Tele-rheumatology for overcoming socioeconomic barriers to healthcare in resource constrained settings: lessons from COVID-19 pandemic

OBJECTIVES

To assess acceptability of teleconsultation among the socioeconomically marginalized sections of patients with rheumatic and musculoskeletal diseases (RMDs), to identify the socioeconomic barriers in continuing rheumatology care during the COVID-19 crisis and to identify patients who could benefit by shifting to tele-rheumatology consultations.

METHODS

This was a cross sectional analytical study done at a tertiary care teaching hospital in India including patients with RMDs who were not on biological diseases modifying agents. Assessment of disease status, socioeconomic status and economic impact of COVID-19 was done via tele-consultation.

RESULTS

Out of the 680 patients satisfying inclusion criteria, 373 completed the study. The format was found easy by 334 (89.6%) of them and 284 (76.1%) considered tele-rheumatology better than in-person consultation. During the pre-COVID months, the median monthly per capita income of the families of our patients and cost of illness was Indian rupees (INR) 2000 (US$ 26) and INR 1685 (US$ 21.91), respectively. Families whose financial needs were met (OR = 0.38, 95% CI: 0.239, 0.598) or those with schooling upto at least secondary school (OR = 0.442, 95% CI: 0.260, 0.752) (P =0.002) were less likely to stop prescription drugs. In a hypothetical model, 289 (77.4%) could be successfully switched to tele-rheumatology follow-up.

CONCLUSION

The acceptability of tele-rheumatology among socioeconomically marginalized patients with RMDs is good. During times of crisis, patients from poorer strata of society and lower educational background are likely to abruptly stop medications. Switching to a telemedicine-based hybrid model is likely to improve drug adherence with substantial savings on loss of pay and out of pocket expenditure.

Cultural adaptation, translation and validation of Cochin Hand Function Scale and evaluation of hand dysfunction in systemic sclerosis

OBJECTIVES

Hand dysfunction causes significant reduction in quality of life in systemic sclerosis. We assessed the validity and reliability of the culturally adapted Indian version of Cochin Hand Function Scale (I-CHFS). We determined the factors contributing to hand dysfunction and its burden on quality of life.

METHOD

I-CHFS was formulated by replacing five questions (questions 7, 9, 10, 14 and 15) in CHFS which were determined as unsuitable in an Indian setting. The instrument was assessed for acceptability, reliability, reproducibility and validity measures. A total of 87 patients were assessed for various demographic and disease parameters, hand disability and quality of life.

RESULTS

The median I-CHFS score was 22(5-54) and 04 (0.5-17.5) among diffuse (dcSSc) and limited cutaneous systemic sclerosis (lcSSc). I-CHFS showed good reproducibility (interclass correlation coefficient = 0.92) and a strong correlation with I-HAQ (r_s = 0.832), usual activities EQ-5D-5L (r_s = 0.744), self-care EQ-5D-5L (r_s = 0.734) and anxiety/depression EQ-5D-5L (r_s = 0.729). It had moderate correlation with pain/discomfort EQ-5D-5L (r_s = 0.661) and hand HAQ (r_s = 0.576) and poor correlation with HAQ-DI (r_s = 0.396) and modified Rodnan skin score (r_s = 0.390). Finger to table distance, finger to palm distance in extension and limited hand modified Rodnan skin score were significantly associated with higher values of I-CHFS.

CONCLUSIONS

Hand dysfunction in systemic sclerosis is substantial and contributes significantly to poor quality of life. The culturally adapted I-CHFS is a valid and reliable tool to assess it and correlated well with the overall disease burden. Key Points • Hand dysfunction is common among systemic sclerosis patients. • Hand dysfunction contributes to the poor quality of life and more disease burden. • Culturally adapted Cochin Hand function Scale helps assess hand dysfunction among Indian scleroderma patients.

Performance of timed function tests as outcome measures in idiopathic inflammatory myopathy-results from a single-centre cohort

OBJECTIVE

To evaluate performance of timed function tests (TFTs) in assessing muscle strength and endurance as determined by Manual Muscle Testing 8 (MMT-8) and Functional Index 2 (FI-2), respectively, in idiopathic inflammatory myopathies (IIM).

METHODS

This cohort study included 42 IIM patients satisfying 2017 EULAR/ACR criteria. Patients were classified as active (n = 18) or inactive disease (n = 24) based on clinical status at baseline. MMT-8, FI-2, 30 s rise from chair test, 30 s 1 kg arm rise test and 2-min walking distance (2MWD) were administered at baseline, 3 months and 6 months. Pearson rank correlation analysis and receiver operating curves were performed to assess the performance of timed function tests.

