Deep Learning Enables Automatic Detection of Joint Damage Progression in Rheumatoid Arthritis-Model Development and External Validation

OBJECTIVES

Although deep learning has demonstrated substantial potential in automatic quantification of joint damage in rheumatoid arthritis (RA), evidence for detecting longitudinal changes at an individual patient level is lacking. Here, we introduce and externally validate our automated RA scoring algorithm (AuRA), and demonstrate its utility for monitoring radiographic progression in a real-world setting.

METHODS

The algorithm, originally developed during the Rheumatoid Arthritis 2-Dialogue for Reverse Engineering Assessment and Methods (RA2-DREAM) challenge, was trained to predict expert-curated Sharp-van der Heijde total scores in hand and foot radiographs from two previous clinical studies (n = 367). We externally validated AuRA against data (n = 205) from Turku University Hospital and compared the performance against two top-performing RA2-DREAM solutions. Finally, for 54 patients, we extracted additional radiograph sets from another control visit to the clinic (average time interval of 4.6 years).

RESULTS

In the external validation cohort, with a root-mean-square-error (RMSE) of 23.6, AuRA outperformed both top-performing RA2-DREAM algorithms (RMSEs 35.0 and 35.6). The improved performance was explained mostly by lower errors at higher expert-assessed scores. The longitudinal changes predicted by our algorithm were significantly correlated with changes in expert-assessed scores (Pearson's R = 0.74, p< 0.001).

CONCLUSION

AuRA had the best external validation performance and demonstrated potential for detecting longitudinal changes in joint damage. Available in https://hub.docker.com/r/elolab/aura, our algorithm can easily be applied for automatic detection of radiographic progression in the future, reducing the need for laborious manual scoring.

Patient-reported outcomes in axial spondyloarthritis and psoriatic arthritis patients treated with secukinumab for 24 months in daily clinical practice

OBJECTIVES

In patients with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA) initiating secukinumab, we aimed to assess and compare the proportion of patients achieving 6-, 12- and 24-month patient-reported outcomes (PRO) remission and the 24-month retention rates.

PATIENTS AND METHODS

Patients with axSpA or PsA from 16 European registries, who initiated secukinumab in routine care were included. PRO remission rates were defined as pain, fatigue, Patient Global Assessment (PGA) ≤2 (Numeric Rating Scale (NRS) 0-10) and Health Assessment Questionnaire (HAQ) ≤0.5, for both axSpA and PsA, and were calculated as crude values and adjusted for drug adherence (LUNDEX). Comparisons of axSpA and PsA remission rates were performed using logistic regression analyses (unadjusted and adjusted for multiple confounders). Kaplan-Meier plots with log-rank test and Cox regression analyses were conducted to assess and compare secukinumab retention rates.

RESULTS

We included 3087 axSpA and 3246 PsA patients initiating secukinumab. Crude pain, fatigue, PGA and HAQ remission rates were higher in axSpA than in PsA patients, whereas LUNDEX-adjusted remission rates were similar. No differences were found between the patient groups after adjustment for confounders. The 24-month retention rates were similar in axSpA vs. PsA in fully adjusted analyses (HR [95 %CI] = 0.92 [0.84-1.02]).

CONCLUSION

In this large European real-world study of axSpA and PsA patients treated with secukinumab, we demonstrate for the first time a comparable effectiveness in PRO remission and treatment retention rates between these two conditions when adjusted for confounders.

Similar levels of disease activity and remission rates in patients with psoriatic arthritis and rheumatoid arthritis-results from the Finnish quality register

OBJECTIVES

To compare the current disease activity and remission rates, and their regional variation in patients with psoriatic arthritis (PsA) and rheumatoid arthritis (RA) in Finland.

METHODS

Data of patients' most recent visit in 1/2020-9/2021 were extracted from the Finnish Rheumatology Quality Register. Measures for disease activity and remission included joint counts, DAS28, cDAPSA, CDAI, the Boolean definition, and physician assessment. Regression analyses were applied, adjusted for age and sex.

