Sara Freeman

ROME – Patients with psoriasis were more likely to develop psoriatic arthritis if they had experienced physical trauma, based on data from a large, population-based study.

The crude incidence of psoriatic arthritis was 30 per 10,000 person-years in psoriasis patients exposed to trauma, compared with 22 per 10,000 person years in those who were not.

The hazard ratio (HR) for increased psoriatic arthritis risk with any trauma was 1.32 after adjusting for multiple factors, including patient age, gender, and the duration of psoriasis, senior study author Dr. Thorvardur Love said during a press briefing at the European Congress of Rheumatology.

“Patients with psoriasis are an easily identifiable group [to study] as they have skin disease on their body,” he noted. They also have a high risk of developing arthritis, at around 10%-30% of patients. This makes them an ideal population to study to try to find factors that might mitigate the risk and potentially have a large impact in clinical practice.

“The idea that trauma precipitates psoriatic arthritis is not new,” observed Dr. Love of Landspitali University Hospital in Reykjavik, Iceland. “It comes a little bit from the Koebner phenomenon, which is when psoriasis patients develop a new lesion in the skin where an injury has been.”

A few small studies had given rise to the idea that trauma could perhaps trigger a deep Koebner phenomenon in patients with psoriasis, and so the aim of the present analysis was to look at this idea in a larger population. Electronic health records of more than 10 million individuals living in the United Kingdom between 1995 and 2013 were analyzed from the Health Improvement Network (THIN) database. Of 70,646 patients with psoriasis who were identified, 15,416 had been exposed to some form of trauma, which was stratified as trauma involving the joints, bones, nerves, or skin.

After 425,120 person-years of follow-up, 1,010 incident cases of psoriatic arthritis had been recorded.

Having bone or joint trauma was found to increase the risk for psoriatic arthritis by 46% (HR, 1.46; 95% confidence interval, 1.13-1.54) and 50% (HR, 1.50; 95% CI. 1.19-1.90), respectively. This was after adjusting for age, gender, date of entry into the THIN database, duration of psoriasis, body mass index, smoking, alcohol consumption, and the number of visits to the general practitioner.

Neither nerve nor skin trauma were associated with an increased risk for psoriatic arthritis. Dr. Love and his fellow researchers also looked to see if patients with psoriasis had an increased risk of rheumatoid arthritis but found no significant association (HR, 1.04; 95% 0.99-1.10).

“The conclusion is that physical trauma is a risk factor for psoriatic arthritis among patients with psoriasis,” Dr. Love said. “We believe this is very important as the baseline risk is so high.”The effect is specific to psoriatic arthritis, as it is not seen in rheumatoid arthritis, which might provide clues for further research, he added. Why trauma might up the risk for developing psoriatic but not other types of inflammatory arthritis remains unclear, but the hypothesis is that patients would need to have a genetic predisposition and the “right types” of T cells in and around the joint that get disturbed in some way, perhaps by infection or by trauma. “I think it’s important to note that at this point we are not making any recommendations to the psoriasis community,” Dr. Love said. He suggested that, before any recommendations could be made, there needed to be a “really robust” conversation between patients, researchers, and physicians to determine exactly what these findings might mean. Certainly more research is needed before suggesting any lifestyle modifications that might help avoid situations associated with certain types of trauma, he said.

A literature review in the journal Clinical Rheumatology provided additional explanation of the deep Koebner effect. The investigators noted in their abstract that “the role of neuropeptides such as substance P and vasoactive intestinal peptide has been highlighted in the synovium after trauma.”

An editorial in the Journal of Rheumatology also suggested areas for additional research. Dr. Ignazio Olivieri of San Carlo Hospital in Potenza, Italy, wrote that “criteria of imputability” that should be met include “single and significant trauma; absence of joint lesion before trauma; localization of arthritis in the area of trauma; and absence or short delay between trauma and onset of arthritis.”

“You might envision treating [psoriasis] patients early [for psoriatic arthritis] if they break a leg or get a joint dislocation, but we are not there yet,” Dr. Love stressed. “This is an idea of where we could take this and where we might actually be able to have an effect.”

The research was performed by researchers at the University of Iceland (Reykjavik) in collaboration with researchers at Harvard Medical School in Boston and the University of Pennsylvania in Philadelphia. It was partially funded by the Icelandic Centre for Research (RANNIS) and the National Institutes of Health. Dr. Love’s associate, Dr. Stefan Thorarensen of the division of public health at the University of Iceland, presented the findings during the clinical science session at the congress.

Dr. Love and his coauthors reported having no financial disclosures.

ROME – Patients with psoriasis were more likely to develop psoriatic arthritis if they had experienced physical trauma, based on data from a large, population-based study.

The crude incidence of psoriatic arthritis was 30 per 10,000 person-years in psoriasis patients exposed to trauma, compared with 22 per 10,000 person years in those who were not.

The hazard ratio (HR) for increased psoriatic arthritis risk with any trauma was 1.32 after adjusting for multiple factors, including patient age, gender, and the duration of psoriasis, senior study author Dr. Thorvardur Love said during a press briefing at the European Congress of Rheumatology.

“Patients with psoriasis are an easily identifiable group [to study] as they have skin disease on their body,” he noted. They also have a high risk of developing arthritis, at around 10%-30% of patients. This makes them an ideal population to study to try to find factors that might mitigate the risk and potentially have a large impact in clinical practice.

“The idea that trauma precipitates psoriatic arthritis is not new,” observed Dr. Love of Landspitali University Hospital in Reykjavik, Iceland. “It comes a little bit from the Koebner phenomenon, which is when psoriasis patients develop a new lesion in the skin where an injury has been.”

A few small studies had given rise to the idea that trauma could perhaps trigger a deep Koebner phenomenon in patients with psoriasis, and so the aim of the present analysis was to look at this idea in a larger population. Electronic health records of more than 10 million individuals living in the United Kingdom between 1995 and 2013 were analyzed from the Health Improvement Network (THIN) database. Of 70,646 patients with psoriasis who were identified, 15,416 had been exposed to some form of trauma, which was stratified as trauma involving the joints, bones, nerves, or skin.

After 425,120 person-years of follow-up, 1,010 incident cases of psoriatic arthritis had been recorded.

Having bone or joint trauma was found to increase the risk for psoriatic arthritis by 46% (HR, 1.46; 95% confidence interval, 1.13-1.54) and 50% (HR, 1.50; 95% CI. 1.19-1.90), respectively. This was after adjusting for age, gender, date of entry into the THIN database, duration of psoriasis, body mass index, smoking, alcohol consumption, and the number of visits to the general practitioner.

Neither nerve nor skin trauma were associated with an increased risk for psoriatic arthritis. Dr. Love and his fellow researchers also looked to see if patients with psoriasis had an increased risk of rheumatoid arthritis but found no significant association (HR, 1.04; 95% 0.99-1.10).

“The conclusion is that physical trauma is a risk factor for psoriatic arthritis among patients with psoriasis,” Dr. Love said. “We believe this is very important as the baseline risk is so high.”The effect is specific to psoriatic arthritis, as it is not seen in rheumatoid arthritis, which might provide clues for further research, he added. Why trauma might up the risk for developing psoriatic but not other types of inflammatory arthritis remains unclear, but the hypothesis is that patients would need to have a genetic predisposition and the “right types” of T cells in and around the joint that get disturbed in some way, perhaps by infection or by trauma. “I think it’s important to note that at this point we are not making any recommendations to the psoriasis community,” Dr. Love said. He suggested that, before any recommendations could be made, there needed to be a “really robust” conversation between patients, researchers, and physicians to determine exactly what these findings might mean. Certainly more research is needed before suggesting any lifestyle modifications that might help avoid situations associated with certain types of trauma, he said.

A literature review in the journal Clinical Rheumatology provided additional explanation of the deep Koebner effect. The investigators noted in their abstract that “the role of neuropeptides such as substance P and vasoactive intestinal peptide has been highlighted in the synovium after trauma.”

