Tsui Yee Lian

Acute lupus myocarditis: clinical features and outcome of an oriental case series.

Symptomatic myocarditis in systemic lupus erythematosus (SLE) is uncommon. We describe the clinical characteristics, management and outcomes of 11 SLE patients without any atherosclerotic risk factors, who presented with acute lupus myocarditis (ALM). All patients were female, 46% Chinese with mean age of 27 < 10 years at diagnosis of SLE. ALM was one of the initial manifestations of SLE in eight (73%) patients. The median duration from onset ALM to initiation of treatment was two weeks (range: 0.3-8). All had clinical feature of left ventricle dysfunction. The most common electrocardiographic feature was nonspecific ST/T wave changes (91%). Common echocardiographic findings included segmental wall motion abnormalities (81%) and decreased left ventricular ejection fraction (81%). Median SLE disease activity index at presentation was 16 (range: 4-30). All patients received high dose corticosteroids and 64% received intravenous pulse cyclophosphamide. There were two deaths (18%) from infections. The remaining nine survivors had no recurrence of ALM nor suffer any SLE-related damage (median SLICC damage score of 0), up to a median follow-up of four years (range: 2.5-10.1). Repeat echocardiography after six months or later showed normal LVEF in eight patients (89%). Early immunosuppressive therapy in ALM, with high dose corticosteroids and pulse intravenous cyclophosphamide, results in good cardiac outcome.

Enhanced expression of interferon-inducible protein-10 correlates with disease activity and clinical manifestations in systemic lupus erythematosus

Our objective was to investigate the serum levels of interferon‐inducible protein‐10 (IP‐10) in systemic lupus erythematosus (SLE) and their correlation with disease activity and organ manifestations. Serum IP‐10 levels were assessed in 464 SLE patients and 50 healthy donors. Disease activity was assessed by the revised SLE Activity Measure, and the concomitant active organ manifestations, anti‐ds DNA antibody titres, complement levels and erythrocyte sedimentation rates recorded. Peripheral blood mononuclear cell (PBMC) synthesis of IP‐10 in SLE patients and controls was determined by in vitro cultures stimulated with mitogen or lipopolysaccharide. Elevated serum IP‐10 levels were observed in SLE patients, which were significantly higher in the presence of active haematological and mucocutaneous manifestations. SLE PBMCs exhibited enhanced spontaneous IP‐10 production in vitro. Serial IP‐10 levels correlated with longitudinal change in SLE activity, even at low levels where anti‐dsDNA antibody and complement levels remain unchanged. These data demonstrate that IP‐10 levels are increased in SLE and serum IP‐10 may represent a more sensitive marker for monitoring disease activity than standard serological tests.

Major gastrointestinal manifestations in lupus patients in Asia: lupus enteritis, intestinal pseudo-obstruction, and protein-losing gastroenteropathy

Gastrointestinal (GI) symptoms are common in patients with systemic lupus erythematosus (SLE) and may be due to the disease itself, side-effects of medications, or non-SLE causes. However, GI manifestations of lupus attract far less attention than the other major organ involvements, are infrequently reviewed and rarely documented in published lupus databases or cohort studies including those from countries in Asia. According to three reports from two countries in Asia, the cumulative prevalence of SLE GI manifestations range from 3.8% to 18%. In this review, we focus on three major GI manifestations in patients from Asian countries: lupus enteritis, intestinal pseudo-obstruction, and protein-losing gastroenteropathy, for which early recognition improves outcome and reduces morbidity and mortality.

Discordant assessment of lupus activity between patients and their physicians: the Singapore experience

