Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis

OBJECTIVE

To assess the intra and interobserver reproducibility of musculoskeletal ultrasonography (US) among rheumatologists in detecting destructive and inflammatory shoulder abnormalities in patients with rheumatoid arthritis (RA) and to determine the overall agreement between US and MRI.

METHODS

A total of 14 observers examined 5 patients in 2 rounds independently and blindly of each other. US results were compared with MRI. Overall agreement of all findings, of positive findings on MRI, as well as intra and interobserver reliabilities, were calculated.

RESULTS

Overall agreement between US and MRI was seen in 79% with regard to humeral head erosions (HHE), in 64% with regard to posterior recess synovitis (PRS), in 31% with regard to axillary recess synovitis (ARS), in 64% with regard to bursitis, in 50% with regard to biceps tenosynovitis (BT), and in 84% for complete cuff tear (CCT). Intraobserver and interobserver kappa was 0.69 and 0.43 for HHE, 0.29 and 0.49 for PRS, 0.57 and 1.00 for ARS, -0.17 and 0.51 for bursitis, 0.17 and 0.46 for BT and 0.52 and 0.6 for CCT, respectively. The intraobserver and interobserver kappa for power Doppler (PD) was 0.90 and 0.70 for glenohumeral signals and 0.60 and 0.51 for bursal signals, respectively.

CONCLUSIONS

US is a reliable imaging technique for most shoulder pathology in RA especially with regard to PD. Standardisation of scanning technique and definitions of particular lesions may further enhance the reliability of US investigation of the shoulder.

Centrally coinjected galanin and a 5-HT1A agonist act synergistically to produce vasodepressor responses in the rat

The present study was undertaken to evaluate the possible functional implications of the previously demonstrated in vitro interactions between galanin and 5-HT1A receptors. To this end we analysed the interactions between galanin and the 5-HT1A receptor agonist 8-OH-2-(di-n-propylamino)-tetralin (8-OH-DPAT) in central cardiovascular regulation. 8-OH-DPAT given intracisternally (i.c.) produced a dose-dependent reduction of blood pressure, the peak action being 32% at 10 nmol of 8-OH-DPAT. Heart rate and respiration rate were not affected. The vasodepressor action of 8-OH-DPAT was counteracted by the 5-HT1A receptor antagonist 1-(2-methoxyphenyl)-4-[4-(2-phthalimido)butyl]piperazine (NAN-190). A threshold dose (1 nmol) of galanin given i.c. was shown to enhance the vasodepressor effect of both an ED50 dose and a threshold dose of 8-OH-DPAT. Quantitative receptor autoradiography showed that the IC50 values for [125I]galanin binding sites were reduced in the presence of 8-OH-DPAT (10 nM) by approximately 40% in the dorsal region of the nucleus of the solitary tract, the area postrema, and the raphe pallidus and obscurus nuclei. Galanin (10 nM) also significantly increased the IC50 value for [3H]8-OH-DPAT binding sites within the nucleus of the solitary tract. The results provide evidence for a synergistic interaction between 8-OH-DPAT and galanin in cardiovascular regulation after their central administration, an interaction possibly related to the ability of 8-OH-DPAT to enhance the affinity of the galanin receptor within regions of the medulla oblongata involved in cardiovascular control.

Giant cavernous hemangioma of the liver: atypical CT and MR findings

The CT and MR appearance of giant cavernous hemangiomas can be confusing, and some atypical radiographic findings have been described. We report the CT and MR features of a giant cavernous hemangioma of the liver with atypical presentation. CT showed a large hypodense geographical lesion involving the majority of the liver and multiple scattered peripheral lesions. The T2-weighted MR images revealed a huge hyperintense lesion with multiple satellite nodules.

Adrenalectomy increases the number of substance P and somatostatin immunoreactive nerve cells in the rat lumbar dorsal root ganglia

