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A prospective study of vasculitis patients collected in a five year period: evaluation of the Chapel Hill nomenclature.

OBJECTIVE To test the usefulness of the Chapel Hill nomenclature, supplemented with surrogate parameters, as diagnostic criteria for primary vasculitides. METHODS To prospectively evaluate vasculitis patients according to a standardised clinical and para-clinical programme. In accordance with the Chapel Hill publication surrogate parameters were used: proteinuria, haematuria and red blood cell casts (glomerulonephritis), angiographic or ultrasonic demonstration of aneurysms or stenoses (arteritis), radiological lung infiltrates or cavitations of more than one months duration (granuloma in the lungs), bloody nasal discharge or crusts, chronic sinusitis, otitis and/or mastoiditis, bone and/or cartilage destruction, and acute hearing loss (granuloma in upper airways). RESULTS The following entities were diagnosed: giant cell arteritis (n=14), Takayasu arteritis (n=1), polyarteritis nodosa (n=2), Wegeners granulomatosis (n=27), Churg-Strauss syndrome (n=2), microscopic polyangiitis (n=12), Henoch-Schönlein purpura (n=2), cutaneous leucocytoclastic angiitis (n=37), and secondary vasculitis (n=21). Giant cell arteritis and cutaneous leucocytoclastic angiitis were in all cases diagnosed by biopsy. Using the Chapel Hill nomenclature supplemented with surrogate parameters, only 8 of 27 patients were diagnosed with Wegeners granulomatosis, and 3 of 12 cases with microscopic polyangiitis. The number of patients in the remaining diagnostic entities were considered to few to evaluate. CONCLUSIONS The Chapel Hill nomenclature, supplemented with surrogate parameters, failed to act as diagnostic criteria in Wegeners granulomatosis and microscopic polyangiitis. The following diagnostic criteria are proposed for Wegeners granulomatosis: (1) Biopsy or surrogate parameter for granulomatous inflammation in the respiratory system and (2) Biopsy verified necrotising vasculitis in small to medium sized vessels or biopsy/surrogate parameter for glomerulonephritis or positive PR3-ANCA test and (3) Lack of eosinophilia in blood and biopsy samples. The following diagnostic criteria are proposed for microscopic polyangiitis: (1) Biopsy verified necrotising vasculitis in small vessels and/or glomerulonephritis with few or no immune deposits and (2) Involvement of more than one organ system as indicated by biopsy verified vasculitis in small to medium sized vessels or surrogate parameter for glomerulonephritis and (3) Lack of biopsy and surrogate parameter for granulomatous inflammation in the respiratory system. Using these criteria all Wegeners patients and 9 of 12 patients with microscopic polyangiitis could be diagnosed.

Soluble urokinase plasminogen activator receptor in plasma of patients with inflammatory rheumatic disorders: increased concentrations in rheumatoid arthritis

OBJECTIVE Urokinase type plasminogen activator (uPA) catalyses the formation of the proteolytic enzyme plasmin, which is involved in matrix degradation in the processes of tissue remodelling. Because of a surface bound uPA receptor (uPAR), expressed by some cell types (for example, macrophages, malignant cells and inflammatory activated synoviocytes), the action of uPA can be localised and intensified. uPAR seems to have a role in the mechanisms leading to invasive growth of malignant tissue and the rheumatoid pannus. uPAR may become cleaved at its cell surface anchor, thus forming a free soluble receptor (suPAR). suPAR is detectable in low but constant values in plasma of healthy people, while increased concentrations are found in patients with disseminated malignant disease, so that suPAR may be an indicator of invasive growth and tissue remodelling. suPAR concentrations in plasma have not previously been measured in rheumatic patients. A controlled cross sectional measurement was performed of suPAR in plasma of patients with various inflammatory rheumatic disorders with special reference to rheumatoid arthritis (RA). METHODS suPAR in plasma was measured by ELISA technique in patients with RA (n=51), reactive arthritis (ReA) (n=23), primary Sjögren’s syndrome (PSS) (n=42) and sex and age matched healthy controls (n=53). RESULTS In the control group suPAR (median) was 0.91 (range 0.56–1.94) μg/l. Median suPAR value in RA was 1.47 (range 0.65–6.62) μg/l; in ReA 0.68 μg/l (range 0.52–1.48) and in PSS 1.12 μg/l (range 0.76–1.92); p versus controls <0.001 in all patient groups. suPAR values in RA were also significantly increased compared with ReA (p<0.001) and PSS (p=0.004) groups. suPAR in RA was positively correlated to C reactive protein (CRP) (p<0.01) and erythrocyte sedimentation rate (p<0.05) and number of swollen joints (p<0.05). The ReA group had the highest CRP values of all groups, but at the same time the lowest suPAR concentrations in plasma. CONCLUSIONS Increased suPAR concentrations were found in plasma in RA, and to a smaller extent also in PSS, but not in ReA. In RA suPAR is related to disease activity. suPAR seems though not merely to be an acute phase reactant like CRP. Increased suPAR values might reflect erosive activity in RA.