Patients with systemic lupus erythematosus often assess their disease activity differently from their physicians. We studied the factors associated with this discordance. The data provided by 534 systemic lupus erythematosus patients were analyzed. We compared the physician and patient assessments of lupus activity on a visual-assessment scale from the same visit. We collected clinical data and scores from MOS 36-Item Short-Form Health Survey, Systemic Lupus Erythematosus Quality-of-Life Questionnaire, Rheumatology Attitudes Index, Systemic Lupus Erythematosus Disease Activity Index, and revised Systemic Lupus Activity Measure. Patients tended to score their disease activity higher than do their physicians, when these factors were present: poorer general health assessment, presence of thrombocytopenia, hypertension and urinary sediments, and difficulty in carrying groceries. Physicians tended to score the disease activity higher than do the patients in these circumstances proteinuria, hemolysis, use of azathioprine or cyclophosphamide, tiredness, photosensitivity, higher revised Systemic Lupus Activity Measure score, casturia, and patient report of being more easily ill than are other patients. There was only moderate correlation between the discordance in the baseline and the subsequent visits. The physician assessment of disease activity at baseline correlated better with an objective measure of disease activity (revised Systemic Lupus Activity Measure) in the subsequent visit than the patient assessment. In conclusion, discordance in the perception of disease activity between patients and physicians may be amenable to intervention.

Achieving consensus in ultrasonography synovitis scoring in rheumatoid arthritis

Ultrasonography is sensitive for synovitis detection but interobserver variation in both acquisition and image interpretation is still a concern. The objective was to assess if a short collegiate consensus would improve inter‐observer reliability in scoring of synovitis.

Urine sVCAM‐1 and sICAM‐1 levels are elevated in lupus nephritis

We sought to evaluate the relationship of urine levels of soluble cellular adhesion molecules sVCAM‐1 (vascular) and sICAM‐1 (intercellular) in systemic lupus erythematosus (SLE) patients with or without lupus nephritis, and to explore their correlation with renal disease activity.

SAT0511 Achieving Consensus in Ultrasonography Synovitis Scoring in Rheumatoid Arthritis

Background Ultrasonography (US) is a sensitive method for synovitis detection in clinical practice but interobserver variation in both acquisition and image intepretation is still a key concern [1]. Various semiquantitative synovitis scoring methods have been proposed in the past for B-mode and PDUS. Recently, the OMERACT US Task Force also proposed the EULAR-OMERACT PDUS composite scoring which had moderate to excellent reliability [2]. However, this has not been tested formally outside of the steering group. Objectives The objective was to evaluate if a collegiate small group consensus would improve US synovitis assessment and scoring in patients with rheumatoid arthritis, in both still images and in image acquisition. Methods Eight rheumatologists from Singapore participated in a 1 day consensus meeting in November 2012, divided into (i) still-image interpretation and consensus followed by (ii) image acquisition and interpretation, according to definitions and synovitis scoring rules endorsed by OMERACT and TUI (Targeted Ultrasound Initiative). Interobserver reliability of semiquantitative scoring in B-mode, Power Doppler (PDUS) and EULAR-OMERACT PDUS composite score was assessed by intraclass correlation co-efficient (ICC). Agreement at the joint region level was calculated using prevalence-adjusted-biased-adjusted-kappa (PABAK). Results For B-mode still images, ICC was good at 0.75 (95%CI 0.66-0.82) while for PDUS images this was excellent; ICC=0.88 (95%CI 0.83-0.92). During image acquisition and interpretation, B-mode scoring showed ICC=0.75 (95%CI 0.66-0.84) while for PDUS the ICC was lower at 0.59 (95%CI 0.48-0.72). The ICC for EULAR-OMERACT PDUS composite synovitis scoring was good at 0.77 (95%CI 0.68-0.85). At the joint level, agreement varied with PABAK being excellent in the small joints of the hands but poor to fair in the wrists, elbows, ankles and MTP, and no agreement at the knees (PABAK range -0.34 to 0.85). Conclusions A consensus meeting between colleagues was useful in improving interobserver variation in synovitis scoring by ultrasonography, but agreement in non-hand joints is still a problem, requiring further standardisation. References Cheung PP, Dougados M, Gossec L. Reliability of ultrasonography to detect synovitis in rheumatoid arthritis: a systematic literature review of 35 studies (1415 patients). Arthritis Care Res (Hoboken) 2010; 62:323-34. Naredo E, Wakefield R, Iagnocco A, et al. The OMERACT Ultrasound Task Force - Perspectives. J Rheumatol 2011;38:2063-7. Disclosure of Interest None Declared

