Boolean Criteria Research Articles

Comparison of treatment of severe rheumatoid arthritis patients with biological agents and JAK-STAT inhibitors. An extension study

IntroductionThis study compared treatment with biologic agents and Janus kinase inhibitors (JAKi) in combination with methotrexate (MTX) for rheumatoid arthritis (RA) in a real-world setting at a large center in Poland. There is a persistent shortage of such studies, and illustrating the switching of medications in search of a suitable way of treatment for a given patient is a crucial step towards future personalized therapy.Aim of the studyThis study is an extension of the initial work published in 2022 in <i>Reumatologia</i>, with the addition of an analysis of patients treated with upadacitinib. The study compared the effectiveness and side effects after treatment of biological disease modifying antirheumatic drugs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs) in combination with MTX.Materials and methodsA total of 130 patients with active severe RA (Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate [DAS28-ESR] value > 5.1) were treated at the Rheumatologic Outpatients Department of the Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland between January 2010 and September 2021. All patients were treated with MTX 25 mg per week. They were divided into two groups: group I (80 patients) treated with biologic agents, and group II (50 patients) treated with JAKi. Assessment of DAS28-ESR and Simplified Disease Activity Index (SDAI) and analy­sis of Boolean criteria for remission were performed. Remission or low disease activity, switching between drugs and adverse events were assessed and compared between studied groups.ResultsPatients treated with tsDMARDs had previously used a higher number of conventional synthetic DMARDs (csDMARDs) and bDMARDs compared to those treated with bDMARDs. However, they achieved lower SDAI and assessment of disease activity using Visual Analogue Scale (VAS) values, and a higher proportion of patients achieved Boolean criteria for remission after treatment.ConclusionsThe results of treatment with JAKi were successful, but the potential side effects indicate that this treatment may not be equally suitable for all RA patients.

An Audit Of Health And Ageing Online Resources: Evaluating Information On Periodontitis And Cardiovascular Disease Associations

Abstract Background In 2019 the European Federation of Periodontology (EFP) and the World Heart Federation (WHF) organized a review of the literature concerning periodontal disease (PD) and cardiovascular disease (CVD). This was to update the existing evidence from a 2012 review. The consensus report established a strong link between severe PD and CVD, however, this vital information may not be reaching the public who stand to benefit from it. Methods A web-based audit to assess the dissemination of information on the PD-CVD association was conducted. Ninety English language websites of foundations, health authorities, and associations focused on aging (54), CVD (21), and general health (15) were included. Dental organisations were excluded. Using Boolean search criteria, websites were examined for webpages informing of the PD-CVD link published in 2019 or later. Pages with the information published before 2019 were also recorded separately. Broken links, paywalled content, and information solely on infective endocarditis were excluded. Pages without metadata on publishing dates were considered older than five years. Results Only 8 (8.8%) sites contained information on the PD-CVD link within the past five years of which 5 (5.5%) gave actionable guidance on how to improve oral health. An additional 9 sites (10%) offering the information were recorded but were older than five years. Conclusion This study reveals a concerning gap in translating research findings from the highest levels of evidence to online resources accessible to the public. This highlights a missed opportunity to empower individuals. The siloed nature of dentistry, with limited collaboration between dental professionals and other health care providers, might be a contributing factor. These findings highlight the need for improved communication strategies and collaborative efforts to bridge this knowledge gap and empower individuals to make informed decisions about their oral and overall health.

La felicidad social como fundamento en el diseño de políticas públicas :Una revisión sistemática

This paper examines the literature on social happiness as a basis for designing public policies. The systematic review initiated with a Scopus search using Boolean criteria, covering the period from 2013 to 2023. 49 out of 943 articles were selected through inclusion and exclusion criteria using RAYYAN software for data management and extraction, and the PRISMA model as a guide to ensure the replicability of the research. The descriptive findings reveal that most publications are from Latin America, showing a consistent increase in scientific output over the years, with 2021 being the peak year for related publications. This paper identifies debates on the viability of using happiness as a foundation in public policy design, importance of impact evaluation, and experimental methods. The document categorizes the macroeconomic, institutional and governmental, sociodemographic, psychological, and environmental and sustainability variables that interrelate with happiness, including factors such as income, economic stability, wealth distribution, state intervention, among other relevant factors. The literature reveals gaps, such as the lack of a universally accepted definition of social happiness and a shortage of longitudinal and experimental studies. Recommendations include a multidimensional approach, consideration of cultural and socioeconomic context, use of experimental methodologies, citizen participation, and incorporating happiness into the political agenda. Final reflections underscore transformative potential of integrating subjective well-being into the government agenda and the associated challenges, such as resistance to change and the lack of consensus on how to define and measure social happiness.

