An Update on the Diagnosis and Management of Calcium Crystal Disease

PURPOSE OF REVIEW

This article aims to review the challenges to diagnosis and management of calcium crystal deposition diseases and evaluate the literature published over the past 3 years.

RECENT FINDINGS

The awaited development of classification criteria is an essential step in the progression of calcium crystal deposition disease clinical research. There have been recent improvements in the accuracy of imaging for the diagnosis of crystal deposition diseases with published definitions of characteristic features. Factors associated with acute flares of disease have been identified and an association with increased cardiovascular risk has been demonstrated. Targeted treatment options for calcium crystal diseases remain elusive. However, there have been advances in understanding the molecular mechanisms of disease revealing potential targets for future drug development. Calcium-crystal deposition diseases are increasing in incidence and prevalence as populations age and continue to associate with a high burden of disability. Despite this, calcium crystal deposition disease remains under-studied with a paucity of evidence-based treatment guidelines.

Evolution of ultrasound in giant cell arteritis

Ultrasound (US) is being increasingly used to diagnose Giant Cell Arteritis (GCA). The traditional diagnostic Gold Standard has been temporal artery biopsy (TAB), but this is expensive, invasive, has a false-negative rate as high as 60% and has little impact on clinical decision-making. A non-compressible halo with a thickened intima-media complex (IMC) is the sonographic hallmark of GCA. The superficial temporal arteries (STA) and axillary arteries (AA) are the most consistently inflamed arteries sonographically and imaging protocols for evaluating suspected GCA should include at least these two arterial territories. Studies evaluating temporal artery ultrasound (TAUS) have varied considerably in size and methodology with results showing wide discrepancies in sensitivity (9–100%), specificity (66–100%), positive predictive value (36–100%) and negative predictive value (33–100%). Bilateral halos increase sensitivity as does the incorporation of pre-test probability, while prior corticosteroid use decreases sensitivity. Quantifying sonographic vasculitis using Halo Counts and Halo Scores can predict disease extent/severity, risk of specific complications and likelihood of treatment response. Regression of the Halo sign has been observed from as little as 2 days to as late as 7 months after initiation of immunosuppressive treatment and occurs at different rates in STAs than AAs. US is more sensitive than TAB and has comparable sensitivity to MRI and PET/CT. It is time-efficient, cost-effective and allows for the implementation of fast-track GCA clinics which substantially mitigate the risk of irreversible blindness. Algorithms incorporating combinations of imaging modalities can achieve a 100% sensitivity and specificity for a diagnosis of GCA. US should be a standard first line investigation in routine clinical care of patients with suspected GCA with TAB reserved only for those having had a normal US in the context of a high pre-test probability.

COVID-19 in Pregnant Women With Rheumatic Disease: Data From the COVID-19 Global Rheumatology Alliance

OBJECTIVE

To describe coronavirus disease 2019 (COVID-19) and pregnancy outcomes in patients with rheumatic disease who were pregnant at the time of infection.

METHODS

Since March 2020, the COVID-19 Global Rheumatology Alliance has collected cases of patients with rheumatic disease with COVID-19. We report details of pregnant women at the time of COVID-19 infection, including obstetric details separately ascertained from providers.

RESULTS

We report on 39 patients, including 22 with obstetric detail available. The mean and median age was 33 years, range 24-45 years. Rheumatic disease diagnoses included rheumatoid arthritis (n = 9), systemic lupus erythematosus (n = 9), psoriatic arthritis/other inflammatory arthritides (n = 8), and antiphospholipid syndrome (n = 6). Most had a term birth (16/22), with 3 preterm births, 1 termination, and 1 miscarriage; 1 woman had yet to deliver at the time of report. One-quarter (n = 10/39) of pregnant women were hospitalized following COVID-19 diagnosis. Two of 39 (5%) required supplemental oxygen (both hospitalized); no patients died. The majority did not receive specific medication treatment for their COVID-19 (n = 32/39, 82%), and 7 patients received some combination of antimalarials, colchicine, anti-interleukin 1β, azithromycin, glucocorticoids, and lopinavir/ritonavir.

CONCLUSION

Women with rheumatic diseases who were pregnant at the time of COVID-19 had favorable outcomes. These data have limitations due to the small size and methodology; however, they provide cautious optimism for pregnancy outcomes for women with rheumatic disease particularly in comparison to the increased risk of poor outcomes that have been reported in other series of pregnant women with COVID-19.