Using an immunocytochemical technique we have analyzed changes in substance P, somatostatin, calcitonin gene-related peptide, and galanin immunoreactivity pattern in the rat dorsal root ganglia. After 7 days of adrenalectomy, sham operated rats were compared with adrenalectomized animals either receiving a daily intraperitoneal injection of 10 mg/kg b.wt. corticosterone or vehicle. Three lumbar ganglia from each animal were blocked, serially cut, and immunostained for each neuropeptide by means of the biotin-avidin-peroxidase technique. A systematic sampling of immunoreactive ganglion cells was performed and the sample number of immunoreactive ganglion cells was calculated. After adrenalectomy, the number of substance P and somatostatin immunoreactive ganglion cells markedly increased ((means +/- S.E.M.): 245 +/- 68 versus 123 +/- 12 for sham operated animals, P < 0.01 (substance P) and 42 +/- 8 as compared to 22 +/- 9 for sham operated animals, P < 0.01 (somatostatin)). No significant changes were found in the number of calcitonin gene-related peptide and galanin immunoreactive cells after adrenalectomy. These results suggest that adrenal steroid hormones may reduce the synthesis of both substance P and somatostatin in the dorsal root ganglion cells. Daily treatment with a high dose of corticosterone, mimicking its serum levels after stress, failed to prevent the increase of peptide contents after adrenalectomy. These observations also indicate that a tonic action of corticosterone on mineralocorticoid receptors may be crucial for peptide regulation in the spinal ganglia. These results may be of relevance to adrenalectomy induced changes in sensory mechanisms, neurogenic inflammation and pain transmission and to a role of substance P and somatostatin in these processes.

Neuropeptides in the cat amygdala

The distribution of seven neuropeptides was studied in the cat amygdala using an indirect immunoperoxidase technique. No labeling was found for luteinizing hormone-releasing hormone or beta-endorphin (1-27). Sparse alpha-melanocyte-stimulating hormone-immunoreactive fibers were found in the basomedial nucleus of the amygdala, whereas a low density of fibers containing alpha-neo-endorphin was observed in the anterior amygdaloid area. Neurotensin was observed in fibers of the anterior amygdaloid area (low density) and both the lateral (low density) and the medial part (moderate density) of the central nucleus. A low density of fibers containing neurokinin A was found in the anterior amygdaloid area, the basolateral nucleus, and the medial part of the central nucleus. A moderate density was observed in the basomedial nucleus and in the medial and cortical nuclei. Fibers containing somatostatin-28 (fragment 1-12) were observed in all the amygdaloid nuclei, whereas immunoreactive cell bodies were found in all the nuclei except in the medial part of the central nucleus and the medial nucleus. Perikarya containing neurokinin A were observed in the latter nucleus. The results point to a discrete distribution of peptidergic fibers in the cat amygdala, as well as the occurrence of neurons containing neurokinin A and somatostatin-28 (fragment 1-12). The distribution of the peptides studied in the cat is compared with the location of the same peptides in the amygdala of other species. The possible diencephalic origin of the peptidergic fibers is also discussed.

Malignant fibrous histiocytoma of the mandible

We report a case of MFH of the mandible in a 16-year-old girl. The mandible is a rare location of MFH of bone, with only 21 cases described in the literature. Clinical, pathologic, and radiologic features are discussed, with special emphasis on the unusual pathologic and radiographic features.

SAT0133 PILOT CLINICAL STUDY OF A NON-INVASIVE AURICULAR VAGUS NERVE STIMULATION DEVICE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Despite the clinical benefit of current pharmacological treatments for rheumatoid arthritis (RA), there remains an unmet need for alternative treatment approaches. Vagus nerve stimulation (VNS) via an implanted device has been shown to attenuate RA disease severity in patients resistant to therapy,1as evidenced by a reduction in the DAS28-CRP score following a month of daily stimulation.

Objectives:

This pilot study investigated the safety and efficacy of a wearable (non-invasive) device that attaches to the outer ear to treat RA via electrical stimulation of the auricular branch of the vagus nerve.

Methods:

Patients with active RA (≥4 tender/swollen joints based on a 28-joint count, Disease Activity Score-28 with C-reactive protein (DAS28-CRP) >3.8, active synovitis detected on ultrasound and MRI) and inadequate response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), or csDMARD and biologic DMARDs (bDMARDs), were enrolled in this open-label study. Patients used the device for up to 30 minutes daily over the course of the 12-week study. The primary endpoint was the change in DAS28-CRP score at Week 12. Secondary endpoints included a safety analysis, proportion of patients achieving ACR20/50/70, the mean change in HAQ-DI and the proportion of patients achieving a HAQ-DI MCID of at least 0.22 over 12 weeks. Additionally, sleep scores were assessed using a visual analogue scale (0-100) at baseline and 12 weeks.

Results:

Thirty patients with active RA were enrolled, of which 27 patients completed the 12-week protocol. Three patients dropped out of the study: two patients decided to seek other treatment and one patient moved out of the country. Data for three additional patients was not included in this dataset as it was still being collected. Of the 24 patients with complete 12-week datasets, 88% were female, the average age was 54.9 years, mean disease duration was 7.3 years, and four patients had an inadequate response to one or two bDMARDs.

