Diagnoses of muscular dystrophy in a veterans health system

INTRODUCTION/AIMS

Early diagnosis of a chronic neuromuscular disease such as muscular dystrophy (MD) generally excludes an individual from active-duty military service. However, it is not known whether veterans are sometimes diagnosed with milder forms of MD at a later timepoint. We aimed to determine the prevalence of MD in a veterans health system.

METHODS

We abstracted clinical and genetic test data on patients who received care for a diagnosis of MD at the North Florida/South Georgia Veterans Health System between 2008 and 2021. We then determined which of these individuals would meet criteria for a definite diagnosis of MD, based on electrodiagnostic testing, muscle biopsy, and genetic testing of the individual or an affected first degree relative.

RESULTS

We identified 12 patients with definite MD and 36 with possible or probable MD. The definite cases included myotonic dystrophy type 1 (4), myotonic dystrophy type 2 (3), oculopharyngeal MD (2), Becker MD (1), distal MD (1), and facioscapulohumeral MD (1). At least five of the cases classified as definite developed symptoms after discharge from active duty.

DISCUSSION

Clinicians who care for veterans should be knowledgeable about, and have access to, diagnostic testing and treatment options for MD. When conducting MD surveillance, it is important to include veterans health systems as a data source. Mild cases of MD and those of later onset appear to be compatible in some cases with successful completion of military service.

Genetic Patterns of Selected Muscular Dystrophies in the Muscular Dystrophy Surveillance, Tracking, and Research Network

Background and Objectives

To report the genetic etiologies of Emery-Dreifuss muscular dystrophy (EDMD), limb-girdle muscular dystrophy (LGMD), congenital muscular dystrophy (CMD), and distal muscular dystrophy (DD) in 6 geographically defined areas of the United States.

Methods

This was a cross-sectional, population-based study in which we studied the genes and variants associated with muscular dystrophy in individuals who were diagnosed with and received care for EDMD, LGMD, CMD, and DD from January 1, 2008, through December 31, 2016, in the 6 areas of the United States covered by the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet). Variants of unknown significance (VUSs) from the original genetic test reports were reanalyzed for changes in interpretation.

Results

Among 243 individuals with definite or probable muscular dystrophy, LGMD was the most common diagnosis (138 cases), followed by CMD (62 cases), DD (22 cases), and EDMD (21 cases). There was a higher proportion of male individuals compared with female individuals, which persisted after excluding X-linked genes (EMD) and autosomal genes reported to have skewed gender ratios (ANO5, CAV3, and LMNA). The most common associated genes were FKRP, CAPN3, ANO5, and DYSF. Reanalysis yielded more definitive variant interpretations for 60 of 144 VUSs, with a mean interval between the original clinical genetic test of 8.11 years for all 144 VUSs and 8.62 years for the 60 reclassified variants. Ten individuals were found to have monoallelic pathogenic variants in genes known to be primarily recessive.

Discussion

This study is distinct for being an examination of 4 types of muscular dystrophies in selected geographic areas of the United States. The striking proportion of resolved VUSs demonstrates the value of periodic re-examinations of these variants. Such re-examinations will resolve some genetic diagnostic ambiguities before initiating repeat testing or more invasive diagnostic procedures such as muscle biopsy. The presence of monoallelic pathogenic variants in recessive genes in our cohort indicates that some individuals with muscular dystrophy continue to face incomplete genetic diagnoses; further refinements in genetic knowledge and diagnostic approaches will optimize diagnostic information for these individuals.

Remineralization potential of phosphorylated chitosan and silver diamine fluoride in comparison to sodium fluoride varnish: invitro study

PURPOSE

The purpose of this study was to evaluate and compare the remineralization potential of phosphorylated chitosan nanoparticles (Pchi) and silver diamine fluoride (SDF) compared to sodium fluoride varnish (NaF) on microhardness of artificial carious lesions in a biomimetic minimally invasive approach that is being regarded as the future of preventive dentistry.

METHODS

The sample size included 40 intact extracted maxillary anterior human teeth. Baseline microhardness was recorded using Vickers hardness test and energy-dispersive X-ray spectroscopy (EDX). Artificial caries-like lesions were created on the exposed enamel by suspending all teeth in demineralizing solution for 10 days in a temperature of 37 °C and then the hardness and EDX were remeasured. Samples were then divided into four main groups: Group A (positive control group) n = 10, treated with NaF, Group B n = 10, treated with SDF, Group C n = 10, treated with Pchi and Group D (negative control group) n = 10 that received no treatment. After treatment, samples were incubated in artificial saliva solution at 37 °C in for 10 days and then reassessed. Data were then recorded, tabulated, and statistically analyzed using Kruskal-Wallis test and Wilcoxon signed test. Scanning electron microscope (SEM) was used to analyze the morphological changes of enamel surface after treatment.

RESULTS

Groups B and C showed the highest calcium (Ca) and phosphate (P) content as well as hardness values, while group B had the highest percentage of fluoride. SEM revealed a smooth layer of mineral formed on the surface of enamel for both groups.

CONCLUSION

Pchi and SDF showed the highest increase in enamel microhardness and remineralization potential.

CLINICAL RELEVANCE

The minimally invasive approach for remineralization could be enhanced using SDF and Pchi.

AB0252 INTOLERANCE TO METHOTREXATE IN RHEUMATOID ARTHRITIS: AN ASSESSMENT WITH THE MISS (METHOTREXATE INTOLERANCE SEVERITY SCORE)

Background

Methotrexate (MTX) is a cornerstone in the treatment of rheumatoid arthritis (RA), in monotherapy or in combination with biological agents. Its prolonged use requires regular clinical and biological monitoring. The purpose of our study is to assess intolerance to MTX and its consequences.

Objectives

The purpose of our study is to assess intolerance to MTX and its consequences.

Methods

This is a cross-sectional study with RA follow-up patients meeting the ACR/EULAR 2010 criteria. An assessment of MTX intolerance was conducted using the Arabic version of the MISS (Methotrexate Intolerance Severity Score). It is a questionnaire containing 12 items covering four areas: abdominal pain, nausea, vomiting and behavioral disorders. A score of six indicates an intolerance.

Results

Forty patients were included: 35 women (87.5%) and 5 men (12.5%) of average age 51.7 years ±12.7 years. The average duration of disease progression was 12.2 years 9.2 [1-40 years]. All patients were treated with methotrexate and supplemented with folic acid. 50% of patients were under 10mg/week of MTX, 27.5% under 15mg/week and 22.5% under 20 mg/week. Patients had been on this treatment for an average of 8.7 years [1-25 years]. The majority of them (97.5%) received corticosteroids in combination, 12.5% received Salazopyrine and 27.5% received biotherapy. Methotrexate intolerance was observed in 16 patients (42.1%). Nausea was observed in 13 patients (81.2%), vomiting in 5 patients (31.2%), abdominal pain in 11 patients (68.8%) and behavioral disorders in all patients. As a result of this intolerance, 18.8% of patients had to stop their treatment, 12.5% decreased the dose on their own, 6.2% took the MTX irregularly, 12.5% switched from the oral route to the intramuscular route and 50% continued to take their treatment in the usual way. The study of correlations did not reveal statistically significant associations between MTX intolerance and age, sex, dose and duration of MTX, the associated intake of salazopyrin, biotherapy and other symptomatic treatments.

Conclusion

The occurrence of an intolerance to MTX is common in patients followed for RA, which may lead to poor adherence to therapy or even a discontinuation of treatment thus decreasing the effectiveness of management. Hence the need to systematically detect this intolerance and react in time.

Disclosure of Interests

None declared

AB0526 ASSESSMENT OF HEALTH-RELATED QUALITY OF LIFE IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS USING SF-36 SCALE

Background

Systemic Lupus Erythematosus (SLE) has diverse effects on patients' health-related quality-of-life (HRQoL), affecting both physical and mental domains of well-being. The Medical Outcomes Survey 36-item Short Form (SF-36) is one of the most common generic instruments used to measure HRQoL in SLE.

Objectives

Our objective in this study is to assess the aspects of HRQoL in patients with SLE and to explore the associations between HRQoL and disease-related parameters.

Methods

A cross-sectional study was conducted in patients followed in the departments of Internal Medicine and Rheumatology in Mahdia, Tunisia, who met either the 1997 ACR or the 2012 SLICC criteria for SLE. We evaluated for each patient, the global score and the eight domains of SF-36 (physical functioning (PF), role physical (RP), bodily pain (BP) and general health (GH) gathered into the Physical Component Summary (PCS); vitality (VT), social functioning (SF), role emotional (RE) and mental health (MH)) gathered into Mental component Summary (MCS), scored from 0 (worst) to 100 (best). The disease activity was evaluated by the SLE Disease Activity Index (SLEDAI).

