ObjectivesTo evaluate whether meteorological parameters influence disease activity in patients with rheumatoid arthritis (RA).MethodsWe assessed correlations between individual meteorological variables and clinical measures of disease activity: clinical disease activity index (CDAI), self-reported pain (by visual analogue scale), tender- and swollen 28 joint counts (TJC and SJC). Assessments documented in our RA database as well as the average temperature and relative humidity, obtained from the Central Institute for Meteorology and Geodynamics, were matched on a daily basis for a period of 10 years between 2005 and 2015, and analyzed using generalized estimating equations (longitudinal data analysis).ResultsA total of 1437 patients with RA (average disease duration at first visit: 4.88±8.63 years; 77% female, mean CDAI 17.8±11.7, mean time in study: 75 month, mean number of visits during study period: 19) were analyzed. Higher temperature and lower humidity were significantly associated with lower CDAI (p=0.0002, and p=0.0332, respectively). Regarding pain, the effects of temperature showed an interaction with humidity: while lower temperatures were associated with higher pain levels at the low and middle tertile of relative humidity, they corresponded to a lower pain level at the high tertile of relative humidity. Temperature showed a significantly negative correlation with TJC (p<0.0001), while relative humidity showed a significantly positive correlation with SJC (p=0.0321). Similar to pain, there was again an interaction of temperature and humidity in the SJC analysis.ConclusionsIn this largest association study of meteorological parameters with RA specific outcomes both temperature and relative humidity were shown to have significant effects on disease activity. Individual measures of disease activity and pain correlated either with temperature or humidity, while the composite CDAI measure correlated with both meteorological variables. These aspects may have to be taken into account in longitudinal analyses of disease activity of RA.Disclosure of InterestNone declared
Background Progression of joint damage in RA occurs primarily in joints that are clinically swollen, and repair is seen only in joints with no clinical swelling.1;2 On the other hand, joints exhibiting US but not clinical swelling may progress radiologically despite clinical remission.3 This discrepancy requires elucidation to understand the value of clinical compared with US joint assessment, since except for histology, there is no true gold standard for US joint activity. Objectives To evaluate the differences in number of clinically and US active joints in RA, with special regards to the impact of US definitions of activity. Methods We performed US imaging of 22 joints of the hands of RA patients in clinical remission (CDAI≤2.8). Each joint was assessed for grey scale synovial hypertrophy (GSSH; 0=no hypertrophy; 1=hypertrophy) and power Doppler (PD) signal (0= no hyperaemia, 1= mild, 2=moderate, 3=marked). We investigated the sensitivity and specificity of clinically swollen joints (SJC) for presence of US changes and repeated this analysis using different cut points and combinations of US definitions. We further assessed changes of CDAI if clinical SJC were replaced by US active joints. Results Of the 58 patients in clinical remission, 96.6% had GSSH and 93.1% had positive PD signals. The sensitivity and specificity of clinical SJC for any US abnormality (GSSH>0 or PD>0) was 1.7% and 100%, respectively. When we used more stringent definitions of US activity (GSSH>0 & PD=3), these values changed to 22.2% and 99%. Replacing clinical by US counts in the calculation of CDAI, the US CDAI values approached the clinical CDAI with increasing stringency of the definition used (Fig.). In fact, the most stringent definition (GSSH>0 & PD=3) revealed identical average values as seen in the clinical CDAI. Conclusions Low PD signals increase the numbers of patients classified as having active joints and lead to a poor sensitivity of clinical assessment in comparison to US assessment. When the PD signal is combined with assessment of GSSH, or the strength of the PD signal is considered, the differences decrease, particularly when looking at their impact on composite indices. The relevance of this finding will have to be tested in relation to radiographic progression of joint damage. References Klarenbeek NB et al. ARD 2010; 69(12):2107-2113. Lukas C et al. ARD 2010; 69(5):851-855. Brown AK et al. Arthritis Rheum 2008; 58(10):2958-2967. Disclosure of Interest None Declared
BackgroundStudies evaluating weather sensitivity among patients with rheumatoid arthritis (RA) have yielded conflicting results.ObjectivesTo evaluate whether patients with RA exhibit sensitivity to outside temperature.MethodsWe assessed correlation between mean daily temperature and self-reported pain (by visual analogue scale), and patient's global assessment of disease activity (PGA). Assessments documented in the RA database of our department as well as the average temperature obtained from the Central Institute for Meteorology and Geodynamics, were matched on a daily basis for a period of 10 years between 2005 and 2015 and analyzed using generalized estimating equation (GEE) and a mixed model analysis (MM). Patients with <5 visits in the study period, or with <1 visit/quarter or with pain=0 in ≥3 consecutive visits and those living outside of the catchment area were excluded. Overlap between responsiveness of pain or PGA to temperature was calculated by Cohen's kappa.ResultsA total of 399 patients with RA (average disease duration at first visit: 6.0±7.6 years, average age: 57.7±13.9 years, 82% female, mean CDAI 19.7±11.5, 59.9% rheumatoid factor positive) were analyzed. Lower temperatures correlated significantly with higher pain levels (estimate: -0.07, p=0.021) in GEE, however the effect size was very small. When we performed MM with temperature as independent variable and VAS pain or PGA as dependent variable, the majority of patients showed no sensitivity to temperature, however 22% of patients were significantly sensitive to cold temperature with an estimate of -0.29 (p<0.0001) for pain and -0.21 (p=0.0005) for PGA (Figure 1). When we evaluated whether patients who demonstrate temperature-sensitivity to pain also exhibit temperature-sensitivity to PGA, we found an excellent overlap between the two patient groups (kappa: 0.81).ConclusionsOur results indicate that a subgroup of patients with RA show significant sensitivity to cold temperature, and that these patients are characterized by higher pain and PGA levels at lower daily temperatures. These aspects may have to be taken into account in longitudinal analyses of disease activity of RA.Disclosure of InterestNone declared
