Latent Class Analysis Identifies Distinct Phenotypes of Systemic Lupus Erythematosus Predictive of Flares after mRNA COVID-19 Vaccination: Results from the Coronavirus National Vaccine Registry for ImmuNe Diseases SINGapore (CONVIN-SING)

We recently reported that messenger ribonucleic acid (mRNA) coronavirus disease 2019 (COVID-19) vaccination was associated with flares in 9% of patients with systemic lupus erythematosus (SLE). Herein, we focused our analysis on patients from a multi-ethnic Southeast Asian lupus cohort with the intention of identifying distinct phenotypes associated with increased flares after mRNA COVID-19 vaccination.

METHODS

Six hundred and thirty-three SLE patients from eight public healthcare institutions were divided into test and validation cohorts based on healthcare clusters. Latent class analysis was performed based on age, ethnicity, gender, vaccine type, past COVID-19 infection, interruption of immunomodulatory/immunosuppressive treatment for vaccination, disease activity and background immunomodulatory/immunosuppressive treatment as input variables. Data from both cohorts were then combined for mixed effect Cox regression to determine which phenotypic cluster had a higher risk for time to first SLE flare, adjusted for the number of vaccine doses.

RESULTS

Two clusters were identified in the test (C1 vs. C2), validation (C1' vs. C2') and combined (C1″ vs. C2″) cohorts, with corresponding clusters sharing similar characteristics. Of 633 SLE patients, 88.6% were female and there was multi-ethnic representation with 74.9% Chinese, 14.2% Malay and 4.6% Indian. The second cluster (C2, C2' and C2″) was smaller compared to the first. SLE patients in the second cluster (C2 and C2') were more likely to be male, non-Chinese and younger, with higher baseline disease activity. The second cluster (C2″) had more incident flares (hazard ratio = 1.4, 95% confidence interval 1.1-1.9, p = 0.014) after vaccination. A higher proportion of patients in C2″ had immunomodulatory/immunosuppressive treatment interruption for vaccination as compared to patients in C1″ (6.6% vs. 0.2%) (p < 0.001).

CONCLUSION

We identified two distinct phenotypic clusters of SLE with different patterns of flares following mRNA COVID-19 vaccination. Caution has to be exercised in monitoring for post-vaccination flares in patients with risk factors for flares such as non-Chinese ethnicity, young age, male gender and suboptimal disease control at the time of vaccination.

A Web-Based Patient Empowerment to Medication Adherence Program for Patients With Rheumatoid Arthritis: Feasibility Randomized Controlled Trial

BACKGROUND

Living with a chronic illness such as rheumatoid arthritis (RA) requires medications and therapies, as well as long-term follow-up with multidisciplinary clinical teams. Patient involvement in the shared decision-making process on medication regimens is an important element in promoting medication adherence. Literature review and needs assessment showed the viability of technology-based interventions to equip patients with knowledge about chronic illness and competencies to improve their adherence to medications. Thus, a web-based intervention was developed to empower patients living with RA to adhere to their disease-modifying antirheumatic drugs (DMARDs) medication regimen.

OBJECTIVE

This study aims to discuss the intervention mapping process in the design of a web-based intervention that supports patient empowerment to medication adherence and to evaluate its feasibility among patients living with RA.

METHODS

The theory-based Patient Empowerment to Medication Adherence Programme (PE2MAP) for patients with RA was built upon the Zimmerman Psychological Empowerment framework, a web-based program launched through the Udemy website. PE2MAP was developed using a 6-step intervention mapping process: (1) needs assessment, (2) program objectives, (3) conceptual framework to guide the intervention, (4) program plan, (5) adoption, and (6) evaluation involving multidisciplinary health care professionals (HCPs) and a multimedia team. PE2MAP is designed as a 4-week web-based intervention program with a complementary RA handbook. A feasibility randomized controlled trial was completed on 30 participants from the intervention group who are actively taking DMARD medication for RA to test the acceptability and feasibility of the PE2MAP.

RESULTS

The mean age and disease duration of the 30 participants were 52.63 and 8.50 years, respectively. The feasibility data showed 87% (n=26) completed the 4-week web-based PE2MAP intervention, 57% (n=17) completed all 100% of the contents, and 27% (n=8) completed 96% to 74% of the contents, indicating the overall feasibility of the intervention. As a whole, 96% (n=24) of the participants found the information on managing the side effects of medications, keeping fit, managing flare-ups, and monitoring joint swelling/pain/stiffness as the most useful contents of the intervention. In addition, 88% (n=23) and 92% (n=24) agreed that the intervention improved their adherence to medications and management of their side effects, including confidence in communicating with their health care team, respectively. The dos and do nots of traditional Chinese medicine were found by 96% (n=25) to be useful. Goal setting was rated as the least useful skill by 6 (23.1%) of the participants.

CONCLUSIONS

The web-based PE2MAP intervention was found to be acceptable, feasible, and effective as a web-based tool to empower patients with RA to manage and adhere to their DMARD medications. Further well-designed randomized controlled trials are warranted to explore the effectiveness of this intervention in the management of patients with RA.

Prevalence and factors associated with flares following COVID-19 mRNA vaccination in patients with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis: a national cohort study

OBJECTIVE

To determine prevalence and factors associated with flares post Coronavirus disease 2019 (COVID-19) mRNA vaccination in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and spondyloarthritis (SpA).

METHODS

A retrospective multi-centre study was conducted (January 2021 to February 2022). Data were collected during index visit, defined as first post-vaccine visit in which the patient had a physician-defined flare, or if at least 3 months had elapsed since first vaccine dose, whichever came first. Factors associated with flares were identified using mixed effects Cox regression and expressed as hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

Total of 2377 patients were included (1563 RA, 415 PsA and 399 SpA). Among patients with RA, PsA and SpA, 21.3%, 24.1% and 21.8% experienced a flare respectively. Of those who experienced a flare, only 10.2%, 11.0% and 14.9% were severe in patients with RA, PsA and SpA respectively. Patients with low or moderate/high disease were more likely to flare compared to those in remission in patients with RA only (HR: 1.68, 95% CI 1.22-2.31; HR: 2.28, 95% CI 1.50-3.48, respectively). Receiving the Moderna vaccine was associated with a higher HR of flare compared to the Pfizer vaccine in patients with PsA only (HR: 2.21, 95% CI 1.20-4.08). Patients who had two vaccine doses were found to be less likely to flare (HR: 0.08, 95% CI 0.06-0.10). HRs of flares were not significantly different among RA, PsA and SpA.

CONCLUSION

About one-fifth of patients experienced a disease flare post COVID-19 mRNA vaccination, but most flares were non-severe. Patients with active disease prior to vaccination should be monitored closely for disease flares, especially in patients with RA.

Recommendations for enhanced primary series (third dose) COVID-19 vaccination for people with rheumatic diseases: Chapter of Rheumatologists, College of Physicians, Singapore

Introduction

This review aims to provide evidence-based recommendations for an enhanced primary series (third dose) coronavirus disease 2019 (COVID-19) vaccination in people with rheumatic diseases (PRDs) in the local and regional context.

Methods

Literature reviews were performed regarding the necessity, efficacy, safety and strategies for enhanced primary series COVID-19 vaccination in PRDs. Recommendations were developed based on evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence was synthesised by eight working group members, and the consensus was achieved by a Delphi method with nine members of an expert task force panel.

