Christophe Hudry

Reproducibility of joint swelling assessments in long-lasting rheumatoid arthritis: Influence on disease activity score-28 values (SEA-repro study part I)

Objectives. To evaluate the reproducibility of clinical synovitis assessments in rheumatoid arthritis and the effect of variability on the Disease Activity Score-28 (DAS28). Methods. Seven healthcare professionals from different cities examined the same patients with active non-early rheumatoid arthritis (RA; duration > 4 yrs), for whom a treatment change was being considered. There was no training session and the examination was to be performed as quickly as possible. The healthcare professionals assessed the 28 joints of the DAS28 in 7 patients (196 joints), then reexamined the same 28 joints in 4 of these 7 patients (112 joints), who had been rendered unrecognizable. Then 7 sonographers examined each of the 7 patients twice, using B-mode and power Doppler ultrasound (PD). The reference standards were presence of synovitis according to at least 50% of clinical examiners and 50% of sonographers. Agreement was assessed by Cohen’s kappa statistic. Results. Intraobserver reliability ranged from 0.31 (least experienced research technician) to 0.77 (most experienced physician). Interobserver reliability ranged from 0.18 to 0.62. The largest difference between the lowest and the highest swollen joint counts in the same patient was 15, and the greatest variation in the DAS28 score was 0.92. Agreement between clinical and sonographic reference standards was 0.46, 0.37, and 0.36 for B-mode, PD, and both, respectively. Conclusion. Clinical inter- and intraobserver reliability is highly dependent on the examiner. Consequences on the DAS28 score can be substantial. Agreement with sonography is poor when both B-mode and PD are used but seems better, although low, when B-mode is used alone.

Reproducibility of Joint Swelling Assessment by Sonography in Patients with Long-lasting Rheumatoid Arthritis (SEA-Repro Study Part II)

Objective. To evaluate the intraobserver and interobserver reproducibility of B-mode and power Doppler (PD) sonography in patients with active long-standing rheumatoid arthritis (RA) comparatively with clinical data. Methods. In each of 7 patients being considered for a change in their RA treatment regimen, 7 healthcare professionals examined the 28 joints used in the Disease Activity Score 28-joint count (DAS28). Then 7 sonographers examined each of the 7 patients twice, using previously published B-mode and PD grading systems. The clinical reference standard was presence of synovitis according to at least 4/7 examiners. The sonographic reference standard was at least grade 1 (ALG1) or 2 (ALG2) synovitis according to at least 4/7 sonographers. Interobserver reproducibility of sonography was assessed versus the sonographer having the best intraobserver reproducibility. Agreement was measured by Cohen’s kappa statistic. Results. Intraobserver and interobserver reproducibility of B-mode and PD used separately was fair to good. Agreement between clinicians and sonographers at all sites using B-mode, PD, and both was 0.46, 0.37, and 0.36, respectively, for grade 1 synovitis; and 0.58, 0.19, and 0.19 for grade 2 synovitis. The number of joints with synovitis was smaller by physical examination (36.7%) than by B-mode with ALG1 (58.6%; p < 0.001). The number of joints with synovitis was higher by physical examination than by PD with both ALG1 (17.8%; p < 0.0001) and ALG2 (6.6%; p < 0.0001). Conclusion. PD findings explain most of the difference between clinical and sonographic joint assessments for synovitis in patients with long-standing RA.

Challenges of Cardiovascular Risk Assessment in the Routine Rheumatology Outpatient Setting: An Observational Study of 110 Rheumatoid Arthritis Patients

An annual assessment of cardiovascular (CV) risk factors in rheumatoid arthritis (RA) is recommended, but its practical modalities have not been determined. The objective was to assess the feasibility and usefulness of a standardized CV risk assessment in RA, performed by rheumatologists during outpatient clinics.

