Amir Emamifar

Is Hearing Impairment Associated with Rheumatoid Arthritis? A Review

Background: Rheumatoid arthritis (RA) is a systemic, inflammatory disease that affects 1% of the population. The auditory system may be involved during the course of disease; however the association of RA and hearing impairment has not been clearly defined. Objective: The objective of this review is to evaluate published clinical reports related to hearing impairment in patients with RA. Furthermore, we discuss possible pathologies and associated factors as well as new treatment modalities. Method: A thorough literature search was performed using available databases including Pubmed, Embase, Cochrane and ComDisDome to cover all relative reports. The following keywords were used: hearing loss, hearing difficulties, hearing disorders, hearing impairment, sensorineural hearing loss, conductive hearing loss, mixed hearing loss, autoimmune hearing loss, drug ototoxicity, drug-induced hearing loss, hearing test, audiometry, auditory dysfunction and rheumatoid arthritis. Conclusion: Based on our review it can be postulated that patients with RA are at higher risk of hearing impairment compared to healthy subjects in their course of the disease. The hearing impairment in RA seems to be a multifactorial condition; however the mechanisms of injury, as well as the relative risk factors, are not completely clear. This review can aid to clarify this condition and is a guide for further evaluation. To the best of our knowledge, this is the first review of hearing impairment in RA.

The Reliability of Disease Activity Score in 28 Joints–C-Reactive Protein Might Be Overestimated in a Subgroup of Rheumatoid Arthritis Patients, When the Score Is Solely Based on Subjective Parameters: A Cross-sectional, Exploratory Study

BackgroundDisease Activity Score in 28 Joints (DAS28) is a scoring system to evaluate disease activity and treatment response in rheumatoid arthritis (RA). A DAS28 score of greater than 3.2 is a well-described limit for treatment intensification; however, the reliability of DAS28 might be overestimated. ObjectiveThe aim of this study was to evaluate the reliability of DAS28 in RA, especially focusing on a subgroup of patients with a DAS28 score of greater than 3.2. MethodsData from RA patients registered in the local part of Danish DANBIO Registry were collected in May 2015. Patients were categorized into 2 groups: First, those with DAS28 >3.2 with at least one swollen joint (SJ) or elevated C-reactive protein (CRP) (“objective group”), and second, patients with a DAS28 >3.2 who had no SJ, and CRP values were within the reference range (“subjective group”). Disease Activity Score in 28 Joints, Clinical Disease Activity Index, and Health Assessment Questionnaire scores were calculated for each group. We defined new score, DAS28 subjective, to focus on subjective parameters. ResultsTwo hundred thirty patients were included; 198 (86.1%) and 32 (13.9%) patients were in the objective and subjective groups, respectively. Patients in the subjective group had lower mean values of DAS28 (P < 0.001) and Evaluator Global Assessment (P < 0.001) with less common immunoglobulin M rheumatoid factor (P < 0.001) and anti–cyclic citrullinated peptide positivity (P = 0.02) and contrarily higher mean values of tender joints (P = 0.04) and DAS28 based on subjective parameters (P = 0.003) compared with the objective group. ConclusionsRheumatoid arthritis scoring systems should be used cautiously in patients who are considered for treatment intensification. Patients with central sensitization and psychological problems and those with false-positive diagnosis of RA are at high risk of overtreatment.

Association of Remitting Seronegative Symmetrical Synovitis with Pitting Edema, Polymyalgia Rheumatica, and Adenocarcinoma of the Prostate

Patient: Male, 83 Final Diagnosis: Remitting seronegative symmetrical synovitis with pitting edema Symptoms: Morning stiffness • pitting edema of the hands • shoulder and hip pain Medication: — Clinical Procedure: 18FDG PET/CT Specialty: Rheumatology Objective: Rare disease Background: Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is a rare condition that occurs in elderly individuals. It can present alone or in association with various rheumatic or malignant diseases. Case Report: An 83-year-old man presented with anemia, hyper-sedimentation, and pitting edema of the back of the hands. The patient complained of pain and stiffness of the shoulder and hip girdles, especially in the morning. He was previously diagnosed with adenocarcinoma of the prostate. After 3 years of watchful waiting, treatment with goserelin, a gonadotropin releasing hormone agonist, was started, when PSA had increased to 67.9 µg/l. About 1 year before the cancer treatment, the patient also presented with sore and swollen hands, compatible with RS3PE, which remitted after a few months of prostatic cancer treatment. Thorough laboratory evaluation was performed upon admission to the Rheumatology Department and he was referred for FDG PET/CT on suspicion of metastases of the previously diagnosed prostatic cancer. PET/CT imaging revealed increased FDG up-take in the soft tissues around the shoulders and hips, but no evidence of bone metastasis or other malignant findings. A diagnosis of polymyalgia rheumatica (PMR) together with RS3PE syndrome was made and treatment with prednisolone 15 mg/d was started, which resulted in rapid resolution of the symptoms. Conclusions: Presence of RS3PE in relation with PMR and prostatic cancer in our patient suggests a common trigger factor. To the best of our knowledge, this is the first report of a case of RS3PE that presented twice with 2 different diagnoses in the same patient.