A meta-analysis of the incidence of acne vulgaris in patients treated with GLP-1 agonists.

With the emerging popularity of GLP-1 receptor agonists, patients are noticing acne vulgaris side effects that are seemingly related to the concurrent treatment with the drug. Due to the correspondence between these drugs' relatively recent emergence in the U.S. market and their high demand, it is important to investigate what is currently known in the literature so that patients can be properly informed. The aim of this study is to investigate the relationship, or lack thereof, between glucagon like peptide 1 (GLP-1) receptor agonist usage and acne-related side effects in patients. A web-based analysis of 6 GLP-1 receptor agonists (3 with a once-weekly dosing schedule, and 3 with a once-daily dosing schedule) was conducted on PubMed online database. Boolean criteria were used to narrow the search. Included in the meta-analysis were 45 research articles that fulfilled the search criteria. The results of the search showed that from the following long-acting GLP-1 receptor agonists, dulaglutide, exenatide extended release, and semaglutide (Wegovy), no conclusive acne side effects were reported. In addition, the results also showed that from the following short-acting GLP-1 receptor agonists, liraglutide, lixisenatide, and semaglutide (Rybelsus), no conclusive acne side effects were reported. Limitations of this study include a limited amount of literature regarding the relationship between GLP-1 agonists and acne vulgaris. It is unlikely that GLP-1 agonists themselves are directly responsible for the acne that some patients may develop during treatment. Rather, it is more probable that the weight loss yielded by treatment with these drugs may induce intrinsic physiologic and hormonal changes that induce or exacerbate acne vulgaris in such patients.

Ultrasound versus clinical remission in patients with early rheumatoid arthritis: concordance and relationship with therapy discontinuation.

To evaluate prevalence of ultrasonographic remission (USR) and concordance with clinical remission in "drug-free" or "on-treatment" patients with early rheumatoid arthritis (RA). We carried out a cross-sectional study including consecutive early RA patients in SDAI remission ≥6 months in the period 06/2022 to 02/2023. CDAI, DAS28, DAS44 and Boolean remission were also evaluated. Patients underwent B-mode and Power Doppler (PD) assessments of 42 joints and 20 tendons. Synovitis, tenosynovitis and PD were graded semi-quantitatively (0-3) using standardised scores. Four definitions of USR were examined: USR1: absence of synovial hypertrophy (SH) and PD; USR2: SH≤1 and PD=0; USR3: SH≤1 and PD≤1; USR4: PD negative. Eighty patients were enrolled, of whom 12 drug-free. Overall remission rates were 100.0%, 83.7%, 91.2%, 96.2% and 80.0% for SDAI, CDIA, DAS28, DAS44 and ACR/EULAR Boolean criteria, respectively. 100% of drug-free patients were in remission according to all indices. The rate of USR in drug-free versus on-treatment remission was 58.3%, 66.7%, 66.7%, 83.3% versus 70.6%, 85.3%, 88.2%, 91.2% for USR1, USR2, USR3 and USR4, respectively. While clinical remission seems more frequent in drug-free patients, USR is more often observed on-treatment.

Harmonizing Medicine and Surgery in the Pursuit of Boolean Remission: A Rheumatological Magnum Opus.