RESULTS

All patients were followed up at 3 months and 39 completed 6 months' follow-up. All the three TFTs had excellent convergent (r > 0.7, P < 0.05) and divergent validity (P < 0.05). Only 2MWD had moderate to strong correlation with ΔMMT-8 at 3 and 6 months among those with active disease (P = 0.001). All the TFTs correlated with ΔFI-2 in active disease but only Δ2MWD correlated with ΔFI-2 in inactive disease at 6 months (r = 0.506, P = 0.036). At a cut-off of 5% improvement in MMT-8, 2MWD had an area under the curve (AUC) of 0.868 with 95% sensitivity with 2% improvement at 3 months. To detect a 10% ΔMMT-8, Δ2MWD at a cut of 8% and 7% had an AUC of 0.909 and 0.893 with a sensitivity of 92% at 3 and 6 months, respectively (P < 0.05).

CONCLUSION

2MWD is a reliable indicator of muscle strength, endurance and treatment response. The 2MWD can be self-administered by patients, making it a potential patient-reported outcome measure.

Clinical and psychosocioeconomic impact of COVID-19 pandemic on patients of the Indian Progressive Systemic Sclerosis Registry (IPSSR)

OBJECTIVES

The aim was to determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on access to health care among patients with scleroderma and to analyse the economic and psychosocial impacts and the infection prevention measures taken by them during the pandemic.

METHODS

A 25-item questionnaire designed to assess the components of the objectives was tele-administered between October 2020 and January 2021 to the patients enrolled in the Indian Progressive Systemic Sclerosis Registry.

RESULTS

Of the 428 patients in the registry, 336 took part in the study. A scheduled outpatient visit was missed by 310 (92.3%) patients, and 75 (22.3%) skipped prescription drugs. During the pandemic, 75 (22.3%) had a family member lose a job. Financial difficulties were reported by 155 (46.1%), with 116 (34.5%) patients having to spend an additional INR 4000 (2000-10 000) [USD 54.9 (27.0-137.4)] to continue treatment. Although 35 patients (10.4%) had at least one symptom suggestive of COVID-19, infection was confirmed in only 4. None of them needed hospitalization or had adverse outcomes. Worsening of scleroderma was seen in 133 (39.6%) individuals, with 15 (4.5%) requiring hospitalization. Most (96%) of the patients were aware of infection prevention measures, and 91 (27.1%) had taken unproven prophylactic medications.

CONCLUSION

Individuals with scleroderma in India have been affected during the pandemic owing to closure of hospital services, lack of transport, loss of jobs and the additional financial burden. Health-care providers should continue to educate patients to stay on their medications and encourage them to be vaccinated for COVID-19.

Kidney histopathology in predicting flares following drug withdrawal in proliferative lupus nephritis in clinical remission

Residual renal histopathological activity at clinical remission in Proliferative Lupus Nephritis (PLN) can predict renal flare upon immunosuppression withdrawal. Data on the role of histological renal remission in predicting extra-renal flares is lacking. We assessed renal histopathology prior to drug withdrawal and the occurrence of renal and extra-renal flares over 52 weeks after drug withdrawal in PLN patients in long-term clinical remission. This is a subgroup analysis of a non-inferiority, open-label randomized (1:1) controlled trial. Patients with biopsy-proven Class III/IV LN in the past (biopsy 1), on immunosuppressants (IS) ≥ 3 years, in clinical remission for ≥ 1 year, on stable prednisolone dose (≤ 7.5 mg/day) plus a maintenance IS and hydroxychloroquine (HCQ) were subjected to a repeat renal biopsy (biopsy 2). Individuals with biopsy 2 having activity index (AI) < 4/24 were randomised to either prednisolone or IS withdrawal. Primary end-point was the proportion experiencing a flare [SELENA-SLEDAI flare index (SFI)] at week 52. Twenty-eight eligible patients underwent biopsy 2 and randomized to prednisolone (n = 15) and IS (n = 13) withdrawal. At biopsy 1, 12 (43%) had class III, 15 (53.5%) had class IV, and 1 (3.5%) had class III + V. At biopsy 2, PLN persisted in 4 (14.2%) while 18 (64.2%) were in histological remission (AI = 0) with 6 (21.4%) in class II. Following drug withdrawal, 9/28 (32%) had flares especially musculoskeletal (55.5%), mucocutaneous (44.4%), and renal (33.3%). Among the four persistent PLN patients, one of the two (50%) with AI = 1 had extra-renal flare while both the two with AI = 2 (100%) had renal and extra-renal flares. In those with histological remission (biopsy 2), 6/18 (66.6%) experienced extra-renal flare of whom one also had renal flare. Upon drug withdrawal, renal histopathology findings with any activity index can predict renal flare while histological remission is not enough to predict extra-renal flare, thus making it an unsuitable marker for deep SLE remission.