Results

Two graded recommendations and one ungraded position statement were developed. PRDs have impaired immunogenicity from the COVID-19 vaccine and are at an increased risk of postvaccine breakthrough severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and poor clinical outcomes, compared to the general population. We strongly recommend that PRDs on immunomodulatory drugs be offered a third dose of the messenger RNA (mRNA) vaccine as part of an enhanced primary series, after the standard two-dose regimen. We conditionally recommend that the third dose of mRNA vaccine against SARS-CoV-2 be given at least 4 weeks after the second dose or as soon as possible thereafter. There is insufficient data to inform whether the third mRNA vaccine should be homologous or heterologous in PRDs.

Conclusion

These recommendations that were developed through evidence synthesis and formal consensus process provide guidance for an enhanced primary series COVID-19 vaccination in PRDs.

Smoking, but not use of complementary and alternative medicine predicts residual functional disability in patients with inflammatory arthritis on biologic disease-modifying anti-rheumatic drugs: Results from the Singapore National Biologics Register

AIMS

To describe inflammatory arthritis (IA) patients initiating biologic disease-modifying anti-rheumatic drugs (bDMARDs) who use complementary and alternative medicine (CAM), and determine the impact of CAM on predicting modified Health Assessment Questionnaire (mHAQ) at 6 months.

METHODS

This was a prospective inception cohort study of patients ≥21 years old initiating a bDMARD for IA after July 2016. Data were obtained via questionnaires and abstraction from medical records. Baseline characteristics between ever-CAM and CAM non-users were compared. CAM as a predictor of mHAQ ≥1 at 6 months after bDMARD initiation was analyzed using multivariate logistic regression, adjusting for other baseline characteristics.

RESULTS

We recruited 299 patients (36.2% male, mean age 49.0 years). There were 45.8% who had rheumatoid arthritis, 54.2% had a spondyloarthropathy, median disease duration of 1.1 years and median mHAQ of 0.4. Compared to CAM non-users, ever-CAM users had a lower mean body mass index, were less likely to speak English, and more likely to smoke and drink alcohol. There was no association of CAM use with high mHAQ and no interaction with smoking. Smoking (odds ratio [OR] 938.9; 95% CI 3.20-275 884.1), baseline mHAQ (OR 252.2; 95% CI 5.34-11 899.2) and Charlson's Comorbidity Index score ≥4 (OR 237.4; 95% CI 1.22-46 184.4) independently predicted high mHAQ at 6 months.

CONCLUSIONS

CAM use was not associated with high mHAQ at 6 months. Smoking was an independent predictor of residual functional disability at 6 months, even after adjusting for age, comorbidity and baseline mHAQ. Greater emphasis on smoking cessation may improve long-term functional outcomes in IA patients on bDMARDs.

Post-mRNA vaccine flares in autoimmune inflammatory rheumatic diseases: Results from the COronavirus National Vaccine registry for ImmuNe diseases SINGapore (CONVIN-SING)

BACKGROUND

Studies of flares of autoimmune inflammatory rheumatic diseases (AIIRD) after COVID-19 mRNA vaccination are limited by small sample size, short follow up or at risk of selection bias.

METHODS

A national retrospective cohort study of consecutive AIIRD patients ≥12 years old, across 8 hospitals who received at least one dose of a COVID-19 mRNA vaccine. Patients were included from the date of 1st vaccine dose and censored at the time of flare or on the date of the clinic visit at least 3 months from cohort entry, whichever came first. Predictors of flare were determined by Cox proportional hazards analysis.

FINDINGS

4627 patients (73% Chinese, 71% female) of median (IQR) age 61 (48, 70) years were included; 42% Rheumatoid arthritis, 14% Systemic lupus erythematosus and 11% Psoriatic arthritis. 47% were in remission, 41% low disease activity, 10% moderate disease activity and 1% in high disease activity. 18% patients flared, of which 11.7% were within the 3-month period of interest. 11.8% patients improved. Median (IQR) time-to-flare was 60 (30, 114) days. 25% flares were self-limiting, 61% mild-moderate and 14% severe. Older patients (53-65 years and >66 years) had a lower risk of flare [HR 0.6 (95% CI 0.5-0.8) and 0.7 (0.6-0.8) respectively]. Patients with inflammatory arthritis and with active disease had a higher risk of flare [HR 1.5 (1.2-2.0) and 1.4 (1.2-1.6), respectively]. Treatment with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), immunosuppression and prednisolone was also associated with an increased risk of flare [HR 1.5 (1.1-2), 1.2 (1.1-1.4) and 1.5 (1.2-1.8) for prednisolone ≤7.5 mg respectively].

INTERPRETATION

There was a moderately high rate of AIIRD flares after mRNA vaccination but also improvement in several patients. Severe flares and hospitalisation were rare. Thus, vaccination remains safe and highly recommended.

POS0200 POST-mRNA VACCINE FLARES IN AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES: INTERIM RESULTS FROM THE CORONAVIRUS NATIONAL VACCINE REGISTRY FOR IMMUNE DISEASES SINGAPORE (CONVIN-SING)

Background

Published data suggest no increased rate of flare of autoimmune inflammatory rheumatic diseases (AIIRD) after COVID-19 mRNA vaccination; however, the studies are limited by small sample size, short follow up or at risk of selection bias (voluntary physician reports or patient surveys).

Objectives

To study flares of AIIRD within three months of the first dose of an anti-SARS-COV2 mRNA vaccine.

Methods

A retrospective cohort study of consecutive AIIRD patients ≥ 12 years old, across six public hospitals in Singapore who received at least one dose of an mRNA (Pfizer/BioNTech or Moderna) vaccine. Data were censored at the first post-vaccine clinic visit when the patient had flared or if ≥ three months had elapsed since the first dose of the vaccine, whichever came first. Predictors of flare were determined by Cox proportional hazards analysis and time to flare was examined using a Nelson Aalen cumulative hazard estimate (Figure 1).

Figure 1.

Nelson-Aalen curve of flares over time

Results

2339 patients (74% Chinese, 72% female) of median (IQR) age 64 (53, 71) years were included in the interim analysis (Table 1). 2112 (90%) had the Pfizer/BioNTech vaccine and 195 (8%) had Moderna, with a median (IQR) interval of 21 (21, 23) days between the two doses. The most common AIIRD diagnoses were Rheumatoid arthritis (1063, 45%), Psoriatic arthritis (296, 12.6%) and Systemic lupus erythematosus (SLE) (288, 12.3%). 186 (8%) were treated with biologics/ targeted disease modifying agents. 2125 (91%) patients were in low disease activity or remission. Treatment was interrupted for vaccination in only 18 (0.8%) patients. Seven (0.3%) patients had previous COVID-19 infection.

Table 1.

Patient characteristics

Baseline characteristicsNo flares(n = 1887, %)Flares within 0—3 months of 1st vaccine dose (n= 272, %)Flares outside of 0 – 3 months after 1st vaccine dose (n = 180, %)Age (median years, IQR)64 (53, 71)61 (50, 69)65 (55, 71)RaceChinese1386 (73)206 (76)129 (72)Malay193 (10)28 (10)20 (11)Indian195 (10)27 (10)26 (14)GenderFemale1367 (72)200 (74)117 (65)Vaccine typePfizer/BioNTech1713 (92)239 (90)160 (90)Moderna149 (8)28 (10)18 (10)DiagnosisRheumatoid Arthritis831 (44)139 (51)93 (52)Systemic Lupus Erythematosus269 (14)20 (7)9 (5)Psoriatic Arthritis225 (12)42 (15)29 (16)Spondyloarthropathies141 (7)21 (7)17 (9)Sjogren’s Syndrome114 (6)15 (6)8 (4)Systemic sclerosis94 (5)4 (1)6 (3)Baseline Physician Disease ActivityRemission1007 (53)99 (36)63 (35)Low Disease Activity731 (39)128 (47)97 (54)Moderate Disease Activity134 (7)40 (15)20 (11)High Disease Activity15 (1)5 (2)0

452 (19%) flares were recorded during 9798.8 patient-months [4.6/100 patient-months, median (IQR) follow up duration 4.2 (3.3, 5.3) months], of which 272 (11.6%) patients flared within the 3-month period of interest and 180 (7.7%) flared outside of the 3-month period (Table 1). Median (IQR) time-to-flare was 40.5 (18, 56.6) days. 60 (22.1%) were mild and self-limiting, 170 (62.5%) were mild-moderate and 42 (15.4%) were severe. 190 (69.8%) of those who flared required escalation of treatment and 15 (5.5%) required hospital admission. 239 (10.2%) had improved disease activity after the vaccine.

