The Infomóvel-An information system for managing HIV/AIDS patients in rural areas of Mozambique

BACKGROUND

Mobile health is gradually revolutionizing the way medical care is delivered worldwide. In Mozambique, a country with a high human immunodeficiency virus prevalence, where antiretroviral treatment coverage is 77% accompanied by a 67% of retention rate, the use of mobile health technology may boost the antiretroviral treatment, by delivering care beyond health facilities and reaching underrepresented groups. Leveraging new technologies is crucial to reach the 95-95-95 United Nations target by 2030. The design, development, implementation, and evaluation of a mobile health platform called Infomóvel were covered in this article. Its intended use involves collaboration with community health workers and aims to increase human immunodeficiency virus patient access, adherence, and retention to care.

METHODS

Using the Design Science Research Methodology, Infomóvel was created, as well as this publication. The explanation of various actions includes everything from problem description to observational study and goal-following for a solution, which results in the design and development of a platform proposal. Before the utility assessment of Infomóvel was conducted to make adjustments, a demonstration phase was conducted in one region of Mozambique.

RESULTS

The initial subjects of the Infomóvel flowchart and physical process design were patients receiving antiretroviral medication who were enrolled in the patients tracking system and who had consented to home visits. The case manager examines the file before importing it into the Infomóvel database stored on a cloud server using the website www.commcarehq.org . The case manager application synchronises with the Infomóvel server database, enabling the import of latest data and access to the lists of new patients and community health workers. The community health worker uses his phone to access his application, which allows him to record the geographic coordinates and sort the list of patients by priority and type of visit.

CONCLUSION

Results from Infomóvel add to the growing body of data showing that mobile health techniques are beneficial for managing stable individuals with chronic conditions in Mozambique. These approaches can be scaled up and better utilised. However, additional studies should be conducted to quantify the resources needed to implement on a larger scale.

O-122 ICSI in a box: development of a successful automated sperm injection robot with external supervision and minimal manual intervention

Study question

Is it possible to automate the way sperm is injected in an oocyte and improve ICSI consistency between embryologists?

Summary answer

The developed ICSI robot demonstrated a high degree of consistency and operator skill independence, allowing human supervision and external control, but minimal manual intervention.

What is known already

ICSI is a clinical procedure that is currently performed worldwide in most IVF centers and its use will only increase with more utilization of egg freezing. Since its implementation, the technique has been conducted manually by highly skilled embryologists. However, success rates can vary significantly depending on the experience of the operator. We leverage our experience in robotics, AI algorithms and embryology to develop an automated ICSI robot that requires minimal manual intervention with the aim to standardize the consistency of the procedure and, ultimately, improve overall results maintaining embryologist oversight.

Study design, size, duration

The ICSI robot was developed to have supervised automated control on critical steps of the injection procedure, including injection pipette advancement, zona pellucida and oolemma penetration with piezo-pulses, and pipette removal after injection. Manual intervention is required only for immobilization and capture of spermatozoa with a joystick gamepad and to release the sperm in the ooplasm, without the need for micromanipulation skills. In parallel, piezo-ICSI was performed in a conventional micromanipulation station as a control.

Participants/materials, setting, methods

Hamster and mouse oocytes were collected from superovulated females. For testing the efficiency of the automated system, hamster oocytes were injected with human donor sperm, as historically used in manual ICSI training programs, and survival rates evaluated after overnight culture. Mouse oocytes were injected with mouse sperm heads and subsequently cultured in vitro for five days. Blastocysts obtained were vitrified and embryo transfers are ongoing to evaluate term developmental rates.

Main results and the role of chance

The technical components of the ICSI robot were engineered to integrate AI algorithms, optics, cell microinjectors and mechatronics. AI algorithms were developed to identify the morphological structures of MII oocytes, including the zona pellucida, perivitelline space and polar body, both in the hamster and mouse models. The system detects and analyzes both the pipette and the oocyte and chooses the best area and plane for injection, allowing automated control of the subsequent injection steps. Using the hamster oocyte-human sperm model, a survival rate of 91% (n = 110) was achieved with the robot, which was statistically similar (p = 0.335) to the results obtained in the controls injected manually (96%, n = 28). The average time spent in each injection cycle, which includes scanning of the oocyte and injection pipette, and injection of the sperm into the oocyte, was approximately two minutes per ICSI operation. This time was comparable to the time required by highly experienced operators with manual piezo-injection. In the mouse, 91% (n = 53) of the oocytes injected survived the procedure, of which, 92% developed to two-cells and 87% to the blastocyst stage. No statistical differences were found when compared these efficiencies with manual controls (n = 40, 98%, 97% and 92%, respectively).

Limitations, reasons for caution

The developed ICSI robot has shown highly consistent results, independently of operator skills, both in hamster and mouse oocytes. However, additional validations should be performed to enlarge the sample size of injected oocytes and to evaluate the efficiency of the system in other oocyte species, including translational studies to humans.

Wider implications of the findings

The combination of multidisciplinary teams allows the development of automated processes that can reduce variability in certain IVF procedures, while supervised and assisted by experienced embryologists. It is expected that other laboratory procedures can be automated in the field of assisted reproductive treatments in a near future.

Trial registration number

N/A

POS0496 YOUNG VERSUS LATE-ONSET RHEUMATOID ARTHRITIS: A PROSPECTIVE 12 MONTH-FOLLOW-UP COHORT STUDY IN AN EARLY ARTHRITIS COHORT

Background:

Rheumatoid Arthritis (RA) is a chronic inflammatory arthropathy that can present at any age. Data regarding differences in the clinical course and outcome in Late-Onset Rheumatoid Arthritis (LORA) comparing to Young-Onset RA (YORA) are conflicting. Some studies suggested that LORA may represent a more benign form of RA (1), while others have shown a poorer prognosis in these patients (2,3). Only a few publications have included patients with early disease (3).

Objectives:

To compare demographic and clinical features between LORA and YORA patients, and clinical activity at baseline and after 12 months of initial therapy, in patients with early disease.

Methods:

We conducted a prospective cohort study of 12 months of follow-up based on an early arthritis clinic. Consecutive patients with early RA – less than 12 months duration – fulfilling ACR/EULAR 2010 and/or ACR 1987 RA classification criteria, were included and classified in LORA (disease onset ≥60 years) and YORA groups. Variables were collected from patients’ registries at first appointment after symptoms onset and after 12 months of treatment, according to a treat-to-target strategy. Independent t-test and chi-square test were performed to compare variables between groups.

Results:

We included 72 patients (40 (55.6%) YORA; 32 (44.4%) LORA), mean age at diagnosis 44.9±1.78 and 72.5± 1.34 years, respectively. In LORA group, the symptoms duration at first observation was shorter (17.0±2.26 vs. 23.8±2.45 weeks; p=0.046) and rheumatoid factor (RF)/ anti-citrullinated protein antibodies (ACPA) positivity was lower (28.1% vs 65.0%; p= 0.002; 31.3% vs 72.5%; p<0.001). At baseline, LORA had higher mean number of tender joints (9.76±1.29 vs 6.50±0.67; p=0.021), erythrocyte sedimentation rate (ESR) (45.7±4.98 vs. 29.3±3.74; p=0.011), C-reactive protein (CRP) (4.63±0.91 vs 2.22±0.46; p=0.022) and disease activity using DAS28-3V (5.11±0.28 vs 4.42±0.19; p=0.046), CDAI (33.7±3.39 vs 23.6±2.18; p=0.015) and SDAI (37.4±3.43 vs 26.3±2.57; p=0.015). At the end of follow-up, there were no statistically significant differences between LORA and YORA groups regarding treatment, disease activity and patient-reported outcomes at 12 months (Table 1).

Table 1.

Clinical variables assessment at 12 months of follow-up.

EORAYORAp-valueTreatment, % users Corticosteroids93.397.4p= 0.576 Methotrexate76.774.4p=0.825 Hydroxychloroquine43.346.2p= 0.815 Sulfasalazine10.015.4p=0.722 Leflunomide3.305.10p=1.000 TNF blockers3.305.10p=0.717DAS28-3V, mean (SD)1.99±0.152.22±0.15p=0.286SDAI, mean (SD)4.64±1.357.68±1.39p=0.128CDAI, mean (SD)4.15±1.176.56±1.32p=0.180Swollen joints, mean (SD)1.29±0.491.03±0.25p=0.613Tender joints, mean (SD)0.32±0.131.28±0.53p=0.084ESR, mean (SD)10.6±1.799.43±1.14p=0.585CRP, mean (SD)0.44±0.090.50±0.15p=0.730PtGA, mean (SD)21.8±5.9029.2±6.11p=0.387PhGA, mean (SD)10.6±3.2613.1±3.11p= 0.593Pain intensity (VAS), mean (SD)20.7±5.8232.7±6.30p=0.169HAQ, mean (SD)0.23±0.0890.54±0.13p=0.060

Legend: DMARD- disease-modifying anti-rheumatic drug; TNF- tumoral necrosis factor; SDAI-simplified disease activity score; CDAI- clinical disease activity score; PtGA/ PhGA – patient’s/ physician’s global assessment of general health; VAS- visual analogic scale; HAQ- health assessment questionnaire.

