Early Arthritis Research Articles

Psoriatic arthritis: State of the art review

Psoriatic arthritis (PsA) accounts for around 20% of referrals to the early arthritis clinic and presents a significant diagnostic and management challenge. Early diagnosis is important to prevent long term functional disability and to ensure optimal management of arthritis and key comorbidities. From the rheumatologist’s perspective, the differential diagnosis includes rheumatoid arthritis, gout and other inflammatory arthritis’s. Once diagnosed, it is essential to assess the disease fully, including arthritis, enthesitis, dactylitis, skin/nail disease and axial involvement. Using this information, appropriate treatment can be planned using therapies that are effective at treating the relevant domains of disease. Despite poor data, traditional disease-modifying anti-rheumatic drugs are commonly used and have been effective in observational studies. Following tumour necrosis factor inhibitors, which have proven excellent efficacy in multiple domains of PsA, new biologics are available or in development and will improve treatment options for people with refractory PsA

Structured and prompt treatment of early arthritis in clinical practice leverages window of opportunity and leads to excellent clinical outcomes: an innovativeretrospective cohort study.

With this work, we evaluated the impact of the Lisbon Early ARthritis cliNic (LEARN) on untreated inflammatory arthritis clinical and patient-reported outcomes. A retrospective cohort study enrolled patients in LEARN since its inception. Patients were followed for 12months and treated to achieve disease remission. Clinical, structural, and quality of life outcomes were assessed. The early arthritis module of the Portuguese Rheumatic Diseases Registry (Reuma.pt) is described. We assessed 292 patients between 2015 and 2022. Mean symptom duration and DAS-28-4V-ESR at baseline were 6.2 ± 3.5months and 5.6 ± 1.3, respectively. Rheumatoid arthritis (56.4%; 40.1% seropositive) and psoriatic arthritis (12.4%) were the most common diagnoses. Most patients were treated with methotrexate (75.3%) combined with low-dose oral prednisolone (88.1%). At 12months, a mean ΔDAS28-4V-ESR improvement of 2.3 ± 0.4 was registered, with 29.5% and 48.9% of patients achieving remission (DAS28-4V-ESR < 2.6) or low disease activity (DAS28-4V-ESR < 3.2), respectively. Among RA patients only, these figures were 20.6% and 46.6%, respectively. A clinically meaningful functional improvement was observed in 72.1% of the patients. Structural progression was limited, affecting only 16.1% of the patients. Fatigue, anxiety, depression, and quality of life also improved substantially, translated by improvements in FACIT, HADS, EQ5D, and SF-36 scores. A structured, dedicated approach to patients with early arthritis resulted in good clinical, structural, and functional outcomes. Furthermore, our findings suggest the window of opportunity for early intervention may have implications for mental health and global well-being. Key Points • Patient assessment is facilitated by reliable electronic clinical records, such as the early arthritis module of the Rheumatic Diseases Portuguese Register (Reuma.pt) which we describe here for the first time. • Inflammatory arthritis was confirmed in the majority of patients observed, but the time to first appointment was above the recommended. • Prompt start of conventional therapy allowed significant disease activity improvement and remission to be achieved in about one-third of the patients. • Key patient-reported outcomes elucidate disease impact and confirm the benefit of early treatment initiation, suggesting a window of opportunity also for mental health and global well-being.

Are seronegative patients with rheumatoid arthritis and clinically suspect arthralgia properly represented in randomized clinical trials?

Rheumatoid arthritis (RA) is a chronic immuno-inflammatory disease whose outcomes can vary greatly from one patient to another. One of the main prognostic factors is the presence of serum autoantibodies, such as rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA). Indeed, when seropositive, patients with RA are at higher risk of radiographic progression, disability, and increased mortality. Moreover, while the introduction of the 2010 American College of Rheumatology/European Alliance of Associations for Rheumatology (ACR/EULAR) classification criteria has allowed for an earlier diagnosis, studies on large early arthritis cohorts have also shown that these criteria are less capable of identifying seronegative patients, who are therefore at a higher risk of being diagnosed and treated late. In light of these, the major randomized controlled trials have mostly enrolled patients with autoantibody-positive disease. However, in recent years, it became evident that the two serotypes of RA differ significantly from many points of view. Alongside this, a greater understanding of the disease pathogenesis, particularly the presence of antibodies in patients' serum even before the onset of arthritis, has generated significant interest in exploring whether the disease could be prevented by treating patients in the pre-arthritis phases. Once again, emerging trials predominantly enroll subjects positive for RA autoantibodies, potentially overlooking seronegative individuals with arthralgia-at-risk.