On multivariate Cox regression analysis, patients in the oldest age tertile [median (IQR) 74 (71, 79) years] were less likely to flare [HR 0.80 (95% CI 0.63, 1.00), p = 0.05] Patients with inflammatory arthritis (compared with connective tissue disease, vasculitis and others) and patients with baseline active disease were more likely to flare [HR 1.72 (95% CI 1.35, 2.20), p < 0.001 and 1.82 (95% CI 1.39, 2.39), p < 0.001 respectively]

Conclusion

There was a moderately high rate of AIIRD flares after mRNA vaccination; however, there was no clustering of flares in the immediate post-vaccine period to suggest causality. Older patients were less likely to flare, while those with inflammatory arthritis and active disease at baseline were more likely to flare.

Disclosure of Interests

Margaret Ma Grant/research support from: Support grant from multiple companies for the Singapore Biologics registry, Amelia Santosa Speakers bureau: Amgen Talk, Consultant of: Pfizer ad board, Kok Ooi Kong: None declared, Chuanhui Xu: None declared, Johnston Tang Gin Xiang: None declared, Gim Gee Teng Speakers bureau: Boehringer Ingleheim, Anselm Mak Speakers bureau: J&J and GSK, Grant/research support from: GSK - the supported studies programme, Sen Hee Tay: None declared, Victoria Wei Wen Ng: None declared, Joshua Zhi En Koh: None declared, Warren Fong Speakers bureau: speaker for Abbvie, DKSH, GSK, Novartis, Li-Ching Chew Speakers bureau: pfizer and Abbvie, Consultant of: Pfizer and Abbvie Advisory Board meeting, Grant/research support from: Abbvie educational grant for ultrasound conference, Andrea Low Speakers bureau: Boehringer Ingeilheim, Consultant of: Consultant/steering group committee for BI and J&J, annie law: None declared, Yih Jia Poh: None declared, Siaw Ing Yeo Grant/research support from: Multiple pharmaceutical companies for the support of the National Biologics Registry, Ying Ying Leung Speakers bureau: Abbvie, DKSH, Jassen, Novartis and Pfizer, Wei-Rui Goh: None declared, Chuah Tyng Yu: None declared, Nur Emillia Roslan: None declared, Stanley Angkodjojo Speakers bureau: Boehringer Ingeilheim, Consultant of: Abbvie and DKSH, Kee Fong Phang: None declared, Thaschawee Arkachaisri: None declared, Melonie Sriranganathan: None declared, Teck Choon TAN: None declared, Peter Cheung Consultant of: Ad board for Boehringer Ingleheim, novartis, janssen and abbvie, Grant/research support from: Novartis, Manjari Lahiri Speakers bureau: J&J, DSKH, Consultant of: DSKH, Gilead, Grant/research support from: Multiple pharma companies contributed to the Singapore Biologics registry

Novartis

Clinical remission of rheumatoid arthritis in a multicenter real-world study in Asia-Pacific region

BACKGROUND

Clinical remission is an attainable goal for Rheumatoid Arthritis (RA). However, data on RA remission rates from multinational studies in the Asia-Pacific region are limited. We conducted a cross-sectional multicentric study to evaluate the clinical remission status and the related factors in RA patients in the Asia-Pacific region.

METHODS

RA patients receiving standard care were enrolled consecutively from 17 sites in 11 countries from APLAR RA SIG group. Data were collected on-site by rheumatologists with a standardized case-report form. Remission was analyzed by different definitions including disease activity score using 28 joints (DAS28) based on ESR and CRP, clinical disease activity index (CDAI), simplified disease activity index (SDAI), Boolean remission definition, and clinical deep remission (CliDR). Logistic regression was used to determine related factors of remission.

FINDINGS

A total of 2010 RA patients was included in the study, the overall remission rates were 62•3% (DAS28-CRP), 35•5% (DAS28-ESR), 30•8% (CDAI), 26•5% (SDAI), 24•7% (Boolean), and 17•1% (CliDR), respectively, and varied from countries to countries in the Asia-Pacific region. Biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) prescription rate was low (17•9%). Compared to patients in non-remission, patients in remission had higher rates of b/tsDMARDs usage and lower rates of GC usage. The favorable related factors were male sex, younger age, fewer comorbidities, fewer extra-articular manifestations (EAM), and use of b/tsDMARDs, while treatment with GC was negatively related to remission.

INTERPRETATION

Remission rates were low and varied in the Asia-Pacific region. Treatment with b/tsDMARDs and less GC usage were related to higher remission rate. There is an unmet need for RA remission in the Asia-Pacific region.

Extrapulmonary manifestations and complications of severe acute respiratory syndrome coronavirus 2 infection: a systematic review

INTRODUCTION

We aimed to describe the extrapulmonary manifestations of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, including their frequency, onset with respect to respiratory symptoms, pathogenesis and association with disease severity.

METHODS

We searched the MEDLINE and Embase databases for SARS-CoV-2-related studies. Meta-analysis, observational studies, case series and case reports published in English or Chinese between 1 January and 1 May 2020 were included. Reports with only paediatric or obstetric cases were excluded.

RESULTS

169 articles were included. Early manifestations (preceding respiratory symptoms until Day 6 of onset) included olfactory and gustatory disturbance (self-reported in up to 68% and 85% of cases, respectively), gastrointestinal symptoms (up to 65.9%) and rash (up to 20.4%). From Day 7 onwards, hypercytokinaemia, paralleled multi-organ complications including acute cardiac injury (pooled incidence of 17.7% in 1,412 patients, mostly with severe disease and 17.4% mortality), kidney and liver injury (up to 17% and 33%, respectively) and thrombocytopenia (up to 30%). Hypercoagulability resulted in venous thromboembolic events in up to 31% of all patients. Uncommon disease presentation and complications comprised Guillain-Barré syndrome, rhabdomyolysis, otitis media, meningoencephalitis and spontaneous pneumomediastinum.

CONCLUSION

Although the systemic manifestations of SARS-CoV-2 infection are variegated, they are deeply interwoven by shared mechanisms. Two phases of extrapulmonary disease were identified: (a) an early phase with possible gastrointestinal, ocular and cutaneous involvement and (b) a late phase characterised by multiorgan dysfunction and clinical deterioration. A clear, multidisciplinary consensus to define and approach thromboinflammation and cytokine release syndrome in SARS-CoV-2 is needed.

Recommendations for COVID-19 vaccination in people with rheumatic disease: Developed by the Singapore Chapter of Rheumatologists

Aim

People with rheumatic diseases (PRD) remain vulnerable in the era of the COVID‐19 pandemic. We formulated recommendations to meet the urgent need for a consensus for vaccination against SARS‐CoV‐2 in PRD.