Conclusion:

LORA patients presented with higher disease activity manifested by higher joint counts and laboratory inflammatory markers but lower RF and ACPA positivity proportion. Despite the more aggressive clinical presentation, the clinical and functional outcomes at 12 months were similar between LORA and YORA patients.

References:

[1]Deal et al. Arthritis Rheum 1985;28(9):987-94.

[2]Arnold et al. Rheumatology (Oxford) 2014; 53:10751086.

[3]Romão et al. Semin Arthritis Rheum 2020;0(4):735-743.

Disclosure of Interests:

None declared

POS0055 SARS-COV-2 OUTBREAK IN AUTOIMMUNE DISEASES: THE EURO-COVIMID STUDY

Background:

Coronavirus disease 2019 (COVID-19), has raised several questions in patients with immune-mediated inflammatory diseases (IMID). Whether the seroprevalence and factors associated with symptomatic COVID-19 are similar in IMID patients and in the general population is still unknown.

Objectives:

To assess the serological and clinical prevalence of COVID-19 in European IMID patients, along with the factors associated with its risk and the impacts the pandemic had on the IMID management.

Methods:

Prospective multicentre cross-sectional study among patients with five IMID (i.e. systemic lupus erythematous, Sjögren’s syndrome, rheumatoid arthritis, axial spondylarthritis or giant cell arteritis) from six tertiary-referral centers from France, Germany, Italy, Portugal, Spain and United Kingdom. Demographics, comorbidities, IMID, treatments, flares and COVID-19 details were collected. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serological tests were systematically performed.

Results:

Between June 7 and December 8, 2020, 3028 patients were included (median age 58 years, 73.9% females). SARS-CoV-2 antibodies were detected in 166 (5.5%) patients. Symptomatic COVID-19 was seen in 122 patients (prevalence: 4.0%, 95% CI 3.4-4.8%); 23 (24.2%) of them were hospitalized and four (3.2%) died. In multivariate logistic regression analysis, symptomatic COVID-19 was more likely to be observed in patients with higher levels of C-reactive protein (OR: 1.18; 95% CI 1.05-1.33; p = 0.006), and increased with the number of IMID flares (OR: 1.27; 95% CI 1.02-1.58; p = 0.03). Conversely, it was less likely to occur in patients treated with biological therapy (OR: 0.51; 95% CI 0.32-0.82; p = 0.006). During the pandemic, at least one self-reported disease flare was seen in 654 (21.6%) patients. Also, 519 (20.6%) patients experienced changes in their treatment, with 125 of these (24.1%) being due to COVID-19.

Conclusion:

The SARS-CoV-2 prevalence in IMID patients over the study period seems to be similar to that of the general population1. The IMID inflammatory status seems to be independently associated with the development of COVID-19.

References:

[1]Pollán M, Pérez-Gómez B, Pastor-Barriuso R, Oteo J, Hernán MA, Pérez-Olmeda M, et al. Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study. Lancet Lond Engl. 2020 Aug 22;396(10250):535–44.

Disclosure of Interests:

None declared.

AB0147 OLDER AGE AT ONSET AND NOT DISEASE ACTIVITY IS ASSOCIATED WITH FUNCTIONAL DISABILITY AT RA DIAGNOSIS: RESULTS FROM AN EARLY ARTHRITIS COHORT

Background:

Rheumatoid Arthritis (RA) is a chronic inflammatory arthropathy that potentially leads to loss of function and disability early in the disease course. (1) Optimizing physical function is one of the primary goals of RA treatment (2). Several demographic, psychosocial and clinical factors may influence the impact of RA upon physical capacity, and understanding their relative contribution to disability at disease diagnosis is key to an effective treatment approach.

Objectives:

To evaluate functional disability at the time of disease diagnosis and identify its demographic and clinical correlates in an early RA cohort.

Methods:

We conducted a cross-sectional study based on a Rheumatology centre early arthritis cohort. Consecutive patients with early RA – less than 12 months duration– fulfilling ACR/EULAR 2010 and/or ACR 1987 RA classification criteria, were included. Variables were collected from patients’ registries at the first rheumatology appointment after symptom’s onset. Functional disability was assessed using the Health Assessment Questionnaire- Disability Index (HAQ-DI) (range 0 to 3, higher values indicating greater disability). Independent t-test, one way-ANOVA and Pearson’s correlation coefficient were performed to evaluate differences between groups. Variables with p<0.1 were included in a stepwise multiple linear regression analysis to assess the independent association of variables with the HAQ-DI at baseline.

Results:

We included 71 patients (63.4% female, mean age 57.2 ±2.01 years). Mean HAQ-DI score was 1.42±0.08. Sociodemographic and clinical variables are described in Table 1. There was a significant difference in HAQ-DI scores between rheumatoid factor (RF) positive (mean 1.24±0.11) and RF negative (1.61±0.113) patients. HAQ-DI was positively weakly correlated with age (r=0.48; p<0.001), CDAI (r=0.43; p=0.038), SDAI (r=0.49; p=0.015), and moderately with DAS28-3V (r=0.60; p<0.001) and DAS28-3V-CRP (r=0.60; p<0.001). The number of tender (r=0.35; p=0.024) and swollen joints (r=0.42; p= 0.005), ESR (r=0.46; p=0.001), CRP (r=0.35; p=0.018), HADS-depression (r=0.46; p=0.023) and educational level (r= -0.48; p=0.002) were also associated with HAQ-DI in univariate analyses. After multivariate regression analysis, age at disease diagnosis (β= 0.022 [95 CI 0.010 to 0.034]; p= 0.001) was the only independent predictor of HAQ-DI (R2= 0.46, p=0.001).

Table 1.

Patients’ baseline sociodemographic and clinical characteristics.

Age at diagnosis (years), mean (SD)57.2±2.01Educational level (years), mean (SD)7.37±0.59Employment: full-time, %42.4Employment: partial-time, %3.00Employment: retired, %48.4Employment: absenteeism in the last month, %1.50Unemployed, %4.50Disease duration at presentation (weeks), mean (SD)20.4±1.70Morning stiffness >30 minutes, %83.0RF positivity, %47.9ACPA positivity, %53.5Fibromyalgia, %6.60DAS28-3V, mean (SD)4.72±0.17CDAI, mean (SD)29.2±2.28SDAI, mean (SD)32.4±2.42PtGA, mean (SD)66.8±3.73PhGA, mean (SD)54.7±3.08Pain intensity (VAS), mean (SD)67.7±3.75EQ-5D score, mean (SD)0.26±0.039HADS-depression, mean (SD)7.17±0.87

Legend: ACPA- anti-citrullinated protein antibodies; ESR- erythrocyte sedimentation rate; CRP- c-reactive protein; DAS- disease activity score; CDAI- clinical disease activity score; SDAI-simplified disease activity score; PtGA/ PhGA – patient’s/physician’s global assessment of general health; VAS- visual analogic scale; EQ-5D- EuroQoL 5-Dimensional Descriptive System; HADS-Hospital Anxiety and Depression Scale.

Conclusion:

Older age at disease onset is associated with greater functional impairment at diagnosis, assessed by HAQ-DI, in this cohort of early RA patients, irrespective of disease activity and other clinical variables. This result suggests that older newly diagnosed RA patients may deserve special attention regarding physical function.

References:

[1]Wolfe F et al. Arthritis Res Ther. 2010; 12(2): R35.

[2]Smolen JS et al. Ann Rheum Dis. 2010; 69:631-637.

Disclosure of Interests:

None declared

POS0878 ULTRASOUND ASSESSMENT OF DERMAL THICKNESS AND SKIN STIFFNESS IN UNDIFFERENTIATED CONNECTIVE TISSUE DISEASE AT RISK FOR SYSTEMIC SCLEROSIS

Background:

High-frequency ultrasound (HFUS) and shear-wave elastography (SWE) allow an objective assessment of skin involvement in systemic sclerosis (SSc) patients.1 Till now it has been applied to patients with established diagnosis.2,3 However, there is no data concerning its application in Undifferentiated Connective Tissue Disease at risk for SSc (UCTD-risk-SSc), i.e., patients with Raynaud’s phenomenon and either SSc marker autoantibodies or typical capillaroscopic findings or both, not satisfying classification criteria for SSc.4

Objectives:

To compare ultrasound-dermal thickness (DT) and skin stiffness, using high-frequency ultrasound and shear-wave elastography, in UCTD-risk-SSc and healthy controls.

Methods:

Forty UCTD-risk-SSc patients and 40 age- and gender-matched healthy controls were included. Ultrasound-DT was measured using an 18MHz probe, and skin stiffness (i.e. shear-wave velocity values, SWV) using the VTIQ software with a 9MHz probe, at the 17 Rodnan skin sites. The mRSS score was, by definition, zero in all sites, both in cases and controls. Continuous data were expressed as the mean (SD), and Mann-Whitney U test was performed to compare differences between the groups, as variables were not normally distributed. Associations between variables were analysed using the Spearman’s correlation.

Results:

SWV values were significantly higher in patients with UCTD-risk-SSc compared with controls at the right and left hands, and in the right and left fingers (table 1). Higher values of ultrasound dermal-thickness were found in the fingers and hands bilaterally, although differences were only significantly at the hands, compared with healthy controls (table 1). There were no significant differences in the other Rodnan skin sites. There was no significant correlation between ultrasound-dermal thickness and stiffness at the same skin site.