An editorial in the Journal of Rheumatology also suggested areas for additional research. Dr. Ignazio Olivieri of San Carlo Hospital in Potenza, Italy, wrote that “criteria of imputability” that should be met include “single and significant trauma; absence of joint lesion before trauma; localization of arthritis in the area of trauma; and absence or short delay between trauma and onset of arthritis.”

“You might envision treating [psoriasis] patients early [for psoriatic arthritis] if they break a leg or get a joint dislocation, but we are not there yet,” Dr. Love stressed. “This is an idea of where we could take this and where we might actually be able to have an effect.”

The research was performed by researchers at the University of Iceland (Reykjavik) in collaboration with researchers at Harvard Medical School in Boston and the University of Pennsylvania in Philadelphia. It was partially funded by the Icelandic Centre for Research (RANNIS) and the National Institutes of Health. Dr. Love’s associate, Dr. Stefan Thorarensen of the division of public health at the University of Iceland, presented the findings during the clinical science session at the congress.

Dr. Love and his coauthors reported having no financial disclosures.

ROME – Patients with psoriasis were more likely to develop psoriatic arthritis if they had experienced physical trauma, based on data from a large, population-based study.

The crude incidence of psoriatic arthritis was 30 per 10,000 person-years in psoriasis patients exposed to trauma, compared with 22 per 10,000 person years in those who were not.

The hazard ratio (HR) for increased psoriatic arthritis risk with any trauma was 1.32 after adjusting for multiple factors, including patient age, gender, and the duration of psoriasis, senior study author Dr. Thorvardur Love said during a press briefing at the European Congress of Rheumatology.

“Patients with psoriasis are an easily identifiable group [to study] as they have skin disease on their body,” he noted. They also have a high risk of developing arthritis, at around 10%-30% of patients. This makes them an ideal population to study to try to find factors that might mitigate the risk and potentially have a large impact in clinical practice.

“The idea that trauma precipitates psoriatic arthritis is not new,” observed Dr. Love of Landspitali University Hospital in Reykjavik, Iceland. “It comes a little bit from the Koebner phenomenon, which is when psoriasis patients develop a new lesion in the skin where an injury has been.”

A few small studies had given rise to the idea that trauma could perhaps trigger a deep Koebner phenomenon in patients with psoriasis, and so the aim of the present analysis was to look at this idea in a larger population. Electronic health records of more than 10 million individuals living in the United Kingdom between 1995 and 2013 were analyzed from the Health Improvement Network (THIN) database. Of 70,646 patients with psoriasis who were identified, 15,416 had been exposed to some form of trauma, which was stratified as trauma involving the joints, bones, nerves, or skin.

After 425,120 person-years of follow-up, 1,010 incident cases of psoriatic arthritis had been recorded.

Having bone or joint trauma was found to increase the risk for psoriatic arthritis by 46% (HR, 1.46; 95% confidence interval, 1.13-1.54) and 50% (HR, 1.50; 95% CI. 1.19-1.90), respectively. This was after adjusting for age, gender, date of entry into the THIN database, duration of psoriasis, body mass index, smoking, alcohol consumption, and the number of visits to the general practitioner.

Neither nerve nor skin trauma were associated with an increased risk for psoriatic arthritis. Dr. Love and his fellow researchers also looked to see if patients with psoriasis had an increased risk of rheumatoid arthritis but found no significant association (HR, 1.04; 95% 0.99-1.10).

“The conclusion is that physical trauma is a risk factor for psoriatic arthritis among patients with psoriasis,” Dr. Love said. “We believe this is very important as the baseline risk is so high.”The effect is specific to psoriatic arthritis, as it is not seen in rheumatoid arthritis, which might provide clues for further research, he added. Why trauma might up the risk for developing psoriatic but not other types of inflammatory arthritis remains unclear, but the hypothesis is that patients would need to have a genetic predisposition and the “right types” of T cells in and around the joint that get disturbed in some way, perhaps by infection or by trauma. “I think it’s important to note that at this point we are not making any recommendations to the psoriasis community,” Dr. Love said. He suggested that, before any recommendations could be made, there needed to be a “really robust” conversation between patients, researchers, and physicians to determine exactly what these findings might mean. Certainly more research is needed before suggesting any lifestyle modifications that might help avoid situations associated with certain types of trauma, he said.

A literature review in the journal Clinical Rheumatology provided additional explanation of the deep Koebner effect. The investigators noted in their abstract that “the role of neuropeptides such as substance P and vasoactive intestinal peptide has been highlighted in the synovium after trauma.”

An editorial in the Journal of Rheumatology also suggested areas for additional research. Dr. Ignazio Olivieri of San Carlo Hospital in Potenza, Italy, wrote that “criteria of imputability” that should be met include “single and significant trauma; absence of joint lesion before trauma; localization of arthritis in the area of trauma; and absence or short delay between trauma and onset of arthritis.”

“You might envision treating [psoriasis] patients early [for psoriatic arthritis] if they break a leg or get a joint dislocation, but we are not there yet,” Dr. Love stressed. “This is an idea of where we could take this and where we might actually be able to have an effect.”

The research was performed by researchers at the University of Iceland (Reykjavik) in collaboration with researchers at Harvard Medical School in Boston and the University of Pennsylvania in Philadelphia. It was partially funded by the Icelandic Centre for Research (RANNIS) and the National Institutes of Health. Dr. Love’s associate, Dr. Stefan Thorarensen of the division of public health at the University of Iceland, presented the findings during the clinical science session at the congress.

Dr. Love and his coauthors reported having no financial disclosures.

ROME – Hydroxychloroquine should not be prescribed for patients with mild to moderate hand osteoarthritis (OA) according to data from a 24-week, randomized, multicenter, placebo-controlled trial.

The results of the Dutch study, presented at the European Congress of Rheumatology by Dr. Natalja M. Basoski of Maasstad Hospital, Rotterdam, the Netherlands, showed that hydroxychloroquine was no better than placebo at reducing patients’ pain and disability, or for improving their physical, social, or emotional well-being.

The primary outcome measure used was reduction in OA hand pain in the preceding 24 hours measured using a 100-mm visual analog scale (VAS) at the end of the study. The mean change in pain using the VAS over 24 weeks was a reduction of 1.3 mm in the hydroxychloroquine-treated patients versus a 0.10-mm rise in the patients who received placebo (P = .82).

There also was no change in the two secondary endpoints of change in total score of the Australian/Canadian Hand Osteoarthritis Index (AUSCAN) and the Arthritis Impact Measurement Scale 2 SF (AIMS2-SF) by the end of the treatment period. Mean changes in AUSCAN total scores were –0.42 and –0.25 (P = .49) and mean reductions in total AIMS2-SF scores were –0.17 and –0.076 (P = .68), comparing hydroxychloroquine with placebo, respectively.

“Osteoarthritis of the hand is one of the most common types of osteoarthritis, leading to pain, stiffness, and loss of function,” Dr. Basoski explained during a clinical science session looking at manifestations of the disease beyond the knee. “Unfortunately, current pharmacological treatment options are limited,” she added.

The underlying pathophysiological mechanisms of OA that primarily affect the hand are not clear, although inflammation is known to have a role, as in knee OA. Hydroxychloroquine is an established disease-modifying antirheumatoid drug that has shown benefit in patients with mild rheumatoid arthritis, which has led many rheumatologists to prescribe off label for the treatment of hand OA as well, Dr. Basoski observed in an interview. Data to support this are lacking, however, so this trial aimed to look at the potential symptom-modifying effects of the drug specifically in OA.

Over a 3-year period starting in July 2010, 202 patients with symptoms of primary mild to moderate hand OA of at least 1 years’ duration were recruited at six hospitals in the Netherlands and randomized to hydroxychloroquine 400 mg/day or matching placebo for 24 weeks. Six patients were lost to follow-up early on in the study, leaving 98 patients in each study arm who could be included in the intent-to-treat analysis. Of these, 22 hydroxychloroquine-treated and nine placebo-treated patients discontinued treatment, 10 and 5 in each group, respectively, because of adverse effects.