Results

Forty SLE patients were enrolled. 90% of patients were female. The mean age was 47.75±17.59 years. The mean disease duration was 2.3±2.9 years. The mean SLEDAI was 5.78±4.94. The most commonly found manifestations of SLE were; cutaneous, musculoskeletal and neuro-psychiatric in 85%, 82.5% and 40% of cases, respectively. The anti-nuclear antibodies were positive in 100% of cases. Serum levels of complement C3 and C4 were low in 20% and 32.5% of cases, respectively. A biological inflammatory syndrome was found in 37.5% of cases and anemia in 42.5% of cases. Anti-malarial were prescribed for 85% of patients, Glucocortoids were prescribed for 62.5% of patients. The SF-36 global score was 60.5 ± 20.5 ranging from 18.5 to 93.1. Eighteen patients (45 %) had impaired HRQoL (SF-36 < 66.7). The physical domains were more affected than the mental ones with mean scores of PCS and MCS of 59.59 and 61.6, respectively. The means of different domains (PF, RP, BP, GH, VT, SF, RE and MH) were respectively 67.87±28.3; 52.5±50; 62.5±29; 55.49±25.6; 56±21.5; 64±25.7; 67.5 ±47.4 and 58.6±18.6. The most severely impacted domains were RP and GH. Increased age was correlated with reduced PF, BP and PCS (p=0.02, p=0.02, p=0.05 respectively). Longer disease duration was associated with reduced GH (p=0.004). The analysis of organ-specific damage revealed that musculoskeletal involvement was significantly associated with lower scores of PF, RP, BP and PCS (p=0.05, p=0.009, p=0.01 and p<0.001, respectively), While neurological involvement was associated with lower scores of SF, VT and MCS (p=0.01, p=0.05 and p=0.04, respectively). The SF-36 global score and its domains had no significant correlations with the SLEDAI, the biological abnormalities or the received treatments.

Conclusion

Impairment in the quality of life can be significant when suffering from SLE, affecting physical health more than mental health according to our study. HRQoL should be included in routine clinical care in SLE patients.

Disclosure of Interests

None declared

AB1229 FRÉQUENCE ET ÉTIOLOGIES DES LOMBOSCIATIQUES SECONDAIRES: EXPÉRIENCE D’UN SERVICE DE RHUMATOLOGIE

Background

Secondary lumbosciatica (LS) is a rare clinical situation, but which must be eliminated in the event of any radiculopathy for better therapeutic management.

Objectives

The objective of our study was to determine the frequency and etiologies of secondary LS among patients hospitalized in the rheumatology department for exploration of lumbosciatica.

Methods

This is a retrospective, single-center study including patients hospitalized in the Rheumatology department of the Taher Sfar hospital in Mahdia for treatment of lumbosciatica, during the period between January 2014 and November 2021.

Results

We included in this study 357 patients hospitalized in our department for exploration of LS. After an etiological assessment, we retained the diagnosis of secondary LS in only 11 patients among our study population, ie 3.1% of cases. Among them, 8 patients were men (72.72%) and the other 3 were women (27.27%) with a sex ratio (M / F) of 2.66. The average age was 65 years with extremes between 55 and 88 years. The mean duration of symptomatology evolution was 6 months with extremes ranging from 15 days to 02 years. The mean pain VAS was 6.8 [2-8], and the majority (81.81% of cases) had inflammatory sciatica. 36.36% of patients (4 cases) had an L5 path, one patient had S1 irradiation and 54.54% (6 cases) had a truncated LS The general deterioration with weight loss was noted in 5 patients (45, 45% of cases) and vesico-sphincteric disorders in 2 patients (18.18%). Physical examination revealed spinal syndrome in 63.63% of cases (7 patients), radicular syndrome in 45.45% of cases (5 patients) and neurological signs of cauda equina syndrome in two patients (18, 18% of cases). Biologically, 81.81% of patients (9cas) had a biological inflammatory syndrome, 36.36% (4cas) had impaired protein electrophoresis (hypo-gamma peak) and 27.27% (3cas) had hypercalcemia. Recourse to CT or lumbar MRI made it possible to objectify tumor bone lesions in 72.72% (8 cases) of patients, of which 3 cases (37.5%) were of prostatic origin, 2 cases (18,18 %) multiple myeloma, one case of small cell carcinoma, one case of squamous cell carcinoma and one case of bladder tumor. For the other three patients (27.27% of cases), LS was caused by infectious spondylodiscitis in the lumbar stages.

Conclusion

As evidenced by our study, secondary sciatica is a very rare clinical situation, more encountered in the elderly with often an alteration of the general condition. But in front of its seriousness and its functional repercussions, arises the need to eliminate it systematically whatever the ground before starting the treatment.

Disclosure of Interests

None declared

AB0305 RELATIONSHIP BETWEEN IMMUNOLOGICAL ASSESSMENT AND PERIODONTAL STATUS IN RHEUMATOID ARTHRITIS

Background

Rheumatoid arthritis (RA) and Periodontitis are two chronic inflammatory diseases, which can share similarities such as the patho-physiological progression and immune regulation.

Objectives

The present study aimed to determine the link between immunological assessment and periodontal status in RA.

Methods

A cross sectional study including RA patients, which consulted or were hospitalized in Rheumatology department in Taher Sfar University Hospital of Mahdia Tunisia, between March 2020 and February 2021. The diagnosis of RA was based on ACR/EULAR 2010 criteria. Oral and periodontal examination was practiced by a trained dentist in the same hospital. Oral hygiene, teeth status (missing teeth) and paradental parameters (bleeding index of Loe and Silness (GI), plaque indexed O’Leary (PI)) were determined for each patient, to assess oral and periodontal diseases in RA.

Results

Our study included 73 patients with an average age of 51.7 years ±11.8 [21-74years]. Sixty-two patients (93.9 % of cases) were women, in which 35 (54.7%) were menopausal. Only one patient was a smoker. Nine patients (13.6% of cases) were diabetic. The mean duration of RA was 11.2 years ± 8.4 [10 months-37 years]. Rheumatoid factor (RF) was positive in 31 Patients (57 % of cases). Anti-citrullinated peptide antibodies (ACPA) were positive in 39 patients (72 %). Antinuclear antibodies (ANA) were positive in 5 patients (9.3%). Fifty patients (80.6%) had radiological impairments and 36 (54.5%) had specific deformations of RA. The disease activity score (DAS28-VS) and (DAS28-CRP) were very high (>5.1) in respectively 14 patients (21.2%) and 8 patients (12%).

Oral examination revealed xerostomia in 37 patients (62.7% of cases). Three patients (4.7% of cases) were toothless. Gingivitis was diagnosed in 45 Patients (65.2% of cases): localized in 13 patients (31.7%) and generalized in 28 patients (68.3%). Periodontitis was seen in 36 (50.7% of cases). Basing on bleeding index of Loe and Silness (GI), 36 patients (51.4%) had degree 2 and 11 patients (15.7%) had degree 3. Supragingival plaque and subgingival plaque were detected respectively in 62 patients (88.6 %) and 60 patients (88.2 %).

We performed statistical analysis which showed that the positivity of ACPA was significantly associated with the presence of gingivitis. The RF or the ANA were not associated with periodontal abnormalities.

Conclusion

In addition to the functional handicap, rheumatoid arthritis has an impact on the oral status, which may be related to the immunological status of patients.

Disclosure of Interests

None declared

AB0302 DIASTOLIC DYSFUNCTION IN RHEUMATOID ARTHRITIS PATIENTS: A COMPARATIVE CROSS-SECTIONAL STUDY

Background

Cardiac failure is an independent risk factor for mortality in Rheumatoid arthritis (RA) and diastolic dysfunction (DD) may act as a precursor for cardiac failure.

Objectives

The aim of our study is to determine the frequency of diastolic dysfunction in rheumatoid arthritis (RA) patients compared to a control group and to focus on associated factors.

Methods

This was a comparative cross-sectional study, including patients diagnosed with RA according to the ACR/EULAR 2010 criteria and control subjects. Each patient underwent transthoracic echocardiography and the DD was assessed by E/A and E/a ratio.

Results

Seventy-two patients with RA and 72 control subjects were included. In our study, there was a clear female predominance in both groups (93.1% vs 94.4%). The mean age of RA patients was 52.9 ± 11.72 years [21-75 years] and that of the control group was 49.26 ± 10.74 years [19-76 years]. In RA group, the mean duration of disease was 12.4 ± 9.9 years [6 months-40 years]. The means of DAS 28 (CRP), DAS 28 (ESR) and HAQ score were respectively 3.4 ± 1.4 [1.2-6.7]; 3.9 ± 1.4 [1.4-7.4] and 0.9 ± 0.7 [0-2.5]. 51.4% of patients had an increased ESR and 37.5% of cases had an increased CRP (CRP>6). In RA group, DD was present in 26 patients (36.1% of cases). The mean value of the impaired E/A ratio was 0.7 ± 0.1 [0.4-0.9] and the mean value of the impaired E/a ratio was 9.8 ± 1.5 [8.5-14.4]. These patients (23 women and 3 men) had a mean age of 56 ± 10.4 years [33-74 years]. Among them, 7 patients had hypertension, 9 patients had cardiac symptoms, 21 patients had a long-standing RA, 17 patients had positive ACPAs and 11 patients had positive RF. In control group, DD was present in 10 patients (13.9% of cases). The mean value of the impaired E/A ratio was 0.6 ± 0.1 [0.4-0.9] and the mean value of the impaired E/a ratio was 9 ± 0.6 [8.4 to 10.1]. Left ventricular diastolic dysfunction was more frequent in RA patients compared with the control group with a significant difference (p<0.01). No significant association was found between diastolic impairment and RA parameters.

Conclusion

Subjects with RA have a higher frequency of diastolic dysfunction than those without RA. Therefore, correct assessment of diastolic function should be considered of pivotal importance in the routine follow-up of RA patients. The identification of predictor factors requires further study.