RESULTS

Data of 3598 patients with PsA (51% female, mean age 54 years) and 13,913 patients with RA (72% female, 74% ACPA-positive, mean age 62 years) were included. The median (IQR) DAS28 was 1.9 (1.4, 2.6) in PsA and 2.0 (1.6, 2.7) in RA (p = 0.94); for cDAPSA, the median (IQR) values were 7.7 (3.1, 14) in PsA and 7.7 (3.3, 14) in RA (p < 0.001). In all regions in both diseases, the median DAS28 was ≤ 2.6 and the median cDAPSA < 13. Remission rates included DAS28 < 2.6 in 73% in PsA and 69% in RA (p = 0.17) and Boolean remission in 17% in PsA and 15% in RA (p < 0.001). By other definitions of remission, the rates ranged between 30% and 46%. Methotrexate was currently used by 49% in PsA and 57% in RA (p < 0.001). Self-administered bDMARDs were currently used by 37% in PsA and 21% in RA (p < 0.001).

CONCLUSION

The overall disease activity was low and similar in patients with PsA and RA across the country. Remission rates varied between 15 and 73%, depending on the definition but were similar in PsA and RA. Key Points • The disease activity and clinical picture was similar between patients with PsA and RA, in a cross-sectional setting in 1.2020-9.2021. • A significant majority of patients with PsA had low disease activity or were in remission according to cDAPSA. Majority of patients with RA were in remission according to DAS28. • Patients with PsA and RA used methotrexate similarly. The utilization of bDMARDs was more prevalent in patients with PsA.

Disease burden measured by patient-reported outcomes: does psoriatic arthritis feel worse than rheumatoid arthritis? A cross-sectional nationwide study

OBJECTIVES

To study the subjective disease burden of patients with psoriatic arthritis (PsA) and rheumatoid arthritis (RA), using patient-reported outcomes (PROs) cross-sectionally.

METHODS

Data of 3598 patients with PsA and 13913 with RA were extracted from the database. Measures included the VAS-values of pain, fatigue and patient global assessment (PGA), HAQ, and disease activity at the most recent visit/remote contact in the period 1.2020 to 9.2021. Values were compared between patients with PsA and RA overall, and by sex and age (<50, 50-59, 60-69 and ≥70 years). Regression analyses were applied.

RESULTS

The overall median (IQR)-values for pain were 29 (10, 56) for PsA and 26 (10, 51) for RA, 29 (9, 60) and 28 (8, 54) for fatigue, 28 (10, 52) and 29 (11, 51) for PGA, 0.4 (0, 0.9) and 0.5 (0, 1.0) for HAQ (p<0.001 for all comparisons; adjusted for sex and age). The median (IQR)-values for pain, fatigue, PGA and HAQ were higher for PsA vs. RA in most age groups for males and females. All PROs were higher in older patients with both diagnoses. The median values for DAS28, doctor global assessment, ESR and CRP were 1.9 vs. 2.0, 8 vs. 8, 7 vs. 8 and 2 vs. 3 in PsA and RA, respectively.

CONCLUSIONS

Overall, both PsA and RA groups showed moderate disease control by patients' perspective, but the burden of disease was higher especially in women with PsA compared to RA. Disease activity was similar and low in both diseases.

Development of prediction model for alanine transaminase elevations during the first 6 months of conventional synthetic DMARD treatment

Frequent laboratory monitoring is recommended for early identification of toxicity when initiating conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). We aimed at developing a risk prediction model to individualize laboratory testing at csDMARD initiation. We identified inflammatory joint disease patients (N = 1196) initiating a csDMARD in Turku University Hospital 2013-2019. Baseline and follow-up safety monitoring results were drawn from electronic health records. For rheumatoid arthritis patients, diagnoses and csDMARD initiation/cessation dates were manually confirmed. Primary endpoint was alanine transaminase (ALT) elevation of more than twice the upper limit of normal (ULN) within 6 months after treatment initiation. Computational models for predicting incident ALT elevations were developed using Lasso Cox proportional hazards regression with stable iterative variable selection (SIVS) and were internally validated against a randomly selected test cohort (1/3 of the data) that was not used for training the models. Primary endpoint was reached in 82 patients (6.9%). Among baseline variables, Lasso model with SIVS predicted subsequent ALT elevations of > 2 × ULN using higher ALT, csDMARD other than methotrexate or sulfasalazine and psoriatic arthritis diagnosis as important predictors, with a concordance index of 0.71 in the test cohort. Respectively, at first follow-up, in addition to baseline ALT and psoriatic arthritis diagnosis, also ALT change from baseline was identified as an important predictor resulting in a test concordance index of 0.72. Our computational model predicts ALT elevations after the first follow-up test with good accuracy and can help in optimizing individual testing frequency.