AB0558 PREVALENCE OF LATENT TUBERCULOSIS INFECTION AND ITS ASSOCIATIONS WITH CLINICAL AND SEROLOGICAL PARAMETERS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Systemic Lupus Erythematosus (SLE) and Tuberculosis are complicatedly related and studies have shown increased risk of TB in SLE. Studies of Latent TB and SLE are inadequate. This study intended to assess the prevalence of latent TB and its association with disease parameters in SLE.

Objectives

To assess the prevalence of latent TB in patients with SLE. To investigate the demographics and clinical characteristics in patients with SLE and concomitant latent TB compared to those without.

Methods

This is a single center cross sectional study. 124 adult patients with SLE without past h/o TB were recruited. SLE demography, disease activity indices, autoantibody profile and steroid use were noted. Presence of Latent TB infection was assessed in all patients based on the IFN-g release assay (TB-IGRA). Based on the results of IGRA, SLE cases were divided into 2 groups-IGRA positive and IGRA negative. The collected parameters were compared between the 2 groups.

Results

Among 124 patients, 19 had latent TB resulting in a point prevalence of 15.4 %. The average disease duration was 4.3 years in IGRA positive and 4.6 in IGRA negative group(p>0.05). Among antibody profile, though no statistical significance among the groups, proportion of antibodies like anti Ku, Ro 60, Ro 52 and La were numerically higher in the IGRA positive group (21.1%, 42.1%, 42.1% and 21.1% respectively) when compared to the IGRA negative group (11.5%, 28.8%, 28.1% and 7.7% respectively). Likewise, anti nucleosome, histone, U1RNP, PCNA, aCLA IgG and IgM, beta 2 GPI IgG and LAC were numerically higher in IGRA negative group (42.3%, 40.4%, 43.3%, 8.7%, 23%, 18.3%, 28.8%, 14.4%) when compared to IGRA positive group (31.6%, 21.1%, 31.6%, 0, 15.8%, 5.3%, 15.8%, 5.3%). Mean clinical SLEDAI was 2.37 ±5.1 in IGRA positive and 3.5 ±5.77 in IGRA negative group. Among clinical features, 1 person in IGRA positive and none in the IGRA negative group had current gastrointestinal involvement. Comparison of other organ manifestations yielded no statistically significant difference in the 2 groups at this point. Serology revealed greater proportion of C4 in IGRA negative as compared to the positive group(p<0.042).

Conclusion

Prevalence of latent TB in SLE cases was 15.4%. Although comparison of demographic, clinical and autoantibody profile did not yield any statistically significant differences, the early turnover from this pilot study mandates further evaluation with larger sample size.

Table 1.

Comparison of clinical and laboratory parameters between IGRA positive and IGRA negative SLE cases

IGRA POSITIVE(n=19)IGRA NEGATIVE(n=105)p VALUEAge(Mean± SD)31.79±9.729.26 ±10.80.199Female Sex n(%)19(100)101(97.1)0.312Anti P0 antibody n(%)3(15.8)14(13.5)0.827Anti Ribo P antibody n(%)2(10.5)13(12.5)0.761Age of disease onset(Mean± SD)25.58± 10.624.62± 10.570.285Disease duration(Mean± SD)4.33 ±4.024.6± 3.530.438Treatment duration(Mean± SD)3.84± 4.124.03± 3.420.439Clinical SLEDAI(Mean± SD)2.37 ±5.13.5 ±5.770.306SLICC ACR DI(Mean± SD)0.105±0.320.231± 0.660.666Current CNS involvement1(5.3)4(3.8)0.781Current renal involvement3(15.8)26(25)0.367Current hematological involvement1(5.3)14(13.5)0.272Current GI involvement1(5.3)00.052Current steroid dose(Mean± SD)11.32± 11.6513.03 ± 11.60.400Serum C3(Mean± SD)0.79 ±0.320.89± 0.470.477Serum C4(Mean± SD)0.19± 0.0720.1635± 0.130.413Anti dsDNA (Mean± SD)458± 400.8379.5± 400.50.454Low C3 n(%)9(52.9)37(38.9)0.108Low C4 n(%)2(11.8)35(36.8)0.042Elevated Antidsdna n(%)6(35.3)37(38.9)3.343