Rare case of medial Hoffa fracture with ipsilateral femur shaft fracture with unusual mechanism of injury

Hoffa’s fracture is a rare fracture which involves coronal fracture of the distal femur involving one or both the condyles. We report a rare combination of Hoffa fracture with ipsilateral femur shaft fracture with an unusual mechanism of injury. This case report will help increase awareness about such combined fracture pattern and eventually avoid missing these important intra-articular injuries- Hoffa’s fracture. In a patient with ipsilateral femur shaft fracture and in polytrauma patients, diagnosis of Hoffa’s fracture is very challenging because of presence of other long bone fracture and injuries. Missed Hoffa’s fracture in a patient with ipsilateral femur shaft fracture may restrict post-operative knee range of motion, knee pain, increased risk of early arthritis and joint deformity and stiffness.

The Romanian Translation and Cultural Adaptation of the Early Arthritis for Psoriatic Patients (EARP) Questionnaire, Psoriasis Epidemiology Screening Tool (PEST), and Toronto Psoriatic Arthritis Screen 2 (ToPAS 2).

Psoriasis is a chronic inflammatory condition mediated by the immune system with various manifestations. The increased prevalence of subclinical joint involvement has led to the development of early diagnostic methods for psoriatic arthritis, including several instruments that have been validated and used in clinical practice. The aim of this study was to perform the Romanian translation, cultural adaptation, and validation of three assessment tools: the Early Arthritis for Psoriatic Patients (EARP) Questionnaire, Psoriasis Epidemiology Screening Tool (PEST), and Toronto Psoriatic Arthritis Screen 2 (TOPAS 2), which are designed to evaluate early-stage arthritis in patients with psoriasis. All the activities were carried out in accordance with the internationally recognized methodology recommended by the International Society for Pharmacoeconomics and Outcome Research (ISPOR), the recommendations of the World Health Organization (WHO) regarding the translation process and the validation of instruments, and data from the international literature. These three questionnaires were administered to 29 patients with psoriasis diagnosed by biopsy. A descriptive study was conducted and the data were analyzed with appropriate statistical tests using the PSPP program. A reliability test was assessed using Cronbach's alpha coefficient. The obtained values were significant for the first two questionnaires, with a value of 0.89 for the EARP and 0.63 for the PEST, but the value was not as significant for ToPAS2, at 0.40. This pilot study revealed that the Romanian and original versions of the three questionnaires are similar.

Persons Who Have Undergone ACL Reconstruction Exhibit Altered Patellofemoral Joint Contact Area: Implications For Early Onset Patellofemoral Joint Arthritis

Persons Who Have Undergone ACL Reconstruction Exhibit Altered Patellofemoral Joint Contact Area: Implications For Early Onset Patellofemoral Joint Arthritis

The Challenge of IBD-Related Arthritis Screening Questionnaires in Early and Predominantly Entheseal Phenotypes.