Initial presentation of early rheumatoid arthritis

OBJECTIVES

To study the joint distribution and clinical picture of rheumatoid arthritis (RA) at the initial presentation in seropositive (anti-citrullinated protein antibody (ACPA) and/or rheumatoid factor (RF) positive) and negative patients and the effect of duration of symptoms on the clinical picture.

METHODS

Data of patients who received reimbursement for DMARDs for newly diagnosed RA in 1/2019 to 9/2021 were extracted from the national databases. Joint counts, presence of symmetrical swelling, other disease activity measures, and patient reported outcomes (PROs) were compared in seropositive and negative patients. Regression analyses were applied to compare clinical variables in patients with duration of symptoms of <3, 3-6, and >6 months, adjusted for age, sex, and seropositivity.

RESULTS

Data of 1816 ACPA and RF-tested patients were included. Symmetrical swelling was present in 75% of patients. Seronegative versus positive patients had higher value for all disease activity measures and PROs including median swollen joint count (SJC46 10 versus 5) and DAS28 (4.7 versus 3.7), (p<0.001). Patients diagnosed in <3 months had higher median pain VAS (62 versus 52 and 50, p<0.001) and HAQ (1.1 versus 0.9 and 0.75, p = 0.002) compared to those with a duration of symptoms of 3-6 and >6 months. Patients diagnosed >6 months were ACPA-positive more frequently (77% versus 70% in other groups, p = 0.045).

CONCLUSION

Incident RA presents mainly as symmetric arthritis. Seronegative patients have higher disease burden at the initial presentation. Patients experiencing more severe pain and decreased functional ability are diagnosed earlier, regardless of ACPA- status.

The feasibility of existing JADAS10 cut-off values in clinical practice: a study of data from The Finnish Rheumatology Quality Register

BACKGROUND

The ten-joint juvenile arthritis disease activity score (JADAS10) is designed to measure the level of disease activity in non-systemic juvenile idiopathic arthritis by providing a single numeric score. The clinical JADAS10 (cJADAS10) is a modification of the JADAS10 that excludes erythrocyte sedimentation rate (ESR). Three different sets of JADAS10/cJADAS10 cut-offs for disease activity states have been published, i.e., the Backström, Consolaro, and Trincianti cut-offs. The objective of this study was to investigate the performance of existing JADAS10 cut-offs in real-life settings using patient data from The Finnish Rheumatology Quality Register (FinRheuma).

METHODS

Data were collected from the FinRheuma register. The proportion of patients with an active joint count (AJC) above zero when classified as being in clinically inactive disease (CID) or low disease activity (LDA) groups according to existing JADAS10/cJADAS10 cut-off levels were analyzed.

RESULTS

A significantly larger proportion of the patients classified as being in CID had an AJC > 0 when using the JADAS10/cJADAS10 cut-offs by Trincianti et al. compared to those for the other cut-offs. In the LDA group, a significantly larger proportion of the polyarticular patients (35%/29%) had an AJC of two when Trincianti JADAS10/cJADAS10 cut-offs were used compared with when Backström (11%/10%) and Consolaro (7%/3%) JADAS10/cJADAS10 cut-offs were used.

CONCLUSIONS

We found the cut-offs proposed by Consolaro et al. to be the most feasible, since these cut-off levels for CID do not result in the misclassification of active disease as remission, and the proportion of patients with AJC > 1 in the LDA group is lowest using these cut-offs.

AB0164 ARE PATIENTS WITH RA IN REMISSION IN FINLAND DURING THE COVID TIMES? RESULTS FROM THE FINNISH QUALITY REGISTER

Background

Worries have been expressed, concerning the care of chronic diseases during the Covid times (1).