Rheumatic diseases encompass a diverse group of musculoskeletal conditions that often lead to inflammation, pain, and significant limitations in patients' lives. While traditional treatment approaches have primarily centered on medications to control symptoms, recent developments have introduced the concept of Boolean remission. Boolean remission offers a comprehensive evaluation of disease activity by considering clinical, biochemical, and patient-reported outcomes. This narrative review explores the multifaceted landscape of Boolean remission in the context of rheumatic diseases, with a focus on rheumatoid arthritis (RA), as it remains a substantial clinical challenge. The review outlines the definition, criteria, historical context, and development of Boolean remission, shedding light on its emergence as a more patient-centered and stringent treatment goal. The role of pharmacological interventions, including immunomodulators and biologics, in achieving Boolean remission is discussed, emphasizing the significance of treatment protocols that encompass regular monitoring, medication adjustment, shared decision-making, and patient education. Surgical interventions, such as joint replacements and synovectomies, complement medication-based strategies when joint damage becomes severe, with adherence to surgical protocols ensuring sustained Boolean remission. The integration of medicine and surgery through integrated care models and interdisciplinary teams is examined as a critical aspect of optimizing patient outcomes. Boolean remission's broader impact on healthcare policies and clinical trial endpoints is explored, underscoring its growing significance in rheumatic disease management. The review concludes by looking towardthe future, where emerging technologies, biomarkers, and personalized medicine approaches hold promise in refining Boolean remission criteria and making it a more attainable and impactful treatment goal. Policy implications suggest the integration of Boolean remission into healthcare quality metrics, incentivizing healthcare providers to prioritize this rigorous standard of care. Boolean remission represents a pivotal shift in the holistic and patient-centered management of rheumatic diseases, offering hope for improved patient outcomes and enhanced quality of life in this challenging clinical landscape.

P137 First-line tumour necrosis factor inhibitor (TNFi) treatment is associated with high multi-criteria remission early on compared to treat-to-target in a treatment naïve RA cohort

Abstract Background/Aims In rheumatoid arthritis (RA) disease assessment, SDAI and Boolean remission criteria are known to be more stringent in comparison to DAS28-ESR. Comparing remission rates across multiple assessment indices provides a more comprehensive evaluation of disease control. In an early RA trial cohort, we aimed to investigate stringent and multi-criteria remission (MCR) rates and evaluate their proportional change in response to treatment. Methods The ‘VEDERA’ trial randomised 120 treatment-naïve, new-onset RA patients to first-line etanercept+methotrexate (ETN+MTX) or methotrexate treat-to-target (MTX-TT) with escalation to ETN+MTX if not in DAS28-ESR remission at week24. Clinical assessments were completed at baseline, weeks12/24/48 (protocolised phase) up to week96 (standard-of-care). Remission cut-points included: DAS28-ESR ≤2.6, SDAI ≤3.3 and Boolean score for individual components≤1. MCR was defined as patients who were in DAS28-ESR, SDAI and Boolean remission concurrently. Descriptive analyses were undertaken to address the above aims. Results Overall, at week12, 26%(31/120) were in SDAI and 13%(16/120) in Boolean remission. This increased to 41%(49/120) and 23%(28/120) respectively by week48. In the ETN+MTX group at week12, 30%(18/60) were in SDAI and 17%(10/60) in Boolean remission. This increased to 43% (26/60) and 32%(19/60) respectively by week48. Stringent remission rates were lower in MTX-TT compared to ETN+MTX and significantly different for Boolean at week48 (15% vs 32%, odds ratio 2.6, 95% confidence interval 1.1 to 6.5, nominal p < 0.05) (Table 1). Of those in remission by the three different criteria, 36%(14/39) were in MCR at week12, with a greater proportion in ETN+MTX group [42%(10/24) compared to 27%(4/15) in MTX-TT]. MCR remained unchanged up to week48 but improved with treatment by week 96 to 45%(27/60). MCR rates did not converge between the 2 treatment groups at week 96 (ETN+MTX 55%; MTX-TT 38%). Conclusion First-line ETN+MTX is associated with higher rates of stringent remission from week 12 compared to MTX-TT, with improvement gradually over time with both strategies. Significantly higher proportion of patients treated with first line ETN+MTX compared to MTX-TT achieved Boolean and MCR. Early TNFi treatment associates with more complete and better cumulative disease activity profile. Patients not meeting MCR early following treat-to-target approach should be considered for more aggressive treatment strategies. Disclosure R. Shukla: None. D. Plant: None. P. Emery: None. M.H. Buch: None.

The Adaption and Validation Processes in Remission Criteria for Rheumatoid Arthritis

The standardization of disease activity assessment in patients with rheumatoid arthritis has improved the comparability of clinical trials. In 2011, the American College of Rheumatology and the European Alliance of Associations for Rheumatology provisionally endorsed the remission criteria for RA; since then, the criteria have been the subject of debate in terms of whether they are too lenient or too stringent. The Patient Global Assessment (PtGA) was one focus of the debate, with a higher PtGA threshold for the Boolean remission criteria being proposed. After validation in 2022, the revised Boolean criteria included a 2 cm PtGA cut-off, with the index-based definitions receiving full endorsement from the American College of Rheumatology and the European Alliance of Associations for Rheumatology.

