Detection bias in open-label trials of anticancer drugs: a meta-epidemiological study

OBJECTIVES

In anticancer clinical trials, particularly open-label trials, central reviewers are recommended to evaluate progression-free survival (PFS) and objective response rate (ORR) to avoid detection bias of local investigators. However, it is not clear whether the bias has been adequately identified, or to what extent it consistently distorts the results. Therefore, the objective of this study was to evaluate the detection bias in oncological open-label trials by confirming whether local investigators overestimate the PFS and ORR compared with the findings of central reviewers.

DESIGN

Meta-epidemiological study.

DATA SOURCES

MEDLINE via PubMed from 1 January 2010 to 30 June 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Open-label, parallel-group superiority, randomised trials of anticancer drugs that adjudicated PFS or ORR by both central reviewers and local investigators.

REVIEW METHODS

We assessed the values for the same outcome (PFS and ORR) adjudicated by both central reviewers and local investigators. A random-effects model was used to estimate the ratio of HR (RHR) for PFS and the ratio of OR (ROR) for ORR between central reviewers and local investigators. An RHR lower than 1 and an ROR higher than 1 indicated an overestimation of the effect estimated by local investigators.

RESULTS

We retrieved 1197 records of oncological open-label trials after full-text screening. We identified 171 records (PFS: 149 records, ORR: 136 records) in which both central reviewers and local investigators were used, and included 114 records (PFS: 92 records, ORR: 74 records) for meta-analyses. While the RHR for PFS was 0.95 (95% CI 0.91 to 0.98), the ROR of ORR was 1.00 (95% CI 0.91 to 1.09). The results remained unchanged in the prespecified sensitivity analysis.

CONCLUSIONS

This meta-epidemiological study found that overestimation of local investigators has a small impact on evaluating PFS and ORR in oncological open-label trials. However, a limitation of this study is that it did not include data from all trials; hence, the results may not fully evaluate detection bias. The necessity of central reviewers in oncological open-label trials needs to be assessed by further studies that overcome this limitation.

TRIAL REGISTRATION NUMBER

CTR-UMIN000044623.

Comprehensive validation of early diagnostic algorithms for myocardial infarction in the emergency department

OBJECTIVE

To comprehensively evaluate diagnostic algorithms for myocardial infarction using a high-sensitivity cardiac troponin I (hs-cTnI) assay.

PATIENTS AND METHODS

We prospectively enrolled patients with suspected myocardial infarction without ST-segment elevation from nine emergency departments in Japan. The diagnostic algorithms evaluated a) based on hs-cTnI alone, such as the European Society of Cardiology (ESC) 0/1-h or 0/2-h and High-STEACS pathways; or b) used medical history and physical findings, such as the ADAPT, EDACS, HEART, and GRACE pathways. We evaluated the negative predictive value (NPV), sensitivity as safety measures, and proportion of patients classified as low or high-risk as an efficiency measure for a primary outcome of type 1 myocardial infarction or cardiac death within 30 days.

RESULTS

We included 437 patients, and the hs-cTnI was collected at 0 and 1 hours in 407 patients and at 0 and 2 hours in 394. The primary outcome occurred in 8.1% (33/407) and 6.9% (27/394) of patients, respectively. All the algorithms classified low-risk patients without missing those with the primary outcome, except for the GRACE pathway. The hs-cTnI-based algorithms classified more patients as low-risk: the ESC 0/1-h 45.7%; the ESC 0/2-h 50.5%; the High-STEACS pathway 68.5%, than those using history and physical findings (15-30%). The High-STEACS pathway ruled out more patients (20.5%) by hs-cTnI measurement at 0 hours than the ESC 0/1-h and 0/2-h algorithms (7.4%).

CONCLUSIONS

The hs-cTnI algorithms, especially the High-STEACS pathway, had excellent safety performance for the early diagnosis of myocardial infarction and offered the greatest improvement in efficiency.

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

Ultrasound guidance versus landmark method for peripheral venous cannulation in adults

BACKGROUND

Peripheral intravenous cannulation is one of the most fundamental and common procedures in medicine. Securing a peripheral line is occasionally difficult with the landmark method. Ultrasound guidance has become a standard procedure for central venous cannulation, but its efficacy in achieving peripheral venous cannulation is unclear.

OBJECTIVES

To evaluate the effectiveness and safety of ultrasound guidance compared to the landmark method for peripheral intravenous cannulation in adults.  SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 29 November 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs (RCTs in which participants are systematically allocated based on data such as date of birth or recruitment) comparing the effects of ultrasound guidance to the landmark method for peripheral intravenous cannulation in adults.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were first-pass success of cannulation, overall success of cannulation, and pain. Our secondary outcomes were procedure time for first-pass cannulation, procedure time for overall cannulation, number of attempts, patient satisfaction, and overall complications. We used GRADE to assess the certainty of the evidence.  Placing a peripheral intravenous line in individuals can be classed as 'difficult', 'moderate', or 'easy'. We use the terms 'difficult participants', 'moderate/moderately difficult participants' and 'easy participants' as shorthand to characterise the difficulty level in placing a peripheral line using the landmark method. We used the original studies' definitions of difficulty levels of peripheral intravenous cannulation with the landmark method. We analysed the results in these subgroups: 'difficult participants', 'moderate participants', and 'easy participants'. We did this because we expected the effect of ultrasound-guided peripheral venous cannulation to be largest in participants classed as 'difficult' and smaller in participants classed as 'moderate' and 'easy'.  MAIN RESULTS: We included 14 RCTs and two quasi-RCTs involving 2267 participants undergoing peripheral intravenous cannulation. Participants were classed as 'difficult' in 12 studies (880 participants), 'moderate' in one study (401 participants), and 'easy' in one study (596 participants). Two studies (390 participants) did not restrict by landmark method difficulty level. The overall risk of bias assessments ranged from low to high. We judged studies to be at high risk of bias mainly because of concerns about blinding for subjective outcomes. In difficult participants, ultrasound guidance increased the first-pass success of cannulation (risk ratio (RR) 1.50, 95% confidence interval (95% CI) 1.15 to 1.95; 10 studies, 815 participants; low-certainty evidence), and the overall success of cannulation (RR 1.40, 95% CI 1.10 to 1.77; 10 studies, 670 participants; very low-certainty evidence). There was no clear difference in pain (mean difference (MD) -0.20, 95% CI -1.13 to 0.72; 4 studies, 323 participants; very low-certainty evidence; numerical rating scale (NRS) 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 119.9 seconds, 95% CI 88.6 to 151.1; 2 studies, 219 participants; low-certainty evidence), and patient satisfaction (standardised mean difference (SMD) 0.49, 95% CI 0.07 to 0.92; 5 studies, 333 participants; very low-certainty evidence; NRS 0 to 10 where 10 is maximum satisfaction). Ultrasound guidance decreased the number of cannulation attempts (MD -0.33, 95% CI -0.64 to -0.02; 9 studies, 568 participants; very low-certainty evidence). Ultrasound guidance showed no clear difference in the procedure time for overall cannulation (MD -24.9 seconds, 95% CI -323.1 to 273.3; 8 studies, 413 participants; very low-certainty evidence) and overall complications (RR 0.64, 95% CI 0.37 to 1.10; 5 studies, 431 participants; low-certainty evidence).  In moderate participants, ultrasound guidance increased the first-pass success of cannulation (RR 1.14, 95% CI 1.02 to 1.27; 1 study, 401 participants; moderate-certainty evidence). No studies assessed the overall success of cannulation. There was no clear difference in pain (MD 0.10, 95% CI -0.47 to 0.67; 1 study, 401 participants; low-certainty evidence; NRS 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 95.2 seconds, 95% CI 72.8 to 117.6; 1 study, 401 participants; high-certainty evidence). Ultrasound guidance showed no clear difference in overall complications (RR 0.83, 95% CI 0.38 to 1.82; 1 study, 401 participants; moderate-certainty evidence). No studies assessed the procedure time for overall cannulation, number of cannulation attempts, or patient satisfaction.  In easy participants, ultrasound guidance decreased the first-pass success of cannulation (RR 0.89, 95% CI 0.85 to 0.94; 1 study, 596 participants; high-certainty evidence). No studies assessed the overall success of cannulation. Ultrasound guidance increased pain (MD 0.60, 95% CI 0.17 to 1.03; 1 study, 596 participants; moderate-certainty evidence; NRS 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 94.8 seconds, 95% CI 81.2 to 108.5; 1 study, 596 participants; high-certainty evidence). Ultrasound guidance showed no clear difference in overall complications (RR 2.48, 95% CI 0.90 to 6.87; 1 study, 596 participants; moderate-certainty evidence). No studies assessed the procedure time for overall cannulation, number of cannulation attempts, or patient satisfaction.  AUTHORS' CONCLUSIONS: There is very low- and low-certainty evidence that, compared to the landmark method, ultrasound guidance may benefit difficult participants for increased first-pass and overall success of cannulation, with no difference detected in pain. There is moderate- and low-certainty evidence that, compared to the landmark method, ultrasound guidance may benefit moderately difficult participants due to a small increased first-pass success of cannulation with no difference detected in pain. There is moderate- and high-certainty evidence that, compared to the landmark method, ultrasound guidance does not benefit easy participants: ultrasound guidance decreased the first-pass success of cannulation with no difference detected in overall success of cannulation and increased pain.

The Impact of the COVID-19 Pandemic and Associated Control Measures on the Mental Health of the General Population : A Systematic Review and Dose-Response Meta-analysis

BACKGROUND

To what extent the COVID-19 pandemic and its containment measures influenced mental health in the general population is still unclear.

PURPOSE

To assess the trajectory of mental health symptoms during the first year of the pandemic and examine dose-response relations with characteristics of the pandemic and its containment.

DATA SOURCES

Relevant articles were identified from the living evidence database of the COVID-19 Open Access Project, which indexes COVID-19-related publications from MEDLINE via PubMed, Embase via Ovid, and PsycInfo. Preprint publications were not considered.

STUDY SELECTION

Longitudinal studies that reported data on the general population's mental health using validated scales and that were published before 31 March 2021 were eligible.

DATA EXTRACTION

An international crowd of 109 trained reviewers screened references and extracted study characteristics, participant characteristics, and symptom scores at each timepoint. Data were also included for the following country-specific variables: days since the first case of SARS-CoV-2 infection, the stringency of governmental containment measures, and the cumulative numbers of cases and deaths.

DATA SYNTHESIS

In a total of 43 studies (331 628 participants), changes in symptoms of psychological distress, sleep disturbances, and mental well-being varied substantially across studies. On average, depression and anxiety symptoms worsened in the first 2 months of the pandemic (standardized mean difference at 60 days, -0.39 [95% credible interval, -0.76 to -0.03]); thereafter, the trajectories were heterogeneous. There was a linear association of worsening depression and anxiety with increasing numbers of reported cases of SARS-CoV-2 infection and increasing stringency in governmental measures. Gender, age, country, deprivation, inequalities, risk of bias, and study design did not modify these associations.

LIMITATIONS

The certainty of the evidence was low because of the high risk of bias in included studies and the large amount of heterogeneity. Stringency measures and surges in cases were strongly correlated and changed over time. The observed associations should not be interpreted as causal relationships.

CONCLUSION

Although an initial increase in average symptoms of depression and anxiety and an association between higher numbers of reported cases and more stringent measures were found, changes in mental health symptoms varied substantially across studies after the first 2 months of the pandemic. This suggests that different populations responded differently to the psychological stress generated by the pandemic and its containment measures.

PRIMARY FUNDING SOURCE

Swiss National Science Foundation. (PROSPERO: CRD42020180049).

POS0681 DRUG RETENTION RATE AND EFFECTIVENESS OF JAK INHIBITOR IN PATIENTS WITH DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS

Background

Recently, the disease activity of rheumatoid arthritis (RA) was improved due to the ‘treat-to-target’ strategy. However, some patients remain various symptoms despite recommended treatment was performed. Then, the term of ‘difficult-to-treat RA (D2TRA)’ is widely recognized. Janus kinase inhibitor (JAKi) might be effective for D2TRA patients, because JAKi can simultaneously block the function of multiple cytokines.

Objectives

The aim of this study was to evaluate drug retention rate and effectiveness of JAKi in patients with D2TRA.

Methods

This study included 220 RA patients (tofacitinib 101, baricitinib 83, upadacitinib 20, peficitinib 14, filgotinib 2) treated with JAKi. Sixty-two patients were treated as first line bDMARDs/JAKi (1st group), 57 patients were treated as second line bDMARDs/ JAKi (2nd group), 101 patients were treated as third and more bDMARDs/ JAKi. In these 101 patients, 25 patients did not met D2TRA criteria (non-D2TRA group) and 76 patients met D2TRA criteria (D2TRA group). Drug retention rate and effectiveness of JAKi were evaluated during 24 weeks in each group.

Results

Usage rate of methotrexate was lower and dosage of glucocorticoid was higher in D2TRA group than in other groups (Table 1). Drug retention rate at 24 weeks was 87.1% (54/62) in 1st group, 80.1% (46/57) in 2nd group, 88% (22/25) in non-D2TRA group, 61.8% (47/76) in D2TRA group. Drug retention rate was lower in D2TRA group compared to 1st group, 2nd group and non-DT2RA group (p<0.01, p=0.03, p=0.01). DAS28-CRP was 4.4, 4.0, 3.9, 4.4 at baseline, 3.0, 3.0, 3.3, 3.5 at 4 weeks, 2.5, 2.9, 2.7, 3.3 at 12 weeks, 2.5, 3.0, 2.9, 3.2 at 24 weeks in 1st group, 2nd group, non-D2TRA group and D2TRA group, respectively. Improvement ratio of DAS28-CRP was 32.9, 27.6, 20.4, 19.3 % at 4 weeks, 40.8, 26.5, 28.1, 19.5 % at 12 weeks, 40.8, 24.6, 18.7, 24.7 % at 24 weeks. DAS28-CRP was improved in all groups. Altough 1st group showed higher improvement ratio of DAS28-CRP at 24 weeks compared to 2nd group, non-DT2RA group and D2TRA group (p<0.01, p<0.01, p<0.01), there was no differences between DT2RA group and 2nd group or non-D2TRA group (p=0.95, p=0.48). SDAI was 22.9, 19.9, 18.3, 23.9 at baseline, 11.8, 11.9, 13.3, 14.4 at 4 weeks, 7.9, 11.3, 8.4, 13.3 at 12 weeks, 8.5, 11.5, 9.7, 12.6 at 24 weeks. CDAI was 21.3, 18.8, 17.6, 21.8 at baseline, 11.3, 11.2, 12.5, 13.9 at 4 weeks, 7.5, 10.9, 8.0, 12.3 at 12 weeks, 8.1, 10.7, 8.6, 12.1 at 24 weeks. HAQ was 1.15, 0.99, 0.89, 1.39 at baseline, 0.84, 0.76, 0.93, 1.22 at 4 weeks, 0.79, 0.84, 0.77, 1.17 at 12 weeks, 0.76, 0.79, 0.76, 1.14 at 24 weeks. Improvement rate of HAQ at 24 weeks were 44.3%, 23.9%, 21.2%, 8.1%.