Objectives

To study the current status of patients with RA in the Finnish quality register database.

Methods

Patients who receive care for RA were identified in the database. Clinical and demographic data from the last visits during 2020-21 were collected, including swollen (SJC46) and tender joint counts (TJC46), doctor assessment of disease activity (Dr global), laboratory tests for inflammatory and serology markers, patient reported outcomes (PROs), and DAS28. Regression models were applied to compare measures of clinical status between the health care regions, adjusted for gender, age, ACPA status, and disease duration.

Results

A total of 14163 patients (72% female, mean (SD) age 62 (14) years, median (IQR) disease duration 8.5 (2.6, 20) years, 84% ACPA positive) were identified. For the entire population, the median (IQR) SJC46 was 0 (0, 1), TJC46 0 (0, 2), ESR 8 (5, 18), CRP 3 (1, 6), and dr global 8 (0, 19). Among PROs, median (IQR) HAQ was 0.5 (0, 1), pain 26 (10, 51), fatigue 28 (8, 54) and patient global 29 (11, 51). Between health care regions, statistically significant differences were found for all variables due to a large sample size. The mean (SD) DAS28 was 2.3 (0.9) for the entire group and 69 % of all patients had DAS28<2.6. The median DAS28 ranged from 2 to 2.7 among health care regions (Figure 1) (p<0.001). Majority of patients were taking csDMARDs only.

Figure 1.

Rheumatoid arthritis in 2020-21: The median DAS28-values in 19 regions in Finland.

Conclusion

The quality register provides comprehensive real-world data on the current status of patients with RA. A majority of patients can be considered being in remission even during the Covid times.

References

[1]Glintborg et al. Rheumatology (Oxford) 2021 Oct 9;60(SI):SI3-SI12

Acknowledgements

I would like to thank The Finnish Society for Rheumatology and The Finnish Psoriasis Association for their grants.

Disclosure of Interests

None declared

AB0168 DISEASE BURDEN MEASURED BY PROs: DOES PSORIATIC ARTHRITIS (PsA) FEEL WORSE THAN RHEUMATOID ARTHRITIS (RA)? A CROSS-SECTIONAL STUDY

Background

Little comparative research has been done comparing disease burden between PsA and RA. Previous studies from Nordic countries and the US have shown small differences (0-10/100 VAS units) in patients with PsA vs. RA. The mean and median VAS levels for PsA and RA ranged between 30-40 for pain and 40-50 for fatigue and patient global health in cross-sectional settings (1, 2, 3).

Objectives

To study the current differences in PROs between PsA and RA in Finland.

Methods

3731 patients receiving care for PsA and 14163 for RA were identified in the national quality register for inflammatory arthritides in 2020-21. Patients were divided into groups by sex and age; <50 years, 50-60 years, 60-70 years and ≥70 years. The VAS values of pain, fatigue and patient global health at the most recent visit were compared in PsA vs. RA between the groups. Descriptive statistics and regression models were used for comparison.

Results

Patients with PsA vs RA were younger (mean (sd) age 54(14) vs 62(14)) and less often women (51% vs. 72%). Median (IQR) disease duration after the first symptoms was 8.6 (3.7, 17) years for PsA and 9.5 (3.3, 21) years for RA. The median (IQR) pain was 29 (10, 56) for all patients with PsA and 26 (10,51) for patients with RA. The corresponding values were: fatigue 28 (9, 60) in PsA vs 28 (8, 54) in RA, and patient global health 28 (10, 51) in PsA and 29 (11, 51) in RA.

Median pain was slightly higher in female PsA patients compared to RA patients in all age groups (29 and 18, 35 and 28, 32 and 27 and 48 and 38) (p<0.001). In males, higher levels of pain in PsA vs. RA were seen in age groups older than 50 years old. Figure 1 illustrates the mean (95% CI) pain for PsA and RA in the age and sex groups.

Median fatigue levels were quite similar between the groups. The median patient global health was higher in female PsA compared to RA patients in age groups <50 years and 50-60 years (20 vs. 29 and 30 vs 37) (p<0.001).