Conclusion:

This study provides the first evidence suggesting that ultrasound-DT and stiffness can discriminate patients with UCTD-risk-SSc from healthy controls. Prospective studies including a larger number of patients with different subsets of UCTD-risk-SSc are needed to investigate diagnostic and prognostic value of the ultrasound parameters in this group.

References:

[1]Santiago T, et al. Arthritis Care Res (Hoboken). 2019;71:563-574.

[2]Hesselstrand R, et al. Rheumatology (Oxford). 2008;47:84-7.

[3]Flower V et al. jrheum.200234.

[4]Valentini, G., et al. Arthritis Care Res, 66: 1520-1527.

Table 1.

Clinical and ultrasound parameters in UCTD-risk-SSc and healthy control groups.

UCTD-risk-SSc (n=40)Healthy controls (n=40)p valueAge, mean (SD)51.4 (14.9)49.8 (13.9)NsFemale, n (%)36 (90.0)36 (90.0)Raynaud phenomenon, %100.0%-ANAs100.0-Anti-centromere, %60.0Anti-Scl70+, %11.5Scleroderma/non-scleroderma pattern in capillaroscopy, %5.0/95.0--Ultrasound parametersDermal thickness (mm) Dorsal hand right0.77 (0.32)0.62 (0.12)0.02 Dorsal hand left0.79 (0.39)0.62 (9.13)0.02 Proximal phalanx right0.64 (0.14)0.61 (0.11)Ns Proximal phalanx left0.66 (0.16)0.60 (0.09)NsSWV values (m/s) Dorsal hand right1.94 (0.40)1.61 (0.24)0.0001 Dorsal hand left1.82 (0.36)1.65 (0.25)0.025 Proximal phalanx right2.09 (0.60)1.68 (0.24)0.001 Proximal phalanx left2.13 (0.82)1.66 (0.27)0.004

Legend: ANA: Antinuclear antibodies; Ns: Non-significant; UCTD: Undifferentiated Connective Tissue Disease; SD: Standard Deviation

Disclosure of Interests:

None declared

AB0223 PHYSICIAN’S GLOBAL ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS IS A RELIABLE AND RESPONSIVE TOOL IN CLINICAL practice

Background:

Physician’s global assessment of disease activity (PhGA) is highly influential upon treatment decisions taken by rheumatologists, surpassing the impact of DAS28. [1, 2]. However, data regarding its psychometric properties are scarce.

Objectives:

To evaluate the reliability and responsiveness of PhGA.

Methods:

We included two consecutive visits of RA patients followed in a Tertiary Rheumatology Department. Socio-demographic (age and gender) and clinical data were collected including tender (TJ28) and swollen (SJC28) joints in 28 count, C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Disease activity Score (DAS28-3v-CRP, DAS28-3v-ESR, DAS28-4v-CRP, DAS28-4v-ESR), PhGA and Patient Global Assessment of disease Activity (PGA) through a Visual Analogic Scale (VAS) 0-100mm. Changes (Δ) between the two visits were calculated. Only patients without missing data were included. Correlations between ΔPhGA and change of other variables were assessed using Pearson’s correlations. Reliability was evaluated through Intraclass Correlation Coefficient (ICC) between two consecutive appointments in a subgroup of patients with stable disease activity (Δ DAS28-4vESR [-0.6 to 0.6]. An ICC above 0.8 was considered indicative of excellent reliability. Sensitivity to change was assessed in the subgroup of patients who improved their disease activity at least 0.6 on DAS28-4V-ESR, through Standardized Response Mean (SRM). The respective intervals of confidence were obtained through bootstrapping procedures. SRM above 0.8 were considered large. Independent factors associated with ΔPhGA were identified through multivariate linear regression analysis. p<0.05 was considered statistically significant

Results:

121 RA patients (84.3% female and 64.0±12.6 years) were included. Δ PhGA was weakly correlated with ΔCRP (r=0.23), Δ PGA (r=0.31) and Δ pain (r=0.37). Moderate to strong correlations were observed with Δ DAS28-3V-ESR (r=0.55), Δ SJC28 (r=0.56), Δ DAS28-3V-CRP (r=0.58), Δ DAS28-3V-CRP (r=0.60), Δ TJ28 (r=0.62) and Δ DAS28-4V-CRP (r=0.63). ICC between two consecutive visits was 0.7, [95%CI:0.47-0.83] and SRM was -1.01 [95%CI:-1.26-(-0.73)]. In the multivariate regression analysis, ΔSJC28 (β=4.01; 95% CI:3.07 to 4.96) and Δ Pain (β=0.18; 95%CI: 0.07 to 0.28) remained as independent factors associated with ΔPhGA (R2:0.49, p<0.01)

Conclusion:

In this study, PhGA showed a high reliability and sensitivity to change regarding disease activity, in clinical practice. Changes in SJC had the strongest association with change in PhGA scoring, but Δ Pain was also significantly correlated (graph 1).

Figure 1.

Graph 1 – Explicative model to variations on PhGA

References:

[1]Choy T et al. Rheum (Oxford, England). 2014;53(3):482-90.

[2]Rohekar G et al. Jour Rheum. 2009;36(10):2178.

Disclosure of Interests:

LILIANA SARAIVA: None declared, Luisa Brites: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Ana Rita Prata: None declared, Mariana Luis: None declared, Flavio Costa: None declared, Pedro Freitas: None declared, Marlene Sousa: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

AB0218 FUNCTIONAL DISABILITY AND PAIN BUT NOT DISEASE ACTIVITY ARE ASSOCIATED WITH POOR HEALTH-RELATED QUALITY OF LIFE IN A COHORT OF RHEUMATOID ARTHRITIS PATIENTS

Background:

Rheumatoid Arthritis (RA) is a systemic autoimmune disease that presents with joint pain and inflammation leading to significant disability and poor health-related quality of life (HRQoL) (1,2). Optimizing long-term HRQoL is the primary goal of disease management in RA (3).

Objectives:

To evaluate HRQoL and identify its influencing clinical and demographic factors in a Portuguese RA population.

Methods:

This is a cross-sectional study including consecutive patients fulfilling the ACR/EULAR 2010 and/or ACR 1987 RA classification criteria, followed at a tertiary Rheumatology Department. Sociodemographic and clinical variables were collected. HRQoL was assessed using the EuroQoL 5-Dimensional Descriptive System (EQ-5D) total score (normal range from -0.496 to 1.000, lower values indicating poorer HRQoL). Independent t-test and Pearson’s correlation coefficient were performed to evaluate EQ-5D differences between groups and examine its relationships with continuous variables, respectively. Variables with p<0.1 in univariate analysis were included in a stepwise multiple linear regression analysis to evaluate the independent association of variables with the EQ-5D score.

Results:

358 RA patients were included (80.20% female, mean age ± SD: 63.22 ± 0.66 years old). Mean EQ5D total score ±SD was 0.48 ± 0.01. Based on EQ-5D domains, 0.60% reported extreme problems with mobility, 3.40% extreme problems with self-care, 2.50% extreme problems with usual activities, 12.0% extreme pain or discomfort, and 7.30% extreme anxiety or depression symptoms (Fig. 1). There was a significant difference in EQ-5D scores between male (M=0.55, SD=0.24) and female gender (M=0.46, SD= 0.27); t (356) = -2.41, p=0.016. EQ-5D was weakly correlated with DAS-28-CRP (r=-0.32; p<0.001), moderately correlated with patient’s global assessment of disease activity (r=-0.54; p<0.001) and pain-visual analogue scale (pain-VAS) scores (r=-0.58; p<0.001) and strongly with Health Assessment Questionnaire (HAQ) score (r=-0.72; p< 0.001). After multivariate analysis, HAQ-score (β=-0.57 [95% CI -0.24 to -0.17]; p<0.001) and pain-VAS ((β=-0.25 [95% CI -0.003 to -0.002]; p<0.001) remained as independent predictors of EQ-5D (R2=0.56, p<0.001).

Conclusion:

Greater functional impairment and pain are associated with poor HRQoL in RA patients, and thus special attention must be given to treatment strategies providing the best patient-centred outcomes.

References:

[1]Yaghoubi et al. J Cardiovasc Thorac Res 2012;4(4):95–101.

[2]José E et al. Ann Rheum Dis 2018;1118–24.

[3]Smolen JS et al. Ann Rheum Dis. 2010; 69:631–637

Disclosure of Interests:

Ana Rita Prata: None declared, Helena Assunção: None declared, Mariana Luis: None declared, Luisa Brites: None declared, Flavio Costa: None declared, João Dinis de Freitas: None declared, Stefanie Silva: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

AB0179 BEYOND DISEASE ACTIVITY, PAIN, “TIME” AND “TIMING” ACCOUNT FOR DISABILITY IN PATIENTS WITH RHEUMATOID ARTHRITIS: RESULTS FROM A REAL-LIFE COHORT

Background:

Patients with rheumatoid arthritis (RA) suffer from joint pain, stiffness and fatigue and are therefore limited in their physical activities. Since functional disability is a major determinant of quality of life in patients with RA, an optimized approach should focus on the maintenance of functional ability.

Objectives:

To evaluate self-reported disability in RA patients and to identify its influencing clinical and demographic factors in a real-life cohort of patients with RA.

