Search

BackgroundWork is an important outcome for people with inflammatory arthritis (IA including PsA, RA, AxSpA) and osteoarthritis (OA). It is known that people with IA and OA are at increased risk of sick leave and have to stop working early due to ill health. In addition to being at increased risk of becoming work disabled and increased absenteeism, high levels of presenteeism (i.e. reduced productivity/limited ability to work due to ill health whilst at work) have also been reported. Several instruments exist to measure presenteeism, including single-item global measures and multi-item instruments. In some studies using single-item global instruments may be more feasible. However, available global instruments differ in concept, recall period and reference. It is important to understand which of the measures have good psychometric properties before using them in clinical studies.ObjectivesTo assess the psychometric properties of four global presenteeism instruments.MethodsPatients with IA or OA were recruited via rheumatology outpatient clinics to a large international, longitudinal observational study including 8 European countries and Canada. Participants completed a survey at baseline, 1, 2, 3, 4 wks, 2 months and 3 months. The four global measures of presenteeism included: Work Productivity and Activity Impairment Questionnaire (WPAI), Work Productivity Scale–Rheumatoid Arthritis (WPS-RA), Work Ability Index (WAI) and the Quality*Quantity questionnaire (QQtotal/10) scale. To facilitate score interpretation the WAI and QQtotal were reversed. Pain was measured using an 11-point Likert scale. Spearman correlations were calculated between the presenteeism measures and the Workplace Activity Limitations Scale (WALS), a validated multi-item measure of presenteeism, and HAQ to evaluate construct validity (validity: r r >0.50-r >0.70=high). Test-retest reliability of the 4 presenteeism scales (baseline-1wk) was measured applying ICC in patients with stable disease (i.e. same pain score at baseline and 1wk) (reliability: ICC0.75=excellent). Responsiveness during 3 months was measured comparing patients with improvement in pain score (>1 point improvement in pain score (~MCID pain)) with patients with no change or worsening in pain score. The two groups were compared applying Mann Whitney U test.ResultsThis international study included 550 patients with a mean age of 47.8 (SD 9.9) yrs and 61.4% were female. Mean (SD) disease duration since diagnosis was 10.8 (10.4) yrs and 91.2% had IA. Mean (SD) presenteeism scores at baseline were: WPAI=2.9 (2.7); WPS-RA=3.4 (2.7); WAI=2.7 (2.4); and QQtotal=3.1 (3.2). The correlations between the global measures and with WALS and HAQ were moderate to good, except for QQtotal and HAQ which was low (Table 1). In patients with the same stable pain scores at baseline-1wk (n=141) ICC scores were good to excellent, respectively: WPAI (0.771), WPS-RA (0.752), WAI (0.663), and QQtotal (0.650). An improvement in pain during the 3 month study duration was observed in 145/381 (38%) of the patients. In these patients a significant reduction in mean (SD) change presenteeism was observed for all four presenteeism scales compared to those with no change or worsening of the pain score: WPAI (-1.0 (2.37) vs 0.68 (2.40), pTable 1.WPAIWPS-RAWAIQQtotalWALSHAQWPAI-0.81640.59920.51840.62690.5592WPS-RA-0.58360.52170.60550.5669WAI-0.58660.52310.5168QQtotal-0.50250.4367ConclusionThe psychometric properties of all 4 global presenteeism scales were moderate to good, with slightly better scores for both the WPS-RA and WPAI instruments both measuring the impact of OA and IA on productivity.Disclosure of InterestsSuzanne Verstappen Consultant of: EUOSHA, Grant/research support from: AbbVie, BMS. EULAR, Annelies Boonen Speakers bureau: Abbvie / Galapagos, Consultant of: Galapagos, Sarah Wilkinson: None declared, Dorcas Beaton: None declared, Ailsa Bosworth: None declared, José Canas da Silva: None declared, Gloria Crepaldi: None declared, Sabrina Dadoun: None declared, Cathie Hofstetter: None declared, Carina Mihai Speakers bureau: Boehringer-Ingelheim, Mepha, MED Talks Switzerland, Consultant of: Boehringer-Ingelheim, Janssen, Grant/research support from: Roche, Boehringer-Ingelheim, Sofia Ramiro Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: Grant: AbbVie, Galapagos, Novartis, Pfizer, UCB, Garifallia Sakellariou Consultant of: Abbvie, BMS and Galapagos., Grant/research support from: Abbvie, BMS and Galapagos., Sandra Meisalu: None declared, Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Novartis, Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, Pfizer., Diane Lacaille: None declared