Dr. Basoski noted that patient characteristics were similar at baseline. Mean age was 57 years, and about 86% of participants were women. Hand OA was defined via American College of Rheumatology criteria and 86% and 91% of hydroxychloroquine- and placebo-treated patients had at least one joint with radiographic evidence of joint disease defined as a Kellgren-Lawrence score of ≥2.

“This is one of the studies that does not support the use of hydroxychloroquine in patients with OA of the hands and mild complaints,” she said in an interview. “It means that you should not prescribe it anymore, at least based on the results of this study.”

Further research is needed to see if there are some patients who might benefit or if it applies to other OA phenotypes, such as erosive hand OA. “More studies should be done, although in our second analysis after the study we tried to differentiate between very low pain and high pain and we still didn’t really see a difference,” she observed.

Erosive hand OA could be a different case, and results of an ongoing UK study should provide insight on whether hydroxychloroquine could be beneficial in these patients.

Although a similar number of patients treated with hydroxychloroquine or placebo in the trial experienced adverse events (21 vs. 24, respectively), there was an increase in allergic reactions (3 vs. 0) and rash or itching (8 vs. 3) with the active treatment.

With hydroxychloroquine seemingly out of the picture, at least in mild to moderate cases, Dr. Basoski advised on how she might treat a patient with primary hand OA. “I would try to start with paracetamol [acetaminophen] at the dose that is currently recommended, like 4 g/day, then eventually try to use opioids, as NSAIDs are not such a good thing to use in the long term.”

Dr. Basoski did not have any conflicts of interest to disclose.

ROME – Hydroxychloroquine should not be prescribed for patients with mild to moderate hand osteoarthritis (OA) according to data from a 24-week, randomized, multicenter, placebo-controlled trial.

The results of the Dutch study, presented at the European Congress of Rheumatology by Dr. Natalja M. Basoski of Maasstad Hospital, Rotterdam, the Netherlands, showed that hydroxychloroquine was no better than placebo at reducing patients’ pain and disability, or for improving their physical, social, or emotional well-being.

The primary outcome measure used was reduction in OA hand pain in the preceding 24 hours measured using a 100-mm visual analog scale (VAS) at the end of the study. The mean change in pain using the VAS over 24 weeks was a reduction of 1.3 mm in the hydroxychloroquine-treated patients versus a 0.10-mm rise in the patients who received placebo (P = .82).

There also was no change in the two secondary endpoints of change in total score of the Australian/Canadian Hand Osteoarthritis Index (AUSCAN) and the Arthritis Impact Measurement Scale 2 SF (AIMS2-SF) by the end of the treatment period. Mean changes in AUSCAN total scores were –0.42 and –0.25 (P = .49) and mean reductions in total AIMS2-SF scores were –0.17 and –0.076 (P = .68), comparing hydroxychloroquine with placebo, respectively.

“Osteoarthritis of the hand is one of the most common types of osteoarthritis, leading to pain, stiffness, and loss of function,” Dr. Basoski explained during a clinical science session looking at manifestations of the disease beyond the knee. “Unfortunately, current pharmacological treatment options are limited,” she added.

The underlying pathophysiological mechanisms of OA that primarily affect the hand are not clear, although inflammation is known to have a role, as in knee OA. Hydroxychloroquine is an established disease-modifying antirheumatoid drug that has shown benefit in patients with mild rheumatoid arthritis, which has led many rheumatologists to prescribe off label for the treatment of hand OA as well, Dr. Basoski observed in an interview. Data to support this are lacking, however, so this trial aimed to look at the potential symptom-modifying effects of the drug specifically in OA.

Over a 3-year period starting in July 2010, 202 patients with symptoms of primary mild to moderate hand OA of at least 1 years’ duration were recruited at six hospitals in the Netherlands and randomized to hydroxychloroquine 400 mg/day or matching placebo for 24 weeks. Six patients were lost to follow-up early on in the study, leaving 98 patients in each study arm who could be included in the intent-to-treat analysis. Of these, 22 hydroxychloroquine-treated and nine placebo-treated patients discontinued treatment, 10 and 5 in each group, respectively, because of adverse effects.

Dr. Basoski noted that patient characteristics were similar at baseline. Mean age was 57 years, and about 86% of participants were women. Hand OA was defined via American College of Rheumatology criteria and 86% and 91% of hydroxychloroquine- and placebo-treated patients had at least one joint with radiographic evidence of joint disease defined as a Kellgren-Lawrence score of ≥2.

“This is one of the studies that does not support the use of hydroxychloroquine in patients with OA of the hands and mild complaints,” she said in an interview. “It means that you should not prescribe it anymore, at least based on the results of this study.”

Further research is needed to see if there are some patients who might benefit or if it applies to other OA phenotypes, such as erosive hand OA. “More studies should be done, although in our second analysis after the study we tried to differentiate between very low pain and high pain and we still didn’t really see a difference,” she observed.

Erosive hand OA could be a different case, and results of an ongoing UK study should provide insight on whether hydroxychloroquine could be beneficial in these patients.

Although a similar number of patients treated with hydroxychloroquine or placebo in the trial experienced adverse events (21 vs. 24, respectively), there was an increase in allergic reactions (3 vs. 0) and rash or itching (8 vs. 3) with the active treatment.

With hydroxychloroquine seemingly out of the picture, at least in mild to moderate cases, Dr. Basoski advised on how she might treat a patient with primary hand OA. “I would try to start with paracetamol [acetaminophen] at the dose that is currently recommended, like 4 g/day, then eventually try to use opioids, as NSAIDs are not such a good thing to use in the long term.”

Dr. Basoski did not have any conflicts of interest to disclose.

ROME – Hydroxychloroquine should not be prescribed for patients with mild to moderate hand osteoarthritis (OA) according to data from a 24-week, randomized, multicenter, placebo-controlled trial.

The results of the Dutch study, presented at the European Congress of Rheumatology by Dr. Natalja M. Basoski of Maasstad Hospital, Rotterdam, the Netherlands, showed that hydroxychloroquine was no better than placebo at reducing patients’ pain and disability, or for improving their physical, social, or emotional well-being.

The primary outcome measure used was reduction in OA hand pain in the preceding 24 hours measured using a 100-mm visual analog scale (VAS) at the end of the study. The mean change in pain using the VAS over 24 weeks was a reduction of 1.3 mm in the hydroxychloroquine-treated patients versus a 0.10-mm rise in the patients who received placebo (P = .82).

There also was no change in the two secondary endpoints of change in total score of the Australian/Canadian Hand Osteoarthritis Index (AUSCAN) and the Arthritis Impact Measurement Scale 2 SF (AIMS2-SF) by the end of the treatment period. Mean changes in AUSCAN total scores were –0.42 and –0.25 (P = .49) and mean reductions in total AIMS2-SF scores were –0.17 and –0.076 (P = .68), comparing hydroxychloroquine with placebo, respectively.

“Osteoarthritis of the hand is one of the most common types of osteoarthritis, leading to pain, stiffness, and loss of function,” Dr. Basoski explained during a clinical science session looking at manifestations of the disease beyond the knee. “Unfortunately, current pharmacological treatment options are limited,” she added.

The underlying pathophysiological mechanisms of OA that primarily affect the hand are not clear, although inflammation is known to have a role, as in knee OA. Hydroxychloroquine is an established disease-modifying antirheumatoid drug that has shown benefit in patients with mild rheumatoid arthritis, which has led many rheumatologists to prescribe off label for the treatment of hand OA as well, Dr. Basoski observed in an interview. Data to support this are lacking, however, so this trial aimed to look at the potential symptom-modifying effects of the drug specifically in OA.

