Interest of a systematic screening of comorbidities in chronic inflammatory rheumatisms

BackgroundPatients with chronic inflammatory rheumatisms (CIR) have a greater risk of cardiovascular events, infections, lung diseases and osteoporosis. European League against Rheumatisms (EULAR) recommends annual evaluation of the cardiovascular risks.MethodsA program of comorbidity screening was set up in a daily clinic of our Rheumatology department and includes:– rheumatism evaluation;– cardiovascular evaluation; clinical examination, blood tests, modified systematic coronary risk evaluation (mSCORE) calculation, vessel ultrasound and echocardiography;– lung evaluation; self-questionnaires and spirometry;– osteoporosis; bone mineral density and FRAX calculation;– check-up of vaccinal status and the recommended neoplasic screenings.ResultsNinety-two patients already benefited from this systematic screening with 83% (n=76) of rheumatoid arthritis, 11% (n=10) of spondyloarthritis, 3% (n=2) of psoriatic arthritis and 4% (n=4) of other diseases. The mean rheumatism duration was 14±9 years, the mean age was 59±11 years and 64% were women. Hypertension was diagnosed in 8.7% (n=8) of the patients; dyslipidemia in 9.8% (n=9); diabetes in 6.5% (n=6) of the patients. The echocardiography showed significant abnormalities (valvular and hypokinesia) in 9% (n=8) of the patients, a significant supra-aortic vessel stenosis was found in 4.5% (n=4) of the population and an abdominal aortic aneuvrysm was diagnosed in 5.7% (n=5). Among 92 patients, 18.4% (n=14) were estimated at high risk of lethal cardiovascular event with a mSCORE≥5 and 27.5% (n=25) patients were sent to a cardiologist to pursue further cardiovascular investigations. Among these, 8 had a myocardial scintigraphy and all were normal. Moreover, 32.6% (n=30) of the patients were estimated at risk of chronic obstructive pulmonary disease or sleep apnea syndrome and were recommended to consult pneumologist. An anti-osteoporosis drug was introduced in 12% (n=11) of the patients. The update of the vaccinations and the neoplasic screenings were prescribed for respectively 52.7% (n=48) and 35.2% (n=32) of the patients.DiscussionA daily hospitalization for comorbidity screening seems worthy with significant abnormalities discovered in 36.2% of the patients. Further investigations were recommended in 50% of the patients. Patient’ satisfaction and the effective impact of the proposed or prescribed measures are under evaluation

Graefes Arch Clin Exp Ophthalmol

Purpose To report the effectiveness of intravitreal aflibercept (IVT-AFL) treatment for diabetic macular edema (DME) in French clinical practice. Methods APOLLON (NCT02924311) was a prospective, observational cohort study of patients with DME. Effectiveness was evaluated by change from baseline in best-corrected visual acuity (BCVA) at 12 months in treatment-naïve patients (i.e., had not received any anti-vascular endothelial growth factor [anti-VEGF] agent, laser, or steroid at IVT-AFL treatment start) and previously treated patients (i.e., previously treated with anti-VEGF agents other than IVT-AFL, laser, or steroids at IVT-AFL treatment start). Secondary endpoints included change in central retinal thickness (CRT) over 12 months, frequency of injections, and proportion of patients with safety events. Results Of the 147 patients followed for at least 12 months and included in the effectiveness analysis, 52.4% (n = 77) were treatment-naïve and 47.6% (n = 70) were previously treated. Mean (standard deviation [SD]) BCVA score at baseline was 62.7 (14.3) Early Treatment Diabetic Retinopathy Study (ETDRS) letters in treatment-naïve patients and 60.0 (13.7) ETDRS letters in previously treated patients. At month 12, mean (SD) change in BCVA was + 7.8 (12.3) letters in treatment-naïve patients and + 5.0 (11.3) letters in previously treated patients. Mean CRT decreased in both patient cohorts. The mean (SD) number of IVT-AFL injections at month 12 was 7.6 (2.5) for treatment-naïve patients and 7.6 (2.3) for previously treated patients. Of 388 patients included in the safety analysis, ocular treatment-emergent adverse events occurred in 54.1% (n = 210) of patients. Conclusion IVT-AFL treatment was associated with improvements in functional and anatomic outcomes in both treatment-naïve and previously treated patients with DME in France