American College of Rheumatology/EULAR Remission Criteria for Rheumatoid Arthritis: 2022 Revision.

In 2011, the American College of Rheumatology (ACR) and EULAR endorsed provisional criteria for remission in rheumatoid arthritis (RA), both Boolean- and index-based. Based on recent studies indicating that a higher threshold for the patient global assessment (PtGA) may improve agreement between the 2 sets of criteria, our goals were to externally validate a revision of the Boolean remission criteria using a higher PtGA threshold and to validate the provisionally endorsed index-based criteria. We used data from 4 randomized trials comparing biologic disease-modifying antirheumatic drugs to methotrexate or placebo. We tested the higher proposed PtGA threshold of 2 cm (Boolean2.0) (range 0-10 cm) compared to the original threshold of 1 cm (Boolean1.0). We analyzed agreement between the Boolean- and index-based criteria (Simplified Disease Activity Index [SDAI] and Clinical Disease Activity Index [CDAI]) for remission and examined how well each remission definition predicted later good physical function (Health Assessment Questionnaire [HAQ] score ≤0.5) and radiographic nonprogression. Data from 2,048 trial participants, 1,101 with early RA and 947 with established RA, were included. The proportion of patients with disease in remission at 6 months after treatment initiation increased when using Boolean2.0 compared to Boolean1.0, from 14.8% to 20.6% in early RA and 4.2% to 6.0% in established RA. Agreement between Boolean2.0 and the SDAI or CDAI remission criteria was better than for Boolean1.0, particularly in early disease. Boolean2.0, SDAI, and CDAI remission criteria had similar positive likelihood ratios (LRs) to predict radiographic nonprogression and a HAQ score of ≤0.5 (positive LR 3.8-4.3). The omission of PtGA (BooleanX) worsened the prediction of good functional outcomes. Using the Boolean 2.0 criteria classifies more patients as achieving remission and increases the agreement with index-based remission criteria without jeopardizing predictive value for radiographic or functional outcomes. This revised Boolean definition and the previously provisionally endorsed index-based criteria were endorsed by ACR and EULAR.

Investigation of remission with ultrasound in patients with rheumatoid arthritis according to different clinical remission criteria

Objectives: To investigate remission with ultrasound (US) in patients with Rheumatoid arthritis (RA) according to different clinical remission criteria. Methods: A total of 105 patients with RA who were in remission for at least 6 months according to disease activity score in the 28 joints using C-reactive protein (DAS28-CRP) were included in the study. US remission rates were analyzed according to different remission criteria [DAS28-CRP, DAS28 using erythrocyte sedimentation rate (DAS28-ESR), clinical disease activity index (CDAI), simplified DAI (SDAI), and the 2011 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) Boolean remission criteria]. US remission was determined as power doppler (PD) US score = 0. Results: Remission rates achieved for each remission criteria were 100%, 82.9%, 55.2%, 58.1% and 42.9% and US remission rates were 57.1%, 57.5%, 53.4%, 55.7%, 57.7% for DAS28 CRP, DAS 28 ESR, CDAI, SDAI, 2011 ACR/EULAR remission criteria, respectively. When the patients compared for the US findings between remission and non-remission patients according to the different clinical remission criteria, no difference was found (p > 0.05). Conclusions: This study shows that clinical remission criterias are not sensitive enough to accurately detect remission and there was no increase in the US remission rates as per the stricter remission criteria. Using US in addition to the clinical criteria would prove to be more useful in evaluating remission.

Retention of subcutaneous abatacept for the treatment of rheumatoid arthritis: real-world results from the ASCORE study: an international 2-year observational study