Disclosure of Interests

None declared

POS0775 COMBINED MODEL OF RENAL HISTOPATHOLOGY AND CLINICAL PARAMETERS BETTER PREDICT ONE YEAR RENAL OUTCOMES IN LUPUS NEPHRITIS: ANALYSIS OF 334 KIDNEY BIOPSIES

Background

Diagnosis of Lupus Nephritis (LN) is currently based on laboratory tests and renal histopathology. Role of histopathological features in determining long term outcomes is unclear.

Objectives

1. To assess if clinical and biochemical parameters at baseline can identify renal histopathological class.

2. To assess the clinico-histopathological predictors of renal response.

Methods

This is a single centre retrospective study comprising 334 LN renal biopsies. Clinical and biochemical parameters at the time of biopsy were noted and their association with histopathological class, activity and chronicity scores (AS/CS) (ISN/RPS classification) were evaluated. Complete, partial or no response (CR, PR, NR) for renal outcome (EULAR/EDTA) at 1 year were assessed for 293 patients. Binary logistic regression was done to look for the predictors of NR.

Results

Class III/IV LN was seen in 240(71.8%). Hypertension was seen in (52.1%) of class III/IV and <25% each with class II, V and combined class(p<0.001). Class III/IV had lower eGFR [87.6(62.75-118.8)] (p<0.001) than the other classes. Nephrotic range proteinuria was seen in 32% of class V and 21% in class III/IV (p=0.004). Among class-III/IV, AS had weak correlation with baseline UPCR (r=0.31) and eGFR (r=-0.172) (p<0.01). CS had weak negative correlation with eGFR (r=-0.212, p<0.01). NR at 1 year was higher in males (OR-4.6,95%CI-1.9-10.8, p<0.001), those with abnormal serum creatinine (OR-3.3,95%:CI1.6-7.02, p-0.001), higher renal SLEDAI (p<0.05), higher AS, CS (p<0.001), interstitial inflammation and tubular atrophy(p<0.005) (Table 1). On binary logistic regression a combined clinico-histopathological model comprising of serum creatinine, UPCR, male sex and CS performed best in predicting NR (Figure 1).

Table 1.

Comparison of baseline characteristics among those who attained any response (CR/PR) versus others at 1 year

ParameterAny response Complete Response CR/PR (n=233)Others (No response/rescue) (n=60)OR (95% CI)P valueFemale/male, n (%)221(94.8)/12(5.2)48(80)/12(20)4.6(1.9-10.8)0.001Median age at nephritis onset28(11-65)25(13-67)0.079Median SLE duration12(0-232)18(0-144)0.770Hypertension, n (%)100(42.9)34(56.7)0.061Creatinine>1.3mg/dL (median, IQR)21(9.0)15(25)3.3(1.6-7.02)0.001eGFR categories, n (%)137(58.8)27(45)1.7(0.96-3.03)0.003>9057(24.5)15(25)61-9034(14.6)9(15)30-604(1.7)8(13.3)<30Active urinary sediments, n (%)132(56.7)44(73.3)0.019uPCR g/day (median with IQR)1.38(0.8-2.67)1.95(1.18-4.19)0.098Class III/IV, n (%)167(71.7)49(81.7)0.117Class V, n (%)17(7.3)5(8.3)0.788Combined class, n (%)7(3.0)3(5.0)0.469Activity score, median with IQR3(1-6)6(3-9)0.001Chronicity score, median with IQR0(0-1)1(0-2)5.06(1.49-17.21)0.001Presence of Crescents, no (%)43(18.5)17(28.3)0.104Fibrinoid necrosis, n (%)28(12.0)7(11.7)0.791Interstitial inflammation, n (%)86(36.9)33(55)2.08(1.17-3.70)0.003Interstitial fibrosis, n (%)23(10.7)9(15)0.273Tubular atrophy, n (%)64(27.5)27(45)0.003Blood vessel changes, n (%)2(0.9)1(1.7)0.606Fibrinoid necrosis206(88.4)50(83.3)0.339Other changes*Figure 1.

