Effectiveness of intravenous methylprednisolone pulse in patients with severe microscopic polyangiitis and granulomatosis with polyangiitis

OBJECTIVES

To evaluate the effectiveness and safety of two different intravenous methylprednisolone (IVMP) pulse doses in patients with severe microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA).

METHODS

We emulated a target trial using observational data from the nationwide registry in Japan. Patients with severe glomerulonephritis or diffuse alveolar haemorrhage were selected and pseudo-randomised into three groups using propensity score-based overlap weighting as follows: non-IVMP, IVMP 0.5 g/day, and IVMP 1.0 g/day. The primary outcome was all-cause death, and the secondary outcomes were composite all-cause death and kidney failure, severe relapse, and serious infection from 2 to 48 weeks after treatment initiation. To estimate the treatment effects, the Cox proportional hazard model and Fine-Gray subdistribution hazard model were used.

RESULTS

In this emulated target trial, of 201 eligible patients (MPA, 175; GPA, 26), 6 (2.8%) died, 4 (2.0%) had kidney failure, 11 (5.3%) had severe relapse, and 40 (19.8%) had severe infections. Hazard ratios (HR) for IVMP 0.5 g/day and IVMP 1.0 g/day pulse groups compared with non-IVMP pulse were as follows: all-cause death = 0.46 (95% confidence interval [95%CI]: 0.07-2.81) and 0.07 (95%CI: 0.01-0.41); all-cause death/kidney failure = 1.18 (95%CI: 0.26-5.31) and 0.59 (95%CI: 0.08-4.52); subdistribution HRs for severe relapse = 1.26 (95%CI: 0.12-13.70) and 3.36 (95%CI: 0.49-23.29); and serious infection = 1.88 (95%CI: 0.76-4.65) and 0.94 (95%CI: 0.28-3.13).

CONCLUSIONS

IVMP 1.0 g/day pulse may improve 48-week mortality in patients with severe MPA/GPA.

Development of quality indicators for pregnancy and childbirth in patients with systemic lupus erythematosus

OBJECTIVES

A quality indicator for the treatment of systemic lupus erythematosus during pregnancy and childbirth that is useful for sharing standard treatment policies has not yet been developed. This study aimed to develop a quality indicator for systemic lupus erythematosus associated with pregnancy and childbirth.

METHODS

To identify candidate quality indicators, we conducted a systematic literature review on the development of quality indicators for systemic lupus erythematosus related to pregnancy and childbirth and on clinical practice guidelines. Candidate quality indicator items were extracted from the final selected articles, and a first evaluation, panel meeting, and second evaluation were conducted to determine whether the candidate items were appropriate as quality indicators. Items for which all panel members reached a consensus were designated pregnancy and childbirth-related systemic lupus erythematosus quality indicators.

RESULTS

Four articles on systemic lupus erythematosus-quality indicator development and 28 practice guidelines were listed through abstract/text screening. Based on these studies, 52 candidate quality indicators were extracted that were limited to items related to pregnancy and childbirth, and 41 items were selected on which all panel members agreed.

CONCLUSION

We developed pregnancy-related systemic lupus erythematosus quality indicators using the RAND/UCLA method and selected 41 items, which could be used clinically.

Physician approval for pregnancy in patients with systemic lupus erythematosus showing only serological activity: A vignette survey study

OBJECTIVE

The European League Against Rheumatism recommends that the disease activity of systemic lupus erythematosus should be stable before pregnancy because complications and disease flares increase if pregnancy occurs while disease activity is high. However, some patients have ongoing serological activity even after treatment. Herein, we investigated how physicians decide on the acceptability of pregnancy in patients showing only serological activity.

METHODS

A questionnaire was administered from December 2020 to January 2021. It included the characteristics of physicians, facilities, and the allowance for pregnancies of patients using vignette scenarios.

RESULTS

The questionnaire was distributed to 4946 physicians, and 9.4% responded. The median age of respondents was 46 years, and 85% were rheumatologists. Pregnancy allowance was significantly affected by the duration of the stable period and status of serological activity [duration: proportion difference 11.8 percentage points (p.p.), P < .001; mild activity: proportion difference -25.8 p.p., P < .001; high activity: proportion difference -65.6 p.p., P < .001]. For patients with high-level serological activity, 20.5% of physicians allowed pregnancy if there were no clinical symptoms for 6 months.

CONCLUSIONS

Serological activity had a significant effect on the acceptability of pregnancy. However, some physicians allowed patients with serological activity alone to become pregnant. Further observational studies are required to clarify such prognoses.

Systematic review for the treatment of older rheumatoid arthritis patients informing the 2024 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis

OBJECTIVES

To update an evidence base informing the 2024 JCR clinical practice guidelines (CPGs) for the management of rheumatoid arthritis (RA) in older adults.

METHODS

Four clinical questions (CQs) regarding efficacy and safety of drug treatment were evaluated, with CQ1 addressing methotrexate (MTX), CQ2 biological disease-modifying antirheumatic drugs (bDMARDs), CQ3 Janus kinase (JAK) inhibitors, and CQ4 glucocorticoids (GCs). Quality of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

Observational studies confirmed a pivotal role of MTX in the treatment of older RA patients. The meta-analysis showed that tumor necrosis factor inhibitors and JAK inhibitors were unequivocally effective in older RA patients. No data indicated that bDMARDs were unsafe for older patients. No safety data for JAK inhibitor use in older patients were available. One randomized controlled trial demonstrated that long-term treatment with low-dose GCs increased risks of GC-associated adverse events. The certainty of overall evidence was very low for all CQs.

CONCLUSION

This systematic review provides the necessary evidence for developing 2024 JCR CPGs for managing older patients with RA. Continued updates on the evidence of JAK inhibitors and GC are desired.

Relationship between falls and the use of hypnotics, antidepressants, antipsychotics, and anxiolytics in patients with rheumatoid arthritis: A cross-sectional study

Objectives This cross-sectional study aimed to determine the relationship between falls and use of psychotropic medications in patients with rheumatoid arthritis. Methods The psychotropic medication group included patients with rheumatoid arthritis prescribed psychotropic medications (hypnotics/sedatives, antidepressants, antipsychotics, and anxiolytic [benzodiazepines] drugs). Poisson regression with robust variance was performed to investigate the relationship between falls and the use of psychotropic medications, with adjustment for age, sex, rheumatoid arthritis disease activity, stroke, dementia, diabetes mellitus, and osteoarthritis. Results Of the 307 patients enrolled, 49 (16.0%) used psychotropic medications, and 70 (22.8%) experienced at least one fall per year. Nineteen of the 49 patients (38.8%) taking psychotropic medications and 51 of 258 (19.8%) not taking psychotropic medications experienced at least one fall per year. Falls were significantly more frequent in the group with psychotropic medications than in the group without psychotropic medications (adjusted incidence rate ratio, 1.63; 95% confidence interval; 1.08-2.48, p = 0.02). No relationship was found between the number of falls and the use of psychotropic medications (adjusted incidence rate ratio, 1.16; 95% confidence interval; 0.39-3.44, p = 0.78). Conclusions There may be a relationship between psychotropic medication use and falls in patients with rheumatoid arthritis.

Association between hypogammaglobulinaemia and severe infections during induction therapy in ANCA-associated vasculitis: from J-CANVAS study

OBJECTIVES

To investigate the association between decreased serum IgG levels caused by remission-induction immunosuppressive therapy of antineutrophil cytoplasmic antibody-associated vasculitis (AAV) and the development of severe infections.

METHODS

We conducted a retrospective cohort study of patients with new-onset or severe relapsing AAV enrolled in the J-CANVAS registry, which was established at 24 referral sites in Japan. The minimum serum IgG levels up to 24 weeks and the incidence of severe infection up to 48 weeks after treatment initiation were evaluated. After multiple imputations for all explanatory variables, we performed the multivariate analysis using a Fine-Gray model to assess the association between low IgG (the minimum IgG levels <500 mg/dl) and severe infections. In addition, the association was expressed as a restricted cubic spline (RCS) and analysed by treatment subgroups.

