Ultrasound Assessment of Psoriatic Arthritis Patients With Clinically Normal Nails and Evaluation of its Correlation with the Disease Activity: A Case-Control Study

OBJECTIVES

Nail unit is one of the targets of ultrasound (US) assessment. We aimed to compare ultrasound parameters of clinically normal nail unit in psoriatic arthritis (PsA) patients with healthy controls (HC) and evaluate their correlations with disease activity.

METHODS

This was a cross-sectional study including patients with PsA and matched HC. Tender (TJC) and swollen joint count (SJC), Psoriasis Area and Severity Index (PASI), and Disease Activity in Psoriatic Arthritis (DAPSA) were collected in PsA patients. Patients underwent US assessment of fingernails with a study of morphological changes and measurement of the thickness of nail bed (NBT), nail plate (NPT), and adjacent skin (ST). Correlation between nail unit parameters and disease activity was studied.

RESULTS

We evaluated 22 PsA patients (219 nails) and 21 HC (210 nails). Mean DAPSA was 21.56 ± 14.36 and mean PASI was 2.19 ± 3.8. PsA patients had more US morphological changes than HC (16.89 vs 3.33%, P = .03). NPT comparison between identical fingernails of PsA and HC did not reveal significant difference. However, NBT was significantly higher in HC (1.77 vs 2.07 mm, P = .027) as well as ST (2.26 vs 2.59 mm, P = .003). TJC and ST were positively correlated (r = .46, P = .03). No correlation was noted between disease activity scores and NPT, NBT, or ST in PsA patients. In biologic parameters, ESR was negatively correlated with ST (r = -.41, P = .05).

CONCLUSIONS

Nail bed and adjacent skin US morphological changes were contributive to distinguish psoriatic from healthy nails. Adjacent skin thickness measurement was positively correlated with TJC and ESR, suggesting that it could be used as an indicator of disease activity in PsA.

Does sacroiliitis is a mandatory criterion for enthesitis-related arthritis diagnosis?

INTRODUCTION AND OBJECTIVES

Magnetic resonance imaging (MRI) sensitivity and specificity seem to be less studied in enthesitis-related arthritis (ERA). We aimed to determine the ability of sacroiliac MRI to diagnose ERA patients.

MATERIALS AND METHODS

We conducted a retrospective study including 44 patients with juvenile idiopathic arthritis (JIA). Each patient had a sacroiliac joint MRI. We divided patients into two groups: G1 patients with ERA and G2 patients with non-ERA subtype.

RESULTS

ERA was noted in 61% of the cases. Sacroiliac joints were painful in 15 patients (34%). MRI was normal in 25 patients (57%) (G1:11 versus G2:14) and showed bone marrow edema in the sacroiliac joints in 19 patients (34%) (G1=16 versus G2=3, p=0.005). Sacroiliac joints MRI's sensitivity and specificity in the ERA diagnosis were 61.54% and 82.35%, respectively. Positive and negative predictive values were 84.21% and 58.33%, respectively. Furthermore, sacroiliac joint pain in the clinical examination was able to predict sacroiliac bone edema in MRI with an odds ratio of 6.8 (95% CI 1.68-28.09; p=0.006).

CONCLUSION

Our study showed that sacroiliac joint MRI has good specificity and positive predictive value in the diagnosis of ERA patients among JIA patients. This underlines the usefulness of sacroiliac joint MRI in the early diagnosis of ERA patients.

Pediatric and adult osteoporosis: a contrasting mirror

Pediatric osteoporosis (PO) is a condition that is currently gaining recognition. Due to the lack of official definitions over the past few decades, the exact incidence of PO is unknown. The research does not provide a specific prevalence of PO in different world regions. However, this is expected to change with the latest 2019 guidelines proposed by the International Society of Clinical Densitometry. Although adult osteoporosis (AO) has been postulated a pediatric disease because its manifestation in adulthood is a result of the bone mass acquired during childhood, differences between PO and AO should be acknowledged. AO is defined as low bone density; however, PO is diagnosed based on existing evidence of bone fragility (vertebral fractures, pathological fractures). This is particularly relevant because unlike in adults, evidence is lacking regarding the association between low bone density and fracture risk in children. The enhanced capacity of pediatric bone for reshaping and remodeling after fracture is another difference between the two entities. This contrast has therapeutic implications because medication-free bone reconstitution is possible under certain conditions; thus, background therapy is not always recommended. In this narrative review, differences between PO and AO in definition, assessment, and medical approach were investigated.

Management of Blau syndrome: review and proposal of a treatment algorithm

Blau syndrome is a rare genetic granulomatosis affecting children. It could be responsible for vision-threatening complications and articular deformation. Due to the rarity of this disease, there are no standardized guidelines for its management. This work aimed to provide an updated overview of the different therapeutic options for Blau syndrome. We conducted research in the PubMed database for the different treatments used in Blau syndrome patients, and we proposed a therapeutic algorithm for disease management. High doses of corticosteroids are considered as a bridging therapy in Blau syndrome. Methotrexate should be initiated if the patient has articular or ocular involvement. An anti-tumor necrosis factor α should be added for patients with uveitis or residual arthritis. If the patient remains symptomatic, a switch to another anti-tumor necrosis factor α is the best option. In non-responders to the first- and second-line biotherapies, a switch to an anti-interleukin 1, an anti-interleukin 6, or tofacitinib is necessary.

CONCLUSION

This article suggested an algorithm for the treatment of Blau syndrome. Other studies are necessary to confirm the efficacy of these treatments.

WHAT IS KNOWN

• Blau syndrome is a rare but severe granulomatosis that could be responsible for vision-threatening complications and articular deformation. • Blau syndrome seems to be refractory to treatments.

WHAT IS NEW

• High doses of corticosteroids are usually insufficient and should be considered only as a bridging therapy. • Blau syndrome could be considered as a poor factor for uveitis, thus, an anti-tumor necrosis factor α should be initiated for patients with uveitis or with residual arthritis.

Anterior Chest Wall Non-traumatic Arthropathies: A Crucial but Often Overlooked Site

OBJECTIVE

The purpose of this study was to describe the distribution of Anterior Chest Wall (ACW) arthropathies in a tertiary care center and identify clinical, biological and imaging findings to differentiate osteoarthritis (OA) from non-osteoarthritis (N-OA) etiologies.

METHODS

Search from medical records from January 2009 to April 2022, including patients with manubriosternal and/or sternoclavicular and/or sternocostal joint changes confirmed by ultrasonography, computed tomography or magnetic resonance imaging. The final study group was divided into OA and N-OA subgroups.

RESULTS

A total of 108 patients (34 males and 74 females, mean age: 47.3 ± 13 years) were included. Twenty patients had findings of OA, while 88 were diagnosed with N-OA pathologies. SpA was the most common etiology in the N-OA group (n = 75). The other N-OA etiologies were less common: rheumatoid arthritis (n = 4), Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome (n = 3), infectious arthritis (n = 3) and microcrystalline arthropathies (n = 3). Regarding the distinctive features, ACW pain was the inaugural manifestation in 50% of patients in OA group and 18.2% of patients in N-OA group (p = 0.003); high inflammatory biomarkers were more common in N-OA group (p = 0.033). Imaging findings significantly associated with OA included subchondral bone cysts (p < 0.001) and intra-articular vacuum phenomenon (p < 0.001), while the presence of erosions was significantly associated with N-OA arthropathies (p = 0.019). OA was independently predicted by the presence of subchondral bone cysts (p = 0.026).

CONCLUSION

ACW pain is a common but often underestimated complaint. Knowledge of the different non-traumatic pathologies and differentiation between OA and N-OA etiologies is fundamental for appropriate therapeutic management.

The childhood arthritis radiographic score of the hip: the proposal cut-off value using cluster analysis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a chronic rheumatic disease that affects children. It is crucial to detect and treat hip involvement in JIA early to prevent functional impairment and reduced quality of life. The Childhood Arthritis Radiographic Score of the Hip (CARSH) is a validated radiographic scoring system used to assess hip involvement in JIA. In this study, we aimed to determine cut-off values for CARSH scores using cluster analysis.

METHODS

The study was conducted as a cross-sectional analysis and included JIA patients with hip involvement who underwent a pelvic radiograph. The same pelvic radiograph was interpreted by two experienced pediatric rheumatologists at baseline and after 3 weeks by both readers for reliability. The CARSH scores were calculated for each hip four times (twice by each reader). For the 50 hips, a total of 200 interpretations of the CARSH score were obtained. Model-based clustering was employed to identify distinct groups of CARSH score interpretations and characterize the phenotype of each cluster.

RESULTS

Twenty-five children with hip involvement were included. The mean age was 13.9 ± 4.6 years. JIA subtypes were as follows: ERA in 64%, oligoarthritis in 16%, psoriatic arthritis in 12%, polyarthritis RF + in 4%, and RF - in 4% of patients. For the 200 hip interpretations, three clusters based on the level of the CARSH were identified by model-based clustering. Cluster 1 consisted of 17 CARSH score interpretations with a median score of 7 ± 3 (ranging from 1 to 15). This group primarily comprised patients with enthesitis-related arthritis (ERA) and psoriatic arthritis. Patients in cluster 1 were generally older, experienced longer diagnostic delays, and had a longer disease duration compared to the other clusters. Cluster 2 exhibited a moderate CARSH score, with an average score of 4 ± 3 (1 to 15). Patients in this group had significantly higher body weight compared to the other clusters. Cluster 3 represented the group with the least severe hip involvement, characterized by CARSH scores of 2 ± 1 (ranging from 0 to 9). This cluster had a higher proportion of male patients and higher C-reactive protein (CRP) levels than the other clusters. Regarding the individual items of the CARSH score, cluster 1 showed higher percentages of hip radiograph abnormalities such as joint space narrowing, erosions, growth abnormalities, and subchondral cysts. Cluster 2 was characterized by a high rate of acetabular sclerosis, with little to no abnormalities in other CARSH score items. Cluster 3 was the only group that exhibited hip subluxation, with minimal abnormalities in the other score items. In conclusion, this study identified three distinct groups of CARSH scores, representing varying levels of severity in hip involvement in JIA. These findings provide valuable insights for clinicians in assessing and managing JIA patients with hip involvement, enabling tailored treatment strategies based on the severity of the condition. Key Points • While a Childhood Arthritis Radiographic Score of the Hip (CARSH) is a valid and reliable tool in hip-related juvenile idiopathic arthritis, its use is limited in daily practice due to the lack of available cut-off values. • The cluster analysis defined three clusters based on the CARSH levels. • Cluster 1 exhibited the highest score with more damage and disability. Cluster 2 involved a moderate score and more overweight patients. Cluster 3 included the least level of the score but with an active disease parameter.

Probability of the 10-year Risk of Hip and Major Osteoporotic Fracture in Non-radiographic Axial Spondyloarthritis

BACKGROUND

Fracture risk in non-radiographic spondyloarthritis is underestimated. A reliable tool such as the Fracture Risk Assessment tool (FRAX) may assess this risk probability. This study aimed to assess the fracture risk by the FRAX score in patients with nr-axSpA and to determine factors associated with high fracture risk.

METHODS

We conducted a retrospective study of nr-axSpA patients meeting the Assessment of SpondyloArthritis International Society (ASAS) classification criteria for spondyloarthritis. All patients had Bone Mineral Density (BMD) by dual-energy X-ray absorptiometry (DEXA). The 10- year probability of major osteoporotic fracture (MOF) and hip fracture (HF) was calculated using the Fracture Risk Assessment Tool (FRAX).

RESULTS

Among 40 patients with nr-axSpA, 27 were women (67.5%). Their mean age was 43.7 ± 12.1 years. The mean disease duration was 3.15 ± 2.7 years. Eighteen patients (45%) had osteopenia, and 12 patients (30%) had osteoporosis. The median HF FRAX was 0% [0-1.2]. The median MOF FRAX was 0.5% [0.3-1.8]. MOF FRAX was positively correlated with age (p = 0.002), disease onset age (p = 0.006), disease duration (p = 0.024), and the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) (p < 0.0001), and negatively correlated with daily calcium intake (p < 0.0001). HF FRAX was positively correlated with mSASSS (p < 0.0001) and negatively correlated with daily calcium intake (p = 0.005).

