In contrast to earlier reports, we found that Enterococcus has emerged as the most frequently isolated microorganism from bile. The importance of enterococcal infection should be recognized, and currently recommended antibiotics need to be re-evaluated since in our bile cultures most provided inadequate coverage for the more frequently encountered microorganisms. The changes in the trends of microorganisms isolated from bile should be considered in cases where patients present with biliary obstruction.

Background:Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are major causes of death in systemic sclerosis (SSc). Six-minute-walk test (6MWT) is a standard outcome measure for exercise capacity in cardiopulmonary diseases. However, the results of 6MWT may not reflect real cardiopulmonary function of SSc patients in whom musculoskeletal system is frequently inflicted.Objectives:This study aimed to evaluate the clinical utility of breath-holding test (BHT) in evaluating cardiopulmonary function in SSc patients, as compared with 6MWT.Methods:Seventy-two patients with SSc were prospectively enrolled and underwent BHT and 6MWT with measurement of Borg score and Scleroderma Health Assessment Questionnaire (SHAQ). Data on diffusing capacity for carbon monoxide (DLCO, %), forced vital capacity (FVC, % and liters), and ejection fraction and pulmonary arterial systolic pressure (PASP) measured by transthoracic echocardiography (TTE), were also collected. For BHT, participants were required to make a maximum expiration followed by a maximum inspiration and to hold the breath as long as possible at maximum inspiratory level. This procedure was repeated three times, with 5-minute intervals. 6MWT was performed according to the American Thoracic Society guidelines. Pearson’s correlation test was applied to demonstrate the relationship between BHT results and each clinical parameter.Results:Among 72 (66 female) patients, mean (SD) age was 57.1 (11.1) years, modified Rodnan skin score 10.6 (10.5), SHAQ 0.64 (0.61) and 6MWT distance 473.5 (95.5) m. Mean BHT time was 35.05 (14.90) sec at the first time, 38.92 (16.14) sec at the second time, and 41.11 (17.71) sec at the third time. The BHT time showed a statistically significant negative correlation with Borg scale (pre-test, r = -0.336, p = 0.002; post-test, r = -0.252, p = 0.034; Figure 1 and Table 1), while 6MWT showed a negative correlation with only post-test Borg scale (pre-test, r = -0.113 p = 0.343; post-test, r = -0.351 p = 0.002; Table 1). The BHT time was positively correlated with DLCO (%, r = 0.409, p < 0.001) and FVC (liters, r = 0.402, p < 0.001) (Table 1). We also found a statistically significant correlation between BHT time and SHAQ score (r = -0.451, p < 0.001; Table 1). However, EF and PASP by TTE showed no significant relationship with BHT time (EF, r = -0.108, p = 0.374; PASP, r = -0.246, p = 0.054; Table 1).Table 1.Pearson’s correlation coefficients (r) for the relation between BHT and clinical parameters in comparison to 6MWT.Pre-test Borg scalePost-test Borg scaleDLCO(%)FVC(L)FVC(%)FVC/DLCOEF(%)PSAP(mm Hg)SHAQ (score)BHT (sec)-0.366**-0.252*0.409***0.402**0.191-0.244***-0.108-0.246-0.451***6MWT (m)-0.113-0.351**0.297*0.321**0.063-0.250*0.137-0.354**-0.531***BHT, breath-holding test; 6MWT, 6-minute-walk test; DLCO, diffusing capacity for carbon monoxide; FVC, forced vital capacity; EF, ejection fraction estimated by transthoracic echocardiography; SHAQ, Scleroderma Health Assessment Questionnaire.* p < 0.05, ** p < 0.01, *** p < 0.001Figure 1.Association of Borg dyspnea scale with breath-holding time.Conclusion:The BHT is a simple, safe, and less time-consuming test, reflective of pulmonary parameters and SHAQ, as compared with 6MWT. Our results suggest that the BHT might be a useful surrogate marker of cardiopulmonary capacity in SSc patients.References:[1]Villalba WO, Sampaio-Barros PD, Pereira MC, Cerqueira EM, Leme CA, Jr., Marques-Neto JF, et al. Six-minute walk test for the evaluation of pulmonary disease severity in scleroderma patients. Chest. 2007;131(1):217-22.[2]Garin MC, Highland KB, Silver RM, Strange C. Limitations to the 6-minute walk test in interstitial lung disease and pulmonary hypertension in scleroderma. J Rheumatol. 2009;36(2):330-6.[3]Barnai M, Laki I, Gyurkovits K, Angyan L, Horvath G. Relationship between breath-hold time and physical performance in patients with cystic fibrosis. Eur J Appl Physiol. 2005;95(2-3):172-8.Acknowledgements:This study would not have been possible without help from research assistant, Sung-Soon Cho.Disclosure of Interests:Jina Yeo: None declared, Mi Hyeon Kim: None declared, Jun Won Park: None declared, Jin Kyun Park: None declared, Eun Bong Lee Consultant of: Pfizer, Grant/research support from: GC Pharma and Handok Inc.