ObjectivesTo evaluate retention, efficacy, and safety of subcutaneous (SC) abatacept over 2 years in patients with moderate-to-severe RA in the Abatacept SubCutaneOus in Routine clinical practicE (ASCORE) study.MethodsPatients with RA who initiated SC abatacept 125 mg once weekly were enrolled in the international, observational, prospective multicentre ASCORE study into biologic-naïve or ≥ 1 prior biologic failure cohorts. Primary endpoint: abatacept retention rate at 2 years. Secondary endpoints: proportion of patients with good/moderate EULAR response rates based on DAS28 (ESR), low disease activity and/or remission according to DAS28 (ESR; ≤ 3.2/ < 2.6), SDAI (≤ 11/ ≤ 3.3), CDAI (≤ 10/ ≤ 2.8), and Boolean criteria. Retention rate by baseline serostatus was evaluated post hoc.ResultsOverall, 47% of patients remained on abatacept for 2 years, irrespective of treatment line. Higher abatacept retention rates were associated with lower prior biologic exposure. Generally, clinical outcomes showed that the proportion of patients with low disease activity/remission was higher in biologic-naïve patients (vs biologic-failure) and similar in those with 1 and ≥ 2 prior biologic failures. In patients on treatment at 2 years, good/moderate EULAR response rates of ~ 80% were consistently noted irrespective of prior biologic exposure. Across treatment lines, retention was greater in patients with seropositive (vs seronegative) RA. Patients with rheumatoid factor/anti-citrullinated protein antibody single-positive RA who were bio-naïve had higher retention than patients who were bio-experienced.ConclusionsIn the ASCORE study, SC abatacept retention was 47% at 2 years with good clinical outcomes and was well-tolerated in the real-world setting. Abatacept retention and clinical response rates were higher in patients who received abatacept as an earlier- versus later-line biologic drug treatment and in those with seropositive RA.Trial registrationClinicalTrials.gov, NCT02090556.

Adipocytokines and achievement of low disease activity in rheumatoid arthritis

PurposeTo determine if adipocytokines are independently associated with the achievement of low disease activity (LDA) over long-term follow-up in a large rheumatoid arthritis (RA) registry. MethodsThis cohort study evaluated adults with RA from the Veteran's Affairs RA Registry. Adipocytokines (adiponectin, leptin, and fibroblast growth factor [FGF]-21) and inflammatory cytokines were measured as part of a multi-analyte panel on banked serum from enrollment. Covariates were derived from medical record, biorepository, and registry databases. Multivariable Cox proportional hazard models evaluated associations between adipocytokines and rates of 1) DAS28 LDA and remission, 2) individual Boolean remission criteria and 3) initiation of a new bDMARD or tsDMARD. ResultsThere were 1,276 participants with a DAS28 >3.2 at enrollment. Of these, 827 achieved LDA and 598 achieved remission over 2,287 and 4,096 person-years, respectively. Patients in the highest quartile of adiponectin had lower rates LDA before and after adjustment [aHR Q4: 0.68 (0.53,0.87) p<0.001]. Those in the highest quartile of leptin and FGF-21 also had lower rates of LDA. Higher quartiles of adipocytokines were also associated with lower rates of achieving a low patient/evaluator global scores and low tender joint counts. Among 1,236 biologic-naïve participants, values above the median for adiponectin [HR: 1.67 (1.23,1.26) p = 0.001] and FGF-21 [HR: 1.27 (1.09,1.47) p = 0.002] were associated with a greater likelihood of initiating a b/tsDMARD. ConclusionsAdipocytokines may serve as prognostic biomarkers of a more severe RA disease course. Additional study is needed to determine whether adipocytokines are phenotypic markers or whether they actively promote disease progression.

Validity and risk of adopting PGA\u2009\u2264\u20092 as a remission criteria of Boolean in clinical practice in patient with rheumatoid arthritis

Validity and risk of setting patient’s global assessment (PGA) ≤ 2 as a Boolean remission criteria substituting PGA ≤ 1 in treating rheumatoid arthritis (RA) was investigated. Patients were recruited from an area cohort, of whom attained Boolean remission (Boolean-1) or near remission with PGA ≤ 2 and the rest components were ≤ 1 (Boolean-2). Simplified disease activity index (SDAI) score was compared according to the criteria variations. A total of 517 patients were studied. Mean SDAI score of patients with Boolean-1 was significantly lower than that of patients with Boolean-2 at acquisition. The trend was evident in the patients who attained Boolean-1 remission. Mean SDAI score at acquisition, 6 months after, and 1 year after of patients who attained Boolean-2 first and then Boolean-1, was significantly inferior to that of patients who attained the remissions at the same time. The mean SDAI score at month 6 in the Boolean-2 was not SDAI remission at all. We concluded that setting PGA ≤ 2 as a remission criteria may not have statistical difference in disease activity from PGA ≤ 1, however, there was an determinant risk to misread that includes patient who losses clinical remission after acquisition.

Comparison of remission criteria in patients with rheumatoid arthritis treated with biologic or targeted synthetic disease-modifying anti-rheumatic drugs: results from a nationwide registry.