Inflammatory bowel disease (IBD)-related arthritis is recognized as the most prevalent extraintestinal manifestation (EIM) of IBD. The objective of this study was to determine the prevalence and characteristics of undiagnosed IBD-related arthritis and to compare two screening questionnaires, DETection of Arthritis in Inflammatory boweL diseases (DETAIL) and IBd Identification of Spondyloarthritis Questionnaire (IBIS-q), for early disease detection. Between April and October 2023, both the DETAIL and IBIS-q questionnaires were administered to consecutive IBD outpatients visiting the University Hospital of Udine, Italy. During routine gastroenterology evaluations, patients aged > 18years with Crohn's disease (CD) or ulcerative colitis (UC) were requested to complete both questionnaires. Subsequently, all patients who completed the questionnaires underwent a blinded rheumatological evaluation within 2weeks. Patients with a previous diagnosis of IBD-related SpA were then excluded. Overall, 203 patients were enrolled, of whom 26 were excluded because of a prior diagnosis of inflammatory arthritis. Among the remaining 177 patients, 10/177 (5.6%) received a new diagnosis of IBD-related arthritis. The median duration of symptoms before diagnosis was 4 (IQR 1.8-10.5) months. Imaging-confirmed enthesitis was the predominant pattern in 8 out 10 cases (80%, with 8 out 8 lacking concomitant peripheral arthritis), axial involvement in 1 out 10 cases (10%), and peripheral arthritis in 1 out 10 cases (10%). The DETAIL questionnaire exhibited higher specificity, but lower sensitivity compared to the IBIS-q, with a sensitivity of 40.0% (12.2-73.8) and specificity of 84.4% (78.0-89.6) versus a sensitivity of 70.0% (34.8-93.3) and specificity of 74.3% (66.9-80.7). Both questionnaires performed less effectively than in other studies. This study highlights a significant proportion of undiagnosed IBD-related arthritis (5.6%). Enthesitis emerged as the predominant pattern of newly diagnosed arthritis in our cohort, likely due to the recent onset of symptoms. Our study underscores the importance of entheseal involvement in early IBD-related arthritis and the importance of incorporating entheseal involvement into screening questionnaires.

Diminished expression of the ubiquitin-proteasome system in early treatment-naïve patients with rheumatoid arthritis and concomitant type 2 diabetes may be linked to IL-1 pathway hyper-activity; results from PEAC cohort

ObjectiveBased on the recent evidence of IL-1 inhibition in patients with rheumatoid arthritis (RA) and concomitant type 2 diabetes (T2D), we evaluated the synovial tissue expression of IL-1 related genes in relationship to the ubiquitin–proteasome system and the effects of insulin on ubiquitinated proteins in fibroblast-like synoviocytes (FLSs).MethodsThe synovial expression of IL-1 pathway genes was compared in early (< 1 year) treatment-naïve RA patients with T2D (RA/T2D n = 16) and age- and sex-matched RA patients without T2D (n = 16), enrolled in the Pathobiology of Early Arthritis Cohort (PEAC). The synovial expression of ubiquitin in macrophages and synovial lining fibroblasts was also assessed by Immunohistochemistry/immunofluorescence and correlated with synovial pathotypes. Finally, FLSs from RA patients (n = 5) were isolated and treated with human insulin (200 and 500 nM) and ubiquitinated proteins were assessed by western blot.ResultsSynovial tissues of RA/T2D patients were characterised by a consistent reduced expression of ubiquitin–proteasome genes. More specifically, ubiquitin genes (UBB, UBC, and UBA52) and genes codifying proteasome subunits (PSMA2, PSMA6, PSMA7, PSMB1, PSMB3, PSMB4, PSMB6, PSMB8, PSMB9, PSMB10, PSMC1, PSMD9, PSME1, and PSME2) were significantly lower in RA/T2D patients. On the contrary, genes regulating fibroblast functions (FGF7, FGF10, FRS2, FGFR3, and SOS1), and genes linked to IL-1 pathway hyper-activity (APP, IRAK2, and OSMR) were upregulated in RA/T2D. Immunohistochemistry showed a significant reduction of the percentage of ubiquitin-positive cells in synovial tissues of RA/T2D patients. Ubiquitin-positive cells were also increased in patients with a lympho-myeloid pathotype compared to diffuse myeloid or pauci-immune-fibroid. Finally, in vitro experiments showed a reduction of ubiquitinated proteins in RA-FLSs treated with a high concentration of insulin (500 nM).ConclusionsA different IL-1 pathway gene expression was observed in the synovial tissues of early treatment-naïve RA/T2D patients, linked to decreased expression of the ubiquitin–proteasome system. These findings may provide a mechanistic explanation of the observed clinical benefits of IL-1 inhibition in patients with RA and concomitant T2D.