Methods

Systematic literature reviews were performed to evaluate: (a) outcomes in PRD with COVID‐19; (b) efficacy, immunogenicity and safety of COVID‐19 vaccination; and (c) published guidelines/recommendations for non‐live, non‐COVID‐19 vaccinations in PRD. Recommendations were formulated based on the evidence and expert opinion according to the Grading of Recommendations Assessment, Development and Evaluation methodology.

Results

The consensus comprises 2 overarching principles and 7 recommendations. Vaccination against SARS‐CoV‐2 in PRD should be aligned with prevailing national policy and should be individualized through shared decision between the healthcare provider and patient. We strongly recommend that eligible PRD and household contacts be vaccinated against SARS‐CoV‐2. We conditionally recommended that the COVID‐19 vaccine be administered during quiescent disease if possible. Immunomodulatory drugs, other than rituximab, can be continued alongside vaccination. We conditionally recommend that the COVID‐19 vaccine be administered prior to commencing rituximab if possible. For patients on rituximab, the vaccine should be administered a minimum of 6 months after the last dose and/or 4 weeks prior to the next dose of rituximab. Post‐vaccination antibody titers against SARS‐CoV‐2 need not be measured. Any of the approved COVID‐19 vaccines may be used, with no particular preference.

Conclusion

These recommendations provide guidance for COVID‐19 vaccination in PRD. Most recommendations in this consensus are conditional, reflecting a lack of evidence or low‐level evidence.

Attitudes and Behaviors of Patients With Rheumatic Diseases During the Early Stages of the COVID-19 Outbreak

Objective.

To evaluate attitudes and behaviors of patients with rheumatic diseases during the coronavirus disease 2019 (COVID-19) pandemic.

Methods.

An online survey delivered by text message to 4695 patients on follow-up at a tertiary rheumatology center. Latent class analysis was performed on the survey variables.

Results.

There were 2239 (47.7%) who responded to the survey and 3 clusters were identified. Cluster 3 (C3) was defined by patients who were most worried about COVID-19, more likely to wear face masks, and more likely to alter or stop their medications. Patients in C3 were more likely to be female, Malay, and unemployed.

Conclusion.

We identified 3 clusters with different healthcare beliefs and distinct sociodemographics.

THU0260 GLUCOCORTICOID DOSE IS AN INDEPENDENT PREDICTOR OF MORTALITY IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS HOSPITALIZED FOR INFECTION

Background:

Infection is an important cause of mortality and morbidity in patients with systemic lupus erythematosus (SLE) and a common cause for hospitalization. Glucocorticoids (GC) may contribute to increased mortality.

Objectives:

We performed a 10-year retrospective study of SLE patients hospitalized for infection, and the clinical predictors of mortality, especially GC dose, in these patients.

Methods:

Diagnosis codes for SLE were obtained from the electronic medical records for hospitalized patients from 2005 to 2015. Chart review was performed to ascertain the indication for hospitalization. The first hospitalization for infection (if any) was used as the index admission. Demographic and clinical characteristics, infection site and immunosuppressive drugs over the past month were abstracted. Multivariable logistic regression was used to determine predictors of all-cause mortality at 1 year.

Results:

Diagnosis codes were obtained for 768 unique SLE patients with 3660 hospitalization episodes over 10 years, of which 689 had a physician diagnosis of SLE on chart review. Of these, 250 (36%) had an index admission for infection. 243/250 (97.2%) fulfilled the ACR 1997 criteria for SLE and were studied further (Figure 1). Median (IQR) age was 45.1 (37.3, 56) years, 86% were female, 72% were Chinese, median (IQR) disease duration was 9 (4, 17) years. 53 (21.8%) patients had chronic kidney disease (CKD), 34 (14%) had diabetes mellitus (DM) and 12 (4.9%) had cancer. 231 (95.1%) patients were on immunosuppressive drugs and 210 (86.4%) were on GC. The median (IQR) GC dose was 8 (5, 15) mg oral prednisolone equivalent per day. The median (IQR) Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score was 4 (1, 10). The most common organism was Escherichia coli, followed by Staphylococcus aureus and Salmonella enteritidis. The respiratory tract was the most common site of infection. 27.9% of patients who had blood cultures performed had bacteremia. There were 11 (4.5%) ICU admissions, 6 (2.5%) patients died in hospital and 1-year all-cause mortality was 13 (5.3%). SLEDAI had only a weak positive correlation with GC dose [R2= 0.039/Pearson’s correlation = 0.197, p = 0.004)] (Figure 2). Increased age (odds ratio (OR) 1.07, 95% CI 1.02-1.12, p = 0.005), average daily GC dose (OR 1.05, 95% CI 1.02-1.09, p = 0.002), bone infections (OR 42.24, 95% CI 2.76-646.8, p = 0.007) and CKD (OR 4.78, 95% CI 1.06-21.54, p = 0.04) were independent predictors of 1-year mortality, after adjusting for gender, SLEDAI, DM, and cancer (Table 1).

Table 1.

Predictors of mortality

FactorsUnivariableOdds Ratio(95% CI)P-valueMultivariableOdds Ratio(95% CI)P-valueAge at admission (years)1.04 (1.005, 1.07)0.021.07 (1.02,1.12)0.005Average dose of oral prednisolone (mg/day)1.04 (1.01, 1.06)0.0061.05 (1.02,1.09)0.002Gender (female vs male)3.52 (1.22, 10.12)0.020.37 (0.07, 2.10)0.26Disease duration > 10 years1.27 (0.49, 3.33)0.62Positive blood culture0.54 (0.17, 1.75)0.30Site of infectionGastrointestinal1 (reference)0.170.06Respiratory1.09 (0.28, 4.29)0.900.71 (0.09, 5.57)0.74Renal0.27 (0.03, 2.48)0.250.44 (0.03, 5.94)0.54Skin, Gynecological, Other0.94 (0.25, 3.51)0.931.04 (0.16, 6.74)0.96Bone11.75 (1.29, 107.1)0.0342.24 (2.76, 646.8)0.007Primary Bacteremia0.00 (0.00, 0.00)0.990.00 (0.00, 0.00)0.99SLEDAI score ≥41.23 (0.47, 3.21)0.660.65 (0.15, 2.74)0.56Diabetes Mellitus0.46 (0.14, 1.50)0.201.61 (0.31, 8.3)0.57Chronic Kidney Disease0.30 (0.11, 0.78)0.014.78 (1.06, 21.54)0.04Cancer0.18 (0.04, 0.77)0.023.52 (0.25, 48.82)0.35

Conclusion:

Higher dose of oral GC was an independent predictor of mortality, even after adjusting for disease activity. It is important to prescribe the minimum effective dose of GC in SLE patients with infection, especially in older patients with CKD and bone infection.

Disclosure of Interests:

Thurston Yan Jia Heng: None declared, Nicholas Chew: None declared, Kexin Amanda Choo: None declared, Aisha Lateef: None declared, Manjari Lahiri Grant/research support from: Manjari Lahiri is the site principal investigator for the Singapore National Biologics Register, which is a multi-pharmaceutical funded register, in which industry sponsors provide support through the Chapter of Rheumatologists, Singapore. Dr Lahiri does not personally receive any remuneration.

FRI0530 THE PREVALENCE AND DETERMINANTS OF SLEEP PROBLEMS IN PATIENTS ACROSS RHEUMATIC DISEASES AND THEIR CORRELATION WITH DISEASE INDICES USING THE ROUTINE ASSESSMENT OF PATIENT INDEX DATA 3 (RAPID3) QUESTIONNAIRE

Background:

Sleep problems are common in rheumatology patients. RAPID3 is a patient reported outcome measure (PROM) that efficiently screens for problems with sleep, anxiety or depression in routine care.

