University Rheumatology Research Articles

SAT0412 Patients with Psoriatic Arthritis HAD Better TNFI Survival than Ankylosing Spondylitis: HÜR-BİO REAL Life Results

BackgroundTNFi drug survival is one of the valid outcome measure in rheumatological diseases. Patients with psoriatic arthritis (PsA) usually have both joint/back pain diseases and skin disorders. Thus, efficacy of...

SAT0347 Patients with Ankylosing Spondylitis and Non-Radiographic Axial Spondyloarthritis HAD Similar TNFI Drug Survival: HÜR-BİO REAL Life Results

BackgroundTNFi drug survival is one of the valid outcome measure in rheumatological diseases. TNFi drug survival is not evaluated adequetly in non-radiographic axial spondyloarthritis (nr-axSpA).ObjectivesObjective of this study was to...

SAT0370 Retention Rate of TNF Blockers is Greater in CASE of Advanced Spinal Ankylosis in Axial Spondyloarthritis: Data from the HÜR-BİO Registry

BackgroundSpinal ankylosis is one of the important factor responsible of functional impairment in ankylosing spondylitis (AS). In advanced disease, there is still the debate of the potential benefit of use...

SAT0367 Frequency of Radiological Hip Involvement and Total Hip Replacement in A Large Single Center Spondyloarthritis Cohort with Biological Treatments: HÜR-BİO REAL Life Results

BackgroundTotal hip replacement (THR) is a favorable treatment option for severe ankylosing spondylitis (AS). However, THR may be an option for another spondyloarthritis (SpA) such as psoriatic arthritis (PsA) and...

Infecciones en pacientes con artritis reumatoide: medicamentos moduladores de la respuesta biológica versus fármacos modificadores de la enfermedad. Seguimiento a un año

BackgroundDisease modifying anti-rheumatic drugs and biological disease modifying drugs are used to control inflammation and prevent progression of joint damage in rheumatoid arthritis. It is still controversial whether these drugs increase the incidence of infection in this disease. MethodsA retrospective cohort study was conducted on a population sample of 383 inpatients and outpatients from a university hospital and referral rheumatology tertiary hospital complex in northwestern Colombia. They were classified according to American College of Rheumatology 1987 classification criteria, with 83 in the biological therapy group, and 300 in the disease modifying antirheumatic drugs group, in order to establish the incidence and risk factors for serious and non-serious infections at 12 months follow-up. ResultsThe majority were females (85%). The biological therapy group presented a greater risk for non-serious [HR 1.73 (95% CI 1.07–2.77; P=.023)] and serious infections [HR 2.56 (95% CI 1.09–6.01; P=.030)]. This finding remained when adjusting for other variables associated with infection (number of disease modifying antirheumatic drugs received, methotrexate, leflunomide and steroids use, diabetes mellitus), with HR for non-serious infection [(1.67, 95% CI 1.05–2.70; P=.030)], and HR for serious infection [(2.67, 95% CI 1.12–6.34; P=.026)]. Chronic lung disease [HR 5.11 (95% CI 1.18–22.08; P=.029)] was an additional risk factor for serious infections. ConclusionsBiological therapy increases the risk of serious and non-serious infections at 12 months, compared to disease modifying drugs, in a group of patients with rheumatoid arthritis. The risk of serious infections also increases with the presence of chronic lung disease

The learning curve of nurses for the assessment of swollen and tender joints in rheumatoid arthritis

ObjectivesIn rheumatoid arthritis (RA), nurses are now increasingly involved in joint count assessment but training is not standardized. The aim was to evaluate and describe the learning curve of nurses for the assessment of swollen and tender joints in RA. MethodTwenty nurses from university rheumatology centres inexperienced with joint counts were allocated to a rheumatologist from their centre (teacher). Acquisition of skills consisted of Phase 1: (training), a centralized 4hour training session, with (a) lecture and demonstration, and (b) practical sessions on patients with their teachers, followed by Phase 2: (practice) involving further practice on 20 patients in their own hospitals. Primary outcome was achievement of adequate swollen joint agreement between nurse and their teacher (“gold standard”) at the “joint” level defined by prevalence adjusted biased adjusted kappa (PABAK)>0.60. Agreement at the “patient” level of swollen joint count (SJC), tender joint count (TJC) as well as DAS28 between nurse and their teacher were assessed with intra-class correlation coefficients (ICC). ResultsDuring the training phase, 75% of nurses achieved a swollen joint PABAK>0.60 when compared with their teachers, which further improved to 89% after the 20 practice patients (Phase 2). Median swollen joint PABAK improved from 0.64 (Q1:Q3 0.55,0.86) to 0.83 (Q1:Q3 0.77,1) by the end of Phase 2. At the “patient” level, SJC agreement remained globally stable (ICC, 0.52 to 0.66), while TJC and DAS28 agreement remained excellent throughout. ConclusionNurses inexperienced in joint counts were able to achieve excellent agreement with their teachers in assessment of tender and swollen joints through a short training session; practice further enhanced this agreement. Larger longitudinal studies are required to assess skills retention.