RESULTS

Of 657 included patients (microscopic polyangiitis, 392; granulomatosis with polyangiitis, 139; eosinophilic granulomatosis with polyangiitis, 126), 111 (16.9%) developed severe infections. The minimum serum IgG levels were measured in 510 patients, of whom 77 (15.1%) had low IgG. After multiple imputations, the confounder-adjusted hazard ratio of low IgG for the incidence of severe infections was 1.75 (95% confidence interval: 1.03-3.00). The RCS revealed a U-shaped association between serum IgG levels and the incidence of severe infection with serum IgG 946 mg/dl as the lowest point. Subgroup analysis showed no obvious heterogeneity between treatment regimens.

CONCLUSION

Regardless of treatment regimens, low IgG after remission-induction treatment was associated with the development of severe infections up to 48 weeks after treatment initiation.

Risk factors for cardiovascular diseases in patients with systemic lupus erythematosus: an umbrella review

Cardiovascular disease in patients with systemic lupus erythematosus (SLE) remains one of the most common causes of death and is caused by several factors, including both traditional and disease-specific risk factors. We aimed to systematically appraise the evidence of cardiovascular disease risk factors focusing on the SLE population. The protocol for this umbrella review is registered in PROSPERO (registration no. CRD42020206858). A systematic literature search was conducted in PubMed, Embase, and the Cochrane Library from database inception to June 22, 2022, for systematic reviews and meta-analyzes that examined cardiovascular disease risk factors in patients with SLE. Two reviewers independently extracted data and assessed the quality of the included studies using the "Assessing the Methodological Quality of Systematic Reviews 2 (AMSTER 2)" tool. Of the 102 identified articles, nine systematic reviews were included in this umbrella review. All included systematic reviews were assessed as critically low quality according to the AMSTER 2 tool. The traditional risk factors identified in this study were older age, male sex, hypertension, dyslipidemia, smoking, and a family history of cardiovascular disease. SLE-specific risk factors were long-term disease duration, lupus nephritis, neurological disorders, high disease activity, organ damage, use of glucocorticoids, azathioprine, and antiphospholipid antibodies, including anticardiolipin antibodies and lupus anticoagulant. This umbrella review identified some cardiovascular disease risk factors in patients with SLE; however, the study quality of all included systematic reviews was critically low. Key Points • We examined the evidence of cardiovascular disease risk factors focusing on patients with systemic lupus erythematosus. • We found that long-term disease duration, lupus nephritis, neurological disorders, high disease activity, organ damage, use of glucocorticoids, azathioprine, and antiphospholipid antibodies, including anticardiolipin antibodies and lupus anticoagulant, were cardiovascular disease risk factors among patients with systemic lupus erythematosus. • The review indicates the need for well-validated and high-quality future reviews that assess major adverse cardiovascular events as an outcome in patients with systemic lupus erythematosus.

Optimal Dose of Intravenous Cyclophosphamide during remission induction therapy in ANCA-associated vasculitis: a retrospective cohort study of J-CANVAS

OBJECTIVES

To identify the optimal dose of intravenous cyclophosphamide (IVCY) for induction therapy for anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV).

METHODS

We retrospectively assessed patients with AAV who received IVCY every 2-3 weeks during the remission induction phase. The associations of the IVCY dose with infection-free survival and relapse-free survival were analysed using a Cox regression model. We compared patients in three categories: very low-dose (VLD), low-dose (LD), and conventional dose (CD) (<7.5 mg/kg, 7.5-12.5 mg/kg, and >12.5 mg/kg, respectively). The non-linear association between IVCY dose and the outcomes were also evaluated.

RESULTS

Of the 80 patients (median age 72 years), 12, 42, and 26 underwent the VLD, LD, and CD regimens, respectively, of whom 4, 3, and 7 developed infection or died. The adjusted hazard ratios for infection or death were 4.3 (95% confidence interval (CI) 0.94-19.8) for VLD and 5.1 (95% CI 1.21-21.3) for CD, compared with LD. We found the hazard ratio for infection or death increased when the initial IVCY dose exceeded 9 mg/kg. Relapse-free survival did not differ clearly.

CONCLUSION

Low-dose IVCY (7.5-12.5 mg/kg) may result in fewer infections and similar relapse rates compared with the conventional regimen (>12.5 mg/kg).

Seasonal Influence on Development of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Retrospective Cohort Study Conducted at Multiple Institutions in Japan (J-CANVAS)

OBJECTIVE

To clarify seasonal and other environmental effects on the onset of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

METHODS

We enrolled patients with new-onset eosinophilic granulomatosis with polyangiitis (EGPA), microscopic polyangiitis (MPA), and granulomatosis with polyangiitis (GPA) registered in the database of a Japanese multicenter cohort study. We investigated the relationship between environmental factors and clinical characteristics. Seasons were divided into 4 (spring, summer, autumn, and winter), and the seasonal differences in AAV onset were analyzed using Pearson chi-square test, with an expected probability of 25% for each season.

RESULTS

A total of 454 patients were enrolled, with a mean age of 70.9 years and a female proportion of 55.5%. Overall, 74, 291, and 89 patients were classified as having EGPA, MPA, and GPA, respectively. Positivity for myeloperoxidase (MPO)-ANCA and proteinase 3 (PR3)-ANCA was observed in 355 and 46 patients, respectively. Overall, the seasonality of AAV onset significantly deviated from the expected 25% for each season (P = 0.001), and its onset was less frequently observed in autumn. In ANCA serotypes, seasonality was significant in patients with MPO-ANCA (P < 0.001), but not in those with PR3-ANCA (P = 0.97). Additionally, rural residency of patients with AAV was associated with PR3-ANCA positivity and biopsy-proven pulmonary vasculitis.

CONCLUSION

The onset of AAV was influenced by seasonal variations and was less frequently observed in autumn. In contrast, the occurrence of PR3-ANCA was triggered, not by season, but by rural residency.

Eosinophilic granulomatosis with polyangiitis developed after dupilumab administration in patients with eosinophilic chronic rhinosinusitis and asthma: a case report

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a form of anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis characterized by eosinophil-rich granulomatous inflammation and small-to-medium vessel vasculitis associated with asthma, rhinosinusitis, and eosinophilia. EGPA is often difficult to distinguish from severe asthma and eosinophilic chronic rhinosinusitis (ECRS) in cases when there are no findings that suggest vasculitis. Dupilumab, an anti-IL-4Rα monoclonal antibody, is expected to be effective in eosinophilic airway inflammatory diseases, such as refractory asthma and chronic rhinosinusitis (CRS). Although transient eosinophilia and eosinophilic pneumoniae have been reported in patients with refractory asthma and CRS associated with dupilumab, few studies have examined the development of EGPA.

CASE PRESENTATION

We report a case of a 61-year-old woman treated with dupilumab for refractory ECRS and eosinophilic otitis media (EOM) complicated by severe asthma. Although she had a previous history of eosinophilic pneumoniae and myeloperoxidase (MPO) ANCA positivity, there were no apparent findings of vasculitis before the initiation of dupilumab. After the second administration of dupilumab, several adverse events developed, including worsening of ECRS, EOM and asthma, and neuropathy. A blood test showed an eosoinophilia and re-elevation of MPO-ANCA levels after the administration of dupilumab. Therefore, dupilumab was discontinued owing to the development of EGPA, and prednisolone and azathioprine administration was initiated for a remission induction therapy.