Background:Biologic or targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARD) are widely used for treatment of rheumatoid arthritis (RA), enabling patients to better achieve remission.Objective:The objective of the study was to investigate and compare remission rates in RA patients treated with different b/tsDMARDs during the period 2013–2019.Design:A longitudinal observational analysis was performed on data from a nationwide RA registry.Methods:Remission rates in the KOBIO-RA registry were defined by a disease activity score in 28 joints (DAS28), clinical disease activity index (CDAI), simplified disease activity index (SDAI), and Boolean-based assessment. After initiating treatment with b/tsDMARDs, yearly remission rates in response to b/tsDMARDs, either all or as subgroups (tumor necrosis factor-α inhibitors, tocilizumab, abatacept, and Janus kinase inhibitors), were investigated for 5 years. Sustained remission was defined as remission maintained for two consecutive years.Results:Patients (N = 1805) who completed at least one follow-up visit were analyzed (mean age = 55 years; 83.2% female). At month 12, 56.0% of patients achieved remission based on DAS28-C-reactive protein (CRP), 36.2% on DAS28-erythrocyte sedimentation rate (ESR), 10.4% on CDAI, 12.7% on SDAI, and 12.9% on Boolean criteria. Sustained remission rates were 62%, 40%, 13%, 11%, and 8% for the DAS28-CRP, DAS28-ESR, Boolean, SDAI, and CDAI remission criteria, respectively. Remission rates using the DAS28 definition varied most among the b/tsDMARD subgroups.Conclusion:Assessment of sustained remission using the CDAI, SDAI, or Boolean criteria is more stringent, yet congruous with the DAS28-based criteria in RA patients treated with b/tsDMARDs.

Ultrasound remission in patients with rheumatoid arthritis in clinical remission.

ObjectivesThe aim of the study was to assess ultrasound (US) remission in patients with rheumatoid arthritis (RA) in clinical remission using different definitions.Material and methodsThis was a cross-sectional study including patients with RA in clinical remission defined by disease activity score (DAS28)-erythrocyte rate (ESR) ≤ 2.6 for at least 6 months. Each patient underwent B-mode and power Doppler (PD) assessments of 42 joints and 20 tendons. B-mode and PD signal for synovitis and tenosynovitis (TS) were defined and graded semi-quantitatively (0–3) according to the outcome measures in rheumatology clinical trials (OMERACT). Several different definitions of US remission were examined: the absence of synovial hypertrophy (SH), TS on B-mode and PD signal, the absence of SH and PD signal, a grade ≤ 1 of SH and the absence of PD, a grade ≤ 1 of SH and PD, the absence of PD, or a grade of PD ≤ 1. The DAS28, clinical disease activity index (CDAI), simple disease activity index (SDAI), and the Boolean American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) remission criteria were compared.ResultsThirty-seven patients were enrolled. The rate of remission according to the different composite indices was 70.2% for the SDAI, 64.8% for the CDAI, and 54% for the ACR/EULAR Boolean criteria. Synovial hypertrophy and TS in B-mode were detected in 94.6% and 40.5% of patients, respectively. Synovitis with PD signal was found in 59.5% and 13.5% of patients had TS with PD, respectively. Ultrasound remission at joints and tendons was found in 5.4–62.2% of patients. For the other remission criteria: CDAI, SDAI, and ACR/EULAR Boolean criteria, 7.7–60% of patients showed US remission at joints and tendons.ConclusionsClinical remission, even classified by strict composite indices, does not seem to be the closest method to the concept of absence of inflammatory activity; hence the interest of integrating US in assessing remission in practice.

A case for associational resistance: Apparent support for the stress gradient hypothesis varies with study system.

According to the stress gradient hypothesis (SGH), ecological interactions between organisms shift positively as environmental stress increases. In the case of associational resistance, habitat is modified to ameliorate stress, benefitting other organisms. The SGH is contentious due to conflicting evidence and theoretical perspectives, so we adopted a meta-analytic approach to determine if it is widely supported across a variety of contexts, including different kingdoms, ecosystems, habitats, interactions, stressors, and life history stages. We developed an extensive list of Boolean search criteria to search the published ecological literature and successfully detect studies that both directly tested the hypothesis, and those that were relevant but never mentioned it. We found that the SGH is well supported by studies that feature bacteria, plants, terrestrial ecosystems, interspecific negative interactions, adults, survival instead of growth or reproduction, and drought, fire, and nutrient stress. We conclude that the SGH is indeed a broadly relevant ecological hypothesis that is currently held back by cross-disciplinary communication barriers. More SGH research is needed beyond the scope of interspecific plant competition, and more SGH research should feature multifactor stress. There remains a need to account for positive interactions in scientific pursuits, such as associational resistance in tests of the SGH.