No further gain can be achieved by calculating Disease Activity Score in 28 joints with high-sensitivity assay of C-reactive protein because of high intraindividual variability of C-reactive protein: A cross-sectional study and theoretical consideration

Abstract Disease Activity Score in 28 joints (DAS28) is commonly used to evaluate disease activity of rheumatoid arthritis (RA) and is a guide to treatment decision. The aim of this study was to evaluate the impact of lower reporting limit for C-reactive protein (CRP), with respect to intraindividual biological variability, on the calculation of DAS28 and subsequent patient classification. This study consists of 2 sections: a theoretical consideration discussing the performance of CRP in calculating DAS28 taking intraindividual biological variation and lower reporting limit for CRP into account and a cross-sectional study of RA patients applying our theoretical results. Therefore, we calculated DAS28 twice, with the actual CRP values and CRP = 9 mg/L, the latter to elucidate the positive effects of reducing the lower reporting limit of CRP from <10 to <3 mg/L. Lower-reporting limit of <10 mg/L leads to overestimate DAS28. However, reducing lower reporting limit for CRP to <3 mg/L results in optimizing DAS28 calculation. Further lowering of reporting limit for CRP to <3 mg/L does not increase the precision of DAS28 owing to the relatively large intraindividual biological variation. Five hundred twelve patients were included. There was a significant difference between recalculated and patients DAS28 (P < 0.001). One hundred nine patients had DAS28 deviation (compatible to remission to low: 66, low to moderate: 39. and moderate to high: 4). Owing to significant impact of intraindividual biologic variation on DAS28 and patient classification, special attention should be paid to calculate DAS28 when CRP values are within normal range. Furthermore, we conclude that results of different studies evaluating DAS28 and treatment response are not comparable if the reporting limits of CRP are unknown.

Septic arthritis and subsequent fatal septic shock caused by Vibrio vulnificus infection

Vibrio vulnificus is a rare but potential fatal bacterium that can cause severe infections. Wound infections, primary sepsis and gastroenteritis are the most common clinical features. Septic arthritis caused by V. vulnificus is an atypical presentation that has been reported in only two case reports; however, it has not been previously noted in Denmark. The authors report a case of septic arthritis caused by V. vulnificus in an immunocompromised patient. The disease progressed to severe sepsis and subsequent death within 10 h of admission.

Rheumatoid arthritis and hearing impairment: a review

3 OP04 HLA-B27 status is associated with TNF-α inhibitor treatment outcomes in ankylosing spondylitis and non radiographic axial spondyloarthritis. An observational cohort study from the nationwide DANBIO registry B Glintborg, IJ Sørensen, M Østergaard, NS Krogh, AA Mohamoud, LS Andersen, JL Raun, O Hendricks, MR Kowalski, L Danielsen, SR Christensen, N Al Chaer, R Pelck, H Nordin, JK Pedersen, DGA Kraus, IMJ Hansen, J Espesen, A Schlemmer, AG Loft, L Salomonsen, L Dreyer, ML Hetland

The ratio of nurse consultation and physician efficiency index of senior rheumatologists is significantly higher than junior physicians in rheumatology residency training: A new efficiency measure in a cohort, exploratory study