Harnessing genetics in the outpatient clinic using polygenic risk scores to aid diagnosis of patients with early inflammatory arthritis: results from the Norfolk Arthritis Register

Harnessing genetics in the outpatient clinic using polygenic risk scores to aid diagnosis of patients with early inflammatory arthritis: results from the Norfolk Arthritis Register

Genetic Variants in RANK and OPG Could Influence Disease Severity and Bone Remodeling in Patients with Early Arthritis.

The aim of this study was to identify single-nucleotide polymorphisms (SNPs) in bone remodeling-related genes associated with disease severity and bone mineral density (BMD) in early arthritis (EA) patients. For this purpose, the genotyping of 552 SNPs located in gene regions of semaphorins 4b, 4d, 4f, DKK1, 2 and 3, sclerostin, OPG, RANK and RANKL was performed using Immunochip from Illumina Inc. in 268 patients from the Princesa Early Arthritis Register Longitudinal (PEARL) study. Measurements of BMD and disease activity were chosen as outcome variables to select SNPs of interest. The relationships of SNPs with the BMD of the forearm, lumbar spine and hip (Hologic-4500 QDR) were analyzed by linear regression adjusted for age, sex, body mass index and presence of anti-citrullinated peptide antibodies (ACPAs). The association of each SNP with activity variables was analyzed by linear regression, logistic regression or ordered logistic regression according to the variable, and multivariate models were adjusted for potentially confounding variables, such as age, sex and presence of ACPAs. These analyses showed that four SNPs located in the genes coding for RANK (TNFRSF11A) and OPG (TNFRSF11B) were significantly associated with clinical variables of severity. SNP rs1805034 located in exon 6 of TNFRSF11A, which causes a non-synonymous (A/V) mutation, showed significant association with BMD and therefore may be considered as a possible biomarker of severity in RA patients. SNPs in the OPG gene showed an association with serum OPG levels and predicted disease activity after two years of follow-up.

Postoperative Radiographic Outcomes Following Abduction-Extension Metacarpal Osteotomy: A Comparison between Early and Advanced Carpometacarpal Arthritis.

Background: This study aimed to investigate the effect of thumb metacarpal osteotomy on dorsal subluxation of the carpometacarpal (CMC) joint and compare the effects of early and advanced osteoarthritis (OA). Methods: We retrospectively reviewed 42 thumbs of 37 patients who underwent metacarpal osteotomy with a postoperative extension angle of 90° or more between January 2018 and October 2021 and were followed up for more than 2 years. The thumbs were classified into two groups: early OA (Eaton stage I or II) and advanced OA (Eaton stage III). We measured the reduction ratio, which was defined as the ratio of improvement in dorsal subluxation, at 3 months and 1 year postoperatively, and at the latest follow-up. We statistically compared the reduction ratio between the two groups and investigated the factors affecting the reduction ratio using correlation analysis. Results: The reduction ratio was significantly higher in the early OA group than in the advanced OA group at 3 months after surgery, whereas no significant difference was found between the two groups at 1 year after surgery and at the latest follow-up. A significant positive correlation was detected between the reduction ratio and the postoperative extension angle. Conclusions: First metacarpal osteotomy reduces dorsal subluxation in both early- and advanced-stage CMC OA. This procedure yields immediate marked reduction in early-stage OA, while improvement of the subluxation progressed gradually in advanced-stage OA. Level of Evidence: Level IV (Therapeutic).

Treatment of early oligoarticular psoriatic arthritis with apremilast: primary outcomes at week 16 from the FOREMOST randomised controlled trial

ObjectivesOligoarticular psoriatic arthritis (PsA) is frequent but rarely studied. The objective was to assess the efficacy of apremilast in early oligoarticular PsA.MethodsFOREMOST (NCT03747939) was a phase 4 multicentre, randomised, double-blind,...

