BackgroundBulgaria is among the countries with the lowest vaccination rate of adult population in Europe. The presence of autoimmune rheumatic disease could further contribute to vaccine hesitancy and skepticism and influence patients’ attitudes towards vaccination [1, 2]. However, little is still known about the willingness and particular causes of hesitancy in patients with inflammatory joint diseases in the skeptical part of adult population across Europe.ObjectivesOur goal was to assess the rate of SARS-CoV-2 vaccination among patients with immune-mediated rheumatic joint diseases receiving biological and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) and to determine the modifiable predictors of vaccination hesitancy.MethodsPatients with rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis undergoing biological or targeted synthetic DMARDs therapy were consecutively selected and included in this single-center cross-sectional study. Excluding criteria in patients were psychiatric or neurological disease preventing understanding or responding to the questions, being illiterate, or not willing to participate in the study. Various demographic, anthropometric, and clinical data were collected. Disease activity was determined using DAS28-CRP for rheumatoid arthritis and peripheral psoriatic arthritis and ASDAS for ankylosing spondylitis and psoriatic spondylitis. All patients were given a questionnaire assessing their vaccination status, hesitancy, and attitude towards vaccination. Binary logistic regression analysis was used to analyze the relationship between self-reported modifiable parameters and vaccination status for SARS-CoV-2.ResultsTwo hundred and one participants were eligible for participating in the study with mean age and BMI of 54.6 years and 28.2, respectively. Of these, 40.3% were women; 30.3% had rheumatoid arthritis, 17.9% - psoriatic arthritis, and 51.7% - ankylosing spondylitis. 29.4 % of all participants had already survived a COVID-19 infection with a mean time of 8.4 months since the COVID-19 onset. Only slightly above 1/3 (35.8%) of the study group was fully vaccinated and the majority of them were vaccinated with BNT162b2 (68.1%). Among the modifiable factors, we identified preceding discussion with a rheumatologist, hesitancy due to autoimmune disease presence and (un)awareness of vaccine safety and efficacy as significant predictors of vaccination statusConclusionOur data suggest that there are still possibilities to influence rheumatic patients on their decision to vaccinate against SARS-CoV-2 in Bulgaria. Raising the awareness of the safety and efficacy of the SARS-CoV-2 vaccines and spending more time on the education of patients with rheumatic diseases may positively affect their attitude towards vaccination.References[1]Gaur P, Agrawat H, Shukla A. COVID-19 vaccine hesitancy in patients with systemic autoimmune rheumatic disease: an interview-based survey. Rheumatol Int. 2021;41(9):1601-1605[2]Georgiev T, Angelov AK. Complexities of diagnosis and management of COVID-19 in autoimmune diseases: Potential benefits and detriments of immunosuppression. World J Clin Cases. 2020 Sep 6;8(17):3669-3678Disclosure of InterestsNone declared
BackgroundRadiologic evidence of sacroiliitis is important for the diagnosis, classification, and management of patients with ankylosing spondylitis (AS)[1]. Conventional radiography (CR) has been the most widely utilized imaging modality for the assessment of sacroiliac involvement in axial spondyloarthritis (AxSpA) because of the low radiation dose, ease of operation, and low expenses. CR is used in both the 1984 modified New York criteria and ASAS criteria for classifying AS and AxSpA but lacks sensitivity for early changes. Though MRI detects early changes of the sacroiliac joints, as well as chronic structural changes, its use is limited by the associated cost, procedural time and certain contraindications. Computed tomography (CT) is a modality that enables visualization of erosions, sclerosis, and new bone formation, with the added benefit of multiplanar cross-sectional imaging.ObjectivesWe aimed to analyze the diagnostic value of computer tomography (CT) features of sacroiliitis for ankylosing spondylitis in patients with inconclusive CR evidence for sacroiliitis.MethodsIn this retrospective monocentric observational study, 50 patients with chronic low back pain (LPB) with a duration longer than three months in the lumbosacral region were included. Using the patient record data were extracted on age, pain duration, and plain radiography. Eligible patients should have had plain radiography without evident radiographic sacroiliitis. All the patients had undergone a CT scan of the sacroiliac joint that a radiologist and rheumatologist evaluated for subchondral osteosclerosis, erosions, joint space narrowing (JSN), subchondral cysts, and ankylosis. Based on the clinical and instrumental findings, including structural changes characteristic of radiographic sacroiliitis, a final decision by a certified rheumatologist was made and a diagnosis of ankylosing spondylitis was set or ruled out.ResultsThe mean age and duration of LBP of the patients were 44.7 (14.7) years and 63.9 months, respectively. Of the 50 included patients, 28 (56%) were females. The mean values of c-reactive protein and erythrocyte sedimentation rate were 13.9 mg/l and 39.4 mm/h. Subchondral osteosclerosis was found in 44 patients (88%), JSN – in 21 patients (42%), erosions – in 17 patients (34%), subchondral cysts – in 10 patients (20%), ankylosis – in 18 patients (36%). Definite CT data for sacroiliitis was seen in 24 patients (48%) and the diagnosis of ankylosing spondylitis was set in 23 patients (46%) of the study group. The likelihood ratios (LR+) for diagnosis of AS were high for erosions (18.4), subchondral cysts (11), ankylosis (6.9) and low for JSN (LR+ 1.9) and ankylosis (LR+ 1.1).ConclusionNearly half of the patients with inconclusive CR evidence for sacroiliitis were diagnosed with AS after CT imaging. Erosions seen on CT increase the likelihood of assuming AS diagnosis. Computed tomography is a useful tool in diagnosing AS, but it is associated with higher ionizing radiation doses.Reference[1]Mandl P, Navarro-Compán V, Terslev L, Aegerter P, van der Heijde D, D’Agostino MA, Baraliakos X, Pedersen SJ, Jurik AG, Naredo E, Schueller-Weidekamm C, Weber U, Wick MC, Bakker PA, Filippucci E, Conaghan PG, Rudwaleit M, Schett G, Sieper J, Tarp S, Marzo-Ortega H, Østergaard M; European League Against Rheumatism (EULAR). EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice. Ann Rheum Dis. 2015 Jul;74(7):1327-39. doi: 10.1136/annrheumdis-2014-206971. Epub 2015 Apr 2. PMID: 25837448.Acknowledgements:NIL.Disclosure of InterestsNone Declared.