Abstract To elucidate the difference between ratios of nurse consultation sought by senior rheumatologists and junior physicians in rheumatology residency training, and also to evaluate physician efficiency index respecting patients with rheumatoid arthritis (RA). Data regarding outpatient visits for RA patients between November 2013 and 2015 were extracted. The mean interval (day) between consultations, the nurse/physician visits ratio, and physician efficiency index (nurse/physician visits ratio × mean interval) for each senior and junior physicians were calculated. Disease Activity Score in 28 joints-C-Reactive Protein (DAS28-CRP) and Health Assessment Questionnaire (HAQ) scores were used to monitor treatment outcome. Therefore, DAS28 and HAQ scores were measured 3 times: firstly at physician consultation, then after nurse consultation, and finally at the third visit, either at a nurse or physician consultation. Of 6046 visits, 3699 visits, planned by 11 physicians (4 specialists and 7 junior physicians), were included. These numbers of visits belonged to 672 RA patients, among which 431 (64.1%) patients were female, the mean age being 64.9 ± 14.1 years, and DAS28 at baseline was 4.5 ± 1.2. The nurse/physician visits ratio (P = .01) and mean efficiency index (P = .04) of senior rheumatologists were significantly higher than that of junior physicians. Regression analysis showed a positive correlation between physician postgraduate experience and physician efficiency index adjusted for DAS28 at baseline and number of patients for each physician (regression coefficient 5.427, 95% confidence interval 1.068–9.787, P = .022). There was a high correlation between physicians’ postgraduate experience (year) and the ratio of nurse/physician visits (r = 0.91, P < .001), and also physician efficiency index (r = 0.94, P < .001). Nurse consultation did not contribute to worsening treatment outcome, since DAS28 and HAQ scores were significantly decreased if physician visits were followed by nurse visits (P = .004 for DAS28 and P = .025 for HAQ). If junior physicians are supervised to refer RA patients with milder and sufficient treatment plan to nurses, the entire department operates more efficiently, leading to prevent additional expenses (due to the differences in yearly salary of physicians and nurses) and human resource waste. Quality of care should be monitored by markers of disease activity and CRP.

Thyroid disorders in patients with newly diagnosed rheumatoid arthritis is associated with poor initial treatment response evaluated by disease activity score in 28 joints-c-reactive protein (das28-crp): An observational cohort study

Abstract To determine the prevalence of thyroid disorders among newly diagnosed rheumatoid arthritis (RA) patients and evaluate the association between clinical characteristics of RA and thyroid disorders, and also initial treatment response in the RA patients with thyroid disorders. Newly diagnosed, adult RA patients who were diagnosed according to the new 2010 American College of Rheumatology/European League Against Rheumatism criteria since January 1, 2010, were included. Patients’ demographic data, serology results including immunoglobulin M rheumatoid factor (IgM RF), anticyclic citrullinated peptide antibody (anti-CCP), and antinuclear antibody (ANA), and also disease activity score in 28 joints-C-reactive protein at the time of diagnosis and after 4 months (±1–2 months) of treatment initiation were extracted from Danish Danbio Registry. Patients’ electronic hospital records for the past 10 years were reviewed to reveal if they had been diagnosed with thyroid disorders or they had abnormal thyroid test. In all, 439 patients were included, female 60.1%, mean age 64.6 ± 15.0 years and disease duration 2.6 ± 1.7 years. Prevalence of thyroid disorders was 69/439 (15.7%) and hypothyroidism was the most frequent disorder (30.4%). The presence of thyroid disorders among RA patients was significantly associated with female sex (P < .001), ANA positivity (P = .04), and anti-CCP ≥100 EU/mL (P = .05). Furthermore, RA patients with thyroid disorders had significantly poorer initial response to RA treatment compared with patients with isolated RA after 4 months of treatment (P = .02). There were no associations between thyroid disorders and age, disease duration, and also IgM RF positivity. Presence of thyroid disorders in RA patients is suggestive of a more aggressive disease and poor outcome, with direct effect on initial treatment response. To diagnose concurrent thyroid disorders at an earlier stage, routine measurement of serum thyroid-stimulating hormone is recommended in all RA patients at the time of diagnosis and with yearly interval thereafter.

Rheumatoid Arthritis and Hearing Impairment

R heumatoid arthritis (RA) is an inflammatory, autoimmune disease that, in addition to primary articular manifestations, affects multiple organs, including the auditory system. Sensorineural hearing loss (SNHL) is the most prevalent type of hearing impairment (HI) affecting patients with RA, noting a prevalence of 25-75 percent, followed by conductive (CHL) and mixed hearing loss (MHL). (Emamifar. Open Rheumatol J 2016;10:26). The objective of this study was to discuss possible pathologies, associated factors, and management of HI in RA patients. Therefore, a comprehensive literature search of available databases including Pubmed, Embase, Cochrane, and ComDisDome was performed.