Table 1.

Baseline characteristics of RA patients

1st group (n=62)2nd group (n=57)non-D2TRA group (n=25)D2TRA group (n=76)Age (years)64.9 ± 14.866.1 ± 11.564.6 ± 16.163.0 ± 15.0Female (%)75.879.096.080.3Disease durations (years)10.4 ± 11.717.6 ± 17.622.6 ± 22.416.3 ± 15.7RF (IU/ml)296.3 ± 1153.8314.9 ± 1037.7262.4 ± 375.9305.9 ± 819.6RF positive ratio (%)81.878.479.275.7Anti CCP antibody (U/ml)221.8 ± 327.2157.8 ± 258.795.9 ± 101.6191.8 ± 250.6Anti CCP antibody positive ratio (%)79.679.672.283.3CRP (U/ml)1.5 ± 2.11.1 ± 2.01.6 ± 1.61.8 ± 2.9MMP-3 (ng/ml)185.7 ± 167.6146.7 ± 122.1190.1 ± 152.6268.0 ± 451.2DAS28-CRP4.3 ± 1.24.1 ± 1.33.9 ± 1.44.4 ± 1.3SDAI21.8 ± 12.221.7 ± 13.118.4 ± 13.023.9 ± 12.8CDAI20.3 ± 11.320.7 ± 12.717.6 ± 12.822.1 ± 12.2HAQ1.1 ± 0.81.2 ± 1.00.9 ± 0.81.4 ± 1.1MTX use (%)69.463.25647.4MTX (mg/day)10.7 ± 3.410.4 ± 3.58.8 ± 3.59.0 ± 4.3Glucocorticoid use (%)29.136.81646.1Glucocorticoid dose (mg/day)3.3 ± 2.13.0 ± 1.53.5 ± 1.95.1 ± 2.8

Conclusion

Drug retention rate of JAKi in treatment of D2TRA group were lower than that of 1st group, 2nd group, and non-D2TRA group. Clinical efficacy of JAKi in D2TRA group were not significantly different to 2nd group and non-D2TRA group. However, HAQ improvement was weak in D2TRA group.

Disclosure of Interests

None declared

AB0188 ULTRASONOGRAPHIC RESIDUAL INTRA-ARTICULAR SYNOVITIS IS MORE SEVERE IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH PREDNISOLONE

Background

The treatment option including biological DMARDs (BIO) and JAK inhibitor (JAK) was expanded, and the number of patients reached to the treatment target are increasing in rheumatoid arthritis (RA). On the other hand, it is also true that some patients are still using prednisolone (PSL). Recently, ultrasound has played a role of sensitive imaging modality in the diagnosis and follow-up of patients with RA. It is known that residual synovitis was found in ultrasound even in patients with clinical remission.

Objectives

We investigated the differences of ultrasonographic intra-articular synovitis findings between treatment drugs in patients with RA.

Methods

From January 2017 to August 2020, 750 RA patients who underwent ultrasound examination were included. A US examination was performed at the bilateral first to fifth metacarpophalangeal (MCP) joints, first interphalangeal (IP) and second to fifth proximal interphalangeal (PIP) joints, wrist joints (three part of radial, medial and ulnar) and first to fifth metatarsophalangeal (MTP) joints, by using HI VISION Ascendus (Hitachi Medical Corporation, Japan) with a multifrequency linear transducer (18-6 MHz). The gray scale and power Doppler findings were assessed by the semi-quantitative method (0-3). All patients were divided into with or without BIO / JAK, methotrexate (MTX) and PSL. Then, patients were matched using the propensity score adjusted for gender, age, RA disease duration, disease activity, CRP value, and MMP-3 value. The total gray scale and power Doppler score (GSUS / PDUS) were compared between treatment drugs of RA by using propensity score matching methods.

Results

The average age of 750 RA patients were 64.5 years and an average disease duration of RA was 13.9 years and females were 581 (77.5%). There were 517 patients (68.9%) treated with BIO/JAK and 233 patients treated without BIO/JAK. The 205 patients in each group were matched. GSUS were 10.6±11.1 vs 9.2±10.4 (p=0.218) and PDUS 7.4±9.2 vs 6.5±9.0 (p=0.328). Ultrasound residual synovitis was not different between with or without BIO/JAK in matched patients. There were 525 patients (70.0%) treated MTX, the average MTX dose was 9.3 mg, and 225 patients treated without MTX. The 203 patients with or without MTX in each group were matched. GSUS were 9.7±10.6 vs 11.4±12.0 (p=0.119) and PDUS 6.6±8.8 vs 8.1±10.1 (p=0.117). Ultrasound residual synovitis was not different between with or without MTX in matched patients. There were 111 patients (14.8%) treated PSL, the average dose was 4.0mg, and 639 patients treated without PSL. The 105 patients with or without PSL in each group were matched. GSUS were 15.7±13.9 vs 11.6±10.6 (p=0.018) and PDUS 11.5±11.4 vs 8.1±9.6 (p=0.021). Ultrasound residual synovitis was more severe treated with PSL than without PSL in matched patients.

Conclusion

In a comparison between RA patients matched backgrounds such as disease activity, there was no difference in ultrasound residual synovitis between patients with or without BIO/JAK and MTX. However, there was significant difference in patients with or without PSL. This suggests that PSL use suppresses clinical symptoms but does not improve synovitis. Thus, it should be noted that joint destruction may progress in patients treating with PSL.

References

[1]Grassi W, Okano T, Di Geso L, Filippucci E. Imaging in rheumatoid arthritis: options, uses and optimization. Expert Rev Clin Immunol. 2015;11:1131-46.

[2]Nguyen H, Ruyssen-Witrand A, Gandjbakhch F, Constantin A, Foltz V, Cantagrel A. Prevalence of ultrasound-detected residual synovitis and risk of relapse and structural progression in rheumatoid arthritis patients in clinical remission: a systematic review and meta-analysis. Rheumatology (Oxford). 2014;53:2110-8.

Acknowledgements

We wish to thank Atsuko Kamiyama, Tomoko Nishimura for clinical assistant, Setsuko Takeda, Emi Yamashita, Yuko Yoshida, Emi Ohtani, Yuka Domae, Asami Yagami, Shingo Washida for their special efforts as a sonographer and collecting data.

Disclosure of Interests

Tadashi Okano Speakers bureau: Asahi Kasei, Astellas, Abbvie, Amgen, Ayumi, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead Sciences, Janssen, Kyowa Kirin, Mitsubishi Tanabe, Novartis, Ono, Pfizer, Sanofi, Takeda, UCB, Grant/research support from: Asahi Kasei, Abbvie, Chugai, Eisai, Mitsubishi Tanabe, Kenji Mamoto: None declared, Yutaro Yamada: None declared, Koji Mandai: None declared, Shohei Anno: None declared, Masahiro Tada: None declared, Kentaro Inui Speakers bureau: Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., Ono Pharmaceutical Co. Ltd., Abbvie GK, Pfizer Inc., Eisai Co.,Ltd., Chugai Pharmaceutical Co., Ltd., Grant/research support from: Janssen Pharmaceutical K.K., Astellas Pharma Inc., Sanofi K.K., Abbvie GK, Takeda Pharmaceutical Co. Ltd., QOL RD Co. Ltd., Mitsubishi Tanabe Pharma, Ono Pharmaceutical Co. Ltd., Eisai Co.,Ltd.,, Tatsuya Koike Speakers bureau: Takeda Pharmaceutical, Mitsubishi Tanabe Pharma Corporation, Chugai Pharmaceutical, Eisai, Abbott Japan, Teijin Pharma, Banyu Pharmaceutical and Ono Pharmaceutical, Hiroaki Nakamura: None declared

AB0229 ACHIEVING GLUCOCORTICOID FREE MIGHT DECREASE RISK FOR CLINICAL FRACTURES IN PATIENTS WITH RHEUMATOID ARTHRITIS - TEN-YEAR FINDINGS FROM THE TOMORROW STUDY

Background

Patients with rheumatoid arthritis (RA) who have muscle weakness and stiff or painful joints might be at increased risk of falls and fractures.

Objectives

The present study prospectively investigates correlations between decreasing doses of glucocorticoid (GC) and the incidence of clinical fractures in patients with RA based on the ten-year findings of the TOMORROW study (UMIN000003876) that started in 2010.

Methods

We evaluated anthropometric parameters, bone mineral density, disease activity, RA medication, and the incidence of clinical fractures over a period of ten years in 202 patients with RA (mean age, 58.6 years; mean disease duration, 14.0 years). We also investigated the effects of GC doses on the incidence of clinical fractures over the same period in patients with RA using multivariate regression analysis.

Results

The incidence of clinical fractures for ten years in patients with RA was 0.036/person-year. There were 89 patients (44.1%) treated with GC at least once during ten years. The incidences of clinical fractures in patients with RA treated with and without GC during ten years were 0.052 and 0.026/person-year, respectively. After adjusting for fracture risk factors including age, sex, smoking, and body mass index, cox proportional hazard model revealed that GC dose of ≥ 2 mg/day at baseline was a significant risk factor for clinical fractures (Hazard ratio [HR]:2.430; 95%CI, 1.040-5.675, p=0.040). Although the risk for clinical fractures did not decrease by just reducing the dose of GC (HR:4.505; 95%CI, 0.589-34.457, p=0.147), it was significantly lower if the dose of GC could be reduced to zero during ten years (HR:0.407; 95%CI, 0.194-0.857, p=0.018).

Conclusion

Medication with even low dose of GC are apparently significantly associated with an increased frequency of clinical fractures among patients with RA. However, if the dose of GC was reduced to free during ten years, the clinical fracture risk could become lower. We concluded that we should decrease the dose of GC to free after controlling disease activity of RA.

Disclosure of Interests

None declared

AB1096 THE INFLUENCE OF THE BEHAVIORAL RESTRICTION OF COVID-19 PANDEMIC FOR THE FRAILTY OF PATIENTS WITH RHEUMATOID ARTHRITIS

Background

We previously reported the prevalence of frailty and relation of disease activity at patients with rheumatoid arthritis (RA)1. The behavioral restriction of COVID-19 pandemic influenced for the lifestyle of people included patients with RA.

Objectives

The relationship between the behavioral restriction of COVID-19 pandemic and frailty was investigated.

Methods

We used the date from prospective observational study (CHIKARA study: UMIN000023744). 70 from 100 patients with RA were followed-up and evaluated the frailty and subcategories (social, physical, mental, nutrition, and cognitive) by frailty checklist. The prevalence of frailty and the change of exercise and daily life activities by visual analog scale were investigated at pre- and post-behavioral restriction. The correlation of frailty and change of amount of exercise and daily life activity examined by univariate analysis.

Results

Mean age was 69.7 years (women n=57, men n=13). The prevalence of frailty at post-behavioral restriction increased compared that at pre-behavioral restriction (post:35.8% vs pre:30.0%). Especially, cognitive and total score at post-behavioral restriction increased significantly. The rate of decrease of exercise by <25%, 26~50%, and 51%< were 70%, 21%, and 9%, respectively (mean:20% decrease). Whereas, the rate of decrease of daily life activities by <25%, 26~50%, and 51%< were 37%, 27%, and 36%, respectively (mean:44% decrease). The change of exercise was significantly negatively correlated with the change of nutrition (R=-0.245, P=0.041) at Table 1. There was no correlation between the change of daily life activities and subcategories.

Table 1.

Univariate analysis of the changes in daily living activities or exercise and those in frailty and subcategories

Change of daily living activitiesChange of exerciseR valueP valueR valueP valueΔ Social0.0990.417-0.0060.962Δ Physical0.1820.130-0.0050.965Δ Mental-0.2000.097-0.2340.051Δ Nutrition-0.2040.091-0.2450.041Δ Cognitive-0.0870.476-0.0340.778Δ Total-0.0910.454-0.1780.140

Δ, change from pre- to post-behavioral restriction.

Analyzed by Spearman’s rank correlation coefficient

Conclusion

The exercise slightly decreased and the daily life activities decreased almost 50% by the behavioral restriction of COVID-19 pandemic. The prevalence of frailty increased 5.8%, and cognitive and total score were significantly high at post-behavioral restriction of COVID-19 pandemic. The decrease of exercise correlated with the worse of nutrition.

References

[1]Tada M, Yamada Y, Mandai K, Hidaka N. Correlation between frailty and disease activity in patients with rheumatoid arthritis: Data from the CHIKARA study. Geriatr Gerontol Int 2019; 19:1220-5.

Disclosure of Interests

None declared

POS0290 THE EFFECTS OF TREATMENT RESPONSE AND RISK FACTOR TO INHIBIT THE CLINICAL RESPONSE IN PATIENTS WITH DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS TREATED WITH IL-6 RECEPTOR INHIBITOR, ABATACEPT AND JAK INHIBITOR

Background

Recently, the disease activity of rheumatoid arthritis (RA) was improved due to the ‘treat-to-target’ strategy. However, some patients remain various symptoms despite recommended treatment was performed. Then, the term of ‘difficult-to-treat RA (D2TRA)’ is widely recognized. It is unknown how the difference of type of biological disease-modifying anti rheumatic dugs (bDMARDs)/Janus kinase inhibitor (JAKi) will affect clinical efficacy in patients with D2TRA. Moreover, the risk factor to inhibit the clinical response in patients with D2TRA is unknown.

Objectives

The aim of this study was to evaluate the treatment response in patients with D2TRA who were treated with interleukin 6 receptor inhibitor (IL-6Ri), abatacept and JAKi.

Methods

This study used the multicenter database included 673 RA patients treated with bDMARDs/JAKi (tocilizumab 240, sarilumab 67, abatacept 146, tofacitinib 101, baricitinib 83, upadacitinib 20, peficitinib 14, filgotinib 2). Two hundred forty-two patients were treated as first line bDMARDs/JAKi (IL-6Ri 117, abatacept 63, JAKi 62), 211 patients were treated as second line bDMARDs/JAKi (IL-6Ri 117, abatacept 37, JAKi 57), 220 patients were treated as third and more bDMARDs/JAKi. In these 220 patients, 82 patients did not meet D2TRA criteria (IL-6Ri 42, abatacept 15, JAKi 25) and 138 patients met D2TRA criteria (IL-6Ri 31, abatacept 31, JAKi 76). In all patients, we analyzed 138 patients with D2TRA (113 female, mean age was 63.1 ± 13.7 years). Drug retention rate and effectiveness of bDMARDs/JAKi in patients with D2TRA were evaluated for 24 weeks. Multivariate linear regression analysis was performed to clarify the risk factors to inhibit the clinical response.

