Showing papers by "Elena Nikiphorou published in 2017"

Secular changes in clinical features at presentation of rheumatoid arthritis: Increase in comorbidity but improved inflammatory states

Abstract: Objective: To examine secular trends in demographic, clinical manifestations and comorbidity on first presentation of RA prior to DMARD treatment. Methods: 2701 patients were recruited over 25years to two UK-based RA inception cohorts: the Early RA Study (9 centres; 1986-2001) and the Early RA Network (23 centres; 2002-2012). Trends in demographic and baseline clinical/laboratory and radiographic variables and comorbidities were estimated using mixed effects models, including random effects for recruitment centre. Results: Age-at-onset increased from 53.2 to 57.7 years in 1990 and 2010 respectively (2.6 months/year; 95% CI 1.2-4.1). Gender-ratio, the proportion living in deprived areas and smoking status were unchanged (p>0.05) and there were no changes in the proportion seropositive or erosive at baseline (p>0.05). After controlling for treatment at the time of assessment, ESR reduced and haemoglobin increased over time (p 0.05). The overall prevalence of comorbidity increased from 29.0% in 1990 to 50.7% in 2010, mainly due to cardiovascular and non-cardiac vascular conditions including hypertension. There was a significant increase in BMI (0.15 units/year; 95% CI 0.11-0.18), resulting in an increase in the prevalence of obesity from 13.3% in 1990 to 33.6% in 2010. Conclusions: Age-at-onset and comorbidity burden, especially obesity have increased at RA presentation over 25 years, reflecting wider demographic trends at the population level. In contrast there were no accompanying changes in disease severity assessed by composite markers of disease activity, radiographic erosions, seropositivity or HAQ at presentation. Treatment strategies in early RA should take greater account of the impact of co-morbidity on outcomes. This article is protected by copyright. All rights reserved.

Biologics registers in RA: methodological aspects, current role and future applications

Abstract: The beginning of the 21st century saw a biopharmaceutical revolution in the treatment of inflammatory rheumatic diseases, particularly rheumatoid arthritis The fast-evolving use of biologic therapies highlighted the need to develop registers at national and international levels with the aim of collecting long-term data on patient outcomes Over the past 15 years, many biologics registers have contributed a wealth of data and provided robust and reliable evidence on the use, effectiveness and safety of these therapies The unavoidable challenges posed by the continuous introduction of new therapies, particularly with regard to understanding their long-term safety, highlights the importance of learning from experience with established biologic therapies In this Perspectives article, the role of biologics registers in bridging the evidence gap between efficacy in clinical trials and real-world effectiveness is discussed, with a focus on methodological aspects of registers, their unique features and challenges and their role going forward

Social Media Use Among Young Rheumatologists and Basic Scientists: results of an International Survey by the Emerging Eular Network (EMEUNET)

Abstract: Objectives To explore perceptions, barriers and patterns of social media (SM) use among rheumatology fellows and basic scientists. Methods An online survey was disseminated via Twitter, Facebook and by email to members of the Emerging European League Against Rheumatism Network. Questions focused on general demographics, frequency and types of SM use, reasons and barriers to SM use. Results Of 233 respondents (47 countries), 72% were aged 30–39 years, 66% female. 83% were active users of at least one SM platform and 71% were using SM professionally. The majority used SM for communicating with friends/colleagues (79%), news updates (76%), entertainment (69%), clinical (50%) and research (48%) updates. Facebook was the dominant platform used (91%). SM was reported to be used for information (81%); for expanding professional networks (76%); new resources (59%); learning new skills (47%) and establishing a professional online presence (46%). 30% of non-SM users justified not using SM due to lack of knowledge. Conclusions There was a substantial use of SM by rheumatologists and basic scientists for social and professional reasons. The survey highlights a need for providing learning resources and increasing awareness of the use of SM. This could enhance communication, participation and collaborative work, enabling its more widespread use in a professional manner.

Reductions in Radiographic Progression in Early Rheumatoid Arthritis Over Twenty-Five Years: Changing Contribution From Rheumatoid Factor in Two Multicenter UK Inception Cohorts.