Diagnostic delay in axial spondyloarthritis: A cross-sectional study of 432 patients

OBJECTIVESnThe diagnostic delay of axial spondyloarthritis (axSpA) is usually reported to be more than seven years but may have decreased recently. The objective was to quantify the diagnostic delay in patients with axSpA in France and to explore its associated factors.nnnMETHODSnTwo cross-sectional observational studies included consecutively patients with axSpA (according to both ASAS criteria and rheumatologist expert opinion). Diagnostic delay was defined as the time interval from the date of first symptoms to the date of diagnosis. Potential predictive factors of diagnostic delay analyzed by multiple linear regression were demographic factors, HLA B27 status, year of diagnosis, clinical presentation and sacroiliitis on MRI or radiography.nnnRESULTSnIn all, 432xa0patients were analyzed: the mean age at diagnosis was 34.2 (standard deviation, 12.5) years, the mean disease duration at the time of the assessment was 11.4 (10.4) years. In all, 66.7% were HLA B27 positive, and 70.2% had radiographic sacroiliitis. The mean diagnostic delay was 4.9 (6.3) years, with a median of 2.0xa0years (interquartile range, 1-7; range: 0-43). In multivariable analysis, factors independently associated with a longer diagnostic delay were: higher age at diagnosis (beta=0.13; P<0.001), less frequent peripheral arthritis or dactylitis (beta=-1.69; P=0.005), and more frequent entheseal pain (beta=1.46; P=0.015).nnnCONCLUSIONnThe median diagnostic delay was 2xa0years indicating diagnostic delay may be for most patients shorter than previously reported. A more typical SpA clinical presentation was associated with a shorter diagnostic delay, whereas sacroiliitis and HLA B27 positivity were not associated with this delay.

2018 update of French Society for Rheumatology (SFR) recommendations about the everyday management of patients with spondyloarthritis

OBJECTIVEnTo update French Society for Rheumatology recommendations about the management in clinical practice of patients with spondyloarthritis (SpA). SpA is considered across the range of clinical phenotypes (axial, peripheral, and entheseal) and concomitant manifestations. Psoriatic arthritis is included among the SpA phenotypes.nnnMETHODSnAccording to the standard procedure advocated by the EULAR for developing recommendations, we first reviewed the literature published since the previous version of the recommendations issued in June 2013. A task force used the results to develop practice guidelines, which were then revised and graded using AGREE II.nnnRESULTSnFour general principles and 15 recommendations were developed. The first four recommendations deal with treatment goals and general considerations (assessment tools and comorbidities). Recommendations 5 and 6 are on non-pharmacological treatments. Recommendation 7 is about nonsteroidal anti-inflammatory drugs, which are the cornerstone of the treatment, and recommendations 8 to 10 are on analgesics, glucocorticoid therapy, and conventional disease-modifying antirheumatic drugs. Biologics are the focus of recommendations 11 through 14, which deal with newly introduced drug classes, including their indications (active disease despite conventional therapy and, for nonradiographic axial SpA, objective evidence of inflammation) and monitoring, and with patient management in the event of treatment failure or disease remission. Finally, recommendation 15 is about surgical treatments.nnnCONCLUSIONnThis update incorporates recent data into a smaller number of more simply formulated recommendations, with the goal of facilitating their use for guiding the management of patients with SpA.

SAT0267 Is the Widely-Used Score in Axial Spondyloarthritis, Basdai (Bath Ankylosing Spondylitis Diseases Activity Index), Influenced by Patients' Optimism? a Cross-Sectional Study of 206 Patients