DELAYED GADOLINIUM-ENHACED MAGNETIC RESONANCE IMAGING OF CARTILAGE IS A PREDICTOR OF PERIACETABULAR OSTEOTOMY FAILURE IN PATIENTS 40 YEARS AND OLDER

Pelvic osteotomies for hip dysplasia results can be variable and depend on the amount of preexisting arthritis. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) is a technique designed to measure early arthritis, and could be used to select hips that would benefit from a joint-preserving reconstructive procedure. Our objective was to investigate the role of preoperative dGEMRIC in predicting the success of PAO in patients 40 and above. We hypothesized that patients who failed had lower preoperative dGEMRIC index compared to those who did not.Following IRB approval, patients 40 or older who underwent PAO between 1990–2013 and had preoperative dGEMRIC scan and minimum follow-up of 4 years were identified. Patients with prior hip surgeries or any pathologies were removed leading to a total of 70 patients (Age: 44.2 ± 2.9 years old, BMI: 25.7 ± 4.5 Kg/m2). We only included the first hip undergoing PAO for those with bilateral PAO. Out of 70, 19 had failure defined by the need for total hip replacement or WOMAC pain score of 10 and above within 10 years after index PAO surgery. Articular cartilage was segmented on the 3D pre-operative dGEMRIC scan. The average thickness and dGEMRIC index across the whole articular surface were analyzed.Failed hips had a lower dGEMRIC index by 115 ± 20 ms (P&lt;0.001). All but one failed hips had a dGMERIC index of 400 or less (range: 313 – 479 ms), while all survived hips had a dGMERIC index of greater than 400 (range: 403 – 691 ms). Similar trends were observed when comparing the dGEMRIC index within the 6 subgroups (P&lt;0.01). There were no differences in cartilage thickness (combined femoral head and acetabular cartilage) between the failed and survived hips (p&gt;0.2).Patients with a high dGMERIC index (indicating high GAG content) may have a higher chance of successful outcomes following PAO. Current efforts are underway to develop a multi-modal predictive model to evaluate risk of failure after PAO.

Electrocardiogram Abnormalities in Children With Lyme Arthritis.

Classically, Lyme disease follows a staged illness pattern with carditis occurring in early disseminated disease and arthritis in late-stage disease. A more comprehensive understanding of Lyme suggests that clinical stages may intersect. Little is known regarding the overlap of electrocardiogram (ECG) abnormalities in children with Lyme arthritis. This study aimed to estimate the prevalence of ECG changes in pediatric patients presenting with Lyme arthritis. In this retrospective, cross-sectional study was conducted at a tertiary care children's hospital in a Lyme endemic area; patients were identified based on Lyme testing performed from January 2012 to August 2022. Children diagnosed with Lyme arthritis by 2-tiered serology with ECGs obtained within 2 days of antibiotic initiation were included. A study cardiologist reviewed all ECGs for evidence of carditis defined as atrioventricular block, ST-T wave changes, QTc interval prolongation, accelerated junctional rhythm or right bundle branch block. Two hundred thirty-three patients were diagnosed with Lyme arthritis; 90 (38.6%) had ECGs completed. Five patients (5.6%) had ECG abnormalities: 3 were diagnosed with first-degree atrioventricular block, 1 with QTc prolongation, and 1 with ST-T wave changes. No clinical or laboratory features in patients with Lyme arthritis were associated with an increased likelihood of having an abnormal ECG. All patients with ECG abnormalities were treated with oral antibiotics, and none had clinically significant cardiac disease. ECG abnormalities in children with Lyme arthritis rarely occur and, when present, are not reflective of clinically significant cardiac disease. These results do not support routine screening ECGs on asymptomatic pediatric patients with Lyme arthritis.

Prioritising Appointments by Telephone Interview: Duration from Symptom Onset to Appointment Request Predicts Likelihood of Inflammatory Rheumatic Disease.