Abstract: This is the peer reviewed version of the following article: Lewis Carpenter, et al, ‘Reductions in Radiographic Progression in Early Rheumatoid Arthritis Over Twenty-Five Years: Changing Contribution From Rheumatoid Factor in Two Multicenter UK Inception Cohorts’, Arthritis Care & Research, Vol. 69 (12): 1809-1817, December 2017, which has been published in final form at https://doi.org/10.1002/acr.23217. Under embargo until 6 Nov 2018 This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving.

Patient-physician collaboration in rheumatology: A necessity

Abstract: Over the past few decades, there has been significant and impressive progress in the understanding and management of rheumatic diseases. One of the key reasons for succeeding in making this progress has been the increasingly stronger partnership between physicians and patients, setting a milestone in patient care. In this viewpoint, we discuss the recent evolution of the physician-patient relationship over time in Europe, reflecting on the 'journey' from behind the clinic walls through to clinical and research collaborations at national and international level and the birth of healthcare professional and 'rheumatic' patient organisations. The role of expert patients and patient advocates in clinical and scientific committees now represents a core part of the decision-making process. In more recent years and following the recognition that the young patients, physicians and academics have a voice and needs of their own, including the need to be educated and instructed, has encouraged the establishment of youth organisations, enabling change and innovation to take place at a uniquely different level.

'Twitterland': a brave new world?

Abstract: In an era of rapidly expanding digital technologies and social media (SM), considerable transformations in the delivery of healthcare are taking place. SM channels such as Facebook and Twitter represent a generation of online platforms that foster user-generated content, social interaction and real-time collaboration.1 In this letter, we review the advantages and disadvantages of engaging with Twitter within the rheumatology field. The ease of access to a wide range of SM platforms provides a dynamic medium for professional interaction. Twitter is gaining increasing attention by healthcare professionals as a platform for information sharing and professional networking, learning and communication. Twitter journal clubs (@RheumJC2 and @EULAR_JC3) are some examples of novel educational uses of Twitter. Despite the many positive applications of Twitter, potential hazards cannot be underestimated. The restricted character count of a tweet (140 characters) represents an important limitation, posing a …

Can Rheumatologists Predict Eventual Need for Orthopaedic Intervention in Patients with Rheumatoid Arthritis? Results of a Systematic Review and Analysis of Two UK Inception Cohorts

Abstract: The structural damage caused by rheumatoid arthritis (RA) can often be mitigated by orthopaedic surgery in late disease. This study evaluates the value of predictive factors for orthopaedic intervention. A systematic review of literature was undertaken to identify papers describing predictive factors for orthopaedic surgery in RA. Manuscripts were selected if they met inclusion criteria of cohort study design, diagnosis of RA, follow-up duration/disease duration ≥3 years, any orthopaedic surgical interventions recorded, and then summarised for predictive factors. A separate predictive analysis was performed on two consecutive UK Early RA cohorts, linked to national datasets. The literature search identified 15 reports examining predictive factors for orthopaedic intervention, 4 inception, 5 prospective and 6 retrospective. Despite considerable variation, acute phase, x-ray scores, women and genotyping were the most commonly reported prognostic markers. The current predictive analysis included 1602 procedures performed in 711 patients (25-year cumulative incidence 26%). Earlier recruitment year, erosions and lower haemoglobin predicted both intermediate and major surgery (P<0.05). Studies report variations in type of and predictive power of clinical and laboratory parameters for different surgical interventions suggesting specific contributions from different pathological and/or patient-level factors. Our current analysis suggests that attention to non-inflammatory factors in addition to suppression of inflammation is needed to minimise the burden of orthopaedic surgery.

Coexistence of SLE, tuberous sclerosis and aggressive natural killer-cell leukaemia: Coincidence or correlated?