Results

Drug retention rate of patients with D2TRA at 24 weeks was 67.7% in IL-6Ri group, 74.2% in abatacept group, 61.8% in JAKi group. Drug retention rate in patients with D2TRA was not different between groups (IL-6Ri vs abatacept: p=0.86, IL-6Ri vs JAKi group: p=0.39, abatacept vs JAKi group: p=0.33). DAS28-CRP at 4, 12, 24 weeks decreased in all group (Figure 1). Abatacept showed lower improvement ratio of DAS28-CRP at 24 weeks compared to IL-6Ri group (IL-6Ri vs abatacept: p<0.01, IL-6Ri vs JAKi: p=0.1, abatacept vs JAKi: p=0.07). Good responder (defined as decrease in DAS28-CRP score > 1.2 with a score < 3.2) was 52.4% patients in IL-6Ri, 17.4% patients in abatacept, 29.8% patients in JAKi. SDAI and CDAI at 4, 12, 24 weeks decreased in all group (Figure 1). There were no diferences between the groups in improvement ratio of SDAI (IL-6Ri vs abatacept: p=0.11, IL-6Ri vs JAKi: p=0.81, abatacept vs JAKi: p=0.08) and CDAI (IL-6Ri vs abatacept: p=0.31, IL-6Ri vs JAKi: p=0.82, abatacept vs JAKi: p=0.13) at 24 weeks. HAQ was 1.42, 1.15, 1.39 at baseline, 1.27, 1.07, 1.22 at 4 weeks, 1.17, 1.07, 1.17 at 12 weeks, 1.26, 1.06, 1.14 at 24 weeks in IL-6Ri group, abatacept and JAKi, respectively. Multivariate linear regression analysis revealed that high HAQ (β=0.28, p=0.02) and high dosage of glucocorticoid (β=0.67, p<0.01) inhibited the improvement of DAS28-CRP. Type of bDMARDs/JAKi (β=-0.09, p=0.36) did not affect the DAS28-CRP improvement for 24 weeks.

Table 1.

Multivariate linear regression analysis of risk factor to inhibit the clinical response in patients with D2TRA.

β95% CIpAge (years)-0.037-0.025, 0.0170.74male-0.047-0.788, 0.4860.64Disease durations (years)-0.048-0.028, 0.0170.63RF (IU/ml)-0.082-0.0004, 0.00020.41Anti CCP antibody (U/ml)0.111-0.0005, 0.0020.26DAS28-CRP-0.063-0.265, 0.1420.55HAQ0.2790.059, 0.7170.02MTX (mg/day)0.136-0.018, 0.0810.21Glucocorticoid dose (mg/day)0.6690.174, 0.324< 0.01Type of bDMARDs/JAKi-0.088-0.415, 0.1510.36

Conclusion

Drug retention rate and clinical efficacy of D2TRA patients were not different among IL-6Ri, abatacept and JAKi. DT2RA patient with functional disorder and high dosage of glucocorticoid were risk factor to inhibit the clinical response.

Disclosure of Interests

None declared

OP0133 THE DECREASE OF MUSCLE MASS BY THE BEHAVIORAL RESTRICTION OF COVID-19 PANDEMIC IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

We previously reported the prevalence of sarcopenia and body compositions at patients with rheumatoid arthritis (RA)1. The behavioral restriction of COVID-19 pandemic influenced for the lifestyle of people included patients with RA.

Objectives

The change of exercise and daily life activity of patients with RA were investigated and body composition and muscle function were compared pre- and post-behavioral restriction.

Methods

We used the date from prospective observational study (CHIKARA study: UMIN000023744). 70 from 100 patients with RA were followed-up and evaluated the change of exercise and daily life activity by visual analog scale. They were measured the muscle mass, fat mass, basal metabolic rate by body composition analyzer and grip strength as muscle function. The relationship between the change of exercise and daily life activity and body composition was investigated by univariate analysis.

Results

Mean age was 69.7 years (women n=57, men n=13). The rate of decrease of exercise by <25%, 26~50%, and 51%< were 70%, 21%, and 9%, respectively (mean:20% decrease). Whereas, the rate of decrease of daily life activities by <25%, 26~50%, and 51%< were 37%, 27%, and 36%, respectively (mean:44% decrease). Muscle mass at post-behavioral restriction decrease significantly compared that at pre-behavioral restriction activities (34.0kg vs 34.7kg, P<0.001). Fat mass at post-behavioral restriction increase significantly compared that at pre-behavioral restriction (16.2kg vs 15.5kg, P=0.014). Grip strength at post-behavioral restriction decrease significantly compared that at pre-behavioral restriction (16.2kg vs 17.2kg, P=0.026). The change of exercise was significantly positively correlated with the change of muscle mass and basal metabolic rate (R=0.273, P=0.021 and R=0.256, P=0.033, relatively) at Table 1. Whereas, the change of daily living activities was not significantly correlated with the change of muscle mass and muscle function.

Table 1.

Univariate analysis of the changes in daily living activities or exercise and those in body composition or muscle function

Change of daily living activitiesChange of exerciseR valueP valueR valueP valueΔ Weight (kg)-0.1230.311-0.1310.279Δ BMI (kg/m2)-0.1080.397-0.1130.345Δ Muscle mass (kg)0.1400.3110.2730.021Δ Fat mass (kg)-0.0610.614-0.0750.539Δ Fat percentage (%)-0.0030.982-0.0180.884Δ Basal metabolic rate (kcal)0.2010.0950.2560.033Δ Grip strength (kg)0.1170.3360.0370.762Δ Walk speed (m/s)0.1690.1610.1390.250

Δ, change from pre- to post-behavioral restriction; BMI, body mass index

Analyzed by Spearman’s rank correlation coefficient

Conclusion

Muscle mass and grip strength decrease and fat mass increase in patients with RA by the behavioral restriction of COVID-19 pandemic. Muscle mass and basal metabolic rate decrease in patients without exercise habits. Maintenance of muscle mass might be important during the COVID-19 pandemic.

References

[1]Tada, M., Yamada, Y., Mandai, K. & Hidaka, N. Matrix metalloprotease 3 is associated with sarcopenia in rheumatoid arthritis - results from the CHIKARA study. Int J Rheum Dis 21, 1962-1969, doi:10.1111/1756-185X.13335 (2018).

Disclosure of Interests

None declared

AB0225 FRAX ASSESSMENT IN PATIENTS WITH RHEUMATOID ARTHRITIS PREDICTED THE REAL INCIDENCE OF CLINICAL FRACTURES FOR 10 YEARS FROM THE RESULTS OF THE 10-YEAR TOMORROW STUDY

Background

To investigate if FRAX in patients with RA can predict the incidence of new clinical fractures for 10 years by using the 10-year data of the TOMORROW study (UMIN000003876) which is a prospective cohort study.

Objectives

To investigate if FRAX in patients with RA can predict the incidence of new clinical fractures for 10 years by using the 10-year data of the TOMORROW study (UMIN000003876) which is a prospective cohort study.

Methods

We calculated ten-year probability of major osteoporotic fracture (FRAX) in 208 RA patients and 205 sex- and age-matched volunteers (Vo), and compared FRAX with the incidence of clinical fractures for 10 years.

Results

The mean FRAX were 14.5 and 8.8% in 175 RA patients and 168 Vo, respectively, in whom we could calculate FRAX at baseline and complete to investigate the incidence of clinical fractures for 10 years from baseline. The mean FRAX in RA patients was significantly higher than that in Vo (P<0.001). The actual incidence of clinical fractures for 10 years in RA patients was significantly higher than that in Vo (33.9 vs 22.9%, P=0.031). In both groups, the actual incidence of clinical fractures was higher than FRAX prediction. Logistic regression analysis revealed that FRAX and FRAX≧15% were the significant risk factors for clinical fractures for 10 years in both groups (Odds ratio (OR), 1.055, P<0.001, 2.943, P=0.043, respectively). The mean FRAX in RA patients with and without clinical fractures for 10 years were 18.5 and 12.5%, respectively (P=0.002). In RA patients, FRAX was also the significant risk factor for clinical fractures (OR, 1.046, P=0.004).

Conclusion

FRAX and the incidence of clinical fractures for 10 years were significantly higher in RA patients than them of Vo. We confirmed that FRAX was the risk factor for clinical fractures in actual clinical practice.

Disclosure of Interests

None declared

AB0405 JAK INHIBITORS IMPROVE PATIENT-REPORTED OUTCOMES SUCH AS PAIN AND HAQ EARLIER THAN ANTI-IL-6 INHIBITORS

Background

Clinical feature of Janus kinase (JAK) inhibitor is recognized as not only suppress inflammation but also improve patient-reported outcomes (PRO) such as pain and health assessment questioner (HAQ) in patients with rheumatoid arthritis (RA). This representative clinical feature was known as a results of phase 3 trial compared to TNF inhibitor. One of the mechanisms of JAK in RA is to suppresses interleikin-6 (IL-6). However, the effect for PRO in JAK inhibitor compared to IL-6 inhibitor have not been known.

Objectives

We investigated the effect for patient-reported outcomes such as pain and HAQ in patients with RA treated with JAK inhibitor compared to IL-6 inhibitor.

Methods

This study was analysed a multicenter database included RA patients treated with biological disease-modifying anti rheumatic dugs (bDMARDs) and JAK inhibitors. In 307 patients treated with IL-6 inhibitor (tocilizumab 240 and sarilumab 67) and 220 patients with JAK inhibitor (tofacitinib 101, baricitinib 83, upadacitinib 20, peficitinib 14 and filgotinib 2), 155 patients were treated as first-line bDMARDs/JAK inhibitor (IL-6R inhibitor 104 and JAK inhibitor 51). In this first-line patients, patients treated with IL-6R inhibitor and JAK inhibitor were matched using the propensity score adjusted for gender, age, RA disease duration, baseline charactristics of disease activity, CRP level, and MMP-3 level. The beaseline data and the change of clinical and laboratory data at 4, 12 and 24 weeks were compared between IL-6 inhibitor and JAK inhibitor.

Results

Thirty-six patients in each group were matched and analyzed. The average age was 62.4 and 62.6 years and the average disease duration of RA was 13.2 and 10.1 years in IL-6 inhibitor and JAK inhibitor. The baseline characteristics were not significantly different in both groups. At week 4, tender joint count (TJC) was significantly improved in JAK inhibitor than IL-6 (IL-6: -1.86 vs JAK: -4.12, p= 0.036) and HAQ was significantly improved in JAK inhibitor than IL-6 (IL-6: -0.04 vs JAK: -0.27, p= 0.041). Moreover, Clinical Disease Activity Index (CDAI) was also improved in JAK inhibitor than IL-6 (IL-6: -6.6 vs JAK: -10.9, p= 0.026) at week 4. However, pain VAS and patient global VAS were not significantly different in each group in week4. TJC, HAQ and CDAI was not different in both groups at week 12 and week 24. On the other hand, ESR was significantly decreased in IL-6 inhibitor than JAK inhibitor at week 4, 12 and 24 (IL-6: -26.6 vs JAK: -14.1, p=0.018 at week 4, IL-6: -32.7 vs JAK: -16.5 p=0.004 at week 12, IL-6: -31.3vs JAK: -17.7 p=0.014 at week 24).

Conclusion

In a comparison between IL-6 inhibitor and JAK inhibitor as a first-line molecular-targeted drug matched baseline charactristics of disease activity, TJC and HAQ was improved in JAK inhibitor earlier than IL-6 inhibitors. JAK inhibitor suppress multi cytokine that might be the reason why JAK inhibitor improve pain. Improvement of patient reported outcome in JAK inhibitor was found also in comparison with IL-6 inhibitor.

References

[1]Taylor PC, Keystone EC, van der Heijde D, et al. Baricitinib versus Placebo or Adalimumab in Rheumatoid Arthritis. N Engl J Med. 2017;376:652-62.

[2]Fleischmann R, Pangan AL, Song IH, et al. Upadacitinib Versus Placebo or Adalimumab in Patients with Rheumatoid Arthritis and an Inadequate Response to Methotrexate: Results of a Phase III, Double-Blind, Randomized Controlled Trial. Arthritis Rheumatol. 2019;71:1788-1800.

Acknowledgements

We wish to thank Atsuko Kamiyama and Tomoko Nishimura for clinical assistant, and all member of Team RA.

Disclosure of Interests

Tadashi Okano Speakers bureau: Asahi Kasei, Astellas, Abbvie, Amgen, Ayumi, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead Sciences, Janssen, Kyowa Kirin, Mitsubishi Tanabe, Novartis, Ono, Pfizer, Sanofi, Takeda, UCB, Grant/research support from: Asahi Kasei, Abbvie, Chugai, Eisai, Mitsubishi Tanabe, Tatsuya Koike Speakers bureau: Takeda Pharmaceutical, Mitsubishi Tanabe Pharma Corporation, Chugai Pharmaceutical, Eisai, Abbott Japan, Teijin Pharma, Banyu Pharmaceutical and Ono Pharmaceutical, Kentaro Inui Speakers bureau: Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., Ono Pharmaceutical Co. Ltd., Abbvie GK, Pfizer Inc., Eisai Co.,Ltd., Chugai Pharmaceutical Co., Ltd., Grant/research support from: Janssen Pharmaceutical K.K., Astellas Pharma Inc., Sanofi K.K., Abbvie GK, Takeda Pharmaceutical Co. Ltd., QOL RD Co. Ltd., Mitsubishi Tanabe Pharma, Ono Pharmaceutical Co. Ltd., Eisai Co.,Ltd., Masahiro Tada: None declared, Kenji Mamoto: None declared, Yutaro Yamada: None declared, kazuki Orita: None declared, Koji Mandai: None declared, Shohei Anno: None declared, Takahiro Iida: None declared, Hiroaki Nakamura: None declared

AB0262 PATIENTS WITH RHEUMATOID ARTHRITIS WHO DEVELOP SARCOPENIA FALL FREQUENTLY: 5-YEAR DATA FROM THE CHIKARA STUDY

Background

Patients with rheumatoid arthritis (RA) are likely to have sarcopenia due to decreased muscle mass and physical function. Some patients develop sarcopenia even if disease activity is well-controlled. We previously reported that 13.2% of RA patients without sarcopenia at baseline developed sarcopenia over a year1.

Objectives

The aim was to longitudinally investigate sarcopenia status and the characteristics of RA patients using data from the prospective, observational CHIKARA study.

Methods

Body composition, laboratory data, disease activity, physical function (HAQ), treatment, and history of falls and fractures were investigated in 100 RA patients who participated in the CHIKARA study at baseline and at 5 years. They were divided into 4 groups depending on their sarcopenia status: no sarcopenia developed (N group; sarcopenia absent at baseline and 5 years); sarcopenia developed (S group; sarcopenia absent at baseline, but present at 5 years); cured (C group; sarcopenia present at baseline, but absent at 5 years); and persistent (P group; sarcopenia present at baseline and at 5 years).