The mean change in DAS28-CRP from baseline to Week 12 was -1.43 (p<0.05; Figure 1) and ACR20/50/70 response rates were 58.3%, 37.5%, and 16.7%, respectively (Figure 2). HAQ-DI change from baseline was -0.50 (p<0.05) at 12 weeks, and 15 out of 24 patients achieved an overall HAQ-DI reduction of 0.22 (62.5%). VAS sleep scores were significantly improved over the 12-week study. Scores for trouble falling asleep, awakened by pain at night, and awakened by pain in morning decreased by 64%, 70%, and 60%, respectively (p<0.05, n = 23). Three study adverse events (AEs) were reported: two device related AEs due skin irritation at the earpiece insertion site and one AE due to mucous accumulation in the throat.

Figure 1Figure 2

Average DAS28-CRP is shown for each study visit. Error bars indicate standard error of mean. Percentage of subjects meeting ACR20/50/70 at 12 weeks.

Conclusion:

In this pilot study, auricular stimulation was well tolerated and daily use over 12 weeks attenuated RA disease severity. Further evaluation in larger controlled studies are needed to confirm whether a non-invasive wearable device might offer an alternative approach for the treatment of RA.

References:

[1]Koopman FA, et al. (2016) Vagus nerve stimulation inhibits cytokine production and attenuates disease severity in rheumatoid arthritis. Proc Nat Acad Sci 2016; 113: 8284–9.

Disclosure of Interests:

Sara Marsal: None declared, Héctor Corominas Speakers bureau: Abbvie, Lilly, Pfizer, Roche, Maria Lopez Lasanta: None declared, D Reina-Sanz: None declared, Carolina Perez-Garcia: None declared, Helena Borrell Paños Speakers bureau: Lilly, Novartis, MSD and Janssen, Raimón Sanmartí Speakers bureau: Abbvie, Eli Lilly, BMS, Roche and Pfizer, J. Narváez: None declared, Clara Franco-Jarava: None declared, Jose Antonio Narvaez: None declared, Juan Jose de Agustin: None declared, Vivek Sharma Shareholder of: Vorso Corp., Konstantinos Alataris Shareholder of: Vorso Corp., Mark C. Genovese Grant/research support from: Abbvie, Eli Lilly and Company, EMD Merck Serono, Galapagos, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, Pfizer Inc., RPharm, Sanofi Genzyme, Consultant of: Abbvie, Eli Lilly and Company, EMD Merck Serono, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, RPharm, Sanofi Genzyme, Matthew Baker Consultant of: Gilead, Vorso, Paid instructor for: Gilead

AB0264 1-YEAR RESULTS OF A NON-INVASIVE AURICULAR VAGUS NERVE STIMULATION DEVICE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Despite the clinical benefits of current pharmacological treatments for rheumatoid arthritis (RA), there remains an unmet need for alternative treatment approaches. Initial results of a 12-week proof-of-concept study of non-invasive, vagus nerve stimulation (VNS) of the auricular branch of the vagus nerve from a wearable device to treat RA showed the device to be well-tolerated with significant reductions in the DAS28-CRP and RA disease severity1.

Objectives:

This analysis presents data from the 9-month extension of the original proof-of-concept study.

Methods:

Following the completion of the 12-week proof-of-concept study, responding patients (defined as achieving a reduction in DAS28-CRP of ≥1.2 from baseline and/or achievement of ACR20) were given the option to enroll in a 9-month extension study. Use of the wearable device continued daily for up to 30 minutes as in the first 12 weeks of the study. Alteration of baseline medication and addition of conventional synthetic disease-modifying antirheumatic drugs (DMARDs) and biologic DMARDs were allowed during the extension phase.

Results:

20/27 patients who completed the initial 12-week study met the enrollment criteria for the extension phase; 19 of those patients consented to participate. 4/19 patients (21%) discontinued the extension study due to lack of efficacy (1 patient after 1 month, 2 patients after 3 months, and 1 patient after 6 months in the extension); 15 patients completed the extension phase. 2/15 patients (13%) added biologic therapy to their treatment regimen. Mean DAS28-CRP reduction from baseline to the end of the extension (12 months total) in all patients completing the extension was 2.23 (95% CI: -1.60, -2.86). For patients who did and did not add biologic therapy, mean DAS28-CRP reduction was 2.98 and 2.11, respectively. Individual DAS28-CRP reductions are shown in the figure 1. Mean HAQ-DI reduction from baseline to the end of the extension in all patients was 0.70. 2 non-device related adverse events were reported in the study extension: one related to cornea transplant and one related to dysesthesia. No serious adverse events were reported during the study extension phase.