CONCLUSION

Our study confirmed the frequency of bone loss during nr-axSpA and showed that osteoporotic risk fracture was related not only to traditional risk factors for osteoporosis but also to disease-related factors.

Foot-related impairment in children with juvenile idiopathic arthritis

AIM

Foot involvement is present in approximately 60%-90% of children with Juvenile idiopathic arthritis (JIA). It is a major cause of disability, which can lead to deterioration in daily activities and quality of life. However, it is often overlooked and can compromise patient management.

PURPOSE

Our objective was to describe the ankle and foot involvement in JIA and to appraise the functional impact of this damage on the child's performance and quality of life by using validated scores.

METHODS

The cross-sectional study included patients with JIA. Functional impairment was assessed through the Juvenile Arthritis Functionality Scale (JAFS) and the Oxford Ankle and Foot Questionnaire for children.

RESULTS

Twenty-three patients aged 12.75 ± 3.9 and with 41 months of disease duration. After completing the Oxford score, the physical domain appeared to be the most altered. A long delay in diagnosis was associated with an alteration in the emotional domain of the Oxford score. Higher disease activity was significantly associated with impairment in both the physical activity and the footwear domains of the Oxford score. As regards clinical examination data, the presence of foot pain as well as the presence of tendinopathy were associated with an alteration of all Oxford score domains. The presence of flat feet significantly affected all domains of the Oxford score. The JAFS was reported to affect the child's performance ability and was associated with impairment in physical activity, school and play, and emotional domains.

CONCLUSION

Ankle and foot involvement was common in our study. Functional ability was most impaired in the lower limbs. High disease activity, foot and ankle pain, tenosynovitis, and flat feet were associated with poorer quality of life and higher functional impact.

Psoriatic Arthritis Quality of Life questionnaire: Translation, cultural adaptation and validation into Arabic language

BACKGROUND

Psoriatic arthritis (PsA) is a multifaceted inflammatory disease that has a strong negative impact on the quality of life (QoL) of patients. The Psoriatic Arthritis Quality of Life (PsAQoL) questionnaire was the first disease-specific patient-derived instrument developed to measure the QoL in patients with PsA. Our objective was to translate the PsAQol into Arabic language and evaluate its reliability and validity in patients with PsA.

METHODS

This was a cross-sectional study including patients with PsA. A clinical and biological assessment of the patients was performed at inclusion. The translation of the original PsAQoL into Arabic was performed by a professional bilingual and lay panel. Eight patients were interviewed to assess face and content validity. A separate sample of PsA patients (n = 30) were invited to participate in a test-retest postal study in order to investigate reproducibility and construct validity. One week separated the two administrations. The Arabic version of Health Assessment Questionnaire (HAQ) was used as a comparator instrument for convergent validity.

RESULTS

Face and content validity were satisfactory. The Arabic version of the PsAQoL was found to be relevant, understandable and easy to complete in only a few minutes. One item was excluded (item 16). It had no correlation with either the other 19 items or the total score of PsAQol. The Arabic PsAQol had excellent internal consistency (Cronbach's a = 0.926), and test-retest reliability (r = 0.982). There was a positive correlation between the total score of the PsAQoL and the Arabic version of HAQ (Spearman's r = 0.838, p < 10-3 ). Exploratory factor analysis had extracted two factors explaining 55% of the total variance.

CONCLUSION

Nineteen items were selected to compose the Arabic version of PsAQoL, which was found to be relevant and understandable and has excellent reliability and construct validity. The new measure will be a valuable new tool for use in routine care for patients' assessment.

Observer design for Takagi-Sugeno fuzzy systems with unmeasured premise variables: Conservatism reduction using line integral Lyapunov function

In this paper, a non-quadratic Lyapunov function is employed to reduce conservatism in a nonlinear observer designed for a class of continuous-time Takagi-Sugeno fuzzy systems with unmeasurable premise variables. This structure presents greater challenges compared to systems with measured variables. To overcome this issue, we utilize the mean value theorem and the sector nonlinearity transformation to convert the nonlinear error dynamics into a linear parameter-varying system. Moreover, we introduce the line integral Lyapunov function, which based on the integral of the membership functions, in order to ensure the global stability of the fuzzy systems under consideration. The use of this function offers several notable advantages over conventional quadratic forms, including a reduction in conservatism. Additionally, this type of functions constructed in a manner that eliminates the need for generating time derivatives of the membership functions, thereby simplifying calculations and analysis in comparison to other nonquadratic functions. Furthermore, it also enables capturing the system's behavior along a trajectory. The stability conditions are more relaxed and expressed as linear matrix inequalities, which can be solved using a linear programming approach through specialized software tools. To validate the effectiveness of the proposed methodology, we conducted a hardware-in-the-loop test using a flexible joint robot. The obtained results clearly underscore the success of the proposed approach.

[Clinical examination of the child's foot]

CLINICAL EXAMINATION OF THE CHILD'S FOOT. The clinical examination of the child's foot is part of the musculoskeletal examination and requires a good knowledge of morphological and physiological features of foot during growth. This article describes the stages of the clinical assessment of the child's foot from walking age onwards, as well as the main disorders to be investigated. The examination consists of a complete physical and musculoskeletal assessment, followed by the foot examination. The latter includes a static examination with inspection of bare feet, followed with a podoscope evaluation, a dynamic examination including an overall analysis of walking, and finally an examination of the footwear. The main static disorders to investigate are the flat foot, defined by the collapse of the internal arch of the foot and considered physiological until the age of 5 or 6, and the Pes Cavus, defined by the accentuation of the plantar arch. A thorough examination, followed by a synthetic clinical reasoning, is necessary to guide the diagnostic and therapeutic management of some disorders.

Low back pain in pregnant women: A necessary or an avoidable evil?

OBJECTIVES

The aim of this study was to determine the prevalence, the main features and the potential risk factors of LBP in pregnant women.

METHODS

This cross-sectional study included 173 pregnant women in the third trimester. Non-inclusion criteria were severe mental disability and known previous history of musculoskeletal diseases. The participants were categorised into two groups: women with pregnancy-related LBP and pain-free women. Demographic, socio-professional, clinical and obstetrical data were compared between the two groups using the appropriate statistical tests.

RESULTS

The mean age was 32.2 ± 5.4 years [17-45]. Among them, 108 (62.4%) reported one or more episodes of LBP during at least 7 days, mostly in the third semester (n = 71). The presence of LBP was significantly associated with history of LBP in previous pregnancies and jobs requiring prolonged standing. Active jobs and the presence of gestational complications were significantly more common in pain-free women. In the multivariate analysis, LBP was independently predicted by the history of LBP in previous pregnancies and the absence of gestational complications.

CONCLUSIONS

The association of LBP with gestational complications as a protective factor has not yet been reported in previous studies. These complications are a common cause of hospitalisation, which represents a period of relative rest during pregnancy. Our results revealed that history of LBP in previous pregnancies, sedentary lifestyle prior to pregnancy and prolonged standing are the main risk factors of LBP. In contrast, rest and avoidance of physical overstrain during pregnancy may be protective factors.

Predictors factors of atlanto-axial subluxation in Tunisian patients with rheumatoid arthritis

BACKGROUND

The aim of this study was to describe clinical and imaging features of atlantoaxial subluxation (AAS) and the associated risk factors in patients with rheumatoid arthritis (RA).

METHODS

We conducted a retrospective and comparative study including 51 RA patients with AAS and 51 RA patients without AAS. Atlantoaxial subluxation was defined by the presence of an anterior C1C2 diastasis on the cervical spine radiograph in hyperflexion and/or an anterior, posterior, lateral or rotatory C1C2 dislocation on MRI with/without inflammatory signal.

RESULTS

In G1, clinical presentations revealing AAS were mainly neck pain (68.7%) and neck stiffness (29.8%). MRI revealed: diastasis C1C2 (92.5%), periodontoid pannus (92.5%), odontoid erosion (23.5%), vertical subluxation (9.8%) and spinal cord involvement (7.8%). A collar immobilisation and corticosteroid boluses were indicated in 86.3% and 47.1% of cases. C1-C2arthrodesis was performed in 15.4% of cases. Atlantoaxial subluxation was significantly associated with: age at disease onset (p = 0.009), history of joint surgery (p = 0.012), disease duration (p = 0.001), rheumatoid factor (p = 0.01), anti-cyclic citrullinated peptide (p = 0.02), erosive radiographic status (p < 0.005), coxitis (p < 0.001), osteoporosis (p = 0.012), extra-articular manifestations (p < 0.001), and high disease activity (p = 0.001). Multivariate analysis identified RA duration (p < 0.001, OR = 1.022 CI[1.01-1.034]) and erosive radiographic status (p = 0.01, OR = 21.236 CI[2.05-219.44]) as predictive factors of AAS.

CONCLUSION

Our study showed that longer disease duration and joint destruction are the major predictive factors of AAS. Early treatment initiation, tight-control and regular monitoring of cervical spine involvement are required in these patients.

Factors associated with poor prognosis of hip arthritis in juvenile idiopathic arthritis: Data from the JIR cohort

OBJECTIVES

Hip involvement remains a predictor of severe juvenile idiopathic arthritis (JIA) course and carries a high risk of disability. This study aims to determine the factors of poor prognosis of hip involvement in patients with JIA and to assess the treatment response.

METHODS

This is a multicenter observational cohort study. Patients were selected from the JIR Cohort database. Hip involvement was defined as clinically suspected and confirmed by an imaging tool. Follow-up data were collected during 5 years.

RESULTS

Among the 2223 patients with JIA, 341(15%) patients had hip arthritis. Male gender, enthesitis-related arthritis, and North African origin were factors associated with hip arthritis. Hip inflammation was associated with disease activity parameters during the first year, particularly Physician Global Assessment, joint count, and inflammatory marks. Structural hip progression was associated with early onset of the disease, a longer time to diagnosis, geographic origin, and JIA subtypes. Anti-TNF therapy was found to be the only treatment able to effectively reduce structural damage progression.

CONCLUSION

The early onset diagnostic delay, origin, and systemic subtype of JIA predict a poor prognosis of hip arthritis in children with JIA. The use of anti-TNF was associated with a better structural prognosis.

Denosumab use in osteogenesis imperfecta: an update on therapeutic approaches

Osteogenesis imperfecta (OI) is an inherited skeletal disorder that leads to bone fragility and multiple fractures. Given advances in the genetic understanding of existing phenotypes and newly discovered mutations, therapeutic management of OI has become challenging. Denosumab, a monoclonal antibody that inhibits the interaction between the receptor activator of nuclear factor kappa B ligand (RANKL) and its receptor RANK, has been approved to treat postmenopausal osteoporosis and emerged as an important therapy for malignancies and other skeletal disorders, including pediatric skeletal conditions such as OI. This review summarizes information about denosumab therapy in OI by exploring its mechanisms of action, main indications, and safety and efficacy. Several case reports and small series have been published about the short-term use of denosumab in children with OI. Denosumab was considered a strong drug candidate for OI patients with bone fragility and a high risk of fracture, particularly for patients with the bisphosphonate (BP)-unresponsive OI-VI subtype. The evidence for denosumab's effects in children with OI indicates that it effectively improves bone mineral density but not fracture rates. A decrease in bone resorption markers was observed after each treatment. Safety was assessed by tracking the effects on calcium homeostasis and reporting side effects. No severe adverse effects were reported. Hypercalciuria and moderate hypercalcemia were reported, suggesting that BPs be used to prevent the bone rebound effect. In other words, denosumab can be used as a targeted intervention in children with OI. The posology and administration protocol require more investigation to achieve secure efficiency.