Figure 1.

Mean (95 % CI) pain in VAS-units for women and men by age groups in 2020-2021

Conclusion

Female patients with PsA report higher levels of pain in all age groups compared to patients with RA. The same was seen in men >50 years old. Concerning fatigue and patient global health, the differences between PsA and RA were smaller. Compared to earlier research in other countries, disease burden observed by PROs appears lower both in PsA and RA in Finland.

References

[1]Pilgaard T et al. Severity of fatigue in people with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis – Results of a cross-sectional study, PLoS One, 2019; 14(6): e0218831

[2]Egholm CL et al. Discordance of Global Assessments by Patient and Physician Is Higher in Female than in Male Patients Regardless of the Physician’s Sex: Data on Patients with Rheumatoid Arthritis, Axial Spondyloarthritis, and Psoriatic Arthritis from the DANBIO Registry, The Journal of rheumatology, 2015 Oct;42(10):1781-5.

[3]Mease PJ et al. Comparative Disease Burden in Patients with Rheumatoid Arthritis, Psoriatic Arthritis, or Axial Spondyloarthritis: Data from Two Corrona Registries, Rheumatology and therapy, 2019 Dec;6(4):529-542

Acknowledgements

I would like to thank The Finnish Society for Rheumatology and The Finnish Psoriasis Association for their grants.

Disclosure of Interests

None declared

Automated Text Message-Enhanced Monitoring Versus Routine Monitoring in Early Rheumatoid Arthritis: A Randomized Trial

OBJECTIVE

Frequent monitoring of patients with early rheumatoid arthritis (RA) is required for achieving good outcomes. This study was undertaken to investigate the influence of text message (SMS)-enhanced monitoring on early RA outcomes.

METHODS

We randomized 166 patients with early, disease-modifying antirheumatic drug-naive RA to receive SMS-enhanced follow-up or routine care. All patients attended visits at 0, 3, and 6 months, and a follow-up visit at 12 months. Treatment was at the physicians' discretion. The intervention included 13 SMSs during weeks 0-24 with questions concerning medication problems (yes/no) and disease activity (patient global assessment [PtGA], scale 0-10). Patients were contacted if response SMSs indicated medication problems or PtGA exceeded predefined thresholds. Primary outcome was 6-month Boolean remission (no swollen or tender joints and normal C-reactive protein levels). Quality of life (QoL; measured by the Short Form 36 survey) and Disease Activity Score in 28 joints (DAS28) were assessed.

RESULTS

Six and 12-month follow-up data were available for 162 and 157 patients, respectively. In the intervention group, 46% of the patients (38 of 82) reported medication problems and 49% (40 of 82) reported text message PtGAs above the alarm limit. Remission rates at 6 months (P = 0.34) were 51% in the intervention group and 42% in the control group. These rates were 57% and 43% at 12 months (P = 0.17) in the intervention and control groups, respectively. The respective mean ± SD DAS28 scores for the intervention and control groups were 1.92 ± 1.12 and 2.22 ± 1.11 at 6 months (P = 0.09); and 1.79 ± 0.91 and 2.08 ± 1.22 at 12 months (P = 0.28). No differences in QoL were observed.

CONCLUSION

The study did not meet the primary outcome despite a trend favoring the intervention group. This may be explained by the notably high overall remission rates.

THU0561 PREDICTING LIVER TOXICITY CAUSED BY CONVENTIONAL SYNTHETIC DISEASE-MODIFYING ANTIRHEUMATIC DRUGS

Background:

Routine laboratory testing is recommended for early identification of toxicity during conventional synthetic disease modifying antirheumatic drug (csDMARD) treatment. Based on expert consensus, testing is recommended every 2–4 weeks for the first 3 moths and quarterly thereafter (1).

Objectives:

In addition to evaluating the incidence of alanine transaminase (ALT) elevations in rheumatoid arthritis (RA) patients initiated on 1–2 csDMARDs, we aimed to distinguish patterns in ALT levels to develop a model for identifying patients at high risk for liver toxicity.