Performance of classification criteria for gout in early and established disease

Objectives To compare the sensitivity and specificity of different classification criteria for gout in early and established disease. Methods This was a cross-sectional study of consecutive rheumatology clinic patients with joint swelling in which gout was defined by presence or absence of monosodium urate crystals as observed by a certified examiner at presentation. Early disease was defined as patient-reported onset of symptoms of 2 years or less. Results Data from 983 patients were collected and gout was present in 509 (52%). Early disease was present in 144 gout cases and 228 non-cases. Sensitivity across criteria was better in established disease (95.3% vs 84.1%, p<0.001) and specificity was better in early disease (79.9% vs 52.5%, p<0.001). The overall best performing clinical criteria were the Rome criteria with sensitivity/specificity in early and established disease of 60.3%/84.4% and 86.4%/63.6%. Criteria not requiring synovial fluid analysis had sensitivity and specificity of less than 80% in early and established disease. Conclusions Existing classification criteria for gout have sensitivity of over 80% in early and established disease but currently available criteria that do not require synovial fluid analysis have inadequate specificity especially later in the disease. Classification criteria for gout with better specificity are required, although the findings should be cautiously applied to non-rheumatology clinic populations.

Study for Updated Gout Classification Criteria: Identification of Features to Classify Gout

To determine which clinical, laboratory, and imaging features most accurately distinguished gout from non‐gout.

Performance of Ultrasound in the Diagnosis of Gout in a Multicenter Study: Comparison With Monosodium Urate Monohydrate Crystal Analysis as the Gold Standard

To examine the performance of ultrasound (US) for the diagnosis of gout using the presence of monosodium urate monohydrate (MSU) crystals as the gold standard.

Development of Preliminary Remission Criteria for Gout Using Delphi and 1000Minds Consensus Exercises

To establish consensus for potential remission criteria to use in clinical trials of gout.

Pattern of bone erosion and bone proliferation in psoriatic arthritis hands: a high-resolution computed tomography and radiography follow-up study during adalimumab therapy

Objectives: To investigate the pattern and development of bone erosion and proliferation in patients with psoriatic arthritis (PsA) during treatment with adalimumab, using high-resolution computed tomography (CT) and conventional radiography. Method: Forty-one biologic-naïve PsA patients were initiated with adalimumab 40 mg subcutaneously every other week. CT and radiography of the 2nd–5th metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints were conducted at baseline (n = 41) and after 24 weeks (n = 32). Changes in bone erosion and proliferation are described and the imaging modalities compared. Results: Ninety percent of bone erosions detected by CT were located in the metacarpal heads, and most frequently in the 2nd-3rd MCP joints. Radial (37%) and ulnar (31%) surfaces were more frequently eroded than dorsal (10%) and palmar (22%) sites. Using CT, bone proliferations were located primarily on the sides of the distal part of the DIP joints (43% of all proliferations), but also proximally in DIP (17%) and MCP joints (27%). For bone erosions and proliferations, respectively, radiography showed a low sensitivity (17% and 26%), but a high specificity (98% and 95%) and accuracy (93% and 87%), with CT as the gold standard reference. Neither CT nor radiography revealed statistically significant changes in bone erosion or proliferation scores between baseline and follow-up. Conclusions: Patterns of bone erosion and proliferation in PsA hands were revealed in more detail by CT than by radiography. No overall progression or repair could be detected during adalimumab treatment with either of the methods.