CONCLUSION

To the best of our knowledge, this is the first case report that suggests that dupilumab may directly trigger the manifestation of vasculitis in patients who were previously MPO-ANCA-positive. Although the precise mechanism of how dupilumab could trigger the development of EGPA requires further elucidation, measuring MPO-ANCA in patients with multiple eosinophilic disorders before the initiation of dupilumab might be helpful when considering the possibility of a latent EGPA. When administering dupilumab to patients with a previous history of MPO-ANCA positivity, clinicians must carefully monitor and collaborate with other specialists in the pertinent fields of study for appropriate usage.

Number of Attending Physicians and Accumulated Organ Damage in Patients with Systemic Lupus Erythematosus: LUNA Registry Cross-Sectional Study

INTRODUCTION

Patients with systemic lupus erythematosus (SLE) frequently change attending physicians. The number of changes in attending physicians is related to the accumulated organ damage in patients with diabetes mellitus and inflammatory bowel disease, although similar results are not known for patients with SLE. This study investigated whether the number of attending physicians after the onset of SLE is associated with organ damage.

METHODS

Patients with SLE were enrolled in a multicenter registry of 14 institutions (the Lupus Registry of Nationwide Institutions). Patients with a disease duration of 6 months to 10 years were included. Exposure was defined as the number of attending physicians. The primary outcome was the Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index (SDI). The secondary outcomes were corticosteroid- and non-corticosteroid-related damage. Multiple logistic regression analysis was used to estimate the association between the number of attending physicians and SDI, adjusting for potential confounders, including age, sex, disease duration, number of hospitalizations due to SLE, disease activity at diagnosis, and emotional health.

RESULTS

Of the 702 patients, 86.5% were women (median age 46 years, interquartile range 35-58). The disease duration was 7.3 years (4.3-11.3), the number of hospitalizations due to SLE was 1 (1-3), the number of attending physicians was 3 (2-4), and SDI was 0 points (0-1). The number of attending physicians was significantly associated with SDI [odds ratio (OR) 1.14, 95% confidence interval (CI) 1.03-1.26]. In the secondary outcome, the number of attending physicians was significantly associated with corticosteroid-related damage (OR 1.22, 95% CI 1.09-1.38). The number of attending physicians was not significantly associated with non-corticosteroid-related damage (OR 1.08, 95% CI 0.99-1.19).

CONCLUSIONS

This study showed that SDI could increase as the number of attending physicians increases. The impact of changing attending physicians warrants greater attention for SLE and other diseases.

Hypertrophic pachymeningitis in ANCA-associated vasculitis: a cross-sectional and multi-institutional study in Japan (J-CANVAS)

BACKGROUND

This study investigated the characteristics of hypertrophic pachymeningitis (HP) in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), using information from a multicenter study in Japan.

METHODS

We analyzed the clinical information of 663 Asian patients with AAV (total AAV), including 558 patients with newly diagnosed AAV and 105 with relapsed AAV. Clinical findings were compared between patients with and without HP. To elucidate the relevant manifestations for HP development, multivariable logistic regression analyses were additionally performed.

RESULTS

Of the patients with AAV (mean age, 70.2 ± 13.5 years), HP was noted in 30 (4.52%), including 20 (3.58%) with newly diagnosed AAV and 10 (9.52%) with relapsed AAV. Granulomatosis with polyangiitis (GPA) was classified in 50% of patients with HP. A higher prevalence of GPA was significantly observed in patients with HP than in those without HP in total AAV and newly diagnosed AAV (p < 0.001). In newly diagnosed AAV, serum proteinase 3 (PR3)-ANCA positivity was significantly higher in patients with HP than in those without HP (p = 0.030). Patients with HP significantly had ear, nose, and throat (ENT) (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.03-2.14, p = 0.033) and mucous membrane/eye manifestations (OR 5.99, 95% CI 2.59-13.86, p < 0.0001) in total AAV. Moreover, they significantly had conductive hearing loss (OR 11.6, 95% CI 4.51-29.57, p < 0.0001) and sudden visual loss (OR 20.9, 95% CI 5.24-85.03, p < 0.0001).

CONCLUSION

GPA was predominantly observed in patients with HP. Furthermore, in newly diagnosed AAV, patients with HP showed significantly higher PR3-ANCA positivity than those without HP. The ear and eye manifestations may be implicated in HP development.

Effects of anti-SSA antibodies on the response to methotrexate in rheumatoid arthritis: A retrospective multicenter observational study

Comparison of clinical response to methotrexate between anti-SSA antibody-positive and -negative patients with methotrexate-naïve rheumatoid arthritis and investigate the reasons for the differences in the response. For this multicenter retrospective cohort study, a total of 210 consecutive patients with rheumatoid arthritis who newly initiated methotrexate were recruited. The effects of anti-SSA antibody positivity on achieving a low disease activity according to the 28-joint Disease Activity Score based on C-reactive protein after 6 months of methotrexate administration were investigated using a logistic regression analysis. This study involved 32 and 178 anti-SSA antibody-positive and -negative patients, respectively. The rate of achieving low disease activity according to the 28-joint Disease Activity Score based on C-reactive protein at 6 months was significantly lower in the anti-SSA antibody-positive group than in the anti-SSA antibody-negative group (56.2% vs. 75.8%, P = 0.030). After 6 months, anti-SSA antibody-positive patients had significantly higher scores on the visual analogue scale (median [interquartile range]: 22 [15–41] vs. 19 [5–30], P = 0.038) and were frequently prescribed nonsteroidal anti-inflammatory drugs (37.5% vs. 18.0%, P = 0.018). In conclusion, the presence of anti-SSA antibodies might be a predictive factor for insufficient responses to treat-to-target strategy in rheumatoid arthritis. Residual pain might contribute to the reduced clinical response to methotrexate in anti-SSA antibody-positive patients with rheumatoid arthritis.

POS0734 THE CLINICAL JUDGMENT FOR THE ACCEPTABILITY OF PREGNANCY IN PATIENTS WITH SEROLOGICALLY ACTIVE SLE IN JAPAN: A NATIONWIDE ONLINE SURVEY FROM THE VIGNETTE STUDY

Background

The risk of pregnancy complications, such as gestational hypertension is high in pregnancies with SLE. In addition, the risk of flare is elevated if pregnancy occurs during the high disease activity. The EULAR recommendation provides a checklist for preconception counseling, in which patients with SLE desiring pregnancy were required the condition that the disease activity prior to pregnancy should be stable for 6-12 months in terms of serological activity (1). However, it does not provide specific criteria for serological activity so that physicians should evaluate the risk of pregnancy in each case by their clinical intuitions.

Objectives

In order to uncover the present clinical situation for the acceptability of pregnancy in patients with SLE, we performed questionnaire survey to physicians regarding to the degree of serological activity.

Methods

This cross-sectional study was performed to physicians registered with the Japanese College of Rheumatology from December 2020 to January 2021 using the online survey. The questionnaire asked about the characteristics of physicians, facilities and the permission of pregnancies with SLE using vignette scenarios. In this study, data from vignettes of women visiting a regular outpatient clinic were used. The vignettes varied in age (28 or 35 years), duration of stable disease and serological activity. Analysis methods were descriptive statistics, chi-square test. generalized estimating equations (GEE) was performed to investigate the relationship between the determining permission for pregnancy and the scenario patient’s characteristics (age, period of stable disease, titer of anti ds-DNA antibody)

Results

The questionnaire was distributed to 4946 physicians, and 463 responded. Completion rate (ratio agreed to participate/finished survey) of survey was 91.1%. The median age of physicians was 46 (interquartile range (IQR) 2-10). The specialty was rheumatology (84.9%), other internal medicine (8%), and pediatrics (5.6%). There were no significant differences in patient’s age about the acceptability of pregnancy (coeffficianet -0.02, 95% CI -0.17 -0.01, p=0.42). Case who had been stable for 6 months were more tolerant of pregnancy than case who had been stable for 3 months (coeffficianet 0.12, 95% CI 0.09-0.15, P<0.001) Pregnancy was not allowed in case with mild or high serological activity (mild: coefficient -0.49, 95% CI -0.29- -0.22, p <0.001, high: -0.64, 95% CI -0.65 - -0.61, p <0.001). In contrast, as many as 92 (19.2%) physicians tolerated pregnancy even in the presence of residual high anti ds-DNA antibody titers. Female physicians are significantly more cautious about pregnancy than male when patients have a serologically high activity (12% vs 37.5%, p<0.001). There were no significant differences in specialty status or clinical experience.