Background The Bath Ankylosing Spondylitis Diseases Activity Index (BASDAI) is widely used to assess disease activity in axial spondyloarthritis (axSpA) and is a criterion for initiating anti-TNF therapy. Psychological distress (anxiety/depression) may be related to BASDAI scores (1), which may be an issue when using the BASDAI to decide on treatment strategies. Do stable personality traits like dispositional optimism-a general positive mood or attitude towards the future-also influence BASDAI results? Objectives To determine if BASDAI scores are influenced by optimism in axSpA. Methods A cross-sectional study was performed in two tertiary care hospitals and one office-based practice in France (2). Patients had definite axSpA according to the rheumatologist. Auto-questionnaires included the BASDAI and optimism, evaluated through the French version of the Life Orientation Test-Revised (LOT-R) (3). The LOT-R consists of 10 questions:the score ranges from 0 (low optimism) to 24 (high optimism). Analyses included Spearman correlation and multivariate regression analyses to explain BASDAI based on optimism, adjusted on demographic variables and anxiety/depression, evaluated through the Hospital Anxiety and depression scale (HADS). Results 206 patients were included: mean age, 46.3 years, 49.0% were men. Mean disease duration was 15.5±10.8 yrs, mean BASDAI (0-10) was 3.8±2.0. Optimism was low to moderate: mean LOT-R score was 13.7±4.3. Optimism was significantly though slightly correlated to BASDAI scores: R=-0.15, p=0.04. However, in the multivariate analysis, there was no significant relationship between BASDAI and optimism. Conclusions Optimism was not associated to BASDAI scores in multivariate analyses. This result confirms that BASDAI is a valid tool, which can be interpreted independently of patients personality traits like optimism. This result is reassuring in view of the reports of a relationship between anxiety/depression and BASDAI. However, optimism is a stable personality trait through life whereas anxiety and depression are variable psychological states. More work is needed on the best ways to analyse SpA activity; in particular ASDAS should be further evaluated. References Brionez TF, et al. Psychological Correlates of Self-Reported Disease Activity in Ankylosing Spondylitis. J Rheumatol 2010; 37:829-34. Fabre S, et al. Do Patients with Axial Spondyloarthritis (AxSpA) Perform Enough Physical Activity? a Cross-Sectional Study of 207 Patients. Arthritis Rheum 2014, 66(suppl):S1125. Scheier MF et al. Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A re-evaluation of the Life Orientation Test. J Pers Soc Psychol 1994, 67:1063-78. Disclosure of Interest None declared

AB0791 Why Do Patients with Axial Spondyloarthritis (AXSPA) Perform Little Aerobic Exercise? A Study of Perceived Barriers and Benefits in 153 Axspa Patients

Background Regular exercise is considered a cornerstone of axSpA treatment, together with medication (1). However, only around half the patients reach the levels of physical activity recommended for health-enhancement and very few regularly perform aerobic exercise (2). Understanding why could help motivate axSpA patients to exercise more. Objectives To explore the benefits and barriers to physical exercise in axSpA patients. Methods A cross-sectional study was performed in two tertiary care hospitals and one office-based practice in France (2). Patients had definite axSpA according to the rheumatologist. Auto-questionnaires evaluating the frequency and type of aerobic exercise, and perceived benefits of and barriers to exercising through the Exercise Benefits/Barriers Score (EBBS) (3), were collected. EBBS comprises 43 items categorised into 5 subscales for benefits (life enhancement, physical performance, psychological outlook, social interaction and preventive health) and 4 subscales for barriers (exercise milieu, time expenditure, physical exertion, family discouragement). Analyses were comparative between men and women. Results In all, 153 patients were analysed: mean age, 45.7±11.1 years, mean disease duration 14.2±9.7 yrs, mean BASDAI (0-100) 36.7±20.7, mean BASFI (0-100) 28.1±25.5, mean BMI 25.2±4.8 kg/m2; 56.2% were men. The main benefits of exercise (for which more than 90% of patients agreed or strongly agreed with the item) were all in the ‘physical performance’ subscale. Highest agreement was found for: improving functioning of cardiovascular system (94.8%), increasing muscle strength (93.5%), level of physical fitness (92.8%), stamina (90.9%), and for women: flexibility (91.0%). The three main barriers were ‘people looking funny in exercise clothes’ (87.6%), ‘too few places to exercise’ (80.4%), and ‘lack of encouragement from family members’ (81.1%). Results were similar for men and women. Conclusions The main barriers to exercising for axSpA patients were ‘exercise milieu’ problems and ‘family discouragement’ while the main perceived benefit was a better physical performance. These findings could be helpful when encouraging physical activity in axSpA patients. References Braun J et al. 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis 2011;70:896–904. Fabre S, et al. Do Patients with Axial Spondyloarthritis (AxSpA) Perform Enough Physical Activity? a Cross-Sectional Study of 207 Patients. Arthritis Rheum 2014, 66(suppl):S1125. Sechrist KR, et al. Development and psychometric evaluation of the exercise benefits/barriers scale, Res Nurs Health 1987;10:357-65. Disclosure of Interest None declared