References

[1]Cavazzana I, Vizzardi E, Franceschini F. Diastolic dysfunction in rheumatoid arthritis : Monaldi Arch Chest Dis 2019; 891137 2019;89.

Disclosure of Interests

None declared

AB0249 EVALUATION OF BELIEFS AND FEARS DURING RHEUMATOID ARTHRITIS TOWARDS CONVENTIONAL BACKGROUND TREATMENTS: STUDY BY BMQ (BELIEF ABOUT MEDICATION QUESTIONNAIRE)

Background

Poor adherence is one of the main causes of therapeutic failure in chronic inflammatory rheumatism, particularly in rheumatoid arthritis (RA). Thus to improve regular intake especially of conventional background treatments (cs-DMARDs), it is important to assess patients’ beliefs and fears about their treatments.

Objectives

Evaluate the beliefs and fears of patients with Rheumatoid arthritis towards their conventional background treatments.

Methods

This is a cross-sectional study with RA follow-up patients meeting the ACR/EULAR criteria. Epidemiological, clinical and paraclinical data were collected. The evaluation of beliefs and fears towards csDMARDs was carried out by the BMQ score which has two five-item scales rated according to a 5-point Likert scale, ranging from 1 (not at all agree) to 5 (strongly agree). The scores of necessity, fear, overuse and nuisance were calculated. Patients were divided into 4 groups according to their beliefs of csDMARDs: accepting, ambivalent, indifferent and septic.

Results

The mean Disease Activity Score (DAS28crp) was 3.5 ±1.54, the mean value of Visual analogue scale of pain (VAS) was 40.5± 20.5, and the mean value of Health Assessment Questionnaire (HAQ) was 1.05± 0.85. All patients were treated with methotrexate and 12.5% with Salazopyrine in combination. The average need score was 20± 2.4, fear score was 16.45± 3, overuse score was 13.67± 2.25 and nuisance score was 10.8± 2.6. Patients’ beliefs about the need for their background treatments were more important than their concerns and fears about the potential consequences of these treatments (p=0.03). A higher necessity score was correlated with the number of painful joints (NAD) (p=0.02) and a higher DAS28 (p=0.05). Patients who were more afraid of their treatments had more joint deformities (p=0.03), higher HAQ functional index (0.007) and a higher VAS value (p=0.01). The belief profile study concluded that 60% of patients were ambivalent, 27.5% accepting, 10% indifferent and 2.5% were septic towards their background treatments.

Conclusion

Our study showed that during RA, knowledge of the profiles of our patients, their beliefs and fears about their treatments especially cs-DMARDs is essential, and could help us to adapt strategies for improving compliance.

Disclosure of Interests

None declared

AB0311 RHEUMATOID ARTHRITIS AND OSTEOPOROSIS: FREQUENCY AND ASSOCIATED FACTORS

Background

In rheumatoid arthritis (RA), persistent systemic inflammation may cause bone and cartilage destruction and systemic osteoporosis (OP).

Objectives

We conducted this study to determine the frequency of OP in RA patients and to focus on associated factors.

Methods

This is a retrospective descriptive and analytic study including consecutive RA patients. The epidemiological, clinical, biological data and the measurement of bone mineral density were collected from patients’ records. A statistical analysis was performed to study the clinico-biological profile of osteoporotic patients and determine factors associated with the development of OP in RA patients.

Results

Seventy-one of RA patients were recruited: 67 females (94.4%) and 4 males (5.6%) with a mean age of 54.28 years ± 11.09 [30-75]. OP was noted in 45.1% of cases (32 patients). The mean T-scores at the lumbar and femoral sites were -2.7 ± 0.6 SD and -1.3 ± 1 SD, respectively. Patients with OP were older (58.8 ± 7.6 years vs 50.5 ± 12.1 years; p <0.01) and with a greater number of postmenopausal women than patients with normal bone density (68.7% vs 41%; p=0.02). Osteoporotic patients had RA duration longer than the other group (15.2 ± 12.5 years vs 11.9 ± 8.2 years; p=0.02) and more extra-articular manifestations associated with RA (100% vs 76.9%; p < 0.01). Both groups were treated with corticosteroid drugs with similar frequency, although patients with normal bone density received biotherapy more frequently than patients with OP (23% vs 18.7%; p= 0.03). The two groups had almost similar disease activity DAS28 ESR (44,3 ± 34 vs 42.7 ± 30.7; p=0.2). The following parameters were not associated with the occurrence of OP in our series: gender, smoking, BMI, ESR, CRP, ACPA, RF, erosive and deforming character of RA.

Conclusion

OP is an extra-articular disease that must be systematically screened throughout the follow-up. In our study, there was no significant difference in disease activity at both groups of patients. However, patients with OP had longer duration of RA, more extra-articular manifestations and were less frequently treated with biotherapy.

References

[1]Hauser B, Riches PL, Wilson JF, Horne AE, Ralston SH. Prevalence and clinical prediction of osteoporosis in a contemporary cohort of patients with rheumatoid arthritis. Rheumatology (Oxford). 2014 Oct;53(10):1759-66.

Disclosure of Interests

None declared

AB1022 PLACE OF BONE MINERAL DENSITY MEASUREMENT IN THE DIAGNOSIS OF ASYMPTOMATIC VERTEBRAL FRACTURES

Background

Vertebral fracture (VF) is the most common fragility fracture. The majority of them are asymptomatic and only third of VFs are clinically recognized. Screening of osteoporosis may increase early detection of these fractures.

Objectives

to emphasize on the routine practice the lateral and frontal X-rays of dorso-lumbar spine each time that the diagnosis of osteoporosis has been made.

Methods

This is a cross-sectional study which includes patients followed for a well-defined rheumatological disease in the rheumatology department at TAHER SFAR University Hospital, Mahdia, Tunisia. All patients had a bone mineral density (BMD) measurement whenever there is an indication according to the HAS 2006 recommendation with a systematic radiography of the dorso-lumbar spine (face and profile incidences).

Results

Thirty seven female patients were enrolled, with a mean age of 59.8 ± 9.9 years. The average body mass index was 30.85 ± 5.7kg/m2 and 83.7% of them were overweight (BMI>25kg/m2). 86.5% of patients had a history of back pain and 16.2% of them had a family history of fracture of the femoral upper extremity. The reasons for performing BMD were dominated by corticosteroid therapy ≥7.5mg/d for more than 3 months and a history of vertebral fracture in 37.8% of cases each and treatment with anti-aromatases in 16.2% of cases .18 patients had a Spinal T-score ≥-2.5 DS. 12 patients had a spinal Tscore between -2.5 DS and -1 DS. 6 patients had a femoral Tscore ≥-2.5 DS and 12 had a femoral Tscore between -2.5 DS and -1DS. 19/37 patients (51.4% of cases) had osteoporosis. 9/19 (47.3%) had a vertebral fracture among which 12% were previously unknown and in women who were fully symptom-free. The vertebral fractures were mainly located at the dorsal-lumbar region: the L1 and T11 vertebrae were fractured in 3 patients and the T12 vertebrae in 3 patients.

Conclusion

Our study showed that nearly half of patients with BMD-objectified osteoporosis had a VF detected on standard X-rays, most of which were previously unknown. It is plausible to speculate the place of this method combining BMD with spinal X-rays in the diagnosis of asymptomatic VFs.

References

[1]doi: 10.18773/austprescr.2016.020

Disclosure of Interests

None declared

AB0541 NEUROPSYCHIATRIC MANIFESTATIONS IN SYSTEMIC LUPUS ERYTHEMATOSUS: PREVALENCE, MANAGEMENT AND ASSOCIATED FACTORS

Background

Neuropsychiatric involvement is one of the major causes of morbidity and mortality in systemic lupus erythematosus (SLE). Its prevalence varies in the literature because of its clinical polymorphism.

Objectives

The aim of our study is to evaluate the clinical, biological, immunological and therapeutic characteristics of neuropsychiatric complications and to analyze the associated factors.

Methods

This is a retrospective descriptive study including patients followed for SLE (ACR 1997/ SLICC 2012) during the period between 2010 and 2021 at the Rheumatology and Internal Medicine departments in Mahdia, Tunisia.