Conclusion

We found that even mild serological activity alone had a significant negative effect on the physician’s decision to allow pregnancy. We conclude that current physicians make cautious decisions about pregnancies of patients with SLE following the recommendation. On the other hand, an additional investigation should be performed about the results of pregnancies in patients with serological abnormalities, since there are some physicians who thought that pregnancy may be acceptable for patients with only serological abnormalities if the clinical symptoms are stable.

References

[1]Ann Rheum Dis．2017 Mar;76(3):476-485

Acknowledgements

I would like to express my gratitude to the members of Japan College of Rheumatology who cooperated in filling out the questionnaire.

Disclosure of Interests

Sakiko Isojima: None declared, Nobuyuki Yajima: None declared, Ryo Yanai: None declared, Yoko Miura: None declared, Shingo Fukuma: None declared, Kayoko Kaneko: None declared, Keishi Fujio: None declared, Kenji Oku: None declared, Masakazu Matsushita: None declared, Takako Miyamae: None declared, Takashi Wada: None declared, Yuko Kaneko: None declared, Yoshiya Tanaka Speakers bureau: Y. Tanaka has received speaking fees and/or honoraria from Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Grant/research support from: Y. Tanaka has received research grants from Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, and consultant fee from Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie., Ayako Nakajima: None declared, ATSUKO MURASHIMA: None declared

AB0242 RELATIONSHIP BETWEEN FALLS AND FALL RISK MEDICATION IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Falls are a serious event that can lead to disability and death. The use of hypnotics, anxiolytics, and antidepressants has been reported drugs associated with higher risk of falls. Rheumatoid arthritis (RA) is associated with a high risk of falls, which is an important issue because it can lead to fractures. Patients with RA have a higher incidence of sleep disorders, depression, and anxiety disorders. They are likely to be prescribed fall risk medications.

Objectives

We conducted a retrospective study of the incidence of falls in patients with RA, who are more prone to fractures and falls, using fall risk medications, especially hypnotics and anxiolytics, which aimed to determine the relationship between falls and fall risk medications in patients with RA.

Methods

This study is a retrospective cohort study conducted in Showa University Hospital between December 1, 2019 and March 31, 2020. We included of RA patients who visited the outpatient and fulfilled the American College of Rheumatology (ACR) /European League against Rheumatism (EULAR) classification 2010 criteria. The main exposure was the fall risk medication. The fall risk medication group was defined as RA patients who were prescribed fall risk medication (sedative/hypnotic, antidepressants, antipsychotics, and anxiolytic (benzodiazepines) drugs) for all the observational period. The comparison group was defined as RA patients who had never been prescribed any fall risk medications. Outcome measure was the prevalence of fall incidents in the past one year, obtained by using questionnaires to patients. Logistic regression analysis was performed to investigated the relationship between the prevalence of fall incidents and the use of fall-risk medications. The co-variables we selected were as follows: age, sex, stroke, dementia, diabetes and osteoarthritis as covariates.

Results

We obtained data from 331 patients, of which 303 were included in the analysis. Among the 303 patients, the median age was 67 years (56-75), and 78.5% were women. Of the 303 patients, 45 patients used fall risk medication and 69 patients experienced at least one fall in a year. Of the 45 patients who used fall risk medication, 18 patients experienced at least one fall in a year. Of the 69 patients who experienced falls, 30 patients experienced twice or more falls in a year. Of the 18 patients who used fall risk medication and experienced falls, 9 patients experienced twice or more falls. 4 patients were admitted to the hospital as result of falls, 2 patients used fall risk medication. These results are shown as percentages in Figure 1. The group of fall risk medication was significantly higher than using non fall risk medication. (adjusted odds ratio (AOR) 2.31, 95% Confidence Interval (CI) 1.14-4.68, p=0.02).

Figure 1.

Conclusion

Use of fall risk medications may have increased falls for patients with RA.

Acknowledgements

Cooperation on data collection: Division of Rheumatology, Department of Medicine, Showa University School of Medicine; Yusuke Miwa, Takeo Isozaki, Kuninobu Wakabayashi, Ryo Takahashi, Sakiko Isojima, Hidekazu Furuya, Nao Ogro, Sho Ishii, Yoko Miura, Mika Hatano, Shinichiro Nishimi, Airi Nishimi, Tomoki Hayashi, Yumeko Taniguchi

Disclosure of Interests

None declared

POS0822 HYPERTROPHIC PACHYMENINGITIS IN ANTINEUTROPHIL CYTOPLASMIC ANTIBODY-ASSOCIATED VASCULITIS: A MULTICENTER SURVEY IN JAPAN

Background

Hypertrophic pachymeningitis (HP), characterized by an inflammatory disorder indicating intracranial or spinal thickening of dura mater, is found to develop as a neurological involvement in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Meanwhile, the previous studies focusing on HP in AAV have been reported as a single-institution study, and the analyses were performed in a small number of patients because HP is a rare neurological disorder. Therefore, neither etiological nor clinical characteristics of HP in AAV have been adequately elucidated.

Objectives

This study clarified the characteristics of HP in AAV by analyzing the information of multicenter study in Japan (Japan collaborative registry of ANCA-associated vasculitis: J-CANVAS).

Methods

We analyzed the clinical information from 541 Asian patients with AAV enrolled in J-CANVAS. Of them, newly diagnosed and relapsed AAV were included in 448 and 93, respectively. The epidemiological and clinical findings were compared between patients with and without HP. Clinical manifestations related to AAV were evaluated based on the Birmingham Vasculitis Activity Score version 3. To elucidate independent factors in HP development, logistic regression analyses were additionally performed.

Results

Of the total 541 patients (mean age: 71±14 years, M:F = 1:1.2), HP was demonstrated in 28 (5.17%), including 17 (3.79%) in newly diagnosed AAV and 11 (11.8%) in relapsed AAV. The classification of granulomatosis with polyangiitis (GPA) was significantly higher in patients with HP than those without HP (50% vs. 21%, p = 0.0007). In newly diagnosed AAV, patients with HP significantly had higher GPA classification and higher positivity for PR3-ANCA than those without HP (53% vs. 17%, p = 0.001; 29% vs. 9%, p = 0.015, respectively). Conversely, positivity for MPO-ANCA was significantly higher in patients with HP than those without HP in relapsed AAV (91% vs. 55%, p = 0.025), despite not significantly different in the classification of AAV. Headache and cranial neuropathies were significant neurological symptoms in patients with HP compared to those without HP (82% vs. 6.6%, p < 0.0001; 32% vs. 2.9%, p < 0.0001, respectively). Besides, ear, nose and throat (ENT) and mucous membranes/eyes were significantly higher involvements in patients with HP than in those without HP (54% vs. 26%, p = 0.003; 29% vs. 9%, p = 0.003, respectively). Moreover, higher complications of “conjunctive hearing loss” and “sudden visual loss”, which are included in the categories of ENT and mucous membranes/eyes involvement, respectively, were significantly indicated in patients with HP than those without HP (39% vs. 7.2%, p < 0.0001; 21% vs. 1.2%, p < 0.0001, respectively). Multivariable logistic regression analysis identified that ENT (odds ratio [OR] 1.28, 95% confident interval [CI] 1.09 to 1.49, p = 0.002) and mucous membranes/eyes involvement (OR 1.37, CI 1.14 to 1.65, p = 0.0006), as well as conjunctive hearing loss (OR 4.52, CI 1.56 to 13.05, p = 0.005) and sudden visual loss (OR 1.84, CI 1.12 to 3.00, p = 0.015), were independent related factors in patients with HP.