Abstract: Sir, We read with great interest the article by Olde Bekkink et al. discussing common pathophysiological mechanisms between systemic lupus erythematosus (SLE) and tuberous sclerosis. We would like to take this opportunity to present the case of a 26 year-old lady with known tuberous sclerosis referred to rheumatology following positive serology with a high titre of anti-dsDNA antibodies. The diagnosis of tuberous sclerosis was given 2 years back, following the discovery of an intraventricular lesion consistent with a sub-ependymal giant cell astrocytoma, along with multiple small sub-ependymal nodules, and cortical or subcortical tubers, some of which contained calcification. There were also multiple renal angiolipomas on a MRI scan of the upper abdomen. Despite the genetic tests for the TSC1 or TSC2 tuberous sclerosis genes being negative, a clinical diagnosis was made. Subsequent immunological tests confirmed the presence of anti-ds DNA antibodies (100 IU/mL, when normal is<15 IU/mL), with negative antinuclear antibodies (ANA) and extractable nuclear antigen antibodies (ENA), based on both the fluoro-enzyme immunoassay (FEIA) and indirect immunofluorescence. Haematological and biochemical tests were within normal limits. There were no clinical manifestations of SLE during her 1 year of follow-up in rheumatology. A review of the literature revealed three cases of SLE in co-existence with tuberous sclerosis, which are further supported by the report by Olde Bekkink et al. They all give rise to the question of a possible common pathophysiological mechanism involving mammalian target of rapamycin (mTOR) in both diseases. The role of mTOR in lupus pathogenesis was analysed in detail in a recent review by Perl et al., where except from the critical role of mTOR activation in the development of abnormal T cells (a common finding in SLE), it seems that the measurement of this activation could be used as a possible biomarker for SLE. There is also increasing evidence that the inhibition of mTOR with sirolimus and everolimus leads to a good clinical outcome in lupus. As far as the tuberous sclerosis is concerned, it is thought that it starts by activation of the mTOR, due to mutations involving the TSC1 or TSC2 genes. Similar to lupus, mTOR inhibitors seem to have a role in the treatment of tuberous sclerosis. Although there remain unanswered questions regarding the pathogenetic correlation of both SLE and tuberous sclerosis, there is emerging evidence of the link between the two. Further research is necessary to shed more light into the common pathogenetic processes characterizing both diseases. Presentation of such cases is important for raising awareness and increasing insight into this exciting, albeit rare disease co-existence.

Intercentre variance in patient reported outcomes is lower than objective rheumatoid arthritis activity measures: a cross-sectional study.

Abstract: Objective To assess intercentre variability in the ACR core set measures, DAS28 based on three variables (DAS28v3) and Routine Assessment of Patient Index Data 3 in a multinational study Methods Seven thousand and twenty-three patients were recruited (84 centres; 30 countries) using a standard protocol in the Quantitative Standard Monitoring of Patients with RA study Analysis of variance (ANOVA) and mixed-effect analysis of covariance models were used to model the relationship between study centre and different patient-reported and physician-reported RA activity measures These models were built to adjust for the remaining ACR core set measure (for each ACR core set measure or each composite index), socio-demographics and medical characteristics ANOVA and analysis of covariance models yielded similar results, and ANOVA tables were used to present variance attributable to recruiting centre Results The proportion of variances attributable to recruiting centre was lower for patient reported outcomes (PROs: pain, HAQ, patient global) compared with objective measures (joint counts, ESR, physician global) in all models In the full model, variance in PROs attributable to recruiting centre ranged from 153% for patient global to 371% for HAQ compared with objective measures that ranged from 592% for physician global to 925% for ESR; and was lower for Routine Assessment of Patient Index Data 3 (26%) compared with DAS28v3 (1175%) Conclusion Intercentre variability in PROs is lower than objective measures of RA activity demonstrating that PROs may be more comparable across centres, and the need for standardization of objective measures

The spectrum of early rheumatoid arthritis practice across the globe: results from a multinational cross sectional survey.

Abstract: OBJECTIVES To explore patterns of real-world early RA (ERA) care across countries. METHODS An online survey was disseminated to practising rheumatologists across Europe and the US, also made accessible on social media between April and May 2015. Survey questions (n=38) assessed the structure and setting of ERA clinics, times to diagnosis and treatment, patient monitoring, guideline use and data recording. RESULTS A total of 212 rheumatologists from 39 countries (76% European) completed the survey. 62% had an ERA clinic based at a university hospital. Patient referral to rheumatology was mainly (78%) via primary care; 44% had an agreed ERA local referral pathway, 15% a national pathway. Only 16% had dedicated ERA clinics, the majority being practitioners in Northern Europe with access to a local or national referral pathway. Data for research were collected by 42%. Treatment guidelines were followed by the majority, especially rheumatologists practising in Europe. Variations existed in the use of initial DMARDs with treatment decisions reported to be influenced by international/national guidelines in 71%/61%. No significant relationship between country gross national income and the availability of ERA clinics was seen. CONCLUSIONS This study provides comparative benchmark information regarding the global provision of ERA care. Substantial variations exist in referral and early assessment pathways with guidelines having a most apparent impact in Northern Europe. Provision of an ERA service does not appear to be constrained by cost, with conceptual factors, e.g. clinician engagement, perhaps playing a role. These initial insights could potentially help harmonise ERA management across countries.