Projection of long-term visual acuity outcomes based on initial treatment response in neovascular age-related macular degeneration

PURPOSE To explore various methods for assessing the early response to vascular endothelial growth factor (VEGF) inhibitors for neovascular age-related macular degeneration and investigate their association with 3 year visual acuity (VA) outcomes. DESIGN Observational study from a prospectively collected registry. PARTICIPANTS Treatment-naïve eyes in the Fight Retinal Blindness! outcomes registry that commenced anti-VEGF therapy between 1st January 2007 and 1st March 2014 that received 3 anti-VEGF injections within the first 3 months. METHODS The early response was defined as occurring up until the 4th injection. Various early response metrics, which included both continuous and categorical variables, were explored: 1) achieving good VA (≥70 letters [20/40]), 2) absolute change in VA from baseline, 3) time to first grading of the choroidal neovascular lesion as inactive, 4) maximum rate of VA change between successive injections. MAIN OUTCOME MEASURES Proportion of eyes achieving ≥70 letters at 3 years. RESULTS This study included 2051 treatment-naïve eyes from 1828 patients. Achieving good vision at 3 years was significantly associated with 1) having good vision by the 4th injection (odds ratio [95% CI]: 9.8 [6.5, 14.7] for VA≥70 vs. VA5 letters) early VA gains (1.8 [1.2, 2.6], P = 0.002 and 1.8 [1.3, 2.5], P 3 injections), 4) gradual change (between -4 and 4 letters) or rapid (>5 letters) gains between successive injections (1.7 [1.1, 2.6], P = 0.015 and 1.6 [1.1, 2.3], P = 0.018 for gradual change and rapid gain vs. rapid loss). Eyes that achieved small or large early gains achieved similar vision at 3 years (65.0 and 64.7 letters respectively), and had better vision than eyes with early VA loss (57.2 letters). CONCLUSIONS Attainment of good vision by the 4th injection was strongly associated with 3 year visual outcomes, while other early response parameters had a moderate association. The early response during the initial 3 monthly loading doses can be a useful guide for subsequent treatment decisions

Retinal microvascular parameters are not associated with reduced renal function in a study of individuals with type 2 diabetes

Abstract The eye provides an opportunistic “window” to view the microcirculation. There is published evidence of an association between retinal microvascular calibre and renal function measured by estimated glomerular filtration rate (eGFR) in individuals with diabetes mellitus. Beyond vascular calibre, few studies have considered other microvascular geometrical features. Here we report novel null findings for measures of vascular spread (vessel fractal dimension), tortuosity, and branching patterns and their relationship with renal function in type 2 diabetes over a mean of 3 years. We performed a nested case-control comparison of multiple retinal vascular parameters between individuals with type 2 diabetes and stable (non-progressors) versus declining (progressors) eGFR across two time points within a subset of 1072 participants from the GoDARTS study cohort. Retinal microvascular were measured using VAMPIRE 3.1 software. In unadjusted analyses and following adjustment for age, gender, systolic blood pressure, HbA1C, and diabetic retinopathy, no associations between baseline retinal vascular parameters and risk of eGFR progression were observed. Cross-sectional analysis of follow-up data showed a significant association between retinal arteriolar diameter and eGFR, but this was not maintained following adjustment. These findings are consistent with a lack of predictive capacity for progressive loss of renal function in type 2 diabetes