Conclusion

GPA could be significantly classified in patients with HP. Notably, patients with HP significantly showed higher positivity for PR3-ANCA than those without HP in newly diagnosed AAV. Furthermore, sudden visual loss and conjunctive hearing loss might be implicated in HP development.

Disclosure of Interests

None declared

POS1475-HPR THE MINIMALLY IMPORTANT DIFFERENCE AS THE INTERPRETABILITY OF EMOTIONAL HEALTH DOMAIN IN JAPANESE VERSION OF LupusPRO FOR SLE PATIENTS; PRELIMINARY RESULTS OF A PROSPECTIVE COHORT STUDY

Background

The minimally important difference (MID) required to interpret the magnitude of changes in lupus patient-reported outcome (LupusPRO), which is a widely used outcome measure of quality of life in SLE patients, remains unclear.

Objectives

We report preliminary results of an ongoing prospective observational study that assesses the MID as the interpretability of emotional health (EH) domain in Japanese version of LupusPRO.

Methods

We recruited subjects at three university hospitals in Japan participating in an ongoing multidisciplinary cohort study (the Lupus registry of Nationwide institutions (LUNA). Of a total of 210 SLE patients enrolled during the 17-month recruitment period, patients with low disease activity, defined as SLE Disease Activity Index 2000 (SLEDAI-2K) ≤ 4, and who were seen at least twice of three months’ duration and responded to both the LupusPRO and health status change questions were included in this subcohort. The second questionnaire was given an allowance period of 30 days before or after the ​three months from starting date. Descriptive statistics were presented as means and standard deviations (SD) or counts and percentages (%). The emotional health score ranges from 0 to 100; a higher score indicates less frequent presence of symptoms. The change in health status was assessed using the 7-point Global Rating of Change 1), and the score = 0 and the score ≥ +1 were considered in the ‘unchanged’ and the minimal ‘improved’ category, respectively. MID was mainly estimated using the mean change of the groups with the score ≥ +1 as the anchor-based method, and the area under the curve (AUC) was also calculated as a sensitivity analysis to estimate MID thresholds 2) and 95% confidence intervals (CI) were constructed using 1000 bootstrapping.

Results

The mean age of the 24 eligible patients was 48 (SD 14), and 88% were female. The glucocorticoid dose, SLEDAI-2K, and Systemic Lupus International Collaborating Clinics /American College of Rheumatology Damage Index were 3.4 (2.1) mg, 1.0 (1.1) and 1.1 (1.9), respectively. The mean EH score was 67.5 (30.3), five patients (21%) had the maximum EH score at baseline, 73.4 (25.0) after three months, 7.2 (18.0) for the change in EH. The correlation coefficient and the AUC for the change in health status and the EH were 0.23 and 0.60. The mean changes were 4.1 (18.4) of the groups with ‘unchanged’ health status and 12.3 (17.1) of the groups with ‘improved’ health status. The MID for improvement was estimated at 12.3 using the anchor-based method, and the cutoff point corresponded to 9.3 [95%CI -6.7 to 25.3]) of the EH change score by the receiver operating curve method.

Conclusion

In this study, the MID (3 months) for the EH domain in the Japanese version of LupusPRO was estimated to be between 9 and 12, which was similar to the results of the previous cross-sectional study 3). The challenge in estimating the MID in our setting was the low correlation with external anchors, even though the study population was limited to patients with low disease activity, because disease activity at baseline can generally influence ‘improved’ health status.

References

[1]Kamper SJ, Maher CG, Mackay G. Global rating of change scales: a review of strengths and weaknesses and considerations for design. J Man Manip Ther. 2009;17(3):163.

[2]Froud R, Abel G. Using ROC curves to choose minimally important change thresholds when sensitivity and specificity are valued equally: the forgotten lesson of pythagoras. theoretical considerations and an example application of change in health status. PLoS One. 2014;9(12):e114468.

[3]Miyawaki Y, Shimizu S, Ogawa Y, et al. Association of glucocorticoid doses and emotional health in lupus low disease activity state (LLDAS): a cross-sectional study. Arthritis Res Ther. 2021;23(1):79.

Acknowledgements

The authors thank Yuka Nakanou for her significant assistance in data management and Kikuko Miyazaki for her expert assistance on this topic.

Disclosure of Interests

Yoshia Miyawaki: None declared, Kenta Shidahara: None declared, Shoichi Nawachi: None declared, Yosuke ASANO: None declared, Yu Katayama: None declared, Keiji Ohashi: None declared, Eri Katsuyama: None declared, Takayuki Katsuyama: None declared, Mariko Narazaki: None declared, Yoshinori Matsumoto Speakers bureau: I received speaker’s fees from Glaxo Smith Kline K.K., KEN-EI SADA Speakers bureau: I received speaker’s fees from Glaxo Smith Kline K.K., Ryo Yanai: None declared, Nobuyuki Yajima: None declared, Ayuko Takatani: None declared, Kunihiro Ichinose: None declared, Jun Wada Speakers bureau: Jun Wada receives speaker honoraria from Astra Zeneca, Daiichi Sankyo, Novartis, Novo Nordisk Pharma, Tanabe Mitsubishi and receives grant support from Astellas, Baxter, Bayer, Chugai, Dainippon Sumitomo, Kyowa Kirin, Novo Nordisk Pharma, Ono, Otsuka, Tanabe Mitsubishi, and Teijin.

AB0625 Association between Cytomegalovirus Reactivation and Renal Prognosis during Remission Induction Therapy for ANCA-Associated Vasculitis

Background

Cytomegalovirus (CMV) has been associated with atherosclerosis in patients with chronic renal failure, and may cause secondary nephrotic syndrome. Therefore, we hypothesized that the reactivation of CMV by immunosuppressive therapy in patients with vasculitis may affect renal function.

Objectives

The purpose of this study was to investigate relationships between CMV infection and renal function during ANCA-associated vasculitis remission induction therapy.

Methods

This retrospective cohort study enrolled microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), and eosinophilic granulomatosis with polyangiitis patients at 25 sites in Japan who had a first or severe relapse between January 2017 and June 2020. Of these, patients with MPA or GPA who had a positive renal lesion score on BVAS (version 3) at baseline, or vasculitis findings on renal biopsy, CMV assayed by 48 weeks of treatment, were included. Patients were divided into two groups based on the presence or absence of a positive CMV antigen test during the remission induction phase (0–48 weeks of treatment). Outcomes were the rate of change in estimated glomerular filtration rate (eGFR) at 48 weeks after initiation of treatment in both groups, as determined by (eGFR at 48 weeks - eGFR at the initiation of treatment)/eGFR at the initiation of treatment; where lower values were associated with worse renal function. General linear models adjusted for age, gender, presence of diabetes or chronic kidney disease, and the use of rituximab or cyclophosphamide were generated.

Results

A total of 387 patients had CMV antigen measured during ANCA-associated vasculitis treatment, of which 164 had renal involvement and eGFR measured at 48 weeks. Seventy-seven (47.0%) were male and the median age was 75 years (range 69–80 years). CMV reactivation was observed in 44 patients (26.8%). The beta coefficient of multiple regression analysis with CMV positive as 1 and negative as 0 was 0.08 (95% confidence interval -0.13 to 0.29) (p = 0.47). The rate of change in eGFR was higher in the CMV positive group, but not statistically significantly.

Conclusion

Contrary to our hypothesis, renal prognoses tended to be better when CMV reactivation was observed. The patients in the CMV reactivation group may have been treated more aggressively, and some patients with a poor prognosis who were not followed up for 48 weeks dropped out. Further research investigating the adjustment of treatment methods is required.