BackgroundHigh transmissibility and immune evasion of SARS-CoV-2 Omicron variant made it dominant variant worldwide since January 2022. Before Omicron era, several studies demonstrated that autoimmune inflammatory rheumatic disease (AIIRD) patients were vulnerable to COVID-19 infection compared to general population. However, there is a lack of epidemiologic data regarding COVID-19 outbreak in patients with AIIRD in Omicron era.ObjectivesTo identify incidence rate, hospitalization rate and potential risk factors for COVID-19 outcomes in AIIRD patients during Omicron outbreak.MethodsThis study was a prospective longitudinal study from January 1 to October 31, 2022. We included patients who visited rheumatology outpatient clinic in a nationwide, tertiary referral center in South Korea. Included patients were classified into two groups (AIIRD and non-AIIRD groups) based on underlying disease. Vaccination and infection history of COVID-19 were obtained through self-report via questionnaire and data from Korea Disease Control and Prevention Agency (KDCA). Main outcome of this study was an incidence of COVID-19 infection during the observation period. Clinical factors associated with the incidence of COVID-19 infection were investigated using Cox proportional hazard model. In the final multivariable model, clinical factors that showed a relevant association (P < 0.1) with the outcome in the univariable analysis were included as covariates.ResultsA total of 1,814 patients were analyzed (AIIRD group: 1,535, non-AIIRD group: 279). The COVID-19 incidence in AIIRD group (47.6%) was higher than that reported in general population of South Korea (43.9%) and this trend was prominent in those aged < 70 years. Longitudinal change in COVID-19 incidence during the observation period showed two peaks in March and August in both groups, which was the same trend with general population. There were 30 cases of hospitalization due to COVID-19 infection, with the rate was comparable between AIIRD and non-AIIRD groups (1.7% vs. 1.5%, P = 0.970). The incidence rate of COVID-19 in the AIIRD group was comparable to that in the non-AIIRD group (47.6% vs. 44.8%, P = 0.386). In the AIIRD group, COVID-19 infection occurred less frequently in patients with old age (≥70 years) and those receiving glucocorticoid treatment. Other clinical factors such as use of DMARDs and biologics, and underlying diseases were not associated with COVID-19 incidence in the multivariable analysis. Of note, at least one COVID-19 vaccination did not lower its incidence (unadjusted HR 1.06 [95% CI 0.82-1.38]). Although patients who received booster vaccination were less likely to be infected with COVID-19 (unadjusted HR 0.79 [0.68-0.92]), this protective effect was significant only in patient younger than 70 years (Figure 1).ConclusionDuring the Omicron outbreak in South Korea, incidence of COVID-19 infection in patients with AIIRD and non-AIIRD was comparable. Immunomodulatory agents and specific rheumatic diseases did not increase the COVID-19 incidence, and booster vaccination against COVID-19 decreased the infection only in patients younger than 70 years.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Objectives: To determine accuracy of ultrasound (US) in classifying placental cord insertion (PCI) site in multiple gestations at a tertiary care center. Methods: A retrospective study of multiple gestations delivered from 2/2003 to 7/2009 was performed. Data included gestational age (GA) at PCI identification, use of in-vitro fertilization (IVF), and PCI characterization by both US and pathology. The distance from PCI to placental edge was measured. To correlate US with pathology data, PCI was classified as central/eccentric, marginal (≤ 1 cm from placental edge), or velamentous (into membranes). Statistical analysis was performed with Chi-square comparison amongst categorical variables. US images were reviewed in discordant cases to determine causality. Results: Twins and triplets were analyzed. 