Associations of B cell-activating factor (BAFF) and anti-BAFF autoantibodies with disease activity in multi-ethnic Asian systemic lupus erythematosus patients in Singapore

To measure the levels of B cell‐activating factor (BAFF) and endogenous anti‐BAFF autoantibodies in a cohort of multi‐ethnic Asian systemic lupus erythematosus (SLE) patients in Singapore, to determine their correlation with disease activity. Serum samples from 121 SLE patients and 24 age‐ and sex‐matched healthy controls were assayed for BAFF and anti‐BAFF immunoglobulin (Ig)G antibody levels by enzyme‐linked immunosorbent assay (ELISA). The lowest reliable detection limit for anti‐BAFF‐IgG antibody levels was defined as 2 standard deviations (s.d.) from blank. Correlation of serum BAFF and anti‐BAFF IgG levels with disease activity [scored by SLE Activity Measure revised (SLAM‐R)], and disease manifestations were determined in these 121 patients. SLE patients had elevated BAFF levels compared to controls; mean 820 ± 40 pg/ml and 152 pg ± 45/ml, respectively [mean ± standard error of the mean (s.e.m.), P < 0·01], which were correlated positively with anti‐dsDNA antibody levels (r = 0·253, P < 0·03), and SLAM‐R scores (r = 0·627, P < 0·01). In addition, SLE patients had significantly higher levels of anti‐BAFF IgG, which were correlated negatively with disease activity (r = –0·436, P < 0·01), levels of anti‐dsDNA antibody (r = –0·347, P < 0·02) and BAFF (r = –0·459, P < 0·01). The majority of patients in this multi‐ethnic Asian SLE cohort had elevated levels of BAFF and anti‐BAFF antibodies. Anti‐BAFF autoantibody levels correlated negatively with clinical disease activity, anti‐dsDNA and BAFF levels, suggesting that they may be disease‐modifying. Our results provide further information about the complexity of BAFF pathophysiology in different SLE disease populations and phenotypes, and suggest that studies of the influence of anti‐cytokine antibodies in different SLE populations will be required when selecting patients for trials using targeted anti‐cytokine therapies.

THU0116 Singapore Patients with Rheumatoid Arthritis Have A Higher Incidence of Solid-Organ Malignancies than The General Population: Findings from The TTSH RA Registry

Objectives Patients with rheumatoid arthritis (RA) have been shown to have an increased risk of developing malignancies. This study was undertaken to determine the incidence and patterns of malignancy in RA patients and identify risk factors of malignancy among patients with RA. Methods Patients from the TTSH RA Registry were followed up longitudinally and those who developed malignancies from 2001 to 2013 after the onset of RA were identified. Age-standardised rates (ASRs) of various cancers were analyzed and compared with the Singapore Cancer Registry data. Risk factors for developing malignancy, including demographics and disease characteristics at baseline, were analyzed using Chi-squared test and students t test. Results Of the 1,134 patients in the registry, 28 patients were excluded as they developed malignancy prior to study enrollment. 1,106 patients were included in the final analysis. Of the 1,106 patients, 81 patients developed malignancies at a mean interval of 15.1 (SD 9.7) years after the onset of RA. The mean age of the 81 patients was 65.9 (SD 10.8) years, of which 61 (75.31%) were females and 69 (85.19%) were Chinese. There were 70 (86.4%) with solid-organ tumours and 11 (13.6%) haematological malignancies. The ASR of cancer in RA patients was 310.3 for males and 232.5 for females per 100,000 person-years, compared with 229.3 (95%CI 226.5–232) for males and 218.3 (95%CI 213.8–216.3) for females in the general population. By cancer type, there is an increased risk of lung cancer, lymphoid neoplasms and stomach cancer in RA compared with the general population. The risks factors for developing malignancy (p<0.05) include male gender, non-Indian ethnicity, onset of RA at an older age, untreated RA and higher disease activity.Table 1. Demographics, disease characteristics and treatment history of patients without malignancy and those who develop malignancy Total No. of patients No. of patients without maligancy No. of patients with maligancy after 1st study entry Univariate test n=1106 (%) n=1025 (%) n=81 (%) p-value (t-test or chi2) Demographics  Age at RA onset (yrs) mean (SD) 45.03 (13.40) 44.58 (13.20) 50.77 (14.59) 0.0001  Age at RA diagnosis (yrs) mean (SD) 47.31 (13.69) 46.74 (13.55) 54.43 (13.52) <0.0001  Duration of RA onset to RA diagnosis (mths) mean (SD) 27.34 (66.63) 26.02 (64.86) 43.96 (84.61) 0.0196  Gender Male 177 (16.02) 157 (15.33) 20 (24.69) 0.0390 Diease characteristics  ESR at 1st study visit mean (SD) 37.58 (27.06) 36.98 (26.60) 45.15 (31.54) 0.0102  CRP at 1st study visit mean (SD) 20.23 (23.21) 19.11 (22.24) 33.56 (30.59) 0.0248  No. of tender joints at 1st study visit mean (SD) 1.84 (3.80) 1.78 (3.69) 2.54 (4.94) 0.0817  No. of swollen joints at 1st study visit mean (SD) 2.34 (3.59) 2.26 (3.45) 3.37 (4.90) 0.0072  DAS28 at 1st study visit mean (SD) 3.35 (1.41) 3.33 (1.39) 3.61 (1.57) 0.0894 Conclusions The incidence of solid-organ malignancies was higher than hematological malignancies, unlike that in the literature. The overall risk of malignancy is higher in RA patients. Chronic inflammation from RA is associated with increased risk of malignancy. Acknowledgement This study is supported by the Centre Grant, National Medical Research Council, Ministry of Health, NMRC/CG/017/2013. Disclosure of Interest None declared