Improving rheumatologic care and education in the Republic of Macedonia: model for rheumatologic education and care in a developing country—ILAR Initiative

Republic of Macedonia is one of the poorest countries in Europe. The health care and health education have been profoundly impacted by the economic shortages in the country since gaining independence in 1991. Of two million population, 29 % are unemployed and 31 % live below poverty level (https://www.cia.gov/library/publications/theworld-factbook/geos/mk.html). The only health insurance is the Universal Health Insurance, which is grossly underfunded leading to chronic shortages of resources. The limited health care resources have especially impacted care for patients with chronic diseases such as rheumatoid arthritis (RA). There are 17 practicing rheumatologists in Macedonia, all employed at the university clinic in the capital city Skopje. The rheumatologic care outside of the capital city is very limited and provided by commuting rheumatologists from the university. In many communities, the rheumatologic care is provided by primary care physicians, orthopedists, and physiatrists. Even in the capital, the standard of care lags behind that of neighboring European Union countries [1]. The average DAS-28 score was 5.2. Methotrexate was the most commonly used disease-modifying antirheumatic drug (DMARD) with average dose of 10 mg/week. Combination therapy of DMARDS is seldom used. The only biological agents available is rituximab and tocilizumab, and the government sponsored health fund allows treatment with biologics for about 100 patients per year. Anti-TNF therapy is not covered by the only health insurance. Macedonia has one of the more restrictive policies in Europe on the utilization of biologics [2, 3]. Pediatric rheumatology does not exist in Macedonia. The current model of training rheumatologists in Macedonia is centralized. Employment in the university rheumatology clinic is a prerequisite for training. This model is a barrier for training rheumatologists outside of the capital, thus compromising the provision of rheumatologic care to more than 50 % of the country’s population. In an effort to improve rheumatologic care and education, we proposed a new model for training and provision of rheumatologic care in Macedonia. This model decentralizes training and provision of care by training individuals from regions outside of the capital. This model would improve patient access, and it would provide early diagnosis and care. We partnered with a local academic center, a community hospital, and a patient advocacy group in a project that would improve access and rheumatologic care in the town of Bitola.

AB1412 Nurses can achieve very good agreement with physicians for joint counts in rheumatoid arthritis – a feasible training method

Background“Tight control” of rheumatoid arthritis (RA) necessitates regular disease activity assessment using clinical joint counts. However, joint counts take time, and are not always performed in busy clinics [1]. Nurses...

SAT0535 Diagnosis, Disease Burden and Disease Manifestations of the Sapho Syndrome in Germany: Results from a Nationwide Patient Survey

BackgroundThe term SAPHO syndrome describes a rare, probably underdiagnosed and heterogeneous disease entity. Characteristic disease features include skin, bone and joint manifestations and a predisposition for involvement of the anterior...

FRI0458 Utility of new asas classification criteria for axial and peripheral spondylarthritis in routine clinical care: a cohort study

BackgroundThe Assessment of SpondyloArthritis international Society (ASAS) classification criteria (ASAScc) for both axial and periheral spondyloarthritis (SpA) have been designed to classify patients early in the disease course. The criteria...