Homocysteine, a marker of cardiovascular disease risk, is markedly elevated in patients with gout

Homocysteine (Hcy) is an amino acid formed by demethylation of methionine. Impaired renal function, enzymatic polymorphisms, and low levels of B-group vitamins dispose to hyperhomocysteinaemia (HHcy).1 ,2 HHcy as well as hyperurecaemia induce reactive oxygen species and impair endothelial function1 ,3 and are associated with increased risk of cardiovascular disease (CVD).1–4 Hcy and urate possibly have additive effects on the endothelial function.5 Studies in normal populations have shown positive correlations between p-Hcy and p-urate,6 ,7 but reports on the prevalence of HHcy in gout patients have shown conflicting results.8–10 To study the prevalence of HHcy in gout—133 …

Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) consensus statement regarding labels and definitions for disease elements in gout

The language currently used to describe gout lacks standardization. The aim of this project was to develop a consensus statement on the labels and definitions used to describe the basic disease elements of gout.

OP0155 Ultrasound as an outcome measurement tool for optimisedmonitoring of gout. validation of the omeract ultrasound definitions of gout elementary lesions

Objectives To evaluate ultrasound (US) as an outcome measurement instrument for monitoring gout patients during urate lowering therapy using the OMERACT US Working Group’s 2015 definitions of US elementary lesions in gout. Methods US examination (28 joints, 26 tendons) were performed in patients with microscopically verified gout who either initiated or increased urate lowering therapy. Joints and tendons were evaluated for the four OMERACT elementary lesions of gout (Double contour, Tophus, Aggregates and Erosions). Furthermore, subcutaneous (SC) oedema was registered and synovitis was graded by grey scale (GS) and colour Doppler (CD) (both graded 0–3). A sum score was calculated for each component for each patient (table 1). Patient Reported Outcomes (PROs) regarding pain (visual analogue scale), numbers of attacks within the last 3 months and physical function (Health Assessment Questionnaire) were obtained, as were C-reactive protein (CRP), p-urate and clinical joint examination. All examinations were repeated after 3 (n=29) and 6 months (n=15, follow-up still ongoing) and changes in scores were evaluated using Wilcoxon-Pratt signed-rank test. Results 29 patients (28 males, 1 female), mean age of 68 (39 – 89) years were included. US showed a numerical, but statistically non-significant (p=0.13), decline in DC count from baseline to 3 months’ follow up, while at 6 months a statistically significant decline was observed (p=0.033). The tophus count decreased non-significantly at both 3 and 6 months’ follow up, whereas the aggregate and erosion counts by large were unchanged. GS synovitis showed a statistically non-significant decrease at follow ups, whereas CD synovitis and SC oedema counts declined significantly at 3 months’ follow up (p=0.033 and 0.044, respectively). P-urate levels decreased statistically significant from baseline to both 3 and 6 months’ follow-up (both p-values<0.001), as did clinical markers such as CRP, joint evaluation, pain and attack frequency.Abstract OP0155 – Table 1 Course of US, biochemical and clinical variables during urate lowering therapy Conclusions Of the four OMERACT US elementary gout lesions only DC count showed a statistically significant decrease as a response to 6 months of urate lowering therapy. The number of tophi had decreased at both 3 and 6 months’ follow up, but not statistically significant. Aggregates and erosions count did not markedly respond to the 6 month treatment. The study indicates that US assessing the OMERACT elementary lesions, particularly DC, is a feasible tool for monitoring gout lesions. However, a follow-up of at least 6 months may be needed to detect change of crystal deposits, as reflected by DC, and presumably an even longer follow-up period is needed to evaluate more massive deposits as tophi. Disclosure of Interest None declared