638 fetuses (302 pregnancies) met criteria. Mean GA at PCI evaluation was 20.9 wks, median 19.0. Using pathology results as gold standard, US correctly identified PCI as central/eccentric, marginal, or velamentous in 69.3% (P < 0.01). US was more accurate for diamniotic-dichorionic twins (73.8% of 382) than diamniotic-monochorionic (59.4% of 155, P = 0.002). US correctly classified 97.5% of central/eccentric, 8.5% of marginal, and 6.1% of velamentous PCIs (438, 118, and 82 cases). Conversely, pathology confirmed US diagnosis of central/eccentric in 71.4%, marginal in 32.3%, and velamentous in 11.1% (of 598, 31, and 9). Comparing normal (central/eccentric) to abnormal (marginal/velamentous), US was less accurate in identifying abnormal (7.5% of 200) than normal (97.5% of 438) PCIs (P < 0.01); no difference was seen for twins (71.9% of 549) vs. triplets (73.5% of 89, P > 0.05). No difference was found in occurrence of velamentous PCI in IVF vs. non-IVF cases (12.5% for both). Conclusions: US classification of PCI was often inconsistent with pathological results in multiple gestations. Discrepant cases were evaluated and suggest evolution/peripheral infarction of the placenta with apparent evolution of the PCI in many instances.

Objectives:To assess the efficacy of prenasal thickness measurements on second trimester ultrasound examination in prenatal prediction of Down syndrome fetuses. Methods: Prenasal thickness was measured from stored fetal profile images during 16-24 week second trimester scans. Images from 115 women with normal fetuses and 15 women with Down syndrome were included. Prenasal thickness was measured as the shortest distance from the anterior edge of the lowest part of the frontal bone to the skin. Delta values for each gestational week for prenasal thickness were calculated for statistical analysis. Results: In the normal group prenasal thickness increased with gestation (prenasal thickness = −28.747 + (2.254 × GA, R2, P < 0.01). There was a statistically significant increase in the mean prenasal thickness measurement in Down syndrome fetuses. The prenasal thickness measurement was above the 95 th centile in 66.7% (10/15) of all Down syndrome cases, including 4 of 5 with an absent nasal bone and 6 of 10 with a nasal bone length above 2.5 mm. Conclusions: Prenasal thickness is increased in fetuses with Down syndrome as compared to normal fetuses. Prenasal thickness may be an additional predictor for Down syndrome on the second trimester ultrasound. Objectives: To determine if sonographic dimensions of the facial profile on a population of fetuses with absent nasal bone, differs from the normal population. Methods: 16 fetuses with absent nasal bone and with an adequate volume dataset of the fetal profile where included in the study. After a multi-planar manipulation to obtain a mid sagittal plane of the profile, 3 different operator measured the distance between the tip of the nose and the mouth (A), between the mouth and the gnathion (B), between the upper philtrum and the mouth (a) and between the mouth and the upper concavity of the chin (b), as recently reported by Goldstein et al, 2010. The values were plotted between the reported confidence limits, analyzing its percentage of distribution when it was corresponding or not to trisomy 21 (T21). Prenasal thickness was also measured. Wilcoxon non parametric test was used to determine differences between groups of measurement. Results: 2 cases were excluded (gestational age more than 26+6 weeks). The mean gestational age of the remaining was 21+3 (range, 18+2-26+5). 10/14 (71.5%) were carriers of T21 and the remaining were fetuses with normal karyotype. The A, B and (a) measurements were registered between the reported intervals of confidence, without statistical differences between both groups of fetuses with/without nasal bone. 60% of the fetuses with T21 had (b) measurement below the interval of confidence. The same measurement, on normal karyotype/absent nasal bone fetuses, were in the normal interval. Concordance between the three operators was found for the measurements, particularly (b). Mean prenatal thickness was 6.26 (T21) and 3.9 mm (non T21). OP09.06 Conclusions:Although the sample is small and ideally must be compared with our own population of healthy fet...