Methods:

We identified RA patients who were initiated a new csDMARD course at the rheumatology clinic of Turku University Hospital in 2013–2019. Baseline and follow-up safety monitoring results were drawn from the electronic health record (EHR) data. Data on diagnoses and csDMARD initiation/cessation dates were manually confirmed from the EHR.

As the primary endpoint, we used ALT-elevations of more than twice the upper limit of reference range (women ≥ 70 U/l, men ≥ 100 U/l) within 6 months after treatment initiation. Intergroup differences were tested using Mann-Whitney test for continuous variables and the chi-square test or Fisher’s exact test (n<5) for categorical variables. Associations between different characteristics and the primary endpoint were tested using Cox proportional hazards regression.

Results:

We identified 2851 RA patients of whom 1017 initiated a new csDMARD course requiring laboratory monitoring. Of these, 860 patients (58.9 years, 68% women, 65% seropositive) were included in the analyses after excluding patients with missing laboratory results (n=148) or elevated ALT at baseline (n=9). Of the 860 patients, 220 initiated two csDMARDs simultaneously [99% sulfasalazine (SSZ) and methotrexate (MTX)]. Primary endpoint was reached in 55 of 860 (6.4%) patients, including 10 who initiated two csDMARDS. Of these 55 patients, primary endpoint was reached in 40 of 55 (73%) patients during first three follow-up tests. In 31 of 55 (56%) patients, including 3 initiators of 2 csDMARDs, elevated ALT led to csDMARD cessation during the first 6 months. In Cox proportional hazards model with age, sex, seropositivity, baseline ALT, and csDMARDs as the explanatory variables, only baseline ALT level [hazard ratio 1.56 per 1 SD increase, 95% confidence interval (CI) 1.30–1.88, p<0.001] was associated with incident ALT-elevations. Survival according to normalized baseline ALT is shown in Figure, where normalized ALT value of 1.0 refers to the upper limit of reference range (women 35 U/l, men 50 U/l).

Table.

Multivariable Cox proportional hazards model including the results of the first follow-up laboratory test. Only values before occurrence of primary endpoint were used (n=843).

CharacteristicHazard ratio (95% CI)P ValueAge (per year)1.00 (0.98-1.02)0.78Sex (male)0.50 (0.21-1.15)0.10Seronegativity0.88 (0.44-1.75)0.71Baseline ALT*1.72 (1.32-2.25)<0.001ALT / t (per 1 SD increase / 30 days)§1.33 (1.17-1.52)<0.001Methotrexate0.58 (0.22-1.52)0.27Sulfasalazine0.95 (0.38-2.35)0.91Azathioprine2.30 (0.48-11.13)0.30Leflunomide1.08 (0.23-5.16)0.92

*Normalized ALT according to sex-specific reference range;§Rate of change from baseline to 1stfollow-up test

Conclusion:

Most incident ALT elevations can be predicted before the first csDMARD dose. Patients with elevated ALT at baseline or a rising trend at first follow-up are at high risk for liver toxicity and benefit from frequent testing.

References:

[1]Saag KG et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008;59:762-84.

Disclosure of Interests:

Laura Kuusalo Consultant of: Gilead, Pfizer Finland, Speakers bureau: Abbvie, Orion, Pfizer Finland, Novartis, Sanofi, Mikko Venäläinen: None declared, Sofia Saranpää: None declared, Heidi Kirjala: None declared, Laura Elo: None declared, Laura Pirilä Consultant of: Novartis, MSD Finland, Roche, Bristol-Myers-Squibb, Pfizer Finland, Sanofi, Abbvie, Eli Lilly Finland, UCB Pharma, Janssen-Cilag, Mylan, Sandoz, Boerhinger-Ingelheim, Paid instructor for: Boehringer-Ingelheim, MSD Finland, Speakers bureau: Boehringer-Ingelheim, Pfizer Finland

Patient-reported outcomes as predictors of remission in early rheumatoid arthritis patients treated with tight control treat-to-target approach