Over a 3-year period starting in July 2010, 202 patients with symptoms of primary mild to moderate hand OA of at least 1 years’ duration were recruited at six hospitals in the Netherlands and randomized to hydroxychloroquine 400 mg/day or matching placebo for 24 weeks. Six patients were lost to follow-up early on in the study, leaving 98 patients in each study arm who could be included in the intent-to-treat analysis. Of these, 22 hydroxychloroquine-treated and nine placebo-treated patients discontinued treatment, 10 and 5 in each group, respectively, because of adverse effects.

Dr. Basoski noted that patient characteristics were similar at baseline. Mean age was 57 years, and about 86% of participants were women. Hand OA was defined via American College of Rheumatology criteria and 86% and 91% of hydroxychloroquine- and placebo-treated patients had at least one joint with radiographic evidence of joint disease defined as a Kellgren-Lawrence score of ≥2.

“This is one of the studies that does not support the use of hydroxychloroquine in patients with OA of the hands and mild complaints,” she said in an interview. “It means that you should not prescribe it anymore, at least based on the results of this study.”

Further research is needed to see if there are some patients who might benefit or if it applies to other OA phenotypes, such as erosive hand OA. “More studies should be done, although in our second analysis after the study we tried to differentiate between very low pain and high pain and we still didn’t really see a difference,” she observed.

Erosive hand OA could be a different case, and results of an ongoing UK study should provide insight on whether hydroxychloroquine could be beneficial in these patients.

Although a similar number of patients treated with hydroxychloroquine or placebo in the trial experienced adverse events (21 vs. 24, respectively), there was an increase in allergic reactions (3 vs. 0) and rash or itching (8 vs. 3) with the active treatment.

With hydroxychloroquine seemingly out of the picture, at least in mild to moderate cases, Dr. Basoski advised on how she might treat a patient with primary hand OA. “I would try to start with paracetamol [acetaminophen] at the dose that is currently recommended, like 4 g/day, then eventually try to use opioids, as NSAIDs are not such a good thing to use in the long term.”

Dr. Basoski did not have any conflicts of interest to disclose.

VIENNA – Measuring cognitive function might help determine if an elderly patient is at risk for developing a host of vascular diseases, including stroke and transient ischemic attack, research presented at the annual European Stroke Conference suggested.

The research, which has been accepted for publication in the Journal of Neurology, showed that lower performance in a measure of global cognitive function was associated with a 57% increase in the risk of stroke and a 69% increase in the risk of coronary heart disease (CHD).

“If a person has a poor performance or clinical impairment in cognitive function, it means that the clinician should perhaps be careful because the patient might be at risk of developing diseases such as stroke, [transient ischemic attack], myocardial infarction, and so on,” Somayeh Rostamian, a nurse scientist at Leiden (the Netherlands) University Medical Center, said in an interview.

During her presentation, she explained that it was well known that cardiovascular risk factors and diseases were associated with mild cognitive impairment. Data also have shown that mild cognitive impairment might signal the onset of common age-related neurologic diseases such as dementia.

“We hypothesized that mild cognitive impairment might be an early manifestation of vascular diseases in subjects without clinically recognized disease,” Ms. Rostamian explained, suggesting it could be “the tip of the iceberg.”

To test their hypothesis, the research team first performed a systematic review and meta-analysis (Stroke 2014;45:1342-8) to look at the available evidence on the association between cognitive impairment and stroke risk. The results showed that stroke risk was increased by 15% overall, although individual study estimates ranged from 1% up to 49%.

“We then decided to look at the association between cognitive function, stroke, and coronary heart disease, and to evaluate the association between cognitive function domains and the risk of such diseases,” Ms. Rostamian said.

Data on the cognitive function of 3,926 men and women aged 70-82 years were obtained from the randomized controlled Prospective Study of Pravastatin in the Elderly at Risk (PROSPER). This trial looked at the role of statin therapy in an elderly cohort that had or were at high risk of developing cardiovascular disease and stroke (Lancet 2002;360:1623-30). Results of the trial suggested that statin therapy might reduce the incidence of transient ischemic attacks by up to 25% (P = .051), but it did not reduce the risk for stroke or have an effect on cognitive function.

Nevertheless, the trial provided information on cognitive function that was assessed at enrollment and then annually, which could be used for the current study. Ms. Rostamian noted that the team used data from the Stroop Color and Word test, the Letter Digit Substitution Test, and the picture-word learning test, which evaluate selective attention, processing speed, and immediate and delayed memory, respectively. A composite score for executive function was obtained by combining the results of the Stroop and the Letter Digit Substitution tests, and a composite score for memory was obtained from the picture-word learning test results.

Over a follow-up period of just over 3 years, there were 155 stroke and 375 coronary events, giving incidences of 12.4 and 30.5 per 1,000 person-years, respectively.

After adjusting for multiple confounding factors, patients in the low tertile of cognitive function had the higher risk of both stroke (relative risk, 1.57; P = .010) and CHD (RR, 1.69; P < .001), compared with those in the high-cognitive function tertile who were used as a reference (RR, 1). Patients in the middle tertile also had an increased risk for both diseases (RR, 1.25 and 1.21, respectively).

The results also suggested that deficits in executive function, rather than memory, were predictive of stroke and CHD. So, it might be more important to assess patients’ ability to perform tasks that involve their ability to pay attention or process information.

Indeed, comparing patients in the low-cognitive and high-cognitive tertiles, the risk for stroke was 51% higher (RR, 1.51; P = .042) and the risk for CHD was 85% higher (RR, 1.85; P < .001). In contrast, there was no increased risk linked to memory deficits, with a RR of 0.87 for stroke and 0.99 when comparing patients in the low- and high-cognitive tertiles.

“Impaired executive function, but not memory, was associated with increased risk of cardiovascular diseases and can be considered as an indicator of cardiovascular events. Lower performance in global cognitive function was associated with a higher risk of stroke and coronary heart disease,” Ms. Rostamian summarized.

“Cognitive assessment might provide a tool for clinicians to identify older subjects at an extra risk for future cardiovascular events,” she concluded.

The original trial was supported by an investigator-initiated grant from Bristol-Myers Squibb, USA. Ms. Rostamian had no conflicts.

VIENNA – Measuring cognitive function might help determine if an elderly patient is at risk for developing a host of vascular diseases, including stroke and transient ischemic attack, research presented at the annual European Stroke Conference suggested.

The research, which has been accepted for publication in the Journal of Neurology, showed that lower performance in a measure of global cognitive function was associated with a 57% increase in the risk of stroke and a 69% increase in the risk of coronary heart disease (CHD).

“If a person has a poor performance or clinical impairment in cognitive function, it means that the clinician should perhaps be careful because the patient might be at risk of developing diseases such as stroke, [transient ischemic attack], myocardial infarction, and so on,” Somayeh Rostamian, a nurse scientist at Leiden (the Netherlands) University Medical Center, said in an interview.

During her presentation, she explained that it was well known that cardiovascular risk factors and diseases were associated with mild cognitive impairment. Data also have shown that mild cognitive impairment might signal the onset of common age-related neurologic diseases such as dementia.

“We hypothesized that mild cognitive impairment might be an early manifestation of vascular diseases in subjects without clinically recognized disease,” Ms. Rostamian explained, suggesting it could be “the tip of the iceberg.”

To test their hypothesis, the research team first performed a systematic review and meta-analysis (Stroke 2014;45:1342-8) to look at the available evidence on the association between cognitive impairment and stroke risk. The results showed that stroke risk was increased by 15% overall, although individual study estimates ranged from 1% up to 49%.

“We then decided to look at the association between cognitive function, stroke, and coronary heart disease, and to evaluate the association between cognitive function domains and the risk of such diseases,” Ms. Rostamian said.