How to optimize recruitment strategies of patients with rheumatic and musculoskeletal diseases for online surveys: experience from an international study

The use of online surveys as a recruitment tool for clinical research has recently expanded; nevertheless, optimal recruitment strategies remain poorly identified. Objectives. The study aimed to identify the most effective recruitment strategies for online research studies and to determine the optimal survey channels for obtaining patients' responses. This is a post-hoc analysis of the ARCOVAX (ArLAR COVID Vaccination) study. Multiple recruitment strategies were disseminated in Arabic, English, and French. The proportion of enrolled patients was correlated with each strategy. Channels used by patients to complete the survey were divided into three categories (social media (SoMe), doctor, and patients' associations). These channels were correlated with the patients' characteristics and the country's Gross Domestic Product (GDP). A total of 1595 patients from 19 Arab countries completed the survey. Patients' mean age was 39 years, 73.2% (1159) were females, 17.8% (284) had a university education level and 93.1% (1468) answered the survey in Arabic. The most effective recruitment strategies were personalized WhatsApp reminders to recruiters (30% of enrolled patients), technical support in response to access issues (27%) and sharing recruitment status by country on a WhatsApp group (24%). The channels used to complete the survey were: SoMe in 45% (711), doctor in 40% (647), and patients' associations in 8.5% (233), and correlated with age and GDP. To optimize recruitment, it is recommended to combine multiple strategies and channels, use the native language and be active (mobilize teams), reactive (provide prompt technical support), and proactive (share regular updates and reminders).

Non-pharmacological therapies in Fibromyalgia: New horizons for physicians, new hopes for patients

INTRODUCTION

Fibromyalgia (FM) is a chronic musculoskeletal condition characterised by reduced quality of life and severe limitations in daily living activities. Considering the wide spectrum of symptoms and the ineffectiveness of a single pharmacological approach, the latest clinical guidelines recommend non-pharmacological therapies as both an alternative and a better-tolerated approach. Several studies have been conducted to determine the effectiveness of non-pharmacological therapies in the management of FM.

AIMS

Through a literature review, this paper aims to describe the different complementary therapies and investigate their potential sustainability and effectiveness on FM symptoms in the short and/or long term.

METHODS

We searched the PubMed and Google Scholar databases using broad search terms up to June 2022, to identify all types of study designs restricted to human subjects on non-pharmacological therapies in FM.

RESULTS

Recent evidence demonstrated that physical activity is the mainstay of therapeutic management, highlighting the relevance of walking as the best method of exercise in FM patients. Nevertheless, adherence to physical activity remains fraught with obstacles that could be overcome with a multimodal and multidisciplinary approach involving a wide range of passive therapies. The effectiveness of passive non-pharmacological therapies remains however unproven in the long term. They can be therefore suggested as 'adjunct' or 'bridge' therapy to improve adherence to physical activity.

CONCLUSION

To conclude, FM management requires a multimodal and symptom-based approach, guided by the predominant bothersome symptom on the one hand, and the preferences of each patient on the other hand.

Primary pachydermoperiostosis associated with pigmented villonodular synovitis: An unknown association?

Primary pachydermoperiostosis is a rare genetic disease affecting the skin and musculoskeletal system. In contrast to secondary hypertrophic osteoarthropathy, primary pachydermoperiostosis is considered a benign condition. While a variety of associated abnormalities have been described in this form, any association with tumors was previously reported in the literature. We hereby describe the first case of a 20-year-old man with primary pachydermoperiostosis revealed by a knee synovial tumor.

Sarcopenia: a new issue in juvenile idiopathic arthritis. A study Protocol

INTRODUCTION

The decrease in muscle function and mass is defined as sarcopenia. Known for a long time as an age-related disorder, sarcopenia is nowadays well recognized in childhood. Juvenile idiopathic arthritis (JIA), a chronic inflammatory joint disease may be associated with loss of skeletal mass.

AIM

This protocol aims to evaluate the prevalence rate of sarcopenia and its associated factors in JIA.

METHODS

To evaluate the prevalence rate and factors associated with sarcopenia in juvenile idiopathic arthritis, we are enrolling 30 children with JIA and 30 healthy children aged between 4-and 16 years. Clinical data will report: age, sex, body mass index, disease duration, and therapeutic management. All participants will undergo the Whole-body Dual-energy X-ray absorptiometry to assess the skeletal muscle mass. The muscle strength will be measured using the handgrip dynamometer and adjusted to the body mass index. Data will be analyzed and compared to age and sex reference curves.

RESULTS

This study aims to detect sarcopenia in JIA children and identify subsequently the main associated factors. By collecting anthropometric data and extracting the main features of the disease, specific metrics will be extracted. Body composition will be obtained using the DXA scans, including appendicular lean mass and skeletal muscle mass. Muscle strength will also be assessed.

CONCLUSION

This study aims to assess sarcopenia in JIA patients, using the sarcopenia update definition. If we will provide conclusive results, it will be possible to better identify the associated factors of sarcopenia and to prevent children from this complication. Clinical trials registration NCT05291416.

Early Identification of Sacroiliitis in Patients with Suspected Spondyloarthritis: A Challenging Task

OBJECTIVE

The purpose of this study was to assess the performance of computed tomography (CT) scan and magnetic resonance imaging (MRI) for detecting sacroiliitis in nonradiographic SpA (nr-SpA).

METHODS

This cross-sectional monocentric double-blind study included 63 patients consulting for symptoms suggestive of SpA between February 2014 and February 2017. Patients with conventional radiographs showing a confirmed sacroiliitis (grade 3 or 4) were not included. Eligible patients underwent CT and MRI of sacroiliac joints (SIJ). CT and MR images were interpreted by 2 experienced musculoskeletal radiologists blinded to clinical and laboratory data. Two professors in rheumatology blinded to radiologists' conclusions analyzed clinical data, laboratory tests, HLA typing, X-rays, CT and MRI images, and divided the patients into 2 groups: confirmed nr-SpA or no SpA. This classification was considered the gold standard when analyzing the results.

RESULTS

46 women and 17 men were included in this study. 47 patients were classified as confirmed nr-SpA (74.6%) and 16 patients as no SpA (25.4%). Sensitivity, specificity, and positive and negative predictive values of CT and MRI for detecting sacroiliitis were, respectively, estimated at 71.7%, 71.4%, 89.2%, 43.5%, and 51.2%, 100%, 100%, and 40%. CT and MRI findings were found to be statistically associated (p<0.001).

CONCLUSION

SIJ MRI is a highly specific method in the detection of sacroiliitis, but with a moderate sensitivity. SIJ CT scan, usually known as the third option after radiography and MRI, has much greater diagnostic utility than it has been documented previously.

Osteonecrosis of the Tarsal Navicular: Not Always Spontaneous!

BACKGROUND

Mueller-Weiss disease, a rare and complex foot condition, is defined as spontaneous and progressive navicular fragmentation leading to midfoot pain and deformity. However, its exact etiopathogenesis remains unclear. We report a case series of tarsal navicular osteonecrosis to describe the clinical and imaging characteristics and etiologic profile of the disease.

METHODS

This retrospective study included five women diagnosed as having tarsal navicular osteonecrosis. The following data were extracted from medical records: age, comorbidities, alcohol and tobacco consumption, history of trauma, clinical presentation, imaging modalities performed, treatment protocol, and outcomes.

RESULTS

Five women with a mean age of 51.4 years (range, 39-68 years) were enrolled in the study. Mechanical pain and deformity over the dorsum of the midfoot was the main clinical presentation. Rheumatoid arthritis, granulomatosis with polyangiitis, and spondyloarthritis were reported by three patients. Radiographs revealed bilateral distribution in one patient. Three patients underwent computed tomography. It showed a fragmentation of the navicular bone in two cases.Magnetic resonance imaging was performed in one patient showing flattening of the lateral aspect of the navicular bone with signal abnormalities. Talonaviculocuneiform arthrodesis was performed in all of the patients.

CONCLUSIONS

Mueller-Weiss disease-like changes may occur in patients with an underlying inflammatory disease such as rheumatoid arthritis and spondyloarthritis.

Vertebral sarcoidosis: diagnosis to management

Sarcoidosis is a systemic inflammatory granulomatous disease that can develop in almost any organ system. Rheumatologists may encounter sarcoidosis in different situations varying from arthralgia to bone involvement. While the peripheral skeleton was a frequent location, data regarding axial involvement is scarce. Most patients with vertebral involvement have a known diagnosis of intrathoracic sarcoidosis. They tend to report mechanical pain or tenderness over the involved area. Imaging modalities, particularly Magnetic Resonance Imaging (MRI), are a mainstay of axial screening. It helps exclude differential diagnoses and delineate the extent of bone involvement. Histological confirmation combined with the ap- propriate clinical and radiological presentation is the key of diagnosis. Corticosteroids remain the cornerstone of treatment. In refractory cases, methotrexate is the steroid- sparing agent of choice. Biologic therapies may be used, although the evidence base for their efficacy is bone sarcoidosis controversial.

18 Does overweight enhance foot disorders in patients with juvenile idiopathic arthritis?

Background

Objectives

Methods

Results

Conclusion

10 Impact of the month of birth on the development of juvenile idiopathic arthritis among Tunisian children

Background

Juvenile idiopathic arthritis (JIA) is the most common inflammatory disease influenced by genetic as well as environmental factors. Prior studies from Israel and USA suggested that JIA had a seasonality of birth, with birth peaking in winter and especially in January.

Objectives

The aim of the study was to evaluate the impact of month of birth and season, and the onset of JIA in Tunisian children.

Methods

We conducted a case-control study including 27 children with JIA compared with a homogeneous control group of 27 children hospitalized in a pediatric orthopedic unit for traumatic reasons and healthy for any chronic inflammatory rheumatism. Statistical differences between groups were also analyzed by non-parametrical tests.

Results

Fifty-four patients (25 females and 29 males) were enrolled. The mean age was 11.04 ± 5.58 years and the mean duration of the diseases was 5.29 ± 3,18 years. The frequency of each JIA subset was at follows: polyarticular rheumatoid factor positive (n = 2), polyarticular rheumatoid factor negative (n = 5), psoriatic arthritis (n = 1), enthesitis-related arthritis (n = 11) and oligoarthritis (n = 8). Although the majority of children with JIA were born in November (22.2%) and December (18.5%), there was no significant difference in month of birth distribution between the cases and the controls. Likewise, there was no significant correlation between season of birth and the onset of the disease (p = 0,6).

Conclusion

This study didn’t show any correlation between season and month birth, and the onset of JIA. Our result may be explained by the weather in Tunisia which is relatively warm with little variation in temperature between seasons compared with the country where they found a significant correlation. It also may be due to the limited number of our cases.

06 Flat foot impairs physical activity in children with juvenile idiopathic arthritis

Background

Children with juvenile idiopathic arthritis (JIA) are less active compared with the general population due to pain and deformities, mainly of the lower limbs. Indeed, only 23% of children with JIA meet the public health recommendations of one h of moderate to vigorous physical activity daily [1]. In this context, foot involvement in JIA is a considerable limiting cause of physical activity.

Objectives

Our study aimed to investigate the types of static foot disorders that impede physical activity in children with JIA.

Methods

We conducted a cross-sectional study of patients with JIA according to the revised ILAR criteria. Socio-demographic and disease-related data were recorded. All patients underwent podoscope examination for varus or valgus deformity of the hindfoot and plantar footprint abnormality (flat foot or hollow foot). Patients with ankle or foot involvement due to congenital malformation or any other cause besides JIA were excluded. The impact of foot involvement on physical activity was assessed by the Oxford ankle foot questionnaire for children (OxAFQ-C). A higher score represents better functioning. We looked for the effect of foot abnormalities and their impact on physical activity.