Results

Our study included 82 SLE patients among whom 29 had neuropsychiatric manifestations (NPM) with a frequency of 35.4%. They were 28 women and 1 man. Their mean age was 52.41 ± 18.11 years [21 - 85]. The mean disease duration was 2.4 ± 3 years [15 days-15 years]. The mean SLEDAI was 9.3 ± 7.85 [0-32]. NPM were inaugural of SLE in 14 cases (17%). Central neurological manifestations consisted of cerebral vasculitis (n=11), epiletic seizures (n=1), ischemic stroke (n=1), aseptic meningitis (n=1) and transverse myelitis (n=1). Peripheral neurological manifestations of mono/polyneuropathy were found in 6 cases. Cranial nerves involvement was described in 2 cases (Optic neuropathy and vestibular nerve damage). Psychiatric manifestations were present in 7 cases (25%): Depression in 4 cases and psychosis in 3 cases. The most frequent associated clinical manifestations were: musculoskeletal (100%), dermatological (89.7%), hematological (72.5%) and cardiovascular (24.1%). Biological findings included: leucopenia (31%), lymphopenia (44.8%), anemia (44.8%) and biological inflammatory syndrome (41.4%). The mean sedimentation rate (ESR) was 53.75 ±34 mm [2-130]. The mean C-reactive Protein was 13.6 ±27.8 mg/dL [0-130]. Anti-nuclear antibodies and anti-DNA were positive in 100% and 41.4% of cases, respectively. Anti-Sm antibodies were positive in 13.5%, anti-SSA in 24.1% and anti-SSB in 13.8% of cases. Antiphospholipid was positive in 8 patients. C3 and C4 consumption was found in 20.7% and 27.6% of cases, respectively. Brain magnetic resonance imaging showed T2 white matter hyperintensities, particularly in the periventricular area, in 8 cases and ischemic brain lesions in 2 cases. The treatment of NPM required: Glucocorticoids (75.9%), Azathioprine (AZT) (24.1%), Cyclophosphamide (13.7%), Mycophenolate Mofetil (3.4%), anticoagulants and antiplatelet agents (40%). The evolution was favorable for our patients except for one patient who developed AZT-induced hepatotoxicity. Statistical analysis showed that NPM were significantly correlated with older age (p=0.003), hematological involvement (p=0.02), lymphopenia (p=0.004), ESR (p=0.01), anti-Sm antibodies (p=0.03) and SLEDAI score (p=0.008).

Conclusion

NPM during SLE are a serious complication of the disease. Our study shows the frequency and variety of neuropsychiatric presentations during SLE. They must be systematically sought, especially if the disease is active, with older patients and anti-Sm antibodies positivity.

Disclosure of Interests

None declared

AB0055 BONE AND MINERAL DISORDERS IN RENAL HEMODIALYSIS PATIENTS

Background

Chronic kidney disease causes many mineral and bone disorders, secondary hyperpathyroidism, adynamic bone disease and osteomalacia which can reduce the bone mineral density (BMD).

Objectives

To analyze the prevalence of osteoporosis in group of patients with chronic renal failure and to evaluate the relation between bone mineral density (BMD) and specific markers of bone turnover in hemodialysis (HD) population.

Methods

This is a cross sectional study conducted in rheumatology department of Taher Sfar university hospital in mahdia, Tunisia. The study involved 61 patients with chronic hemodialysis. they were invited to participate and were included after signing informed consent until the calculated sample size was reached. Patients were asked to undergo a hip and lumbar (L2-L4) densitometry by DXA to measure bone mineral density (BMD). Serum levels of iPTH and alkaline phosphatase (ALP) were measured before the dialysis session.

Results

The studied group of 61 patients was 26 females (42,6%) and 35 males (57.4%), there mean age was 53.9 [17-83] years, with mean dialysis duration 6,1 years. The mean onset age of hemodialysis therapy was 44.7 +/- 15.4 years. It was diabetic nephropathy in 25 cases (41%) vascular nephropathy in 15 cases and tubulointerstitial nephropathy in 21 cases (34,4). 23 patients (37,7%) had osteoporosis using the WHO criteria (T-score < -2,5), 26 patients (42,6%) had osteopenia and 12 patients had normal BMD. The mean serum level of iPTH with normal BMD and lower BMD 167,84 vs 535,71 respectively. the mean serum level of ALP with normal BMD and lower BMD 144,59 vs 271,99 respectively (p<0,001). The mean duration of dialysis therapy with normal BMD and lower BMD 4,57 years vs 6,55 years (p<0,001).

Conclusion

Our study showed that osteoporosis is common in dialysis patients. The main determinants of BMD is PTH activity and the duration of dialysis therapy. the importance of prevention and treatment of metabolic bone disease has become better appreciated.

Disclosure of Interests

None declared

AB0169 INTEREST OF THE ECHOCARDIOGRAPHY IN SCREENING OF CARDIAC INVOLVEMENT IN RHEUMATOID ARTHRITIS PATIENTS

Background:

Rheumatoid arthritis (RA) is the most common chronic inflammatory disease which usually affects peripheral joints.Extra-articular manifestations can occur during the course of this disease and even before the onset of arthritis, such as cardiac impairment that is a common cause of mortality in RA.

Objectives:

The aim of our study is to identify the prevalence of cardiac manifestations in RA using the echocardiography exam and to elaborate its associated factors.

Methods:

This is a cross-sectional study including consecutive RA’s patients which consulted the rheumatology department in Taher Sfar hospital. The diagnosis of RA was elaborate according to ACR/EULAR 2010 criteria. The epidemiological, clinical and biological data were collected from patients’ records. Echocardiography was performed by a trained cardiologist in the same hospital, using the transthoracic approach.

Results:

Our study included 67 patients: 63 women (94%) and 4 men (6%), with an average age of 52.55 years [21-75 years] and mean disease duration of 11.85 years [10-40]. Joints deformities were present in 37 cases (55.2%) and radiographic joint damage in 49 cases (73.1%). 34 (50.7%) of the patients had an ESR greater than 30 mm/hour and 24 (35.8%) had a CRP greater than 6mg/L. The mean DAS28-CRP was 3.35 [1.24-6.7] and the mean DAS28-ESR was 4 [1.4-7.35]. Cardiac symptomatology was present in 22 cases (32.8%), dominated by dyspnea on effort in 22 cases (32.8%), dyspnea at rest in 4 cases (6%), chest pain in 8 cases (11.9%)and palpitation in 2 cases (3%). The echocardiography abnormalities were found in 44 cases. Valve damage was detected in 35 patients (52.2%), of which only 2 were significant. Valvular abnormalities were dominated by mitral valve regurgitation and mitral valve thickening in 11 cases (16.4%) each, aortic valve regurgitation in 6 cases (9%),aortic valve thickening in 2 cases (3%), aortic valve stenosis in 3 cases (4.5%),aortic valve calcification in 12 cases (17. 9%) aortic valve nodule in 1 case (1.5%), pulmonary insufficiency in 10 cases (14.9%) and tricuspid insufficiency in 25 cases (37.3%).Pericarditis was found in 2 cases (3%), pulmonary arterial hypertension (PAH) in 5 cases (7,5%) and Left ventricular hypertrophy in 14 cases (20,9%). The study of E/A and E/E’ ratios revealed diastolic dysfunction in 23 cases (34.3%).The mean of longitudinal global strain measure was -17,83 [-21,9 to -10] and it revealed systolic dysfunction in 18 cases (26.86%). Cardiac impairment detected by echocardiography did not appear to be associated with the age (p=0.39) or the disease duration (p=0.62) nor the importance of biological inflammation(p=0.1). However, joints deformities and RA activity (DAS28) were significant predictors of cardiac involvement (p=0.01; p=0.03).

Conclusion:

Our study shows that cardiac impairment in RA was often asymptomatic and was correlated with the disease activity. The echocardiography with the strain measure represents an excellent tool for its detection in early stages.

References:

[1]Guedes C, Bianchi-Fior P, Cormier B, Barthelemy B, Rat AC, Boissier MC. Cardiac manifestations of rheumatoid arthritis: A case-control transesophageal echocardiography study in 30 patients. Arthritis Care Res. 2001;45(2):129–35.

Disclosure of Interests:

None declared

AB0192 EVALUATION OF TEMPOROMANDIBULAR JOINT INVOLVEMENT IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Rheumatoid Arthritis (RA) is the most common chronic inflammatory disease usually involves peripheral joints with a symmetric distribution. The temporomandibular joint (TMJ) is seldom joint to be affected first in the disease course.

Objectives:

The Aim of our study is to describe and to assess the prevalence of temporomandibular joint (TMJ)disorders in patients with Rheumatoid arthritis (RA).

Methods:

A cross sectional study including RA patients, which consulted or were hospitalized in Rheumatology department in Taher Sfar Hospital of Mahdia Tunisia, during a period of 10 months. The diagnosis of the RA was secured by the ACR/EULAR 2010, Rheumatoid Arthritis Classification Criteria. The clinical TMJ examination was performed by a trained dentist in the same hospital. We assessed TMJ pain with VAS (visual analog scale) which varies from 0 to 10. The following key parameters were evaluated: The pain on the TMJs by bilateral palpation; The TMJ sounds (clicking or crepitus) during opening closing of the mandible; dysfunction and movement alterations. Clinical and sociodemographic parameters were also determined.

Results:

Our study included 51 patients with an average age of 51.11 years ±12.4 [21-74years]. 50patients (92.6%of cases) were women and 8 patients (14.8%) were diabetic. Only one patient was a smoker. The mean duration of RA was 10.7 years 7.7± [10months-35years]. Rheumatoid factor (RF) was positive in 25 Patients (46.3%of cases). Anti-citrullinated peptide antibody (ACPA) was positive in 32 patients (59.3 %).41patients (75.4%) had radiological impairments and 28 (51.9%) had specific deformations of RA. The average disease activity score (DAS28-VS) and (DAS28-CRP) were respectively 4.1±1.5 [1.4-7.3] and 3.4±1.5 [1.24-6.71]. TMJ pain was present in 29 patients (56.9 %) which67.7% appeared before ten years. 5 patients (16.7%) had VAS more than 7 that mean a severe pain. TMJ involvement was bilateral in 64.3% and unilateral in 35.7 %. Functional difficulties were detected in 22 patients (44.9 %). TMJ examination had also revealed a limitation of mouth opening in 11 patients (21.2 %), a movement alteration in 13 patients (27.79 %), a clicking in joint mobility in 13 patients (81.3 %) and joint crepitus in 1 patient (6.3%). Disease duration was associated with TMJ pain(p=0.05) and mobility alterations (p=0.04). Functional difficulties of the TMJ were correlated with DAS28 (p=0.02). In our study we found also that duration of corticosteroid therapy had in impact on TMJ pain (p=0.01), functional difficulties (p=0.01) and movements alterations (p=0.004).