Results

Seventy RA patients completed the survey. There were no differences among the 4 groups in disease activity, physical function, and treatment. The N group, accounting for 67.1% of all patients, was young and had high body mass index, muscle mass, fat mass, estimated bone mass, and body metabolic rate at baseline. On the other hand, the S group, accounting for 4.3% of all patients, fell significantly more frequently (p=0.035), 3.3 times during 5 years. The P group, accounting for 18.6% of all patients, had significantly higher MMP-3 at baseline (p=0.006). The C group accounted for 10.0% of all patients (Table 1).

Table 1.

Characteristics of 77 RA patients by sarcopenia status at baseline and at 5-year follow-up

no development (n=47)development (n=3)cured (n=7)persisted (n=13)p valueage, years63 (57.5, 70)76 (74.5, 81)66 (54, 70)73 (65, 82)0.006disease duration, years6.5 (1.1, 10.7)15.2 (14.9, 20.7)11.4 (7.2, 14.8)3.5 (1.1, 6.5)0.021MTX dose, mg/day8.1 ± 3.76.0 ± 2.07.4 ± 3.86.2 ± 4.80.406biologics use, %36.266.728.623.10.513GC use, %23.4028.615.40.701average GC dose, mg/day3.5 ± 1.103.7 ± 1.86.3 ± 1.80.833CRP, mg/dl0.1 (0.04, 0.18)0.04 (0.04, 0.23)0.2 (0.12, 0.47)0.19 (0.08,0.82)0.22MMP-3, ng/ml62.2 (50.3, 98.6)58.9 (47.8, 71.3)74.9 (58.3,147.2)160 (90.8,262)0.006DAS28ESR3.34 ± 0.914.11 ± 0.723.36 ± 1.383.79 ± 1.200.355mHAQ0.25 (0, 0.5)0.63 (0.56, 1.25)0.87 (0.25, 1.0)0.25 (0.13, 0.75)0.132BMI, kg/m223.22 ± 3.5121.4 ± 2.2518.69 ± 2.0819.56 ± 2.39<0.001SMI, kg/m26.73 ± 0.76.1 ± 0.25.51 ± 0.145.79 ± 0.6<0.001fat percentage, %30.39 ± 8.7730.03 ± 9.1225.04 ± 6.2323.75 ± 6.560.051estimated bone mass, kg2.2 (2, 2.4)1.9 (1.75, 1.95)1.6 (1.55, 1.9)1.9 (1.7, 2.2)0.001BMR, kcal1101 (1051, 1198)986 (934, 1010)896 (872, 994)978 (902,1107)<0.001ΔDAS28ESR-0.15 ± 0.84-0.43 ± 1.730.04 ± 0.89-0.59 ± 1.330.445ΔSMI, kg/m2-0.06 ± 0.34-0.38 ± 0.570.25 ± 0.220.08 ± 0.420.038fall, times1.63.331.290.380.045

Data are shown as mean ± standard deviation (SD) or median (25th, 75th percentile).

GC: glucocorticoids, MMP-3: matrix metalloproteinase 3, DAS: disease activity score, HAQ: health assessment questionnaire, BMI: body mass index, SMI: skeletal muscle mass index, BMR: body metabolization rate, Δ:change during 5 years.

Conclusion

Overall, 4.3% of RA patients developed sarcopenia and fell frequently during 5-year follow-up. Patients who develop sarcopenia require special care because they are at high risk of falls.

References

[1]Y Yamada, M Tada, K Mandai et al. Glucocorticoid use is an independent risk factor for developing sarcopenia in patients with rheumatoid arthritis: from the CHIKARA study. Clin Rheumatol 2020 Jun;39(6):1757-1764.

Disclosure of Interests

None declared

AB0387 THE RELATIONSHIP BETWEEN JAK INHIBITORS AND CREATINE KINASE ELEVATION IN PATIENTS WITH RHEUMATOID ARTHRITIS: A REAL-WORLD CLINICAL STUDY

Background

Some cases of creatine kinase (CK) elevation caused by Janus kinase (JAK) inhibitor treatment for rheumatoid arthritis (RA) have been reported in clinical trials1. However, the frequency and patients’ background characteristics in clinical practice are unknown.

Objectives

The correlation between JAK inhibitor treatment for RA and changes in CK levels in clinical practice were investigated using a multicenter database.

Methods

The multicenter database of JAK inhibitors was used, and 103 (tofacitinib 46, baricitinib 44, upadacitinib 11, peficitinib 1, filgotinib 1) of 265 RA patients were followed up at 24 weeks, and their CK levels were evaluated. The time-dependent change of CK was evaluated by sex and analyzed by the Wilcoxon signed-rank test. The percentage abnormal from the standard titer was calculated. The factors related to an elevated CK at 24 weeks were investigated using patients’ background characteristics at the time of starting JAK inhibitors by univariate analysis.

Results

Women accounted for 85.4% of the patients, the median age was 68 years, disease duration was 15 years, and the mean DAS28ESR was 5.00. The CK levels of both men and women were significantly elevated at 4 weeks and maintained until 24 weeks (men, women: 63, 62 (0 weeks), 101, 95 (4 weeks), 119, 96 (12 weeks), 155, 99 (24 weeks), U/L, P<0.001) (Figure 1). The percentage abnormal was also significantly increased at 4 weeks and maintained until 24 weeks (5.8% (0 weeks), 20.7% (4 weeks), 26.3% (12 weeks), 24.3% (24 weeks), P=0.002). The factors significantly positively related to elevated CK levels at 24 weeks were male, CK, creatinine, and lactate dehydrogenase (LDH), and stage, class, modified health assessment questionnaire, estimated glomerular filtration rate (eGFR), and glucocorticoid use were significantly negatively correlated (Table 1). There were no significant differences in CK elevation among the agents.

Table 1.

Characteristics at the time of starting JAK inhibitors related to elevated creatine kinase levels at 24 weeks

UnivariateData at stating JAK inhibitorsR valueP valueCreatine kinase0.653<0.001Gender, men0.2470.012Steinbrocker stage-0.2150.039Steinbrocker class-0.2770.008modified health assessment questionnaire-0.2680.008Creatinine0.2890.003eGFR-0.2310.019LDH0.2010.041Glucocorticoid use-0.4090.008

Analyzed by Spearman rank correlation coefficient

Figure 1.

Time-dependent changes of CK in all RA patients

Conclusion

CK was significantly elevated at 4 weeks and maintained until 24 weeks. However, no patients complained of muscle pain and stopped JAK inhibitors. Patients with high CK, low eGFR, high LDH, or maintained activities of daily living at the time of starting JAK inhibitors tended to have high CK levels at 24 weeks.

References

[1]Fleischmann, R. et al. Upadacitinib Versus Placebo or Adalimumab in Patients With Rheumatoid Arthritis and an Inadequate Response to Methotrexate: Results of a Phase III, Double-Blind, Randomized Controlled Trial. Arthritis & rheumatology (Hoboken, N.J.) 71, 1788-1800, doi:10.1002/art.41032 (2019).

Disclosure of Interests

None declared

POS0631 EVEN LOW-DOSE GLUCOCORTICOID USE IS A RISK FACTOR FOR CLINICAL FRACTURES IN PATIENTS WITH RHEUMATOID ARTHRITIS: TEN-YEAR FINDINGS OF THE TOMORROW STUDY

Background

Patients with rheumatoid arthritis (RA) who have sarcopenia and stiff or painful joints might be at increased risk of falls and fractures.

Objectives

The present study aimed to prospectively identify the incidence of clinical fractures and associated risk factors in patients with RA in a cohort study named the TOMORROW (UMIN000003876) that started in 2010.

Methods

We evaluated anthropometric parameters, bone mineral density (BMD), disease activity, RA medication at entry and observed the incidence of clinical fractures during ten years in 202 patients with RA (mean age, 58.6 y; medication with biological agents, 54.9%) and 202 age- and sex-matched non-RA volunteers (Vo) (mean age, 57.4 y). We compared the incidence of clinical fractures between patients with RA and Vo for ten years, and analyzed the risk factors for clinical fractures using Cox proportional hazard model.

Results

The incidences of clinical fractures were 0.036 and 0.024/person-year in patients with RA and Vo, respectively. Cox proportional hazard model revealed that low BMD at the thoracic vertebrae (< 0.7 g/cm2) and history of fractures at entry were significantly associated with the incidence of clinical fractures (Hazard ratio [HR]1.737, p=0.020 and HR1.514, p=0.047, respectively) in all participants. RA morbidity, however, was not (HR1.398, p=0.112). In patients with RA, medication with GC at entry was a significant risk factor for clinical fractures (HR1.898, p=0.017). Additionally, a mean GC dose (≥ 2 mg/day) at entry and during the ten-year period increased risk for fractures (HR 2.189, p=0.004, 1.866, p=0.022, respectively).

Conclusion

RA per se was not a risk factor for clinical fractures in this cohort. Low BMD at the thoracic vertebrae at entry and the use of GC with even low dose at entry and during ten years were significantly associated with an increased frequency of clinical fractures among patients with RA.

Disclosure of Interests

None declared

Prediction models for severe manifestations and mortality due to COVID-19: A systematic review

BACKGROUND

Throughout 2020, the coronavirus disease 2019 (COVID-19) has become a threat to public health on national and global level. There has been an immediate need for research to understand the clinical signs and symptoms of COVID-19 that can help predict deterioration including mechanical ventilation, organ support, and death. Studies thus far have addressed the epidemiology of the disease, common presentations, and susceptibility to acquisition and transmission of the virus; however, an accurate prognostic model for severe manifestations of COVID-19 is still needed because of the limited healthcare resources available.

OBJECTIVE

This systematic review aims to evaluate published reports of prediction models for severe illnesses caused COVID-19.

METHODS

Searches were developed by the primary author and a medical librarian using an iterative process of gathering and evaluating terms. Comprehensive strategies, including both index and keyword methods, were devised for PubMed and EMBASE. The data of confirmed COVID-19 patients from randomized control studies, cohort studies, and case-control studies published between January 2020 and May 2021 were retrieved. Studies were independently assessed for risk of bias and applicability using the Prediction Model Risk Of Bias Assessment Tool (PROBAST). We collected study type, setting, sample size, type of validation, and outcome including intubation, ventilation, any other type of organ support, or death. The combination of the prediction model, scoring system, performance of predictive models, and geographic locations were summarized.

RESULTS

A primary review found 445 articles relevant based on title and abstract. After further review, 366 were excluded based on the defined inclusion and exclusion criteria. Seventy-nine articles were included in the qualitative analysis. Inter observer agreement on inclusion 0.84 (95%CI 0.78-0.89). When the PROBAST tool was applied, 70 of the 79 articles were identified to have high or unclear risk of bias, or high or unclear concern for applicability. Nine studies reported prediction models that were rated as low risk of bias and low concerns for applicability.

CONCLUSION

Several prognostic models for COVID-19 were identified, with varying clinical score performance. Nine studies that had a low risk of bias and low concern for applicability, one from a general public population and hospital setting. The most promising and well-validated scores include Clift et al.,¹⁵ and Knight et al.,¹⁸ which seem to have accurate prediction models that clinicians can use in the public health and emergency department setting.

High variability in results and methodological quality among overlapping systematic reviews on the same topics in surgery: a meta-epidemiological study

BACKGROUND

Redundant publication of systematic reviews and meta-analyses (SRs/MAs) on the same topic presents an increasing burden for clinicians. The aim of this study was to describe variabilities in effect size and methodological quality of overlapping surgery-related SRs/MAs and to investigate factors associated with their postpublication citations.

METHODS

PubMed/MEDLINE was searched to identify SRs/MAs of RCTs on thoracoabdominal surgeries published in 2015. Previous SRs/MAs on the same topics published within the preceding 5 years (2011-2015) were identified and 5-year citation counts (through to 2020) were evaluated. Discrepancies in pooled effect sizes and their methodological quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR) among overlapping SRs/MAs were assessed. The SR/MA-level factors associated with 5-year citation counts were explored, using a mixed-effects regression model with a random intercept for surgical topics.

RESULTS

A total of 57 surgery-related SRs/MAs (48 topics) published in 2015 were identified, and 146 SRs/MAs had overlapping publications on 29 topics (60.4 per cent of all topics) in the preceding 5 years. There was considerable variability in methodological quality of SRs/MAs and coverage probability for relevant RCTs, resulting in discrepant effect size estimates for the same topic. High quality (AMSTAR score 8-11) was independently associated with higher 5-year citation counts (coefficient = 32.82; 95 per cent c.i. 15.63 to 50.02; P < 0.001).

CONCLUSION

Overlapping SRs/MAs with high variability in results and methodological quality were common in surgery. A high-quality SR/MA score was an independent predictor of more frequent citations. Researchers and journal editors should concentrate their efforts on limiting publications to higher-quality reviews.

Five Key Papers About Emergency Department Fall Evaluation: A Curated Collection for Emergency Physicians

The evaluation of patients who have experienced a fall has been an integral part of geriatric emergency care. All physicians who engage in the care of the geriatric population in acute settings need to familiarize themselves with the current literature on this topic. However, it can be challenging to navigate the large body of literature on this topic. The purpose of this article is to identify and summarize the key studies that can be helpful for faculty interested in an evidence-based fall evaluation.

The authors compiled a list of key papers on emergency department (ED) based upon a structured literature search supplemented with suggestions by key informants and an open call on social media; 32 studies on ED evaluation were identified. Our authorship group then engaged in a modified Delphi technique to develop consensus on the most important studies about fall evaluation for emergency physicians. This process eventually resulted in the selection of the top five articles on fall evaluation. Additionally, we summarize these studies with regard to their relevance to emergency medicine (EM) trainees and junior faculty.

Evaluation of older patients with a history of falls is a challenging but crucial component of EM training. We believe our review will be educational for junior and senior EM faculty to better understand these patients' care and to design an evidence-based practice.

POS1456-HPR THE SERUM IRON LEVEL MIGHT BE USEFUL IN DETERMINING THE SEVERITY OF MALNUTRITION IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

The Global Leadership Initiative on Malnutrition (GLIM) criteria, the first international criteria for diagnosis of malnutrition, was released in 2018 [1]. Patients with rheumatoid arthritis (RA) are thought to be prone to malnutrition due to decreased food intake and increased muscle catabolism caused by chronic inflammation or pain. However, there has been no report to assess the nutritional status of RA patients in accordance with the GLIM criteria. In addition, commonly used blood nutrient indicators such as albumin might not be appropriate as nutritional indicators for RA because these values are affected by inflammation.

Objectives:

This study aims to examine the rates of malnutrition in RA patients according to GLIM criteria, and the relationship between blood nutrient indicators and the severity of malnutrition.

