controls). Controls were matched 2:1 on age, enrollment date, follow-up time, and study group (WHI clinical trial or observational study). We measured a panel of thirteen PMs and creatinine in two or three urine samples per participant over 1 to 3 years. Multivariable conditional logistic regression analysis was used to estimate risk ratios and 95% confidence intervals (RR, 95% CI) for breast cancer risk associated with each PM, with incorporation of measurement error correction approaches to account for the moderate within-participant variability of PMs. Results Overall, we did not observe statistically significant associations between individual PMs and breast cancer risk in analyses adjusted for matching factors, creatinine, body mass index, smoking status, and race/ethnicity: e.g., mono-2-ethylhexyl phthalate (MEHP; p trend = 0.31; e.g., RR 0.91, 95% CI, 0.62–1.33), monoethyl phthalate (MEP; p trend = 0.16; e.g., RR 0.80, 95% CI, 0.55–1.16 for 4th quartile vs. 1st quartile), monohydroxy-isobutyl phthalate (MHiBP; p trend = 0.11; e.g., RR 0.78, 95% CI, 0.51–1.18 for 4th quartile vs. 1st quartile, and monobenzyl phthalate (MBzP; p trend = 0.11; e.g., RR 0.86, 95% CI, 0.57–1.28 for 4th quartile vs. 1st quartile). Conclusions These results indicate that urinary phthalate metabolite levels are not related to increased breast cancer risk. However, some phthalate metabolites may be associated with decreased risk, possibly through anti-estrogenic actions. Future analyses will explore grouping metabolites by parent phthalate and also will separately evaluate breast cancer risk by tumor estrogen receptor status and explore potential effect modification.

Chikungunya Virus Infection: An Update on Joint Manifestations and Management

The advent of sophisticated diagnostics has enabled the discovery of previously unknown arthropod-borne viruses like Chikungunya. This infection has become increasingly prevalent in the last 10 years across the Indian Ocean and has been brought to media attention by a recent outbreak in the Caribbean. The outbreak has been aided by a drastic rise in air travel, allowing infected individuals to transport the virus to previously unaffected regions. In addition, a recently documented viral mutation has allowed its transmission by the Aedes albopictus mosquito, therefore facilitating outbreaks in Southern Europe and the USA. The duration and extent of the arthritis seen peri- and post infection has become a topic of academic interest. Although published data are largely observational, there has been a definite increase in original research focusing on this. Symptoms can persist for years, particularly in older patients with pre-existing medical conditions. The etiology is still not fully understood, but viral persistence and immune activation within synovial fluid have been shown in mouse models. There have been no prospective clinical trials of treatment in humans; however, animal trials are in process. The mainstay of treatment remains anti-inflammatories and steroids where necessary. The clinical presentation seems to mimic common rheumatological conditions like rheumatoid arthritis; therefore recent recommendations suggest the use disease-modifying agents as a common practice for the specific syndrome. This review uses recent published data and draws on our own clinical experience to provide an overview of joint complications of Chikungunya infection.

Ultrasound-detected subclinical inflammation was better reflected by the disease activity score (DAS-28) in patients with suspicion of inflammatory arthritis compared to established rheumatoid arthritis

Limited data are available about the ultrasound (US)-detected inflammatory features in patients with suspicion of inflammatory arthritis (S-IA) vs. established rheumatoid arthritis (RA). Our study aimed to assess if the presence of power Doppler (PD) can be predicted by a combination of clinical, laboratory and US parameters. We conducted a real-life, retrospective cohort study comparing clinical, laboratory and US parameters of 108 patients with established RA and 93 patients with S-IA. We propose a PD signal prediction model based on a beta-binomial distribution for PD variable using a mix of outcome measures. Patients with RA in clinical remission had significantly more active inflammation and erosions on US when compared with patients with S-IA with similar disease scores (p = 0.03 and p = 0.01, respectively); however, RA patients with different disease activity score (DAS-28) scores had similar PD scores (p = 0.058). The PD scores did not correlate with erosions (p = 0.38) or DAS-28 scores (p = 0.28) in RA patients, but they correlated with high disease activity in S-IA patients (p = 0.048). Subclinical inflammation is more common in patients with RA in clinical remission or with low disease activity than in patients with S-IA; therefore, US was more useful in assessing for true remission in RA rather than diagnosing IA in patients with low disease activity scores. This is the first study to propose a PD prediction model integrating several outcome measures in the two different groups of patients. Further research into validating this model can minimise the risk of underdiagnosing subclinical inflammation.