Disclosure of Interests

None declared

POS0247 GLUCOCORTICOID TAPERING STRATEGY FOR ANCA-ASSOCIATED VASCULITIS: ADDRESSING THE GAP BETWEEN RECOMMENDATIONS AND REAL-WORLD PRACTICE

Background

Antineutrophil cytoplasmic antibody -associated vasculitis (AAV) is usually treated with combination of high-dose glucocorticoid (GC) and immunosuppressive agents, followed by tapering GC dose. Although the European League Against Rheumatism (EULAR) has specific recommendations for tapering the GC dose, clinicians often taper it slower than recommended due to concerns of potential disease relapse. However, such slower taper may prolong GC exposure for the patients, increasing the risk of adverse events, particularly infection.

Objectives

The aims of our study were (1) to clarify GC dose tapering in the treatment of AAV in a real-world setting, in contrast to the EULAR recommendation of 2015 and (2) to compare the incidence of AAV relapse and severe infection between patients underdoing EULAR-recommended tapering and those undergoing slower tapering than the recommendation.

Methods

In this multicenter (25 sites in Japan), observational, retrospective study of AAV, 541 patients who had initial or severe relapse were enrolled between January 2017 and June 2020. Of these, 349 patients with microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA) who entered in GC tapering phase after successful induction treatment were included. These patients were then grouped on the pace of GC tapering, defined as the GC dose at 12 weeks after treatment initiation: (1) EULAR group: 7.5-10 mg/day of GC, according to the EULAR recommendation of 2015, and (2) SLOWER group: >10 mg/day of GC. Their baseline characteristics and clinical outcomes were compared. Primary outcome was defined as relapse-free days from treatment initiation, whereas secondary outcome included the incidence of infectious events requiring hospitalization within 48 weeks from treatment initiation. Multivariable analysis was performed to assess the relationship between tapering pace and clinical outcomes.

Results

There were 44 patients (12.6%) in the EULAR group and 290 (83.2%) in the SLOWER group. Regarding baseline characteristics, compared with the EULAR group, the SLOWER group had significantly higher serum C-reactive protein level (EULAR, 5.89 ± 6.89 mg/dL vs SLOWER, 7.56 ± 6.01 mg/dL; p = 0.03), as well as a trend toward higher Birmingham Vasculitis Activity Score (version 3) (EULAR, 11.80 ± 7.01 SLOWER, 13.93 ± 7.06; p = 0.08) We did not observe any significant differences in the frequency of relapses between the two groups (EULAR, 8/44, 18.2% vs SLOWER, 55/290, 19.0%; p = 0.63). Multivariable Cox proportional hazard analysis revealed no relationship GC dose at 12 weeks from treatment initiation and incidence of relapse. However, upon logistic regression analysis, the SLOWER group was found to have significant higher risk of a severe infectious event within 48 weeks from treatment initiation (p = 0.046; hazard ratio, 1.27; 95% confidence interval, 1.004 – 1.601).

Conclusion

Our finding indicates that clinicians tended to taper GC slower for patients with higher disease activity. However, slower GC taper was not found to reduce the frequency of relapse. In addition, slower GC taper was found to increase the risk of a severe infection. Hence, clinicians should pay attention not only relapsing but also late GC taper resulting in the risk of serious infection, especially in patients with higher disease activity of AAV.

References

[1]Eur J Clin Invest 2015;45 (3): 346–368.

[2]Rheumatology (Oxford). 2021 Dec 24;61(1):205-212.

[3]Arthritis Res Ther. 2021 Mar 20;23(1):90.

[4]Scand J Rheumatol. 2022 Jan 20;1-13.

[5]J Rheumatol. 2018 Apr;45(4):521-528.

[6]Rheumatol Adv Pract. 2021 Mar 9;5(3):rkab018.

[7]Ann Rheum Dis. 2016 Sep;75(9):1583-94.

Figure 1.

Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

Disclosure of Interests

None declared

Bilateral renal subcapsular hematoma caused by polyarteritis nodosa: a case report

Polyarteritis nodosa, which is a systemic vasculitis of small- and medium-sized arteries, can cause arterial aneurysms in various organs, sometimes resulting in aneurysm rupture and hemorrhage. A kidney is one of the major targets of polyarteritis nodosa. Here, we report a 73-year-old woman who presented with sudden-onset high fever, diarrhea, and renal injury with bilateral renal subcapsular hematoma shown on contrast-enhanced computed tomography scan. She did not have trauma and significant medical history other than breast cancer in remission. Serological and immunological tests except for anti-Sjögren's syndrome-A and anti-Sjögren's syndrome-B were all negative. Digital subtraction angiography revealed bilateral intrarenal micro aneurysms, which allowed us to diagnose the patient with polyarteritis nodosa. As continuous monitoring of bilateral intrarenal hematoma by ultrasonography and computed tomography scan did not detect progression of intrarenal hemorrhage and extra renal hematoma, transcatheter arterial embolization and nephrectomy were not performed. Although hemodialysis therapy was required temporarily for acute kidney injury with anuria, her general condition and kidney function remarkably improved after receiving systemic immunosuppressive therapy with corticosteroids and cyclophosphamide. In conclusion, this is a rare case of polyarteritis nodosa manifesting as spontaneous bilateral subcapsular renal hemorrhage with deteriorated renal function, which was successfully treated with immunosuppressive therapy.

Impact of Magnetic Field Configuration on Heat Transport in Stellarators and Heliotrons

We assess the magnetic field configuration in modern fusion devices by comparing experiments with the same heating power, between a stellarator and a heliotron. The key role of turbulence is evident in the optimized stellarator, while neoclassical processes largely determine the transport in the heliotron device. Gyrokinetic simulations elucidate the underlying mechanisms promoting stronger ion scale turbulence in the stellarator. Similar plasma performances in these experiments suggests that neoclassical and turbulent transport should both be optimized in next step reactor designs.

POS0455 EFFECT OF ANTI-Ro/SSA ANTIBODIES FOR TREATMENT RESPONSE TO METHOTREXATE IN RHEUMATOID ARTHRITIS: A RETROSPECTIVE MULTICENTER OBSERVATIONAL STUDY

Background:

Several previous observational studies have suggested that patients with anti-Ro/SSA antibody-positive rheumatoid arthritis (RA) may respond poorly to treatment, including tumor necrosis factor inhibitors1. However, its influence on methotrexate (MTX) treatment, which is the anchor drug of treat-to-target strategy in RA treatment, remains unclear.

Objectives:

We compared the clinical response to MTX in both anti-Ro/SSA antibody-positive and -negative patients with MTX-naiive RA and investigated the reasons for the difference in response.

Methods:

We recruited 210 consecutive patients with RA who were newly started on MTX in this retrospective cohort study. The effect of the presence of anti-Ro/SSA antibodies on achieving low disease activity (LDA) of DAS28-CRP at six months after initiating MTX was investigated by using logistic regression analysis. CDAI, SDAI, concomitant using DMARDs and painkillers, patient’s and evaluator’s VAS, tender joint counts, and swollen joint counts at six months were also compared between the anti-Ro/SSA-positive patients and -negative patients. Missing data were imputed by using multiple imputations before multivariate analysis.

Results:

32 anti-Ro/SSA antibody-positive patients and 178 anti-Ro/SSA antibody-negative patients were included. The rate of achieving DAS28-LDA at six months was significantly lower in the anti-Ro/SSA antibody-positive patients than those in the anti-Ro/SSA antibody-negative patients (56.2% versus 75.8%, P=0.03). in the logistic regression analysis, the presence of anti-Ro/SSA antibodies was an independent negative predictor for achieving DAS-28-LDA at six months (OR:0.431, 95%CI: 0.190-0.978, P=0.044) (Table1). Anti-Ro/SSA antibody-positive patients had significantly higher patient’s VAS at six months (median [IQR]: 22 [15-41] vs 19 [5-30], P=0.038), and prescribed NSAIDs (37.5% vs 18.0%, P=0.018). CDAI and SDAI after six months were not significantly different between the group.