Data on the cognitive function of 3,926 men and women aged 70-82 years were obtained from the randomized controlled Prospective Study of Pravastatin in the Elderly at Risk (PROSPER). This trial looked at the role of statin therapy in an elderly cohort that had or were at high risk of developing cardiovascular disease and stroke (Lancet 2002;360:1623-30). Results of the trial suggested that statin therapy might reduce the incidence of transient ischemic attacks by up to 25% (P = .051), but it did not reduce the risk for stroke or have an effect on cognitive function.

Nevertheless, the trial provided information on cognitive function that was assessed at enrollment and then annually, which could be used for the current study. Ms. Rostamian noted that the team used data from the Stroop Color and Word test, the Letter Digit Substitution Test, and the picture-word learning test, which evaluate selective attention, processing speed, and immediate and delayed memory, respectively. A composite score for executive function was obtained by combining the results of the Stroop and the Letter Digit Substitution tests, and a composite score for memory was obtained from the picture-word learning test results.

Over a follow-up period of just over 3 years, there were 155 stroke and 375 coronary events, giving incidences of 12.4 and 30.5 per 1,000 person-years, respectively.

After adjusting for multiple confounding factors, patients in the low tertile of cognitive function had the higher risk of both stroke (relative risk, 1.57; P = .010) and CHD (RR, 1.69; P < .001), compared with those in the high-cognitive function tertile who were used as a reference (RR, 1). Patients in the middle tertile also had an increased risk for both diseases (RR, 1.25 and 1.21, respectively).

The results also suggested that deficits in executive function, rather than memory, were predictive of stroke and CHD. So, it might be more important to assess patients’ ability to perform tasks that involve their ability to pay attention or process information.

Indeed, comparing patients in the low-cognitive and high-cognitive tertiles, the risk for stroke was 51% higher (RR, 1.51; P = .042) and the risk for CHD was 85% higher (RR, 1.85; P < .001). In contrast, there was no increased risk linked to memory deficits, with a RR of 0.87 for stroke and 0.99 when comparing patients in the low- and high-cognitive tertiles.

“Impaired executive function, but not memory, was associated with increased risk of cardiovascular diseases and can be considered as an indicator of cardiovascular events. Lower performance in global cognitive function was associated with a higher risk of stroke and coronary heart disease,” Ms. Rostamian summarized.

“Cognitive assessment might provide a tool for clinicians to identify older subjects at an extra risk for future cardiovascular events,” she concluded.

The original trial was supported by an investigator-initiated grant from Bristol-Myers Squibb, USA. Ms. Rostamian had no conflicts.

VIENNA – Measuring cognitive function might help determine if an elderly patient is at risk for developing a host of vascular diseases, including stroke and transient ischemic attack, research presented at the annual European Stroke Conference suggested.

The research, which has been accepted for publication in the Journal of Neurology, showed that lower performance in a measure of global cognitive function was associated with a 57% increase in the risk of stroke and a 69% increase in the risk of coronary heart disease (CHD).

“If a person has a poor performance or clinical impairment in cognitive function, it means that the clinician should perhaps be careful because the patient might be at risk of developing diseases such as stroke, [transient ischemic attack], myocardial infarction, and so on,” Somayeh Rostamian, a nurse scientist at Leiden (the Netherlands) University Medical Center, said in an interview.

During her presentation, she explained that it was well known that cardiovascular risk factors and diseases were associated with mild cognitive impairment. Data also have shown that mild cognitive impairment might signal the onset of common age-related neurologic diseases such as dementia.

“We hypothesized that mild cognitive impairment might be an early manifestation of vascular diseases in subjects without clinically recognized disease,” Ms. Rostamian explained, suggesting it could be “the tip of the iceberg.”

To test their hypothesis, the research team first performed a systematic review and meta-analysis (Stroke 2014;45:1342-8) to look at the available evidence on the association between cognitive impairment and stroke risk. The results showed that stroke risk was increased by 15% overall, although individual study estimates ranged from 1% up to 49%.

“We then decided to look at the association between cognitive function, stroke, and coronary heart disease, and to evaluate the association between cognitive function domains and the risk of such diseases,” Ms. Rostamian said.

Data on the cognitive function of 3,926 men and women aged 70-82 years were obtained from the randomized controlled Prospective Study of Pravastatin in the Elderly at Risk (PROSPER). This trial looked at the role of statin therapy in an elderly cohort that had or were at high risk of developing cardiovascular disease and stroke (Lancet 2002;360:1623-30). Results of the trial suggested that statin therapy might reduce the incidence of transient ischemic attacks by up to 25% (P = .051), but it did not reduce the risk for stroke or have an effect on cognitive function.

Nevertheless, the trial provided information on cognitive function that was assessed at enrollment and then annually, which could be used for the current study. Ms. Rostamian noted that the team used data from the Stroop Color and Word test, the Letter Digit Substitution Test, and the picture-word learning test, which evaluate selective attention, processing speed, and immediate and delayed memory, respectively. A composite score for executive function was obtained by combining the results of the Stroop and the Letter Digit Substitution tests, and a composite score for memory was obtained from the picture-word learning test results.

Over a follow-up period of just over 3 years, there were 155 stroke and 375 coronary events, giving incidences of 12.4 and 30.5 per 1,000 person-years, respectively.

After adjusting for multiple confounding factors, patients in the low tertile of cognitive function had the higher risk of both stroke (relative risk, 1.57; P = .010) and CHD (RR, 1.69; P < .001), compared with those in the high-cognitive function tertile who were used as a reference (RR, 1). Patients in the middle tertile also had an increased risk for both diseases (RR, 1.25 and 1.21, respectively).

The results also suggested that deficits in executive function, rather than memory, were predictive of stroke and CHD. So, it might be more important to assess patients’ ability to perform tasks that involve their ability to pay attention or process information.

Indeed, comparing patients in the low-cognitive and high-cognitive tertiles, the risk for stroke was 51% higher (RR, 1.51; P = .042) and the risk for CHD was 85% higher (RR, 1.85; P < .001). In contrast, there was no increased risk linked to memory deficits, with a RR of 0.87 for stroke and 0.99 when comparing patients in the low- and high-cognitive tertiles.

“Impaired executive function, but not memory, was associated with increased risk of cardiovascular diseases and can be considered as an indicator of cardiovascular events. Lower performance in global cognitive function was associated with a higher risk of stroke and coronary heart disease,” Ms. Rostamian summarized.

“Cognitive assessment might provide a tool for clinicians to identify older subjects at an extra risk for future cardiovascular events,” she concluded.

The original trial was supported by an investigator-initiated grant from Bristol-Myers Squibb, USA. Ms. Rostamian had no conflicts.

VIENNA – Reperfusion within 6 hours of a stroke proved to be a better predictor of both imaging and clinical outcomes than recanalization in an analysis of patients included in a multicenter, prospective, longitudinal study.

Indeed, when reperfusion was achieved, penumbra salvage was more likely (P < .0001), there was less lesion growth (P = .0002), and a smaller overall infarct size (P < .0001).

“Early revascularization is the main therapeutic goal in ischemic stroke as it can reduce infarct growth and improve clinical recovery,” said Tae-Hee Cho, Ph.D., who presented the research at the annual European Stroke Conference.

Dr. Cho of Hôpital Neurologique Pierre Wertheimer in Lyon, France, noted that reperfusion and recanalization are often closely related but can be disassociated with one occurring without the other. Although prior studies have looked at which might be a better marker for poststroke outcomes, later time windows were involved, so the aim of the present research was to look at an earlier point in time.

The I-KNOW European consortium database was used to identify patients with acute ischemia in the anterior circulation who had a confirmed occlusion on magnetic resonance angiography (MRA) and in whom reperfusion and recanalization had been assessed on a repeat scan, either within 6 hours of symptom onset if intravenous tissue plasminogen activator (tPA) was used or within 12 hours if no tPA was given.

Of 168 patients included in the database, 46 had the necessary data and were analyzed. The median age of the included patients was 69 years (range, 64-74). The majority was male (61%), with a median lesion size of 18.9 mL measured using diffusion-weighted magnetic resonance imaging.