Conclusion:

Benefits from the use of the wearable device were maintained over longer periods of time from the initial 12-week proof-of-concept study, with few safety concerns as no additional side effects were observed.

References:

[1]Marsal S et al. Non-invasive Vagus Nerve Stimulation Improves Signs and Symptoms of Rheumatoid Arthritis: Results of a Pilot Study [in press]. The Lancet Rheumatol, 2021

Disclosure of Interests:

Sara Marsal Speakers bureau: BMS, Pfizer, UCB, Celgene, Roche, Sanofi, Consultant of: Pfizer, Abbvie, Roche, Celgene, Galapagos, MSD, UCB, BMS, Sanofi, Grant/research support from: Pfizer, Abbvie, Roche, Celgene, MSD, UCB, BMS, Novartis, Janssen, Sanofi, Héctor Corominas: None declared, Juan Jose de Agustin: None declared, Carolina Perez-Garcia: None declared, Maria Lopez Lasanta: None declared, Helena Borrell Paños: None declared, D Reina-Sanz: None declared, Raimón Sanmartí: None declared, J. Narváez: None declared, Clara Franco-Jarava: None declared, Charles Peterfy Speakers bureau: Novartis, Bristol Myers Squibb, Amgen, Consultant of: Multiple companies on behalf of Spire Sciences Inc., Jose Antonio Narvaez: None declared, Vivek Sharma Shareholder of: Nēsos Corp, Employee of: Nēsos Corp, Konstantinos Alataris Shareholder of: Nēsos Corp, Employee of: Nēsos Corp, Mark C. Genovese Shareholder of: Gilead Sciences, Nēsos Corp, Employee of: Gilead Sciences, Matthew Baker Shareholder of: Nēsos Corp, Consultant of: Nēsos Corp

Mapping of neurokinin b in the cat brainstem

We studied the distribution of neurokinin B-immunoreactive cell bodies and fibers in the cat brainstem using an indirect immunoperoxidase technique. The highest density of immunoreactive fibers was found in the motor trigeminal nucleus, the laminar and alaminar spinal trigeminal nuclei, the facial nucleus, the marginal nucleus of the brachium conjunctivum, the locus coeruleus, the cuneiform nucleus, the dorsal motor nucleus of the vagus, the postpyramidal nucleus of the raphe, the lateral tegmental field, the Kölliker-Fuse nucleus, the inferior central nucleus, the periaqueductal gray, the nucleus of the solitary tract, and in the inferior vestibular nucleus. Immunoreactive cell bodies containing neurokinin B were observed, for example, in the locus coeruleus, the dorsal motor nucleus of the vagus, the median division of the dorsal nucleus of the raphe, the lateral tegmental field, the pericentral nucleus of the inferior colliculus, the internal division of the lateral reticular nucleus, the inferior central nucleus, the periaqueductal gray, the postpyramidal nucleus of the raphe, and in the medial nucleus of the solitary tract. This widespread distribution of neurokinin B in the cat brainstem suggests that the neuropeptide could be involved in many different physiological functions. In comparison with previous studies carried out in the rat brainstem on the distribution of neurokinin B, our results point to a more widespread distribution of this neuropeptide in the cat brainstem.

AB1343 ON THE DEVELOPMENT OF NEW DISEASE ACTIVITY SCORES FOR REMOTE ASSESSMENT OF PATIENT WITH RHEUMATOID ARTHRITIS USING THERMOGRAPHY AND MACHINE LEARNING

Background

Disease activity scores are used in the follow-up of patients with rheumatoid arthritis (RA). These scores include variables obtained through physical examination, such as the tender and swollen joint count. In telematic consultations it is not possible to determine these variables. Thermography is a safe and fast technique that measures heat through infrared imaging. Inflammation of the joints causes an increase in temperature and could therefore be detected by thermography. Machine learning methods are highly accurate in analyzing medical images, and could be used to analyze thermal images automatically. Thermography of hands, patient global health (PGH) and acute phase reactants could be combined to develop new activity scores that facilitate remote assessment of RA patients.

Objectives

To develop new disease activity scores based on the machine learning analysis of thermal images of the hands, PGH and acute phase reactants.