Objectives:

To study prevalence and determinants of self-reported sleep problems across rheumatic diseases in Rheumatology clinics in Singapore, and its correlation with disease indices.

Methods:

RAPID3 questionnaire was filled electronically over 6 months. Demographic data and SNOWMED diagnoses codes were matched through hospital electronic medical records. RAPID3 comprised of 3 questions measuring the extent of difficulty getting a good night’s sleep and dealing with anxiety or depression. Significant problems were considered if they had “much difficulty” or were “unable to do” the component. The relationship of sleep with anxiety, depression, physical function (measured by modified health assessment questionnaire, mdHAQ), pain and patient global assessment (using visual analogue scale, VAS), was evaluated using Pearson’s correlation. Factors associated with significant sleep problems were evaluated by logistic regression.

Results:

4078 patients [mean (SD) age 55.8 (16.3) years, 67.9% female, 70.6% Chinese] were invited to participate, of which 2625 (64.4%) responded. SNOMED diagnosis codes were available for 1570 (59.8%) patients- majority had inflammatory arthritides (n= 843, 53.7%) (Figure 1).

Mean mdHAQ was 0.3 (0.5), pain VAS was 2.4 (2.3) and global VAS was 2.6 (2.2). Data on disease duration, clinical features and medications were not available. 39.3%, 27.5% and 23.8% had problems with sleep, anxiety and depression respectively; and 7.3%, 4.5% and 4.3% had significant problems respectively. Sleep moderately correlated with anxiety (r=0.463, p<0.001) and depression (r=0.436, p<0.001) and weakly correlated with mdHAQ (r= 0.289, p<0.001), global (r=0.339, p<0.001) and pain VAS (r= 0.314, p<0.001).

In multivariable logistic regression, significant sleep problems were associated with anxiety (OR 4.733, CI 2.172-10.310, p<0.001), mdHAQ score ≥ 1 (OR 2.920, CI 1.691-5.043, p< 0.001) and pain VAS >3 (OR 1.884, CI 1.093-3.247, p=0.023). Patients with osteoarthritis and fibromyalgia were more likely than those with inflammatory arthritides to have significant sleep problems, though we were unable to adjust for body mass index as data were unavailable (Table 1).

Table 1.

Determinants of significant disturbances in sleep in patients with rheumatic diseases

VariablesUnivariableMultivariableOdds ratio (95% CI)p-valueOdds ratio (95% CI)p-valueGenderFemale1.79 (1.245-2.57)0.0021.49 (0.86-2.59)0.16EthnicityChineseRefRefMalay1.04 (0.62-1.73)0.890.73 (0.33-1.61)0.43Indian1.59 (1.03-2.44)0.040.97 (0.49-1.90)0.92Others1.05 (0.62-1.77)0.870.92 (0.43-2.00)0.84Age (years)1.00 (1.00-1.01)0.36--mdHAQ ≥16.25 (4.46-8.75)<0.0012.92 (1.69-5.04)0.001Pain VAS >34.15 (3.07-5.61)<0.0011.88 (1.09-3.25)0.02Global VAS > 34.25 (3.13-5.76)<0.0011.63 (0.95-2.80)0.07Significant anxiety15.99 (10.71- 23.89)<0.0014.73 (2.17-10.31)<0.001Significant depression15.58 (10.35-23.45)<0.0013.02 (1.29-7.10)0.11Primary rheuma-tological diagnosisInflammatory arthritidesRefRefConnective tissue diseases1.18 (0.73-1.90)0.510.9 (0.51-1.59)0.71Crystal arthritides1.06 (0.48-2.33)0.880.83 (0.34-2.03)0.68Osteoarthritis3.09 (1.31-7.32)0.012.96 (1.19-7.36)0.02Fibromyalgia9.05 (2.04-40.05)0.0049.62 (2.11-43.84)0.003Others1.63 (0.82-3.29)0.171.20 (0.58-2.47)0.63

Conclusion:

Sleep problems are common in rheumatology patients and correlate significantly with disease indices and psychological distress. Rheumatologists should routinely screen for sleep difficulties, especially in patients with osteoarthritis and fibromyalgia.

References: -

Acknowledgments:

Nil.

Disclosure of Interests:

Charlotte Tan: None declared, Peter Cheung: None declared, Manjari Lahiri Grant/research support from: Manjari Lahiri is the site principal investigator for the Singapore National Biologics Register, which is a multi-pharmaceutical funded register, in which industry sponsors provide support through the Chapter of Rheumatologists, Singapore. Dr Lahiri does not personally receive any remuneration.

FRI0033 ANTI-CARBAMYLATED PROTEIN POSITIVITY PREDICTS DAS28-REMISSION AT 12 MONTHS IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS: RESULTS FROM THE SINGAPORE EARLY ARTHRITIS COHORT

Background:

Anti-carbamylated protein antibody (anti-carp) positivity has been associated with poorer outcomes in Western cohorts of early rheumatoid arthritis; however, it is unknown if this applies to Asians.

Objectives:

We determined whether anti-carp predicted DAS28-remission, disability and radiographic progression in a multi-ethnic Asian ERA cohort.

Methods:

Patients with physician diagnosed ERA (symptom duration ≤1 year) were recruited from the Singapore Early Arthritis Cohort (n= 317) by convenience sampling. Serum anti-carp was measured cross-sectionally using a commercial ELISA (SincereBio). The test was repeated in 40 healthy individuals to establish the optimal sensitivity and specificity for the diagnosis of RA via a receiver operating curve. Disease activity (DAS28-ESR or DAS28-CRP) was recorded at baseline, 3, 6 and 12 months. Two independent accessors quantified the radiographic damage at baseline and at follow-up using the modified Sharp van der Heijde score (mSS). We used multivariable logistic regression to determine whether anti-carp predicted the following outcomes; (i) DAS-28 remission at 12 months, (ii) any disability (mHAQ>0) at 12 months and (iii) radiographic progression (any increase in the mSS). In each regression model, we chose covariates known to influence the dependent variable in our cohort or from literature.

Results:

One hundred patients were recruited, of mean age (SD) 49.8 (12.5) years, median (IQR) disease duration 10.2 (6.9-15.1) weeks at cohort entry and baseline median DAS-28 4.5 (2.9-5.9) (Table 1). The anti-carp assay was performed after a median (IQR) disease duration of 2.24 (1.82-3.14) years. 93 patients had baseline hand radiographs and 66 had follow-up hand radiographs after ≥ 12 months. Receiver operating characteristics curve yielded optimal sensitivity (95%) and specificity (60%) for the diagnosis of RA at 1.60OD. Therefore, 60 patients were anti-carp positive and 35 patients (37.2%) were positive for RF, ACPA and anti-carp (Figure 1). Anti-carp positivity independently predicted DAS28-remission at 12 months (OR 3.41, 95% CI 1.08-10.7,p=0.04) (Table 2). Anti-carp positivity did not predict disability at 12 months (OR 0.61, 95% CI 0.18-2.07,p=0.43) or radiographic progression (OR 0.23, 95% CI 0.03-2.03,p=0.18).

Table 1.