Methods:

In this study, we conducted a cross-sectional survey of 135 female RA patients in 2020. According to the GLIM criteria, patients were considered to be malnourished if patients had one of the following phenotypic: (1) low body mass index, (2) non-volitional weight loss, (3) reduced muscle mass, and one of the following etiologic: (1) reduced food intake or assimilation, (2) disease burden/inflammatory condition. Reduced muscle mass was evaluated by measuring calf circumference, and inflammatory condition was evaluated by Disease Activity Score (DAS) 28. In accordance with the GLIM criteria, the severity of malnutrition was judged as three levels: no problem, moderate, and severe malnutrition. Albumin, transthyretin, transferrin, retinol binding protein, zinc, iron, ceruloplasmin, and total cholesterol were assessed as blood nutrition indicators. Also grip strength was assessed. We compared each nutritional indicator among the three groups according to the severity of malnutrition using age-adjusted analysis of covariance, and examined the relationship between each nutritional indicator and the severity of malnutrition using receiver operating characteristic (ROC) analysis.

Results:

In RA patients, 20% were classified as severe malnutrition, and 40% were moderate or more. Serum iron levels were significantly lower in the severe malnutrition group compared to the no problem group (p = 0.001). In ROC analysis, serum iron, zinc, albumin, and grip strength (area under curve; AUC; 0.680, 0.696, 0.636, 0.790, respectively) were significant parameters for classification of moderate and severe malnutrition. Serum iron and grip strength (AUC for respective parameters were 0.741, 0.747) were significant parameters for classification of severe malnutrition.

Conclusion:

Evaluation based on the GLIM criteria showed that about 40% of RA patients were under moderate or severe malnutrition. It was suggested that serum iron and grip strength might be useful to predict the severity of malnutrition.

References:

[1]Cederholm T, Jensen GL, Correia MITD, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community. Clinical Nutrition 2019; 38: 1-9.

Acknowledgements:

We thank to Tomoko Nakatsuka, and the Center for Drug & Food Clinical Evaluation, Osaka City University Hospital, for management and collection of the study data. We also thank to study participants.

Disclosure of Interests:

Yoshinari Matsumoto Grant/research support from: Yamada Research Grant, Yuko Sugioka: None declared, Masahiro Tada: None declared, Tadasi Okano Speakers bureau: AbbVie, Asahikasei, Astellas Pharma Inc, Ayumi Pharmaceutical, Bristol-Myers Squibb, Chugai Pharmaceutical, Daiich Sankyo, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, Novartis Pharma, Ono Pharmaceutical, Pfizer, Sanofi, Takeda Pharmaceutical, Teijin Pharma and UCB, Grant/research support from: AbbVie, Eisai, Mitsubishi Tanabe Pharma Corporation and Nipponkayaku, Kenji Mamoto: None declared, Kentaro Inui Speakers bureau: Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., Ono Pharmaceutical Co. Ltd., Abbvie GK, Pfizer Inc., Eisai Co., Ltd., Chugai Pharmaceutical Co., Ltd, Grant/research support from: anssen Pharmaceutical K.K., Astellas Pharma Inc., Sanofi K.K., Abbvie GK, Takeda Pharmaceutical Co. Ltd., QOL RD Co. Ltd., Mitsubishi Tanabe Pharma, Ono Pharmaceutical Co. Ltd., Eisai Co., Ltd., Daiki Habu: None declared, Tatsuya Koike Speakers bureau: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB, Grant/research support from: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB

AB0813 DEVELOPING SARCOPENIA IS A RISK FACTOR FOR FRACTURES IN PATIENTS WITH RHEUMATOID ARTHRITIS: 4-YEAR DATA FROM THE CHIKARA STUDY

Background:

Patients with rheumatoid arthritis (RA) tend to have sarcopenia due to decreased muscle mass and function. We previously reported that 13.2% of RA patients without sarcopenia at baseline developed sarcopenia over a year using data from the prospective, observational CHIKARA study1.

Objectives:

The aim was to investigate sarcopenia status and the characteristics of RA patients longitudinally.

Methods:

Body composition, laboratory data, disease activity, physical function, treatment, and history of falls and fractures were investigated in 100 RA patients who participated in the CHIKARA study at baseline and at 4 years. The patients were divided into 4 groups depending on their sarcopenia status: no sarcopenia development (N group), sarcopenia development (S group), cured (C group), and persisted (P group).

Results:

Of the 77 RA patients who completed the survey, 48 were in the N group; their body mass index, skeletal muscle mass index, fat percentage, estimated bone mass, and body metabolization rate at baseline were significantly elevated. On the other hand, 6 patients were in the S group; 83.3% of them experienced fractures during the 4 years, significantly more than in the other groups. Ten patients were in the P group, and their baseline MMP-3 was significantly higher than in the other groups. Thirteen patients were in the C group. There were no differences among the 4 groups in disease activity and physical function (Table 1).

Table 1.

Characteristics of 77 RA patients by sarcopenia status at baseline and at 4-year follow-up.

no development(n=48)development(n=6)cured(n=10)persisted(n=13)p valueBaseline age, years64.5 (57.8, 72)70.0 (65.5, 72.3)61.0 (54.5, 68.3)72 (68, 81)0.062 disease duration, years4.6 (1.1, 9.9)11.7 (2.8, 18.9)8.1 (4.2, 14.3)4.0 (2.2, 7.7)0.427 biologics use, %37.516.730.023.10.617 GC use, %27.116.710.023.10.678 MMP-3, ng/ml66.8 (51.8, 103)52.5 (40.0, 56.7)82.8 (57.8, 186)157.5 (90.8, 250)0.001 DAS28ESR3.43 ± 0.873.48 ± 1.323.36 ± 1.083.80 ± 1.270.661 mHAQ0.31 (0, 0.50)0.19 (0.03, 0.44)0.38 (0, 0.84)0.50 (0.25, 0.88)0.383 BMI, kg/m223.4 ± 3.621.6 ± 2.419.2 ± 1.619.5 ± 2.6<0.001 SMI, kg/m26.8 ± 0.86.2 ± 0.65.8 ± 0.55.7 ± 0.6<0.001 fat percentage, %30.4 ± 8.429.1 ± 9.123.9 ± 4.025.1 ± 8.30.046 estimated bone mass, kg2.2 (2.0, 2.4)1.9 (1.8, 2.1)2.0 (1.7, 2.1)1.7 (1.7, 1.9)0.012 BMR, kcal1100 (1031, 1197)1029 (918, 1070)1012 (917, 1057)934 (894, 1006)0.005Change during 4 years ΔDAS28ESR-0.34 ± 0.97-0.52 ± 0.98-0.60 ± 1.46-0.56 ± 1.140.834 ΔmHAQ0 (-0.25, 0.16)0.19 (0, 0.56)-0.06 (-0.44, 0.94)0 (-0.38, 0.38)0.357 ΔSMI, kg/m20.0 ± 0.3-0.6 ± 0.30.3 ± 0.4-0.0 ± 0.3<0.001 fall, %43.883.330.023.10.079 fracture, %14.683.320.023.10.002

Data are shown as mean ± standard deviation (SD) or median (25th, 75th percentile).

GC: glucocorticoids, BMI: body mass index, SMI: skeletal muscle mass index, BMR: body metabolization rate.

Conclusion:

Overall, 7.8% of RA patients developed sarcopenia during the 4-year follow-up period, and they developed fractures more frequently. Evaluation of sarcopenia is important for risk assessment of fractures.

References:

[1]Y Yamada, M Tada, K Mandai et al. Glucocorticoid use is an independent risk factor for developing sarcopenia in patients with rheumatoid arthritis: from the CHIKARA study. Clin Rheumatol 2020 Jun;39(6):1757-1764.

Disclosure of Interests:

Yutaro Yamada: None declared, Masahiro Tada: None declared, Koji Mandai: None declared, Noriaki Hidaka: None declared, Hiroaki Nakamura Grant/research support from: Astellas and Asahi Kasei

POS0532 AveRAGE PREDNISOLONE DOSE OF ONLY 1 MG PER DAY WAS RISK FACTOR FOR CLINICAL FRACTURES IN PATIENTS WITH RHEUMATOID ARTHRITIS - NINE-YEAR FINDINGS OF THE TOMORROW STUDY

Background:

Previous cohort studies showed that the use of prednisolone (PSL) was a risk factor for clinical fractures in patients with rheumatoid arthritis (RA). However, there are few reports on relationship between PSL dose and clinical fractures.

Objectives:

The present study aimed to determine the effect of PSL dose on the incidence of clinical fractures in the RA patients treated with PSL.

Methods:

We evaluated anthropoetric parameters, bone mineral density (BMD), disease activity score 28-erythrocyte sedimentation rate (DAS28-ESR), RA medication (methotrexate (MTX) dose, use of biologic disease modified anti-rheumatic-drugs (bDMARDs), and PSL dose) and the incidence of clinical fractures during nine years in RA patients who participant the TOMORROW study (UMIN000003876), which is a 10-years prospective cohort study. Data on clinical fracture was self-reported on the questionnaires. In this analysis, the data of RA patients treated with PSL at least once during nine-year period were evaluated. We analyzed the average dose of PSL until the incidence of the clinical fractures. The risk factor for clinical fractures were analyzed by using Cox proportional hazard model with adjustment for age, sex, body mass index (BMI), and smoking history.

Results:

We analyzed the data of 67 RA patients treated with PSL. Among them, median age was 61.8 year, 56 patients (83.6%) were female, 47 patients (70.1%) were never smoker and median disease duration was 12.1 year. The number of patients treated with PSL at baseline was 48 (69.1%). During 9 years, 23 clinical fractures were observed in 67 patients, and the incidence of clinical fracture was 0.046/person-year. In 19 patients, who were not treated with PSL at baseline but treated with PSL at least once during 9 years, 5 clinical fractures were observed. In 67 RA patients, Cox proportional hazard analysis revealed that baseline disease activities, BMD at thoracic vertebrae and medication were not significant risk factors for clinical fractures. However, average PSL dose of more than only 1 mg/day was a significant risk factor for the incidence of clinical fracture (hazard ratio (HR): 2.80; p=0.03) (Table 1).

Table 1.

Adjusted hazard ratio for clinical fractures in patients with rheumatoid arthritis treated with PSL.

* Adjusted Hazard ratio95% Confidence intervalP valueCRP (mg/dL)1.290.88-1.910.19RF (IU/mL)0.990.99-1.000.07ACPA (U/mL)0.990.98-1.000.18DAS28-ESR0.990.71-1.390.97BMD at thoracic vertebrae (mg/cm2)0.020.00-1.000.05bDMARDs use0.550.23-1.320.18Bisphosphonate use2.330.95-5.710.07average dose of MTX (mg/week)1.020.92-1.120.74average score of DAS28-ESR1.150.76-1.750.52average dose of PSL more than 1mg/day2.81.09-7.240.03

*Hazard ratio was adjusted for age, sex, body mass index (BMI), and smoking history. RF, Rheumatoid factor; ACPA, Anti-cyclic citrullinated peptide antibody; DAS28-ESR, disease activity score 28-erythrocyte sedimentation rate; BMD, Bone mineral density; bDMARDs, biologic disease modified anti-rheumatic-drugs; MTX, methotrexate; PSL, prednisolone.

Conclusion:

In RA patients treated with PSL, average PSL dose of only 1mg/day significantly increased the risk for the incidence of clinical fractures. Even for established RA patients, continuous use or initiation of low PSL dose was apparently significant risk factor for clinical fractures.

Disclosure of Interests:

Hitoshi Yoshimura: None declared, Tatsuya Koike Grant/research support from: Takeda Pharmaceutical, Mitsubishi Tanabe Pharma Corporation, Chugai Pharmaceutical, Eisai, Abbott Japan, Teijin Pharma, Banyu Pharmaceutical and Ono Pharmaceutical, Kenji Mamoto: None declared, Yuko Sugioka: None declared, Tadashi Okano: None declared, Masahiro Tada: None declared, Kentaro Inui Grant/research support from: Janssen Pharmaceutical K.K. and Astellas Pharma Inc, Hiroaki Nakamura: None declared

POS0517 A LONGITUDINAL STUDY OF SARCOPENIA, LOCOMOTIVE SYNDROME, AND FRAILTY IN PATIENTS WITH RHEUMATOID ARTHRITIS: FROM THE CHIKARA STUDY

Background:

Rheumatoid arthritis (RA) patients have a high frequency of sarcopenia, and they commonly have reduced physical function. We previously reported that the prevalence of sarcopenia was 28%, that of frailty was 18.9%, and that of pre-frailty was 38.9% in RA patients1,2, and 13.2% of RA patients developed sarcopenia within a year 3.

Objectives:

To investigate the risk factors for new onset of sarcopenia, locomotive syndrome, and frailty in patients with RA and the course of each disease.

Methods:

Two-year follow-up data from the rural group of the prospective, observational CHIKARA study were used. Sarcopenia was diagnosed using the criteria of the Asian Working Group for Sarcopenia 2014, locomotive syndrome was diagnosed using locomotive 5, and frailty was diagnosed using the basic checklist. New onset of the disease over the 2-year follow-up period was studied, excluding cases that had the disease at baseline. Improvement was defined as cases with disease at baseline that no longer met the diagnostic criteria after 2 years. Differences in the characteristics of each disease were tested using the Chi-squared test and the paired t-test.

Results:

The 81 patients with RA (82.7% female) had mean age 66.9±11.5 years, mean DAS28-ESR 2.9±1.2, methotrexate use in 81.5% (with a dose of 9.9±2.7 mg/week), and glucocorticoid (GC) use in 22.2% (with a dose of 3.1±1.7 mg/week). The baseline prevalence was 44.4% for sarcopenia, 35.8% for locomotive syndrome, and 25.9% for frailty, and the new onset rate was 4.4% for sarcopenia, 15.4% for locomotive syndrome, and 13.3% for frailty. Of the patients with each disease at baseline, 36.1% had sarcopenia, 20.7% had locomotive syndrome, and 33.3% had frailty, and of those with each disease at 2 years, 36.1% had sarcopenia, 20.7% had locomotive syndrome, and 33.3% had frailty. The new onset sarcopenia and locomotive syndrome groups had significantly higher rates of GC use (p=0.036, p=0.007, paired t-test) and significantly higher doses (p=0.01, p=0.001, paired t-test) than the groups without new onset sarcopenia and locomotive syndrome. High baseline disease activity was an independent predictor of new onset of locomotive syndrome on multivariate logistic regression analysis (OR=3.21, p=0.015).

Conclusion:

The new onset rates at 2 years were 4.4% for sarcopenia, 15.4% for locomotive syndrome, and 13.3% for frailty. In the new onset sarcopenia and locomotive syndrome groups, both GC use and dosage were significantly higher.

References:

[1]Tada M, et al. Matrix metalloprotease 3 is associated with sarcopenia in rheumatoid arthritis - results from the CHIKARA study. Int J Rheum Dis. 2018 Nov;21(11):1962-1969.

[2]Tada M, et al. Correlation between frailty and disease activity in patients with rheumatoid arthritis: Data from the CHIKARA study. Geriatr Gerontol Int. 2019 Dec;19(12):1220-1225.