Conclusion:

The presence of anti-Ro/SSA antibodies might be one of the predictive factors for the insufficient response to treat to target strategy in RA treatment. Residual pain was suspected as one of the mechanisms contributing to the lesser clinical response of MTX in anti-Ro antibody-positive RA.

References:

[1]Ran Matsudaira wt al. J Rheumatol 2011;38(11):2346-54

Table 1.

Logistic regression analysis for the rate of achieving DAS28 low disease activity at six months.

Risk factor Odds ratio95%CIP valueAge at onset0.9930.968-1.0180.586Sex (woman)0.6430.300-1.3840.258RF-positive1.9620.853-4.5110.112ACPA-positive0.5520.225-1.3510.192Anti-Ro/SSA antibody-positive0.4310.190-0.9780.044

Disclosure of Interests:

None declared

Prevalence and treatment conditions for hypertension and dyslipidaemia complicated with systemic lupus erythematosus: A multi-centre cross-sectional study

OBJECTIVE

This study aimed to assess the prevalence and actual treatment conditions for hypertension and dyslipidaemia complicated with systemic lupus erythematosus (SLE).

METHODS

This was a cross-sectional study. We established the lupus registry of nationwide institutions (LUNA), a multi-centre cohort of SLE patients in Japan. From February 2016 to July 2018, 597 SLE patients were registered in the LUNA. We evaluated the incidence of hypertension and dyslipidaemia and analysed the risk factors for hypertension and dyslipidaemia by logistic regression analysis.

RESULTS

Overall, 597 patients were enrolled in the study. The median age was 44 years, and 88.0% of the patients were female. Among all the patients, 92.9% used prednisolone. The prevalence of hypertension and dyslipidaemia was 43.9% and 54.7%, respectively. Among the patients receiving medication for hypertension, 24.7% exhibited insufficient control (systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg), and among those receiving medication for hyperlipidaemia, 48.1% showed insufficient control (low-density lipoprotein cholesterol >140 mg/dL or triglyceride >150 mg/dL). The risk factors for hypertension were age, body mass index (BMI), disease duration, past maximum dose of prednisolone, and renal involvement, whereas those for dyslipidaemia were age and BMI.

CONCLUSION

About half of the patients had hypertension or dyslipidaemia, and a considerable number of cases were poorly controlled despite medication. Our data suggest that physicians should treat SLE activity as well as its complications, especially the common risk factors for atherosclerosis.

Candidatus Mycoplasma haemohominis in Human, Japan

Hemotropic mycoplasmas are common pathogens in animals, but it remains unclear what role these pathogens play in human infections. We report clinical and biologic characterization of Candidatus Mycoplasma haemohominis infection in a 42-year-old man in Japan. The patient had severe hemophagocytic syndrome 1 month after an accidental needlestick injury. Metagenomic deep sequencing identified Candidatus M. haemohominis and determined its draft genome for an isolate from serum of the patient. A high copy number of the Candidatus M. haemohominis genome was detected in serum and bone marrow samples. Electron microscopy examination showed morphologic characteristics of Candidatus M. haemohominis. Levofloxacin monotherapy induced resistance caused by a gyrase A gene mutation in the quinolone resistance–determining region, but a combination treatment with moxifloxacin and minocycline was effective. We identified Candidatus M. haemohominis in a patient who had life-threatening symptoms related to multiple organ infection. Human infection with this mycoplasma might occur more frequently than has been generally recognized.

Development of new experimental setup focusing on long-pulse magnetic reconnection by using rotating magnetic field technique

A new closed-type experimental setup to achieve a long-pulse magnetic reconnection in weakly ionized plasmas was developed by using a rotating magnetic field (RMF) technique. The experimental setup has a cylindrical vacuum vessel in which two sets of four antennas are equipped to generate RMF which drives steady azimuthal electron current in two torus plasmas. This device provided a quasi-steady magnetic reconnection condition in weakly ionized plasmas with ionization fraction of less than 1%. The proposed experimental setup will extend the research area of laboratory reconnection experiments and be helpful to comprehend the reconnection process in weakly ionized plasmas such as solar chromosphere.

Is the serum oxytocin level altered by treatment in rheumatoid arthritis patients complicated with depression?

Objective

The objective of this study was to investigate the factors associated with depression, including serum oxytocin (OXT) levels, disease activity, activities of daily living (ADL), and quality of life (QOL), and their effects on rheumatoid arthritis (RA).

Methods

This study included 42 RA patients who received treatment with a biological agent. We measured the following variables before and after 6 months of treatment: baseline characteristics, including age, sex, disease duration, smoking, and body mass index (BMI); prednisolone and methotrexate dose; serum level of matrix metalloproteinase-3 (MMP-3); erythrocyte sedimentation rate (ESR); and C-reactive protein (CRP) level. The disease activity of RA was assessed using the Simplified Disease Activity Index (SDAI); depression was assessed using the Hamilton Depression Rating Scale (HAM-D); ADL was assessed using the Health Assessment Questionnaire; and QOL was assessed using the Short Form (SF)-36. Serum OXT levels were determined using enzyme-linked immunosorbent assay.

Results

The HAM-D score significantly correlated with the SDAI, and the mental component summary (MCS) score of SF-36. However, the serum OXT levels did not correlate with the HAM-D score. Regression analysis using the HAM-D score as the objective variable identified female sex, smoking, BMI, and all the three component scores of SF-36, but not serum OXT levels, as significant factors. Comparisons between before and after treatment showed that the HAM-D score improved from 5 to 1.5; however, the serum OXT levels did not change.

Conclusion

The variables of female sex, smoking, BMI, and QOL correlated with depression complicated with RA. However, serum OXT levels did not correlate directly.

Predictor of the Simplified Disease Activity Index 50 (SDAI 50) at Month 3 of bDMARD Treatment in Patients with Long-Established Rheumatoid Arthritis

Objectives:

The Simplified Disease Activity Index (SDAI) 50 has good agreement with European League Against Rheumatism (EULAR) response measures for early Rheumatoid Arthritis (RA). There have been reports on early RA, but not on long-established RA. In this study, we analysed the relationships between various baseline factors and SDAI 50 after three months of treatment with biological disease-modifying antirheumatic drugs (bDMARDs) to determine the prognostic factors for long-established RA.

Methods:

Subjects were 260 RA patients who had been treated with bDMARDs for 3 months. The following characteristics were investigated: Patient backgrounds, the erythrocyte sedimentation rate (ESR), C-reactive protein and serum matrix metalloproteinase-3 levels, SDAI scores, and health assessment questionnaire disability index and short form-36 scores. As a primary outcome index, the SDAI response was defined as a 50% reduction in the SDAI score between baseline and 3 months (SDAI 50).

Results:

Baseline values of disease duration (odds ratio: 0.942, 95% CI: 0.902-0.984), smoking history (odds ratio: 2.272, 1.064-4.850), 28-tender joint count (odds ratio: 0.899, 0.827-0.977), evaluator's global assessment (odds ratio: 1.029, 1.012-1.047) and ESR (odds ratio: 1.015, 1.001-1.030) were determined to be significant factors based on logistic regression analysis.

Conclusion:

Our study demonstrated that RA patients with shorter disease duration, no smoking, and higher RA disease activity are more likely to achieve SDAI 50 through bDMARD treatment.