Methods

Multicenter observational study conducted in the rheumatology and radiology service of two hospitals. Patients with RA, psoriatic arthritis, undifferentiated arthritis and arthritis of hands secondary to other diseases that attended the follow-up visits were recruited. Companions of patients and healthcare professionals were also recruited as healthy subjects. In all cases, a thermographic image of the hands was taken using a Flir One Pro or a Thermal Expert TE-Q1 camera connected to a smartphone. Ultrasound (US) of both hands was performed. The degree of synovial hypertrophy (SH) and power doppler (PD) was assessed for each joint (score from 0 to 3). Machine learning was used to quantify joint inflammation from the thermal images using US (SH+PD) as ground truth. This score has been named ThermoJIS. RA patients whose thermal image was taken with the Thermal Expert TE-Q1 camera were used to evaluate the performance (test dataset). The other participants were used as training dataset. The PGH, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were also assessed in the test dataset. ThermoDAS (ThermoJIS + PGH), ThermoDAS-ESR (ThermoJIS + PGH + ESR) and ThermoDAS-CRP (ThermoJIS + PGH + CRP) activity scores were developed using a linear regression. The Spearman’s correlation coefficient of ThermoJIS, ThermoDAS, ThermoDAS-ESR and ThermoDAS-CRP vs. SH, PD, PGH, ESR and CRP were used to characterize the new developed disease activity scores. The study was approved by the Clinical Ethics and Research Committee of both centers.

Results

The total number of recruited subjects were 616 (475 for the training and 141 for the testing dataset). The correlations obtained between the different activity scores (ThermoJIS, ThermoDAS, ThermoDAS-ESR and ThermoDAS-CRP) vs. SH, PD, PGH, ESR and CRP are shown in Table 1. All correlations are statistically significant.

Table 1.

Spearman’s correlations of the developed scores vs synovial hypertrophy (SH); vs power doppler (PD); vs patient global health (PGH); vs erythrocyte sedimentation rate (ESR) and vs C-reactive protein (CRP).

SHPDPGHESRCRPThermoJIS0.420.430.180.160.12ThermoDAS0.500.530.870.160.19ThermoDAS-ESR0.540.530.790.490.33ThermoDAS-CRP0.600.600.770.490.54

Conclusion

ThermoJIS shows moderate correlation with US but weak correlation with PGH and acute phase reactants, suggesting that ThermoJIS is non-redundant with symptoms and laboratory assessment. Adding PGH and acute phase reactants to ThermoJIS improves all correlations, including correlation with US. These thermographic scores do not require a physical examination, opening an opportunity to facilitate remote consultations in RA patients.

References

[1]Lynch CJ et al. New machine-learning technologies for computer-aided diagnosis. Nat Med. 2018 Sep;24(9):1304-1305.

[2]Tan YK et al. Thermography in rheumatoid arthritis: a comparison with ultrasonography and clinical joint assessment. Clin Radiol. 2020 Dec;75(12): 963.

Disclosure of Interests

None declared

SAT0567 USE OF THERMOGRAPHY OF HANDS AND MACHINE LEARNING TO DIFFERENTIATE PATIENTS WITH ARTHRITIS FROM HEALTHY SUBJECTS

Background:

The early diagnosis of rheumatic diseases improves their prognosis. However, patients take several months to reach the rheumatologist from the beginning of the first symptoms. Thermography is a safe and fast technique that captures the heat of an object through infrared photography. The inflammation of the joints causes an increase in temperature and, therefore, can be measured by thermography. Machine learning methods have shown that they are capable of analyzing medical images with an accuracy similar or superior to that of a healthcare professional.

Objectives:

Develop an algorithm that, based on thermographic images of hands and machine learning, differentiates healthy subjects from patients with rheumatoid arthritis (RA), psoriatic arthritis (PA), undifferentiated arthritis (UA) and arthritis of hands secondary to other diseases (SA).

Methods:

Multicenter observational study conducted in the rheumatology and radiology service of two hospitals. Patients with RA, PA, UA and SA who attended the followup visit and healthy subjects (companions and healthcare proffesionals) were recruited. In all cases, a thermal image of the hands was taken using a Flir One Pro or Thermal Expert TE-Q1 camera connected to the mobile and an ultrasound of both hands. The degree of synovial hypertrophy (SH) and power doppler (PD) was assessed for each joint (score from 0 to 3). Inflammation was defined as the presence of SH> 1 or PD> 0. Machine learning was used to classify patients with RA, PA, UA and SA with inflammation evidenced by ultrasound and healthy subjects from thermographic images. The evaluation of the classifier was performed by leave-one-out cross-validation and the area under the ROC curve (AUCROC) in those subjects whose thermal image was performed with the Thermal Expert TE-Q1 camera. The study was approved by the Clinical Ethics and Research Committee of the centers.