2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis

© 2021 The Authors. Published by BMJ. This is an open access article available under a Creative Commons licence. The published version can be accessed at the following link on the publisher’s website: http://dx.doi.org/10.1136/annrheumdis-2021-220249Background: An important but often insufficient aspect of care in people with inflammatory arthritis (IA) is empowering patients to acquire a good understanding of their disease and building their ability to deal effectively with the practical, physical and psychological impacts of it. Self-management skills can be helpful in this regard. Objectives: To develop recommendations for the implementation of self-management strategies in IA. Methods: A multidisciplinary taskforce of 18 members from 11 European countries was convened. A systematic review and other supportive information (survey of healthcare professionals (HCPs) and patient organisations) were used to formulate the recommendations. Results: Three overarching principles and nine recommendations were formulated. These focused on empowering patients to become active partners of the team and to take a more proactive role. The importance of patient education and key self-management interventions such as problem solving, goal setting and cognitive behavioural therapy were highlighted. Role of patient organisations and HCPs in promoting and signposting patients to available resources has been highlighted through the promotion of physical activity, lifestyle advice, support with mental health aspects and ability to remain at work. Digital healthcare is essential in supporting and optimising self-management and the HCPs need to be aware of available resources to signpost patients. Conclusion: These recommendations support the inclusion of self-management advice and resources in the routine management of people with IA and aim to empower and support patients and encourage a more holistic, patient-centred approach to care which could result in improved patient experience of care and outcomes.This project has received funding by the European League Against Rheumatism, Project number: PAR028.Published versio

HDL cholesterol efflux capacity in rheumatoid arthritis patients: contributing factors and relationship with subclinical atherosclerosis

Background: Lipid profiles appear to be altered in rheumatoid arthritis (RA) patients because of disease activity and inflammation. Cholesterol efflux capacity (CEC), which is the ability of high-density lipoprotein cholesterol to accept cholesterol from macrophages, has been linked not only to cardiovascular events in the general population but also to being impaired in patients with RA. The aim of this study was to establish whether CEC is related to subclinical carotid atherosclerosis in patients with RA. Methods: We conducted a cross-sectional study that encompassed 401 individuals, including 178 patients with RA and 223 sex-matched control subjects. CEC, using an in vitro assay, lipoprotein serum concentrations, and standard lipid profile, was assessed in patients and control subjects. Carotid intima-media thickness (CIMT) and carotid plaques were assessed in patients with RA. A multivariable analysis was performed to evaluate the relationship of CEC with RA-related data, lipid profile, and subclinical carotid atherosclerosis. Results: Mean (SD) CEC was not significantly different between patients with RA (18.9 ± 9.0%) and control subjects (16.9 ± 10.4%) (p = 0.11). Patients with RA with low (? coefficient ?5.2 [?10.0 to 0.3]%, p = 0.039) and moderate disease activity (? coefficient ?4.6 [?8.5 to 0.7]%, p = 0.020) were associated with lower levels of CEC than patients in remission. Although no association with CIMT was found, higher CEC was independently associated with a lower risk for the presence of carotid plaque in patients with RA (odds ratio 0.94 [95% CI 0.89?0.98], p = 0.015). Conclusions: CEC is independently associated with carotid plaque in patients with RA

2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis

Background An important but often insufficient aspect of care in people with inflammatory arthritis (IA) is empowering patients to acquire a good understanding of their disease and building their ability to deal effectively with the practical, physical and psychological impacts of it. Self-management skills can be helpful in this regard. Objectives To develop recommendations for the implementation of self-management strategies in IA. Methods A multidisciplinary taskforce of 18 members from 11 European countries was convened. A systematic review and other supportive information (survey of healthcare professionals (HCPs) and patient organisations) were used to formulate the recommendations. Results Three overarching principles and nine recommendations were formulated. These focused on empowering patients to become active partners of the team and to take a more proactive role. The importance of patient education and key self-management interventions such as problem solving, goal setting and cognitive behavioural therapy were highlighted. Role of patient organisations and HCPs in promoting and signposting patients to available resources has been highlighted through the promotion of physical activity, lifestyle advice, support with mental health aspects and ability to remain at work. Digital healthcare is essential in supporting and optimising self-management and the HCPs need to be aware of available resources to signpost patients. Conclusion These recommendations support the inclusion of self-management advice and resources in the routine management of people with IA and aim to empower and support patients and encourage a more holistic, patient-centred approach to care which could result in improved patient experience of care and outcomes