Methods:

Cross-sectional study of consecutive patients with RA fulfilling the ACR/EULAR 2010 and/or ACR 1987 RA classification criteria, followed in a Portuguese tertiary care centre. Variables collected included socio-demographic and clinical variables (disease duration; time from symptoms onset to diagnosis, classified as short (≤ 2 years) and long (> 2 years); time of diagnosis, categorised as <2000, 2000-2009, ≥2010); DAS28-CRP-3V and its individual components; pain assessed through visual analogue scale (0-100 mm) and self-perception of anxiety/ depression through EQ5D dimension 5. Disability was assessed through Health Assessment Questionnaire (HAQ) score and categorised as none-to-mild (<1) or moderate-to-severe (1-3). Comparison between groups was assessed through chi-square or T-student test, as adequate. Variables with p<0.1 and others clinically relevant in the researcher’s perspective were included in a multivariable logistic regression model. Previously to the analysis, all the assumptions were verified. Given the implementation of new strategies regarding diagnosis and treatment of RA in the last decade, a subgroup analysis was performed for patients with diagnosis performed after 2010).

Results:

A total of 251 patients were included (78.9% female, aged 62.0±12.1 years, disease duration 16.7±11.2 years), with a mean DAS28-CRP-3V of 2.24 ±0.87, with 65.3% being in remission or low disease activity. The mean HAQ score was 1.2±0.8. Over half of the patients (56.2%) reported moderate-to-severe disability. In the univariate analysis, moderate-to-severe disability was more frequent in female patients (60.6% vs 39.6%, p<0,006), in patients with moderate-to-severe self-perception of anxiety/depressive symptoms (67.2% vs 44.2%, p<0.001) and in patients with diagnosis before the year 2000, 2000-2009 than ≥2010 (71.4% vs 63.1% vs 36.7%; p< 0.001). In addition, patients with moderate-to-severe disability tended to be older (65.05 vs 57.98, p<0,001), to have longer disease duration (20.07 vs 12.39, p <0.001), to report more pain (VAS 58.08 vs 28.62, p<0.001) and to have higher disease activity (2.48 vs 1.95, p=0.001). In the multivariable analysis, pain (OR=1.04; 95%CI 1.03-1.06, p<0.001), disease activity (OR=1.51; 95%CI 1.01-2.26, p=0.049), and time of diagnosis (OR=0.553, 95%CI 0.38 -0.81, p=0.002) remained as independent factors associated with moderate-to-severe disability (R2: 0.40, p<0,001). In the subgroup of patients diagnosed after 2010, a longer time to diagnosis (>2 years) (OR=7.97, 95%CI 1.88-34.06; p=0.005) and pain (OR=1.05, 95%CI 1.03-1.08; p<0,001) remained as independent factors (R2= 0.44, p=<0.001).

Conclusion:

Functional disability remains a major problem in our patients with RA, despite clinical remission. Beyond non-modifiable factors, disease activity and pain are associated with higher disability. Moreover, in the subgroup of patients diagnosed after 2010 a long time to diagnosis was the major predictor of disability. However, a large variance of the reported functional disability remains unexplained. Hence, other factors should be properly evaluated in our patients in order to achieve a more holistic approach aiming at reducing functional disability.

Disclosure of Interests:

Helena Assunção: None declared, Ana Rita Prata: None declared, Mariana Luis: None declared, Luisa Brites: None declared, João Dinis de Freitas: None declared, Flavio Costa: None declared, Stefanie Silva: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

SAT0184 MAINTENANCE THERAPY WITH AZATHIOPRINE ASSOCIATED WITH HIGHER RISK OF FLARE IN PROLIFERATIVE LUPUS NEPHRITIS

Background:

Goals of lupus nephritis (LN) maintenance treatment include prevention of LN flares and long-term preservation of renal function, while minimizing drug iatrogenicity. There is an unmet need for identifying predictors of LN flare in order to guide optimization of maintenance immunosuppression.

Objectives:

To identify predictors of LN flare after attainment of complete renal response (CRR) in patients with proliferative LN.

Methods:

Retrospective cohort study over 36 months including patients with SLE fulfilling the ACR’97 and/or the SLICC’12 classification criteria, enrolled in the CHUC Lupus Cohort between 1999 and 2018, with a biopsy-proven proliferative LN (class III/IV) and who attained CRR (proteinuria <0.5g/day and normal renal function, according to EULAR/ERA-EDTA definition) following induction treatment. Only proteinuric flares were considered and defined as doubling of proteinuria to >1g/day. Clinical-analytic characteristics at baseline (time of first CRR attainment after induction) were compared using survival analysis for time-to-flare. Variables with p<0.10 on univariate analysis with Log-Rank tests were further evaluated as predictors with multivariate Cox proportional hazards regression models (Backward Stepwise method, Wald-based), with estimation of hazard ratios (HR) with 95% confidence intervals (95%CI).

Results:

A total of 50 patients in CRR were included in the analysis (78.4% female, age at baseline 30.0 ± 12.5 years-old). Over the follow-up period, 10 patients (20.0%) experienced a proteinuric flare, within a mean time of 29.1 months (95%CI 26.89-31.37). In univariate analysis, age <30years (p=0.020), arterial hypertension (p=0.020) and presence of anti-RNP antibody (p=0.002) at baseline were associated with higher risk of LN proteinuric flares. In multivariate analysis, age <30 years (HR 26.56; 95%CI 1.93-365.08; p=0.014), arterial hypertension (HR 8.30; 95%CI 1.21-56.92; p=0.031), use of antihypertensive antiproteinuric drugs (angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers) (HR 11.18; 95%CI 1.24-100.66; p=0.031) and maintenance therapy with azathioprine (HR 6.23; 95%CI 1.51-25.66; p=0.011) (Figure 1) were predictors of LN proteinuric flares.

Figure 1.

Conclusion:

In patients with proliferative LN, proteinuric flares are a frequent event after induction treatment leads to CRR. Younger age, arterial hypertension, use of antihypertensive drugs and use of azathioprine as maintenance therapy were risk factors for LN proteinuric flare in this cohort.

Disclosure of Interests:

Mariana Luis: None declared, Ana Rita Prata: None declared, Helena Assunção: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Luís Inês: None declared

FRI0165 RISK OF CKD IN MEMBRANOUS AND PROLIFERATIVE LUPUS NEPHRITIS - ANALYSIS OF A NATIONWIDE MULTICENTRE COHORT

Background:

Lupus nephritis (LN) is one of the most severe manifestations of Systemic Lupus Erythematosus.

Objectives:

1) To compare proliferative (PLN), membranous (MLN) and mixed LN regarding clinical and laboratory presentation. 2) To investigate predictors of progression to chronic kidney disease (CKD).

Methods:

Multicentre observational study, with retrospective analysis of a prospective cohort, using data from the Portuguese registry of rheumatic diseases – Reuma.pt. Patients with biopsy-proven PLN, MLN and mixed LN were included. Groups were compared using Pearson’s Chi-Square for categorical variables and One-Way ANOVA or Kruskal-Wallis for numerical variables. COX regression analysis was used to investigate predictors of CKD (defined as estimated glomerular filtration rate [eGFR] lower than 60 mL/min/1.73m2for at least 3 months) and Kaplan-Meier curves were drawn.

Results:

236 patients were included. Median follow-up was 8 years (IQR 11; maximum 35 years). As seen in table 1, the level of proteinuria did not differ between groups; however, MLN patients presented with significantly lower serum creatinine. Levels of complement C3 and C4 were reduced in PLN but normal in MLN patients, and there were fewer patients with positive anti-dsDNA antibodies in the MLN group (p<0.001). On univariable COX regression, mixed histology was associated with progression to CKD (HR 26 [95% CI 3 - 255], p 0.005) (figure 1), however, it lost significance after adjusting for eGFR. In fact, eGFR≤75 at one year after the renal biopsy (HR 21 [95% CI 7 - 65], p<0.001) was the strongest predictor of CKD, even after adjusting for hypertension or histology.

Table 1.

Comparative description of the Reuma.pt cohort of patients with proliferative, membranous and mixed LN

PLNMLNMixedPTotal, N186428Females, N (%)157 (85)39 (95)4 (50)0.004EthnicityWhite European, N (%)163 (90)31 (78)7 (88)0.115Other, N (%)19 (10)9 (23)1 (13)Age LN diagnosis(y), median (IQR)30 (20)34 (16)42 (25)0.409SLEDAI at LN diagnosis, median (IQR)16 (9)10 (10)21 (17)0.006*uPCR at LN diagnosis, median (IQR)1675 (2598)1698 (2153)2160 (3320)0.629Creatinine at LN diagnosis, median (IQR)0.80 (0.32)0.70 (0.20)1.00 (0.95)0.006*eGFR at LN diagnosis, mean ± SD98 ± 33112 ± 1782 ± 450.019*Albumin at LN diagnosis, mean ± SD34 ± 734 ± 730 ± 60.390C3 at LN diagnosis, mean ± SD0.65 ± 0.260.90 ± 0.350.53 ± 0.30<0.001*Positive anti-dsDNA LN diagnosis, N (%)115 (91)11 (48)6 (86)<0.001*Use of antimalarials, N (%)166 (94)36 (92)8 (100)0.688Use of immunosuppressants, N (%)163 (94)33 (87)8 (100)0.245Use of corticosteroids, N (%)145 (84)33 (85)7 (100)0.511CKD after LN diagnosis, N (%)27 (15)1 (3)3 (38)0.018*ESRD, N (%)7 (4)1 (3)2 (25)0.016Deaths, N (%)14 (8)2 (5)00.610

uPCR: urinary protein-creatinine ratio, mg/g; y: years; Creatinine presented in mg/dL, eGFR in mL/min/1.73m2,albumin in g/L and C3 in g/L

Note: Baseline data (LN diagnosis) in grey; other data refer to the course of disease

*Significant difference between the proliferative and membranous groups

Figure 1.