Changes in the incidence and management of spinal tuberculosis in a French University Hospital Rheumatology Department from 1966 to 2010

IntroductionTwo previous single-center studies in a university hospital rheumatology department suggested an increase in the incidence of spinal tuberculosis in France in the 1990s. Our objective in this study was to obtain incidence data on spinal tuberculosis since 1995 in the same department and to describe changes over the entire study period from 1966 to 2010. We also compared patients seen between 1966 and 1995 to those seen between 1995 and 2010. MethodsWe conducted a retrospective review of all cases of spinal tuberculosis seen in our rheumatology department between 1966 and June 1995 and between July 1995 and 2010. We collected the annual incidence, clinical and radiological features, and diagnostic and therapeutic strategies. ResultsOne hundred and thirty patients were managed between 1966 and 2010. The number of cases declined in the 1970s and 1980s then increased over the next two decades. None of the patients had HIV infection. Over 70% of patients were from continental France. Compared to patients seen during the earlier period, those seen after June 1995 were older (62.8±17.2 vs. 53±14.3 years, P=0.0006), had more comorbidities, and more often exhibited severe radiological findings (including multilevel involvement, epidural involvement, and abscesses). No changes occurred in time to diagnosis or management strategies. ConclusionThe incidence of spinal tuberculosis in a university hospital rheumatology department has increased over the last two decades, chiefly as a result of reactivation of past tuberculosis, as opposed to origin from endemic countries or HIV infection.

Improving agreement in assessment of synovitis in rheumatoid arthritis

ObjectiveSynovitis assessment through evaluation of swollen joints is integral in steering treatment decisions in rheumatoid arthritis (RA). However, there is high inter-observer variation. The objective was to assess if a short collegiate consensus would improve swollen joint agreement between rheumatologists and whether this was affected by experience. MethodsEighteen rheumatologists from French university rheumatology units participated in three 30minutes rounds over a half day meeting evaluating joint counts of RA patients in small groups, followed by short consensus discussions. Agreement was evaluated at the end of each round as follows: (i) global agreement of swollen joints (ii) swollen joint agreement according to level of experience of the rheumatologist (iii) swollen joint count and (iv) agreement of disease activity state according to the Disease Activity Score (DAS28). Agreement was calculated using percentage agreement and kappa. ResultsGlobal agreement of swollen joints failed to improve (kappa 0.50 to 0.52) at the joint level. Agreement between seniors did not improve but agreement between newly qualified rheumatologists and their senior peer, which was initially poor (kappa 0.28), improved significantly (to 0.54) at the end of the consensus exercises. Concordance of DAS28 activity states improved from 71% to 87%. ConclusionConsensus exercises for swollen joint assessment is worthwhile and may potentially improve agreement between clinicians in clinical synovitis and disease activity state, benefit was mostly observed in newly qualified rheumatologists.

Exercise Recommendations in Patients With Newly Diagnosed Fibromyalgia

To evaluate exercise recommendations in patients newly diagnosed with fibromyalgia. A retrospective chart review. A public university rheumatology clinic. Patients newly diagnosed with fibromyalgia (N = 122). Frequency and type of exercise recommendations. The mean (standard deviation) age of these patients with fibromyalgia was 45 ± 12 years; 91% were women. Exercise was recommended as part of the documented treatment plan in 47% of these patients (57/122); only 3 patients had a documented contraindication for exercise. Aquatic exercise was most frequently recommended (56% [32/57]), followed by combined aquatic-aerobic exercise (26% [15/57]), and, infrequently, aerobic exercise only (5% [3/57]); only 7% of these patients (4/57) were referred for physical therapy. The primary method of communication was verbal discussion (94% [54/57]). Although there is well-documented evidence that exercise is beneficial for patients with fibromyalgia, we found that less than half of patients with newly diagnosed fibromyalgia in our study were provided recommendations to initiate an exercise program as part of their treatment plan. Further investigation of these findings are warranted, including evaluation of other university and community rheumatology practices as well as that of other physicians caring for patients with fibromyalgia. However, our findings indicate that there appears to be an opportunity to provide more specific and practical education regarding the implementation of an exercise regimen for patients with newly diagnosed fibromyalgia. Physiatrists may be particularly well suited to manage the exercise component of patients with fibromyalgia because of their specialized training in exercise prescription.

Utility of the new rheumatoid arthritis 2010 ACR/EULAR classification criteria in routine clinical care

ObjectivesThe new 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria for rheumatoid arthritis (RA) have been designed to classify early onset RA, but has not been studied to...