Persistent lymphopenia is an independent predictor of mortality in critically ill emergency general surgical patients

INTRODUCTION

Lymphopenia has been associated with poor outcome following sepsis, burns and trauma. This study was designed to establish whether lymphocyte count was associated with mortality in emergency general surgery (EGS) patients, and whether persistent lymphopenia was an independent predictor of mortality.

METHODS

A retrospective review of a prospectively compiled database of adult patients requiring ICU admission between 2002 and 2013 was performed. EGS patients with acute intra-abdominal pathology and organ dysfunction were included. Lymphocyte counts obtained from the day of ICU admission through to day 7 were examined. Multivariate logistic regression models were used to determine the relationship between persistent lymphopenia and outcome. The primary outcome measure was in-hospital mortality.

RESULTS

The study included 173 patients, of whom 135 (78 %) had a low lymphocyte count at admission to ICU and 91 % (158/173) developed lymphopenia on at least one occasion. Lymphocyte counts were lower among non-survivors compared with survivors on each day from day 2 (0.62 vs 0.81, p = 0.03) through to day 7 (0.87 vs 1.15, p < 0.01). Patients with a persistently low lymphocyte count during the study period had significantly higher mortality when compared to patients with other lymphocyte patterns (64 vs 29 %, p < 0.01). On multivariate regression analysis, persistent lymphopenia was independently associated with increased in-hospital mortality [odds ratio 3.5 (95 % CI 1.7-7.3), p < 0.01].

CONCLUSION

Lymphopenia is commonly observed in critically ill EGS patients. Patients with persistent lymphopenia are 3.5 times more likely to die and lymphopenia is an independent predictor of increased mortality in this patient group.

Teriparatide: an unexpected adjunct for the treatment of a long-standing infected elbow prosthesis prevented arm amputation

A 76-year-old woman with rheumatoid arthritis, osteoporosis and multiple comorbidities presented with septic left elbow prosthesis. Treatment included combination antibiotic therapy and removal of the prosthesis. Weeks later she was started on teriparatide. Her elbow symptoms resolved. In our experience, this is the first case in the literature reporting teriparatide efficacy in the treatment of septic arthritis.

Case report: passive transfer of hepatitis B antibodies from intravenous immunoglobulin

Background

Prior to initiating immunosuppressive therapy in the treatment of autoimmune inflammatory conditions, it is a requirement to screen for certain viral serology, including hepatitis B (HBV). A positive result may indicate the need for antiviral therapy, or contraindicate immunosuppression all together. An accurate interpretation of serological markers is therefore imperative in order to treat patients appropriately. We present a case of passive anti-HBV antibody transfer following intravenous immunoglobulin (IVIg) infusion, in which misinterpretation of serology results almost led to inappropriate treatment with antiviral therapy and the withholding of immunosuppressive agents. This phenomenon has been previously reported, but awareness remains limited.

Case presentation

A 50 year old Caucasian gentleman with a history of allogeneic haematopoietic stem cell transplant for transformed follicular lymphoma was admitted to hospital with recurrent respiratory tract infections. Investigation found him to be hypogammaglobulinaemic, and he was thus given 1 g/kg of intravenous immunoglobulin. The patient also disclosed a 3-week history of painful, swollen joints, leading to a diagnosis of seronegative inflammatory polyarthritis. Prior to initiating long term immunosuppression, viral screening found hepatitis B serology suggestive of past infection, with positive results for both anti-HBc and anti-HBs antibody, but negative HBV DNA. In response, prednisolone was weaned and the local hepatology team recommended commencement of lamivudine. Having been unable to identify a source of infection, the case was reported to the local blood centre, who tested a remaining vial from the same batch of IVIg and found it to be anti-HBc and anti-HBs positive. Fortunately the blood products were identified and tested prior to the patient initiating HBV treatment, and the effect of a delay in starting disease-modifying therapy was inconsequential in light of an excellent response to first-line therapies.

Conclusion

Misinterpretation of serology results following IVIg infusion may lead to significant patient harm, including unnecessary antiviral administration, the withholding of treatments, and psychosocial damage. This is especially pertinent at a time when we have an ever increasing number of patients being treated with IVIg for a wide array of immune-mediated disease. Passive antibody transfer should be considered wherever unexpected serological changes are identified.