POS0140 URATE-LOWERING THERAPY REDUCES NON-EPISODIC FOOT PAIN IN PATIENTS WHO FAIL TO MEET ACR/EULAR 2015 GOUT CLASSIFICATION CRITERIA: AN EFFECT PREDICTED BY ULTRASOUND

Background:

Emerging evidence that the joints of asymptomatic hyperuricaemic individuals contain monosodium urate (MSU) deposits and that alternative presentations of foot pain occur in hyperuricaemia suggests that preclinical phases may occur prior to a first episodic gout attack. (1) This case–control study evaluates urate deposition in hyperuricaemic individuals not fulfilling the current gout classification criteria, as well as a potential therapeutic role for urate lowering therapy (ULT).

Objectives:

To investigate whether ULT reduces non-episodic foot pain in patients who fail to meet ACR/EULAR 2015 gout classification criteria.

Methods:

Following informed consent, hyperuricaemic individuals with persistent, non-episodic foot pain (n=53) not fulfilling ACR/EULAR 2015 gout classification criteria, were compared with asymptomatic hyperuricaemic controls (n=18). Ultrasound (US) of bilateral first metatarsophalangeal (MTP) joints and features of MSU deposition including double contour (DC) sign, tophus and juxta-articular erosion were recorded. Cases only were treated with febuxostat or allopurinol daily for 6 months. Serum urate, 24-hour and 7-day visual analogue score (VAS) 0–100 mm pain scales and the Manchester Foot Pain and Disability Index (MFPDI) were recorded before treatment and after 3 and 6 months. MTP Ultrasound was repeated after a minimum of 6 months on treatment.

Results:

53 hyperuricaemic individuals with persistent, non-episodic foot pain not meeting the ACR/EULAR 2015 gout classification criteria were recruited. At baseline MTP US DC sign, erosion and tophus occurred in 62.5%, 20.8% and 49% of cases, respectively. No US features of gout occurred in controls. No significant difference was seen in baseline serum urate between cases (481±14 mg/dL) versus controls (437±14; p=NS). Serum urate in cases fell at 3 months (325±25; p<0.01) and 6 months (248±19; p<0.01). For cases, baseline 24-hour pain VAS (46±3.9) reduced at 3 months (32±4.1; p<0.05) and 6 months (21±5.2; p<0.05) of ULT. The 7-day pain VAS (59±3.9) decreased at 3 months (35±4.5; p<0.05) and 6 months (30±5.3; P<0.05). MFPDI (17±1.4) decreased at 3 month (13±1.8; p=<0.05) and 6 months (11±2.2; p=<0.05). When cases were grouped according to the presence (N=33) or absence (N=18) of DC sign on baseline US, no differences were observed for baseline pain scores. Following ULT however, 24-hour pain VAS were significantly lower in DC positive patients at 3 months (22±4.48 DC positive vs 42±6.14 DC negative; p<0.05) and 6 months (12.±5.4 vs 33±8.4; p<0.05). The 7-day pain VAS were significantly lower in DC positive patients at 3 months (23±4.6 vs 47±6.6; p<0.05) and MFDPI were significantly lower in DC positive patients at 3 months (10±1.9 DC positive vs 19±2.9 DC negative; p<0.05).

Conclusion:

These findings indicate that persistent, non-episodic foot pain in hyperuricaemia is both associated with US features of MSU deposition and is responsive to ULT. Symptomatic hyperuricaemia occurring prior to episodic gout therefore represents an earlier or alternative disease presentation. Changes to the ACR/ EULAR classification criteria to include non-episodic foot pain in the presence of US features of gout may increase the sensitivity of disease classification at an early stage, leading to improved future treatment strategies and long-term outcomes.

References:

[1]Stewart S, Dalbeth N, Vandal AC, Rome K. Characteristics of the first metatarsophalangeal joint in gout and asymptomatic hyperuricaemia: A cross-sectional observational study. J Foot Ankle Res. 2015;8(1):1–8.

Disclosure of Interests:

None declared

POS1162 PREDICTORS OF HOSPITALISATION IN PATIENTS WITH RHEUMATIC DISEASE AND COVID-19 IN IRELAND: DATA FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE PHYSICIAN-REPORTED REGISTRY

Background:

There is limited data regarding the risk of hospitalisation in patients with rheumatic disease and COVID-19 in Ireland.

Objectives:

We used the COVID-19 Global Rheumatology Alliance (GRA) registry data to study outcomes and their predictors.

Methods:

We examined data on patients and their disease-related characteristics entered into the COVID-19 GRA provider registry from Ireland (24th March 2020 to 31st August 2020). Multivariable logistic regression was used to assess the association of demographic and clinical characteristics with hospitalisation.