Comparable long-term outcomes between DAS28-ESR remission criteria and ACR/EULAR definitions in patients with established rheumatoid arthritis.

To compare long-term clinical, immunological, and radiographic outcomes between five sets of remission criteria (four clinical and one ultrasound (US)-based) in a cohort of RA patients in a clinical care setting. RA patients in remission (DAS28-ESR <2.6) were selected. HandUS assessments were made, and serum levels of inflammation/angiogenesis biomarkers were determined at baseline. Changes in baseline treatment and radiographic progression, defined as the variation in the modified Sharp van der Heijde score (mSHS) at 5 years, were analyzed. Five concepts were used to define remission: DAS28-ESR<2.6, SDAI<3.3, CDAI<2.8, Boolean criteria and Power Doppler score (PD)=0. Eighty-seven patients with DAS28-ESR<2.6 were included. One-third fulfilled SDAI (33.3%), CDAI (31%), and Boolean (35.6%) remission criteria, and 25.3% had no PD signal in the US evaluation. 26 patients (29.9%) changed therapy, ranging from 13.6% (PD remission) to 33.3% (CDAI remission) (p=0.11). Serum levels of ANG (p=0.015) and TNFa (p=0.025) were significantly lower in patients with Boolean remission, whereas IL-18 levels were significantly lower in those with PD remission (p=0.049). Patients without PD in the US assessment had significantly-lower mSHS erosion progression (p=0.014) at 5 years. Patients with established RA in DAS28-ESR remission had comparable clinical and radiographic outcomes in SDAI, CDAI, and Boolean definitions in a clinical care setting. US remission remained the closest to structural damage abrogation. Key Points • This study provides real world data on long-term outcomes of five clinical and imaging remission criteria in rheumatoid arthritis. • DAS28-ESR remission criteria had comparable radiographic progression and clinical prognosis than more stringent criteria in clinical practice. • US-based remission was closest to structural damage abolishment.

Understanding evidence-based lead mitigation: Is the lead mitigation advice and strategies being communicated to citizens evidence-based?

Background and Hypothesis: The CDC has declared that there is no safe blood lead level for a child, but still approximately 37 million homes are lead-contaminated of which 4 million are home to small children. Lead abatement is an expensive strategy to remove all lead hazards rendering a home lead-free. Many of these lead-contaminated homes are in lower socioeconomic areas which makes lead abatement nearly impossible. Given the expense of lead abatement, low-cost interim controls are needed to reduce lead exposure thus creating a lead-safe home. We hypothesize that updated lead mitigation strategies need pursued, and there is a large disparity of lead information disseminated between health departments. &#x0D; &#x0D; Project Methods: Using JSTOR and Boolean criteria, we conducted a systematic literature review on evidence-based, do-it-yourself (DIY) lead mitigation strategies for sources of lead contamination. Once the literature review was completed, QualtricsR was used to quantitatively and qualitatively evaluate the 50 state health department’s websites for lead policy, user friendliness, and recommended lead interim controls as compared to the literature review. &#x0D; &#x0D; Results: Results from the literature indicate that there is a lack of current information regarding new strategies for lead mitigation. Research prior to the year 2000 shows that cleaning flat surfaces by wet mopping, washing hands frequently, mulching, removing shoes before entering the home, and painting over deteriorating paint significantly reduces lead accumulation in the home. Preliminary results from the website review found that there is no baseline of uniform information being distributed, and evidence-based practices are not included for each state health department. &#x0D; &#x0D; Potential Impact: The lack of continuity nationwide for lead mitigation showcases that families are not receiving all of the information that research has to offer to help keep their homes safe. This research indicates that there is a need for national lead policies and recommendations, so each family in the U.S. is equally informed.