At admission, the middle cerebral artery was occluded at M1 in 15 patients, 22 had M2 occlusion, 9 had M3 occlusion, and 1 patient had A1 occlusion. The median penumbra volume was 13.3 mL.

“Reperfusion and recanalization were assessed within 6 hours in all patients,” Dr. Cho observed. The median delay was 302 minutes, he added.

Results showed that reperfusion occurred in 27 (59%) patients and recanalization in 19 (41%) patients. Around 30% achieved reperfusion without recanalization, but the latter didn’t occur if reperfusion was not present.

“All imaging events were significantly improved by reperfusion,” Dr. Cho reported. This was not seen with recanalization, he observed. A similar pattern was seen for favorable clinical responses, which was defined as a fall of 8 points or a score of 0-1 on the National Institutes of Health Stroke Scale.

Dr. Cho noted that the research, which was published in Stroke just before the conference, showed that reperfusion within 6 hours of symptom onset was better than recanalization at predicting imaging outcomes and that it might be a reliable surrogate for clinical outcome.

Dr. Jenny Tsai and Dr. Gregory Albers of the Stanford Stroke Center in Palo Alto, Calif., commented on the data independently in an editorial accompanying the published paper, noting, “Optimal stroke therapy should result in both recanalization and reperfusion.”

They suggested that the higher rate of reperfusion than recanalization in the study is perhaps not unexpected “because recruitment of collateral circulation can occur rapidly in the setting of an acute vessel obstruction.”

They also observed that, while the findings suggest that reperfusion is of greater physiologic importance, these are not discrete or static entities. Imaging provides “a snapshot of an evolving process” and “an occluded vessel at a moment in time does not imply that beneficial recanalization did not occur subsequently.”

However, the editorialists concluded that, “if you must choose one, we agree with Cho et al.: the Oscar goes to reperfusion.”

Dr. Cho and Dr. Tsai had no disclosures. Dr. Albers is an equity shareholder in iSchemaView.

VIENNA – Reperfusion within 6 hours of a stroke proved to be a better predictor of both imaging and clinical outcomes than recanalization in an analysis of patients included in a multicenter, prospective, longitudinal study.

Indeed, when reperfusion was achieved, penumbra salvage was more likely (P < .0001), there was less lesion growth (P = .0002), and a smaller overall infarct size (P < .0001).

“Early revascularization is the main therapeutic goal in ischemic stroke as it can reduce infarct growth and improve clinical recovery,” said Tae-Hee Cho, Ph.D., who presented the research at the annual European Stroke Conference.

Dr. Cho of Hôpital Neurologique Pierre Wertheimer in Lyon, France, noted that reperfusion and recanalization are often closely related but can be disassociated with one occurring without the other. Although prior studies have looked at which might be a better marker for poststroke outcomes, later time windows were involved, so the aim of the present research was to look at an earlier point in time.

The I-KNOW European consortium database was used to identify patients with acute ischemia in the anterior circulation who had a confirmed occlusion on magnetic resonance angiography (MRA) and in whom reperfusion and recanalization had been assessed on a repeat scan, either within 6 hours of symptom onset if intravenous tissue plasminogen activator (tPA) was used or within 12 hours if no tPA was given.

Of 168 patients included in the database, 46 had the necessary data and were analyzed. The median age of the included patients was 69 years (range, 64-74). The majority was male (61%), with a median lesion size of 18.9 mL measured using diffusion-weighted magnetic resonance imaging.

At admission, the middle cerebral artery was occluded at M1 in 15 patients, 22 had M2 occlusion, 9 had M3 occlusion, and 1 patient had A1 occlusion. The median penumbra volume was 13.3 mL.

“Reperfusion and recanalization were assessed within 6 hours in all patients,” Dr. Cho observed. The median delay was 302 minutes, he added.

Results showed that reperfusion occurred in 27 (59%) patients and recanalization in 19 (41%) patients. Around 30% achieved reperfusion without recanalization, but the latter didn’t occur if reperfusion was not present.

“All imaging events were significantly improved by reperfusion,” Dr. Cho reported. This was not seen with recanalization, he observed. A similar pattern was seen for favorable clinical responses, which was defined as a fall of 8 points or a score of 0-1 on the National Institutes of Health Stroke Scale.

Dr. Cho noted that the research, which was published in Stroke just before the conference, showed that reperfusion within 6 hours of symptom onset was better than recanalization at predicting imaging outcomes and that it might be a reliable surrogate for clinical outcome.

Dr. Jenny Tsai and Dr. Gregory Albers of the Stanford Stroke Center in Palo Alto, Calif., commented on the data independently in an editorial accompanying the published paper, noting, “Optimal stroke therapy should result in both recanalization and reperfusion.”

They suggested that the higher rate of reperfusion than recanalization in the study is perhaps not unexpected “because recruitment of collateral circulation can occur rapidly in the setting of an acute vessel obstruction.”

They also observed that, while the findings suggest that reperfusion is of greater physiologic importance, these are not discrete or static entities. Imaging provides “a snapshot of an evolving process” and “an occluded vessel at a moment in time does not imply that beneficial recanalization did not occur subsequently.”

However, the editorialists concluded that, “if you must choose one, we agree with Cho et al.: the Oscar goes to reperfusion.”

Dr. Cho and Dr. Tsai had no disclosures. Dr. Albers is an equity shareholder in iSchemaView.

VIENNA – Reperfusion within 6 hours of a stroke proved to be a better predictor of both imaging and clinical outcomes than recanalization in an analysis of patients included in a multicenter, prospective, longitudinal study.

Indeed, when reperfusion was achieved, penumbra salvage was more likely (P < .0001), there was less lesion growth (P = .0002), and a smaller overall infarct size (P < .0001).

“Early revascularization is the main therapeutic goal in ischemic stroke as it can reduce infarct growth and improve clinical recovery,” said Tae-Hee Cho, Ph.D., who presented the research at the annual European Stroke Conference.

Dr. Cho of Hôpital Neurologique Pierre Wertheimer in Lyon, France, noted that reperfusion and recanalization are often closely related but can be disassociated with one occurring without the other. Although prior studies have looked at which might be a better marker for poststroke outcomes, later time windows were involved, so the aim of the present research was to look at an earlier point in time.

The I-KNOW European consortium database was used to identify patients with acute ischemia in the anterior circulation who had a confirmed occlusion on magnetic resonance angiography (MRA) and in whom reperfusion and recanalization had been assessed on a repeat scan, either within 6 hours of symptom onset if intravenous tissue plasminogen activator (tPA) was used or within 12 hours if no tPA was given.

Of 168 patients included in the database, 46 had the necessary data and were analyzed. The median age of the included patients was 69 years (range, 64-74). The majority was male (61%), with a median lesion size of 18.9 mL measured using diffusion-weighted magnetic resonance imaging.

At admission, the middle cerebral artery was occluded at M1 in 15 patients, 22 had M2 occlusion, 9 had M3 occlusion, and 1 patient had A1 occlusion. The median penumbra volume was 13.3 mL.

“Reperfusion and recanalization were assessed within 6 hours in all patients,” Dr. Cho observed. The median delay was 302 minutes, he added.

Results showed that reperfusion occurred in 27 (59%) patients and recanalization in 19 (41%) patients. Around 30% achieved reperfusion without recanalization, but the latter didn’t occur if reperfusion was not present.

“All imaging events were significantly improved by reperfusion,” Dr. Cho reported. This was not seen with recanalization, he observed. A similar pattern was seen for favorable clinical responses, which was defined as a fall of 8 points or a score of 0-1 on the National Institutes of Health Stroke Scale.

Dr. Cho noted that the research, which was published in Stroke just before the conference, showed that reperfusion within 6 hours of symptom onset was better than recanalization at predicting imaging outcomes and that it might be a reliable surrogate for clinical outcome.