Background: This study aims to determine the rate of inflammatory rheumatic diseases (IRDs) in a cohort of initial referrals and the efficacy of prioritising appointments to the early arthritis clinic (EAC) based on symptom duration. Methods: In the present study, we used algorithm-based telephone triage to assign routine care appointments according to the time between symptom onset and request for an appointment (cut-off criterion: 6 months). This retrospective, monocentric analysis evaluated the effectiveness of our triage in identifying patients with IRDs as a function of the assigned appointment category (elective, EAC, or emergency appointment). Results: A total of 1407 patients were included in the study (34.7% male; 65.3% female). Of the 1407 patients evaluated, 361 (25.7%) presented with IRD. There were significant differences in the frequency of inflammatory diagnoses between appointment categories (p < 0.001): elective 13.8%, EAC 32.9%, and emergency 45.9%. The sample without the emergency category included a total of 1222 patients. The classification into "inflammatory" or "non-inflammatory" in this subsample was as follows: Sensitivity was 37.7%, and specificity was 92.6%. The positive predictive value (PPV) was 59.8%, and the negative predictive value (NPV) was 83.6%. Overall, 80.2% of patients were correctly assigned using the appointment category and C-reactive protein (CRP). Conclusions: The algorithm-based triage system presented here, which focuses on the time between symptom onset and request for an appointment, allows for the prioritisation of appointments in favour of patients with IRDs and thus earlier initiation of therapy.

Small Fiber Neuropathy Associated with Post-COVID-19 and Post-COVID-19 Vaccination Arthritis: A Rare Post-Infective Syndrome or a New-Onset Disease?

Post-COVID-19 (PC) and post-COVID-19 vaccination (PCV) syndromes are considered emergent multidisciplinary disorders. PC/PCV small fiber neuropathy (SFN) was rarely described and its association with undifferentiated arthritis (UA) was never defined. We aimed to evaluate PC/PCV-UA associated with the recent onset of severe lower limb paresthesia, compare SFN positive (+) to negative (-) patients, and evaluate changes in biomarkers in SFN+ during treatments. Nineteen PC/PCV-UA-patients with possible SFN underwent skin biopsy at the Usl Tuscany Center (Florence) early arthritis outpatient clinic from September 2021 to March 2024. Eight selected SFN+ were compared to ten SFN- patients. In SFN+ patients, baseline joint ultrasound (US), electromyography (EMG), optical coherence tomography (OCT), and skin biopsy were repeated at six months. Moreover, SFN+ patients were clinically assessed by a 0-10 numeric rating scale for neurological symptoms and DAS28/ESR up to 12 months follow-up. SFN+ patients showed a lower intraepidermal nerve fiber density at histopathological examination of skin biopsies and a higher frequency of OCT and EMG abnormalities in comparison to SFN- patients. In SFN+ patients, US and DAS28/ESR significantly improved, while intraepidermal nerve fiber density did not significantly change at the six-month follow-up. Fatigue, motor impairment, burning pain, brain fog, and sensitivity disorders decreased at long-term follow-up (12 months).

Early identification of rheumatoid arthritis: does it induce treatment-related cost savings?

ObjectiveEarly diagnosis and treatment-start is key for rheumatoid arthritis (RA), but the economic effect of an early versus a later diagnosis has never been investigated. We aimed to investigate whether...

Outcomes of Arthroscopic Debridement of the First Carpometacarpal Joint: A Systematic Review.

Background: Arthroscopic debridement is increasingly being utilised in patients with early-stage first carpometacarpal joint (FCMCJ) arthritis but has limited supportive evidence. This systematic review evaluates the literature, and reports on outcomes and adverse events following this procedure. Methods: An electronic literature search of PubMed, Embase, Medline and Cochrane Central, looking for studies describing outcomes following arthroscopic debridement in FCMCJ arthritis, was performed in November 2022. Studies where bony resection or interposition was performed as adjuncts were excluded. Reported outcomes included visual analogue scores (VAS) for pain; Disabilities of Arm, Shoulder and Hand (DASH) scores; pinch and grip strength; complications and re-operations. Results: Out of a total of 90 studies revealed from the search, only two studies were eligible for inclusion, with a cohort of 34 patients. Following arthroscopic debridement for FCMCJ osteoarthritis, the mean VAS improved by four units, mean DASH by 22 points, grip strength by 4.5 kg and pinch strength by 2 kg at mean follow-up of 18 months. The pooled complication and re-operation rates were 8.8% and 23.5%, respectively. Conclusions: There is a lack of evidence supporting the utility of FCMCJ arthroscopy and debridement in the management of patients with early arthritis. Although the limited evidence suggests that there may be some therapeutic benefit, further large-scale prospective studies need to be performed before making conclusive recommendations. Level of Evidence: Level III (Therapeutic).