BackgroundThe absence of categorical radiographic evidence of structural changes in the sacroiliac joints serves to distinguish AS from nr-axSpA. Both groups of patients are characterized by active inflammatory changes, established by magnetic resonance tomography (MRI) of the sacroiliac joints, which, with the progression of the disease, are structurally progressive.ObjectivesTo determine whether it is possible to detect erosions, subchondral osteosclerosis and bone marrow metaplasia on a magnetic resonance imaging of the sacroiliac joints in patients with non-radiographic axial spondyloarthritis and symptom duration less than 3 years.MethodsA cross-sectional survey was conducted with rheumatologists and their consulting patients in Bulgaria from February 2012 through April 2019. Patients who had a rheumatologist confirmed diagnosis of nr-axSpA were eligible to participate. All patients met ASAS criteria for IBP with duration from 3 months to 2 years. All patients had no changes reported after the conventional X-ray of the sacroiliac joints and a performed subsequent MRI. Sacroiliac joint inflammation was assessed using the Canadian Spondyloarthritis Research Consortium (SPARCC). The SPARCC scores of sacroiliac joint inflammation and sacroiliac joint structural damage (SSSD) (erosions, bony brain metaplasia and subchondral osteosclerosis) were evaluated by both - a radiologist and rheumatologist.ResultsA total of 98 patients with non-radiographic were included in this analysis. A higher proportion of patients were male patients (51% vs 37%). The mean age was 33.8±7.71 with mean symptoms duration 0.76±0.26 years. MRI showed bone marrow edema (BME) in all 98 patients and at least 1 structural lesion in 32 patients (92.5%). The most prevalent chronic lesions were erosive changes in 7.14% (n = 7) and narrowed joint space in 7.14% (n = 7). Fat metaplasia was found in 5.10% (n = 5) in the patients with nonradiographic spondyloarthritis. The mean values of SPARCC score in patients with the different arm of nr-ax SpA is 22.42 ± 15.18. The burden of disease activity measured by BASDAI, ASDAS-CRP and VAS as well as ASQoL did not differ in patients with SSSD compared with those with BME only (p>0.05)ConclusionPatients with nr-ax SpA are characterized by a short duration of symptoms. Regardless of this recent onset and initially normal X-ray image of the sacroiliac joints, in some patients there are objective data of previous inflammation of the sacroiliac joints that may had not be detected on X-ray. That arise the question of low sensitivity of conventional radiography as well as the presence of risk factors for rapid structural damage and progression in some patients with nr-ax SpA.References[1]Baraliakos X, Hermann K, Landewe R, et al. Assessment of acute spinal inflammation in patients with ankylosing spondylitis by magnetic resonance imaging: a comparison between contrast enhanced T1 and short tau inversion recovery (STIR) sequences. Ann Rheum Dis 2005; 64: 1141.[2]Du MS, Xiong XQ, Liu H, Qin X, Hu XF, Chen W. The evaluation of bone marrow edema in sacroiliac joint in patients with ankylosing spondylitis using magnetic resonance imaging Dixon sequence. BMC Musculoskelet Disord. 2021 Nov 1;22(1):919.[3]Carita Tsoi, James Francis Griffith, Ryan Ka Lok Lee, Priscilla Ching Han Wong, Lai Shan Tam, Quant Imaging Med Surg. 2019 Feb; 9(2): 318–335.[4]Braun J, Sieper J, Bollow M. Imaging of Sacroiliitis. Clin Rheumatol, 2000; 19, 51–57.Acknowledgements:NIL.Disclosure of InterestsNone Declared.