Kaplan-Meir curves showing cumulative survival free of CKD in patients with PLN, MLN and mixed LN

Conclusion:

Our results support previous findings from single-centre studies suggesting that MLN has a different serological profile than PLN, possibly reflecting different pathogenesis. Renal function at one year predicts long-term outcome in LN.

Disclosure of Interests:

Filipa Farinha: None declared, Sofia C Barreira: None declared, Maura Couto: None declared, Margarida Cunha: None declared, Diogo Fonseca: None declared, Raquel Freitas: None declared, Luís Inês: None declared, Mariana Luis: None declared, Carla Macieira: None declared, Ana Rita Prata: None declared, Joana Rodrigues: None declared, Bernardo Santos: None declared, Rita Pinheiro Torres: None declared, Ruth J. Pepper: None declared, Anisur Rahman: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer

AB0749 COMPARING PATIENT-PHYSICIAN DISCORDANCE IN RA AND PsA PATIENTS

Background:

Patient global Assessment (PGA) of disease activity is considered a key patient reported outcome in Rheumatoid Arthritis (RA) and Psoriatic Arthritis (PsA), both being included in combined indices of disease activity. However, patients and physicians frequently disagree in their assessment.

Objectives:

This study aimed at comparing the degree of this discrepancy and its determinants in RA and PsA.

Methods:

Cross sectional study including 100 patients with RA (ACR/EULAR 2010 criteria) and 100 patients with PsA with predominant peripheral joint involvement (CASPAR criteria), aged ≥18 years, randomly selected from the electronic registry Reuma.pt. Data were collected from the most recent rheumatology visit during the last year: sociodemographic data, disease duration (years), tender and swollen joint counts 0-28 (TJC and SJC), disease activity (DAS28 3V-PCR), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), patient’s pain assessment, PGA and physician global assessment (PhGA). The discrepancy between patients and physicians (ΔPPhGA) was defined as PGA minus PhGA, and a difference > |20mm| was taken as “discordance”. Categorical variables are presented as proportions and continuous variables as mean (±SD). Patient and clinical characteristics were compared between patients with RA and PsA using t- test and χ2 test, as adequate. Variables with p<0.05 or clinically relevant were included in multivariable logistic regression analysis to identify correlates for ΔPPhGA in the whole sample. A p≤0.05 was considered statistically significant.

Results:

Compared to PsA, patients with RA were more often female (90% Vs 49%,p< 0.05), older (66.7 ± 10.7 Vs 58.3 ± 12.2 years,p< 0.05) and had a shorter disease duration (18.2 ± 9.8 Vs 19.9 ± 9.7 years,p= 0.202). Regarding disease activity, the RA and PsA groups were comparable: DAS28 3V-PCR (2.3 ± 0.9 Vs 2.4 ± 1.0,p= 0.34). Patients with RA had a higher mean ΔPPhGA (30.4 ± 30.6 Vs 25.4 ± 27.5,p< 0.05), and were more frequently discordant to the physician (69% Vs 51%,p< 0.05). In univariable analysis, having RA, higher patient’s pain assessment and higher ESR were associated to patient-physician discordance. In multivariable analysis, only patient’s pain assessment (OR 1.04 [95% CI 1.03-1.06], p = 0.00) and TJC (OR 0.82 [95% CI 0.68-0.97], p = 0.02) remained as predictors of discordance.

Conclusion:

Despite comparable disease activity scores in RA and PsA patients, RA patients tend to have a worst self-perception of their disease activity compared to their physician´s. Patient’s pain assessment and TJC were the only predictors of patient-physician discordance, irrespective of the disease.

Disclosure of Interests:

Luisa Brites: None declared, LILIANA SARAIVA: None declared, Flavio Costa: None declared, João Dinis de Freitas: None declared, Mariana Luis: None declared, Ana Rita Prata: None declared, Helena Assunção: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, João Rovisco: None declared, Catia Duarte: None declared

SAT0185 PREDICTORS OF POOR RENAL OUTCOME IN PATIENTS WITH PROLIFERATIVE LUPUS NEPHRITIS: A 36-MONTHS COHORT STUDY

Background:

The EULAR/ERA-EDTA recommendations for lupus nephritis (LN) state that renal response should be achieved within 12 months following induction therapy. However, there is an unmet need for early predictors of renal outcome in order to adjust the immunosuppression regimen and optimize the renal outcome.

Objectives:

To identify predictors of poor renal outcome at baseline, 3 months and 6 months after starting induction therapy.

Methods:

Retrospective cohort study over 36 months including patients with Systemic lupus erythematosus (SLE) fulfilling the ACR’97 and/or the SLICC’12 classification criteria and with biopsy-proven proliferative LN (class III/IV), enrolled in the CHUC Lupus Cohort from 1999 to 2018. Poor renal outcome was defined as longer time to complete renal response (CRR), characterized by proteinuria <0.5g/day and normal renal function, according to EULAR/ERA-EDTA criteria. Clinical-analytical characteristics at baseline, 3 months and 6 months after starting induction treatment were compared using survival analysis for time-to-CRR. Variables with p<0.25 on univariate analysis using Log-Rank tests were further evaluated as predictors applying multivariate Cox proportional hazards regression models (Backward Stepwise method, Wald-based) with estimation of hazard ratios (HR) and 95% confidence intervals (95%CI).

Results:

56 patients were included (76.8% female, age at LN diagnosis 30.0 ± 13.2 years). Over the follow-up, 51 patients (91.1%) achieved CRR, within a median time of 6.0 months. In multivariate analysis, predictors of poor renal outcome were proteinuria >2g/day at baseline (HR 1.98; 95%CI 1.04-3.77; p=0.037) and induction therapy with pulse cyclophosphamide (CYC), as compared to mycophenolate mofetil (MMF) (HR=2.05; 95%CI 1.07-3.94; p=0.030) (Figure 1). Diabetes mellitus (HR=6.0; 95%CI 1.24-29.07; p=0.026) and negative anti-RNP antibody (HR 3.17; 95%CI 1.27-7.93; p=0.013) at baseline predicted poor renal outcome at 3 months. At this timepoint, level of proteinuria and clearance rate were not predictive of renal response. At 6 months, no predictors of LN outcome were found for those patients that did not achieve CRR up to this timepoint. Use of glucocorticoid pulses and/or antihypertensive drugs did not predict LN outcome.

Figure 1.

Conclusion:

In this SLE cohort, most patients with proliferative LN achieved CRR. Proteinuria above 2 g/day at baseline and diabetes mellitus were predictors of poor renal outcome, while positive anti-RNP was protective. Induction treatment with CYC was associated with poorer outcome as compared with MMF. Given the retrospective non-randomized nature of this study, caution is needed when drawing conclusions regarding both treatments efficacy.

Disclosure of Interests:

Mariana Luis: None declared, Ana Rita Prata: None declared, Helena Assunção: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Luís Inês: None declared

SAT0593 ANA TESTING IN THE (VERY) ELDERLY: EXPECTATION VERSUS REALITY

Background:

Antinuclear antibodies (ANA) are frequently used as a screening tool for systemic autoimmune rheumatic diseases (SARD), although they are also present in 10-15% of the adult healthy population. SARD have their peak incidence in the young/ middle-aged adult. As age progresses, the incidence of SARD decreases while the prevalence of ANA tends to increase, with some series reporting up to 30% prevalence in older ages1.

Objectives:

To determine the clinical significance and utility of ANA testing in a population over 85 years of age.

Methods:

We conducted a retrospective study of patients over the age of 85 who underwent ANA testing due to a SARD suspicion at our hospital autoimmunity laboratory, from 2011 to 2018. Justification for ANA request was collected from patient’s clinical records. Patients with pre-established diagnosis of SARD and patients with no justification given for ANA request were excluded from the analysis. ANA titer (positive ≥ 1:160) and cellular staining patterns were assessed by indirect immunofluorescence (Hep-2 cells).

Results:

Ages ranged from 85 to 98 years, with 58.8% being females. The prevalence of ANA in this population was 61.5%, mostly in lower titers (1:160 in 45.0%, 1:320 in 31.9%, 1:640 in 20.3% and 1:1280 in 2.7%). Dense fine speckled pattern was by far the most common cellular staining pattern (79.1%). A suspicion of SARD was the reported reason for ANA testing in 34,5% (n=296) of the 854 patients submitted to this test. The main clinical clues justifying SARD suspicion were: arthralgia/arthritis (11.9%), thrombocytopenia (10.0%), pancytopenia (10.0%), spotless fever (8.2%), interstitial lung disease (4.8%), pleural (6.1%) and pericardial (4.1%) effusion. Over a median follow-up of 1.0 year, 10 patients (3.4%) were diagnosed with a SARD, only one being an ANA-related disease: 5 cases of polymyalgia rheumatica, 2 cases of rheumatoid arthritis, 1 case of giant cell arteritis, 1 case of Sjogren syndrome and 1 case of sarcoidosis. In 60% of patients with a confirmed SARD, the main reason for suspicion was the presence of arthralgia/ arthritis. Positive ANA testing showed a 90.0% sensitivity and a 39.6% specificity for SARD. This translates into a positive predictive value of 5.0%.