BackgroundMusculoskeletal ultrasonography (MSUS) is a useful tool for the diagnosis of several Rheumatic and Musculoskeletal Diseases (RMDs) but its role in the diagnostic pathways in clinical practice is still unclear as feasibility issues limit its application as a bed side technique.ObjectivesTo optimize the use of US in clinical practice, the MSUS Study Group of the Italian Society for Rheumatology aimed to develop an algorithm combining US with clinical and laboratory findings to improve the differential diagnosis among patients presenting with joint swelling.MethodsBased on a systematic literature review1 and experts’ opinion, MSUS Study Group Members attempt to identify a set of statements including the main US elementary lesions useful for US scanning in the suspicion of Rheumatoid arthritis (RA), Psoriatic arthritis (PsA), Rheumatic Polymyalgia (PMR), Gout, Calcium Pyrophosphate Deposition Disease (CPPD), Osteoarthritis (OA). Then, the MSUS Study Group defined through a survey and ranked in a 1000minds exercise the most important clinical/laboratory findings for the differential diagnosis of those diseases. Higher-ranked items were fitted in an algorithm driving the differential diagnosis of RMDs to a reduced spectrum of 2 to 4 possible diseases. Finally, the algorithm supported the performance of US according to the established scans for those specific diseases. To assess the algorithm’s performance, a pilot study was conducted on 59 patients, comparing the algorithm-based diagnosis with the final diagnosis based on rheumatologist’s experience and/or on classification criteria.ResultsSets of elementary US lesions and a scanning protocol for each included pathology were created (Table 1), optimized towards high sensibility and specificity. Among the findings evaluated, the age (Table 1.Elementary ultrasound lesions and joints to be scanned for each included pathologyDiseaseSites to scanUS elementary lesionsRAII-IV MCPsSynovial Hypertrophy (SH), Power Doppler (PD), erosionsWristV MTPPsAII-III MCPsPeritendonitisPIPsEnthesitisSoft tissue oedemaFlexor tendons of the handsTenosynovitisSoft tissue oedemaAchille’s tendon enthesisPD, erosionsProximal patellar tendon enthesisCPPDKnees (menisci and Hyaline Cartilage)CPP depositsWrist (triangular fibrocartilage complex)Any involved sitesCPP deposits, SH, PDGoutKneesDouble contour, tophiI MTPInvolved sitesSHPDOAInvolved sitesOsteophytesCartilage changesPMRShouldersBursitisArthritisRotator cuff integrityFigure 1.The final algorithmConclusionThe diagnostic algorithm produced in this pilot study correctly classified patients with the most prevalent RMDs in clinical practice. A longitudinal study on a large sample size is ongoing to evaluate the added value of US when implemented in this algorithm regarding diagnostic certainty, accuracy and early diagnosis.References[1]Sakellariou G, Scirè CA, Adinolfi A, Batticciotto A, Bortoluzzi A, Delle Sedie A, et al. Differential Diagnosis of Inflammatory Arthropathies by Musculoskeletal Ultrasonography: A Systematic Literature Review. Front Med. 7 maggio 2020;7:141.Disclosure of InterestsNone declared

BackgroundUltrasound (US) has proven to be an excellent imaging technique for detecting calcium pyrophosphate (CPP) deposition disease (CPPD); it is also widely available and inexpensive and can be performed during the clinic visit making it the preferred imaging modality for many rheumatologists. However, no validated grading systems have yet been developed allowing for a quantification of the extent of crystal deposition in CPPD.ObjectivesThe aim of this study was to develop a scoring system for the quantification of CPP deposition at a patient level according to the OMERACT framework.MethodsAs part of the OMERACT methodology, we performed a systematic literature review (SLR) and meta-analysis aimed to estimate the prevalence of CPP deposition in peripheral joints by imaging, in order to identify relevant joints for CPPD monitoring. A preliminary survey was also circulated among the members of the OMERACT US – CPPD working group to collect their own suggestions according to their personal experience. Subsequently, a Delphi survey was prepared and circulated between members of the group, including statements that reflected both the results of the SLR and of the preliminary survey. In total, 32 statements were generated regarding the type of scoring for single structures, the sites to be included, the final scoring at patient level, and the scanning technique. Participants were asked to reply on a 5-point Likert scale (1, strongly disagree to 5, strongly agree) and agreement was achieved when 4 and 5 grades reached 75% or more of concordance. In case of disagreement, new statements were proposed according to the members’ suggestions and circulated for voting in a subsequent round. After agreement of a scoring system, the validation process began. Two rounds of a web-based exercise on static images were conducted on 120 images representing equally all sites under investigation and all degrees of crystal deposition, to assess the intra- and inter-reader reliability of the new scoring system. Representative images of the scoring system were visible throughout the entire exercise in order to facilitate the scoring of the lesions.ResultsThree Delphi rounds were needed to reach agreement on all items. 32/41 members of the OMERACT US-CPPD working group replied in the first round, 26/32 in the second, and 25/26 in the third round. Twenty statements were approved in the first round, 3 in the second, and 3 in the third round. Only the knees (menisci and hyaline cartilage) and the triangular fibrocartilage of the wrist were included in the final score, using a four-grade system (0-3). It was decided that each anatomical structure should be scored separately and then also summed in order to define the joint score. The sum of the assessed joints was the total score at patient level. The final scoring system with the definitions and the relative technical notes is represented in Figure 1. 