SAT0125 The impact of selected comorbidities on treatment outcome in patients with rheumatoid arthritis: an exploratory cohort study.

Background Patients with Rheumatoid Arthritis (RA) may present with various comorbidities resulting in worse treatment response.[1-2] Objectives To investigate the impact of selected comorbid diseases on RA outcome with the aim of Disease Activity Score in 28 joints-C-Reactive Protein (DAS28-CRP). Methods All our RA patients were included in this study. Patients’ demographics, serology results and DAS28-CRP at the time of diagnosis and after 4 months of treatment initiation were collected. Patients’ electronic hospital records were evaluated for a positive history of thyroid diseases, Diabetes Mellitus (DM), primary hyperparathyroidism, vitamin B12 deficiency and presence of other diagnosed autoimmune diseases. Results 1035 RA patients were included. 63.4% were female, mean of age 67.1 years, mean of disease duration 9.6 years, 58.6% rheumatoid factor positive and 51.3% anti-cyclic citrullinated peptide positive. The observed prevalence of thyroid diseases was 11.8%, DM 10.4%, primary hyperparathyroidism 2.8%, vitamin B12 deficiency 5.8%, and other diagnosed autoimmune diseases 1.6%. There were significant associations between presence of thyroid diseases and female gender (p<0.001); DM and greater age (p<0.001); primary hyperparathyroidism and longer disease duration (p=0.002); other diagnosed autoimmune diseases and antinuclear antibody positivity (p<0.001). RA patients with thyroid diseases (p=0.001) and other comorbid autoimmune diseases (p<0.001) had significantly poorer initial response to the RA treatment compared to patients with isolated RA. Univariate analyses revealed that age, presence of thyroid diseases, presence of other diagnosed autoimmune diseases and DAS28-CRP at the time of diagnosis were significantly associated with ∆DAS28-CRP. Additionally, multivariate analysis demonstrated that ∆DAS28-CRP deterioration was significantly correlated to the presence of thyroid diseases (unstandardized regression coefficient (standard error);-0.188(0.088),p=0.030) and presence of other diagnosed autoimmune diseases (-0.537(0.208),p=0.010). (table1)Table 1 Univariate and multivariate analysis of risk factors for ∆DAS28-CRP. Variables Univariate analysis Multivariate analysis Backward analysis Gender 0.028 (0.066) 0.058 (0.056) Age 0.007 (0.002)** 0.003 (0.002) Disease duration 0.000 (0.003) - 0.003 (0.003) IgM-rheumatoid factor -0.055 (0.065) 0.014 (0.068) Anti-cyclic citrullinated peptide antibody -0.098 (0.065) -0.041 (0.068) Antinuclear antibody 0.003 (0.086) -0.042 (0.067) Presence of Thyroid diseases -0.315 (0.098)** -0.188 (0.088)* -0.160 (0.081)* Presence of Primary Hyperparathyroidism -0.059 (0.193) 0.008 (0.159) Presence of Diabetes Mellitus 0.077 (0.104) -0.023 (0.086) Presence of vitamin B12 deficiency 0.102 (0.136) 0.047 (0.112) Presence of other diagnosed autoimmune diseases -0.895 (0.249)** -0.537 (0.208)* -0.565 (0.204)* Thyroid stimulating hormone level 0.013 (0.008) 0.011 (0.007) DAS28-CRP at time of diagnosis 0.724 (0.027)** 0.711 (0.029)** 0.715 (0.029)** *P value <0.05, ** P value <0.005 Conclusions RA patients are at increased risk of specific comorbidities with possible impact on the treatment outcome. The authors, therefore, recommend to do periodical assessment of comorbidities to diagnose concurrent comorbid diseases as early as possible. References: [1] Emamifar A, et al. Thyroid disorders in patients with newly diagnosed rheumatoid arthritis is associated with poor initial treatment response evaluated by disease activity score in 28 joints-C-reactive protein (DAS28-CRP): An observational cohort study. Medicine (Baltimore) 2017;96:e8357. [2] Emamifar A, et al. Patients with newly diagnosed Rheumatoid Arthritis are at increased risk of Diabetes Mellitus: An Observational Cohort study. Acta Reumatol Port 2017 [Epub ahead of print]. Disclosure of Interest: None declared