Person-focused care for young people with rheumatic and musculoskeletal diseases: young rheumatologists' and EULAR Young PARE perspectives

Abstract: In recent years, the evolution of healthcare challenged the management of people with rheumatic and musculoskeletal diseases (RMDs). From disease-centred care to person-focused care, a holistic approach along with patient empowerment about their disease, improved the physician-patient relationship and allowed to achieve better outcomes with lower healthcare costs. Nevertheless, RMDs may occur from childhood to the old age and to date very few studies have addressed the needs and priorities of young people with RMDs. However, the image of RMDs is still associated with the elderly population. In this regard, the group of young people with arthritis and rheumatism in Europe (PARE) was recently developed within European League Against Rheumatism to represent the voice of the young affected and to carry out projects aiming for a better understanding of these specific aspects. This viewpoint discusses the needs and priorities of young people compared with adult people with RMDs, based on the available literature and on the results of the PARE Youth research project, aiming to identify the next steps of actions that need to be taken to improve the current situation.

SAT0099 Polypharmacy is associated with an increased risk of adverse outcomes in patients with rheumatoid arthritis

Abstract: Background In the general population, polypharmacy (PP) is associated with increased risk of adverse events. The relationship between adverse outcomes and PP in Rheumatoid Arthritis (RA) has not been studied in depth. The mantra of treatment in RA encourages PP through combination Disease Modifying Anti-Rheumatic Drugs (DMARD). Objectives To study the relationship between PP and serious adverse events in RA, including the influence of DMARDs within the PP count. Methods Data from the British Society for Rheumatology Biologics Register were analysed. PP was defined as number of drugs co-prescribed at baseline, with two models: (1) including DMARDs (2) excluding DMARDs from the medication count. PP was stratified by 0–5, 6–9 and >10. Patients were studied from initiation of 1st biologic until 1st serious adverse event (SAE), 3 years of follow up, or last available visit, whichever came first. A Cox-proportional hazard model was used, with adjustment for a priori selected cofounders. Results This study included 15,004 patients commencing biologics. The demographics are shown in table 1. Excluding DMARDs from the PP cohort, 7,115 (47%) of the patients were taking up to 5 drugs; 6,010 (40%) were taking 6 to 9 drugs; 1,870 (12%) were taking 10 or more medications. Higher levels of PP associated with older age, more severe disease, and longer disease duration. PP predictably associated with comorbidities; the relationship was not linear: comorbidity count appeared to show a ceiling effect. The overall incidence of SAEs was 25.5/100 person years (95% CI 24.7–26.3). The rate of SAEs increased across the PP counts (See Table 1). The relationship remained significant after adjusting for comorbidities. Including DMARDs within the PP count attenuated the association. Conclusions PP is common in patients with RA and is associated with adverse outcomes especially when patients are on >10 drugs. Including or excluding DMARDs from the PP model had negligible impact on findings. The relationship between PP and comorbidity is worthy of further research, as PP represents a potentially simple but valuable predictor of adverse outcomes, and a suitable surrogate for comorbidity in epidemiological analyses. Disclosure of Interest None declared

SAT0098 The association between work disability and mental health in rheumatoid arthritis

Abstract: Background Rheumatoid arthritis (RA) is characterised by joint inflammation, resulting in functional impairment. Consequently, it has long been recognised that work disability is common in RA. However, despite significant pharmacological advances in disease control, little is known about contemporary impact upon work. Depression has emerged in recent years as a key comorbidity in RA. In the general population, depression is strongly correlated with work disability Objectives To establish the extent to which depression associates with work ability in RA in a cross sectional study. Methods Our hospital routinely collects data via an electronic screening interface, which incorporates a series of validated questionnaires, which patients complete via an iPad while waiting for their appointment. The dataset is linked to the clinical record. For this study, cross sectional data were extracted on adults with RA. Question 2 of the Work and Social Adjustment Scale (“Because of my [RA] my ability to work is impaired”) was used as a measure or work disability (scale 0–8). Mental health status was collected using the Patient Health Questionnaire-2 (PHQ), with a score≥3 considered a positive screen for depression. Results Of 385 patients with RA were included in the analysis. Their demographics are shown in the Table.1 Patients scoring 3 or more on the PHQ had more severe RA (higher DAS/HAQ), but there was no significant difference in age, sex or disease duration. 124 (32%) reported no work disability, with the overall mean score 3.0. Patients screening positive for depression had a significantly lower work ability even after adjusting for available confounders. Conclusions There is a significant correlation between depression in RA and work ability, which persists even after accounting for disease severity. The magnitude of association observed was even greater than that seen between physical function and work. Although unmeasured confounding remains likely, these data confirm the link between depression and work in RA. It is likely that the relationship is bidirectional, between depression and work in RA. Beyond the importance of addressing work ability in RA, the results highlight the need for screening and targeting depression as part of routine clinical care beside the holistic approach of mangement. Disclosure of Interest None declared