Linkage of Type I Interferon Activity and TNF-Alpha Levels in Serum with Sarcoidosis Manifestations and Ancestry

BACKGROUND: Both type I interferon (IFN), also known as IFN-α and tumor necrosis factor alpha (TNF-α) have been implicated in the pathogenesis of sarcoidosis. We investigated serum levels of these cytokines in a large multi-ancestral sarcoidosis population to determine correlations between cytokine levels and disease phenotypes. METHODS: We studied serum samples from 98 patients with sarcoidosis, including 71 patients of African-American ancestry and 27 patients of European-American ancestry. Serum type I IFN was measured using a sensitive reporter cell assay and serum TNF-α was measured using a commercial ELISA kit. Clinical data including presence or absence of neurologic, cardiac, and severe pulmonary manifestations of sarcoidosis were abstracted from medical records. Twenty age-matched non-autoimmune controls were also studied from each ancestral background. Differences in cytokine levels between groups were analyzed with Mann-Whitney U test, and correlations were assessed using Spearman's rho. Multivariate logistic regression models were used to detect associations between cytokines and clinical manifestations. RESULTS: Significant differences in cytokine levels were observed between African- and European-American patients with sarcoidosis. In African-Americans, serum TNF-α levels were significantly higher relative to matched controls (P = 0.039), and patients with neurologic disease had significantly higher TNF-α than patients lacking this manifestation (P = 0.022). In European-Americans, serum type I IFN activity was higher in sarcoidosis cases as compared to matched controls, and patients with extra-pulmonary disease represented a high serum IFN subgroup (P = 0.0032). None of the associations observed were shared between the two ancestral groups. CONCLUSIONS: Our data indicate that significant associations between serum levels of TNF-α and type I IFN and clinical manifestations exist in a sarcoidosis cohort that differ significantly by self-reported ancestry. In each ancestral background, the cytokine elevated in patients with sarcoidosis was also associated with a particular disease phenotype. These findings may relate to ancestral differences in the molecular pathogenesis of this heterogeneous disease

EULAR points to consider for conducting clinical trials and observational studies in individuals at risk of rheumatoid arthritis

Background Despite growing interest, there is no guidance or consensus on how to conduct clinical trials and observational studies in populations at risk of rheumatoid arthritis (RA). Methods An European League Against Rheumatism (EULAR) task force formulated four research questions to be addressed by systematic literature review (SLR). The SLR results informed consensus statements. One overarching principle, 10 points to consider (PTC) and a research agenda were proposed. Task force members rated their level of agreement (1–10) for each PTC. Results Epidemiological and demographic characteristics should be measured in all clinical trials and studies in at-risk individuals. Different at-risk populations, identified according to clinical presentation, were defined: asymptomatic, musculoskeletal symptoms without arthritis and early clinical arthritis. Study end-points should include the development of subclinical inflammation on imaging, clinical arthritis, RA and subsequent achievement of arthritis remission. Risk factors should be assessed at baseline and re-evaluated where appropriate; they include genetic markers and autoantibody profiling and additionally clinical symptoms and subclinical inflammation on imaging in those with symptoms and/or clinical arthritis. Trials should address the effect of the intervention on risk factors, as well as progression to clinical arthritis or RA. In patients with early clinical arthritis, pharmacological intervention has the potential to prevent RA development. Participants’ knowledge of their RA risk may inform their decision to participate; information should be provided using an individually tailored approach. Conclusion These consensus statements provide data-driven guidance for rheumatologists, health professionals and investigators conducting clinical trials and observational studies in individuals at risk of RA