Results:

Of 105 patients, 47 (45.6%) were hospitalised and 10 (9.5%) died. Multivariable logistic regression analysis showed age (OR=1.06, 95%CI 1.01 to 1.10), number of comorbidities (OR=1.93, 95%CI 1.11 to 3.35), and glucocorticoid use (OR=15.01, 95%CI 1.77 to 127.16) were significantly associated with hospitalisation. A diagnosis of inflammatory arthritis was associated with a lower odds of hospitalisation (OR=0.09, 95%CI 0.02 to 0.32).

All significant variable modelMost parsimonious modelUnadjusted OR (95% CI)Adjusted OR (95%CI)*Adjusted p-value*Adjusted OR (95%CI)&Adjusted p-value&Female0.45 (0.20-1.02)0.33 (0.05-2.23)0.34 (0.09-1.36)0.128Age (years)1.08 (1.05-1.11)1.04 (0.97-1.10)0.2241.06 (1.01-1.10)0.010Inflammatory arthritis0.11 (0.05-0.28)0.14 (0.02-0.95)0.0440.09 (0.02-0.32)<0.001Connective Tissue Disease and Other1.56 (0.62 - 3.92)No comorbidities0.11 (0.04-0.30)0.76 (0.09-6.58)0.802Most common comorbiditiesCOPD / asthma4.77 (1.23-18.54)3.09 (0.16-60.07)0.456CVD3.40 (1.31-8.85)0.11 (0.01-1.88)0.129Hypertension3.71 (1.52-9.08)0.56 (0.04-7.94)0.668Obesity0.58 (0.10-3.30)Number of comorbidities (Median, IQR)3.01 (1.92-4.72)2.99 (0.59-15.02)0.1841.93 (1.11-3.35)0.020Never Smokerref.0.889Ever Smoker3.17 (1.18-8.89)1.19 (0.10-13.68)Medication prior to COVID-19 diagnosisGlucocorticoids9.26 (1.95-43.89)18.14 (1.13-290.81)0.04115.01 (1.77-127.16)0.013csDMARD monotherapy0.42 (0.17-1.00)b/tsDMARD (monotherapy or in combination with csDMARD)0.24 (0.10-0.58)1.36 (0.19-9.72)0.557

Conclusion:

Increasing age, comorbidity burden, and glucocorticoid use were associated with hospitalisation, while a diagnosis of inflammatory arthritis was associated with lower odds of hospitalization.

Disclosure of Interests:

Richard Conway Speakers bureau: Janssen, Roche, Sanofi, Abbvie, Elena Nikiphorou Speakers bureau: AbbVie, Eli-Lilly, Gilead, Celltrion, Pfizer, Sanofi, Christiana Demetriou: None declared, Candice Low: None declared, Kelly Leamy: None declared, John Ryan: None declared, Ronan Kavanagh: None declared, Alexander Fraser: None declared, John Carey: None declared, Paul O’Connell: None declared, Rachael Flood: None declared, Ronan Mullan: None declared, David Kane: None declared, Philip Robinson Speakers bureau: UCB, Roche, Pfizer, Gilead, Janssen, Novartis, Eli Lilly, Abbvie, Grant/research support from: Abbvie, UCB, Novartis, Janssen, Pfizer, Jean Liew Grant/research support from: Pfizer, Rebecca Grainger Speakers bureau: Pfizer, Cornerstones, Janssen, Novartis, Abbvie, Geraldine McCarthy: None declared.

SAT0561 METATARSOPHALANGEAL JOINT MEDIAL COLLATERAL LIGAMENT MEASUREMENT, A NOVEL ULTRASOUND FEATURE OF MONOSODIUM URATE DEPOSITION IN THE JOINT

Background:

Acute gouty arthritis most commonly initially affects the first metatarsophalangeal joint (MT1). (1) Musculoskeletal ultrasound (US) is a reliable tool for detecting monosodium urate crystal (MSU) deposition in gout and hyperuricemia with validated, ultrasound features of double contour (DC) sign, tophus, and erosions. (2, 3) The collateral ligaments of MT1, which originate on the medial and lateral epicondyles of the metatarsals and extend to the proximal phalanx, function to stabilize the joint. (4) While tophus deposition typically occurs between the medial collateral ligament (MCL) and head of MT1, small MSU aggregates may be indistinguishable from surrounding tissue. In this study using US, we propose that an increased vertical depth between the superficial surface of the MCL to cortical surface of MT1 (dMC-MT) is indicative of MSU deposition (see figure 1). The aim was to evaluate associations of dMC-MT with serum uric-acid level (sUA) in a cohort of individuals with hyperuricaemia and non-episodic foot pain. We propose a novel sonographic feature of MSU crystal deposition in the MT joint.