ROC curve and AUC for the three different models

Model 1: Baseline serum creatinine, urine PCR, male sex; AUC – 0.694(0.609-0.779), p <0.001

Model 2: Baseline serum creatinine, urine PCR, male sex, chronicity score; AUC – 0.740(0.660-0.820), p<0.001

Model 3: Baseline serum creatinine, urine PCR, male sex, chronicity score, crescents, interstitial inflammation; AUC – 0.744(0.664-0.824), p<0.001

Conclusion

Clinical and biochemical parameters can predict the renal histological class to a fair extent but has limited value in predicting the activity and chronicity parameters. Since a combination of clinical and histopathology parameters are better in predicting renal outcomes, performing renal biopsies should be encouraged in LN.

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

POS0392 ROLE OF SEMIQUANTITATIVE THIGH MAGNETIC RESONANCE IMAGING (tMRI) IN DETERMINING SKELETAL MUSCLE OUTCOMES AT BASELINE AND ON FOLLOW UP IN IDIOPATHIC INFLAMMATORY MYOPATHIES (IIMs)

Background

Idiopathic Inflammatory Myopathies (IIMs) are characterized by muscle inflammation and associated muscle weakness. Semiquantitative scoring of thigh Magnetic Resonance Imaging (tMRI) has shown contradictory results in associating muscle inflammation, damage, and clinically assessed muscle weakness. Moreover, there are no studies assessing the role of tMRI detected muscle damage in determining long-term recovery of muscle strength and endurance.

Objectives

To correlate tMRI scores for muscle edema, fascial edema, muscle atrophy, and fatty infiltration with consecutively collected manual muscle testing 8 (MMT-8) scores and muscle enzymes. To determine the role of baseline tMRI changes in achieving maximum muscle power during follow-up.

Methods

This is a retrospective analysis of a single-center myositis cohort. IIM patients (n=55) who underwent baseline tMRI (STIR and T1 sequences) at the time of diagnosis were included. Baseline demographic, clinical, and serological parameters were noted. MRI T1 weighted sequence and STIR sequence axial and coronal images were assessed for intramuscular and fascial edema, atrophy and fatty replacement using a semiquantitative score and the percentage of muscle involvement for each parameter was calculated. MMT-8 values and muscle enzyme levels which remained unchanged at least for 6 months during follow-up were noted for 42 patients. MMT-8 ≥74 was taken as near normal muscle power based on the fact that 75% of IIM patients in remission for a long duration achieved MMT-8 of≥74 in our cohort. Spearman correlation was done between clinical parameters, muscle enzymes, and tMRI scores. Baseline parameters of patients who achieved and did not achieve MMT8≥74 were compared. Multiple linear regression was performed to assess the tMRI variables predicting a higher MMT-8 during follow-up

Results

The median age was 36 (27.25-44.75) years, median duration of disease at presentation was 4 months (2-10), median duration of follow up was 24 months (6.75-38.25). Dermatomyositis, Polymyositis and Antisynthetase syndrome comprised of 58.2%, 7.3% and 30.9% cases respectively. Baseline muscle enzymes CPK(r=0.531), AST(r=0.535) and ALT(r=0.442) showed significant positive correlation(p<0.01) with muscle edema. Baseline MMT-8 showed significant negative correlation with muscle edema(r=-0.657) and fascial edema(r=-0.522) (p<0.01). Follow up MMT-8 showed significant negative correlation with muscle edema(r=-0.359), muscle atrophy (r=-0.319) and fatty infiltration(r=-0.308) (p<0.05) (Figure 1). Baseline MMT-8 and MRI fatty infiltration were significantly different between patients who achieved and did not achieve MMT-8 of ≥74 on follow-up (Table 1). Multiple regression analysis revealed adjusted R2 value of 0.386. Baseline MMT-8(β=0.372) and muscle atrophy(β=-0.459) significantly predicted MMT-8 on follow-up

Table 1.