Results

A total of 23 patients were collected. The mean age was 12.7 ± 3 [6–18] years and the mean age at diagnosis was 9.3 ± 3 [3–16] years. There was a female predominance with a sex ratio of 0.42. The majority of patients had secondary education (52%). The distribution of the different subtypes was dominated by the oligoarticular form (30%) and the enthesitis-related arthritis form (26%), followed by the polyarticular FR + (n = 1), polyarticular FR- (n = 3), psoriatic arthritis (n = 3), systemic (n = 1) and undifferentiated (n = 1) forms. The mean physical activity score assessed by the Oxford score was 73.52 ± 35.8 [0 – 100]. Plantar footprint abnormalities of the hollow and flat foot were found in 39% and 30% of cases respectively. These abnormalities were unilateral and bilateral in 7 and 9 patients respectively. Eleven patients (48%) had a hindfoot abnormality and 30% of them had a limitation of joint movement range. There was no statistically significant association between the physical domain of the Oxford score and the presence of a limited range of the talocrural joint (p> 0.05). A significant reduction in physical activity was associated with hindfoot pain (5.37 vs 89.56; p< 0.001) but was not associated with the presence of hindfoot abnormalities (p = 0.05). The presence of flat feet was significantly associated with impairment in all domains of the Oxford score, particularly in the physical domain (36.79 for the flat foot group vs 89.2 for the group without flat feet, p = 0.001). However, the presence of a hollow foot did not lead to an alteration of the physical activity of JIA patients (p> 0.05).

Conclusion

Our study showed that the flat foot was associated with a reduction in physical activity. Early detection of this abnormality and adapted podiatric care could improve the function of young patients with JIA.

References

[1] Gueddari S, Amine B, Rostom S, et al. Physical activity, functional ability, and disease activity in children and adolescents with juvenile idiopathic arthritis. Clin Rheumatol. 2014; 33(9):1289–1294.

The implication to policy, practice, research and advocacy

It is important to ensure that children with juvenile idiopathic arthritis are receiving appr

22 Monitoring of juvenile idiopathic arthritis: don’t miss the foot deformities!

Background

Foot deformities seem to be frequent in children with Juvenile Idiopathic Arthritis (JIA) [1,2]. These deformities can deeply affect the child’s activity and alter his quality of life.

Objectives

To study the association between disease activity and foot deformities in JIA patients.

Methods

We conducted a cross-sectional study including patients meeting the International League of Associations for Rheumatology (ILAR) 2001 criteria for JIA. For each patient, we collected the following data: age, disease duration, tender joint count (TJC), swollen joint count (SJC), Patient Global Assessment (PGA), Visual Analogic Scale (VAS), and therapeutic management. Disease activity was assessed using the Juvenile Arthritis Disease Activity score (JADAS). Foot deformities were assessed using an optical podoscope. C-reactive protein (CRP) and Erythrocyte sedimentation rate (ERS) levels were measured. Statistical analysis was performed using SPSS software.

Results

We included 35 patients. Forty-three percent of the patients were boys (n = 15). The mean age was 12.2 ± 3.61 years. The mean disease duration was 4.1 ± 3.29 years. The mean PGA and the mean VAS were 3.4 ± 3.02 and 3.37 ± 2.92, respectively. The mean TJC and the mean SJC were 1.48 ± 1.69 and 0.61 ± 0.77, respectively. The mean CRP and ESR were 7.51 ± 11.85 mg/l and 18.88 ± 15.53 mm, respectively. Twenty-four patients were under non-steroidal anti-inflammatory drugs (69%), 12 patients were under methotrexate (34%), and 5 patients were under TNFα inhibitor (14%).

The mean JADAS was 7.58 ± 6.3. Seventeen percent of the patients had the inactive disease (n = 6). Foot deformities were found in 80% of the patients (n = 28). They were flatfoot in 40% (n = 14) and pes cavus in 46% (n = 16). These deformities were bilateral in 18 cases (51%). Hallux valgus was present in 14% of the cases (n = 5). Foot deformities were associated to a higher PGA (4.04 ± 3.01 vs 0.86 ± 1.2, p< 10^–3), VAS (3.93 ± 2.94 vs 1.14 ± 1.46, p = 0.022), CRP level (8.84 ± 13.1 vs 2.79 ± 2.5 mg/l, p = 0.039), and higher JADAS (9.12 ± 6.25 vs 2.08 ± 1.93, p< 10^–3).

Conclusion

Our study showed that foot deformities are common in JIA. Interestingly, these deformities are associated with a higher CRP level and a higher disease activity. These results suggest that an early screening of foot deformities is advisable in patients with active disease.

References

1. Truckenbrodt H, Häfner R, von Altenbockum C. Functional joint analysis of the foot in juvenile chronic arthritis. Clin Exp Rheumatol. 1994; 12 Suppl 10: S91-96.

2. Gschwend N, Ivosevic-Radovanovic D. [The child’s foot in juvenile polyarthritis (cP)]. Orthopade. 1986; 15(3):212–9.

05 Methotrexate improve the foot functional impairment in juvenile idiopathic arthritis

Background

Foot involvement in juvenile idiopathic arthritis (JIA) is common and affects about 60% of children [1]. Often overlooked by patients and practitioners, ankle and foot disability has been poorly studied and there are no accepted clinical practice guidelines for the diagnostic approach, as well as for the therapeutic management.

Objectives

Our study aimed to evaluate the effect of medical treatments on functional disability related to foot involvement in JIA.

Methods

We conducted a cross-sectional study including patients with JIA according to the revised ILAR criteria, collected from the rheumatology department of the Kassab National Institute. Sociodemographic and disease data (activity assessed by the Juvenile Arthritis Disease Activity Score 10 (JADAS-10) and therapeutic modalities) were recorded. Ankle and foot involvement were investigated by questioning and physical examination. We used the Oxford ankle foot questionnaire for children (OxAFQ-C); a validated, simple and reproducible score to assess the impact on the quality of life of children with foot problems [2]. This questionnaire encompasses 14 items corresponding to three dimensions: physical, school and play, and emotional. Higher scores represent better functioning. We searched for an association between the different drug treatments for JIA and the OxAFQ-C score.

Results

The study included 23 patients. The mean age was 13 ± 4 [6–18] years. The sex ratio was 0.42 with a female predominance. The age of the disease was 49 ± 40 months [6–180 months]. The distribution of the different forms of JIA was as follows: oligoarticular (n = 7), enthesitis-related arthritis (n = 6), polyarticular FR + (n = 1), polyarticular FR- (n = 3), psoriatic arthritis (n = 3), systemic (n = 1) and undifferentiated (n = 1). Pain on walking and limitation of the talocrural joint was found in 39% and 30% respectively. The mean JADAS-10 score was 6.72 ± 6.1 [0–20]. Ten patients had high activity. Eighteen patients (78%) were taking level I analgesics and 14 patients (61%) were on non-steroidal anti-inflammatory drugs, 12 of them on demand. Naproxen was the most commonly used drug, followed by diclofenac. Eleven patients (48%) were on a disease-modifying anti-rheumatic drug (csDMARD). Methotrexate (MTX) was prescribed in 30% of cases with a mean dose of 7.91 mg/week [7.5–10]. Only one patient was on sulfasalazine. Four patients (17%) were treated with biologics: Etanercept (n = 3) and Tocilizumab (n = 1). The mean scores of the different domains of (OxAFQ-C) were as follows: 73.52 ± 35.89 [0—100] in the physical domain, 84.2 ± 30 [6.25—100] in the school and play domain, 88.75 ± 24.71 [12.5 – 100] in the emotional domain. There was no statistically significant association between the different domains of the Oxford score and the use of analgesics or NSAIDs (p> 0.05). Similarly, there was no statistically significant association between the different domains of the Oxford score and treatment with biotherapy (p> 0.05). However, patients on MTX had less functional impairment of the feet with a significant improvement in the physical domain (99.26 on MTX vs 62.5 without MTX, p = 0.02, r = 0.6).

Conclusion

Our work showed that only methotrexate was associated with an improvement in functional foot outcomes in JIA. Further studies are needed to highlight the effect of other therapies, especially biologics.

References

[1] Arkell-Kautiainen M, Haapasaari J, Kautiainen H, Vilkkumaa I, Mälkiä E, Leirisalo-Repo M. Favourable social functioning and health-related quality of life of patients with JIA in early adulthood. Ann Rheum Dis. 2005; 64(6):875–880

[2] Morris C, Liabo K, Wright P and Fitzpatrick R. Development of the Oxford ankle foot questionnaire: finding out how children are affected by foot and ankle problems. Child: care and health development. 2007; 33(5): 559–68.

The implication to policy, practice, research and advocacy

More studies are needed regarding the effect of therapeutics on foot involvement in JIA children

21 Disease activity and body mass index in juvenile idiopathic arthritis: is the truth revealed?

Background

Objective

Methods

Results

Conclusion

19 Maternal and early childhood exposures in relation to juvenile idiopathic arthritis

Background

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children. JIA likely has a complex aetiology, with multiple genetic and environmental factors contributing to its development. Existing data on associations between maternal and early childhood exposures and JIA is rare. Previous studies showed potential role for prematurity, number of siblings and infections.

Objectives

The aim of our study is to assess maternal and early childhood exposures in patients with JIA.

Methods

Mothers of children with JIA followed in rheumatology department were asked about maternity related data as well as the course of perinatal period of the child with JIA based on the International League of Associations for Rheumatology (ILAR) criteria. Exposure information from birth included: Maternal factors (age when they had the first child, age when they had the child with JIA, plurality (singleton, twin/multiple gestation), number of prior fetal losses, number of prior births; delivery method (vaginal, cesarean section)) and also information about birth weight (low (&lt;2500 grams), normal (2500– 4000 grams), excessive (4000+ grams)); size for- gestational-age and gestational age (preterm, normal term, post term) and postpartum complications.

Results

Thirty children (sixteen females and fourteen males) with JIA were included. The most common type of JIA was enthesitis-related in 13 cases, then oligoarthritis in 8 cases, polyarthritis without rheumatoid factor in 4 cases, polyarthritis with positive rheumatoid factor in 2 cases and psoriatic arthritis in 3 cases. The mean age of the mothers was 27.1 years [22–40] when they had their first child and 30.27 years [22–42] when they had their child with JIA. They were nulliparous in 40% of the cases. All of the children were from a singleton pregnancy. Thirty percent of the mothers had at least one prior fetal loss before they had their child with JIA. During their pregnancy with their child with JIA, five mothers had pre-eclampsia and two of them had gestational diabetes. None of them smoked during the pregnancy. Only 2 children had preterm birth. Birth weight was normal (2.500–4.000 grams) in 24 cases, low in 3 cases (&lt;2.500 grams) and above normal (&gt;4000 grams) in 3 cases. Size for gestational age was normal in all cases. Nineteen mothers had vaginal delivery and eleven had cesarean section. Neonatal complications were noted in 7 cases who needed to be admitted to neonatal intensive care unit (1 for hypoglycemia, 1 for jaundice, 2 for infection, 1 for respiratory distress and two because of preterm birth). Maternal complications were noted in four cases: 2 postpartum hemorrhage and 2 postpartum infections.

Conclusion

Our study assessed maternal and early childhood exposures in patients with JIA. Further studies are required to explore associations between these factors and the occurrence of the disease for a better knowledge of etiologies of JIA and for a possible prevention from this pathology.

AB0215 DOES THE PARITY IMPROVE THE RHEUMATOID ARTHRITIS ACTIVITY?

Background

The parity seems to decrease the risk of auto-immune diseases like Rheumatoid arthritis (RA). The risk reduction appeared when the parity number reached two [1]. The activity of RA improved during pregnancy and flares postpartum, but the relationship of parity to RA prognosis is unclear. The impact of childbirth on disease activity is less studied.

Objectives

We aimed to investigate the impact of parity on rheumatoid arthritis activity.

Methods

We conducted a retrospective study including patients fulfilling the American Congress Of Rheumatology / European League Against Rheumatism (ACR EULAR) 2010 criteria.