Dr. Jenny Tsai and Dr. Gregory Albers of the Stanford Stroke Center in Palo Alto, Calif., commented on the data independently in an editorial accompanying the published paper, noting, “Optimal stroke therapy should result in both recanalization and reperfusion.”

They suggested that the higher rate of reperfusion than recanalization in the study is perhaps not unexpected “because recruitment of collateral circulation can occur rapidly in the setting of an acute vessel obstruction.”

They also observed that, while the findings suggest that reperfusion is of greater physiologic importance, these are not discrete or static entities. Imaging provides “a snapshot of an evolving process” and “an occluded vessel at a moment in time does not imply that beneficial recanalization did not occur subsequently.”

However, the editorialists concluded that, “if you must choose one, we agree with Cho et al.: the Oscar goes to reperfusion.”

Dr. Cho and Dr. Tsai had no disclosures. Dr. Albers is an equity shareholder in iSchemaView.

ROME – A quick ultrasound scan of the hand may be all that is needed to help determine if a patient with early inflammatory arthritis will go on to develop rheumatoid arthritis (RA).

Adjusted odds ratios (OR) for making a diagnosis of RA were 7.1 for having cyclic citrullinated peptide or rheumatoid factor antibodies (P < .0001), 7.9 for having 10 or more joints involved (P < .0001), and 6.6 for having tenosynovitis in the hand or wrist (P < .0001). The association held in patients with seronegative disease, with an OR of 7.6 for having 10 or more involved joints (P < .0001) and 4.8 for hand/wrist tenosynovitis (P = .003).

Sara Freeman

Rheumatologists are challenged to diagnose rheumatoid arthritis early, particularly in patients who may have had symptoms for only a few weeks, said Dr. Andrew Filer, senior lecturer at the University of Birmingham (England).

“One of the problems is that, in the first 3 months of the disease, it really is undifferentiated in a lot of patients, even using the 2010 [American College of Rheumatology/European League Against Rheumatism response] criteria for rheumatoid arthritis,” he said. While about a third of patients with inflammatory arthritis will go on to develop RA, the net has been cast so wide that there are patients whose inflammatory arthritis will resolve without treatment, he added.

Dr. Filer and his associates have been working for the past 15 years to find ways to help clinicians identify RA as early as possible. Some of their most recent research has focused on using musculoskeletal ultrasound to examine the small joints (Ann. Rheum. Dis. 2011;70:500-7) and has already shown that it is more accurate than traditional clinical assessment at predicting patient outcomes in very early arthritis.

Results from the Birmingham Early Arthritis Cohort (BEACON) presented at the European Congress of Rheumatology show that ultrasound-detected tenosynovitis can independently identify patients who will go on to develop RA.

The study involved 107 patients with at least one swollen joint and whose symptoms had started in the last 3 months. Of these, 43 developed very early RA, 20 had non-RA persistent disease, and the remaining 44 had resolving disease at 18-month follow-up.

Although a wide variety of tendons throughout the body was examined, including those in the shoulders, ankles, hands, and wrists, it was the extensor carpi ulnaris (ECU) tendon in the wrists and flexor tendons in the fingers that were found to be the most important to examine. The ECU tendon is responsible for straightening and rotating the wrist, as well as integral for gripping and pulling.

“Looking at the tendons was a new area for us, and it’s taken a while for organizations like OMERACT [Outcome Measures in Rheumatology] to come up with some usable criteria and grading,” Dr. Filer observed. Now that these exist and show that ultrasound is a reproducible tool for evaluating tenosynovitis in RA (Ann. Rheum. Dis. 2013;72:1328-34), it was possible to conduct the current prospective study.

Dr. Filer discussed the findings in a press briefing ahead of their scientific presentation by clinical research fellow Dr. Ilfita Sahbudin and noted that tenosynovitis was more difficult to assess clinically than joint inflammation as it was more “hidden.”“Even if it’s really established rheumatoid disease it’s quite difficult for even experienced rheumatologists to detect swelling of tendons; [we] really have to use imaging like ultrasound or MRI to detect this reliably,” he said at the briefing. “Scanning of wrist ECU and finger flexor tendons adds robust diagnostic data for RA in that first window of very early disease.”

Dr. Filer suggested that early arthritis clinics should start to integrate these scans into their protocols to validate the findings.

He reported having no financial disclosures.

[email protected]

ROME – A quick ultrasound scan of the hand may be all that is needed to help determine if a patient with early inflammatory arthritis will go on to develop rheumatoid arthritis (RA).

Adjusted odds ratios (OR) for making a diagnosis of RA were 7.1 for having cyclic citrullinated peptide or rheumatoid factor antibodies (P < .0001), 7.9 for having 10 or more joints involved (P < .0001), and 6.6 for having tenosynovitis in the hand or wrist (P < .0001). The association held in patients with seronegative disease, with an OR of 7.6 for having 10 or more involved joints (P < .0001) and 4.8 for hand/wrist tenosynovitis (P = .003).

Sara Freeman

Rheumatologists are challenged to diagnose rheumatoid arthritis early, particularly in patients who may have had symptoms for only a few weeks, said Dr. Andrew Filer, senior lecturer at the University of Birmingham (England).

“One of the problems is that, in the first 3 months of the disease, it really is undifferentiated in a lot of patients, even using the 2010 [American College of Rheumatology/European League Against Rheumatism response] criteria for rheumatoid arthritis,” he said. While about a third of patients with inflammatory arthritis will go on to develop RA, the net has been cast so wide that there are patients whose inflammatory arthritis will resolve without treatment, he added.

Dr. Filer and his associates have been working for the past 15 years to find ways to help clinicians identify RA as early as possible. Some of their most recent research has focused on using musculoskeletal ultrasound to examine the small joints (Ann. Rheum. Dis. 2011;70:500-7) and has already shown that it is more accurate than traditional clinical assessment at predicting patient outcomes in very early arthritis.

Results from the Birmingham Early Arthritis Cohort (BEACON) presented at the European Congress of Rheumatology show that ultrasound-detected tenosynovitis can independently identify patients who will go on to develop RA.

The study involved 107 patients with at least one swollen joint and whose symptoms had started in the last 3 months. Of these, 43 developed very early RA, 20 had non-RA persistent disease, and the remaining 44 had resolving disease at 18-month follow-up.

Although a wide variety of tendons throughout the body was examined, including those in the shoulders, ankles, hands, and wrists, it was the extensor carpi ulnaris (ECU) tendon in the wrists and flexor tendons in the fingers that were found to be the most important to examine. The ECU tendon is responsible for straightening and rotating the wrist, as well as integral for gripping and pulling.

“Looking at the tendons was a new area for us, and it’s taken a while for organizations like OMERACT [Outcome Measures in Rheumatology] to come up with some usable criteria and grading,” Dr. Filer observed. Now that these exist and show that ultrasound is a reproducible tool for evaluating tenosynovitis in RA (Ann. Rheum. Dis. 2013;72:1328-34), it was possible to conduct the current prospective study.

Dr. Filer discussed the findings in a press briefing ahead of their scientific presentation by clinical research fellow Dr. Ilfita Sahbudin and noted that tenosynovitis was more difficult to assess clinically than joint inflammation as it was more “hidden.”“Even if it’s really established rheumatoid disease it’s quite difficult for even experienced rheumatologists to detect swelling of tendons; [we] really have to use imaging like ultrasound or MRI to detect this reliably,” he said at the briefing. “Scanning of wrist ECU and finger flexor tendons adds robust diagnostic data for RA in that first window of very early disease.”

Dr. Filer suggested that early arthritis clinics should start to integrate these scans into their protocols to validate the findings.

He reported having no financial disclosures.

[email protected]

ROME – A quick ultrasound scan of the hand may be all that is needed to help determine if a patient with early inflammatory arthritis will go on to develop rheumatoid arthritis (RA).