Background Progression of joint damage as measured radiographically is a hallmark of rheumatoid arthritis (RA), and its reduction a key claim for traditional and novel antirheumatic drugs. Data from clinical trials may be interpreted to indicate that the observed progression of RA (in comparator groups of clinical trials) has decreased over the past two decades.1 Although these observations mainly stem from clinical trials, it has been hypothesized that RA may have become a less destructive disease. Objectives To evaluate the frequency as well as the level of radiographic progression in real life routine RA patients in the 21st century. Methods RA patients of our outpatient clinic, who had two x-rays performed over a three to five year interval between the years 2000 and 2012 were included. X-rays of the hands and feet were scored according to the Sharp van der Heijde (SvdH; range 0-448) method.2 Clinical and demographic data were collected from the patients’ charts. Disease activity was assessed using the clinical disease activity index (CDAI-average over time). Patients were separated into three periods of time (2000-2004, 2005-2008, 2009-2012) and the annual radiographic progression was calculated based on the observed progression in these periods. The mean number of joints with radiographic progression per patient, as well as the mean grade of progression per joint (erosion/joint space narrowing, JSN) were evaluated. Lack of progression was defined as no progression in total SvdH. Results Of the 444 patients included (mean duration of RA 7.4±9.4 years, 56.2% rheumatoid factor positive, 62.0% ACPA positive), 406 (91.4%) showed radiographic progression over a mean of 3.8±0.6 years. In all progressors we found no difference in rates of total radiographic progression, erosion score, or JSN, the three different time periods (Table 1). Conclusions Only a minority of patients did not progress structurally over three to five years. The temporal trend analysis indicates that on the background of similar average disease activity and mixed treatment, the overall annual progression was constant during the last decade. However, in general progression of joint damage was low. References Rahman MU et al. Ann Rheum Dis 2011; 70(9):1631-1640. van der Heijde D. J Rheumatol 1999; 26(3):743-745. Disclosure of Interest None Declared
Background Ultrasound (US) assessment was shown to be a sensitive tool for the evaluation of joint activity in patients with rheumatoid arthritis (RA). Synovial effusion and synovial hypertrophy can be evaluated by gray scale (GS), while hypervascularisation, as a marker of inflammation, can be measured using power Doppler signals (PD). Both types of signals are highly sensitive, and may persist even in clinical inactivity, i.e. when swelling or tenderness are absent. It is conceivable that such subclinical US signals may resolve if clinical inactivity is sustained, but this has not yet been shown during long-term follow-up. Objectives To investigate the persistence of subclinical US signals in previously clinically active joints in relation to prolonged clinical inactivity. Methods We performed US imaging including GS and PD, each graded on a four point scale (0=no, 1=mild, 2=moderate and 3=marked) of 22 joints of the hands of RA patients. We then selected all joints with no clinical activity at the time of the US examination. Based on a routine clinic database with 3-monthly joint assessments, the last time point of clinical joint activity (swelling, tenderness or both) was identified. The time between the last clinical joint activity and the current sonographic assessment in that joint was determined and persistence of subclinical US activity was estimated for all patients and all joints. Results We assessed a total of 1980 joints in 90 RA patients. 1329 (67.1%) joints were positive on GS and 410 (20.7%) showed PD signals. The median (IQR) time between the last visit exhibiting swollen or tender joint(s) and the US assessment showing PD/GS-signals in the same now clinically inactive joint(s) was 3.6 (1.2; 6.3) and 3.5 (1.3; 5.6) years, respectively. We found that the time between last clinical activity (swelling and/or tenderness) and positive sonographic assessment was significantly shorter in joints showing GS signals ≥2 than in joints with GS=1 (median [IQR] 2.6 [0.6; 2.6] vs. 3.9 [1.9; 6.6]; p<0.001), for PD signals there was also a trend towards shorter periods of clinical remission in highly active joints (median [IQR] of 2.4 [0.5; 5.3] for PD≥2 vs. 4.3 [1.0; 6.2] for PD=1; p=0.066). In joints showing highly positive GS and PD signals (both ≥2), the time to the last clinical activity was even shorter, with a median of 1.4 years. (Figure 1) Figure 1. Kaplan Meier curve for subclinical sonographic activity in joints showing GS ≥2 and PD signals. GS, grey scale; PD, power Doppler. Conclusions We conclude that subclinical joint activity is long lasting in RA joints in clinical remission, but resolves over time. The latter is indicated by a shorter period from last clinical activity for strong signals (PD ≥2, GS ≥2) as compared to weak signals (PD ≤1, GS ≤1). Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3247
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