We collected epidemiological, clinical, biological (C-reactive protein: CRP, erythrocyte sedimentation rate (ESR), immunological status (rheumatoid factor RF and anti-citrullinated protein/peptide antibody ACPA), and disease activity index (The Disease Activity Score 28 DAS 28). We divided our patients into two groups: group (G1): the nulliparous women; group 2 (G2): women who gave birth.

Results

Ninety-two patients were enrolled. There were 14 men and 78 women. The mean age was 59.56 ± 11.7 years. The mean disease duration was 9.32 ± 8.22 years. Among 78 women, we found 50 patients with parity. The main swollen joint was 3.34 ± 3.6 in G2 versus 4.44 ± 4.04 in G1 (p=0.94). The mean painful joints were 6.74 ± 5.12 and 9 ± 9.19 (p=0.28), respectively. However, the inflammatory syndrome is higher among women in G2. The mean CRP level was 15.1 mg/l, and the mean ESR was 37.7 mm. In G1, the RF and ACPA were 131 UI/l and 281 UI/l, respectively compared with 568 UI/L and 315UI/l, respectively in G2.

A significant difference was noted in the DAS28-CRP between the two groups (G2: 4.18 ±1.23 versus G1: 4.49 ± 2.5, p=0.04).

However, no association was found between parity and disease activity using the DAS28-ESR.

Conclusion

Our study showed that parity could have a protective effect on disease activity. It seems to be associated with a lower joint count and a lower rate of RF and ACPA. However, more studies are necessary to conclude these issues.

References

[1]Chen WMY, Subesinghe S, Muller S, Hider SL, Mallen CD, Scott IC. The association between gravidity, parity and the risk of developing rheumatoid arthritis: A systematic review and meta-analysis. Semin Arthritis Rheum. avr 2020;50(2):252‑60.

Disclosure of Interests

None declared

AB0819 Impact of childbirth on the sacroiliac joints in non-radiographic axial Spondyloarthritis

Background

The era of magnetic resonance imaging (MRI) has contributed to a better assessment of patients with early disease stages of axial spondyloarhtis (ax-SpA), to the extent that a new entity has emerged. Indeed, the spectrum of SpA has broaden to include non-radiographic axial spondyloarthritis (nr-axSpA). Childbirth has been found to be associated with bone marrow edema (BME) in the sacroiliac joints (SIJ) [1], yet the extent of these lesions is inadequately described, which complicates the distinction with nr-axSpA.

Objectives

This study aimed to explore the impact of childbirth on MRI findings and BME in nr-axSpA.

Methods

We conducted a cross-sectional study including women diagnosed with nr-axSpA according to the ASAS (Assessment of SpondyloArthritis international Society) criteria. Socio-demographic data as well as childbirth history were recorded. The sacroiliac joints manoeuvers’ examination were also transcribed. Ultrasound of the SIJ as well MRI-SIJ was performed in all the women. The sequence protocol included the following: T1-weighted, T2-weighted and axial STIR and were scored for BMO. We investigated an association between the number of children and MRI abnormalities mainly the presence of BME. The level of significance was fixed for p<0.05.

Results

The study included 30 women. The mean age at diagnosis was 40±9.8 years old [21-59] and the mean age at inclusion was 49±11 years old [26-74]. The median number of children was 2 [0-7]. Half of the patients were multiparous. Doppler ultrasound of the SIJ was found in 59.1% of cases. Overall, 36.7% of the women fulfilled the ASAS definition of a positive MRI. BME was displayed on STIR MRI sequence in 26.5% of cases and was equally present at the right SIJ compared with the left (26.7% vs 23.3%). Gadolinium enhancement was found in 16.7% of cases and subchondral erosions were found in 36.7% of cases. There was no association between the different sacroiliac maneuvers on physical examination and the number of children: distraction test (p=0. 145), compression test (p=0.088), Gaenslen test (p=0.475), and Mennel test (p=0.088). BME was more frequent among multiparous women (33% vs 29%) without reaching a statistically significant difference (p=0.635). There was no association between the number of children and Hyper T1 (p=0.608), T1 gadolinium (p=0.55) as well as sclerosis (p=0.55). Similarly, there was no association between the presence of Doppler signal on ultrasound and multiparity (p=0.5).

Conclusion

Our study showed that MRI-SIJ findings were similar in nr-axSpA women regardless of the number of children, mainly BME. More trials are needed to evaluate the discriminatory capacity of MRI abnormalities and to palliate to the lack of specificities of the ASAS MRI criteria.

References

[1]Germann C, Kroismayr D, Brunner F, Pfirrmann CWA, Sutter R, Zubler V. Influence of pregnancy/childbirth on long-term bone marrow edema and subchondral sclerosis of sacroiliac joints. Skeletal Radiol. 2021;50(8):1617-1628.

Disclosure of Interests

None declared

POS1313 HIP INVOLVEMENT IS A MORE FREQUENT COMPLICATION IN ENTHESITIS-RELATED ARTHRITIS COMPARING TO THE ADULT SPONDYLARTHRITIS

Background

The hip disease develops in 30% to 50% of children with juvenile idiopathic arthritis (JIA) and is associated with poor outcomes and functional impairment. The coxitis in enthesitis-related arthritis (ERA or juvenile-onset spondyloarthritis) patients was frequent but weakly studied.

Objectives

To assess the occurrence of coxitis in patients with ERA and compare it to that of older patients with spondyloarthritis (SpA).

Methods

We conducted a retrospective comparative study including patients with ERA and adult spondyloarthritis patients.

The first group included patients under 16 years old fulfilling the International League of Associations for Rheumatology (ILAR). The second group of patients fulfilled the Assessment of SpondyloArthritis International Society (ASAS) 2009 criteria.

We studied the socio-demographic characteristics of both groups, the hip involvement occurrence, and the treatment modalities.

Quality of life was appraised by the Study 36-item Short-Form Health Survey (SF-36) and the Ankylosing spondylitis quality of life test (ASQOL).

Results

Forty ERA (mean age= 25,3 ± 10,15) patients and 134 SpA (mean age=37,96±11,77) patients were enrolled. Seventeen ERA patients (42,5%) had coxitis at recruitment compared to 28 SpA patients (20,9%), p=0,06. More than half of the ERA patients were positive to HLAb27, compared to the SpA group (44,7%) without reaching a significant threshold, p=0,07. The mean delay of coxitis onset in ERA patients was 4,66 ± 8,46 years, and was 5,65 ± 6,85 years in SpA patients, with no significant difference between the two groups (p=0,527). There was no difference between the two groups for the coxitis being unilateral or bilateral (p=0,272 and 0,169 respectively). Regarding the treatment approach, local therapy was proposed to 11 patients in the ERA group and 13 patients in the SpA group (p=0,07), with synoviorthesis being the most common therapy. Total hip replacement was done in 8 ERA patients (of which seven were bilateral) and in 17 SpA patients (of which ten were bilateral), without reaching the significant threshold (p=0,858). There was no significant difference between the two groups on the period when the total hip replacement was done (p=0,925). Quality of life assessed by the ASQOL and the SF-36 was comparable between the two groups (p=0,666 and 0,326; respectively).

Conclusion

Our study shows the high prevalence of hip involvement in the juvenile group of SpA. This complication occurs within the five years of disease outcomes and constitutes a turning point in their lives.

Disclosure of Interests

None declared

AB1255 ASSESSMENT OF SLEEP DISTURBANCES IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS

Background

Sleep problems are common among children with chronic illnesses such as Juvenile Idiopathic Arthritis (JIA), which is one of the most common rheumatic diseases in childhood. Sleep disturbances collectively refer to impairments in the ability to initiate or maintain sleep. They can be measured by parent or child self-report and by objective measures such as actigraphy and polysomnography.

Objectives

The aim of this study was to assess sleep disorders in children with JIA.

Methods

Parents of children suffering from JIA (according to the International League of Associations for Rheumatology (ILAR)), followed in rheumatology department were asked to complete a specific specialized scale for children (HIBOU) [1] to screen sleep disorders. This scale assesses five aspects of sleep: irregular schedule and daytime drowsiness, insomnia, moves in sleep, nose obstruction and ultra-vigilance. Parents were asked to answer 8 questions rated from 1 to 3 according to the frequency of the problem, 1: rarely, 2: 3 to 4 times a week and 3 if 5 to 7 times a week. If the sum is ≤ 9, only sleep hygiene is recommended. If the sum is between 10 and 15 the child requires regular supervision. If the sum is between 16 and 24, the child needs to be referred to a specialist. General demographic and clinical information (family history of chronic inflammatory disease, child’s current age, diagnosis and type of JIA, duration of disease progression and activity of the disease) were also collected.

Results

Twenty-four children with a mean age of 12 years [4-16] were included in the study. The gender ratio was 1. The mean duration of the disease was 4 years with extremes from three months to thirteen years. The frequency of each JIA subset was as follows: polyarticular with rheumatoid factor (n= 2), polyarticular without rheumatoid factor (n=5), psoriatic arthritis (n= 1), enthesitis-related arthritis (n=10) and oligoarthritis (n= 6). Irregular sleep schedule and daytime drowsiness were reported at least 3 times a week by 58.3% of the children. Insomnia and inability to initiate sleep were reported in 29.3% of the children at least 3 times a week. Parents reported exaggerated moves during sleep in 50% of the cases and airway obstruction or snoring in 58.3% more than 3 times a week. Difficulties to maintain a good night of sleep more than three times a week were reported in 25% of cases. To sum up, 29.2% of the children had a score above 15 and needed to be referred to a specialist and 58.3% of them need a regular supervision of their sleep and may need to be referred to a specialist. Only three children had a score under 9 and don’t have concerning sleep disorders according to this scale.

Conclusion

This study showed that sleep disorders are a common challenge in children and adolescents with JIA which could have a huge impact on their physical and psychosocial health-related quality of life. This study highlights the need for assessment of sleep disorders in JIA patients.

References

[1]Benhaberou-Brun D. HIBOU: pour évaluer les troubles du sommeil [HIBOU: evaluating sleep disorders in children]. Perspect Infirm. 2011;8(6):35-37.

Disclosure of Interests

None declared

AB0820 Remission criteria in non-radiographic axial spondyloarthritis: don’t miss subclinical inflammation

Background

With the advent of the treat-to-target strategy (T2T), clinical remission has become the main objective to achieve in patients with rheumatic diseases. Contrary to rheumatoid arthritis, the T2T strategy is less codified in axial spondyloarthritis, even more in non-radiographic SpA (nr-axSpA) [1]. More importantly, T2T based on imaging remission and guidance for tapering medication has not been extensively studied.

Objectives

The objective of this study was to investigate the prevalence of bone marrow edema in the sacroiliac joint of nr-axSpA patients in remission.

Methods

We undertook a cross-sectional study including nr-axSpA patients according to the ASAS criteria, treated with NSAIDs. Socio demographic data as well disease characteristics were recorded. Disease activity parameters were also collected including the duration of morning stiffness, the number night awakening, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). MRI-SIJ was performed for all the patients. All the images were screened for bone marrow edema with the corresponding sequence (short tau inversion). To define remission, we used in addition to BASDAI<4, more stringent criteria: BASDAI<4 and CRP<6 mg/l and ESR<20 mm/h and EGM<4 [2]. The level of significance was fixed for p<0.05.

Results

The study included 43 nr-axSpA patients. There was a female predominance with a sex ratio of 0.43. The mean age of the patients was 42±12 years [20-71] and the mean disease duration was 17±9.7 years [4-38]. The mean ESR and CRP were 2.2 mg/L [2-65] and 6.4mm/h [1-47], respectively. A higher level of acute phase reactants was found in 40.5% of cases (ESR: 35.7%, CRP: 11.9%). Forty percent of the patients had high CRP or ESR despite BASDAI<4. According to BADSAI<4, of the 15 patients in remission, BME was displayed in 43.5% of the cases. According to the used criteria, 25.6% of the patients were in remission, of which 45.4% exhibited BME in the sacroiliac joint. There was no statistically significant association between disease activity according to the used definition and the presence of BME (p=0.473). Nr-axSpa patients in remission without BME had more durable morning stiffness and articular involvement without reaching a statistically significant difference (p=0.361, p=0.08 respectively). Similarly, we did not find an association between this subgroup and sex, age, night awakenings, the presence of HLAB27 (p>0.05).