Conclusion:

TMJ is very rare to be affected in the early phase of the disease, thus patient may develop signs and symptoms in the course of time. Our study showed the frequency of TMJ disorders and the most important factors were the activity of RA and the duration of the disease course.

Disclosure of Interests:

None declared

AB0339 PREVALENCE AND ASSOCIATED FACTORS OF LOW BONE MINERAL DENSITY IN ADULTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Patients with Systemic Lupus Erythematosus (SLE) are at risk of osteoporosis (OP) and fragility fractures (FFx) because of the disease or its treatments. We assessed the prevalence and risk factors for OP in patients with SLE.

Objectives:

Our objective is to determine the prevalence of bone mineral density (BMD) loss and fracture risk factors in SLE patients undergoing dual-energy X-ray absorptiometry (DXA).

Methods:

This is a cross sectional study conducted during the year 2020 in the Rheumatology and internal medicine departements in Taher Sfar hospital of Mahdia, Tunisia. We included patients aged ≥18 years with a diagnosis of SLE according to the 1997 ACR or 2012 SLICC criteria. Patients with renal or hepatic osteodystrophy, or receiving bisphosphonates were excluded from the study. The BMD values were measured by DXA. The T-score, Z-scores and BMD of the lumbar spine (LS) and femoral neck (FN) were determined. OP was defined as a value of the T-score less or equal to -2.5 SD for postmenopausal women and men aged more than 50 years old, and Z-scores less or equal to -2 for premenopausal women and men aged less than 50 years old.

Results:

Forty-six SLE patients were included. The mean age was 47.19±16.45 years [18-85], with a mean disease duration of 2.52±3.46 years [15days-15years]. The mean SLEDAI score was 5.34±4.82. As regards menstrual history of female patients: 56.5% were premenopausal, 43.5% were post-menopausal and 6% had premature menopause. 13% of our patients gave history of smoking. The mean BMI was 27.6 ± 6 kg/m2 [15-39.8]. FFx were diagnosed in 4 patients (9%) and the mean age of the first fracture was 45years. GCs were used in 65.2% of cases (30 patients). The mean daily dose of GCs was 10 mg/day and the mean cumulative dose was 20g. Calcium and Vitamin D intake was mentioned in 65.2% of cases (30 patients). The association of SLE with other rheumatic diseases was found in 14 of patients. The mean T-score at FN and LS were respectively 0.02±1.17 and -1.32±1.36. The mean Z-score at FN and LS were respectively 0.53±1.14 and -0.6±1.26. It was found that 17 patients (37% of cases) had OP, 12 had osteopenia (26%) and 17 patients (37%) had normal BMD. 37% of patients had OP at LS, 23.9% osteopenia at LS, 6.5% OP at FN and 21.7% osteopenia at FN. Low BMD was significantly correlated with increased age (p=0.01) and disease duration(p=0.05),post-menopausal status(p=0.04), higher BMI (p=0.004), musculoskeletal involvement (p=0.01), association to other rheumatic diseases (p=0.01), higher disease activity by SLEDAI score (p=0.05), higher Erythrocyte sedimentation Rate (p=0.01) and C-Reactive Protein (p=0.007), low serum complement C3 (p=0.009) and C4 (p=0.04) and cumulative doses of GCs (p=0.01).

We found also that BMD at LS was mostly affected by GCs intake, BMI and CRP while BMD at FN was mostly affected by SLEDAI score, C3 and C4 (p<0.001 in all cases). Gender, history of smoking and cardiovascular comorbidities had no significant impact on BMD.

Conclusion:

OP is a common but unrecognised complication of SLE with increased frequency of both peripheral and vertebral FFx. Our study suggests a high risk profile for OP and FFx in SLE which seems to be associated with age, disease duration, post-menopausal status, BMI and GCs.

References:

[1]Dey, M., & Bukhari, M. (2018). Predictors of fracture risk in patients with systemic lupus erythematosus. Lupus, 27(9), 1547–1551.

Disclosure of Interests:

None declared

AB0337 ASSESSMENT OF HEALTH-RELATED QUALITY OF LIFE IN SYSTEMIC LUPUS ERYTHEMATOSUS USING THE SLEQoL (SYSTEMIC LUPUS ERYTHEMATOSUS-SPECIFICQUALITY OF LIFE QUESTIONNAIRE)

Background:

Patients withsystemic lupus erythematosus (SLE) have a better survival than decades ago. Nevertheless, they still experience a low health-related quality of life (HRQoL). The Systemic Lupus Erythematosus-Specific Quality of Life Questionnaire (SLEQoL) is one of the most widely used specific tools for measuring HRQoL in SLE.

Objectives:

The aim of our study is to assess the impact of the SLE in the HRQoL using the SLEQoL tool.

Methods:

This is a cross-sectional study during a period of the year 2020, including patients followed in the departments of Internal Medicine and Rheumatology in Mahdia, Tunisia. All patients were diagnosed with SLE based in ACR 1997/SLICC2012. The SLEQoL is composed of 40 items scored from 1 to 7, it includes six HRQoL domains: physical functioning (Items 1 to 6), activities (items 7 to 15), symptoms (items 16 to 23), treatment (items 24 to 27), mood (items 28 to 31) and self-image (items 32 to 40) with higher values corresponding to worse HRQoL.

Results:

Forty patients were enrolled. The age of the SLE patients (36 females/4 males) ranged from 11 to 87 years. The mean age was 47.75±17.59 years. The mean disease duration was 2.3 ±2.9 years. The mean SLEDAI score was 5.78±4.94. The main target organs involved were cutaneous, musculoskeletal, neurological, pulmonary, cardiovascular and renal in 85%, 82.5%, 32.5%, 17.5%, 15% and 7.5% of cases respectively. The biologic analysis showed the positivity of anti-nuclear antibodies in 97.5% of cases, low serum complement C3 and C4 in 20% and 32.5% of cases respectively. A biological inflammatory syndrome was found in 37.5% of cases and Anemia in 42.5%. 85% of SLE patients were treated by anti-malarial, 62.5% were treated by Glucocorticoids and 5% by Methotrexate. The mean SLEQoL global score was 77.92 ± 34.02 [40-153]. The means of different domains (physical functioning, activities, symptoms, treatment, mood and self-image) were respectively 12.1±6.49 [6-30]; 19.6±10.9 [9-49]; 16.4±8.1 [8-34]; 5.5±2.36 [4-14]; 9.6±5.4 [4-20]; 14.9±7.5 [9-36]. The most severely impacted domains were activities and symptoms. The less affected domains were treatment and mood. The SLEQoL global score was correlated with increased age (p=0.03), longer disease duration (p=0.05), SLEDAI score (p=0.02), visual analog scale of pain (p=0.04), musculoskeletal manifestations (p=0.04), cutaneous manifestations (p=0.05) and pulmonary manifestations (p=0.05). By analyzing biological tests of our patients, we found a correlation between the SLEQoL global score and Erythrocyte sedimentation rate [ESR] (p=0.05), Anemia (p=0.04), low serum complement C3 (p=0.02) and C4 (p=0.003). SLEQoL global score and its six domains were not correlated with gender, educational level nor marital status.

Conclusion:

Our study showed that HRQoL is impaired in patients with SLE. The most important predictors of low HRQoL were older age, longer disease duration, some clinical manifestations, biological activity disease indicators (ESR, anemia and low complement level) and the SLEDAI score.

References:

[1]Leong, K. P., Kong, K. O., Thong, B. Y. H., Koh, E. T., Lian, T. Y., Teh, C. L., et al (2005). Development and preliminary validation of a systemic lupus erythematosus-specific quality-of-life instrument (SLEQOL). Rheumatology, 44(10), 1267–1276.

Disclosure of Interests:

None declared

POS0585 ORAL STATUS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) is a systemic auto immune inflammatory disorder, which primarily affects the synovial joints, but it may have an impact on oral health.

Objectives:

The present study aimed to describe oral manifestations in patients with Rheumatoid arthritis (RA).

Methods:

A cross sectional study including RApatients, which consulted or were hospitalized in Rheumatology department in Taher Sfar Hospital of Mahdia Tunisia, during a period of 10 months. The diagnosis of RA was based on ACR/EULAR 2010 criteria. Oral and periodontal examination was practiced by a trained dentist in the same hospital. Oral hygiene, teeth status (missing teeth) and paradental parameters (bleeding index of Loe and Silness (IG), plaque indexed O’Leary (IP) were determined for each patient, to assess oral and periodontal diseases in RA.