BackgroundPrevious studies have suggested that primary prophylaxis against pneumocystis pneumonia (PCP) using trimethoprim-sulfamethoxazole (TMP-SMX) is beneficial in patients with rheumatologic diseases receiving immunosuppressive drugs[1]. However, there is little evidence for an optimal prophylaxis duration or a time point of prophylaxis withdrawal.ObjectivesThis study aims to investigate the risk factors that are associated with PCP occurrence despite its primary prophylaxis, and, ultimately, to provide evidence regarding the ideal schedule for primary PCP prophylaxis.MethodsThis case-control study included treatment episodes of patients with rheumatic diseases who received prophylactic TMP-SMX with immunosuppressive treatment between 2010 and 2022 in a tertiary referral center in South Korea. The index date was defined as the date of starting the prophylactic dose of TMP-SMX. We captured PCP cases that occurred within 1 year from the index date based on the review of the medical record by two independent expert investigators. The effect of clinical factors, such as demographics, underlying disease, immunosuppressive treatment, and pattern of prophylaxis on the PCP occurrence was examined using binary logistic regression.ResultsA total of 1,379 treatment episodes were analyzed, and eleven cases of PCP occurred during the observation—a one-year PCP incidence of 0.80 (95% CI=0.40-1.43) per 100 person-years. In 10 cases (90.9%), PCP occurred after discontinuation of TMP-SMX prophylaxis, with a mean (SD) interval of 185.6 (90.9) days. The mean (SD) duration of prophylaxis in the PCP group was 108.5 (132.3) days. The main reasons for prophylaxis withdrawal in the PCP group were adverse events (5 cases) and treating physicians’ decisions (5 cases). The dose of glucocorticoid at the time of prophylaxis cessation was the most critical risk factor for PCP. Patients who were receiving glucocorticoid more than 15 mg/day of prednisone equivalent at the time of TMP-SMX discontinuation showed a significantly higher odds of developing PCP (OR=15.06; 95% CI=1.92-117.94). The prophylaxis duration and presence of structural lung disease were not associated with PCP. This result was consistent in the multivariable analysis adjusted for age, underlying disease, rituximab treatment, azotemia, and lymphopenia (adjusted OR=12.21; 95% CI=1.52-98.24) (Table 1).ConclusionDiscontinuation of TMP-SMX during glucocorticoid treatment greater than 15 mg of prednisone equivalent significantly increases the risk of PCP, which suggests that a time when glucocorticoids are tapered to less than 15mg/day of prednisone dosage equivalent may be a reasonable time to consider withdrawing PCP prophylaxis.Reference[1]Park JW, Curtis JR, Moon J, Song YW, Kim S, Lee EB. Prophylactic effect of trimethoprim-sulfamethoxazole for pneumocystis pneumonia in patients with rheumatic diseases exposed to prolonged high-dose glucocorticoids. Ann Rheum Dis. 2018;77(5):644-9.Table 1.Factors associated with PCP despite primary prophylaxisUnivariableMultivariableOR (95% CI)POR (95% CI)PAge1.06 (1.01-1.11)0.021.05 (0.10-1.10)0.08Sex, female0.71 (0.22-2.35)0.58SLE0.34 (0.04-2.64)0.30AAV4.19 (1.27-13.84)0.020.50 (0.08-3.07)0.46Other vasculitis0.65 (0.14-3.02)0.58Inflammatory myopathies0.55 (0.07-4.33)0.57Rheumatoid arthritis3.01 (0.38-24.03)0.30Others3.81 (0.47-30.57)0.21Rituximab6.03 (1.82-19.99)<0.014.06 (0.87-18.99)0.08Cyclophosphamide1.55 (0.41-5.87)0.52Mycophenolate mofetil0.99 (0.13-7.76)0.99Azathioprine1.00 (0.13-7.90)1.00Prophylaxis duration0.10 (0.99-1.00)0.16Last Gc dose ≤ 15 mg15.06 (1.92-117.94)0.0112.21 (1.52-98.24)0.02Azotemia9.88 (2.13-45.94)0.007.04 (1.31-37.71)0.02Lymphopenia5.18 (1.51-17.81)0.013.13 (0.86-11.39)0.08Structural lung disease2.34 (0.71-7.70)0.16* Adjusted for clinical factors with relevant association (P < 0.1) in univariable analysisAAV, ANCA associated vasculitis; Gc, glucocorticoid; SLE, systemic lupus erythematosusAcknowledgements:NIL.Disclosure of InterestsNone Declared.