Conclusion

Our study showed that even when using stringent criteria, subclinical remission evidenced by BME was not achieved in nr-ax SpA. Nevertheless, imaging remains one important parameter to consider in therapeutic decision making. More studies are needed to identify the best criteria for an optimal remission in this population.

References

[1]Aouad K, De Craemer AS, Carron P. Can Imaging Be a Proxy for Remission in Axial Spondyloarthritis?. Rheum Dis Clin North Am. 2020;46(2):311-25.

[2]Navarro-Compán V, Plasencia-Rodríguez C, de Miguel E, et al. Anti-TNF discontinuation and tapering strategies in patients with axial spondyloarthritis: a systematic literature review. Rheumatology (Oxford). 2016;55(7):1188-94.

Disclosure of Interests

None declared

AB1262 PERFORMANCE OF JADAS-ESR AND JADAS-CRP IN THE ASSESSMENT OF DISEASE ACTIVITY IN TUNISIAN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS

Background

The Juvenile Arthritis Disease Activity Score (JADAS) is a feasible tool which consists of four items: tender (TJC) or swollen joint count (SJC), the physician and the patient’s/parent’s global assessment and the erythrocyte sedimentation rate (ESR). C-reactive protein (CRP) has also been suggested as an alternative inflammatory marker.

Objectives

To compare the performance of JADAS-ESR and JADAS-CRP in the evaluation of JIA activity.

Methods

Twenty nine patients who met the International League of Associations for Rheumatology (ILAR) criteria for JIA were enrolled in the study. Disease activity was assessed by the JADAS-ESR and JADAS-CRP scores at 54 consultations, 29 at baseline and 25 during the last follow-up consultation. Data of JIA subtypes, disease duration and treatment were retrospectively collected from medical records. All data were checked for normality by the Kolmogorov-Smirnov test. The Spearman correlation was used for data analysis and p values less than 0.05 were considered statistically significant.

Results

The mean age of our population was 13.1±4.2 years [4-21] and the sex ratio of males to females was 1.07. The mean disease duration was 4.69±3.26 years [0.3-13]. JIA subtypes were: enthesis-related arthritis (n=12), polyarthritis (n=7), oligoarthritis (n=6), undifferentiated (n=3) and psoriatic arthritis (n=1). At baseline most of our patients (51,73%) were not under treatment, 34.49% were under non-steroidal anti-inflammatory drugs (NSAIDs) and 13.8% under methotrexate (MTX). At the last follow-up consultation 41.38% of the patients were under MTX, 34.49% under NSAIDS and 10.35% under TNF inhibitor (Etanercept). At baseline JADAS-ESR1 was correlated to JADAS-CRP1 (p<0.001, r=0.808) in all AIJ subtypes. JADAS-ESR1 and JADAS-CRP1 were not correlated to ESR1 (p=0.416, p=0.661) nor to CRP1 (p=0.376, p=0.058). Both JADAS-ESR1 and JADAS-CRP1 were correlated to TJC1 (p<0.0001, r=0.643; p=0.015, r=0.502) and only JADAS-ESR1 was correlated to SJC1 (p=0.012, r=0.461). At the last follow-up consultation, correlations were observed between JADAS-ESR2 and JADAS-CRP2 (p<0.001, r=0.992) in all AIJ subtypes. JADAS-ESR2 and JADAS-CRP2 were both correlated to CRP2 (p=0.015, p=0.003) but not to SJC (p=0.175, p=.119), nor to ESR2 (p=0.535, p=0.426).

Conclusion

Our study suggests that both JADAS-ESR and JADAS-CRP correlate closely during the follow-up of JIA. JADAS-CRP could be recommended for assessing disease activity in JIA.

Disclosure of Interests

None declared

AB0768 Influence of continuous non-steroidal anti-inflammatory drugs intake on bone marrow edema in non-radiographic Spondyloarthritis

Background

The concept of non-radiographic axial spondyloarthritis (nr-axSpA) has revolutionized the classical understanding of axSpA. Indeed, it facilitated the classification of patients with axSpA who did not present substantial structural damage as it was only detectable on magnetic resonance imaging of the sacroiliac joints (MRI-SIJ) [1]. Continuous non-steroidal anti-inflammatory (NSAIDs) intake has been reported as a potential factor reducing the sensitivity of MRI-SIJ to detect bone marrow edema (BME).

Objectives

The aim of the study was to investigate the effect of continuous NSAIDs intake on BME in nr-axSpA.

Methods

We undertook a cross-sectional study including nr-SpA according to the ASAS criteria and treated with NSAIDs at baseline. Socio demographic data as well disease characteristics were recorded. Disease activity parameters were also collected including the duration of morning stiffness, night awakenings, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). MRI-SIJ was performed for all the patients. All the images were screened for bone marrow edema with the corresponding sequence (short tau inversion). Patients were grouped according to NSAIDs intake: G1: continuous versus G2 occasional. The level of significance was fixed for p<0.05.

Results

The study included 43 nr-axSpA patients. There was a female predominance with a sex ratio of 0.43. The mean age of the patients was 42±12 years [20-71] and the mean disease duration was 17±9.7 years [4-38]. The mean morning stiffness duration was 47.3±45.6 [15-240] minutes. The mean spinal VAS was 5.9±2.6 [0-10]. Nearly 41% of the patients had an active disease with a mean BASDAI of 4.7± 2.1 [0-8.6]. The prescribed NSAIDs were as follows: Diclofenac (44 %), Indomethacin (8%), Ketoprofen (18%), Meloxicam (3%), Celecoxib (3%), Piroxicam (3%) and Naproxen (21%). Nearly half of the patients were continuously taking NSAIDs (52.6%) versus occasional intake (47.4%). Four patients failed two NSAIDs and were treated with a third one. Both groups were comparable for age (p=0.193), sex (p=0.386), and disease duration (p=0.4). Similarly, there were no statistically significant differences regarding disease activity parameters between both groups: numerical rating scale of pain (p=0.713), ESR (p=0.314), CRP (p=0.644), morning stiffness (p=0.428), night awakening (p=1), as well as BASDAI (p=0.514). Regarding MRI-SIJ findings, hyper signal in STIR sequence was comparable between both groups (G1: 35% vs G2:33%, p=0.914). Moreover, the increased signal with Gadolinium injection on T1-weighted images was similar between both groups (p=0.113).

Conclusion

Our study showed that continuous NSAIDs intake was not associated with significant changes in MRI-SIJ features. This study suggests that a NSAID-free period is not necessary before assessing bone marrow edema on MRI-SIJ.

References

[1]Aouad K, De Craemer AS, Carron P. Can Imaging Be a Proxy for Remission in Axial Spondyloarthritis?. Rheum Dis Clin North Am. 2020;46(2):311-25.

Disclosure of Interests

None declared

AB0870 ASSESSMENT OF FRACTURE RISK IN PATIENTS WITH NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS

Background

Spondyloarthritis (SpA) is a chronic inflammatory disease that predominantly affects the sacroiliac joints and the spine. Patients with SpA have an increased risk of osteoporosis and fracture resulting from a combination of inflammation and immobility. The non-radiographic form for SpA (nr-axSpA) has the same predictors factors of bone fragility however the real fracture risk is unknown in this phenotype.

Objectives

This study aims to investigate BMD and the Fracture Risk Assessment Tool (FRAX) in patients with nr-axSpA.

Methods

We conducted a retrospective study including 40 patients with nr-axSpA, according to the ASAS criteria. For the enrolled patient, we collected the clinical and biological data. We calculated the disease activity using the Bath Ankylosing Spondylitis disease activity (BASDAI) and the Ankylosing Spondylitis Disease Activity Score (ASDAS). Functional impairment was assessed by the Ankylosing Spondylitis Functional Index (BASFI). We measured the bone mineral density using the dual-energy X-ray absorptiometry (DXA) in the anteroposterior lumbar, lateral spine, and hip neck. The ten-year probability of major osteoporotic fracture was calculated using the Tunisian version of Fracture Risk Assessment Tool (FRAX).

Results

Twenty-seven women (67.5%) and thirteen men (32.5%) were enrolled. The mean age was 41.5 years (±11.2), and the mean disease duration was 3,1 years (±2.7). The mean BASDAI and ASDAS CRP was 4.7 ± 2.2 and 3.27 ± 1.29, respectively. The mean BASFI was 3.6 ± 2.5. According to World Health Organization (WHO) criteria, 45% of patients displayed osteopenia and 30% osteoporosis. The mean major osteoporotic fracture (MOF) score was 0,09 ± 0,25 [0-1,3]. The MOF was significantly associated with BMD (p=0.000). The variables associated with MOF were a high physician’s global assessment score, a high BASFI, and female gender, but without significant relation. However, no correlation was found between the MOF and the disease duration, the presence of peripheral arthritis or enthesitis, and the ASDAS.

Conclusion

In nr-axSpA, patients with low BMD had a higher calculated 10-year fracture risk. FRAX score is related to functional impairment and gender. Disease activity does not affect the probability of fracture.

Disclosure of Interests

None declared

AB1111 NO INCREASED RISK OF ADVERSE EVENTS OF THE WHO-VALIDATED COVID-19 VACCINES IN PATIENTS WITH RHEUMATIC DISEASES TREATED WITH BIOLOGICS

Background

The COVID-19 pandemic is a major concern for the management of patients with rheumatic diseases (RD). Indeed, an increasing risk of coronavirus infection has been demonstrated in these patients, explained on the one hand by the chronic inflammation and on the other hand by the immuno-modulating treatments used [1]. In this context, vaccination represent an efficient mean to prevent infections and should be included in the management of these patients.

Objectives

The objective of our study was to determine the peculiarity of vaccination against SARS-COV2 in patients with RD treated with biologic therapies.

Methods

We conducted a cross-sectional study during August 2021, including patients with RD: rheumatoid arthritis (RA) and spondyloarthritis (SpA). Sociodemographic data as well as disease characteristics were recorded. Patients were asked to answer a self-questionnaire about SARS-COV2 vaccination: modalities, time between doses, type of vaccine, adverse events, and time to biologic injection. We compared these results between the two groups: group 1 patients on biologics and patients on conventional disease-modifying antirheumatic drugs (DMARDs). A significance level was set for p<0.05.

Results

The study included 102 patients with RD: RA (65.3%) and SpA (34.7%). The mean age was 52.4 ± 13 years [19-77]. There was a female predominance (71 women and 31 men) with a gender ratio of 0.4. The mean duration of disease progression was 7.8 ± 5 years [1-35]. Fifteen percent of patients were on corticosteroids with a mean dose of 6.7 mg [2-20] of prednisone equivalent. A CsDMARD was prescribed alone in 36.3% of cases and combined with a biologic in 18% of cases. SARS-COV2 infection was found in 27.3% of cases, of which 19% had a severe form. Sixty percent of patients received the SARS-COV2 vaccine, and 25% of them received only the first dose. The mean time between the two injections was 27 ± 7.6 days [23-67 days]. The most common type of vaccine was Pfizer (54.4%), Moderna (5.5%), followed by AstraZeneca (20%), Sinovac (16.4%), Johnson (1.8%) and Sputnik (1.8%). Three patients deferred their biotherapy injection by one week. Only one patient discontinued methotrexate therapy for one month. Sixteen patients reported adverse events such as injection site pain (62.5%), disease flare (12.5%) and fatigue and fever (25%). Patients receiving biologics were not at greater risk of SARS-COV2 infection (p=0.076) or hospitalization (p=0.131) compared to patients receiving conventional therapy. Similarly, patients on conventional therapy did not report more adverse events (p=0.678). The vaccination rate was significantly higher in patients on biologics compared to patients on CsDMARD: 72% versus 43%, p=0.004.