Results:

500 subjects were recruited from March 2018 to January 2020, of these 73 were excluded due to poor quality in the thermal image (moved or absence of temperature contrast between hand and background). Of the 427 subjects analyzed, 129 corresponded to healthy subjects, 138 to patients without evidence of inflammation and 160 to patients with inflammation evidenced by ultrasound (116 RA and 44 PA, UA or SA). Of these, 42% were taken using the Thermal Expert TE-Q1 camera. An AUCROC of 0.73 (p-value <0.01) was obtained for the healthy classifier vs RA and 0.72 (p-value <0.01) for the healthy classifier vs PA, UA and SA.

Conclusion:

A classification model has been developed capable of differentiating patients with RA, PA, UA and SA with evidence of inflammation from healthy subjects. These results open an opportunity to develop tools that facilitate early diagnosis.

References:

[1]Barhamain AS, Magliah RF, Shaheen MH, Munassar SF, Falemban AM, Alshareef MM, Almoallim HM. The journey of rheumatoid arthritis patients: a review of reported lag times from the onset of symptoms. Open Access Rheumatol. 2017 Jul 28;9:139-150. doi: 10.2147/OARRR.S138830. eCollection 2017. Review.

[2]Lynch CJ, Liston C. New machine-learning technologies for computer-aided diagnosis. Nat Med. 2018 Sep;24(9):1304-1305. doi: 10.1038/s41591-018-0178-4.

[3]Brenner M, Braun C, Oster M, Gulko PS. Thermal signature analysis as a novel method for evaluating inflammatory arthritis activity. Ann Rheum Dis. 2006 Mar;65(3):306-11.

Disclosure of Interests:

None declared

Renin-angiotensin system in thyroidectomized rats at different periods of development

The relationship between the renal function and some components of the renin-angiotensin system has been studied in hypothyroid rats thyroidectomized surgically at different periods of their life. Changes in plasma renin concentration (PRC) depending on the period hypothyroidism were induced. Results showed that the renin release control could result from an equilibrium between the reduced beta-adrenergic activity and the marked natriuresis observed in hypothyroidism. A reduction in plasma angiotensinogen concentration (PAC), due to a decrease in its hepatic production, was observed in thyroidectomized animals. PAC reduction was independent of the hypothyroidism induction period. Alterations in plasma renin activity (PRA) were a consequence of PRC and PAC changes in thyroidectomized animals, as an increase in fractional sodium excretion (FENa) time course dependent, was found in these rats.

OP0300 USE OF THERMOGRAPHY OF HANDS AND MACHINE LEARNING TO QUANTIFY JOINT INFLAMMATION AND ESTIMATE DAS28, CDAI, SDAI IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Disease activity scores such as DAS28, CDAI and SDAI are used in the follow-up of patients with rheumatoid arthritis (RA). These scores include variables obtained on physical examination such as the tender joint count (TJC) and the swollen joint count (SJC). In telematic consultations, it is not possible to determine these variables by physical joint assessment. Therefore, it is necessary to develop new tools that allow detecting joint inflammation in places close to the patient. Thermography is a safe and fast technique that measures heat through infrared imaging. Inflammation of the joints causes an increase in temperature and can therefore be detect by thermography. Machine learning methods are highly accurate in analyzing medical images automatically.

Objectives:

To develop an algorithm that, based on thermographic images of hands and machine learning, learn to quantify joint inflammation in patients with RA and estimate the DAS28, CDAI, SDAI by including the patient global health (PGH).

Methods:

Multicenter observational study conducted in the rheumatology and radiology service of two hospitals. Patients with RA, psoriatic arthritis (PA), undifferentiated arthritis (UA) and arthritis of hands secondary to other diseases (SA) that attended the follow-up visits were recruited. Companions of patients and healthcare professionals were also recruited as healthy subjects (HS). In all cases, a thermographic image of the hands was taken using a Flir One Pro or a Thermal Expert TE-Q1 camera connected to a smartphone. Ultrasound (US) of both hands was performed in patients with RA, PA, UA and SA. The degree of synovial hypertrophy (SH) and power doppler (PD) was assessed for each joint (score from 0 to 3). Machine learning was used to quantify joint inflammation (SH+PD) from the thermal images using US as ground truth. RA patients whose thermal image was taken with the Thermal Expert TE-Q1 camera were used to evaluate the performance (test dataset). The other participants were used as training dataset. The TJC, SJC, PGH, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were also assessed in the test dataset. A linear regression was used to estimate the DAS28, CDAI and SDAI with the resultant joint inflammation quantification from the thermal images and the PGH. Performance was evaluated by means of Pearson’s correlation coefficient. The study was approved by the Clinical Ethics and Research Committee of both centers.