Comparison between those who achieved near-normal muscle power versus others

Follow up MMT-8<74 (n=8)Follow up MMT-8 ≥74 (n=34)P-valueAge (years) (median, IQR)36.5(27-47.5)36(28.75-44.25)1.000Duration of disease (months) (median, IQR)6(4-10.5)3.5(2.75-9.75)0.459Baseline muscle enzymes and MMT-8 (median, IQR)CPK (IU/L)1758(116-6160)680(57.5-3595)0.410LDH (IU/L)496(240-823)616.50(289.25-753)0.672AST (IU/L)112(76-201.5)69.5(40.5-226.25)0.352ALT (IU/L)74.50(65.5-139.75)69(36-142.25)0.560MMT-8 baseline (0-80)49.5(47.25-56)63(53.75-73.25)0.007MRI thigh scores (median, IQR)Muscle edema%22.41(5.65-63.33)10.37(0.00-28.70)0.070Fascial edema %43.33(18.61-78.06)33.89(11.49-50.56)0.478Muscle atrophy %2.22(0.28-20.83)0.00(0.00-2.50)0.081Fatty infiltration %6.67(2.78-18.61)0.56(0.00-3.61)0.010Figure 1.

Correlation between baseline and Follow up MMT-8 with tMRI scores.

Conclusion

Low baseline MMT-8 and presence of muscle atrophy at baseline are predictors of poor outcome. Hence performing a baseline MRI will help in the prognosis.

Disclosure of Interests

None declared

Effect of skin phototype on quantitative nailfold capillaroscopy

Objectives

To determine the impact of Fitzpatrick scale-based skin phototype on visualization of capillary density using nailfold capillaroscopy in healthy Indian adults.

Methods

In this cross-sectional study, healthy adults were examined for nailfold capillaroscopy findings utilizing a portable capillary microscope at 800× magnification. Photographs of two contiguous areas measuring 1 mm2 each of the distal row of capillaries were captured. Images were captured from the central area of all fingers except thumb in both hands. Capillary density and morphology of nailfold capillaroscopies were assessed by two blinded assessors. The nailfold capillaroscopy parameters were compared between the Standard Fitzpatrick scale-based skin phototypes.

Results

A total of 118 healthy adults were enrolled in the study. Type III, IV, V, and VI skin phototypes were seen in 27 (22.90%), 32 (27.19%), 29 (24.58%), and 30 (25.42%) participants, respectively. All participants (100%) had normal nailfold capillaroscopy morphology and architecture. Zero capillaries were visible in 11 fingers among 5 patients (4.24%) and all of them had Type VI phototype. The median capillary density per mm was 5.19 (interquartile range = 4.37-6.75) with 90 (76.27%) participants having less than seven capillaries. The median average capillary density was significantly different (p-value < 0.0001) across Type III (8.13, interquartile range = 6.44-8.88), Type IV (5.67, interquartile range = 4.41-6.98), Type V (4.94, interquartile range = 4.19-5.38), and Type VI (4.53, interquartile range = 3.72-4.91) phototypes (p < 0.05).

Conclusion

The number of capillaries visualized during nailfold capillaroscopy decreases as the skin pigmentation increases. There is a need to redefine the nailfold capillaroscopy density and avascularity by taking skin phototype as one of the determinants before labeling a nailfold capillaroscopy finding with less visualized capillaries as abnormal.

Performance of Clinical and Biochemical Parameters in Identifying Renal Histopathology and Predictors of One-Year Renal Outcome in Lupus Nephritis-A Single Centre Study from India

Objectives: To assess the performance of clinical and biochemical parameters in identifying renal histopathology. To assess the performance of a combination of demographic, clinical, serological and histopathological parameters in determining renal response at one year. Methods: Data of biopsy-proven (ISN/RPS—2003 criteria) Lupus Nephritis (LN) were extracted from the institute database. Demographic, clinical and biochemical parameters at the time of biopsy were noted, and their associations with histopathological class, activity and chronicity scores were evaluated. Follow-up data at one year were collected. Complete, partial or no response (CR, PR, NR) for renal outcomes at one year and the predictors of NR were assessed. Results: Out of the 333 renal biopsies, 240 (71.8%) were Class III/IV. More patients with Class III/IV LN had hypertension (52.1%) and low eGFR (p < 0.001). Among Class III/IV, AS correlated weakly with UPCR (r = 0.31, p < 0.01), eGFR (r = −0.172; p < 0.01) and CS with eGFR (r = −0.212; p < 0.01). The presence of either hypertension, UPCR > 0.5 g/day, active urinary sediments or serum creatinine >1.3 g/dL had a sensitivity of >96% and specificity of <9% in detecting proliferative LN, crescents, interstitial inflammation and chronicity. NR was higher in males (aOR:3.9, 95% CI:1.4−11.0, p < 0.001), those with abnormal baseline creatinine (aOR: 1.9, 95% CI: 1.1−3.2, p < 0.001), higher renal SLEDAI (p < 0.05), higher AS, CS (p < 0.001) and interstitial inflammation (p < 0.005). In the binary logistic regression, the combination of male sex, baseline creatinine, UPCR and CS performed best in predicting NR (AUC: 0.762; 95% CI: 0.684−0.840, p < 0.001). Conclusions: Clinical and biochemical parameters alone have a poor specificity in identifying renal histopathology. A combination of demographic, clinical and histopathology parameters can better predict renal outcomes at one year.

