Trends in severe outcomes in SARS-CoV-2-positive hospitalized patients with rheumatic diseases: a monocentric observational and case-control study in northern Italy

Rheumatic disease patients are at greater risk of infection due to their disease, comorbidities, and immunosuppressive therapy. COVID-19 outcomes in this patient setting appeared to be similar to those of the general population. However, data on this topic were mainly related to small studies on a limited number of patients. Consequently, to date, this field remains poorly explored, particularly in the pre-vaccine era. This monocentric study aimed to describe the intrahospital mortality in rheumatic patients with SARS-CoV-2 consecutively hospitalized from 21 February to 31 December 2020, before anti-SARS-CoV-2 vaccine administration spread, compared with non-rheumatic patients. Of 2491 included patients, 65 [3%, median (interquartile range) age 75 (64.76-82.239 years, 65% women] were suffering from rheumatic diseases. A total of 20 deaths were reported [case fatality rate 31%, 95% confidence interval (CI): 19-42] compared with 433 deaths (19%, 95% CI: 17-20) in patients without rheumatic diseases (p=0.024). However, the rheumatic disease was not associated with a significant increase in univariate mortality hazards (hazard ratio 1.374, 95% CI: 0.876-2.154), and after adjustment (hazard ratio 1.199, 95% CI: 0.759-1.894) by age, sex and Charlson comorbidity index. The incidence of intensive care unit admission, death, and discharge in the case-control study was comparable between rheumatic and non-rheumatic patients. The presence of rheumatic diseases in SARS-CoV-2-hospitalized patients did not represent an independent risk factor for severe disease or mortality.

Atrial fibrillation incidence in SARS-CoV-2 infected patients: predictors and relationship with in-hospital mortality

Background

Among the different CardioVascular (CV) manifestation of the COronaVIrus-related Disease (COVID) particular attention has been paid to arrhythmia and particularly to Atrial fibrillation (AF). The aim of our study was to assess the incidence of AF episodes in patients hospitalized for COVID and to evaluate its predictors and its relationship with in-hospital all-cause mortality.

Methods

We enrolled 3435 cases of SARS-CoV2 infection admitted in four hospitals in Northern Italy. We collected data on clinical history, vital signs, Intensive Care Unit (ICU) admission, laboratory tests and pharmacological treatment. AF incident and all-cause in-hospital mortality were considered as outcomes.

Results

145 (4.2%) patients develop AF during hospitalization, with a median time of 3 days (IQR: 0, 11.5) from admission. Incident AF patients were older and had lower eGFR, lower platelet and lymphocytes count and higher C-Reactive Protein (CRP), were admitted more frequently to ICU and more frequently died compared to subjects that didn't present AF. At the Cox regression model significant determinants of incident AF were older age (HR 1.070; 95% CI: 1.048, 1.092), history of AF (HR 2.800; 95% CI: 1.465, 5.351), ischemic heart disease (HR 0.324; 95% CI: 0.130, 0.811) and ICU admission (HR 8.030; 95% CI: 4.511, 14.292). Incident AF was a predictor of all-cause mortality (HR 1.679; 95% CI: 1.170, 2.410), together with age (HR 1.053; 95% CI: 1.042, 1.065), dementia (HR 1.553; 95% CI 1.151, 2.095), platelet count (HR 0.997; 95% CI: 0.996, 0.999) higher CRP (HR 1.004; 95% CI: 1.003, 1.005) and eGFR (HR: 0.991; 95% CI: 0.986, 0.996)

Conclusion

AF present as the main arrhythmia in COVID-19 patients and its development during the hospitalization strongly relates with in-hospital mortality.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): ASST GOM Niguarda Ca' Granda, Milan, Italy

AB0641 An ultrasonographic study of the salivary glands in a cohort of patients affected by cryoglobulinemia vasculitis: preliminary results

Background

Xerostomia and xerophthalmia can occur in many diseases, rheumatological or not and are often reported by patients affected by cryoglobulinemia vasculitis1, particularly if related to the Hepatitis C virus infection (HCV)2. On the other hand, the Ultrasound (US) was extensively used for detecting pathological findings of the salivary glands3, possibly associated to many rheumatological diseases.