A baffling case of severe systemic inflammation. Putting the pieces together: genes, environment and triggers

Abstract: Herein we report a complex case with heterozygosity for MEFV with atypical Adult Onset Still’s Disease (AOSD) in a 39-year-old Colombian woman, in her 3rd pregnancy trimester. At 33 weeks gestation, she presented with a sore throat, polyarthralgia, myalgia and pleuritic chest pains. She had an erythematous maculopapular rash thought to be pregnancy-related pruritic eruption. Earlier in pregnancy she had developed biopsy-confirmed reactive axillary lymphadenopathy. Past surgery included breast augmentation and bariatric surgery; family history unremarkable. Clinically she was tachycardic with wrist, metacarpophalangeal and proximal interphalangeal joint synovitis. She had bilateral pitting leg oedema which gradually spread to the abdomen, associated with worsening hypoalbuminaemia.

SAT0040 Assessing 5-year radiographic progression in rheumatoid arthritis patients with moderate disease: findings from a uk multi-centre prospective observational study

Abstract: Background Early, intensive treatment to achieve remission, or at least low disease target (Treat-to-Target, T2T), is advocated to prevent and/or reduce structural joint damage and disability in early Rheumatoid Arthritis (RA). A recent study shows how patients with moderate disease exhibit similar rates of functional disability and orthopaedic surgical interventions to those patients with high disease1. To our knowledge, no study has looked at longitudinal observational data to investigate the progression of structural joint damage in these patient sub-groups. Objectives To investigate the long-term progression of radiographic joint damage in patients with sustained moderate disease activity. Methods Demographic, clinical, laboratory and radiographic data from the Early Rheumatoid Arthritis Study (ERAS) was available for 1,465 patients. Radiographic damage was scored using the modified Sharp/van der Heijde (SvdH) method. The original three variable 44 joint count Disease Activity Score (DAS-44) was used. Mean DAS-44 over the first 5 years was estimated for patients with at least two DAS-44 scores. Patients were stratified based on EULARs thresholds of low ( 3.7) disease. Mixed-effects negative binomial regression modelled patients9 radiographic progression over 5 years, whilst controlling for key confounders, including age at onset, sex, rheumatoid factor status and baseline functional disability. Results A total of 1,110 patients with 3,751 observations over the 5 year period (mean =3.4 observations per patient) were analysed. 396 (36%), 363 (33%) and 351 (32%) patients were classified in the low, moderate and high DAS-44 groups respectively. The low group had lower SvdH scores at 1 year compared to the moderate group (12.9 vs. 19.2, p Conclusions Sustained moderate disease over the first five years of RA indicates similar levels of radiographic progression compared to sustained high disease. This study provides support on the importance of tight treatment control with early and aggressive therapy according to T2T principles. Preventing sustained moderate disease activity states can help reduce radiographic progression and consequently joint destruction, minimising the risk of disability in the long-term. References Nikiphorou, E. et al. Association between rheumatoid arthritis disease activity, progression of functional limitation and long-term risk of orthopaedic surgery: combined analysis of two prospective cohorts supports EULAR treat to target DAS thresholds. Ann. Rheum. Dis. annrheumdis–2015–208669 (2016). Disclosure of Interest L. Carpenter Grant/research support from: NIHR Programme Grant, S. Norton: None declared, E. Nikiphorou: None declared, K. Jayakumar: None declared, D. McWilliams: None declared, J. Dixey: None declared, P. Kiely: None declared, D. Walsh: None declared, A. Young: None declared