BackgroundTumor necrosis factor inhibitors (TNFi) have become a mainstay of management for axial spondyloarthritis (axSpA). However, it remains unclear whether patients with axSpA should continue the standard-dose TNFi after achieving stable disease activity. Although complete discontinuation of TNFi is followed by early relapse in most cases, several studies documented that reduced doses of TNFi in patients with prolonged low disease activity showed similar effects on disease control and drug survival compared to standard dose of TNFi. One of the main problem in the dose-tapering strategies for TNFi is a selection of the appropriate patient. However, there has been a lack of robust evidence regarding clinical factors predicting the flare after tapering of TNFi in patients with axSpA.ObjectivesThis study aims to develop and validate the prediction model to select the patients in whom tapering of TNFi does not lead to flare.MethodsWe used the data from Korean College of Rheumatology Biologics registry, which included a total of 1,730 patients receiving biologic DMARD from 2017 to 2019 in South Korea. In this study, a total of 526 patients who were initially treated with the standard-dose TNFi and tapered the dose after at least 1 year of the treatment were analyzed. Dose quotient (DQ, 0-1) was applied to quantified TNFi used during interval. The main outcome was an occurrence of flare defined as ASDAS-CRP score of ≥2.1 after 1 year of tapering TNFi. To develop the prediction model, clinical factors having relevant association (p < 0.1) with the outcome were first selected as candidate predictors. Logistic regression using a stepwise approach through backward elimination was used for the final model.ResultsPatients’ mean (SD) age was 37.5 (11.9) years, 418 (79.5%) were men, and 474 (90.1%) were HLA-B27 positive. Mean disease duration was 5.0 (6.1) years and 433 (82.3%) were TNF naïve. The mean BASFI and ASDAS-CRP at baseline were 3.4 (2.6) and 3.7 (1.0), respectively. Approximately two-thirds of the patients (65.8%) were initiated TNFi tapering at the first 1 or 2 years from baseline. At the time of TNFi tapering, the mean DQ was 0.67 (0.15) and 381 (72.4%) were prescribed concurrently with NSAIDs, and the mean BASFI and ASDAS-CRP were 1.3 (1.8) and 1.6 (0.9), respectively. During 12 months of follow up starting from the TNFi tapering, 127 (24.1%) experienced the flare. The multivariable analysis revealed that HLA-B27 positivity (OR 0.337; 95% CI 0.161-0.705; p=0.004), inflammatory back pain (OR 2.920; 95% CI 1.283-6.648; p=0.011), ASDAS-CRP at tapering (OR 2.798; 95% CI 2.030-3.856; p<0.001), and BASFI at tapering (OR 1.214; 95% CI 1.051-1.402; p=0.008) were significantly associated with flare. Based on the results of the logistic regression analysis, the predicted probability was calculated by the following formula: P=1/[1+ exp{-(1.088 x HLA-B27 negativity + 1.072 x inflammatory back pain + 1.567 x psoriasis + 0.623 x family history of axSpA + 1.092 x diabetes mellitus + 0.435 x DQ at TNFi tapering + 1.029 x ASDAS-CRP at TNFi tapering + 0.194 x BASFI at TNFi tapering)}]. The best cut-off value of the model to define the flare was 0.2416 (95% CI 0.176, 0.301) with sensitivity 74.0% and with specificity 81.0%. AUC was 0.828 (95% CI 0.786-0.869) indicating a good predication (Figure 1). The internal validation with bootstrapping showed minimal overfitting (estimated AUC 0.794) and good calibration between observed and predicted values (calibration slope 1.110, 95% CI 0.903, 1.317; intercept 0.026, 95% CI -0.091, 0.039).Figure 1.Apparent performance of developed model for prediction of flare after 12 months of tumor necrosis factor inhibitors tapering.ConclusionWe developed the prediction model for the flare after 12 months of TNFi tapering in patients with axSpA. It might be applicable in real world setting, although external validation will be required in the future investigation.References[1]Zavada J, et al. Ann Rheum Dis. 2016;75(1):96-102.AcknowledgementsWe greatly thank to the the Clinical Research Committee of the Korean College of Rheumatology and all participating hospitals.Disclosure of InterestsNone declared