Objectives

The aim of this study was to detect, in patients affected by cryoglobulinemia vasculitis, the presence and the grade of pathological findings at level of the major salivary glands.

Methods

From January to December 2021, we enrolled consecutive oupatients patients affected by cryoglobulinemia (age ≥ 18 yo and a diagnosis of cryoglobulinemia vasculitis according to 2002 or 2011 classification criteria). Exclusion criteria were a previous diagnosis of other vasculitis/connective tissue diseases/inflammatory arthropathies, concomitant not rheumatological diseases or the intake of drugs possibly related to sicca syndrome symptoms. For each patient, the demographic, anthropometric and clinical history data, particularly about the cryoglobulinemia symptoms (either previous and ongoing) and past or current therapies have been collected. Furthermore, the values of erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], Rheumatoid Factor [RF] and C4 serum complement fraction have been recorded. The presence and the titre of the cryoglobulins have been recorded. For each patient, the Schirmer’s Test and the evaluation of the unstimulated whole salivary (UWS) flow were performed. The Schirmer Test was considered positive if < 5 mm/min at least in one eye and the UWS flow was defined pathological if < 1,5 ml/15 min.

Each patient was submitted to the US examination (Esaote MyLab Twice) of both parotid and submandibular glands. Each gland was evaluated using a semiquantitative score 0-3, according to the OMERACT definitions3. The US score was considered pathological if ≥2. Thus, at patient level, a sum dichotomous score (normal/pathological>) was provided, defining it as “pathological” if any parotid or submandibular glands scored ≥ 2.

Results

We enrolled 20 patients, all females, with a mean age of 68.8 years (SD± 13.32) and a mean disease duration of 11.76 (SD±8.25). For 18 patients was reported a previous HCV infection. 16/18 HCV + subjects reached the remission of the infection with undetectable HCV viremia. Among the patients enrolled, 10 referred at least one syndrome sicca symptom: 5 patients both xerostomia and xerophthalmia, 4 only xerostomia and 1 only xeropthalmia. Considering blood tests, the cryoglobulins were detected in 14, the ESR title was above the limit in 7 patients and the CRP in 3. The RF was detected in 12 subjects. The Schirmer’s test was pathological in 9 patients while the UWS flow was under the limit in 3. As regards the US reports, 2 patients had pathological features scored as≥2, while 7 patients showed minor alterations scored as 1. So, according to the sum score, only 2 patients were classified as pathological. No correlations were identified between the clinical and the US data.

Conclusion

In this cohort of patients with cryoglobulinemia, the US mainly showed mild pathological features at level of the parotid and submandibular structure, suggesting that syndrome sicca symptoms could be related to different pathological mechanisms in these patients, possibly strongly associated to HCV infection. Further and larger studies are necessary to confirm our preliminary data.

References

[1]Baer AN et al, Rheum Dis Clin North Am. 2018

[2]Sebastiani M et al, Current Drug Targets 2017

[3]La Paglia G et al, Clin Rheumatology 2019

Disclosure of Interests

Antonella Adinolfi Speakers bureau: BMS, Paid instructor for: Janseen, Nicola Ughi Speakers bureau: ROCHE, PFIZER, ALFASIGMA, ABBVIE, GALAPAGOS, BRISTOL MYERS SQUIBB, Paid instructor for: JANSSEN, Davide Antonio Filippini: None declared, Michel Chevallard: None declared, Laura Belloli: None declared, Cinzia Casu: None declared, Maria Di Cicco: None declared, Clizia Gagliardi: None declared, Maria Chiara Gerardi Speakers bureau: Eli-Lilly, Marina Muscarà: None declared, Elisa Verduci: None declared, oscar massimiliano epis: None declared

POS1543-HPR Joining Telemedicine Services in Rheumatology: the Role Played by Personalized Experience From Patients’ Perspective

