Rikke Asmussen Andreasen

Prognostic factors associated with mortality in patients with septic arthritis: a descriptive cohort study

Objectives: To evaluate the 30-day mortality rate of septic arthritis (SA) in adults in Funen, central Denmark, and to explore whether, at the time of SA presentation, risk factors for the 30-day mortality rate could be revealed. Our secondary objective was to describe the microbiological aetiologies, systemic signs of inflammation, and co-morbidity. Method: A descriptive study identifying patients with SA from central Denmark, during the period 2006–2013, by the use of joint fluid culture data retrieved from the electronic database at the Department of Clinical Microbiology, Odense University Hospital. Patients with a positive joint fluid culture were considered eligible and their medical records were examined. Results: We identified 215 patients with SA, mean age 64.8 years. At presentation, mean C-reactive protein (CRP) was 204 mg/L, mean white blood cell count (WBC) 11.9 × 109/L, and mean body temperature 37.6°C. A total of 101 patients (47%) had a prosthetic joint, 46 (21%) had an inflammatory joint disease, and 24 (11%) had diabetes mellitus (DM). Staphylococcus aureus was the most common pathogen (104 patients, 48.4%). The 30-day mortality rate was 9.3% and the significant risk factor for death was liver disease at time of presentation [odds ratio (OR) 40.40, 95% confidence interval (CI) 5.38–303]. The other factors tested such as age > 65 years, elevated temperature, rheumatoid arthritis (RA), prostheses, and diabetes mellitus (DM) did not reach statistical significance. Conclusions: In our sample of patients with SA, we found a 30-day mortality rate in almost one in 10 adults. Among possible explanations, our study indicates that liver disease is a clinically relevant risk factor.

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.

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.

Clinical characteristics of importance to outcome in patients with axial spondyloarthritis: protocol for a prospective descriptive and exploratory cohort study

Introduction Spondyloarthritis (SpA) is a heterogeneous spectrum of rheumatic diseases with either predominantly axial inflammatory symptoms of the spine and sacroiliac joints or predominantly peripheral arthritis. The two main entities of axial SpA (axSpA) are ankylosing spondylitis or non-radiographic axSpA (nr-axSpA). Tumour necrosis factor-α inhibitors have revolutionised the treatment of patients with axSpA who failed to respond to non-steroidal anti-inflammatory drugs and physical therapy. Chronic pain is common in patients with SpA and may still persist despite the lack of signs of inflammation. This has led researchers to hypothesise that central pain sensitisation may play a role in the generation of chronic pain in SpA. The painDETECT Questionnaire (PDQ) is a screening tool developed to detect neuropathic pain components. The primary objective is to explore the prognostic value of the PDQ regarding treatment response in patients with axSpA 3 months after initiating a biological agent. Secondary aim is to evaluate the impact of extra-articular manifestations, comorbidities and patient-reported outcomes and elucidate if these factors influence treatment response. Method and analysis We will include 60 participants (≥18 years of age) diagnosed with axSpA independent of main entity, who initiate or switch treatment of a biologic. Data will be collected at baseline and at endpoint following Danish clinical practice (≥3 months) of treatment with biologics. We will explore whether the PDQ and other phenotypical patient characteristics are prognostically important for response to biological therapy according to established response criteria like 50% improvement in the Bath Ankylosing Spondylitis Disease Activity Index (50%) and Ankylosing Spondylitis Disease Activity Score. Ethics and dissemination The study is approved by the Region of Southern Denmark’s Ethics committee (S-20160094) and has been designed in cooperation with patient representatives. The study is registered at clinicaltrials.gov (NCT02948608, pre-results). Dissemination will occur through publication(s) in international peer-reviewed journal(s).