Results:

Our study included 51 patients with an average age of 51.11 years ±12.4 [21-74years].50patients (92.6%of cases) were women and 8patients (14.8%) were diabetic. Only one patient was a smoker. The mean duration of RA was 10.7 years 7.7± [10months-35years]. Rheumatoid factor (RF) was positive in 25 Patients (46.3%of cases). Anti-citrullinated peptide antibody (ACPA) was positive in 32 patients (59.3 %).41patients (75.4%) had radiological impairments and 28(51.9%) had specific deformations of RA. The average disease activity score (DAS28-VS) and (DAS28-CRP) were respectively 4.1±1.5[1.4-7.3] 3.4±1.5 [1.24-6.71]. Oral examination revealed a poor oral hygiene in 36patients (69.2% of cases) and 4.7% of our patients (2 cases) were toothless. Xerostomia was observed in 32 patients (80%). Gingivitis was diagnosed in 26 Patients (52%): localized in 6 patients (26.1%) and generalized in 17 patients (73.9%). 21 patients had periodontitis (41.2%). Basing on bleeding index of Loe and Silness (IG),27 patients (55.1%) had degree 2 and9 patients (18.8 %) had degree 3. Supragingival plaque and subgingival plaque were detected respectively in 45 patients (90 %) and 47 patients (95.9 %). In our study, tooth loss was significantly correlated with increased age (p=0.001) and post-menopausal status (p=0.03). Xerostomia, gingivitis and periodontitis were associated with increased age. But no association was found between oral manifestations and DAS28 nor biological inflammatory parameters.

Conclusion:

Rheumatoid arthritis is destructive and disabling rheumatism with a great risk to develop dental and periodontal diseases. So, it is important to systematically control oral hygiene of our patients to prevent complications.

Disclosure of Interests:

None declared

AB0897-HPR EVALUATION OF ANXIETY AND DEPRESSION IN PATIENTS WITH KNEE OSTEOARTHRITIS USING THE HAD “HOSPITAL ANXIETY AND DEPRESSION SCALE”

Background:

Knee osteoarthritis is considered to be one of the most common causes of functional impairment, which affects the quality of life of patients leading to severe mood disorders. Our goal is to evaluate the frequency of depression and anxiety in patients with knee osteoarthritis.

Objectives:

Evaluate the frequency of depression and anxiety in patients with knee osteoarthritis.

Methods:

This is a cross-sectional study over a period of 7 months from February to August 2016, including consecutively patients who consulted in the Rheumatology department at Mahdia university hospital for knee osteoarthritis. We evaluated for each patient a validated version of HAD “Hospital Anxiety and Depression scale”. This score includes 14 items each one rated from 0 to 3 and two components including depression and anxiety.

Results:

We included in our study 66 patients (56 women and 10 men) with an average age of 60.3 years [40-90 years]. Knee osteoarthritis was bilateral in 56.1% of cases. The examination found limited mobility of the knee in 45.5% and flessum in 13.8% of cases. Standard radiography showed stage 1 knee osteoarthritis in 4.5%, stage 2 in 31.8%, stage 3 in 56.1% and stage 4 in 7.6% of cases. All our patients were treated with analgesics, NSAIDs in 95.5%, local corticosteroid infiltrations in 43.9% and hyaluronic acid in 7.6% of cases.The mean visual analog scale(VAS)was 5.84 ±1.7 out of 10 [2-9]. The mean overall WOMAC index was 47.15±15.6 [12-82]. The average Lequesne index was 16.8±13.1, moderate disability was found in 3% of cases, significant disability in 6.1% of cases, very significant disability in 18.2% of cases and extreme disability in 72.7% of cases. The mean depression score was 9.3±2.6 [4-16], with 24.6% of the patients had no depressive symptomatology (score ≤7), 40% had doubtful depressive symptomatology (score between 8 and 10) and 35.4% of them had certain depressive symptomatology (score ≥11).The mean anxiety score was 8.88 ± 4 [0-19], 33.3% of patients had no anxiety symptoms (score ≤ 7), 34.8% had doubtful anxiety (score between 8 and 10) and 31.8% had certain anxiety (score ≥11). The statistical study found a significant correlation between the depression score and WOMAC score, but we did not find an association with age, sex, radiological stage, mobility limitation and VAS. Regarding anxiety, there was a correlation with age, WOMAC score and female gender. On the other hand, there was no correlation with VAS, Lequesne score, radiological stage and limitation of mobility.

Conclusion:

Although knee osteoarthritis appears to be a benign pathology, its impact can be severe, including depression and anxiety, which are mainly influenced by the degree of functional disability. Hence psychological care is sometimes necessary in these chronic degenerative diseases.

Disclosure of Interests:

None declared

AB0064 EVALUATION OF QUALITY OF LIFE IN RHEUMATOID ARTHRITIS USING SF-36 AND HAQ SCALES

Background:

The assessment of health-related quality-of-life (HRQoL) in rheumatoid arthritis (RA) is becoming a common tool in clinical practice. The medical outcomes survey short form 36 (SF- 36) is one of the most widely used tools for measuring HRQoL in RA as well as the HAQ scale.

Objectives:

The aim of our study is to evaluate the impact of the RA in the quality of life (QoL) of our patients using the SF-36 and the HAQ questionnaires.

Methods:

This is a cross-sectional study during a period of the year 2020, including 70 patients followed in the department of Rheumatology in Mahdia, Tunisia. All patients were diagnosed with RA based in ACR 1987/EULAR 2010. We evaluated for each patient, the mean global scale and the eight domains of SF-36 (physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), a social functioning (SF), role emotional (RE) and mental health (MH)), scored from 0 (worst) to 100 (best).

Results:

Our study included 70 patients (59 females/11males) with an age ranged from 21 to 76 years. The mean age was 54 ± 12 years. The mean duration of the disease was 11 ± 10 years [1-40]. The mean number of tender joints was 9.7 ±9.4 and swollen joints were 4.2 ±6.1. The mean disease activity score (DAS28) was 4.6 ±1.9 [1.2-8.4]. The mean HAQ score was 1.5±1.3, 47.1% of patients had specific joint deformations, 82.9% had radiologic involvement and 31.4% had osteoporosis. The biologic analysis showed that the mean ESR was 46.7 ± 30.5 and the CRP was 15.8 ±23.3. Rheumatoid factors were positive in 42.9% of cases, the ACPA were positive in 50% of cases. 84.3% of RA patients were treated by methotrexate, 4.3% were treated by salazopyrin and 11.4% were treated by biologic treatments.

The SF-36 global score was 50.4 ± 26.3 [15.3-92.8]. 46 patients (65.7% of cases) had impaired QoL (SF-36<66.7). The means of different domains (PF, RP, BP, GH, VT, SF, RE, MH) were respectively 51; 41.4; 51.4; 50; 51.2; 57.7; 41.9; 59.2. The most severely impacted domains were the RP and RE.

Our study showed a significant correlation between the SF-36 global score and the number of tender joints (p=0.002), the DAS28 (p=0.017) and the HAQ(p=0.000).

Conclusion:

Our study showed that 65.7% of RA patients presented impaired QoL (SF-36<66.7), which is associated with high disease activity. So it’s important to jugulate the disease, in order to ameliorate the quality of life of our patients.

References:

[1]Matcham, F., Scott, IC, Rayner, L., Hotopf, M., Kingsley, GH, Norton, S.,… Steer, S. (2014). L’impact de la polyarthrite rhumatoïde sur la qualité de vie évalué à l’aide du SF-36: une revue systématique et une méta-analyse. Séminaires sur l’arthrite et les rhumatismes, 44 (2), 123-130. doi: 10.1016 / j.semarthrit.2014.05.001.

Disclosure of Interests:

None declared

AB0261 IMPACT OF COMORBIDITIES IN THE DISEASE ACTIVITY OF PATIENTS WITH SPONDYLOARTHRITIS AND RHEUMATOID ARTHRITIS: TUNISIAN REGISTRY (BINAR)

Background:

Comorbidities can be associated with rheumatoid arthritis (RA) and spondyloarthritis (SpA). This association can be fortuitous but can also be secondary to rheumatism itself or to the effects of the treatments used. These comorbidities can worsen the disease and even increase patient mortality.

Objectives:

To assess the prevalence of comorbidities in RA or SpA patients from the Tunisian BIologics National Registry (BINAR) and to focus on their influence on the disease activity.

Methods:

BINAR is a multicenter non-interventional and prospective study, conducted in Tunisia with 80 rheumatologists over a period of three years. It included patients with RA (ACR / EULAR 2010 criteria) or SpA (ASAS 2009 criteria). Data were collected and analyzed through an electronic platform managed by DACIMA. They included demographic data, smoking status and types of comorbidities (cardiovascular disease, diabetes, dyslipidemia, osteoporosis, high blood pressure (HBP), neoplasia, gastrointestinal ulcer, depression and fibromyalgia). RA activity was evaluated by the DAS28-VS score and SpA activity by the BASDAI and ASDAS-CRP scores.

Results:

We included 298 patients (175 PR and 123 SpA) making the mean sex ratio 0.6 and mean age 49.18 years ± 14.1 [18-79]. Mean BMI was 27.0 ± 5.5 kg / m2[15 -45] and 17.7% of the patients were current smokers. Concerning disease activity, mean DAS28-VS in RA was at 4.9 ± 1.5 [1.1 - 8.1 and mean BASDAI and ASDAS-CRP, in SpA, were respectively 4.1 ± 1.8 and 2.8 ± 1.1. Comorbidities were noted in 54% of patients (62.1% in SpA and 37.9% in RA), with an average of 1.7 comorbidities per patient.