Background

With the beginning of the Covid-19 pandemic, many hospital departments worldwide, including rheumatology ones, were forced to implement telemedicine strategies. Telemedicine revealed to be an umbrella term, with various practical implementations and different degrees of preparedness1. Some practitioners were already familiar with telemedicine, as in the case of the Rheumatology Unit of ASST Niguarda Hospital in Milan (Italy), where telemedicine projects have been implemented for more than a decade with structured design and organized processes. Moreover, patients in Niguarda have experimented telemedicine with personalized mixes of channels, including e-mails and phone calls, Patient Reported Outcomes questionnaires, and home delivery of drugs. This represents a paradigmatic case study that enables us to deepen essential questions on the success of telemedicine.

Objectives

Given that the last decision on joining telemedicine rests with patients2, we decided to adopt their perspective. We deepened three main aspects: i) the benefits perceived, ii) the willingness to enrol in future projects, iii) the preference on the service-mix, i.e., on-distance contacts rather than in-person visits. Most importantly, we investigated differences in the three areas among all patients based on the type of personalized experience had.

Methods

We conducted a survey from November 2021 to January 2022, enrolling randomly outpatients who attended the rheumatology unit for any reason. The survey originated from well-known surveys, such as the TeleHealth Usability Questionnaire3 and the Intention to use telehealth services4. However, we decided to overcome the usual separation that makes surveys addressed either to users or no users of telemedicine. Our survey comprised an introductory set of questions related to personal, social, clinical and ICT skills information, followed by the central part on telemedicine, which explored the three areas mentioned: benefits, adherence, preferences on service-mix. For this part, questions were the same for all patients apart from the tense used, being conditional tense for no-users and past tense for users. All the answers were analysed with descriptive statistics and regression models.

Results

A complete response was given by 400 patients: 71% were female, 59% were 40-64 years old, 53% of them declared to work, and the diseases most represented were Rheumatoid Arthritis (36%) and Osteoporosis/arthrosis (21%).

The descriptive statistics revealed interesting differences between users and no users, e.g., the desire to participate in future projects was stated by 95% of users, 81% of no users. These results were confirmed by multivariate logistic regression models that controlled for the influencing patients’ characteristics (such as being old or a frequent hospital attender).

It emerged that no-users imagined wide-ranging benefits. As for the willingness to participate to future telehealth projects, even if personal characteristics showed an impact (e.g., being a worker increased the probability to adhere), other things being equal, having had a more intense experience of telemedicine increased the odds of accepting by 3.1 times (95% C.I. 1.04-9.25), compared to no users. Furthermore, the more telemedicine was experienced, the higher the willingness to substitute in-person with online contacts.

Conclusion

Our study contributes to enlighten the crucial role played by the telemedicine experience in determining patients’ preferences. On one side, users appeared more aware of the realistic benefits to be expected from telemedicine. On the other side, it seemed that the more telemedicine was experienced, the higher the willingness to adhere to future projects and to increase on-distance contacts.

References

[1]Hashiguchi T.C.O. 2020. Bringing health care to the patient: An overview of the use of telemedicine in OECD countries.

[2]Eze ND et al. 2020 PloS one

[3]ParmantoB, et al. 2016 International journal of telerehabilitation

[4]Ghaddar S et al. 2020 Journal of Medical Internet Research

Acknowledgements

This study would not have been possible without the support of the whole staff of the Rheumatology unit who contributed to the distribution of the survey

Disclosure of Interests

Elisabetta Listorti: None declared, Lucia Ferrara: None declared, Antonella Adinolfi Speakers bureau: Janssen, BMS, Maria Chiara Gerardi: None declared, Nicola Ughi Speakers bureau: ROCHE, PFIZER, ALFASIGMA, ABBVIE, JANSSEN, GALAPAGOS, BRISTOL MYERS SQUIBB, Valeria Tozzi: None declared, oscar massimiliano epis: None declared

AB1406 TELERHEUMATOLOGY FOR IMPROVING FIRST ACCESS TO THE OUTPATIENT CLINIC: A PILOT PROSPECTIVE MONOCENTRIC ITALIAN STUDY

Background

The COVID-19 public health emergency has amplified both the potential value and the challenges with healthcare providers deploying telehealth solutions. Furthermore, outpatients may wait up to several months for their first appointment with specialists including rheumatologists for diseases other than COVID-19. In Italy it is now possible to get access to telemedicine services within the national healthcare systems, yet only follow-up visits are allowed for reimbursement purposes. Instead, it is not clear the role of telemedicine as a tool for improving first access and patient acceptance of this innovation.