A multi-biomarker disease activity score can predict sustained remission in rheumatoid arthritis

BackgroundReliable assessment of remission is important for the optimal management of rheumatoid arthritis (RA) patients. In this study, we used the multi-biomarker disease activity (MBDA) test to explore the role of biomarkers in predicting point remission and sustained remission.MethodsRA patients on > 6 months stable therapy in stable low disease activity (DAS28-ESR ≤ 3.2) were assessed every 3 months for 1 year. Baseline, intermittent (IR) and sustained (SR) remission were defined by DAS28-ESR, DAS28-CRP, simple disease activity index (SDAI), clinical disease activity index (CDAI) and ACR/EULAR Boolean criteria. Patients not fulfilling any remission criteria at baseline were classified as ‘low disease activity state’ (LDAS). Patients not fulfilling any remission criteria over 1 year were classified as ‘persistent disease activity’ (PDA). MBDA score was measured at baseline/3/6 months. The baseline MBDA score, the 6-month time-integrated MBDA score and MBDA biomarkers were used for analyses. The area under the receiver operating characteristic curve (AUROC) assessed the ability of the MBDA score to discriminate between remission and non-remission. Biomarkers were analysed at baseline using the Mann-Whitney test and over time using the Jonckheere-Terpstra trend test.ResultsOf 148 patients, 27% were in the LDAS, 65% DAS28-ESR remission, 51% DAS28-CRP remission, 40% SDAI remission, 43% CDAI remission and 25% ACR/EULAR Boolean remission at baseline. Over 1 year, 9% of patients were classified as PDA. IR and SR were achieved in 42%/47% by DAS28-ESR, 46%/29% by DAS28-CRP, 45%/20% by SDAI, 44%/21% by CDAI and 35%/9% by ACR/EULAR Boolean criteria, respectively. By all remission criteria, baseline MBDA score discriminated baseline remission (AUROCs 0.68–0.75) and IR/SR (AUROCs 0.65–0.74). The 6-month time-integrated MBDA score discriminated IR/SR (AUROCs 0.65–0.79). Baseline MBDA score and concentrations of IL-6, leptin, SAA and CRP were significantly lower in all baseline remission criteria groups vs LDAS. They and the 6-month time-integrated values were lower among patients who achieved IR/SR vs PDA over 1 year.ConclusionsThis study demonstrated that the MBDA score and its biomarkers IL-6, leptin, SAA and CRP differentiated between small differences in disease activity (i.e. between low disease activity and remission states). They were also predictors of remission over 1 year.

THU0135 PATIENT GLOBAL ASSESSMENT LEVELS PRECLUDE THE MAJORITY OF RHEUMATOID ARTHRITIS PATIENTS OTHERWISE IN REMISSION, FROM REACHING THIS STATUS: SYSTEMATIC LITERATURE REVIEW AND META-ANALYSES INCLUDING 23,297 PATIENTS

Background: Based on the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) Boolean-based remission definition for rheumatoid arthritis (RA), the main reason for near-misses (failing Boolean remission solely due to one criterion >1) is a patient global assessment (PGA) >1/10.1-3 The frequency of this PGA-near-remission status has not been well established. Objectives: To synthesize the overall prevalence of ACR/EULAR Boolean-based remission and PGA-near-remission cross-sectionally in published studies, and to explore association with disease duration. Methods: We systematically searched PubMed database (from 1/jan/2011 till 15/jan/2020) for “Rheumatoid arthritis” AND Boolean [OR synonyms] AND PGA [OR synonyms], and carried out a hand search of the references of the included studies. Two reviewers independently assessed the study inclusion and extracted the data (n (%) of patients in each remission status, mean (SD) disease duration, and country/city). Studies were excluded if any of the four Boolean criterion was not considered (e.g. C-Reactive Protein not assessed), or if only patients with low disease activity or remission were selected. If different time assessments were provided, we selected the 1y follow-up, as the most common. Random effects meta-analyses of proportions with double arcsine transformation were performed (also by disease duration subgroups) using MEDCALC®. Heterogeneity was assessed by I2. Results: From 41 studies identified, 8 studies concerning 12 subsamples were analysed (n=23,297 patients; of which 22% had ≤2 years mean disease duration). The overall prevalence of Boolean remission was 12% (95%CI: 10-15%, p Conclusion: The overall prevalence of PGA-near-remission in patients with RA followed in clinical practice was 1/3 more prevalent than Boolean remission, a difference more pronounced in patients with established disease. Overall, over 61% of all RA patients otherwise in remission failed to satisfy the Boolean definition of remission solely due to a PGA>1. The use of PGA in the definition of treatment target exposes a substantial proportion of patients to the risk of overtreatment with immunosuppressive agents, while being deprived of the adjunctive therapy they probably need.