Results:

The total number of recruited subjects was 521 (422 for the training and 99 for the testing dataset). In the training dataset, the thermography of 296 patients was taken with the Flir One Pro (163 RA, 17 PA, 22 UA, 12 SA and 82 HS) and 126 with the Thermal Expert TE-Q1 camera (6 RA without clinical data, 20 PA, 7 UA, 23 SA and 70 HS).

We found higher correlations between joint inflammation variables (US and SJC) and thermography (0.48, p<0.01 for US and 0.48, p<0.01 for SJC) than between joint inflammation variables (US and SJC) and the PGH (0.29, p<0.01 for US and 0.35, p<0.01 for SJC). Thermography did not show statistically significant correlation with the PGH (0.14, p=0.164). The linear regression of thermography and the PGH showed strong correlation with the DAS28 (0.73, p<0.01), CDAI (0.84, p<0.01) and SDAI (0.82, p<0.01).

Conclusion:

Thermography of hands and machine learning can effectively quantify joint inflammation and can be used in combination with the PGH to estimate disease activity scores. These results open an opportunity to develop tools that facilitate telematic consultations in patients with RA.

References:

[1]Brenner M, Braun C, Oster M, Gulko PS. Thermal signature analysis as a novel method for evaluating inflammatory arthritis activity. Ann Rheum Dis. 2006;65(3):306-11

[2]Lynch CJ, Liston C. New machine-learning technologies for computer-aided diagnosis. Nat Med. 2018;24(9):1304-1305

[3]Tan YK, Hong C, Li H, Allen JC Jr, Thumboo J. Thermography in rheumatoid arthritis: a comparison with ultrasonography and clinical joint assessment. Clin Radiol. 2020;75(12):963

Disclosure of Interests:

None declared.

Involvement of oxytocin in the nucleus tractus solitarii on central cardiovascular control: interactions with glutamate

Oxytocin (OT) is a peptide involved in several physiological functions in the central nervous system including central cardiovascular regulation. To clarify the role of endogenous OT in cardiovascular control, one group of anesthetized rats received unilateral microinjections of the OT receptor antagonist [d(CH(2))(5),Tyr(Me)(2),Orn(8)]-vasotocin (OTA) in the nucleus tractus solitarii (NTS) and a second group was injected with specific OT antiserum (Anti-OT). Moreover, the modulation of the cardiovascular effect of L-glutamate (GLU) by OT was also evaluated by cardiovascular analysis using effective and threshold doses of GLU. Mean arterial pressure (MAP) and heart rate (HR) were measured from a femoral catheter. OTA significantly (p<0.01) decreased the vasopressor and tachycardiac long-lasting response elicited by an effective dose of OT. Microinjections of Anti-OT antibody did not modify the values of MAP and HR compared with the control group. With regard to the OT/GLU coinjections, a subthreshold dose of OT significantly (p<0.001) counteracted the vasodepressor and bradycardiac responses induced by GLU. The coinjection of subthreshold doses of OT and GLU did not produce a change in MAP or in HR. These findings seem to exclude an endogenous tonic action of OT on central regulation of MAP and HR, although they confirm the significant role of OT on central cardiovascular control within the NTS. In fact, the modulation of GLU responses by OT supports the importance of OT on the central cardiovascular adjustments likely acting on the baroreceptor reflex sensitivity.

AB0398 AURICULAR TRANSCUTANEOUS HI-FREQUENCY E-MMUNOTHERAPY SEQUENCES (ATHENS) FOR THE TREATMENT OF RHEUMATOID ARTHRITIS: 1-YEAR CHANGES IN SYNOVITIS, OSTEITIS, AND BONE EROSION

Background

Current pharmacological treatments remain inadequate for a significant proportion of patients with rheumatoid arthritis (RA), and thus alternative treatment approaches are needed. Prior results from the first 12 weeks of a proof-of-concept (POC) study showed that ATHENS, a non-invasive high-frequency vagus nerve therapy, was well-tolerated with meaningful reductions in RA disease severity as measured by the American College of Rheumatology response criteria (ACR) and the Disease Activity Score using 28 joints (DAS28)[1].

Objectives

The current analysis assessed long-term changes (52 weeks total follow-up) in disease activity as measured by ACR, DAS28, and the following MRI-assessed changes: synovitis, osteitis, bone erosion, and cartilage loss.