Patient Attitudes Toward Western Medicine and the Future of Chinese Medicine for Spondyloarthritis

Spondyloarthritis (SpA) and ankylosing spondylitis (AS) have a significant social and economic impact on ethnic Chinese patients. Western medicine, especially NSAIDs and disease-modifying anti-rheumatic drugs (DMARDs), are standard mainstream therapies for patients with SpA and AS. However, patient compliance with these medications is poor, due to the fear of side effects. In spite of their poor functional status and disease activity, less than 40% of AS patients are regularly treated. Complementary and alternative medicine (CAM) is very popular in Asian countries like China, Korea, Japan, India and Taiwan. A Korean survey in university hospital rheumatology clinics showed that 155 patients (68.5%) reported using at least one form of CAM during the previous 12 months. Herbal remedies and acupuncture were the most frequently used categories of CAM. Compared to conventional Western treatments, CAM is seen to have advantages in terms of a lower incidence of adverse reactions, greater patient choice, psychological comfort, and an increased quality of the patient/ therapist relationship. Common symptoms treated by CAM were pain (80%), decreased functioning (43%), and lack of energy (24%). Tripterygium wilfordii Hook. f. (Lei Gong Teng), Tetrandrine (Tet), acupuncture and Tai Chi are some examples of potential Chinese medicine treatments for spondyloarthritis. CAM usage is a worldwide trend. However, further study, including basic research and well-designed clinical trials, is warranted. Patients should be instructed to discuss treatment strategies for their disease, and the use of CAM, with their rheumatologists. Keywords: Western medicines, alternative medicine, Herbal remedies, acupuncture

The relationship between disability and self‐care agency of Turkish people with rheumatoid arthritis

This study aims to determine the relationship between disability levels and self care agency scores in Turkish patients with rheumatoid arthritis and to investigate the factors affecting them. Self-care agency is the complex acquired ability to meet one's constant requirements for care that regulates life processes, maintains or promotes the integrity of human structure, functioning and development, and promotes well-being. Forty-three consecutive patients with Rheumatoid Arthritis (M/F: 11/32; mean age 49.53 +/- 13.37 years; disease duration 118.32 +/- 76.55 months), being followed up by Ege University Rheumatology Outpatient Department and all fulfilling ACR 1987 criteria were included in this study. Data collection instruments used in this study were Informative-Demographic Data Form, Health Assessment Questionnaire (including disability index and pain scale) and Self-as-Carer Inventory. The mean disability index, the mean pain score and the mean self-care agency score of patients were 0.53 (SD 0.45), 1.48 (SD 0.74) and 80.95 (SD 27.80) were respectively. Self-care agency of patients found moderate level. It was found that a positive correlation between the disability index and the self-care agency scores (r = 0.488; p < 0.01). It was found that in male (t = 0.907; p = 0.000), in patients graduate from university (F = 0.271; p = 0.001), the self-care agency was better than other patients. In conclusion we found that in Turkish patients with Rheumatoid Arthritis, the higher the disability rate was, the lower the self-care agency score was. Disability, pain and their impact on self-care agency should be focused on in everyday care for Rheumatoid Arthritis patients. These areas are most important in nursing care and should be considered while organizing the medical treatment and rehabilitation programme.

Impact of medical practices on the costs of management of rheumatoid arthritis by anti-TNFα biological therapy in France

When the anti-TNFα drugs first came onto the market, their high price was the subject of much debate. Moreover, we must add the costs associated with their administration to the purchase price. Variations in medical practices may be the source of substantial variations in these costs. Objective. – To compare the costs involved with the use of infliximab and etanercept in the treatment of rheumatoid arthritis (RA) and to study the impact of variations in medical practices on them. Methods. – A pragmatic cost minimization analysis was conducted from the payer's perspective to compare the costs of administration, that is, the direct medical costs, of the first two available anti-TNFα agents: infliximab and etanercept. Records of 60 patients from three university hospital rheumatology departments were reviewed retrospectively for a 52-week period. This analysis considered the following costs: purchase costs for the drugs and for any co-prescribed disease-modifying drugs, inpatient or outpatient administration, medical follow-up and the transportation costs associated with treatment that were reimbursed by the French health insurance system. Costs that did not differ between the two products were excluded (work-up for inclusion, etc.). Results. – Data were collected for 58 patients, 30 treated with infliximab and 28 with etanercept. Patients' mean age was 52 years; 81% were women. RA had first developed on average 15 years earlier; the disease was positive for rheumatoid factors in 68% of cases and erosive in 93%. The total average annual cost of administration did not differ for infliximab and etanercept: 19,469 and 19,619 €, respectively ( P = 0.56). The mean costs of administration nonetheless varied considerably between the three hospital centers: from 16,566 to 24,313 € for infliximab ( P < 0.0001) and from 16,069 to 24,383 € for etanercept ( P < 0.0001). Conclusion. – The financial burden of biological treatments for RA is strongly influenced by the substantial heterogeneity in medical practices.