Objectives

To investigate the feasibility of a ‘teletriagerheum’ service before the first visit and to identify potential benefits and disadvantages of it by comparing first face-to-face visit preceded by ‘teletriagerheum’ service to regular first visit without it.

Methods

A pilot prospective monocentric study was conducted. Consecutive patients were contacted by phone 30 days before the scheduled rheumatological first visit by administrative staff to investigate their willingness to receive 20 days before the first visit a phone call (‘teletriagerheum’ service) by a physician of the Rheumatology Unit. The ‘teletriagerheum’ service aimed at investigating the reason for the visit and at prescribing additional exams or specialistic consultations before the face-to-face first visit to facilitate the diagnosis process or anticipate the appointment in case of urgency. Socio-demographic characteristics, reason for referral, face-to-face visit duration, number of additional exams prescribed, number of definite diagnosis at first visit in the ‘teletriagerheum’ group were compared to the ones receiving regular first visit without ‘teletriagerheum’ service.

Results

In October 2021 a total of 102 patients were phone called by administrative staff: 18 (17.6%) did not answer for a maximum of three times, 9 (8.8%) responded but refused the ‘teletriagerheum’ service (6 cancelled the visit, 1 postponed, 2 for unknown reason) and 75 (73.5%) accepted the service, but 21 were not real first visits and 8 patients did not answer the call of physician. Among the remaining 46 (45.1%) pts (the ‘teletriagerheum’ group) the median call time was 11.5 minutes (IQR 5-15 min), blood exams were prescribed to 34 (74%) and instrumental exams to 8 (17.4%). Further consultation was prescribed only to 1 patient and the visit was not anticipated in any case. A preliminary diagnosis was possible in 36 (78.2%). In most of the cases (33, 76%) no difficulties were reported by the physician, in 7 (16.3%) there were difficulties in communication, in 1 (2.3%) difficulty to get the history from a patient suffering from a psychiatric disorder. Socio-demographic characteristics, Information and communication technologies skills, face-to-face visit duration were not statistically different between the ‘teletriagerheum’ group (46 pts) and the group receiving regular first visit without ‘teletriagerheum’ service (52 pts).

In the ‘teletriagerheum’ group, a lower number of blood exams (14% vs 46%, p<0.005) and a lower number of instrumental exams (25% vs 45%, p=0.04) were prescribed during the face-to-face first visit; a higher percentage of definitive diagnosis (79% vs 67%, whilst not statistically significant p=0.2) and a lower number of patients requiring a visit before 6 months (26% vs 54%, p<0.05) were observed compared to the group without teletriagerheum service.

Conclusion

These preliminary data showed that telemedicine for the first rheumatological visit was well-accepted by patients searching for rheumatology consultations and had the potential to be a tool for improving clinical diagnosis and rheumatological follow up in everyday clinical practice. A larger cohort will let us to further explore the potential benefits of telemedicine to improve accessibility to rheumatological services.

References:

-

Disclosure of Interests

None declared

Sick leave request following anti-COVID-19 vaccine administration is low among healthcare workers: results from a retrospective cross-sectional monocentric study

OBJECTIVE

Anti-COVID-19 vaccines were mainly associated with non-serious adverse events (AEs), whose prevalence was reported to be up to 70% in healthcare workers (HCWs). This may lead to sick leave requests, but this impact has never been quantified. This study aimed to investigate the absence from work among HCWs following anti-COVID-19 vaccination. Its association with age and previous COVID-19 infection was also assessed.