The most common comorbidities were osteoporosis (38.8%), cardiovascular disease (20.1%), diabetes (16.8%), HBP (18.1%), dyslipidemia (6.7%) and GIU (6.0%). Depression, fibromyalgia and neoplasia were mentioned in 1.7%, 1% and 1%, respectively.

No correlation was found between the number of comorbidities and the activity level of RA: DAS28-VS (p=0.12), nor the activity level of SpA: BASDAI(p=0.07), ASDAS-CRP(p=0.15). Correlations were studied between each comorbidity and activity disease parameters of RA and SpA, they are specified in Table 1. We found that only the presence of osteoporosis was associated with SpA activity, (ASDAS-CRP; p = 0.02).

Tableau n°1:

Relation between comorbidities and the disease activity parameters of rheumatoid arthritis and Spondyloarthritis

DAS 28 ESRBASDAIASDAS CRPDiabetesp = 0.737p = 0.633p = 0.652High Blood pressurep = 0.252p = 0.998p = 0.323Obesityp = 0.565p = 0.585p = 0.904Dyslipidemiap = 0.332p = 0.349p = 0.997Osteoporosisp = 0.372p = 0.989p = 0.020Gastrointestinal ulcerp = 0.829p = 0.286p = 0.910

DAS: disease activity score; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; ASDAS: Ankylosing Spondylitis Disease Activity Score

Conclusion:

According to this study, in patients with RA and SpA associated comorbidities may occur more frequently than expected (54%). However, they had no relation to the activity of the disease according to their frequencies or their types, except osteoporosis which was significantly associated with the SpA activity. Identifying these comorbidities may affect the management and treatment decisions for these patients to ensure an optimal clinical outcome.

Acknowledgments:

none

Disclosure of Interests:

None declared

AB0319 DRUG SURVIVAL OF BIOLOGICS IN RHEUMATOID ARTHRITIS: PRELIMINARY DATA FROM THE TUNISIAN BINAR REGISTRY

Background:

The arrival of Biotherapy has changed the management and prognosis of rheumatoid arthritis (RA). However, drug survival of the first biotherapy is changing according to the studies.

Objectives:

We aimed to report the data on the drug survival of biotherapies in RA, collected from the Tunisian BIologics National Registry (BINAR)

Methods:

BINAR is a multicenter non-interventional and prospective study, conducted in Tunisia with 80 rheumatologists over a period of three years. It included patients with RA (ACR / EULAR 2010 criteria) and refractory to conventional background treatments (csDMARDs), who required the use of biological treatment of anti TNF, anti IL6 or Rituximab type. Data were collected and analyzed through an electronic platform managed by DACIMA. Sociodemographic data (age, gender, body mass index (BMI), smoking) and characteristics of RA (duration of evolution, erosive character) were collected. RA activity was studied by the DAS28-VS score and drug survival was evaluated by the duration of the biologics.

Results:

We included 175 patients with a sex ratio of 5.7 and a mean age of 54.1 ± 12.6 years [19-79]. Patients were smoking in 6.7% of cases and mean BMI was 27.9 ± 5.2 kg/m2[15.1-45.2]. RA was erosive in 73.1% of cases and the mean disease duration was 6.7±3.5 years. Disease activity was moderate (mean DAS28vs: 4.9±1.5). Concerning the treatments, 139 (79.4%) of the patients received TNFα inhibitor, 31 (17.7%) of the patients were on IL6 inhibitor and 15 (8.6%) were on Rituximab.

The mean duration of drug survival for TNFα inhibitor agents was 15.2 months, 18 months for anti IL6 and 16.3 months for Rituximab. The drug was discontinued by 19 patients (10.8%). The causes of discontinuation were primary failure in 31.8% (7 subjects), secondary escape in 9.1% (4 subjects), the occurrence of adverse effects in 31.8% (7 subjects), intolerance to drug in 9.1% (2 subjects), non-compliance for one patient and for other reasons in one case.

The drug survival of TNF inhibitor was not associated with socio-demographic data (gender (p=0.9), age (p=0.4), smoking (p=0.9), BMI (p=0.9)), nor with the characteristics of the disease duration (p = 0.5), DAS28 vs (p = 0.9), association with a csDMARDs (p = 0.2)) except the presence of erosion (p = 0.013).

Also, drug survival of IL6 inhibitor drugs was not associated with socio-demographic parameters (gender (p = 0.1), age (p= 0.6), smoking (p= 0.6), BMI (p = 0.4)) and the characteristics of the disease (duration (p = 0.9), erosive character (p = 0.6), DASvs (p = 0.1), association with a csDMARDs (p = 0.2)).

Similarly, drug survival of Rituximab was not associated with socio-demographic data (gender (p = 0.6), age (p = 0.7), BMI (p = 0.7)) or with the characteristics of RA (duration of evolution (p= 0.5), erosive character (p = 0.6), DASvs (p = 0.08), association with a csDMARDs (p = 0.5))

Conclusion:

Our study demonstrated that IL6 inhibitor had the longest duration of drug survival (18 months). The major causes of cessation were dominated by primary failure and the occurrence of an adverse event. Finally, the drug survival of TNF inhibitor agents was associated with the erosive character.

Acknowledgments:

none

Disclosure of Interests:

None declared

AB0182 EVALUATION OF THE SOCIO-PROFESSIONAL IMPACT OF ANKYLOSING SPONDYLITIS AND RHEUMATOID ARTHRITIS IN TUNISIA: DATA FROM THE BINAR REGISTRY

Background:

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are disabling and common chronic inflammatory rheumatic diseases.

Objectives:

The aim of our study was to evaluate the socio-professional impact of RA and AS.

Methods:

Using the Biological National Registry (BINAR) data, which includes ten tunisian rheumatology centers,we identified patients≥18 years with AS and RA according to the ACR and EULAR 2010 criteria(RA) and ASAS 2009 (AS), receiving biotherapy for less than two years.

Results:

298 patients were included in the study. The percentage of patients with RA was 58.7 % and those with AS 41.3%. The sex ratio was 0.6. The average age of the onset of the disease was 49.1 years ± 14.1 years [18–79]. For marital status, 72% were married, single (25%), widowed (2.6%) and divorced (0.4%). 22.4% of patients were illiterate, 32.7 % (primary), 28.3% (secondary) and 16.6% had an university level. For the RA population, a high disease activity (DAS28-ESR >5.1) was detected in 36% of patients, an erosive arthritis in 73.1% and 7.2% had a coxitis. In the AS group, an elevate BASDAI (BASDAI≥4) was detected in 56.9% of patients and 39% had coxitis. All patients have received Biological therapy concomitant with corticosteroids (59.1%), methotrexate (42.6%), salazopirine (20.8%) and leflunomide (4.7%). 54% of patients had a comorbidity, of which 1.7% was depression. More than half of our patients (54.3%) were unemployed, 40 % were professionally active, and 5.7% were retired due to the rheumatic condition. Absence from work was observed in 15.1% of cases with a total duration exceeding three months in 55.5% of cases. 37.9 % of patients were physically active: regularly (9.8%), irregularly (28.1%) and (62.1%) were sedentary. For the functional impact, HAQ score was 1.31± 0.7 for RA and BASFI was 5.2 ± 4.8 for AS. The working abandonment is significantly associated to: marital status (p=0.039), low level of education (p=0.04),depression (p<0.001), high activity of AS (p=0.004) and BASFI>4 (p=0,001).

Conclusion:

RA or AS requiring biotherapy have a high socio-economic impact and are responsible for absenteeism at work and even for early working abandonment. Early therapeutic management and a global assessment are essential in order to improve quality of life and working conditions. Longitudinal studies are needed to assess the effect of biological therapy on the socio-professional impact of these chronic inflammatory rheumatic disease.

Disclosure of Interests:

None declared

AB0300 SEVERITY FACTORS IN RHEUMATOID ARTHRITIS AND SPONDYLOARTHRITIS IN NEWLY TREATED PATIENTS WITH BIOLOGICS: SURVEY OF THE BINAR REGISTRY

Background:

Rheumatoid arthritis (RA) and spondyloarthritis (SA) are two heterogeneous diseases but both being major causes of disability in our practice. Biologic treatments have changed miraculously the course of these diseases in the past two decades.

Objectives:

To determine severity factors in RA and SA patient newly treated with biologics.

Methods:

A survey using results of the Tunisian registry BINAR including ten rheumamtology centers was conducted. Adults of 18 years or more were included. Only those meeting the ACR/EULAR 2010 critera for RA or the ASAS 2009 criterea for SA and treated with biologics for 2 years or less were included.