Authors’ reply: Prognostic factors associated with mortality in patients with septic arthritis: a descriptive cohort study

change on leucocyte esterase test strip; (iii) elevated synovial fluid polymorphonuclear neutrophil (PMN) percentage; (iv) a single positive periprosthetic culture; and (v) positive histological analysis of periprosthetic tissue (2). There are different types of PJIs. Acute postoperative infections are defined as infections of the prosthesis that occur within 90 days after surgery (2). Infections diagnosed later than 90 days after surgery are defined as chronic PJIs (2). Each type has its own treatment modality. In acute PJIs, usual care means debridement, antibiotics, and implant retention (2, 5). Chronic PJIs are treated with implant revision surgery (2, 5). In general, antibiotics are administered for a minimum of 3 months in both acute and chronic PJIs (2, 5). This is due to biofilm formation that occurs on the prosthesis, which functions as a foreign body (2, 5). Therefore, antibiotics that penetrate biofilms are recommended (2, 5). Treatment of native SA generally consists of 6 weeks of antibiotics with needle aspiration or arthroscopy of the joint (6). Furthermore, there are other factors that may influence the primary outcomes of this study. The characteristics of patients with a TJA in the general population may be different from those of the native joint group. The threshold for operating on vulnerable patients with chronic diseases has decreased (7). So, within the population of patients who receive TJAs, comorbidities may be more often present and they generally have a higher age (7). The conclusion of the authors that the 30 day mortality rate in their study could not be explained by comorbidities or old age in native SA may have to be reconsidered after eliminating these factors. Concerning their secondary outcomes, there also are some points of discussion that may be important in interpreting the results of this study. Systemic signs are less common in chronic PJIs (2). Therefore, the secondary objective, to describe systemic signs of inflammation, could be biased in case a significant number of the included patients had chronic PJIs. Furthermore, the authors have given averages for several microorganisms for the WBC count in synovial fluid, but it is not known whether they were aware that the cut-offs for WBC and PMNs in synovial fluid are different between acute and chronic PJIs (2). The cutoffs presented in this study may also be biased because of this phenomenon. In conclusion, this study could be a valuable addition to the current literature in determining prognostic factors associated with mortality in patients with SA in native joints and in PJIs. A recommendation would be to split these different pathologies into separate groups. For the group of PJIs it is recommended also to differentiate between acute and chronic joint infections.

Polymyalgia rheumatica and giant cell arteritis—three challenges—consequences of the vasculitis process, osteoporosis, and malignancy: A prospective cohort study protocol

Introduction: Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are common inflammatory conditions. The diagnosis of PMR/GCA poses many challenges since there are no specific diagnostic tests. Recent literature emphasizes the ability of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) to assess global disease activity in inflammatory diseases. 18F-FDG PET/CT may lead to the diagnosis at an earlier stage than conventional imaging and may also assess response to therapy. With respect to the management of PMR/GCA, there are 3 significant areas of concern as follows: vasculitis process/vascular stiffness, malignancy, and osteoporosis. Methods and analysis: All patients with suspected PMR/GCR referred to the Rheumatology section of Medicine Department at Svendborg Hospital, Denmark. The 4 separate studies in the current protocol focus on: the association of clinical picture of PMR/GCA with PET findings; the validity of 18F-FDG PET/CT scan for diagnosis of PMR/GCA compared with temporal artery biopsy; the prevalence of newly diagnosed malignancies in patients with PMR/GCA, or PMR-like syndrome, with the focus on diagnostic accuracy of 18F-FDG PET/CT scan compared with conventional workup (ie, chest X-ray/abdominal ultrasound); and the impact of disease process, and also steroid treatment on bone mineral density, body composition, and vasculitis/vascular stiffness in PMR/GCA patients. Ethics and dissemination: The study has been approved by the Regional Ethics Committee of the Region of Southern Denmark (identification number: S-20160098) and Danish Data Protection Agency (J.nr 16/40522). Results of the study will be disseminated via publications in peer-reviewed journals, and presentation at national and international conferences.

Mycoplasma infection inducing flare of Behcet´s disease in young man

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

There is a risk of overtreatment when the Disease Activity Score in 28 joints is based solely on subjective parameters. A cross-sectional, exploratory, DANBIO study.

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

Significance of the lower reporting limit and intraindividual biological variability for C-reactive protein in calculating the Disease Activity Score in 28 joints (DAS28): theoretical considerations

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