SAT0060 Orthopaedic Surgery in an Asian Rheumatoid Arthritis Cohort: Predictors and Impact on Quality of Life

Objectives To identify predictors of orthopaedic surgery and its impact on quality of life in a South-East Asian rheumatoid arthritis registry cohort. Methods Data was collected from patients enrolled in the Tan Tock Seng Hospital Rheumatoid Arthritis Registry. All patients fulfilled the 1987 ACR criteria for RA. The clinical, extraarticular features (EAF), disease activity score (DAS 28), functional status (Health Assessment Questionnaire, HAQ) and health- related quality of life measures (SF-36) were prospectively collected since 2001. Comparison between those with and without orthopaedic surgical procedures (groups I and II respectively) at entry to the registry till 2013 or death was done. Risk factors for surgery at study entry were determined using logistic regression (STATA SE 10), adjusted for age and disease duration. Results The study comprised of 1049 patients, predominately Chinese (77.9%); 190 patients (18.1%) had surgery (synovectomy 6.4%, arthroplasty 17.5%, arthodesis 1.1%). The mean age of groups I and II were similar (49.2 vs 48.2 years, p=0.35), mean duration from onset of RA to 1st joint surgery was 136.2 months. Group I had significantly longer symptoms before seeking rheumatologists (mean 63.5 vs 32.0 months, p<0.0001), duration from onset of RA to 1st disease modifying drug (74.2 vs 39.3 months, P<0.0001) and disease duration (243.1 vs 151.6 months, p<0.0001). Higher deformed joint count (mean 4.8 vs 1.7, OR 1.13, p<0.001), presence of radiographic erosions (70.4 vs 52.3%, OR 1.46, p<0.05), EAF (36.3 vs 24.1%, OR 1.67, p=0.004), HAQ score >1.5 (15.4 vs 7.5%, OR 3.08, p<0.001 and not DAS 28 or RF positivity were predictive of orthopaedic surgery. Lower scores were seen for the physical functioning domains of the SF36 in the group that had orthopaedic surgery, but there was no significant difference in the mental component between the two groups. Conclusions Delayed diagnosis and delay in initiation of disease modifying therapy were positive predictors of orthopaedic surgery in our cohort of RA patients, independent of disease activity scores and rheumatoid factor positivity. RA patients in this cohort who required orthopaedic intervention report significantly poorer scores on physical quality of life measures. Acknowledgements This study is supported by the Centre Grant, National Medical Research Council, Ministry of Health, Singapore. (CG12Aug17) Disclosure of Interest None declared