[3]Yamada Y, et al. Glucocorticoid use is an independent risk factor for developing sarcopenia in patients with rheumatoid arthritis: from the CHIKARA study. Clin Rheumatol. 2020 Jun;39(6):1757-1764.

Disclosure of Interests:

None declared

POS0514 IMPORTANCE OF BODY MASS MEASUREMENT AND THE GRIP STRENGTH TEST TO PREDICT FALLS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

We previously reported that the prevalence of sarcopenia was 28% in patients with rheumatoid arthritis (RA) in a cohort study 1. RA patients have a high risk of falls and fractures 2. However, the predictors of falls and fractures in RA patients are not known.

Objectives:

Whether evaluation of muscle mass and function at baseline could predict falls and fractures during four-year follow-up was investigated.

Methods:

The four-year follow-up data from a prospective, observational study (CHIKARA study: Correlation researcH of sarcopenIa, sKeletal muscle and disease Activity in Rheumatoid Arthritis) were used. Muscle mass was measured by a body impedance analyzer, and leg muscle mass was calculated. The leg muscle score (max: 100, min: 0) reflected the ratio of leg muscle mass to overall weight. Grip strength as an indicator of muscle function was evaluated using a digital, hand-held, isokinetic dynamometer. The correlations between muscle mass or function and falls or fractures were analyzed by survival rates and Cox hazard ratios. Leg muscle mass and grip strength were investigated by receiver operating characteristic (ROC) curve analysis for correlations with falls or fractures.

Results:

A total of 100 RA patients (female: 78%, mean age: 66.1 years) were enrolled; 35 patients had falls, and 19 patients had fractures during the four-year follow-up. The leg muscle score, grip strength, age, and fractures at baseline were significantly correlated with falls. The cut-off values of the leg muscle score and grip strength were calculated to be 84.5 points (sensitivity: 0.79, specificity: 0.43) and 15.9 kg (sensitivity: 0.56, specificity: 0.70), respectively, by ROC curve analysis. The patients were divided into four groups by their leg muscle scores and grip strength; the numbers of falls and fractures are shown in Table 1 for each group. The fall-free survival rate was significantly lower in the group with low leg muscle score and low grip strength (35.3%) than in the other groups (P=0.002) (Figure 1). The hazard ratio for the both low group was significantly increased, 3.6-fold (95%CI: 1.1-11.5), compared to that in the both high group.

Table 1.

Numbers of falls and fractures by category of leg muscle score and grip strength

LG + GS+(n=34)LG - GS+(n=12)LG + GS-(n=37)LG - GS-(n=17)P value*Falls, N6515110.010Fractures, N34660.072

LG+: leg muscle score >84.5 points, GS+: grip strength >15.9kg, LG-: leg muscle score ≤84.5 points, GS+: grip strength ≤15.9kg

*: compared in four groups by Kruskal-Walls test.

Figure 1.

Fall-free survival rate in the four groups

Conclusion:

RA patients with both low leg muscle score and low grip strength at baseline were at high risk for falls during the four-year follow-up period. Evaluation of muscle mass and function can predict falls in RA patients.

References:

[1]Tada, M., Yamada, Y., Mandai, K. & Hidaka, N. Matrix metalloprotease 3 is associated with sarcopenia in rheumatoid arthritis - results from the CHIKARA study. Int J Rheum Dis21, 1962-1969, doi:10.1111/1756-185X.13335 (2018).

[2]van Staa, T. P., Geusens, P., Bijlsma, J. W., Leufkens, H. G. & Cooper, C. Clinical assessment of the long-term risk of fracture in patients with rheumatoid arthritis. Arthritis Rheum54, 3104-3112, doi:10.1002/art.22117 (2006).

Disclosure of Interests:

None declared

OP0319 OSTEOSARCOPENIA INCREASES THE RISK OF FALLS IN PATIENTS WITH RHEUMATOID ARTHRITIS: RESULTS OF A FOUR-YEAR LONGITUDINAL STUDY

Background:

Osteosarcopenia is defined as osteoporosis combined with sarcopenia. Both osteoporosis and sarcopenia are risk factors for falls and fractures in healthy individuals1. The relationships of falls and fractures to osteosarcopenia in rheumatoid arthritis (RA) patients are unknown.

Objectives:

The synergistic effect of osteoporosis and sarcopenia and the impact of osteosarcopenia on falls and fractures in RA patients were investigated using four years of data from a longitudinal study.

Methods:

The data from a prospective, observational study (CHIKARA study: UMIN000023744) were examined. The patients were divided into four groups according to their baseline status: no sarcopenia and osteoporosis (SP-OP-); only sarcopenia (SP+OP-); only osteoporosis (SP-OP+); and both sarcopenia and osteoporosis (SP+OP+). Sarcopenia was diagnosed by the criteria of the Asia Working Group on Sarcopenia 20142. Patients with osteoporosis were defined as those having a therapeutic intervention for osteoporosis. The survival rate and Cox hazard ratio were analyzed using falls and fractures as endpoints, adjusted by age, sex, and body mass index.

Results:

A total of 100 RA patients (female 78%, mean age 66.1 years) were enrolled. The number of SP-OP-, SP+OP-, SP-OP+, and SP+OP+ patients was 45, 17, 27, and 11, respectively. Their baseline characteristics are shown in Table 1. A total of 35 patients had falls, and 19 patients had fractures during the four-year follow-up. The fall-free survival rate in the SP-OP-, SP+OP-, SP-OP+, and SP+OP+ groups was 75.6%, 64.7%, 51.9%, and 36.4%, respectively; that of the SP+OP+ group was significantly lower than that of the other groups (P=0.021) (Figure 1). The fracture-free survival rate in the SP-OP-, SP+OP-, SP-OP+, and SP+OP+ groups was 86.7%, 82.4%, 81.5%, and 54.5%, respectively. That of the SP+OP+ group was relatively lower than that of the other groups (P=0.121). The hazard ratio of falls was significantly increased in the SP+OP+ group by 3.32-fold (95%CI: 1.01-10.9) compared to that in the SP-OP- group, whereas that in the SP+OP- and SP-OP+ groups was 2.58-fold (95%CI: 0.75-8.8) and 2.29-fold (95%CI: 0.94-5.6) higher, respectively. There were no significant differences compared to the SP-OP- group. The hazard ratio of fractures in the SP+OP+ group was increased 2.73-fold (95%CI: 0.61-12.2) compared to that in the SP-OP- group.

Table 1.

Baseline characteristics of the four groups

SA-OP-SA+OP-SA-OP+SA+OP+P value*Female, %73.358.888.91000.027Age, years63 (49, 72)69 (60, 79)73 (64, 75)73 (65, 81)0.008Disease duration, years4.4 (1.0, 8.4)4.0 (1.3, 8.9)7.6 (1.5, 14.5)10.5 (3.2, 26.5)0.035DAS28-ESR3.14 (2.66, 3.70)3.55 (3.01, 4.65)3.93 (3.28, 4.63)3.53 (2.48, 3.89)0.01mHAQ0.25 (0, 0.375)0.375 (0.125, 0.875)0.375 (0.125, 0.875)0.5 (0.125, 0.875)0.065MTX, mg/week, rate (%)8.4 ± 2.9 (86.7)8.7 ± 3.5 (70.6)8.3 ± 2.8 (92.6)6.8 ± 1.0 (90.9)0.388Glucocorticoid, mg/day, rate (%)3.7 ± 1.9 (20.0)6.3 ± 1.8 (11.8)4.0 ± 1.7 (44.4)3.8 ± 1.8 (18.2)0.400Body mass index, kg/m223.4 ± 3.819.2 ± 2.321.7 ± 2.419.2 ± 2.0<0.001

Data are shown as mean ± standard deviation (SD) or median (25th, 75th percentile).

*: compared in four groups by Kruskal-Walls test.

Figure 1.

Fall-free survival rates of the four groups.

Conclusion:

The survival rates with the endpoints of falls and fractures in RA patients with osteosarcopenia were lower during the four-year follow-up. In particular, the risk of falls increased with the synergistic effect of osteoporosis and sarcopenia in RA patients.

References:

[1]Dennison, E. M. et al. Fracture risk following intermission of osteoporosis therapy. Osteoporos Int30, 1733-1743, doi:10.1007/s00198-019-05002-w (2019).

[2]Chen, L. K. et al. Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc15, 95-101, doi:10.1016/j.jamda.2013.11.025 (2014).

Disclosure of Interests:

None declared.

POS0466 RHEUMATOID ARTHRITIS PER SE IS NOT RISK FACTOR FOR CLINICAL FRACTURES: NINE-YEAR FINDINGS OF THE TOMORROW STUDY

Background:

Patients with rheumatoid arthritis (RA) who have sarcopenia and stiff or painful joints might be at increased risk of falls and fractures.

Objectives:

The present study aimed to prospectively identify the incidence of clinical fractures and associated risk factors in patients with RA in a cohort study named the TOMORROW (UMIN000003876) that started in 2010.

Methods:

We evaluated anthropometric parameters, bone mineral density (BMD), disease activity, RA medication at baseline and observed the incidence of clinical fractures during nine years in 202 patients with RA (mean age, 58.6 y; medication with biological agents, 54.9%) and 202 age- and sex-matched non-RA volunteers (mean age, 57.4 y). We compared the incidence of clinical fractures between patients with RA and controls for nine years, and analyzed the risk factors for fractures using Cox proportional hazard model.

Results:

The incidence of clinical fractures in RA patients was significantly higher compared to controls (27.5 vs 18.3%, p=0.04). However, Cox proportional hazard model, adjusted by age, sex, smoking and body mass index, revealed that low BMD at thoracic vertebrae (< 0.7 g/cm2) significantly associated to the incidence of clinical fractures (hazard ratio [HR], 1.86, p=0.02), but not RA morbidity (HR 1.47, p=0.10) (Table 1). Among patients with RA, low BMD at the thoracic vertebrae (< 0.7 g/cm2) was the most prominent risk factor for clinical fractures (HR, 2.66, p=0.02) (Table 1). Although the use of glucocorticoid (GC) at baseline (HR, 1.68, p=0.09) was not a significant risk factor for fractures, a mean GC dose (≥ 2 mg/day) at entry increased risk for clinical fractures in the patients (HR, 1.91, p=0.04) (Table 1).

Conclusion:

RA per se was not a risk factor for clinical fractures in this cohort. Low BMD at the thoracic vertebrae and the use of GC with even low dose at entry were apparently significant risk factors for the incidence of clinical fractures among patients with RA.

Disclosure of Interests:

Kenji Mamoto: None declared, Tatsuya Koike Grant/research support from: Takeda Pharmaceutical, Mitsubishi Tanabe Pharma Corporation,

Chugai Pharmaceutical, Eisai, Abbott Japan, Teijin Pharma, Banyu Pharmaceutical and Ono Pharmaceutical, Yutaro Yamada: None declared, Tadashi Okano: None declared, Yuko Sugioka: None declared, Masahiro Tada: None declared, Kentaro Inui Speakers bureau: Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., Ono Pharmaceutical Co. Ltd., Abbvie GK, Pfizer Inc., Eisai Co.,Ltd., Chugai Pharmaceutical Co., Ltd., Grant/research support from: Janssen Pharmaceutical K.K., Astellas Pharma Inc., Sanofi K.K., Abbvie GK, Takeda Pharmaceutical Co. Ltd., QOL RD Co. Ltd., Mitsubishi Tanabe Pharma, Ono Pharmaceutical Co. Ltd., Eisai Co.,Ltd., Hiroaki Nakamura: None declared

AB0266 ANALYSIS OF STRESS AND FATIGUE IN PATIENTS WITH RHEUMATOID ARTHRITIS USING A DIGITIZING DEVICE

Background:

Stress and fatigue are evaluated subjectively by patients using a visual analog scale (VAS) and questionnaires such as the SF-36 and the FACIT Fatigue Scale. Such evaluations are based on patients’ self-reported outcomes. It is difficult to evaluate stress and fatigue objectively. A digitizing device was used to quantify stress objectively.

Objectives:

To evaluate the correlations of a digitizing device and a VAS or a questionnaire about stress and fatigue, and the relationships with disease activity of patients with rheumatoid arthritis (RA).

Methods:

Data from a prospective observational study (CHIKARA study: Correlation researcH of sarcopenIa, sKeletal muscle and disease Activity in Rheumatoid Arthritis) were used. The study protocol was reported previously1. A total of 84 RA patients entered the study and were evaluated using a stress digitizing device (Smart Pulse, MEDICORE Co. LTD). This device evaluates stress based on heart rate variability theory2. The objective physical stress score (O-physical ST), mental stress score (O-mental ST), and total stress score (O-total ST) were calculated, ranging from 0 to 100 (higher score indicating greater stress). A questionnaire for stress, the Perceived Stress Scale3(PSS) 10 Japanese version (minimum 0, maximum 40), and VAS evaluations of stress (stress-VAS) and fatigue (fatigue-VAS) were carried out. The correlations between subjective and objective methods were analyzed. The relationships between stress, fatigue, and disease activity of RA patients were examined.

Results:

The patients’ mean age was 68.6 years (women n=66, men n=18), disease duration was 8.8 years, DAS28ESR was 3.24, and modified Health Assessment Questionnaire (mHAQ) was 0.5. The average PSS10 was 26.1, which was higher than in healthy individuals (20.3). The fatigue-VAS was higher than the stress-VAS (41.3 vs 34.5 mm). The O-physical ST score was similar to the O-mental ST score (39.5 vs 37.4). Correlations are shown in Table. The O-physical ST was positively correlated with the fatigue-VAS (R=0.243 p=0.026), and the O-mental ST was also positively correlated with the stress-VAS (R=0.267 p=0.014). However, there was no correlation between the PSS10 and objective stress parameters. The DAS28-ESR was correlated with the fatigue-VAS (R=0.223 p=0.041) and the O-total ST (R=0.329 p=0.002). The stress scale (O-total ST) was worse with moderate and high disease activity than in remission (Figure).

Conclusion:

The stress score obtained by an objective digitizing device was correlated with stress- and fatigue-VAS scores. However, there was no correlation with the PSS10 questionnaire. It was found that the fatigue-VAS score and the objective total stress score were high with worse disease control.

References:

[1]Tada, M., Yamada, Y., Mandai, K. & Hidaka, N. Matrix metalloprotease 3 is associated with sarcopenia in rheumatoid arthritis - results from the CHIKARA study.Int J Rheum Dis21, 1962-1969, doi:10.1111/1756-185X.13335 (2018).

[2]Heart rate variability: standards of measurement, physiological interpretation and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology.Circulation93, 1043-1065 (1996).

[3]Cohen, S., Kamarck, T. & Mermelstein, R. A global measure of perceived stress.J Health Soc Behav24, 385-396 (1983).

Table.