Conclusion:

ANA are highly prevalent in elderly patients under SARD suspicion, while the incidence of SARD is very low, which explains the low positive predictive value of ANA testing. Interestingly, only one among the ten cases of SARD confirmed was indeed an ANA-related disease (Sjogren syndrome).

References:

[1]Selmi C, Ceribelli A, Generali E, et al. Serum antinuclear and extractable nuclear antigen antibody prevalence and associated morbidity and mortality in the general population over 15 years.Autoimmun Rev. 2016;15(2):162–166. doi:10.1016/j.autrev.2015.10.007

Disclosure of Interests:

Mariana Luis: None declared, Anália Carmo: None declared, Rosário Cunha: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Tânia Santiago: None declared

THU0111 PHYSICIAN’S GLOBAL ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS: WHAT DO WE REALLY MEAN?

Background:

Physician’s global assessment of disease activity (PhGA) is included in some scores of disease activity and, demonstrably, plays a major role upon treatment decisions in rheumatoid arthritis (RA) [1, 2, 3]. Therefore, understanding the reasons underlying the physician´s assessment is crucial.

Objectives:

To understand the reasons underlying the physician´s assessment.

Methods:

Cross-sectional study, including consecutive RA patients followed in a Tertiary Rheumatology Department. Socio-demographic (age and gender) and clinical data were collected through a standardized protocol, including 28 tender (TJ28) and swollen (SJC28) joints count, C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Disease activity Score (DAS28-4v-CRP and DAS28-4v-ESR), PhGA and Patient Global Assessment of disease Activity (PGA) through a Visual Analogic Scale (VAS) 0-100mm, Health Assessment Questionnaire (HAQ), European Quality of Life-5 Dimensions (EQ-5D) and Hospital Anxiety and Depression Scale (HADS). Correlation between PhGA and other continuous variables was evaluated through Pearson´s Correlation Coefficient and variables with p<0.05 in univariate analysis were included in multivariable linear regression (stepwise model).

Results:

392 RA patients (80.6% female, 65.3±12.6 years) were included. PhGA was weakly correlated with CRP (r=0.23), TJC28 (r=0.35), PGA (r=0.26), HAQ (r=0.31) and EQ5D (r=-0.21). Moderate correlations were observed with SJC28 (r=0.45) and DAS-4V-CRP (r=0.48). In multivariable analysis, SJC28 (β=4.14, 95%CI:3.16-5.12), CRP (β=0.22; 95%CI: 0.02-0.03), HAQ (β=4.46, 95%CI:1.50-7.42) and PGA (β=0.08; 95%CI:0.00-0.16) remained as independent correlates of PhGA (R2=0.27, p<0,05).

Conclusion:

In this study, PhGA was associated with SJC28, CRP, HAQ and PGA, suggesting that physicians adopt a comprehensive reading of the disease into account. However, a large proportion of the variance of PhGA remains unexplained. Given its driving role in treatment decisions, the need to standardize and better understand PhGA seems to deserve a closer attention.

References:

[1]Ward MM, et al. Art Car Res. 2017;69(8):1260-5.

[2]Desthieux C, et al. Art Car Res (Hoboken). 2016;68(12):1767-73.

[3]Kaneko Y, et al. Mod Rheumatol. 2018;28(6):960-7.

Disclosure of Interests:

LILIANA SARAIVA: None declared, Luisa Brites: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Ana Rita Prata: None declared, Mariana Luis: None declared, Flavio Costa: None declared, Pedro Freitas: None declared, Marlene Sousa: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

SAT0029 PATIENT-PHYSICIAN DISCORDANCE IN ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS

Background:

In rheumatoid arthritis (RA), global disease activity is commonly assessed, from the patient’s and the physician’s perspective, through a 100mm VAS. Previous studies have commonly shown a considerable discrepancy between the patient’s and physician’s assessment.

Objectives:

This study aimed evaluating patient-physician discordance in the assessment of disease activity and to explore its determinants.

Methods:

Cross sectional study including RA patients (ACR/EULAR 2010 classification criteria), aged ≥ 18 years, followed in a single tertiary centre. Data were collected from the most recent evaluation including sociodemographic features, disease duration (years), disease activity (DAS 28 3V-PCR), tender and swollen joint count 0-28 (TJC and SJC), VAS-pain-patient, patient and physician global assessment (PGA and PhGA respectively), erythrocyte sedimentation rate (ESR), C-reactive protein (CPR), Health assessment questionnaire (HAQ) and EuroQol five-dimension scale (EQ5D). The discrepancy between patients and physicians (ΔPPhGA) was defined as PGA minus PhGA, and a difference > |20mm| was considered as “discordant”. A descriptive analysis was performed and variables described as proportions or means (+/- SD), as adequate. Correlation between ΔPPhGA and other variables was assessed through Pearson’s correlation and comparison between groups through t-test. Variables with p<0.05 or otherwise considered clinically relevant were included in multiple linear regression analysis to identify predictors for ΔPPhGA. A p≤0.05 was considered statistically significant.

Results:

In total, 467 patients with RA were included (81.2% female; mean age 63.9% ± 12.2 years). PGA and PhGA were discordant in 61.7% of the cases, the patient scoring higher than the physician in 95% of these cases. The proportion of concordance increased (p< 0.01) when considering only patients in remission (DAS 28 3V <2.6), (Graph 1). ΔPPhGA was moderately correlated with VAS-pain-patient (r = 0.59) and weakly correlated with SJC (r = -0.12), HAQ (r= 0.27), EQ5D (r = -0.28) and age (r = 0.21); all p<0.01. In multivariate analysis, VAS-pain-patient (β 0.74, 95% CI 0.62-0.88, p=0.00) and TJC (β 0.16, 95% CI 0.45-0.48, p=0.02) remained associated with a higher ΔPPhGA.

Conclusion:

Our study confirmed that a significant discrepancy between patients and physicians in the assessment of global disease activity is frequent in clinical practice, probably due to valorization of different parameters. This was much less pronounced among patients in remission. Higher VAS-pain-patient and TJC were independent predictors of greater discrepancy between patients and physician’s assessment.

Disclosure of Interests:

Luisa Brites: None declared, Flavio Costa: None declared, João Dinis de Freitas: None declared, Mariana Luis: None declared, Ana Rita Prata: None declared, Helena Assunção: None declared, LILIANA SARAIVA: None declared, Marlene Sousa: None declared, Ana Rita Cunha: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

Ultrasound measurement of anatomical parameters of the upper airway in adults

BACKGROUND

Most of the works on ultrasound airway anatomy are limited to a morphological description. A study was conducted in order to provide an objective normal range of measurements.

MATERIALS AND METHODS

Observational study to describe the ultrasound characteristics of the upper airway in adults without clinical difficult airway criteria, compared to cadaver dissection anatomical models.

RESULTS

The study included 45 volunteers (27 men and 18 women), and 3fresh cadavers. The quality of the examination was very good/good in 93% of the cases.

MEASUREMENTS

tracheal diameter (1.3±0.3cm), vocal cord (1.6±0.5cm), cricothyroid membrane (0.94±0.32cm), cricotracheal membrane (0.3±0.09cm), thickness of the muscles in the floor of the mouth (MFM) (1.5±0.26cm), sub-mandibular subcutaneous fat plus MFM (2.11±0.34cm), hyoid-mandible distance (5.35±0.69cm), palate-floor of the mouth distance (4.92±0.5cm), palate-anterior border of the mandible (5.51±0.7cm), and palate-pharynx angle (114±14). Observed differences: Males had a larger tracheal diameter than females (M: 1.4±0.3 vs. F: 1.2±0.2cm, p=0.014). Subject height showed a significant correlation with the tracheal diameter (R: 0.501, p<0.001), as well as the length of the vocal cord (R: 0.363, p=0.016), the thickness of MFM (R=0.299, p=0.046) as well as the hyoid-mandible (R: 0.556; p<0.001) and palate-mandible distances (R: 0.362; p=0.015).

CONCLUSIONS

Ultrasound allows the anatomy of upper airway to be evaluated, as well as to calculate distances between the anatomical structures. The study defines these distances in adult volunteers without clinical difficult airway criteria.

A predictive test for difficult intubation in laryngeal microsurgery. Validation study

BACKGROUND

In 2003 a simple test to detect difficult intubation (DI) in patients underwent laryngeal microsurgery was described. The present study was conducted to validate the test.