Predictors of DAS28-remission at 12 months

VariableN (%)Univariable Logistic RegressionMultivariable Logistic RegressionORpOR (CI)SEpAnti-carp60 (60)3.0 (1.31−6.88)0.013.41 (1.08−10.7)1.990.04SerologyRF and ACPA negative31 (33.0)RefEither RF or ACPA positive11 (11.7)0.99 (0.25−3.93)0.991.10 (0.17−7.04)1.040.92RF and ACPA positive52 (55.3)1.12 (0.45−2.75)0.800.89 (0.28−2.81)0.520.84Baseline DAS28Remission17 (17.4)RefLow DA10 (10.2)0.50 (0.05−4.67)0.540.13 (0.01−1.67)0.170.12Mod DA32 (32.7)0.29 (0.05−1.65)0.160.10 (0.02−0.68)0.100.02High DA39 (39.8)0.18 (0.04−0.90)0.040.06 (0.01−0.41)0.06<0.01Combination csDMARDs or biologic DMARD74 (74)1.13 (0.46−2.76)0.801.97 (0.58−6.67)1.230.28Radiographic damage at baseline11 (20)1.79 (0.65−4.95)0.261.27 (0.33-4.95)0.880.73Tertiary education23 (38.3)0.77 (0.34-1.77)0.540.42 (0.12-1.45)0.270.17EthnicityChinese42 (70)RefMalay39 (68.4)0.61 (0.22-1.71)0.350.56 (0.14-2.25)0.400.41Indian8 (13.3)0.60 (0.20-1.77)0.350.79 (0.20-3.13)0.560.74Females46 (76.7)0.43 (0.17-1.11)0.080.48 (0.13-1.85)0.330.29

Conclusion:

Contrary to previous studies done on Western cohorts where anti-carp predicted worse outcomes, anti-carp positivity predicted DAS28-remission at 12 months in our multi-ethnic Asian cohort. This suggests that different genetic and environmental determinants account for anti-carp expression in patients with RA.

Disclosure of Interests:

Jiacai Cho: None declared, Anselm Mak Speakers bureau: Professor Anselm Mak has been paid as a speaker for Johnson & Johnson., Sachin Agrawal: None declared, Preeti Dhanasekaran: None declared, Lay Kheng Teoh: None declared, Peter Cheung: None declared, Manjari Lahiri Grant/research support from: Manjari Lahiri is the site principal investigator for the Singapore National Biologics Register, which is a multi-pharmaceutical funded register, in which industry sponsors provide support through the Chapter of Rheumatologists, Singapore. Dr Lahiri does not personally receive any remuneration.

The cost of repetitive laboratory testing for chronic disease

Interval laboratory investigations are necessary for monitoring chronic diseases. However, testing too frequently may not be beneficial clinically and can be considered low-value care. We examined the frequency of glycosylated haemoglobin, lipids, iron panels (serum iron, ferritin, transferrin, iron binding) thyroid function (free T4 and thyroid stimulating hormone) and 25-OH vitamin D tests in a 1290-bed tertiary hospital in Singapore. All tests done over a 20-month period (January 2016 to August 2017) were retrieved from the laboratory database. Of the 275 565 tests done for 115 971 patients, 5.2% were repeat tests done at intervals shorter than the minimum retesting interval, as defined by the Royal College of Pathologist and Irish Guidelines on the Use of the Laboratory. Using the Centers for Medicare and Medicaid Services Clinical Laboratory Fee Schedule, we estimated a cost burden of US$222 096 per year. Strategies to reduce unnecessary repetitive testing can result in significant cost savings.

Singapore Chapter of Rheumatologists updated consensus statement on the eligibility for government subsidization of biologic and targeted-synthetic therapy for the treatment of rheumatoid arthritis

INTRODUCTION

Approximately 30% of patients with rheumatoid arthritis (RA) respond inadequately to conventional-synthetic disease-modifying anti-rheumatic drugs (csDMARDs). However, widespread use of biologic DMARDs (bDMARDs) and targeted-synthetic (tsDMARDs) is limited by cost. We formulated updated recommendations for eligibility criteria for government-assisted funding of bDMARDs/tsDMARDs for RA patients in Singapore.

MATERIALS AND METHODS

Published guidelines regarding use of bDMARD and tsDMARDs were reviewed. We excluded those without a systematic literature review, formal consensus process or evidence grading. Separately, unpublished national reimbursement guidelines were included.

RESULTS

Eleven recommendations regarding choice of disease activity measure, initiation, order of selection and continuation of bDMARD/tsDMARDs were formulated. A bDMARD/tsDMARD is indicated if a patient has: (a) at least moderately active RA with a Disease Activity Score in 28 joints/erythrocyte sedimentation rate (DAS28-ESR) score of ≥3.2; (b) failed ≥2 csDMARD strategies, 1 of which must be a combination; (c) received an adequate dose regimen of ≥3 months for each strategy. For the first-line bDMARD/tsDMARD, either tumor necrosis factor inhibitors (TNFi), non-TNFi (abatacept, tocilizumab, rituximab), or tsDMARDs, may be considered. If a first-line TNFi fails, options include another TNFi, non-TNFi biologic or tsDMARDs. If a first-line non-TNFi biologic or tsDMARD fails, options include TNFi or another non-TNF biologic or tsDMARD. For continued bDMARD/tsDMARD subsidization, a patient must have a documented DAS28-ESR every 3 months and at least a moderate European League Against Rheumatism response by 6 months.

CONCLUSION

These recommendations are useful for guiding funding decisions, making bDMARD/tsDMARDs usage accessible and equitable in RA patients who fail csDMARDs.

Sociodemographic factors as determinants of disease, disability and quality of life trajectories in early rheumatoid arthritis: A multi-ethnic inception cohort study

OBJECTIVE

This study aims to describe the association between sociodemographic factors and trajectories of disease, disability and health-related quality of life (HRQoL) in early rheumatoid arthritis (ERA).

METHODS

Data were collected prospectively over 3 years in the Singapore Early Arthritis Cohort study. Trajectories were modeled using multi-trajectory group-based trajectory modeling (GBTM) and determinants of trajectory membership were identified using multinomial logistic regression.

RESULTS

Two hundred and thirteen patients were included: 58.2% Chinese, 16.4% Malay, 21.6% Indian, mean (SD) age 51.3 (12.6) years and symptom duration 21.8 (15.3) weeks. In the multi-trajectory analysis, three groups of disease trajectories and corresponding disability and HRQoL trajectories were identified: group 1 (moderate disease rapid response, 49.9%), group 2 (high disease rapid response, 31.1%) and group 3 (high disease slow response, 19.1%). Malay patients had higher relative risk ratio (RRR) of being in trajectory groups 2 and 3 compared to group 1 (RRR = 2.30, 95% CI 1.05-3.98 and RRR = 4.02, 95% CI 1.45-6.43, respectively) while patients with tertiary education had lower relative risk (RRR = 0.56, 95% CI 0.45-0.89 and RRR = 0.33, (95% CI 0.14-0.83, respectively). In the analysis of individual outcomes, ethnicity, education level and body mass index were determinants of the heterogeneous disease activity trajectories. Gender and education level were determinants of the disability trajectories. Only gender was a determinant of the HRQoL trajectories. Further, 96.2% of the patients were treated with conventional synthetic disease-modifying antirheumatic drugs.

CONCLUSION

Disparities in sociodemographic factors should be taken into consideration in formulating treatment strategies in ERA.

Predicting flares in patients with stable systemic lupus erythematosus

OBJECTIVES

Data on flares in Asian patients with systemic lupus erythematosus (SLE) are scarce. Here, we aim to identify the baseline predictors of flares in a cohort of Southeast Asian patients with SLE.