Correlation coefficients of subjective and objective evaluations of stress and fatigue in patients with RA

PSS10Stress-VASfatigue-VASO-physical STO-mental STO-total STPSS100.580**0.404**0.0660.0550.004Stress-VAS0.673**0.0070.267*0.023Fatigue-VAS0.243*0.0590.160O-physical ST-0.224*0.708**O-mental ST-0.017O-total ST

*: p<0.05, **: p,0.01, Spearman rank correlation coefficient

Disclosure of Interests:

None declared

SAT0044 ADIPOCYTOKINE FLUCTUATES WITH INFLAMMATORY MARKERS OR DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS FROM FIVE-YEAR DATA OF TOMORROW STUDY

Background:

Leptin and adiponectin have been thought to be adipocytokines that promote or suppress inflammation, respectively.

Objectives:

The aim of this study was to investigate the relationship between adipocytokine and inflammatory markers or disease activity in patients with rheumatoid arthritis (RA) by using 5-year data of TOMORROW study which is a cohort study and started from 2010.

Methods:

We evaluated inflammatory markers, disease activity score (DAS)-CRP, medication and levels of adipocytokines in 202 patients with RA (mean age, 58.6 y; medication with biological agents, 54.9%) and 202 age- and sex-matched healthy volunteers (controls; mean age, 57.4 y). We eventually compared leptin or adiponectin concentrations in 183 RA patients and 190 controls from 2010 (BL) to 2015 (5Y) and investigated the relationship between adipocytokines and CRP or DAS in patients by using Spearman correlation analysis.

Results:

The levels of leptin and adiponectin in patients were significantly higher than controls at all time points. Adiponectin level of patients significantly increased from BL to 5Y compared to controls (Table 1). In patients, adiponectin showed significant negative correlation with CRP at both of BL and 5Y (BL:R=-0.174, 5Y:R=-0.240; p<0.05), however, not with DAS at BL and 5Y. Leptin positively correlated with CRP at 5Y(R=0.207; p<0.05), but not with CRP at BL or DAS at any time. Adiponectin levels at BL and 5Y were significantly higher in biologics users at BL and significantly increased from BL to 5Y compared to patients without biologics. No association between leptin levels and the use of biologics (Table 2).

Conclusion:

The level of adiponectin in RA patients with continuous treatments for 5 years increased, and the trend was more pronounced in biologics users. These results might indicate that adiponectin is a cytokine involved in anti-inflammatory effects.

Disclosure of Interests:

Kenji Mamoto: None declared, Kentaro Inui Grant/research support from: Janssen Pharmaceutical K.K., Astellas Pharma Inc., Sanofi K.K., Abbvie GK, Takeda Pharmaceutical Co. Ltd., QOL RD Co. Ltd., Mitsubishi Tanabe Pharma, Ono Pharmaceutical Co. Ltd., Eisai Co.,Ltd.,, Speakers bureau: Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., Ono Pharmaceutical Co. Ltd., Abbvie GK, Pfizer Inc., Eisai Co.,Ltd., Chugai Pharmaceutical Co., Ltd., Tadashi Okano Grant/research support from: AbbVie, Eisai, Mitsubishi Tanabe Pharma Corporation and Nipponkayaku, Speakers bureau: AbbVie, Asahikasei, Astellas Pharma Inc, Ayumi Pharmaceutical, Bristol-Myers Squibb, Chugai Pharmaceutical, Daiich Sankyo, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, Novartis Pharma, Ono Pharmaceutical, Pfizer, Sanofi, Takeda Pharmaceutical, Teijin Pharma and UCB, Yuko Sugioka: None declared, Masahiro Tada: None declared, Tatsuya Koike Grant/research support from: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB, Speakers bureau: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB, Hiroaki Nakamura Grant/research support from: Astellas Pharma Inc. and Asahi Kasei Pharma Co.

FRI0051 RHEUMATOID ARTHRITIS PATIENTS WITH HIGH DISEASE ACTIVITY AND TREATED WITH HIGH DOSE GLUCOCORTICOID FREQUENTLY FALL: NINE YEARS OF THE TOMORROW STUDY

Background:

Falling is a multicausal phenomenon resulting from complex interactions between intrinsic and extrinsic or environmental factors. Patients with rheumatoid arthritis (RA) who have muscle weakness and stiff or painful joints might be at increased risk of falling. However, little is known about the exact properties of risk factors for falling in patients with RA. Recently, the disease activity of RA has been more satisfactorily controlled by the ‘‘treat-to-target’’ strategy, including the use of biologics. Given this new era, it is important to accurately estimate the incidence of falling in patients with RA and to elucidate contributing risk factors.

Objectives:

The objective of this study was to evaluate the incidence of falling and associated risk factors in 208 patients with RA and in age- and sex-matched 205 controls (Co) who participated in the TOMORROW (TOtalManagementOfRisk factors inRheumatoid arthritis patients to lOWer morbidity and mortality) study, a 10-year cohort study that started in 2010 in Japan. This research was conducted using TOMORROW study data for 9 years.

Methods:

We evaluated the incidence of falling by self-administered questionnaire every year and confirmed them by medical records. We also collected information about general health status, body composition including bone mineral density, lean body mass, fat mass and laboratory data. We compared the frequency of the incidence of falling in RA patients and Co for 9 years and analyzed risk factors for falling.

Results:

A total of 157 patients with RA (mean age: 57.1 ± 12.5 years, female: 84.7%, mean disease duration 13.9 ± 12.0 years) and 169 Co (mean age: 57.6 ± 12.5 years, female: 84.0%) completed 9 years observation. The rate of individuals who fell did not differ between two groups (RA: 66.9%, Co: 59.2%, p=0.19). However, number of falls was higher in RA than Co (0.35 vs 0.21/person-year, p=0.03). Multivariate logistic regression analysis adjusted for age, sex and BMI, revealed that RA was not a risk factor for the incidence of falling (OR: 1.36, 95%CI: 0.8-2.32, p=0.26) and the history of falling was a risk factor for the incidence of falling (OR: 3.27, 95%CI: 1.78-7.0, p<0.001). Multivariate linear regression analysis adjusted for age, sex and BMI, revealed that mHAQ (β=0.17, p=0.04), mean DAS28-CRP over 9 years (β=0.19, p=0.02) and mean dosage of glucocorticoid over 9 years (β=0.18, p=0.03) were the risk factors for number of falls (table 1).

Table 1.

Multivariate linear regression analysis of risk factors associated with number of falls sustained by patients RA.

RAN=157Number of fallsβpAt the entryAnti-CCP antibody (U/mL)0.0160.835RF (IU/ml)0.0200.803History of falling0.1030.201DAS28-CRP0.0780.333mHAQ0.1690.039Dose of GC (mg/day)0.0280.7239 yearsAverage DAS28-CRP0.1850.024Average dose of GC (mg/day)0.1790.025

RA, rheumatoid arthritis; CCP, cyclic citrullinated peptide; RF, Rheumatoid factor; DAS28-CRP, disease activity score 28 with C-reactive protein; mHAQ, modified Health Assessment Questionnaire; GC, glucocorticoid.

Conclusion:

There was no difference in the incidence of falling between RA and Co. However, number of falls was significantly higher in RA group. High disease activity and higher dosage of glucocorticoid were the risk factors for number of falls among RA patients.

References:

[1]C Armstrong et al, Ann Rheum Dis 2005;64:1602–1604

[2]M Hayashibara et al, Osteoporos Int 2010;21:1825–1833

Acknowledgments:

We wish to thank Atsuko Kamiyama, Tomoko Nakatsuka and all participants in this study.

Disclosure of Interests:

Shohei Anno: None declared, Yuko Sugioka: None declared, Kenji Mamoto: None declared, Tadashi Okano Grant/research support from: AbbVie, Eisai, Mitsubishi Tanabe Pharma Corporation and Nipponkayaku, Speakers bureau: AbbVie, Asahikasei, Astellas Pharma Inc, Ayumi Pharmaceutical, Bristol-Myers Squibb, Chugai Pharmaceutical, Daiich Sankyo, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, Novartis Pharma, Ono Pharmaceutical, Pfizer, Sanofi, Takeda Pharmaceutical, Teijin Pharma and UCB, Masahiro Tada: None declared, Kentaro Inui Grant/research support from: Janssen Pharmaceutical K.K., Astellas Pharma Inc., Sanofi K.K., Abbvie GK, Takeda Pharmaceutical Co. Ltd., QOL RD Co. Ltd., Mitsubishi Tanabe Pharma, Ono Pharmaceutical Co. Ltd., Eisai Co.,Ltd.,, Speakers bureau: Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., Ono Pharmaceutical Co. Ltd., Abbvie GK, Pfizer Inc., Eisai Co.,Ltd., Chugai Pharmaceutical Co., Ltd., Tatsuya Koike Grant/research support from: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB, Speakers bureau: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB, Hiroaki Nakamura Grant/research support from: Astellas Pharma Inc. and Asahi Kasei Pharma Co.

FRI0609-HPR NUTRIENTS INTAKE CONDITION RELATES TO MAINTENANCE LOW DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS DURING 6 YEARS: TOMORROW STUDY

Background:

We have previously reported that nutritional intake status might relate to disease activity (1). Nutritional survey on prospective cohort study in rheumatoid arthritis (RA) patients and information about relationship between nutritional intake status and disease activity was very limited.

Objectives:

This study aimed to obtain data from a cohort study for new nutritional therapy in RA patients.

Methods:

We used TOMORROW cohort study data which conducted from years of 2010 to 2020. Two hundred and eight RA patients, and 205 non-RA sex and age matched controls were investigated, and we analyzed data from 2011 to 2017. Nutritional intake status was compared between who maintain lower disease activity during 2011 to 2017 (LDA group) and being higher disease activity even once in 2011 to 2017 (non-LDA group). Disease activity was evaluated by DAS28-ESR in every year and nutritional intake status was surveyed by brief self-administered diet history questionnaire (BDHQ) in 2011 and 2017.

Results:

In RA patients, the change value from 2011 to 2017 of iron (odds ratio; 2.37), thiamin (OR; 2.96) and folic acid (OR; 3.16) intake which adjusted by energy intake, age, rheumatoid factor and medication status were extracted as independent factors for maintain LDA by multivariate logistic regression. These nutrients intake in RA patients was significantly lower than control both in 2011 and 2017. In RA patients, iron and folic acid intake in LDA group was significantly lower than non-LDA group in 2011. Folic acid intake was increased in LDA group and decreased in non-LDA group over time, and these nutrients showed significant differences in change value between LDA group and non-LDA group (p<0.05).

Conclusion:

The overtime change value in iron, thiamin and folic acid related to maintain six years low disease activity in RA patients.

References:

[1] Matsumoto Y, Sugioka Y, Tada M, Okano T, Mamoto K, Inui K, et al. Monounsaturated fatty acids might be key factors in the Mediterranean diet that suppress rheumatoid arthritis disease activity: The TOMORROW study. Clinical Nutrition 37:675-680, 2018

Disclosure of Interests:

Yoshinari Matsumoto Grant/research support from: Yamada Research Grant (grant No.249), Yuko Sugioka: None declared, Masahiro Tada: None declared, Tadashi Okano Grant/research support from: AbbVie, Eisai, Mitsubishi Tanabe Pharma Corporation and Nipponkayaku, Speakers bureau: AbbVie, Asahikasei, Astellas Pharma Inc, Ayumi Pharmaceutical, Bristol-Myers Squibb, Chugai Pharmaceutical, Daiich Sankyo, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, Novartis Pharma, Ono Pharmaceutical, Pfizer, Sanofi, Takeda Pharmaceutical, Teijin Pharma and UCB, Kenji Mamoto: None declared, Kentaro Inui Grant/research support from: Janssen Pharmaceutical K.K., Astellas Pharma Inc., Sanofi K.K., Abbvie GK, Takeda Pharmaceutical Co. Ltd., QOL RD Co. Ltd., Mitsubishi Tanabe Pharma, Ono Pharmaceutical Co. Ltd., Eisai Co.,Ltd.,, Speakers bureau: Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., Ono Pharmaceutical Co. Ltd., Abbvie GK, Pfizer Inc., Eisai Co.,Ltd., Chugai Pharmaceutical Co., Ltd., Daiki Habu: None declared, Tatsuya Koike Grant/research support from: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB, Speakers bureau: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB

AB0265 REDUCTION OF APPENDICULAR SKELETAL MASS INDEX IS A PREDICTOR OF FRACTURE IN PATIENTS WITH RHEUMATOID ARTHRITIS BASED ON THE THREE-YEAR FOLLOW-UP DATA OF THE CHIKARA STUDY

Background:

Patients with rheumatoid arthritis (RA) have lower muscle mass1and a higher risk of fragility fracture2compared with healthy individuals. The predictors for fractures among baseline data and the chronological changes of disease activity, body composition, and muscle mass are unknown.

Objectives:

The predictors for fractures were investigated over a 3-year period in a longitudinal study.

Methods:

The 3-year follow-up data from a prospective observational study (CHIKARA study: Correlation researcH of sarcopenIa, sKeletal muscle and disease Activity in Rheumatoid Arthritis) were used. The patients’ fractures were counted, and correlations between fractures and disease activity, body composition, and sarcopenia were investigated. Muscle mass, body fat mass, total body water, bone mass, and basal metabolic rate were measured using a body composition analyzer. The fracture-free survival rate was calculated. The relationships between fractures and each parameter at baseline and the changes over the 3-year period (Δ) were investigated by univariate and multivariate analyses.

Results:

A total of 100 patients (78 female, average age 68 years) were enrolled in this study; 12 patients (10 female and 2 male) had fractures during the 3-year follow-up, and the fracture-free survival rate was 86.9%. The Δmodified Health Assessment Questionnaire (mHAQ), Δweight, Δmuscle mass, Δestimated bone mass, Δbasal metabolic rate, and Δappendicular skeletal muscle index (ASMI) were predictors for fractures. On the other hand, body composition, disease activity, and sarcopenia at baseline were not correlated with fractures (Table 1). The ΔASMI was an independent predictor for fractures on multivariate analysis (odds ratio:0.015, P=0.026). The estimated cut-off value of the ΔASMI was 0.14 kg/m2on receiver operating characteristic curve analysis (Figure). When the ΔASMI decrease was greater than or equal to 0.14 kg/m2for three years, the odds ratio of fractures was significantly increased 9.8-fold, compared to a ΔASMI decrease less than 0.14 kg/m2(P=0.001).

Table 1.

Predictors for fractures in patients with RA

UnivariateR valueP valueBaselineAge, year0.1720.087DAS28-ESR-0.0830.411mHAQ0.0770.447Weight, kg0.0210.837Muscle mass, kg-0.00350.728Estimated bone mass, kg-0.0200.845Sarcopenia-0.0930.356Change of 3-year periodΔDAS28-ESR0.1870.088ΔmHAQ0.2240.040ΔWeight, kg-0.2240.045ΔMuscle mass, kg-0.2530.023ΔEstimated bone mass, kg-0.2360.034ΔBasal metabolic rate, kcal/day-0.2480.025ΔAppendicular skeletal muscle index, kg/m2-0.3520.001

Conclusion:

The fracture-free survival rate was 86.9% in this 3-year longitudinal study. It was difficult to predict future fractures from the baseline data. Reduction of the ASMI was an independent predictor for fractures. Alleviating muscle mass loss may prevent fractures.