Conclusion

Our work demonstrated that patients treated with biologics adhered to vaccination and did not have more SARS-COV2 infections or adverse events compared to patients on conventional treatment.

References

[1]Akiyama S, Hamdeh S, Micic D, Sakuraba A. Prevalence and clinical outcomes of COVID-19 in patients with autoimmune diseases: a systematic review and meta-analysis. Ann Rheum Dis. 2020;80:384-391.

Disclosure of Interests

None declared

AB1259 THE NEUTROPHIL-TO-LYMPHOCYTE AND THE PLATELET-TO-LYMPHOCYTE RATIOS AS INFLAMMATORY MARKERS IN JUVENILE IDIOPATHIC ARTHRITIS

Background

The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) have recently emerged as potential indicators of systemic inflammation in chronic rheumatic diseases such as polymyalgia rheumatica, rheumatoid arthritis, and spondyloarthritis.

Objectives

To investigate the value of NLR and PLR as inflammatory markers in juvenile idiopathic arthritis (JIA) and to explore possible associations with disease activity parameters.

Methods

We enrolled 29 patients with JIA according to International League of Associations for Rheumatology (ILAR) criteria. Tender joint count (TJC), swollen joint count (SJC) and laboratory tests were retrospectively collected from medical records. Disease activity was also assessed by the Juvenile Arthritis Disease Activity Score (JADAS). All data were checked for normality by the Kolmogorov-Smirnov test. The Spearman correlation was used for data analysis and p values less than 0.05 were considered statistically significant.

Results

A total of 54 consultations (29 at baseline and 25 at the last follow-up consultations) of 29 patients were included in our study. The mean age was 13.1±4.2 years [4-21] and the sex ratio of males to females was 1.07. JIA subtypes were: enthesis-related arthritis (n=12), polyarthritis (n=7), oligoarthritis (n=6), undifferentiated (n=3) and psoriatic arthritis (n=1). At baseline 51,73% of the patients were not under treatment, 34.49% were under non-steroidal anti-inflammatory drugs (NSAIDs) and 13.8% under methotrexate (MTX). At the last follow-up consultation 41.38% of the patients were under MTX, 34.49% under NSAIDS and 10.35% under Etanercept. At baseline, NLR1 was positively correlated with TJC1 (p=0.022, r=0.424) and SJC1 (p=0.014, r=0.453) but not with C-reactive protein CRP1 (p=0.512) neither erythrocyte sedimentation rate ESR1 (0.096) nor disease activity scores JADAS-CRP1 (p=0.063) and JADAS-ESR1 (p=0.091). PLR1 was positively correlated with SJC1 (p=0.004, r=0.521) and both disease activity scores JADAS-CRP1 (p=0.026, r=0.462) and JADAS-ESR1 (p=0.052, r=0.364). At the follow-up consultations only PLR2 was positively correlated to CRP2 (p=0.045, r=0.404). No correlation was noted between NLR2 and PLR2 and JADAS-CRP2 (p=0.281, p=0.063) and JADAS-ESR2 (p=0.324, p=0.082).

Conclusion

Our study suggests that NLR and PLR may be used as assessment tools of disease activity in patients with JIA. Further studies with larger sample sizes are needed to confirm these results and to explore the value of these ratios in the follow-up and the prognosis of JIA.

Disclosure of Interests

None declared

AB0285 MTX REDUCED THE CARDIOVASCULAR RISK IN RHEUMATIC DISEASES

Background

The relationship between cardiovascular risk (CVR) and inflammatory rheumatic diseases (IRD) remains certain [1].

The aggressive suppression of systemic inflammation by the CsDMARDs or biologics may lower this risk.

Objectives

The purpose of this study was to assess the protective role of the different treatments in rheumatoid arthritis (RA) and spondyloarthritis (SpA).

Methods

We carried out 107 patients followed up for IRD between March and December 2020. We collected the socio-demographic data of patients, the clinical and biological characteristics of the disease. Prescribed treatments were specified.

CVR was assessed by measuring, in centimeters, the Intima-media Thickness (IMT) at the level of the left (LCC) and right (RCC) common carotid arteries and by calculating the Framingham risk score (FRS) for each patient. Individuals with IMT≥0.9 mm or an FRS≥20% were considered as those with high CVR (HCVR).

Results

Of the 107 surveyed patients, 56% had RA (n=47) and 44% had SpA (n=60). Among them, 55% were male. The mean age was 43.9±14.2 years. The mean disease duration was 117.3±89 months. The mean BASDAI was 4.98 ±2.7. The mean DAS28 was 4.13±1.5. Seventy percent of patients had active disease. Conventional DMARDs were prescribed in 54.7% of cases: Methotrexate (95% in RA versus 5% in SpA) and Sulfasalazine (13% in RA versus 30% in SpA), NSAIDs in 57.3% of patients (4.5% in RA versus 96.6% in SpA), corticosteroids (CT) in 25% (47.5% in RA versus 8.5% in SpA), and biotherapy in 9% of cases (12.8% in RA versus 6.7% in SpA).

The mean FRS was 5.98 ± 6.6. The mean IMT was 0.58±0.15. About 60% of patients were considered with HCVR.

NSAIDs were associated with an increase in IMT in the LCC (p<0.001) and in the RCC (p<0.001). MTX had a significant protective effect on IMT in LCC (p=0.001).

However, there was no association between CT use and IMT. Regarding FCS, no significant association was found based on MTX (p=0.09), NSAIDs (p=0.11), CT (p=0.45) nor biologic use (p= 0.74).

Conclusion

In our study, patients taking MTX had a lower IMT than those not taking this molecule. NSAIDs were associated with an increase in IMT. However, we didn’t observe any effect of CT and biologic treatment on CVR in our population.

References

[1]Cho SK, Kim D, Won S, Lee J, Park B, Jang EJ, Bae SC, Sung YK. Impact of anti-rheumatic treatment on cardiovascular risk in Asian patients with rheumatoid arthritis. Semin Arthritis Rheum. 2018;47(4):501-506.

Disclosure of Interests

None declared

AB1254 CHALLENGES FACED BY FAMILIES OF CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS

Background

Juvenile idiopathic arthritis (JIA) is the most common inflammatory rheumatism of childhood. Diagnostic and therapeutic approaches are difficult for families to sustain with significant psychological and social effect.

Objectives

The aim of this study is to understand the different challenges faced by families with children suffering from JIA.

Methods

Parents of children with JIA (according to the International League of Associations for Rheumatology (ILAR)) followed in rheumatology department were asked to complete a survey in order to screen the impact of their children’s disease on their family life. Open-ended questions and directed questions were included. General demographic and clinical information (family history of chronic inflammatory disease, child’s current age, diagnosis and type of JIA and, duration of disease progression) were also collected.

Results

The study included 24 children with a gender-ratio of 1. The mean age was 12.4 years old [4-16]. The mean duration disease was 4 years with extremes varying from 3 months to 13 years. The frequency of each JIA subset was at follows: polyarticular with rheumatoid factor (n= 2), polyarticular without rheumatoid factor (n=5), psoriatic arthritis (n= 1), enthesitis-related arthritis (n=10) and oligoarthritis (n= 6). Twenty-four parents completed the survey. The mother was the one who answered the questions in 83% of the cases. Other family members with a chronic rheumatic disease were reported in 40% of the families.

Parents noted negative impact on their work in 50% of cases (40% missing time from work, 10% changing work schedule) and, significant parental stress, anxiety, and fatigue in 75% of the cases. In 33% of the cases, parents had difficulty getting the required medical care and attention for their child’s illness because of financial issues and 37.5% of them were feeling anxiety regarding diagnosis uncertainty. Parents reported worry about their child’s daily functioning and future in 75% of the cases. They noted psychological impact on the child itself in 58% of the cases and child missing school in 41% of the cases. The most common resources parents used for information were health care professionals in 54.2 % of the cases and 45.8% of them got additional information from online research.

Conclusion

Parents of children with JIA share common challenges due to their child’s illness including a substantial impact on their work and personal wellness in addition to the psychosocial impact of the disease on the child. Support groups or educational sessions may be needed to provide guidance for these families to cope with disease.

Disclosure of Interests

None declared

AB1248 CONTRIBUTION OF IMAGING IN THE DIAGNOSIS OF ATRAUMATIC HIP

Background

Joint pain of the hip in children and adolescents is one of the most frequent symptoms seen by pediatricians, orthopedists, and pediatric rheumatologists, with an annual incidence of 148.1/100 000 [1]. The identification of an etiology for atraumatic hip pain is challenging. Even though imaging findings are often various and nonspecific, they are necessary for an accurate diagnosis.

Objectives

The main goal of this study is to investigate the contribution of the different imaging techniques in the diagnosis of the hip main in children.

Methods

We conducted a retrospective study including children and adolescents with atraumatic hip pain recruited from the Kassab institute of orthopedics. Transcribed data included age, sex, and the etiology of the hip disease. We also recorded different imaging techniques performed for the diagnosis: plain radiography, ultrasound (US), Computed tomography (CT) as well as magnetic resonance imaging (MRI).

Results

The study included 81 patients. There was a male predominance (59.3% boys versus 40.7% girls) with a sex ratio of 1.45. The mean age at diagnosis was 9.9 years [1-16]. The mean disease duration was eight months [0.1-156]. Hip disorders were distributed as follows: Legg-Calvé-Perthes disease (n=3), epiphysiolysis of the femoral head (n=30), transient synovitis of the hip (n=7), septic hip (n=10), tumor (n=4), hip dislocation (n=8), hip dysplasia (n=4), juvenile idiopathic arthritis with coxitis (n=15). The hip X-ray was abnormal in 75.6% of cases. The hip US was performed in 34.2% of the patients and showed abnormalities in most of the cases (88.5%). US findings were as follows: joint effusion (n=26), synovial thickening (n=18), synovitis (n=12), and a positive power Doppler signal (n=7). Seven patients underwent pelvic CT scans. The main findings were joint effusion (n=2), synovial thickening (n=1), and hip dysplasia (n=4). MRI of the hip was carried out in 23 children and was contributive in 91.3% of the cases. The main findings were as follows: joint effusion (n=12), synovitis (n=10), bone marrow edema (n=8), synovial thickening (n=7), nidus (n=3) and tumoral process (n=1).

Conclusion

Our study showed that hip X-ray and US are the first-line imaging modalities in an atraumatic hip diagnosis. However, in other cases, further investigations may be needed to make an early diagnosis and avoid adverse sequelae.

References

[1]Yagdiran A, Zarghooni K, Semler JO, Eysel P. Hip Pain in Children. Dtsch Arztebl Int. 2020;117(5):72-82.

Disclosure of Interests

None declared

AB1405 THE USEFULNESS OF TELEMEDICINE IN RHEUMATOLOGY: POINTS OF VIEW OF PRACTITIONERS AND PATIENTS

Background

The advent of COVID-19 has allowed a rapid expansion of telemedicine (TM) and its implementation in various specialties. Despite this extensive use of TM, its role in rheumatology is conflicting and much remains unknown about TM’s acceptability and efficiency in rheumatology [1].

Objectives

Our study aimed to evaluate rheumatologists’ and patients’ willingness for TM and factors helping to adopt this alternative.

Methods

We conducted a cross-sectional study including patients attending our rheumatology department as well as rheumatologists. Patients were contacted by phone and rheumatologists were invited to answer a questionnaire via Google Form. We evaluated their points of view and suitability for TM by inquiring about their experience with tele-rheumatology, information technology supports, personal barriers to telemedicine, and reasons for adopting this alternative. Moreover, additional questions probed the clinician’s perception of the appropriate clinical context for TM application as well as the corresponding legislation.