METHODS

Consecutive adult patients with prevalent SLE according to the 1997 ACR or 2012 SLICC criteria were enrolled and followed three-monthly. Clinical and laboratory data were collected at every visit using a standardised protocol. Flares were defined using the SELENA-SLEDAI Flare Index (SFI). Baseline predictors of flare in patients with stable disease (SLE Disease Activity Index-2K (SLEDAI-2K) of ≤ 4) were determined using Cox proportional hazards.

RESULTS

Of the 210 patients recruited, 148 (70.5%) were Chinese. The median (IQR) SLEDAI-2K at entry was 2 (0-4) and the median (IQR) disease duration was 10 (4.4-16.4) years. At baseline, 152 (72.4%) patients had stable disease. After a median (IQR) follow-up of 31.5 (24.1-36.3) months, 109 (51.9%) flared. Stable patients who flared tended to be in the lowest tertile of age (HR 3.08, 95% CI 1.72-5.48, p < 0.01), had thrombocytopenia (HR 5.01, 95% CI 1.32-18.99, p = 0.02), hypocomplementemia (HR 3.35, 95% CI 1.54-7.30, p < 0.01) and had the highest baseline prednisolone doses (HR 2.39, 95% CI 1.28-4.46, p = 0.01). Conversely, patients in the lowest tertile of disease duration tended not to flare (HR 0.41, 95% CI 0.21-0.80, p = 0.01).

CONCLUSION

Flares are common in Asian SLE patients with initial stable disease. Close monitoring is needed for patients who are younger, with longer disease duration, thrombocytopenia, hypocomplementemia, or who required a higher baseline prednisolone dose.

IgG4-Related Kidney Disease: A Curious Case of Interstitial Nephritis with Hypocomplementemia

IgG4-related kidney disease has been relatively newly recognized over the last two decades as a combination of an autoimmune and allergic disorder, with elevated serum IgG4 level and hypocomplementemia among its characteristic features. Here we report the case of a man with interstitial nephritis presenting with acute kidney injury and hypocomplementemia but normal serum IgG4 level and provide a literature review of IgG4-related kidney disease. This case highlights the importance of IgG4-related kidney disease as an important differential diagnosis in any patient presenting with a clinical syndrome mimicking acute interstitial nephritis with hypocomplementemia. A high index of suspicion with a low threshold for performing a native kidney biopsy would be paramount as patients do respond well to corticosteroid therapy.

Increasing podiatry referrals for patients with inflammatory arthritis at a tertiary hospital in Singapore: A quality improvement project

BACKGROUND

Foot disease is highly prevalent in people with inflammatory arthritis and is often under-recognized. Podiatry intervention can significantly reduce foot pain and disability, with timely access being the key factor. The aim of this study was to plan and implement a quality improvement project to identify the barriers to, and improve, uptake of podiatry services among patients with inflammatory arthritis-related foot problems seen at a tertiary hospital in Singapore.

METHOD

A 6-month quality improvement program was conducted by a team of key stakeholders using quality improvement tools to identify, implement and test several interventions designed to improve uptake of podiatry services. The number of patients referred for podiatry assessment was recorded on a weekly basis by an experienced podiatrist. The criterion for appropriate referral to podiatry was those patients with current or previous foot problems such as foot pain, swelling and deformity.

RESULTS

Interventions included education initiatives, revised workflow, development of national guidelines for inflammatory arthritis, local podiatry guidelines for the management of foot and ankle problems, routine use of outcome measures, and introduction of a fully integrated rheumatology-podiatry service with reduced cost package. Referral rates increased from 8% to 11%, and were sustained beyond the study period. Complete incorporation of podiatry into the rheumatology consultation as part of the multidisciplinary team package further increased referrals to achieve the target of full uptake of the podiatry service.

CONCLUSION

Through a structured quality improvement program, referrals to podiatry increased and improved the uptake and acceptance of rheumatology-podiatry services.

Patient-reported outcomes in Asia: evaluation of the properties of the Rheumatoid Arthritis Impact of Disease (RAID) score in multiethnic Asian patients with rheumatoid arthritis

Patient-reported outcomes (PROs) such as the Europe-developed Rheumatoid Arthritis Impact of Disease (RAID) are important to assess patients' quality of life. Their interpretation may be culture-dependent. To evaluate the potential utility of RAID in multiethnic Asian rheumatoid arthritis (RA) patients. Cross-sectional study of English-speaking RA patients in a Singapore tertiary center. Validity of RAID (scored between 0 and 10 with higher score indicating worse status) was assessed by Spearman's correlation with patient global assessment (PGA), DAS28 and short form 12 (SF-12). Consistency was assessed by Cronbach's alpha and test-retest reliability by intra-class correlation coefficient (ICC) 7 days after (n = 20). Feasibility was assessed by % of missing data. Eighty-two patients were analyzed: median age 53 years (Q1:Q3 44.7; 60.7), disease duration 4.2 years (1.4; 8.8), 66 (81%) women and 54 (66%) Chinese. Although RA was moderately active (median DAS28, 3.2 (2.5; 4.3)), RAID score was very low (median, 1.9 (0.6; 3.7)) with 44 (53.7%) patients having RAID score between 0 and 2. RAID was strongly correlated with PGA (r = 0.75), and moderately with other outcomes (DAS28 r = 0.46, SF12 physical r = -0.45 and SF12 mental r = -0.52, p < 0.0001 for all). Consistency was high (Cronbach's alpha = 0.91). Test-retest reliability was excellent; ICC = 0.84 (95% confidence interval 0.74-0.90). Feasibility was good with only 2 patients with missing data. Despite considerable floor effects, the RAID appeared to be a valid and practical PRO to assess the impact of RA in Asia. Multiethnic Asian patients may underestimate the impact of their disease compared to European patients.

Prevalence of foot problems in people with inflammatory arthritis in Singapore

Background

Foot problems are highly prevalent in people with inflammatory arthritis reported from studies in the UK, Europe and New Zealand, but there is limited evidence from Southeast Asia. The study aim was to evaluate the prevalence of foot problems in people with inflammatory arthritis in Singapore.

Methods

People with inflammatory arthritis were recruited from the rheumatology outpatient clinic of a tertiary hospital in Singapore. Disease and clinical characteristics included age, sex, disease duration, current blood tests and medications. The Leeds Foot Impact Scale was used to evaluate foot impairment/disability and the Modified Health Assessment Questionnaire was used to assess global function.

Results

We recruited 101 people with inflammatory arthritis, of which 50 % were female. The majority of participants were Chinese (70 %). The mean (SD) age was 52 (15) years, and the mean (SD) disease duration was 9.3 (0.3) years. The most commonly reported inflammatory arthritic conditions were rheumatoid arthritis (46), gout (31) and spondyloarthritis (15 %). The mean (SD) of the total Leeds Foot Impact Scale was 17 (13) indicating moderate to severe levels of foot impairment and activity limitation. Over 80 of participants reported foot pain during the course of their condition, and 48 % reported current foot pain. Despite the high prevalence of foot pain, only 21 participants (21 %) had been referred to a podiatrist.

Conclusion

This is the first study to investigate the prevalence of foot problems in people with inflammatory arthritis from Singapore. The majority of the participants reported foot problems, but had not been referred to a podiatry service.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-016-0169-y) contains supplementary material, which is available to authorized users.

Footwear characteristics in people with inflammatory arthritis in Singapore

Background

Foot problems are common in people with inflammatory arthritis. Despite suitable footwear having the potential to alleviate pain, improve mobility and maintain independence, previous studies have found many people with inflammatory arthritis wearing poorly fitting and inappropriate footwear. Footwear styles and characteristics have not been reported in a Singapore inflammatory arthritis population. The objective of this study was to identify current footwear styles and characteristics of footwear worn by people with inflammatory arthritis in Singapore.