The Relationship between the Serum Oxytocin Levels, Disease Activity, the ADLs and the QOL in Patients with Rheumatoid Arthritis

Objective To investigate the factors associated with depression, including the serum oxytocin (OXT) levels, disease activity, activities of daily living (ADLs) and quality of life (QOL), and their effects on rheumatoid arthritis (RA). Methods This study included 42-RA-patients. We measured the following variables before and after 6 months of treatment with biological disease-modifying antirheumatic drugs (bDMARDs): the baseline characteristics (including age, sex, disease duration, smoking, and body mass index), the doses of prednisolone and methotrexate, the serum level of matrix metalloprotease-3, the erythrocyte sedimentation rate and the C-reactive protein level. The disease activity of RA was assessed using the Simplified Disease Activity Index (SDAI), depression was assessed using the Hamilton Depression Rating Scale (HAM-D), the ADLs were assessed using the Health Assessment Questionnaire disability index and the QOL was assessed using the Short Form (SF)-36. The serum OXT levels were determined using an enzyme-linked immunosorbent assay. Results The HAM-D score was significantly correlated with the SDAI, and the mental component summary score of the SF-36. However, the serum OXT levels were not correlated with the HAM-D score. The serum OXT levels before and after bDMARDs treatment did not differ to a statistically significant extent, regardless of the presence of depression. Although the differences in the serum levels of OXT were observed prior to the initiation of treatment, there was no gender difference after treatment. Conclusion Although RA complicated by depression may be related to the following high disease activity, a poor QOL and poor ADLs, the serum OXT levels were not directly correlated.

Clinical Characteristics of Rheumatoid Arthritis Patients Achieving Functional Remission after Six Months of Non-tumor Necrosis Factor Biological Disease-Modifying Antirheumatic Drugs (DMARDs) Treatment

Objectives We aimed to identify the factors that predict the likelihood of remission based on a health assessment questionnaire (HAQ) in rheumatoid arthritis (RA) patients who received non-tumor necrosis factor (TNF) biologics for six months before they commenced definitive treatment. Methods The subjects consisted of 97 RA patients treated with tocilizumab or abatacept for 6 months. The following characteristics were investigated: age, gender, body mass index, steroid and methotrexate dosage, serum matrix metalloproteinase-3 levels, simplified disease activity index (SDAI) score, HAQ score (for assessing the activities of daily living [ADL]) and the short form (SF)-36 score (for assessing the quality of life [QOL]). Remission based on the HAQ score is defined as HAQ ≤0.5 after 6 months of treatment. The subjects were divided into two groups: patients with HAQ score ≤0.5 and HAQ score >0.5, and a retrospective study was conducted. Results The group of RA patients who entered remission based on the HAQ (53 patients) had a lower SDAI than the patients who did not enter remission (44 patients), and the RA patients had a lower tender joint count (TJC) and HAQ scores and a lower physician's global assessment (PGA) than those who did not enter remission. The physical component summary score (PCS) and role/social component summary score (RCS) of the SF-36 summary score were higher in the remission patients than in those without. Before the start of the treatment, the HAQ score, patients' global assessment (PtGA) and PCS and mental component summary score (MCS) of the SF-36 were determined based on a logistic regression analysis. Conclusion Our findings suggest that RA patients with lower HAQ scores and PtGA and higher PCS and MCS of the SF-36 at baseline are more likely to achieve HAQ remission with non-TNF biologic treatment than others.

Clinical Characteristics of Rheumatoid Arthritis Patients Achieving Functional Remission with Six Months of Biological DMARDs Treatment

Objective Although previous studies have reported the prognostic factors for functional remission, no reports have cited the predictive factors. Our aim was to study the predictive factors for functional remission, which is a treatment goal in rheumatoid arthritis (RA), after receiving biological disease-modifying antirheumatic drugs (bDMARDs) treatment for six months. Methods The study consisted of 333 RA patients treated with bDMARDs for six months. The following patient characteristics were investigated: age, gender, disease duration, type of bDMARDs, baseline steroid and methotrexate dosage, and levels of serum rheumatoid factor, matrix metalloprotease, anti-cyclic citrullinated peptides antibody, tumor necrosis factor-α, and interleukin-6. In our evaluation, we used the Simplified Disease Activity Index (SDAI) for RA disease activity, health assessment questionnaire disability index (HAQ-DI) for activity of daily living, Short Form (SF)-36 for quality of life, and Hamilton Depression Rating Scale (HAM-D) or Self-rating Depression Scale (SDS) to determine the patients' depression status. The subjects were divided into two groups: patients with HAQ-DI≤0.5 and HAQ-DI>0.5 at 6 months. Results A univariate analysis comparing a group of RA patients without functional remission (n=68) showed that the patients with functional remission (n=164) had the following in common compared with those without remission: younger age, shorter disease duration, lower baseline steroid dosage, lower SDAI, lower HAQ-DI, higher SF-36, and lower HAM-D. Only lower HAQ-DI scores and "mental health" score on the SF-36 were detected using a logistic regression analysis. Conclusion These findings suggested that RA patients with lower HAQ-DI and lower depression scores at baseline were more likely to achieve functional remission using bDMARDs treatment than those without these variables.

Combined infliximab and methotrexate treatment improves the depressive state in rheumatoid arthritis patients more effectively than methotrexate alone

OBJECTIVE

Rheumatoid arthritis (RA) patients have a greater depressive tendency than normal subjects, and infliximab is known to provide quick therapeutic effects and to have high bioavailability for RA. We therefore investigated whether the depressive state of RA patients would be improved by infliximab.

MATERIAL AND METHODS

The Self-Rating Depression Scale (SDS) was used to evaluate 34 RA patients before and 14 or 30 weeks after inflixi mab treatment using the SDS and Disease Activity Score (DAS) 28. The SDS and DAS28 results before and after treatment were compared.

RESULTS

We also included 42 cases treated with methotrexate as the control group. The SDS decreased in both groups, and the intraindividual vari ability was p<0.001, indicating that the drugs had significantly different effects on the SDS. The DAS tended to decrease in both groups, but the intraindividual variability was p=0.199, indicating no difference between the two drugs.

CONCLUSION

This study is a preliminary study, but the data suggest that infliximab may reduce RA disease activity and improve the depressive state.

Serum anticyclic citrullinated protein antibody titers are correlated with the response to biological agents in patients with rheumatoid arthritis

Anticyclic citrullinated protein antibody (ACPA) is known as an important indicator for diagnosis of rheumatoid arthritis (RA). Our aim was to examine the relationship between the serum ACPA titer at baseline and responsiveness to biological agents (antagonists of either tumor necrosis factor or interleukin 6) in patients with RA. ACPA was measured using second-generation chemiluminescent enzyme immunoassay. Disease activity was assessed using disease activity scores 28. Fifty-seven RA patients with biological agents were enrolled, and the median ACPA titer at baseline was 110.0 U/mL. The median ACPA titer was 23.3 U/mL and 183.0 U/mL in the good and moderate response groups, respectively, which were significantly lower than in the no response group (404.0 U/mL). In addition, 69.2% and 26.9% of patients with low (<100 U/mL) and moderate (100–499 U/mL) basal ACPA titers showed a moderate to good response. Of the patients with higher (≥500 U/mL) basal ACPA titers, only 14.0% and 42.5% showed a good or moderate response, respectively. The remission rate was 77.8% in the ACPA-negative, which was significantly higher than the rate of 25% in the ACPA-positive patients. The results suggest that the ACPA titers are correlated with the efficacy of the biological agents used in patients with RA.

A case of Degos disease: demonstration of C5b-9-mediated vascular injury

A 68-year-old Japanese male presented with atrophic erythematous white lesions with peripheral dark reddish rims on his back. Multiple ulcers were detected from his stomach to his large intestine using endoscopy. Although the patient was given high doses of a steroid, aspirin, dipyridamole, and intravenous immunoglobulin therapy, he died of gastrointestinal hemorrhage, perforation and septic shock. An autopsy examination revealed pauci-inflammatory thrombotic microangiopathy with endothelial cell injury, fibrous occlusive arteriopathy, and vascular C5b-9 deposition in the wall of the gastrointestinal tract from the esophagus to the large intestine as well as in the dermis of the skin.