PATIENTS AND METHODS

This is a retrospective observational cross-sectional study on administrative data about sick leave requests after anti-COVID-19 vaccination. All the HCWs employed at the Niguarda Hospital (Milan, Italy) who received the vaccine from December 27, 2020 to February 28, 2021 were included.

RESULTS

In total, 4,088 HCWs received the first dose of the vaccine and 4,043 completed the vaccination cycle. After the first injection, 1.6% of HCWs requested sick leave, while after the second injection, the number of requests significantly increased (+6.1%, p<0.001). A significant increase in sick leave was detected for those who have had SARS-CoV-2 infection after the first injection (+2.3%, p<0.001). After the second dose, a significant increase in sick leave was observed in the 20-30-year-old group compared to >30 years (+3.6%, p=0.017), if HCWs without a history of SARS-CoV-2 infection were considered.

CONCLUSIONS

The requests for sick leave among HCWs following the anti-COVID-19 vaccine were limited and higher after the second injection. This may help the management of the human resources when the large-scale administration of the anti-COVID-19 vaccines will involve other categories of workers.

Host factors and history of SARS-CoV-2 infection impact the reactogenicity of BNT162b2 mRNA vaccine: results from a cross-sectional survey on 7,014 workers in healthcare

OBJECTIVE

This study aimed to improve the post-marketing surveillance on mRNA anti-SARS-CoV-2 vaccines, characterizing the adverse events (AEs) after the first dose of mRNA BNT162b vaccine. The associations between the AEs and individuals' characteristics were explored.

PATIENTS AND METHODS

All adult healthcare workers at Niguarda Hospital (Milan, Italy) who were referred for the first dose of vaccine were offered to participate in a cross-sectional survey during the second-dose administration, between 18 January and 7 February 2021. All participants completed a questionnaire about age, gender, weight, height, medical history, concurrent therapies, employment status, previous diagnosis/testing for SARS-CoV-2 infection, and a list of 24 AEs (solicited AEs). The development of at least one solicited AEs was the main outcome. AEs were stratified by the presence of injection-site symptoms, systemic symptoms or both, and the differences between strata were assessed as a secondary outcome. Biometric data and reports of a previous diagnosis of SARS-CoV-2 infection were also explored, as predictors of the main outcome.

RESULTS

7,014 healthcare workers were included. An incidence of 3 per 10.000 persons for serious AEs following the first administration of the mRNA BNT162b vaccine was found. An association between the development of non-serious AEs with young age, female gender, low body mass index, and previous history of SARS-CoV-2 was described.

CONCLUSIONS

This real-life study supported data on the safety profile of the BNT162b2 mRNA vaccine. Our findings on the associations between the development of non-serious AEs with some individual characteristics may help physicians and patients make educated and informed medical decisions towards anti-COVID-19 vaccination.

THU0590 WHEN RARE IS EVEN RARER: A COMPLEX CASE OF BEHCET DISEASE

Background:

Behcet disease is a rare inflammatory disorder with the unique ability to affect vessels of any size. The disease could be associated to thrombosis in both the venous and arterial compartment, and often aneurysms. In particular, the presence of aneurysms of the pulmonary artery is rarely, if ever, seen in conditions other than Behcet. Cardiac involvement, albeit uncommon, is also described and associated to a severe prognosis. The treatment is based on immunosuppressants, meanwhile the use of anticoagulants -especially when aneurysms are present- is debated.

Objectives:

To describe a complex case of Behcet disease.

Methods:

We report the case of a 45 years old man of Chinese origin who presented to A&E with fever and acute dyspnea. Blood test revealed raised ESR and CRP and raised neutrophil count. Chest X rays showed bilateral opacities suggesting pneumonia. The patient did not improve over the course of antibiotics. Later on, he presented with an episode of hemoptysis and worsening dyspnea, so he was admitted to the Intensive Care Unit. CT showed bilateral pulmonary thromboembolism and aneurysm of the pulmonary artery. Echocardiogram and cardio-MRI revealed a large, mobile thrombus within the right atrium. Extensive work-up for infections and cancer was unrevealing. ANA, ENA and ANCA antibodies were negative. On the basis of a past medical history of recurrent oral ulcers and papulopustular skin lesions that patient admitted on questioning, a diagnosis of Behcet disease was suspected. In keeping with that, HLA-B51 turned out positive. The patient was promptly started on IV steroid pulses followed by Cyclophosphamide 1 gr IV monthly for six months, then on IV anti-TNF alpha Infliximab. He was also commenced on low molecular weight heparin (LMWH) and subsequently direct factor Xa inhibitor Apixaban.