Identifying prognostic factors for remission in early rheumatoid arthritis (ERA) patients is of key clinical importance. We studied patient-reported outcomes (PROs) as predictors of remission in a clinical trial. We randomized 99 untreated ERA patients to receive remission-targeted treatment with three disease-modifying antirheumatic drugs and prednisolone for 24 months, and infliximab or placebo for the initial 6 months. At baseline, we measured following PROs: eight Short Form 36 questionnaire (SF-36) dimensions, patient's global assessment [PGA, visual analogue scale (VAS)], Health Assessment Questionnaire (HAQ), and pain VAS. We used multivariable-adjusted regression models to identify PROs that independently predicted modified American College of Rheumatology remission at 2 years. Follow-up data at 2 years were available for 93 patients (92%), and 58 patients (62%) were in remission. At baseline, patients who achieved remission had higher radiological score (p = 0.04), lower tender joint count (p = 0.001), lower PGA (p = 0.005) and physician's global assessment (p = 0.019), lower HAQ (p = 0.016), less morning stiffness (p = 0.009), and significantly higher scores in seven out of eight SF-36 dimensions compared with patients who did not. In multivariable models that included all PROs, remission was associated with SF-36 dimensions higher vitality (odds ratio 2.01; 95% confidence interval 1.19-3.39) and better emotional role functioning (odds ratio 1.64; 95% confidence interval 1.01-2.68). PGA, pain VAS, HAQ, and other SF-36 dimensions were not associated with remission. We conclude that self-reported vitality and better emotional role functioning are among the most important PROs for the prediction of remission in ERA.

Psychiatric (axis I) and personality (axis II) disorders in patients with burning mouth syndrome or atypical facial pain

Background and aims

Burning mouth syndrome (BMS) and atypical facial pain (AFP) are often persistent idiopathic pain conditions that mainly affect middle-aged and elderly women. They have both been associated with various psychiatric disorders. This study examined current and lifetime prevalence of psychiatric axis I (symptom-based) and II (personality) disorders in patients with chronic idiopathic orofacial pain, and investigated the temporal relationship of psychiatric disorders and the onset of orofacial pain.

Method

Forty patients with BMS and 23 patients with AFP were recruited from Turku university hospital clinics. Mean age of the patients was 62.3 years (range 35–84) and 90% were female. BMS and AFP diagnoses were based on thorough clinical evaluation, and all patients had undergone clinical neurophysiological investigations including blink reflex and thermal quantitative tests. Current and lifetime DSM-IV diagnoses of axis I and II disorders were made on clinical basis with the aid of SCID-I and II-interviews. The detected prevalence rates and their 95% confidence intervals based on binomial distribution were compared to three previous large population-based studies.

Results

Of the 63 patients, 26 (41.3%) had had an axis I disorder that preceded the onset of orofacial pain, and 33 (52.4%) had had a lifetime axis I disorder. Rate of current axis I disorders was 36.5%, indicating that only about 16% of lifetime disorders had remitted, and they tended to run chronic course. The most common lifetime axis I disorders were major depression (30.2%), social phobia (15.9%), specific phobia (11.1%), and panic disorder (7.9%). Twelve patients (19.0%) had at least one cluster C personality disorder already before the emergence of orofacial pain. Patients with cluster C personality disorders are characterized as fearful and neurotic. None of the patients had cluster A (characterized as odd and eccentric) or B (characterized as dramatic, emotional or erratic) personality disorders. The most common personality disorders were obsessive–compulsive personality (14.3%), dependent personality (4.8%), and avoidant personality (3.2%). The majority of the patients (54%) had also one or more chronic pain conditions other than orofacial pain. In almost all patients (94%) they were already present at the onset of orofacial pain.

Conclusions

Our results suggest that major depression, persistent social phobia, and neurotic, fearful, and obsessive–compulsive personality characteristics are common in patients with chronic idiopathic orofacial pain. Most psychiatric disorders precede the onset of orofacial pain and they tend to run a chronic course.

Implications

We propose that the high psychiatric morbidity, and comorbidity to other chronic pain conditions, in chronic idiopathic orofacial pain can be best understood in terms of shared vulnerability to both chronic pain and specific psychiatric disorders, most likely mediated by dysfunctional brain dopamine activity.