METHODS

Patients with laryngeal disease scheduled for laryngeal microsurgery were included. The variables evaluated were eleven parameters: Mallampati Score ≥III, thyromental distance <6.5cm, mouth opening <40mm, limitation of the temporomandibular joint, pathological dentition, arched paladet, maxillary deficiency, neck mobility <90°, body mass index, symptoms of laryngeal dysfunction, and tumour of supraglottic region. A rapid examination of the airway by an expert anaesthesiologist was carried out just before induction. DI was defined by a Cormack laryngeal view gradeiii-iv and/or if auxiliary equipment was required to achieve orotracheal intubation. A comparison of ROC curves was conducted to estimate the best predicting cut-off, as well as differences between the index described in 2003 and the rapid assessment by an expert anaesthesiologist.

RESULTS

One hundred and five patients were included in the study. The incidence of DI according to the predefined criteria was 45% (47 patients). The score at the cut-off of 5 provides a sensitivity of 89% and a specificity of 55%. The fast-evaluation by an expert anaesthesiologist obtained similar sensitivity (89%) and better specificity (81%). Area under curve (AUC) was 0.87, similar to a fast evaluation (AUC: 0.85; P=.71).

CONCLUSION

The index was validated at a cut-off of ≥5, being a useful and reliable test to predict DI in patients with laryngeal diseases and it is a useful tool for anaesthesiologists with conventional training.

Priapism associated with lumbar stenosis in a dog

Priapism, a persistent long-lasting involuntary erection of the penis, is uncommon in dogs. In this report, the case of a 13-year-old male Pointer, referred to our services due to persistent exposition of the penis, is described. This condition was consecutive to an intermittent priapism situation lasting for several days, which has been initially attributed to the inflammation and haematoma associated with a perianal bite. The owners became unable to retract the penis into the prepuce. At presentation, the dog was anorectic for 48 h, intolerant to manipulation, and showed poor body condition and unsteady locomotion. During physical evaluation, a marked engorgement of the local vessels in the prepuce and penis was found. An abdominal X-ray was asked under the suspicion of a neurogenic origin for the clinical situation, which showed evidences of spondylosis. After discussion of the clinical condition, the owners asked for euthanasia. The necropsy confirmed the engorgement of the regional vessels deriving from the pudendal arteries and blood accumulation within all the cavernous spaces, accompanied by congestion and thrombosis within the erectile structures of the penis. No significant changes were observed in the pelvic organs that could be at the origin of priapism. The lumbar-sacral spinal regions were carefully inspected and evidenced signs of L7-S1 stenosis due to spondylosis. The case presented herein is a rare situation of priapism of neurogenic origin in a dog. Necropsy findings suggest that it was consecutive to cauda equina compression due to lumbar spinal stenosis.

Right aortic arch with aberrant left subclavian artery and anomalous origin of right pulmonary artery from ascending aorta

The authors report a case of a neonate that was operated on with the diagnosis of right aortic arch and aberrant left subclavian artery and anomalous origin of right pulmonary artery from ascending aorta. Computed tomography (CT) scan suggested double aortic arch and cardiac catheterization suggested anomalous origin of right pulmonary artery from ascending aorta versus aorto-pulmonary window. The final diagnosis was made at the operation. There was a right aortic arch and aberrant left subclavian artery and persistent ductus arteriosus. Surgical repair consisted of section of the ductus arteriosus and reimplantation of the right pulmonary artery in the main pulmonary artery.

Gallic acid and tannase accumulation during fungal solid state culture of a tannin-rich desert plant (Larrea tridentata Cov.)

Larrea tridentata (Sesse & Mocino ex DC.) Coville, also known as Larrea, gobernadora, chaparral, or creosote bush, is a shrubby plant which dominates some areas of the desert southwest in the United States and Northern Mexico and its use has not been exploited and standardized. In this study, gobernadora was studied to evaluate its potential use for support of solid state culture. Influence of two minimal media added with gobernadora powder as the sole carbon source and inducer of tannin-degrading enzymes was evaluated. Cultures were initially 70% moisture, had a pH of 5.5 and were inoculated with Aspergillus niger Aa-20 at 2 x 10(7) spores per gram of media. Analysis of pH, moisture, tannin uptake, gallic acid accumulation and tannase production were evaluated. Results indicated a high content of condensed (39.4%dm) and hydrolysable (22.8%dm) tannins. Invasion capacity of fungal growth was of 0.15 mmh(-1). Tannase production reached values of 1040 Ul(-1) at 43 h of culture. During the first 48 h of culture, the concentration of gallic acid accumulation was 0.33 gl(-1). Gobernadora is a potential source of gallic acid and tannase production by solid state culture; however, further optimization of the process is needed.

[Incidence of pain upon injection of a new formula of propofol in a fat emulsion of medium- and long-chain triglycerides]

OBJECTIVE

To study the incidence of pain upon injection of 1% propofol (Propofol-Lipuro 1%, B. Braun, Melsungen, Germany) in a 10% fat emulsion containing equal proportions (50:50) of medium- and long-chain triglycerides.

PATIENTS AND METHODS

The subjects were 600 adult patients scheduled for elective surgery. The use of premedication was left to the discretion of the anesthesiologist. All patients received the study anesthetic injected slowly (20-40 mg per 10 seconds) at a dose of 1.5 to 2.5 mg/Kg. Variables recorded were incidence and type of pain upon administering the anesthetic, the patients' clinical characteristics, premedication administered, and method of venous puncture. Bivariate and multivariate statistical analyses were performed to determine factors associated with the appearance of pain.

RESULTS

The overall incidence of pain upon administration of propofol-lipuro was 27%. Pain was moderate to intense in 9%. Premedication did not affect the incidence of pain with injection. The risk factors that predicted the appearance of pain were injection through a small-caliber catheter (> 18 G) and injection on the dorsal hand (P < 0.05).

CONCLUSIONS

The incidence of pain upon injection of propofol-lipuro is low in comparison with incidence rates reported in the literature for the traditional formula, but administration of the fat emulsion formula through a vein on the dorsal side of the hand or through a venous catheter smaller than 18 G should be avoided. Double-blind randomized controlled trials should be conducted to clarify the advantages that propofol-lipuro seems to offer.

Airway ignition during CO2 laser laryngeal surgery and high frequency jet ventilation

We present a case of a patient submitted for extirpation of a neoplasm of the larynx, by means of carbon dioxide laser surgery. High frequency jet ventilation was applied by means of orotracheal intubation with two Teflon catheters, 2 mm in external diameter and 30 cm in length, attached with three equally placed strips of adhesive paper tape. One catheter was used to inject the jet volume and the other used to measure the airway pressure. The adhesive strips were moistened and FiO2 was lower than 50%. After 30 min using the laser, an airway fire was noticed. Ventilation was interrupted and the catheters were removed. The patient was reintubated with an endotracheal tube of 6 mm ID and the surgical procedure was continued until the tumour was removed. Two factors contributed to the airway fire: the ignition of the lowest adhesive strip that had dried and the use of the laser in the mode of continuous pulsation.

Comparison of two schedules for administering oral low-dose methotrexate (weekly versus every-other-week) in patients with rheumatoid arthritis in remission: a twenty-four week, single blind, randomized study

OBJECTIVE

To compare the efficacy of 2 low-dose oral methotrexate (MTX) schedules in maintaining remission in patients with rheumatoid arthritis (RA).

METHODS

Patients with RA were included if they were receiving treatment with weekly MTX for at least 9 months and the RA was in remission (defined by American College of Rheumatology [ACR] criteria) for at least 6 months. Patients were stratified by treatment and randomly assigned to weekly or every-other-weekly (EOW; reducing their monthly dose by half) treatment with MTX. Patients were evaluated by a rheumatologist (blinded to the treatment schedule) at baseline and at 6, 12, and 24 weeks. The evaluations included joint counts, Ritchie Articular Index, Health Assessment Questionnaire Disability Index, physician's and patient's global health assessments, visual analog scale for pain, and incidence of adverse effects. Laboratory evaluations were done at baseline and at week 24.

RESULTS

Fifty-one patients were included (26 taking weekly MTX, 25 taking EOW MTX). Baseline comparisons showed no differences between the groups. The mean duration of RA was <3 years in both groups, and they had been started on weekly MTX treatment early after diagnosis. After 24 weeks, >90% of the patients in both groups continued in remission. Evaluations of disease activity at 6 and 12 weeks showed no between-group differences. EOW MTX patients who experienced relapse were switched back to weekly MTX, and after a few weeks, their RA was again controlled. The incidence of adverse effects was slightly higher in the weekly MTX group, although the difference did not reach statistical significance. The observed laboratory values were very similar for both groups, except for the serum aspartate aminotransferase and alanine aminotransferase levels, which decreased in the EOW MTX group and were statistically significant at week 24 (P = 0.04 and P = 0.006, respectively).

CONCLUSION

EOW MTX represents a valid therapeutic alternative for a specific subgroup of RA patients, as outlined by the ACR remission criteria. Patients with a short disease duration who were treated early after disease onset with weekly MTX and who achieve sustained remission have a higher probability of success with the EOW MTX schedule.

[Profile of the patient who drops out of neuropediatric follow-up]

INTRODUCTION

Patients who drop out of programmed follow-up cause adverse effects to both themselves and the running of the medical.

OBJECTIVE

To obtain information which would permit us to modify guidelines for medical care in cases with particular diagnoses, so as to avoid interrupting follow-up.

PATIENTS AND METHODS

We selected all the patients who attended during 1995, and on 31 December 1995 had not been discharged or died. We considered a patient to have dropped out of follow-up when there was failure to attend the centre during two consecutive years without a justifiable reason. Logistic regression analysis was used to determine the profile of the patients who dropped out of follow-up.