Methods

Following the completion of the 12-week POC study, patients achieving a reduction in DAS28-CRP of ≥1.2 were given the option to enroll in the 9-month open-label extension (OLE) study. During the extension phase, patients were to use the wearable device for 15 minutes per day. Adjustment of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic disease-modifying antirheumatic drugs (bDMARDs) were allowed during the OLE. Changes from baseline were assessed at 12 weeks (end of initial POC) and 52 weeks (end of the OLE). Structural damage and disease progression were evaluated by standardized MRI of the wrist and hand, with and without intravenous gadolinium-based contrast. MRIs were evaluated by two independent, central readers, blinded to clinical information and visit-order of the images, and were scored for synovitis, osteitis and bone erosion using the OMERACT-RAMRIS method. Cartilage loss was also determined using the 9-point cartilage loss scale (CARLOS).

Results

Twenty-seven of 30 patients completed the initial 12-week study, of whom 19 consented and entered the OLE. Of those 19 patients, 4 (21%) discontinued due to lack of efficacy, while the remaining 15 completed the 9-month extension. Due to the COVID-19 pandemic, 7 patients were unable to complete a 52-week MRI scan; MRI evaluations at baseline, 12 weeks, and 52 weeks were available for 8 patients.

DAS28-CRP mean (standard deviation [SD]) change from baseline was -1.78 (1.01) at 12 weeks (n=19; p<0.0001) and -2.30 (1.22) at 52 weeks (n=15; p<0.0001). ACR20, ACR50, and ACR70 response rates were 68%, 42%, and 21% at 52 weeks (n=19; discontinued participants were deemed non-responders). MRI analysis of synovitis, osteitis, bone erosion, and cartilage loss showed no evidence of disease progression through 52 weeks compared with baseline (Table 1).

Table 1.

Change in MRI OMERACT-RAMRIS from baseline to week 52

ScoreBaseline (n=8)Week 12 (n=8)Week 52 (n=8)Change Week 12 vs BL (n=8)Change Week 52 vs BL (n=8)CARLOS, mean (SD)3.9 (5.6)3.9 (5.6)3.9 (5.6)0.0 (0.0)0.0 (0.0)Erosion, mean (SD)10.8 (10.3)10.5 (10.3)10.6 (10.3)-0.3 (0.4)-0.1 (0.8)Osteitis, mean (SD)2.8 (4.1)2.3 (3.7)1.0 (1.1)-0.5 (1.1)-1.8 (3.1)Synovitis, mean (SD)4.0 (4.2)4.1 (4.7)3.3 (4.0)0.1 (0.6)-0.7 (1.0)

CARLOS = Cartilage loss score; OMERACT = Outcome Measures in Rheumatology; RAMRIS = Rheumatoid Arthritis Magnetic Resonance Imaging Scoring System

During the 9-month extension study, two new adverse events were reported (cornea transplant and right hand dysesthesia) in 2 (11%) patients; neither was treatment-related and both resolved without intervention. No serious adverse events were reported.

Conclusion

In patients with an initial treatment response to the Nēsos ATHENS therapy in the 12-week POC study, reductions in DAS28-CRP were sustained through 52 weeks. Although results should be interpreted cautiously given the small sample size and lack of control arm, MRI evaluation of synovitis, osteitis, bone erosion, and cartilage loss suggested no disease progression.

References

[1]Marsal, S., The Lancet Rheumatology, 2021. 3(4): p. e262-e269.

Disclosure of Interests

Charles Peterfy Consultant of: Nesos Corp, Employee of: Spire Sciences, Héctor Corominas: None declared, Juan Jose de Agustin: None declared, Carolina Perez-Garcia: None declared, Maria Lopez Lasanta: None declared, Helena Borrell Paños: None declared, D Reina-Sanz: None declared, Raimón Sanmartí: None declared, J. Narváez: None declared, Jose Antonio Narvaez: None declared, Vivek Sharma Shareholder of: Nesos Corp., Employee of: Nesos Corp., Konstantinos Alataris Shareholder of: Nesos Corp., Employee of: Nesos Corp., Mark C. Genovese Shareholder of: Nesos Corp. and Gilead, Employee of: Gilead, Matthew Baker Shareholder of: Nesos Corp., Consultant of: Nesos Corp., Sara Marsal Consultant of: Nesos, Pfizer, Sandoz, Novartis, Gilead, Grant/research support from: Nesos, BMS, Celgene, Merck Sharp and Dohme, Pfizer, Sandoz, Novartis, Sanofi, Janssen, Union Chimique Belge Pharma