Methods

One-hundred-and-one participants with inflammatory arthritis were recruited from the rheumatology outpatient clinic of a large public hospital in Singapore. Disease and clinical characteristics were recorded. A patient-reported outcome included current foot pain. An objective footwear assessment of style, age of shoe, fit and construction was conducted.

Results

The majority of participants were Chinese women with a mean (SD) age was 52.0 (15.0) years old and a mean (SD) disease duration of 9.3 (0.3) years. We found 50 % of participants (n = 51) reported footwear problems. Sandals (n = 27, 26 %), flip-flops (n = 19, 19 %) and moccasin type (n = 19, 19 %) was the most common footwear choice. Evaluation of footwear characteristics found that there was a lack of motion control features. Only 32 (32 %) participants had correctly fitting footwear with regard to length, width and depth. No participant was wearing therapeutic footwear.

Conclusion

This study provides the first insight into footwear preferences of people with inflammatory arthritis in Singapore. Use of slip-on and poorly fitting footwear was found to be common in people with inflammatory arthritis. Further research on footwear preferences in Southeast-Asian communities needs to take into account cultural habit and preference, socio-economic status, footwear options and affordability.

Experiences of Patients With Rheumatoid Arthritis: A Qualitative Study

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that greatly impacts one's physical and psychosocial well-being. The purpose of this study was to explore the experiences and support needs of adult patients living with RA. A descriptive qualitative study was conducted, and 16 adults with RA were interviewed from October 2013 to January 2014. The transcribed data were analyzed using thematic analysis. Five themes were identified: altered physical capacity and well-being, psychological and emotional challenges, changes in social life, coping strategies, and support received and further support needs. This study provided insights into the experiences and support needs of patients with RA in Singapore. Physical and psychosocial challenges experienced by patients affected their daily and social activities. Patients' needs for variety of support should be addressed.

Platelet-activating factor promotes motility in breast cancer cells and disrupts non-transformed breast acinar structures

A plethora of studies have demonstrated that chronic inflammatory microenvironment influences the genesis and progression of tumors. Such microenvironments are enriched with various lipid mediators. Platelet activating factor (PAF, 1-alkyl-2-acetyl-sn-glycero-3-phosphocholine) is one such lipid mediator that is secreted by different immune cell types during inflammation and by breast cancer cells upon stimulation with growth factors. Overexpression of PAF-receptor has also been observed in many other cancers. Here we report the possible roles of PAF in tumor initiation and progression. MCF10A, a non-transformed and non-malignant mammary epithelial cell line, when grown as 3D 'on-top' cultures form spheroids that have a distinct hollow lumen surrounded by a monolayer of epithelial cells. Exposure of these spheroids to PAF resulted in the formation of large deformed acinar structures with disrupted lumen, implying transformation. We then examined the response of transformed cells such as MDA-MB 231 to stimulation with PAF. We observed collective cell migration as well as motility at the single cell level on PAF induction, suggesting its role during metastasis. This increase in collective cell migration is mediated via PI3-kinase and/or JNK pathway and is independent of the MAP-kinase pathway. Taken together this study signifies a novel role of PAF in inducing transformation of non-tumorigenic cells and the vital role in promotion of breast cancer cell migration.

Singapore Chapter of Rheumatologists consensus statement on the eligibility for government subsidy of biologic disease modifying anti-rheumatic agents for the treatment of psoriatic arthritis

AIM

In Singapore, patients with psoriatic arthritis (PsA) constitute a significant disease burden. There is good evidence for the efficacy of anti-tumor necrosis factor (anti-TNF) in PsA; however cost remains a limiting factor. Non-biologic disease modifying anti-rheumatic drugs (nbDMARDs) hence remain the first-line treatment option in PsA in spite of limited evidence. The Singapore Chapter of Rheumatologists aims to develop national guidelines for clinical eligibility for government-assisted funding of biologic disease modifying anti- rheumatic drugs (bDMARDs) for PsA patients in Singapore.

METHODS

Evidence synthesis was performed by reviewing seven published guidelines on use of biologics for PsA. Using the modified Research and Development/University of California at Los Angeles Appropriateness Method (RAM), rheumatologists rated indications for therapies for different clinical scenarios. Points reflecting the output from the formal group consensus were used to formulate the practice recommendations.

RESULTS

Ten recommendations were formulated relating to initiation, continuation and options of bDMARD therapy. The panellists agreed that a bDMARD is indicated if a patient has active PsA with at least five swollen and tender joints, digits or entheses and has failed two nbDMARD strategies at optimal doses for at least 3 months each. Any anti-TNF may be used and therapy may be continued if an adequate PsARC response is achieved by 3 months after commencement.

CONCLUSION

The recommendations developed by a formal group consensus method may be useful for clinical practice and guiding funding decisions by relevant authorities in making bDMARD usage accessible and equitable to eligible patients in Singapore.

Health-related quality of life and its predictors among patients with rheumatoid arthritis

BACKGROUND

Limited studies have examined the predictors of HRQoL among patients with rheumatoid arthritis. This study helped to ascertain the predictors of HRQoL from the pool of influencing factors identified by previous studies.

AIM

This study investigated the health-related quality of life (HRQoL) of adult patients with rheumatoid arthritis and its predictors.

METHODS

Using a descriptive correlational design, this study explored the relationship between HRQoL and pain, functional disability, anxiety, depression, medication adherence and social support. Eligible outpatients (n=108) were recruited via their attending doctors who were co-investigators of this study. Informed consent forms were distributed and questionnaires administered in a teaching hub by the main researcher.

RESULTS

Significant correlations were found between HRQoL and all of the study variables. Pain, functional disability and depression were main predictors of HRQoL.

CONCLUSIONS

Future evidence-based interventions focusing on pain relief, delaying disability or improving functional ability and reducing depressive symptoms are required to enhance the HRQoL of patients with rheumatoid arthritis.

Consensus development on eligibility of government subsidisation of biologic disease modifying anti-rheumatic agents for treatment of ankylosing spondylitis: The Singapore experience

INTRODUCTION

The beneficial effects of biologic disease-modifying anti-rheumatic drugs (bDMARDs), such as tumour necrosis factor inhibitors (anti-TNF) in active ankylosing spondylitis (AS) are well established. The significant costs on patients in the absence of financial subsidization can limit their use. The objective was to describe a consensus development process on recommendations for government-assisted funding of biologic therapy for AS patients in Singapore.

METHODS

Evidence synthesis followed by a modified RAND/UCLA Appropriateness Method (RAM) was used. Eleven rheumatologists rated indications for therapies for different proposed clinical scenarios. Points reflecting the output from the formal group consensus were used to formulate 10 practice recommendations.

RESULTS

It was agreed that a bDMARD (anti-TNF) is indicated if a patient has active AS with a Bath Ankylosing Spondylitis Activity Index (BASDAI) ≥ 4 and spinal pain of ≥ 4 cm on visual analogue scale (VAS) on two occasions at least 12 weeks apart, despite being on a minimum of two sequential non-steroidal anti-inflammatory drugs at maximal tolerated dose for at least 4 weeks, in addition to adherence to an appropriate physiotherapy program for at least 3 months. To qualify for continued biologic therapy, a patient must have documentation of response every 3 months and at least 50% improvement in BASDAI and reduction of spinal pain VAS ≥ 2 cm.

CONCLUSION

A validated and feasible consensus process can enable pragmatic standardized recommendations to be developed for bDMARD subsidization for AS patients in a local Asian context.