RESULTS

Of the patients attended during one year and whose treatment should have been continued, 16% dropped out; 70% of those who dropped out of their follow-up treatment were somewhat older than the rest and came in particular from two of the five health districts of the province. They had tics, tension headaches and migraine. Only three independent factors are associated with dropping out: absence of complementary tests, which is favorable, and epilepsy or previous long-term follow-up which is unfavorable.

CONCLUSION

Reduction in the programmed follow-up of patients with conditions which do not require complementary tests may reduce the drop out rate and improve the functioning of the Neuropaediatric Clinic.

Intraoperative respiratory failure in a patient after treatment with bleomycin: previous and current intraoperative exposure to 50% oxygen

Patients treated with bleomycin (BLM) are at risk of developing acute respiratory distress syndrome (ARDS) post-operatively, and this has been associated with high intraoperative concentrations of oxygen. We report progressive arterial desaturation noticeable 2 h after the start of a 4-h radical neck dissection for which the anaesthesia included 50% O2 in N2O. The patient had received two courses of bleomycin within the previous 2 months and had undergone an uneventful right hemiglossectomy under shorter but otherwise similar anaesthesia 4 weeks previously. His pulmonary function tests before the second procedure showed a slight depression of diffusing capacity (DLco) to 80% of predicted and minimal airway obstruction consistent with his history of smoking. The pulse oximetric reading during his second procedure reached 75%, but rose to 95% after treatment with methylprednisolone salbutamol and inspired O2 concentrations between 80% and 100%. By the end of the procedure, he satisfied the criteria for ARDS and was transferred to the ICU, where he developed bilateral pneumonia, deteriorated and died of multiple organ failure. This case suggests that the risk of hyperoxic pulmonary damage in patients exposed to bleomycin may increase not only with the degree and duration of hyperoxia in a given exposure, but also with the latent effects of recent previous exposure. Near normality of pulmonary function tests cannot be taken as reassurance, and small changes may have more adverse prognostic significance than in patients who have not been exposed to bleomycin.

Effects of anesthetic technique on the hemodynamic response to microlaryngeal surgery

Our aim was to study the attenuation of the hemodynamic response to microlaryngeal surgery by beta-blocking agents used as support drugs to the anesthetic technique. The study was carried out in 30 patients randomly allocated to one of three groups. The control group received only anesthetic drugs. The second group received labetalol hydrochloride 0.3 mg/kg 3 minutes before induction and 0.15 mg/ kg 2 minutes prior to the start of suspension of the larynx. The third group received esmolol hydrochloride 500 micrograms/kg 3 minutes prior to induction and a continuous infusion of 300 micrograms/kg during the surgical procedure. Hemodynamic data in the three groups were compared by analysis of variance. A statistically significant difference (p < .05) was found in hemodynamic data among the two groups treated with blocking agents and the control group. The addition of beta-blocking agents to the anesthetic technique attenuates the hemodynamic response to suspension laryngoscopy.

[Comparative study of high-frequency jet ventilation in 4 types of patients undergoing laryngeal microsurgery]

OBJECTIVE

To study high frequency jet ventilation (HFJV) in patients with chronic obstructive pulmonary disease (COPD) who are obese or who have tracheal or laryngeal stenosis, conditions which are often found in patients undergoing microsurgery of the larynx (MSL), comparing the results with those for a group of controls, patients with no stenosis who were also undergoing MSL.

PATIENTS AND METHOD

Eighty patients were distributed in four groups as follows: those meeting the criteria for a diagnosis of COPD (n = 20), those who were overweight (n = 24), those with stenosis over 50% of the laryngeal opening (stenosis group, n = 10) and those with no associated pathology (control group, n = 26). HFJV was administered through a 2.2 mm internal diameter orotracheal injection catheter, using an Ergojet CVT (Temel, S.A.). The ventilatory protocol was as follows: rate 100 breaths/min, inspiratory time 30%, generator pressure (GP) 2.2 to 3.3 kg/cm2 and FiO2 70% to 90%. We analyzed the GP administered, jet volume (Vjet) delivered, maximum (PAWmax) and minimum (PAWmin) airway pressures, oxygen hemoglobin saturation (SpO2), partial pressures of O2 (pO2) and CO2 (pCO2) in arterial blood, and end-tidal pressure of CO2 (PETCO2) at baseline and 10 and 20 min after the start of HFJV. Because monitoring was invasive, the study was designed for a small series of patients and we believe it should not be generalized to include all patients undergoing MSL under normal conditions.

RESULTS

HFJV had to be abandoned and conventional ventilation used in 4 patients (2 in the COPD group and 2 in the obese group). Ventilation was judged adequate in the remaining patients, with the observations that in the COPD group, pO2 levels were lower than in the control group at the 10 min readings and pCO2 levels were higher at both the 10 and 20 min readings. PAW levels were higher throughout the procedure in both the COPD and stenosis groups. In the obese patients, pCO2 was higher at both the 10 and 20 min recordings.

CONCLUSION

HFJV provides effective ventilation for most patients undergoing MSL, even if they are obese or have COPD or laryngeal stenosis.

[External laryngeal injuries. Study of 12 cases]

Laryngeal trauma can cause severe, life-threatening damage in the upper respiratory tract. Management of trauma presents difficulties with respect to airway control and the procedural decisions are challenging. We studied 12 patients treated at our hospital after laryngeal trauma of various degrees of severity. Respiratory failure detected in some cases was critical from the moment of trauma, whereas other patients were asymptomatic at first but experienced progressive respiratory failure over the next few hours. We looked at the method applied to gain initial control of the upper airway and also considered the laryngeal lesions themselves, associated lesions and established treatment. We then looked for relationships between these and evolution and laryngeal sequelae 6 months after trauma. In agreement with other studies we found that the severity of sequelae depends on the severity of the lesion incurred and on how early treatment is established. The choice of whether to use orotracheal intubation or tracheotomy to control the upper airway was less important, as that decision would depend largely on severity of the lesion, although orotracheal intubation is recommended whenever possible.

[Comparative study between anesthesia by continuous perfusion with propofol or thiopental-isoflurane in laryngeal surgery]

OBJECTIVE

To compare two anesthetic protocols for maintenance of anesthesia during laryngectomy (propofol vs thiopental-isoflurane), assessing its effects on intraoperative hemodynamic stability and recovery time after withdrawal of anesthesia.

PATIENTS AND METHOD

Thirty-one patients undergoing laryngectomy. Anesthetic technique was the same except for the maintenance anesthetic used (isoflurane in group I [n = 16]; propofol in group P [n = 15]). We recorded heart rate and systolic/diastolic arterial pressure before surgery, 10 minutes after induction, at 10, 60 and 120 min after start of surgery and at the end of the procedure. Postanesthesia recovery time was measured by the Steward test (recovery of consciousness, control of voluntary movement and of breathing) applied at 3, 5, 10, 30 and 60 min after withdrawal of anesthesia.

RESULTS

There were no demographic differences between the two groups and heart rate and systolic/diastolic pressures were comparable. Postanesthetic recovery time was shorter in group P than in group I, with a statistically significant difference 5 min after withdrawal of drug (p < 0.05) owing to the item recovery of consciousness in the Steward test (p < 0.05 at times 5 and 10 min for this item). There were no significant differences in control of breathing or movement.

CONCLUSIONS

Propofol for anesthetic maintenance is effective and safe. There are no differences in hemodynamic changes produced by propofol and isoflurane. Time until recovery of consciousness is longer with isoflurane, although we believe that this is not clinically relevant in this type of procedure.

The effect of ketanserin on post-anaesthetic vasoconstriction and shivering

Two homogeneous groups of 20 healthy women submitted to elective gynaecological surgery, who presented after anaesthesia with peripheral vasoconstriction and shivering, were included in a randomized, double-blind study. The first group received 10 mg ketanserin, a new pure antagonist of serotoninergic S2 receptors. The second group received 10 ml saline as placebo. Blood pressure, heart rate, pulse wave amplitude, and rectal and cutaneous temperatures were measured before and 5, 15 and 30 min after treatment. Vasoconstriction, shivering and discomfort were classified as intense, moderate or absent at these times. Venous and arterial blood gases were determined before and 15 min after treatment. Blood pressure and heart rate decreased slightly after ketanserin administration and this decrease was statistically significant. Increases in rectal temperature were similar in both groups. Peripheral temperature, measured in the big toe, significantly decreased in the placebo group but did not change after ketanserin. Vasoconstriction, shivering, discomfort and pulse wave amplitude improved significantly following ketanserin. We conclude that ketanserin may be effective in treating this post-operative complication, the possible mechanism being the vasodilatation it causes; a central serotoninergic blockade could also be implied.

Sacro-iliitis in a heroin addict. A contra-indication to spinal anaesthesia

A case is presented of a pregnant heroin addict patient, with a septic sacro-iliitis due to Staphylococcus aureus. The incidence of joint infections in heroin addicts and the difficulty of diagnosis is discussed with the potential risks of spinal or extradural anaesthesia when there is infection in joints close to the needle site. Caution is advised with patients addicted to heroin who have low back pain and may have infectious sacro-iliitis.