POS0890 MACROVASCULAR DYSFUNCTION AND ITS CLINICAL IMPLICATION IN SYSTEMIC SCLEROSIS

Background:

Even though microvascular dysfunction has been implicated in pathogenesis of scleroderma (SSc), there is minimal evidence to suggest presence of macrovascular dysfunction. The clinical implication of macrovascular dysfunction in SSc is unknown. Moreover, data on the correlation between dysfunction in small and large blood vessel is inconclusive. [1-2]

Objectives:

To study the correlation between macrovascular dysfunction as assessed by percent change in flow mediated vasodilation (FMD) of brachial artery and microvascular dysfunction as assessed by nail fold capillaroscopy (NFC) findings in SSc. To assess the clinical impact of macrovascular dysfunction.

Methods:

This cross-sectional comparative study enrolled patients with SSc and age and gender matched healthy controls. FMD change was calculated using standard USG probe of 5 to 6 MHz in right brachial diameter from the average of 3 consecutive end diastolic frames. NFC was performed using portable nail fold capillary microscope at 800X magnification. Clinical features of SSc were compared between SSc patients with and without macrovascular dysfunction.

Results:

This study enrolled 59 SSc patients including 29 (49.2%) diffuse, 20 (20.4%) limited, 08 (10.2%) sine SSc and 2 patients (3.4%) with myositis overlap. SSc patients had significantly (p-<0.0001) lower % FMD change compared to healthy controls. NFC showed significantly higher architecture distortion (p-<0.0001), loss of capillaries (p-<0.0001) and abnormal capillaries (p-<0.0001). There was no correlation between FMD change and capillary density (p-0.381), avascular area (p-0.266) and abnormal capillaries (p-0.899). None of the clinical features like pulmonary hypertension, digital ulcer burden, acro-osteolysis and auto amputation were different between SSc with and without macrovascular dysfunction.

Conclusion:

Macrovascular dysfunction in SSc is substantial and it seems to be independent of the microvascular dysfunction. The clinical implications of macrovascular dysfunction are yet to be identified.

References:

[1]Schioppo T, Orenti A, Boracchi P, De Lucia O, Murgo A, Ingegnoli F. Evidence of macro- and micro-angiopathy in scleroderma: An integrated approach combining 22-MHz power Doppler ultrasonography and video-capillaroscopy. Microvasc Res. 2019 Mar;122:125–30.

[2]Rollando D, Bezante GP, Sulli A, Balbi M, Panico N, Pizzorni C, et al. Brachial Artery Endothelial-dependent Flow-mediated Dilation Identifies Early-stage Endothelial Dysfunction in Systemic Sclerosis and Correlates with Nailfold Microvascular Impairment. J Rheumatol. 2010 Jun 1;37(6):1168–73.

Table 1.

Comparison of various parameters between the SSc patients with healthy controls.

ParameterFrequency (percentage)/median (interquartile range)SSc patients (n=59)Healthy controls (n=64)Demographic detailsAge in years38 (27-46)36.5 (28.25-42)Gender Male03 (5.1%)03 (4.7%) Female56 (95.1%)61 (95.3%)FMD findings FMD % change*4.54 (3.13-8.82)10.30 (8.33-13.16)NFC findings Number of capillaries*51 (38-63)121 (113-128) Average capillary density*3.19 (2.38-3.94)7.56 (7.06-8) Disorganized architecture (%)*37.5 (12.5-37.5)0 U shape (%)*50 (36.59-68.09)85.51 (82.97 – 88.53) Abnormal (%)*36.11 (14.03-55.26)0 Enlarged (%)*10.63 (2.94-23.68)0 Giant (%)*21.05 (0-45.45)0 Microhemorrhages (%)*6.25 (0-12.5)0 Neoangiogenesis (%)*3.85 (0-20)0 Avascular area (%)*50 (31.25- 75)0

*parameters with statistically significant (p value< 0.0001) difference among two groups. SSc; Systemic Sclerosis, FMD; flow mediated vasodilatation, NFC; nail fold capillaroscopy

Figure 1.