Results:

The patient improved significantly with progressive regression of the pulmonary CT changes. He was discharged and able to get back to his daily life activities. After 2 years and a half of treatment, the aneurysm was stable and the intracardiac thrombus completely cleared.

Conclusion:

This case is of particular interest because of the concomitant presence of two rare vascular complications of Behcet disease-intracardiac thrombosis (<1-2%, less than 100 cases described worldwide) and pulmonary artery aneurysm (1-2%). Prompt introduction of immunosuppressant therapy was associated with a favorable outcome with no recurrence. We could speculate that, to some extent, the concomitant use of anticoagulants may have contributed to the complete resolution of the intracardiac thrombosis.

Disclosure of Interests :

MARIA DI CICCO: None declared, oscar massimiliano epis Consultant of: yes, Speakers bureau: yes, Cinzia Casu: None declared, Antonella Adinolfi: None declared, Luisa Alvaro: None declared, Valeria Campanella: None declared, Michel Chevallard: None declared, Marina Muscarà: None declared, Mariaeva Romano: None declared, Emanuela Schito: None declared, Nicola Ughi: None declared, Elisa Verduci: None declared, Davide Antonio Filippini: None declared

Prevalence of undiagnosed autoimmune rheumatic diseases in the first trimester of pregnancy. Results of a two-steps strategy using a self-administered questionnaire and autoantibody testing

OBJECTIVE

To evaluate the prevalence of undiagnosed rheumatic diseases in the first trimester of pregnancy.

DESIGN

We screened for rheumatic diseases in 1210 consecutive pregnant women during the first trimester of pregnancy using a 10-item questionnaire.

SETTING

A university hospital in northern Italy.

POPULATION

One hundred and thirty-seven (11.3%) women who answered positively to at least one question constituted the cases and were compared with 107 negative controls.

METHODS

Cases and controls were tested for rheumatic autoantibodies (antinuclear antibody, anti-double-stranded DNA, anti-extractable nuclear antigen, anticardiolipin antibody, anti-beta2-glycoprotein I antibodies and lupus anticoagulant) and were evaluated by a rheumatologist for a definite diagnosis of rheumatic disease.

MAIN OUTCOME MEASURES

Prevalence of undiagnosed rheumatic disease in the first trimester of pregnancy.

RESULTS

The overall rate of positivity to the antibodies tested was 43.1% (59/137) among cases and 9.3% (10/107) in the controls (P < 0.001). A definitive diagnosis of rheumatic disease was made in 35 cases (25.5%) and in none of the controls (P <0.001). In stepwise logistic regression analysis, photosensitivity (adjusted OR 5.72; 95% CI 2.38-13.8), erythema or malar rash (adjusted OR 3.91; 95% CI 1.53-10) and history of two or more miscarriages (adjusted OR 5.6; 95% CI 1.55-20.6) were independent predictors of a definitive diagnosis of rheumatic disease (area under receiving operator curve = 0.814; 95% CI 0.76-0.86). Birthweight was lower (3180 g +/- 475 compared with 3340 g +/- 452, P= 0.008), and overall serious pregnancy complications (miscarriage, fetal growth restriction, delivery before 34 weeks of pregnancy and severe pre-eclampsia) were higher among cases (12/137) than controls (2/107) (adjusted OR 5.60; 95% CI 1.29-24.3; P= 0.021).

CONCLUSIONS

A two-step screening process with a self-administered questionnaire proved to be a useful method to screen for undiagnosed rheumatic diseases during the first trimester of pregnancy.