Objectives:

1.)To evaluate the association between sUA and dMC-MT

2.)To record the presence/absence of classical features of MSU deposition including; double contour sign, erosions and tophi in a cohort of patients with hyperuricaemia and foot pain.

3.)To evaluate the associations between sUA and dMC-MT in those with\without classical features of MSU deposition (DC, erosion, tophi).

Methods:

Following informed consent, hyperuricaemic patients (n = 52) underwent bilateral US of the 1MT using LogiqE9 at 15 MHz. Features of MSU deposition including DC sign, tophus and juxta-articular erosion were recorded. The dMC-MT was measured as the mean of the perpendicular distance between the superficial surface of the midpoint of the MCL to the MT1 head. Statistical analysis was performed using SPSS V.25 software. Data presented as MEAN ± S.E unless otherwise indicated.

Results:

DC sign, tophus and erosion occurred in 31%, 20.7% and 19% of cases, respectively. Mean sUA was higher in tophus positive (540 ± 36) versus non tophus (470 ± 16) (p<0.01) and erosion positive (522 ± 32) versus non erosion (477± 17) patients. dMC-MT was significantly greater in tophus positive patients (0.34cm ± 0.17cm) versus non tophus (0.27cm ± 0.01cm) (p < 0.01). dMC-MT was significantly greater in erosion positive patients (0.31cm ± 0.18cm) versus non erosion (0.28cm +0.01cm) (p < 0.05). In DC negative patients dMC-MT was significantly correlated with increasing sUA (r = 0.34 p = <0.05). No correction between dMC-MT and sUA was seen in DC positive patients.

Conclusion:

dMC-MT is significantly greater both in patients with tophus and erosions indicating its role as an additional marker of MSU crystal deposition. Furthermore a significant association between dMC-MT and sUA in DC negative patients suggests that dMC-MT may be a more sensitive indicator of early urate deposition in a subset of patients where the earliest site of urate deposition has not occurred directly on to articular hyaline cartilage. dMC-MT may therefore be a sensitive tool for very early urate deposition. Further studies clarifying a role for dMC-MT are now required.

References:

[1]Wallace SL, Robinson H, Masi AT, Decker JL, Mccarty DJ, Yü T -f. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum. 1977;20(3):895–900.

[2]Howard RG, Pillinger MH, Gyftopoulos S, Thiele RG, Swearingen CJ, Samuels J. Reproducibility of musculoskeletal ultrasound for determining monosodium urate deposition: Concordance between readers. Arthritis Care Res. 2011;63(10):1456–62.

[3]Stewart S, Dalbeth N, Vandal AC, Rome K. Characteristics of the first metatarsophalangeal joint in gout and asymptomatic hyperuricaemia: A cross-sectional observational study. J Foot Ankle Res. 2015;8(1):1–8.

[4]Finney FT, Cata E, Holmes JR, Talusan PG. Anatomy and Physiology of the Lesser Metatarsophalangeal Joints. Foot Ankle Clin. 2018;23(1):1–7.

Disclosure of Interests:

None declared

Shrinking lung syndrome and systemic lupus erythematosus: a case series and literature review

Shrinking lung syndrome (SLS) is a rare manifestation of systemic lupus erythematosus, characterized by progressive dsypnoea, reduced lung volumes and associated restrictive lung physiology. Here, we provide two previously unreported cases, and review the available literature on the pathophysiology, clinical features and management of SLS. Effective treatment can prevent further deterioration or lead to improvement in abnormal lung function. A heightened awareness of SLS and its management is therefore required to prevent disease progression and increased morbidity.

Low temperature laser scanning microscopy of a superconducting radio-frequency cavity

An apparatus was developed to obtain, for the first time, 2D maps of the surface resistance of the inner surface of an operating superconducting radio-frequency niobium cavity by a low-temperature laser scanning microscopy technique. This allows identifying non-uniformities of the surface resistance with a spatial resolution of about 2.4 mm and surface resistance resolution of ~1 μΩ at 3.3 GHz. A signal-to-noise ratio of about 10 dB was obtained with 240 mW laser power and 1 Hz modulation frequency. The various components of the apparatus, the experimental procedure and results are discussed in detail in this contribution.