33/41 members participated to the reliability exercise. The inter-reader reliability of the scoring was substantial (kappa of 0.72), and the intra-reader reliability was almost perfect (kappa of 0.82).ConclusionThis is the first study for developing a scoring system for the extent of CPP crystal deposition in patients with CPPD. The scoring system demonstrated to be reliable in static images. The next step of the validation process is to assess the reliability of the scoring system in a patient-based exercise. This study represents a fundamental step in the OMERACT process of validating US as an outcome measure instrument, and above proposed scoring system will hopefully provide a useful tool for clinical practice and research.Disclosure of InterestsNone declared

BackgroundOver the past 20 years, despite the widespread diffusion of dedicated early arthritis clinics (EAC) and more sensitive classification criteria, the percentage of patients seen within the window of opportunity remains low, and the new RA criteria, heavily weighted on autoantibodies, may have further hindered the recognition and treatment of seronegative patients.Objectiveswe analysed changes in the diagnostic delay and clinical presentation of patients with RA admitted to the EAC of the Division of Rheumatology of the San Matteo University Hospital, Pavia, Italy, from its institution in 2005 to 2017.MethodsReferral criteria to the EAC have remained stable over the years and include ≥3 swollen joints (SJs) or, in case of 30 min. From all early arthritis patients (n=1.553), we selected 668 patients fulfilling at enrolment at least the 1987 ACR criteria for RA before December 2010 (n=345, 88.4% also fulfilling 2010 criteria), and at least the 2010 ACR/EULAR criteria after January 2011 (n=323, 63.5% also fulfilling 1987 criteria). Time from first self-reported joint symptom to referral (diagnostic delay) was compared across different time periods: (i) 2005-2007; (ii) 2008-2010; (iii) 2011-2013; (iv) 2014-2017. Clinical characteristics were collected according to standardised assessments. Data were analysed in the total population and after stratification for the autoantibody status (double negative for rheumatoid factor, RF, and anti-citrullinated protein antibodies, ACPA vs RF and/or ACPA positive).ResultsIn all, the diagnostic delay collectively increased from a mean (SD) of 20.8 (20.5) weeks before 2010 to 24.4 (20.6) weeks thereafter (p=0.02), and the proportion of patients diagnosed within 12 weeks non-significantly decreased from 39.3% to 35.3%. Still, patients presented with progressively milder inflammatory markers despite unchanged joint tenderness and patient-reported outcomes (PROs). Trends were, however, remarkably different in different autoantibody subgroups. In RF/ACPA-positive patients, a stable proportion of 41-44% was diagnosed within 12 weeks (Figure 1A). At presentation, patients had fewer SJs and lower C-reactive protein (CRP) levels; the mean decrease of SJs and CRP from 2005-2007 to 2014-2017 were -5.6 and -1.1 mg/dl, respectively (Figure 1B). The improvement in PROs was smaller but still significant over time (Figure 1C). In contrast, in autoantibody-negative patients, the proportion of patients diagnosed within 12 weeks progressively decreased from 37.9% to 25.6% (p=0.08) (Figure 1D). Furthermore, the improvement over time of inflammatory features, especially of SJs, was significant but smaller than autoantibody-patients, and PROs such as pain and global assessment of disease activity remained severely impacting with mean values of up 60 mm even in recent times (Figure 1E,F).Figure 1.Time to diagnosis and clinical presentation of autoantibody-positive and –negative patients with early rheumatoid arthritis. (A, D) Proportion of patients diagnosed within 12 weeks from symptoms’ onset among autoantibody-positive (A) and autoantibody-negative (D) rheumatoid arthritis (RA) in different time periods. (B, C, E, F) Values of swollen joints (SJC28), C-reactive protein (CRP) (B, E), and visual analogue scales (VAS) for pain and patient global assessment (PGA) of disease activity (C, F) in autoantibody-positive (B, C) and autoantibody-negative (E, F) RA in different time periods. Values are expressed as means and standard errors.ConclusionCollectively, our data indicate that a large proportion of patients with RA still lack early diagnosis despite dedicated early access to rheumatology care; from 2010 onwards, autoantibody-positive patients are diagnosed with a milder and less disabling disease, while autoantibody-negative patients are at increased risk of delayed diagnosis, and remain burdened with severe diseaseDisclosure of InterestsLudovico De Stefano Speakers bureau: Gilead, Bernardo D’Onofrio: None declared, Garifallia Sakellariou: None declared, Antonio Manzo: None declared, Carlomaurizio Montecucco Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Pfizer, Roche, Sanofi, Serena Bugatti Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Pfizer, Sanofi, Grant/research support from: Pfizer