The prognostic value of IgA anti-citrullinated protein antibodies and rheumatoid factor in an early arthritis population with a treat-to-target approach.

The mucosal origin hypothesis of rheumatoid arthritis has renewed the interest in IgA autoantibodies, but their added value over IgG anti-citrullinated protein antibody (ACPA) and IgM rheumatoid factor (RF) for modern treatment outcomes remains unknown. We aimed to investigate the prognostic value of IgA-ACPA and IgA-RF for treatment outcomes in an early arthritis population. IgA-ACPA/RF isotypes were measured in baseline sera from 480 inflammatory arthritis (IA) patients, who were included in the treatment in the Rotterdam Early Arthritis Cohort trial (tREACH). The tREACH trial was a multicentre, stratified, single-blinded trial with a treat-to-target approach. The prognostic value of IgA-ACPA/RF was determined by evaluating differences in (1) quick-attained (< 6months after diagnosis) and persistent remission rates, (2) DMARD-free remission and (3) biological use between IA patients with and without IgA-ACPA/RF over 3years of follow-up. IgA-ACPA was present in 23% of patients and overlapped with IgG-ACPA positivity in 94%. Similarly, IgA-RF overlapped with IgM-RF in 90% of patients. IgA-ACPA positivity was associated with lower DFR rates and more biological use, but this effect was largely mediated by the presence of IgG-ACPA, since this effect disappeared after stratification for IgG-ACPA(HR 0.6, 95%CI 0.2-1.6 for DFR). No differences were observed in 'quick-attained and persistent remission' rates and for IgA-RF. Their seems to be no additional value of IgA-ACPA and IgA-RF for modern, long-term clinical outcomes. The effects of IgA-ACPA seen in our study are largely mediated by the presence of IgG-ACPA. Based on these results, there is no rationale for measuring these isotypes in daily practice.

Patients Journey Before Early Rheumatoid Arthritis Diagnosis Contributes to disease's Activity Level: A Real-Life Study.

The help-seeking process in rheumatoid arthritis (RA) patients is challenging, and its study is limited in Latin America. The study describes the real-life journey before patients' incorporation into an early arthritis clinic (EAC) and its impact on baseline and 1-year cumulative disease activity levels. The patient's journey was assessed through a questionnaire that captured the patient's path from the first disease-related symptom to the initial assessment in the EAC. A disease activity (28 joints evaluated)-erythrocyte sedimentation rate (DAS28-ESR) score >5.1 defined a high-disease activity level. The mean of individual consecutive DAS28-ESR scores summarized cumulative DAS28-ESR. Multiple logistic regression analysis identified factors associated with a DAS28-ESR score >5.1 at the first assessment. Linear regression analysis assessed the impact of general practitioner (GP)-first consultant and time on disease-modifying antirheumatic drugs (DMARDs) on baseline and cumulative DAS28-ESR scores. Through January 2023, the EAC had 241 RA patients, among whom 209 (86.7%) completed the patients' journey questionnaire (PJQ) and 176 (84.2%) at least 1 year of follow-up. A GP was the first consultant in 76.6% of the patients, and only 12.4% were prescribed DMARDs. Patients had additional evaluations with either rheumatologists (38.6%) or other specialists (31.6%), and half of them were initiated DMARDs. GP-first consultant (adjusted odds ratio: 2.314, 95% confidence interval: 1.190-4.500, p = 0.013) and time on DMARDs (adjusted odds ratio: 0.738, 95% confidence interval: 0.585-0.929, p = 0.010) were associated with baseline DAS28-ESR score >5.1. The B coefficient magnitudes for GP-first consultant and time on DMARDs to predict cumulative DAS28 progressively decreased during the first year of follow-up. Patients' journey before recent-onset RA diagnosis predicts first-year disease activity levels.