Symptoms of depression and anxiety in functionally disabled rheumatic pain patients

The aim of the present work was to study correlations between self-assessment of symptoms of depression, anxiety, rheumatic pain and functional disability. One hundred patients admitted to a university rheumatology clinic were tested in a consecutive manner, applying the Hospital Anxiety and Depression Scale (HADS). In addition, the patients were asked to express a quantitative measure of their subjective pain and functional disability on visual analogue scales (VAS). Regression analysis (analysis of variance) showed significant correlation between rheumatic pain and depression (P=0.04), between rheumatic pain and anxiety (P=0.03) and between rheumatic pain and functional disability (P<0.000). Significant correlations were also seen between depressive symptoms and functional disability (P=0.01) and between anxiety and functional disability (P=0.002). The correlation between symptoms of anxiety and depression was at a P=0.000 level. Applying the experience from this study and introducing, as part of a clinical examination, a minimum of psychiatric investigation based on self-assessment of anxiety and depression will provide relevant and reliable information sufficient for following up with specific psychiatric investigations and therapy. This in turn will be positive for those of the rheumatic patients having a comorbid mental health problem.

Thrombin activatable fibrinolysis inhibitor in Behçet's disease

Introduction Thrombin activatable fibrinolysis inhibitor (TAFI) is a procarboxypeptidase downregulating plasmin formation, thereby causing a tendency for thrombosis development. Since, Behçet's disease (BD) is a systemic vasculitis, which is commonly complicated by arterial and venous thrombosis, we aimed to find out plasma TAFI levels in BD, compared with healthy controls. We also searched whether plasma TAFI levels were significantly different between Behçet's subgroups with and without thrombosis. Materials and methods In this study, 105 BD patients (M/F: 64/41; mean age 36±1 years), followed up by Ege University Rheumatology Department were enrolled. The exclusion criteria were hemophilia, hyperlipidemia, diabetes mellitus, hepatic diseases renal failure, antiphospholipid positivity, oral contraceptive use and pregnancy. Age-and sex-matched healthy controls ( n=53) were also included. Plasma TAFI levels were measured by ELISA. Since TAFI is also an acute-phase reactant, we also measured other inflammatory markers such as C-reactive protein (CRP). Results Plasma TAFI levels were significantly higher in Behçet's patients (91.1±7.4 ng/ml) compared with healthy controls (14.3±4.5 ng/ml) ( P<0.001), but there were no significant difference between the subgroups with and without thrombosis. In BD, there was no correlation between plasma TAFI levels and CRP. Conclusions Regardless of manifest thrombosis, plasma TAFI levels in BD were significantly higher than in healthy controls. High TAFI levels might possibly contribute to the thrombotic tendency in BD. Future studies investigating TAFI gene polymorphism and functional activity are clearly needed, to clarify the exact role of TAFI in Behçet's thrombosis.

Occupational exposure to crystalline silica and risk of systemic lupus erythematosus: a population-based, case-control study in the southeastern United States.

Crystalline silica may act as an immune adjuvant to increase inflammation and antibody production, and findings of occupational cohort studies suggest that silica exposure may be a risk factor for systemic lupus erythematosus (SLE). We undertook this population-based study to examine the association between occupational silica exposure and SLE in the southeastern US. SLE patients (n = 265; diagnosed between January 1, 1995 and July 31, 1999) were recruited from 4 university rheumatology practices and 30 community-based rheumatologists in 60 contiguous counties. Controls (n = 355), frequency-matched to patients by age, sex, and state of residence, were randomly selected from driver's license registries. The mean age of the patients at diagnosis was 39 years; 91% were women and 60% were African American. Detailed occupational and farming histories were collected by in-person interviews. Silica exposure was determined through blinded assessment of job histories by 3 industrial hygienists, and potential medium- or high-level exposures were confirmed through followup telephone interviews. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated by logistic regression. More patients (19%) than controls (8%) had a history of medium- or high-level silica exposure from farming or trades. We observed an association between silica and SLE (medium exposure OR 2.1 [95% CI 1.1-4.0], high exposure OR 4.6 [95% CI 1.4-15.4]) that was seen in separate analyses by sex, race, and at different levels of education. These results suggest that crystalline silica exposure may promote the development of SLE in some individuals. Additional research is recommended in other populations, using study designs that minimize potential selection bias and maximize the quality of exposure assessment.