References:

[1]Inui K., Koike T., Tada M., et al. Sarcopenia is apparent in patients with rheumatoid arthritis, especially those with biologics -TOMORROW study-.EULAR2015 abstract (AB0359).

[2]van Staa TP, Geusens P, Bijlsma JW, et al. Clinical assessment of the long-term risk of fracture in patients with rheumatoid arthritis.Arthritis Rheum.2006; 54: 3104–12.

Disclosure of Interests:

None declared

THU0138 AGEING IN RA PATIENTS DETERIORATED MODIFIED HEALTH ASSESSMENT QUESTIONNAIRE (MHAQ) OVER A 7-YEAR PERIOD INDEPENDENTLY FROM DISEASE ACTIVITY

Background:

Recent advances of treatment for rheumatoid arthritis (RA) realizes us to set the treatment goal as remission. As the results, health assessment questionnaire (HAQ) has been also becoming better in these years. On the other hand, progress in ageing has been a major issue in Japan, including the patients with RA. which is thought as one of the factors affecting HAQ.

Objectives:

To evaluate the impact of ageing on HAQ in RA patients.

Methods:

The data of 208 RA patients used in this study was collected over a 7-year period from 2010 to 2017 as part of a prospective cohort study (TOMORROW Study: UMIN000003876) that included RA patients and age- and sex-matched volunteers recruited through mass media as controls. The data of RA patients included anthropometric, blood test data, disease activity score28-CRP (DAS28) and modified HAQ (mHAQ), together with baseline (BL) characteristics. The course of mHAQ for 7 years were analyzed by repeated measure ANOVA, and association between the changes of mHAQ at year-7 from BL (ΔmHAQ) and BL factors were analyzed by multiple regression analysis.

Results:

Two hundred and eight RA patients (153 women; mean age 58.1 years) were enrolled in the present study. Modified HAQ decreased significantly over the 7-year study period in RA patients. When the patients were stratified into 3 groups (lower than 2.7, between 2.7 and 4.1, over 4.1) by DAS28 at BL, mHAQ of the patients with high disease activity (DAS28: over 4.1) at BL was significantly worse than other groups (p=0.018; repeated measure ANOVA). There was no interaction between time and 3 groups (p=0.118; repeated measure ANOVA). Multiple regression analysis with ΔmHAQ as the outcome variable and ACPA, age, BMI, CRP, DAS28, MMP-3 at BL as independent variables revealed that age (p=0.034) and DAS28 (p=0.042) were independently related with ΔmHAQ.

Conclusion:

Ageing in RA patients impacted worsening of mHAQ over a 7-year period independently from disease activity. On assessing mHAQ in elderly RA patients, we must consider the age as well as the disease activity.

Disclosure of Interests:

Kentaro Inui Grant/research support from: Janssen Pharmaceutical K.K., Astellas Pharma Inc., Sanofi K.K., Abbvie GK, Takeda Pharmaceutical Co. Ltd., QOL RD Co. Ltd., Mitsubishi Tanabe Pharma, Ono Pharmaceutical Co. Ltd., Eisai Co.,Ltd.,, Speakers bureau: Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., Ono Pharmaceutical Co. Ltd., Abbvie GK, Pfizer Inc., Eisai Co.,Ltd., Chugai Pharmaceutical Co., Ltd., Yuko Sugioka: None declared, Tadashi Okano Grant/research support from: AbbVie, Eisai, Mitsubishi Tanabe Pharma Corporation and Nipponkayaku, Speakers bureau: AbbVie, Asahikasei, Astellas Pharma Inc, Ayumi Pharmaceutical, Bristol-Myers Squibb, Chugai Pharmaceutical, Daiich Sankyo, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, Novartis Pharma, Ono Pharmaceutical, Pfizer, Sanofi, Takeda Pharmaceutical, Teijin Pharma and UCB, Masahiro Tada: None declared, Kenji Mamoto: None declared, kazuki Orita: None declared, Hiroaki Nakamura Grant/research support from: Astellas Pharma Inc. and Asahi Kasei Pharma Co.

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

A comprehensive validation of very early rule-out strategies for non-ST-segment elevation myocardial infarction in emergency departments: protocol for a multicentre prospective cohort study

INTRODUCTION

Recent advances in troponin sensitivity enabled early and accurate judgement of ruling-out myocardial infarction, especially non-ST elevation myocardial infarction (NSTEMI) in emergency departments (EDs) with development of various prediction-rules and high-sensitive-troponin-based strategies (hs-troponin). Reliance on clinical impression, however, is still common, and it remains unknown which of these strategies is superior. Therefore, our objective in this prospective cohort study is to comprehensively validate the diagnostic accuracy of clinical impression-based strategies, prediction-rules and hs-troponin-based strategies for ruling-out NSTEMIs.

METHODS AND ANALYSIS

In total, 1500 consecutive adult patients with symptoms suggestive of acute coronary syndrome will be prospectively recruited from five EDs in two tertiary-level, two secondary-level community hospitals and one university hospital in Japan. The study has begun in July 2018, and recruitment period will be about 1 year. A board-certified emergency physician will complete standardised case report forms, and independently perform a clinical impression-based risk estimation of NSTEMI. Index strategies to be compared will include the clinical impression-based strategy; prediction rules and hs-troponin-based strategies for the following types of troponin (Roche Elecsys hs-troponin T; Abbott ARCHITECT hs-troponin I; Siemens ADVIA Centaur hs-troponin I; Siemens ADVIA Centaur sensitive-troponin I). The reference standard will be the composite of type 1 MI and cardiac death within 30 days after admission to the ED. Outcome measures will be negative predictive value, sensitivity and effectiveness, defined as the proportion of patients categorised as low risk for NSTEMI. We will also evaluate inter-rater reliability of the clinical impression-based risk estimation.

ETHICS AND DISSEMINATION

The study is approved by the Ethics Committees of the Kyoto University Graduate School and Faculty of Medicine and of the five hospitals where we will recruit patients. We will disseminate the study results through conference presentations and peer-reviewed journals.

Influence of the trapeziometacarpal joint fusion on thumb muscles and thumb-tip movement: A cadaveric study

BACKGROUND

Trapeziometacarpal (TMC) arthrodesis provides stability and strength of the thumb, whereas fixation of the TMC joint restricts motion of the thumb, which may consequently impair the activity of daily living. The objective of our study was to investigate how length and area of the thumb-tip trajectory were reduced after the TMC joint fusion.

METHODS

Six fresh, frozen cadavers were used for this study. Tension was applied to the distal tendons of 4 extrinsic thumb muscles (extensor pollicis longus, flexor pollicis longus, abductor pollicis longus, and extensor pollicis brevis) by servomotor, whereas tension was applied to 4 intrinsic muscles (abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and adductor pollicis) using static weights. The thumb-tip trajectory was examined using a motion capture system without tension and with 5 different weights to induce intrinsic muscle tension before and after the TMC joint fusion.

FINDINGS

When tension was applied to the intrinsic muscles, the length of the thumb-tip trajectory decreased in all conditions compared with that before the TMC joint fusion, whereas the trajectory decreased only when the abductor pollicis longus was pulled. The overall thumb-tip trajectory area was reduced to approximately 30% compared with that before the TMC joint fusion.

INTERPRETATION

Thumb-tip trajectory was restricted by the TMC joint fusion to approximately 30%. However, the reduced area was found tolerable for performing daily activities. Thus, arthrodesis can be the first-line treatment in patients who wish to engage in activities of daily living without difficulties.

Evaluating Progression-Free Survival as a Surrogate Outcome for Health-Related Quality of Life in Oncology: A Systematic Review and Quantitative Analysis

IMPORTANCE

Progression-free survival (PFS) has become a commonly used outcome to assess the efficacy of new cancer drugs. However, it is not clear if delay in progression leads to improved quality of life with or without overall survival benefit.

OBJECTIVE

To evaluate the association between PFS and health-related quality of life (HRQoL) in oncology through a systematic review and quantitative analysis of published randomized clinical trials. Eligible trials addressed oral, intravenous, intraperitoneal, or intrapleural chemotherapy or biological treatments, and reported PFS or health-related quality of life.

DATA SOURCES

For this systematic review and quantitative analysis of randomized clinical trials of patients with cancer, we searched Medline, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 2000, through May 4, 2016.

STUDY SELECTION

Paired reviewers independently screened citations, extracted data, and assessed risk of bias of included studies.

DATA EXTRACTION AND SYNTHESIS

We examined the association of difference in median PFS duration (in months) between treatment groups with difference in global, physical, and emotional HRQoL scores between groups (standardized to a range of 0-100, with higher scores representing better HRQoL) using weighted simple regressions.

MAIN OUTCOME AND MEASURE

The association between PFS duration and HRQoL.

RESULTS

Of 35 960 records screened, 52 articles reporting on 38 randomized clinical trials involving 13 979 patients across 12 cancer types using 6 different HRQoL instruments were included. The mean (SD) difference in median PFS between the intervention and the control arms was 1.91 (3.35) months. The mean (SD) differences in change of HRQoL adjusted to per-month values were -0.39 (3.59) for the global domain, 0.26 (5.56) for the physical domain, and 1.08 (3.49) for the emotional domain. The slope of the association between the difference in median PFS and the difference in change for global HRQoL (n = 30 trials) was 0.12 (95% CI, -0.27 to 0.52); for physical HRQoL (n = 20 trials) it was -0.20 (95% CI, -0.62 to 0.23); and for emotional HRQoL (n = 13 trials) it was 0.78 (95% CI, -0.05 to 1.60).

CONCLUSIONS AND RELEVANCE

We failed to find a significant association between PFS and HRQoL in cancer clinical trials. These findings raise questions regarding the assumption that interventions prolonging PFS also improve HRQoL in patients with cancer. Therefore, to ensure that patients are truly obtaining important benefit from cancer therapies, clinical trial investigators should measure HRQoL directly and accurately, ensuring adequate duration and follow-up.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

Altered expression of glutamate transporter-1 and water channel protein aquaporin-4 in human temporal cortex with Alzheimer's disease

AIMS

Glutamate neurotoxicity plays an important role in the pathogenesis of various neurodegenerative disorders. Many studies have demonstrated that glutamate transporter-1 (GLT-1), the dominant astrocytic glutamate transporter, is significantly reduced in the cerebral cortex of patients with Alzheimer's disease (AD), suggesting that glutamate-mediated excitotoxicity might contribute to the pathogenesis of AD. In a previous study, we have demonstrated marked alterations in the expression of the astrocytic water channel protein aquaporin-4 (AQP4) in relation to amyloid β deposition in human AD brains. As a functional complex, GLT-1 and AQP4 in astrocytes may play a neuroprotective role in the progression of AD pathology. However, few studies have examined the correlation between the expression of GLT-1 and that of AQP4 in human AD brain.

METHODS

Here, using immunohistochemistry with antibodies against GLT-1 and AQP4, we studied the expression levels and distribution patterns of GLT-1 in areas showing various patterns of AQP4 expression in autopsied temporal lobes from eight patients with AD and five controls without neurological disorders.

RESULTS

GLT-1 staining in the control group was present throughout the neocortex as uniform neuropil staining with co-localized AQP4. The AD group showed a significant reduction in GLT-1 expression, whereas cortical AQP4 immunoreactivity was more intense in the AD group than in the control group. There were two different patterns of GLT-1 and AQP4 expression in the AD group: (i) uneven GLT-1 expression in the neuropil where diffuse but intense AQP4 expression was evident, and (ii) senile plaque-like co-expression of GLT-1 and AQP4.

CONCLUSIONS

These findings suggest disruption of glutamate/water homoeostasis in the AD brain.

Prototyping Sensor Network System for Automatic Vital Signs Collection

Objective: Development of a clinical sensor network system that automatically collects vital sign and its supplemental data, and evaluation the effect of automatic vital sensor value assignment to patients based on locations of sensors.

Methods: The sensor network estimates the data-source, a target patient, from the position of a vital sign sensor obtained from a newly developed proximity sensing system. The proximity sensing system estimates the positions of the devices using a Bluetooth inquiry process. Using Bluetooth access points and the positioning system newly developed in this project, the sensor network collects vital sign and its 4W (who, where, what, and when) supplemental data from any Blue-tooth ready vital sign sensors such as Continua-ready devices. The prototype was evaluated in a pseudo clinical setting at Kyoto University Hospital using a cyclic paired comparison and statistical analysis.

Results: The result of the cyclic paired analysis shows the subjects evaluated the proposed system is more effective and safer than POCS as well as paper-based operation. It halves the times for vital signs input and eliminates input errors. On the other hand, the prototype failed in its position estimation for 12.6% of all attempts, and the nurses overlooked half of the errors. A detailed investigation clears that an advanced interface to show the system’s “confidence”, i.e. the probability of estimation error, must be effective to reduce the oversights.

Conclusions: This paper proposed a clinical sensor network system that relieves nurses from vital signs input tasks. The result clearly shows that the proposed system increases the efficiency and safety of the nursing process both subjectively and objectively. It is a step toward new generation of point of nursing care systems where sensors take over the tasks of data input from the nurses.

Diagnostic criteria for adult-onset leukoencephalopathy with axonal spheroids and pigmented glia due to CSF1R mutation

BACKGROUND AND PURPOSE

To establish and validate diagnostic criteria for adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP) due to colony-stimulating factor 1 receptor (CSF1R) mutation.

METHODS

We developed diagnostic criteria for ALSP based on a recent analysis of the clinical characteristics of ALSP. These criteria provide 'probable' and 'possible' designations for patients who do not have a genetic diagnosis. To verify its sensitivity and specificity, we retrospectively applied our criteria to 83 ALSP cases who had CSF1R mutations (24 of these were analyzed at our institutions and the others were identified from the literature), 53 cases who had CSF1R mutation-negative leukoencephalopathies and 32 cases who had cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) with NOTCH3 mutations.

RESULTS

Among the CSF1R mutation-positive cases, 50 cases (60%) were diagnosed as 'probable' and 32 (39%) were diagnosed as 'possible,' leading to a sensitivity of 99% if calculated as a ratio of the combined number of cases who fulfilled 'probable' or 'possible' to the total number of cases. With regard to specificity, 22 cases (42%) with mutation-negative leukoencephalopathies and 28 (88%) with CADASIL were correctly excluded using these criteria.

CONCLUSIONS

These diagnostic criteria are very sensitive for diagnosing ALSP with sufficient specificity for differentiation from CADASIL and moderate specificity for other leukoencephalopathies. Our results suggest that these criteria are useful for the clinical diagnosis of ALSP.