Results

Overall, 135 responses were collected including 60 rheumatologists and 75 patients. The distribution of diagnosis was as follows: rheumatoid arthritis (RA) (n=15), spondyloarthritis (SpA) (n=20), juvenile idiopathic arthritis (n=23), and osteoarthritis (n=17). Of the rheumatologists, 76.2 % were aged between 30 and 50 years old, 79.3% reported working at an academic center, and the majority were physician-level practitioners (71.2%), working for more than 5 years (61%). Afforded electronic devices were as follows: laptop (87.9%), smartphone (70.7%), afforded headset microphone (24.1%), camera (29.3%) for doctors. Forty-six percent of the rheumatologists estimate that they have a good internet connexion, 62.7% had an appropriate place for teleconsultation. Nearly, 40.7% of the rheumatologists were familiar with the concept of TM but only 39% reported experience with TM. Willingness to accept this model of care for rheumatologists and patients was found in 78% and 37.3% respectively. According to the doctors, the benefits of TM encompassed tele-training (61.7%), remote medical monitoring (61.7%) especially during the COVID-19 (70.2%), benefits for patients (74.5%), reduced inequalities in access to healthcare (46.8%), and improved quality of care (29.8%). The main barriers to TM were the lack of clear legislation (47.8%) and financial compensation (17.4%). Clinicians and patients identified common barriers to effective tele-rheumatology as the inability to perform a physical exam (91.3% vs 33.3%), the fear of trivializing the disease (34.8% vs 36%), and the lack of resources and infrastructures (43.5% vs 29.3%). The majority of the doctors (86.2%) expressed their willingness to attend training workshops. Reported areas to apply TM according to the doctors were mainly osteoarthritis (76.3%) and rheumatic diseases (64.4%), but also pediatric rheumatology (28.8%) and undiagnosed new patients (3.4%). Regarding legislation, most of practitioners estimated that it should be selective with specific authorizations (42.4%) or relaxed with the possibility of derogation (32.2%). Twenty-two percent of them reported that legislation should be strict with the possibility of sanctions, whereas a minority (3.4%) opted for a free practice without regulation at all. Factors associated with adherence to TM were age<40 years (p=0.036) for doctors and familiarity with the concept (p=0.006) and electronic devices afforded (p=0.000) for the patients.

Conclusion

Findings from this study showed the reluctance of the patients to adhere to TM compared to doctors. Concerns and risks may lessen for both sides, once remote consultations are applied. Nevertheless, patient education is required for the success of TM application.

References

[1]Sloan M, Lever E, Harwood R, et al. Telemedicine in rheumatology: A mixed methods study exploring acceptability, preferences and experiences among patients and clinicians [published online ahead of print, 2021 Oct 26]. Rheumatology (Oxford). 2021;keab796.

Disclosure of Interests

None declared

AB1249 IMPACT OF OVERWEIGHT AND OBESITY ON HIP INVOLVEMENT IN JUVENILE IDIOPATHIC ARTHRITIS

Background

The prevalence of obesity among children is on the rise, becoming a worldwide epidemic. The overweight is also associated with mechanical stress in the weight-bearing joint especially in the hip joint. Previous studies showed that increased Body mass index was a predicting factor of a poor outcomes [1].

Objectives

In this regard, we proposed to evaluate the effect of obesity on hip involvement in JIA patients.

Methods

We conducted a cross-sectional study including children with JIA according to the International League of Associations for Rheumatology (ILAR)). Transcribed data included age, sex and the characteristics of the disease (subtype of JIA, disease duration). Data on hip involvement was also collected. Weight and height of each patient was recorded. The body mass index (BMI) was calculated (Kg/m2). We compared these parameters between two groups: G1: presence of coxitis and G2: absence of coxitis.

Results

The study included 62 patients with a male perdominance: sex ratio was 2.3. The mean age of onset of the disease was 11.4 years [3-16].The frequency of each JIA subset was at follows: polyarticular with rheumatoid factor (n=2), polyarticular without rheumatoid factor (n=4), systemic (n= 1), enthesitis-related arthritis (n=44), oligoarthritis (n=8), psoriatic arthritis (n=3). Hip involvement was reported in 71 % of cases and was bilateral in 81% of patients. The mean weight (Kg) and height (meter) was similar between the two groups (57.4 in G1 vs 53.6 in G2, p=0.486) and (1.61 in G1 vs 1.58 in G2, p=0.483) respectively. The prevalence of overweight patients was higher in G1 than G2 without reaching a statistically significant correlation (23% vs 12.5%, p=0.518). Similarly, there was no statistically significant correlation between the body mass index (Kg/m2) and coxitis (22.2 vs 21, p=0.45). Moreover, a higher BMI was not associated with a limited range of motion as well as hip replacement (p=0.7, p=0.1 respectively).

Conclusion

Our study showed that BMI did not impact hip involvement in juvenile idiopathic arthritis patients. As obesity confers an additional health risk, addressing this co-morbidity should be a health priority in these patients.

References

[1]Makay B, Gücenmez ÖA, Ünsal E. Inactive Disease in Enthesitis-related Arthritis: Association of Increased Body Mass Index. J Rheumatol. 2016;43(5):937-43.

Disclosure of Interests

None declared

AB1128 MAINTENANCE THERAPY FOR PATIENTS WITH RHEUMATIC DISEASES DURING THE COVID-19

Background

The Covid-19 pandemic has been raging for more than a year in a pandemic mode. Since then, many questions have been raised regarding the management of patients with rheumatic diseases (RD). In this context, the maintenance therapy of conventional, biologic and targeted synthetic disease-modifying antirheumatic drugs (Cs DMARDs, bDMARDs and tsDMARDs respectively) during the Covid-19 infection remains a subject of debate given their immunosuppressive effects as well as their potential generation of lung fibrosis. While the EULAR 2020 guidelines emphasize that discontinuation or maintenance should be discussed on a case-by-case basis, the ACR guidelines advocate discontinuation of all therapies except for the anti-interleukin-6 [1,2].

Objectives

The objective of our work was to report our real-life experience of therapeutic maintenance during the covid-19 pandemic.

Methods

We conducted a cross-sectional study of patients with RD: rheumatoid arthritis (RA) and spondyloarthritis (SpA) recruited from the rheumatology department of the Kassab Institute of Orthopedics. All the patients were asked to complete a questionnaire about their disease management in the era of the Covid-19. The questionnaire included sociodemographic data, treatment modalities, as well as data related to the infection with the Covid-19 (severe forms defined by the need for oxygen therapy or hospitalization), and changes in treatment during the infection.

Results

The study included 102 patients with RA (65.3%) and SpA (34.7%). The mean age was 52.4 ± 13 [19-77] years. There was a female predominance with a sex ratio of 0.4. The mean duration of the disease was 7.8 ± 5 years [1-35]. Fifteen percent of patients were on corticosteroids with a mean dose of 6.7±4.5 mg/L [2-20] of prednisone equivalent. A CsDMARD was prescribed alone in 36.3% of cases and combined with a biologic in 18% of cases. A Covid-19 infection was occurred at least once in 25.5% of cases, of which 19.2% had a severe form (hospitalization (15.4%), oxygen therapy (19.2%)). No deaths were observed. The treatments received during the covid-19 infection were: corticosteroids (n=5), heparin therapy (n=6) and antibiotic therapy (n=10). No patient tapered treatment dosage of DMARDs but discontinuation was reported by 4 patients with a mean time between discontinuation and resumption of 2.1 ± 2 months [0.5-5 months]. The cessation of the treatment was dictated by the treating physician in 2 cases and involved csDMARD in 3 cases (Methotrexate (n=2), Leflunomide (n=1)) and biologics in only one patient. There were no cases of clinical pulmonary worsening upon resumption of the treatments. We found no statistically significant association between severe forms of the infection and the type of RD (p=0.925), as well as the presence of comorbidities (p=0.825). Similarly, the presence of severe forms was not associated with the use of long-term NSAIDs (p=0.29), corticosteroids (p=0.85), or biological treatment (p=0.7). However, maintenance therapy was significantly associated with a lower risk of severe forms (p=0.013).

Conclusion

Our work showed that the maintenance of conventional treatment during Covid-19 infection was associated with a lower risk of severe forms. Our results, along with those of other studies in the literature, support the maintenance of antirheumatic treatments.

References

[1]Landewé RB, Machado PM, Kroon F, et al. EULAR provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of SARS-CoV-2. Ann Rheum Dis. 2020;79(7):851-8.

[2]Roongta R, Ghosh A. Managing rheumatoid arthritis during COVID-19. Clin Rheumatol. 2020 Nov;39(11):3237-44.

Disclosure of Interests

None declared

Management of chronic recurrent multifocal osteomyelitis: review and update on the treatment protocol

INTRODUCTION

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder primarily affecting children. It is characterized by a peripheral involvement of the metaphysis of long bones rather than axial involvement. Due to the scarcity of the disease, there are no guidelines regarding its management.

AREAS COVERED

This review aims to provide an overview of the different therapeutic alternatives and recent protocols. For this reason, first-line and second-line treatment, as well as the impact of new therapies, are discussed in depth. We conducted a search through PubMed on the different aspects of CRMO. Outcomes were categorized as first and second-line treatments.

EXPERT OPINION

Non-steroidal anti-inflammatory drugs remain the keystone of CRMO management and are proposed as the first-line treatment. In the case of vertebral involvement, bisphosphonate should be considered, even as a first-line treatment. Several case series and retrospective studies highlight the efficacy of anti-TNF agents. Their use could be an optimal treatment choice for CRMO with comorbid immune-mediated diseases. The potentially favorable effect of interleukin-1 antagonists remains to be determined.

Enthesitis-related arthritis: monitoring and specific tools

OBJECTIVES

In this article, the authors aimed to review the different tools used in the monitoring of enthesitis-related arthritis.

SOURCES

The authors performed a literature review on PubMed, Google Scholar, and Scopus databases. The dataset included the original research and the reviews including patients with enthesitis-related arthritis or juvenile spondylarthritis up to October 2020.

SUMMARY OF FINDING

Enthesitis-related arthritis is a category of juvenile idiopathic arthritis. It is characterized by the presence of enthesitis, peripheral arthritis, as well as axial involvement. The only validated tool for disease activity measurement in juvenile idiopathic arthritis is the Disease Activity Score: It has proven its reliability and sensitivity. Nevertheless, due to an absence of validated evaluation tools, the extent of functional impairment, as well as the children and parents' perception of the disease, could not be objectively perceived. Despite the great progress in the field of imaging modalities, the role they play in the evaluation of disease activity is still controversial. This is partially due to the lack of validated scoring systems.

CONCLUSIONS

Further work is still required to standardize the monitoring strategy and validate the outcome measures in enthesitis-related arthritis.

Impact of lean and fat mass on disease activity and function in spondyloarthritis

BACKGROUND AND AIMS

Changes in body mass composition such as reduced lean and fat mass can occur in a patient with rheumatic diseases. However, data about body composition in spondyloarthritis (SpA) showed conflicting results. The aim of the present study was to assess by DXA the distribution of lean and fat mass in SpA patients compared to healthy controls and to investigate the association between body mass composition and disease characteristics.

METHODS

We conducted a cross-sectional case-control study including 50 SpA patients and 50 controls. Sociodemographic data as well as disease characteristics were assessed. Body composition measurements, biochemical and inflammatory serum markers were evaluated. Radiographic data (Bath Ankylosing Radiologic Index and the modified Stroke Ankylosing Spondylitis Spine Score was also recorded.

RESULTS

No statistically significant correlation was found between the two groups regarding bone mineral density, body mass distribution. However, a lower weight was observed in the study group compared to the control group (p=0.043). Male gender and younger age were associated with a higher lean mass (p=0.05). C-reactive protein (CRP) level was positively correlated with lean mass (r=0.38, p=0.023). Similarly, BASFI was higher in patients with lower fat mass (r=-0.42, p=0.024). A longer duration of NSAIDs intake was associated with a lower lean mass and a higher fat mass. However, no correlations were found between body mass composition and BASRI mSASSS scores as well as bone mineral density and calcium intake.

CONCLUSION

Our findings suggest that younger age, male gender, and axial phenotype were associated with higher lean mass.