Scatter plot showing correlation between FMD percentage change and average capillary density. (r= 0.116) (P-value - 0.381)

Disclosure of Interests:

None declared

Semi-quantitative thigh magnetic resonance imaging scores in assessing disease activity and determining long-term clinical outcome in idiopathic inflammatory myopathies: a causal mediation analysis

OBJECTIVES

To evaluate the relationship of thigh MRI (t-MRI) with manual muscle testing-8 (MMT-8), muscle enzymes and autoantibodies. To determine the causal and mediating factors resulting in poor recovery of MMT-8 in inflammatory myositis (IIM).

METHODS

This was a single-centre retrospective study in IIM patients. t-MRI was semi-quantitatively scored for muscle oedema, fascial oedema, muscle atrophy and fatty infiltration. Spearman correlation of t-MRI scores was done with muscle enzymes at baseline, and MMT-8 at baseline and on follow-up. Causal mediation analysis was performed with age, sex, symptom duration, autoantibodies, diabetes and BMI as independent variables, follow-up MMT-8 as dependent and t-MRI scores as mediating variables.

RESULTS

Baseline evaluation was done on 59 and follow-up on 38 patients. Median follow-up of the cohort was 31 (10-57) months. Baseline MMT-8 negatively correlated with muscle oedema (r = -0755), fascial oedema (r = -0.443) and muscle atrophy (r = -0.343). Creatinine kinase (r = 0.422) and aspartate transaminase (r = 0.480) positively correlated with muscle oedema. Follow-up MMT-8 correlated negatively with baseline atrophy (r = -0.497) and fatty infiltration (r = -0.531). On follow-up, MMT-8 males had positive total effect (estimate (95%CI)) via atrophy [2.93 (0.44, 4.89)] and fatty infiltration [2.08 (0.54, 3.71)]. Antisynthetase antibody had a positive total effect via fatty infiltration [4.50 (0.37, 7.59)]. Age had a negative total effect via atrophy [-0.09 (0.19, -0.01)] and fatty infiltration [-0.07 (-0.15, -0.01)]. Disease duration had a negative total effect via fatty infiltration [-0.18 (-0.27, -0.02)].

CONCLUSION

Baseline fatty infiltration and muscle atrophy resulting from older age, female sex, longer disease duration and absent anti-synthetase antibodies, partly mediate muscle recovery in IIM.

Exploratory clinical subgroup clustering in systemic sclerosis: Results from the Indian Progressive Systemic Sclerosis Registry

Objective

To conduct an exploratory cluster analysis of systemic sclerosis patients from the baseline data of the Indian systemic sclerosis registry.

Methods

Patients satisfying American College of Rheumatology-European League Against Rheumatism classification criteria for systemic sclerosis were included. The clusters formed using clinical and immunological parameters were compared.

Results

Of the 564 systemic sclerosis registry participants, 404 patients were included. We derived four clusters of which three were anti-topoisomerase I predominant and one was anti-centromere antibody 2 dominant. Cluster 1 (n-82 (20.3%)) had diffuse cutaneous systemic sclerosis patients with the most severe skin disease, anti-topoisomerase I positivity, males, younger age of onset and high prevalence of musculoskeletal, vasculopathic and gastrointestinal features. Cluster 2 (n-141 (34.9%)) was also diffuse cutaneous systemic sclerosis and anti-topoisomerase I predominant but with less severe skin phenotype than cluster 1 and a lesser prevalence of musculoskeletal, vasculopathic and gastrointestinal features. Cluster 3 (n-119 (29.5%)) had limited cutaneous systemic sclerosis patients with anti-topoisomerase I positivity along with other antibodies. The proximal muscle weakness was higher and digital pitting scars were lower, while other organ involvement was similar between clusters 2 and 3. Cluster 4 (n-62 (15.30%)) was the least severe group with limited cutaneous systemic sclerosis and anti-centromere antibody predominance. Age of onset was higher with low musculoskeletal disease and a higher presence of upper gastrointestinal features. The prevalence of interstitial lung disease was similar in the three anti-topoisomerase I predominant clusters.

Conclusion

With exploratory cluster analysis, we confirmed the possibility of subclassification of systemic sclerosis along a spectrum based on clinical and immunological characteristics. We also corroborated the presence of anti-topoisomerase I in limited cutaneous systemic sclerosis and the association of interstitial lung disease with anti-topoisomerase I.