BackgroundVaccines are one of the most efficient tools to prevent infectious diseases at a population level. Their importance is even greater in immunocompromised patients providing efficient and safe protection against common viral and bacterial infections. According to the current EULAR recommendations based on solid evidence over the recent years, non-live vaccines such as influenza, pneumococcal, tetanus toxoid, and others are safe and can be administered to patients with inflammatory rheumatic diseases during the glucocorticoid and/or disease-modifying antirheumatic drug (DMARD) therapy. Furthermore, influenza and pneumococcal vaccines “should be strongly considered” and the tetanus toxoid vaccination should be received in accordance with the recommendations of the general population¹.ObjectivesWe aimed to investigate the coverage for influenza, pneumococcal, and tetanus toxoid vaccination in a cohort of patients with inflammatory rheumatic diseases on biological or targeted synthetic DMARDs.MethodsTwo hundred and one patients, aged 18 or older, were included in this single-center cross-sectional study after signing an informed consent form. They suffered from rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS) and were on biological or targeted synthetic DMARDs. Individuals with psychiatric or neurological diseases preventing understanding or responding to the questions were excluded from the study. Patients’ anthropometric, clinical, and demographic characteristics were collected via detailed anamnesis and clinical examination. Disease activity was evaluated using DAS28-CRP for patients with RA and peripheral PsA and ASDAS for those with axial disease (AS and axial PsA). All patients were asked to fill in a survey determining their immunization status for influenza, pneumococcal, and tetanus toxoid vaccines and whether they had a preceeding discussion with their rheumatologist about recommended vaccines during their routine medical visits.ResultsOf the 201 included patients, 40.3% (n=81) were females. Patient distribution according to their disease was as follows: 30.3% (n=61) RA patients, 51.7% (n=104) AS patients, and 17.9% PsA patients (n=36). Mean age, disease duration, and body mass index values were 54.62 (14.4) years, 11.04 (8.6) years and 28.2 (5.3), respectively. 27.4% of patients were on concomitant glucocorticoid treatment. Only 13.9% (n=28) and 1.5% (n=3) were vaccinated against seasonal influenza and pneumococcal infections, respectively. Patients who had а preceeding discussion about seasonal influenza and pneumococcal immunization with their rheumatologist had approximately 13 and 32 times higher probability to get vaccinated than people who did not (OR=12.9, p < 0.001 and OR 32.5, p = 0.01, respectively). Regular reimmunizations against diphtheria and tetanus according to the Immunization Calendar of the Republic of Bulgaria were carried out by only 44.8% (n=90) of the studied population.ConclusionCoverage of recommended vaccines in our group of Bulgarian patients on biological or targeted synthetic DMARDs is very low. Discussion about the potential benefits and safety profile of the recommended vaccines may increase patients’ willingness to vaccinate and prevent common infectious diseases in immunocompromised rheumatic patients.Reference[1]Furer V, Rondaan C, Heijstek MW, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases.Ann Rheum Dis. 2020;79(1):39-52. doi:10.1136/annrheumdis-2019-215882Acknowledgements:NIL.Disclosure of InterestsNone Declared.
Objectives: Aim of the study was to assess the therapeutic efficacy and safety of upadacitinib in Rheumatoid arthritis patients with moderate to high disease activity in real-world clinical practice and to identify predictors of therapeutic success. Materials and methods: A retrospective single-center study was performed in RA patients treated with upadacitinib 15 mg daily. Demographic and clinical indicators were analyzed. The effectiveness and safety of the medication were evaluated over a six-month period. Disease activity was assessed with index-based scores. The primary endpoint was defined as low disease activity over a six-month treatment period with upadacitinib 15 mg/day (DAS28CRP ≤ 3.2, CDAI ≤ 10 and SDAI ≤ 11). Results: 41 patients were included, mean age 56.56 years (± 13.4), with long-standing RA (8 years ± 5.8), mostly female (80.5%). 19.5% of them were obese (BMI ≥ 30 kg/m2), 80.5% had osteoarthritis and 58.5% - hypertensive disease. Erosive arthritis was observed in 41.5% of patients and 61% had functional class III motor deficit. "Bio-naïve" were 58.5%, the rest had previous experience with biologic therapy. Upadacitinib was used as monotherapy in 90% of patients and in combination with Methotrexate in 10%. There was a significant reduction in the painful and swollen joint counts, VAS and CRP six months after starting treatment with upadacitinib. Low disease activity was achieved by a significant proportion of patients (DAS28CRP-70.7%, CDAI-60.5% and SDAI 63.2%). Therapeutic outcome was not determined by demographics, clinical factors, comorbidities, or prior biologic treatment. Increase in liver enzymes (n=3), decrease in hemoglobin levels (n=2), and urinary tract infection (n=2) were the adverse events recorded over the six-month treatment period. One patient died from COVID-19. Conclusion: A significant proportion of RA patients on treatment with upadacitinib 15 mg was able to achieve the therapeutic target in real clinical settings. No predictors of therapeutic efficacy were found. The registered side effects do not differ from the safety profile of the medication.
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