Results:

Two hundred and ninety-eight patientd were enrolled including 111 males and 187 females (sexe ratio H/F of 0.6. The mean age was 49.1 years ± 14.1. The mean disease duration was 6.7 years ± 3.5 for RA and 6.5 years ±3.6 for SA. All patients were prescribed biologics for poor response under NSAIDS or conventional DMARDS. Smoking was reported in 17.7% patients. High disease activity defined as a DAS 28 VS score>5,1 in RA and was reported in 36% of cases. HAQ>2 was present in 14.3%, erosive forms were reported in 73.1% of cases. Rheumatoid factor (RF) and anti cetrullinated peptide antibodies were highly positive (>3x normal rates) in 71,2% and 62.4% of cases respectively. As for AS, active disease was defined by ASDAS CRP or ASDAS VS>2,1 or BASDAI>4 and was reported in 39%, 39.8% and 56.9 % of cases respectively. The functional score BASFI>4 was reported in 54.5% of cases. On the whole, a coxitis was noted in 48.8% of cases and extra articular manifestations (EAM) were present in 59.3 % of cases. Statistical analysis for SA patients didn’t show an association between active disease (ASDAS>2,1 and different parameters (genre (p=0.205), smoking (p=0.120), inflammation in biology (p=0.481), uveitis (p=0.241) and the presence of coxitis (p=0.375)). Nevertheless, RA patients with severe disease were more likely men (p= <0.001). Other features for RA patients showed no significant statistical difference (age (p= 0.253), inflammation on biology (p=0.963), positive RF (p=0.789), ACPA positive (p=0.258), présence de EAM (p=0.382), erosive forms (p=0.203) and HAQ≥2 (p =0.219).

Conclusion:

It’s important to determine clinical, biological and radiographic factors in RA and SA patients as well as activity scores in order to recognize patients potentially at risk of poor progression and for better therapeutic management and biologic treatment may have an influence on these factors.

References:

[1]Wagner E, Ammer K, Kolarz G, Krajnc I, Palkonyai E, Scherak O, et al. Predicting factors for severity of rheumatoid arthritis: a prospective multicenter cohort study of 172 patients over 3 years. Rheumatol Int. 1 sept 2007;27(11):1041‑8.

Disclosure of Interests:

None declared

AB0277 PREVALENCE OF HEPATITIS MARKERS IN PATIENTS TREATED WITH BIOLOGICAL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS: RESULTS OF THE TUNISIAN REGISTRY BINAR

Background:

In the recent decades, biological disease-modifying antirheumatic drugs (bDMARDs) have significantly improved management and quality of life in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA).

However, bDMARDs have also a strong influence on the immune system, leading to a risk of serious infection. Reactivation of hepatitis B (HBV) and C (HCV) virus is one of the most redoubtable complications of these immunosuppressive agents.

Objectives:

The aims of this study were to determine the screening rate for hepatitis B and C before starting a biological treatment and to examine the prevalence of their markers in patients with RA or SpA.

Methods:

Our study evaluated all patients included in the Tunisian registry BINAR (Biologic National Registry) since 2018 who had RA (ACR/EULAR 2010) or SpA (ASAS criteria) aged with more than eighteen years old and receiving their first bDMARDs during the two past years.

The following information were retrieved from the registry: demographic data on the patients, disease parameters, medication, HBV surface antigen (HBs Ag), antibody to HBs Ag (Anti HBs), antibody to HBV core antigen (Anti HBc), HBV-DNA, antibody to HCV (anti HCV) status and liver function tests (AST: aspartate aminotransferase; ALT:alanine aminotransferase).

Results:

A total of 298 patients was included, 111 men and 178 women, with a mean age of 49.2 ± 14.1 years old [18-79]. Among them, 58.7% were diagnosed with RA and 41.3% were diagnosed with SpA. The mean disease duration was 6.7±3.5 years [1-12] in patients with RA and 6.5±3 [1-12] in patients with SpA. The mean Disease Activity Score (DAS28) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were respectively of 4.9±1.5 [1-8] and 4.1±1.8 [0-9].

Therapeutically, 167 patients (56%) were on Prednisone at a mean daily posology of 8.2±5.4 mg [4-60] and 70.3% on conventional synthetic disease modifying antirheumatic drug (csDMARD) in association with bDMARDs. It was about Tumor Necrosis Factor alpha antibodies (anti TNF a) in 87.9% of cases, Tocilizumab in 10.4% of cases and Rituximab in 5% of cases.

A screening of HBV was performed in 286 patients (96%). Ag HBs was positive in two cases (0.7%), and anti-HBc was positive in 16 cases (6.4%) which indicate a prior HBV infection. Fifteen patients (6%) were immunized with positive anti HBs. HBV-DNA was measured in 177 cases (66.8%) and was positive in 15 patients (6%).

HCV infection was searched in 282 patients (94.6%) and anti-HCV was negative in all cases.

AST and ALT mean rates were respectively of 18.3 [2-108] and 17.9 UI/l [2-74]. A perturbation of these liver function tests was observed in 13 patients (4.4%).

Conclusion:

Screening for hepatitis B and C were performed respectively in 96% and 94% of our Tunisian patients before receiving any bDMARDs. This should be systematic to avoid HBV reactivation which can lead to fulminant hepatic failure with a severe prognosis.

Disclosure of Interests:

None declared

Apixaban-Associated Spontaneous Splenic Rupture-A Case Report

Introduction A 62-year-old lady presented to The Emergency Department (ED) with one-day history of dizziness, vomiting and feeling weak. ECG showed new onset Atrial Fibrillation. Four days ago, she was referred to the Cardiology team where she underwent PCI and was discharged on Apixaban and Plavix. Two days later she represented to the ED pale and hypotensive with BP 70/50. CT-Abdomen showed a large splenic hematoma and thickening of the inferior wall of the stomach. Treatment She was then taken for an emergency laparotomy with splenectomy and partial gastrectomy. She became septic post-operative, responded well to antibiotics and was discharged after 18 days on lifelong prophylactic oral antibiotics. Conclusion Spontaneous splenic rupture in a patient on Direct Oral Anticoagulants (DOAC) presented with abdominal pain could be even with no history of trauma.

Explaining union participation: The effects of union commitment and demographic factors

This study examined the relationship between trade union commitment and union participation among blue-collar workers in South Africa. Survey questionnaires were completed by 93 participants (response rate = 62 %). Findings are consistent with previous research and showed that after controlling for demographic factors, 43% of the variance in participation can be explained by union commitment. In this study, Black participants displayed significantly higher levels of commitment and participation than their Coloured counterparts did.

Referral of epileptic patients in North East Coast of West Malaysia an area with poor MRI coverage: an analysis

Advances in neuroimaging techniques, particularly Magnetic Resonance Imaging (MRI), have proved invaluable in detecting structural brain lesions in patients with epilepsy in developed countries. In Malaysia, a few electroencephalography facilities available in rural district hospitals run by trained physician assistants have Internet connections to a government neurological center in Kuala Lumpur. These facilities are more commonly available than MRI machines, which require radiological expertise and helium replacement, which may problematic in Southeast Asian countries where radiologists are found in mainly big cities or towns. We conducted a cross-sectional study over a two year period begining January 2001 on rural patients, correlating EEG reports and MRI images with a clinical diagnosis of epilepsy to set guidelines for which rural patients need to be referred to a hospital with MRI facilities. The patients referred by different hospitals without neurological services were classified as having generalized, partial or unclassified seizures based on the International Classification of Epileptic Seizures proposed by the International League Against Epilepsy (ILAE). The clinical parameters studied were seizure type, seizure frequency, status epilepticus and duration of seizure. EEG reports were reviewed for localized and generalized abnormalities and epileptiform changes. Statistical analysis was performed using logistic regression and area under the curve. The association between clinical and radiological abnormalities was evaluated for sensitivity and specificity. Twenty-six males and 18 females were evaluated. The mean age was 20.7 +/- 13.3 years. Nineteen (43.2%) had generalized seizures, 22 (50.0%) had partial seizures and 3 (6.8%) presented with unclassified seizures. The EEG was abnormal in 30 patients (20 with generalized abnormalities and 10 localized abnormalities). The MRI was abnormal in 17 patients (38.6%); the abnormalities observed were cerebral atrophy (5), hippocampal sclerosis (4), infarct/gliosis (3), cortical dysgenesis (2) and tumors (2). One patient had an arachnoid cyst in the right occipital region. Of the 17 patients with an abnormal MRI, 14 had an abnormal EEG, this difference was not statistically significant. There was no significant associaton between epileptographic changes and MRI findings (p = 0.078). EEG findings were associated with MRI findings (p = 0.004). The association between an abnormal EEG and an abnormal MRI had a specificity of 82.4%, while epileptogenic changes had a specificity of 64.7% in relation to abnormal MRI findings. This meants that those patients in rural hospitals with abnormal EEGs should be referred to a neurology center for further workup and an MRI to detect causes with an epileptic focus.

[Value of the determination of erythrocyte haloperidol ketone reductase activity in the evaluation of haloperidol therapy]

Serum levels of haloperidol and reduced haloperidol as well as the reduced haloperidol/haloperidol ratios were determined in nine acute schizophrenics on oral haloperidol medication and correlated over 21 days with psycho pathology and extra-pyramidal symptom scores. We have investigated red blood cells haloperidol reductase activity in the group of patients. Significant correlations were found between haloperidol plasma levels and positive sub scale for each patient (r = 0.86 and p < 0.01; r = 0.70 and p < 0.05). We found a correlation between red blood cells reductase activity and the improvement of the psychotic anxiety scale (r = 0.64/and p < 0.05; r = 0.67 and p < 0.05), but not with reduced haloperidol/haloperidol ratios in plasma. The knowledge of reductase activity could predict the treatment response in acute schizophrenic patients. We suggest that the reported inter individual and inter ethnic differences in haloperidol and reduced haloperidol and in clinical response and adverse effects may be a reflection of genetic control of the two oxidative pathways mediated by cytochrome P450 isozyme and/or the reductase pathway mediated by haloperidol reductase in individual subject.