Patient preferences among third agent HIV medications: a US and German perspective

The objective is to assess patient preferences for attributes associated with third agent HIV medications, including fosamprenavir/ritonavir (FPVr), fosamprenavir (FPV), lopinavir/ritonavir (LPVr), atazanavir (ATZ), and efavirenz (EFV). Subjects with HIV were recruited in the US and Germany to complete a computerized adaptive conjoint survey that assessed 13 attributes, including moderate to severe side effects, regimen convenience, drug resistance and efficacy. Literature on the target third-agent HIV drugs was used to identify percentage risk and severity level descriptions for each attribute. The derived preference (utility) weights for each attribute level informed the calculation of relative importance estimates for each attribute and the desirability of combinations of attributes matching the respective target third agents. The analysis included 288 HIV-positive participants (US: 132; Germany: 156), 205 of whom were treatment-experienced and 83 of whom were treatment-naïve. Of the 13 medication attributes evaluated, developing drug resistance, the risk of lipodystrophy, the risk of gastronitestinal side effects (diarrhoea, nausea and vomiting) and regimen convenience had the greatest impact on preferences. The profile based on FPVr was most preferred. Differences in the risk of developing drug resistance, risk of lipodystrophy, risk of gastrointestinal side effects and regimen convenience would likely be most influential in the perceived relative value of a third-agent medication. Physicians may wish to consider these features, especially when discussing HIV treatment options with their patients.

Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention

We have analyzed the incidence, management, and outcome of 84 cases of coronary artery perforation in patients who underwent percutaneous coronary intervention at our institution. This complication was more frequent in female patients and in patients who underwent lesion modification with atheroablative devices. A total of 8 patients (9.5%) died after the procedure. They were usually older and had a higher incidence of cardiac tamponade; a larger percentage of these patients underwent emergency surgery than those who survived.

A comparison of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty in patients on hemodialysis

The hospital records of 22 patients on hemodialysis undergoing coronary artery bypass grafting, and 19 others undergoing percutaneous transluminal coronary angioplasty were reviewed to compare the outcomes of these procedures in this population. Evidence of previous myocardial infarction or triple vessel or left main coronary artery disease was more common in patients undergoing coronary artery bypass graft than those undergoing percutaneous transluminal coronary angioplasty. Perioperative mortality and complication rates following coronary artery bypass graft (4.5% and 41%, respectively) were similar to those following percutaneous transluminal coronary angioplasty (5.3% and 42%). Cardiac event-free rates at 18 months by life-table analysis following coronary artery bypass graft and percutaneous transluminal coronary angioplasty were 87 +/- 16% and 40 +/- 14%, respectively. Survival at 18 months were 67 +/- 17% following coronary artery bypass graft and 69 +/- 14% following percutaneous transluminal coronary angioplasty. Cardiac events were observed to occur in three patients undergoing coronary artery bypass graft at a median of 10 months, and in nine patients following percutaneous transluminal coronary angioplasty at a median of 6 months. One patient required percutaneous transluminal coronary angioplasty after the initial coronary artery bypass graft. Seven patients required repeat percutaneous transluminal coronary angioplasty, and two patients underwent coronary artery bypass graft after initial percutaneous transluminal coronary angioplasty. Although these conclusions are limited by the retrospective nature of the study, it is concluded that coronary artery bypass graft can be performed with morbidity and mortality equivalent to percutaneous transluminal coronary angioplasty, and provides better cardiac event-free rates than percutaneous transluminal coronary angioplasty in patients on hemodialysis. Percutaneous transluminal angioplasty does not appear to be justified in this population because of its unacceptably high restenosis and cardiac event rates.

Topographical ventilation and perfusion distribution during IPPB in the lateral posture

We measured topographical ventilation and perfusion distribution in the gravity field using 133Xe in 5 normal subjects either during natural breathing or during intermittent positive pressure ventilation (IPPB) in the lateral decubitus posture. The ratio of ventilation of upper regions to that of lower regions increased from 0.61 +/- 0.10 (mean +/- SE) during natural breathing to 0.95 +/- 0.08 during IPPB. In contrast, the ratio of regional perfusion was unchanged in the 2 conditions. Consequently, distribution of regional ventilation-perfusion ratios became less homogeneous during IPPB. Whereas during natural breathing the ratio of ventilation-perfusion of upper regions to that of lower regions was 1.09 +/- 0.18, during IPPB this ratio was 1.52 +/- 0.14. Despite the differences in regional ventilation distribution between natural breathing and IPPB, analysis of multiple-breath 133Xe washouts measured at the mouth did not reveal any difference. The results are consistent with the hypothesis that the magnitude of diaphragmatic tension is the main determinant of topographical ventilation distribution in the lateral posture.