Adjusted odds ratios (OR) for making a diagnosis of RA were 7.1 for having cyclic citrullinated peptide or rheumatoid factor antibodies (P < .0001), 7.9 for having 10 or more joints involved (P < .0001), and 6.6 for having tenosynovitis in the hand or wrist (P < .0001). The association held in patients with seronegative disease, with an OR of 7.6 for having 10 or more involved joints (P < .0001) and 4.8 for hand/wrist tenosynovitis (P = .003).

Sara Freeman

Rheumatologists are challenged to diagnose rheumatoid arthritis early, particularly in patients who may have had symptoms for only a few weeks, said Dr. Andrew Filer, senior lecturer at the University of Birmingham (England).

“One of the problems is that, in the first 3 months of the disease, it really is undifferentiated in a lot of patients, even using the 2010 [American College of Rheumatology/European League Against Rheumatism response] criteria for rheumatoid arthritis,” he said. While about a third of patients with inflammatory arthritis will go on to develop RA, the net has been cast so wide that there are patients whose inflammatory arthritis will resolve without treatment, he added.

Dr. Filer and his associates have been working for the past 15 years to find ways to help clinicians identify RA as early as possible. Some of their most recent research has focused on using musculoskeletal ultrasound to examine the small joints (Ann. Rheum. Dis. 2011;70:500-7) and has already shown that it is more accurate than traditional clinical assessment at predicting patient outcomes in very early arthritis.

Results from the Birmingham Early Arthritis Cohort (BEACON) presented at the European Congress of Rheumatology show that ultrasound-detected tenosynovitis can independently identify patients who will go on to develop RA.

The study involved 107 patients with at least one swollen joint and whose symptoms had started in the last 3 months. Of these, 43 developed very early RA, 20 had non-RA persistent disease, and the remaining 44 had resolving disease at 18-month follow-up.

Although a wide variety of tendons throughout the body was examined, including those in the shoulders, ankles, hands, and wrists, it was the extensor carpi ulnaris (ECU) tendon in the wrists and flexor tendons in the fingers that were found to be the most important to examine. The ECU tendon is responsible for straightening and rotating the wrist, as well as integral for gripping and pulling.

“Looking at the tendons was a new area for us, and it’s taken a while for organizations like OMERACT [Outcome Measures in Rheumatology] to come up with some usable criteria and grading,” Dr. Filer observed. Now that these exist and show that ultrasound is a reproducible tool for evaluating tenosynovitis in RA (Ann. Rheum. Dis. 2013;72:1328-34), it was possible to conduct the current prospective study.

Dr. Filer discussed the findings in a press briefing ahead of their scientific presentation by clinical research fellow Dr. Ilfita Sahbudin and noted that tenosynovitis was more difficult to assess clinically than joint inflammation as it was more “hidden.”“Even if it’s really established rheumatoid disease it’s quite difficult for even experienced rheumatologists to detect swelling of tendons; [we] really have to use imaging like ultrasound or MRI to detect this reliably,” he said at the briefing. “Scanning of wrist ECU and finger flexor tendons adds robust diagnostic data for RA in that first window of very early disease.”

Dr. Filer suggested that early arthritis clinics should start to integrate these scans into their protocols to validate the findings.

He reported having no financial disclosures.

[email protected]

VIENNA – Handheld ECG monitors offered a practical, noninvasive solution to detecting atrial fibrillation in patients who had been diagnosed with ischemic stroke or transient ischemic attack in a retrospective hospital-based study.

The results presented at the annual European Stroke Conference showed an overall detection rate of 7.6%, which is in the same range seen in previous studies of handheld ECG monitors but was higher than in most studies that used 24-hour Holter monitoring, said study investigator Dr. Ann-Sofie Olsson of Hallands Hospital Halmstead (Sweden).

The retrospective study included data on 356 patients who had been seen at the hospital for ischemic stroke or transient ischemic attack (TIA) and who had undergone intermittent handheld ECG testing to monitor for atrial fibrillation (AF). The mean age of patients was 66 years, 53% were male, and 46% were diagnosed with ischemic stroke and 56% with TIA. The mean baseline CHA₂DS₂-VASc score was 4.2, suggesting patients were at reasonably moderate risk of subsequent AF-related stroke.

The ECG monitor used consisted of a small, lightweight plastic box that patients held by two thumb sensors for 10, 20, or 30 seconds, with measurements taken twice a day (morning and evening) for 14 days. The sensors, which provided lead I of a standard ECG, provided information on atrial movement that was transmitted to a data server and was viewed via a web browser.

“We defined a positive investigation as either atrial fibrillation for a minimum of 10 seconds or a short, irregular supraventricular arrhythmia, Dr. Olsson explained.

Overall, 27 (7.6%) of the 356 patients evaluated had a positive result, with a 95% confidence interval ranging from 5.1% to 10.1%. While there was no statistically significant difference in AF detection rates between men (8.5%) and women (6.5%), detection rates were higher if patients had had an ischemic stroke rather than a TIA (11% vs. 5%, P = .032). There was also a trend (P = .051) for better detection rates in older (≥65 years) than younger (<65 years) patients, at 8.8% vs. 4.2%, respectively.

“It is natural to ask ourselves whether we can improve the detection rates by selecting higher-risk patients,” Dr. Olsson said, commenting on the lower detection rate seen in TIA patients despite there being more TIA cases in the study cohort.

“We saw high adherence to the monitoring; only six (1.5%) patients did not complete the investigation,” said Dr. Olsson, noting that older age did not seem to be an obstacle to performing the ECG with the handheld monitor as the oldest patient in the study was 90 years.

Dr. Olsson noted that the monitor used in the study had a sensitivity of 96% and a specificity of 92%.

Dr. Olsson reported having no relevant financial disclosures.

VIENNA – Handheld ECG monitors offered a practical, noninvasive solution to detecting atrial fibrillation in patients who had been diagnosed with ischemic stroke or transient ischemic attack in a retrospective hospital-based study.

The results presented at the annual European Stroke Conference showed an overall detection rate of 7.6%, which is in the same range seen in previous studies of handheld ECG monitors but was higher than in most studies that used 24-hour Holter monitoring, said study investigator Dr. Ann-Sofie Olsson of Hallands Hospital Halmstead (Sweden).

The retrospective study included data on 356 patients who had been seen at the hospital for ischemic stroke or transient ischemic attack (TIA) and who had undergone intermittent handheld ECG testing to monitor for atrial fibrillation (AF). The mean age of patients was 66 years, 53% were male, and 46% were diagnosed with ischemic stroke and 56% with TIA. The mean baseline CHA₂DS₂-VASc score was 4.2, suggesting patients were at reasonably moderate risk of subsequent AF-related stroke.

The ECG monitor used consisted of a small, lightweight plastic box that patients held by two thumb sensors for 10, 20, or 30 seconds, with measurements taken twice a day (morning and evening) for 14 days. The sensors, which provided lead I of a standard ECG, provided information on atrial movement that was transmitted to a data server and was viewed via a web browser.

“We defined a positive investigation as either atrial fibrillation for a minimum of 10 seconds or a short, irregular supraventricular arrhythmia, Dr. Olsson explained.

Overall, 27 (7.6%) of the 356 patients evaluated had a positive result, with a 95% confidence interval ranging from 5.1% to 10.1%. While there was no statistically significant difference in AF detection rates between men (8.5%) and women (6.5%), detection rates were higher if patients had had an ischemic stroke rather than a TIA (11% vs. 5%, P = .032). There was also a trend (P = .051) for better detection rates in older (≥65 years) than younger (<65 years) patients, at 8.8% vs. 4.2%, respectively.

“It is natural to ask ourselves whether we can improve the detection rates by selecting higher-risk patients,” Dr. Olsson said, commenting on the lower detection rate seen in TIA patients despite there being more TIA cases in the study cohort.

“We saw high adherence to the monitoring; only six (1.5%) patients did not complete the investigation,” said Dr. Olsson, noting that older age did not seem to be an obstacle to performing the ECG with the handheld monitor as the oldest patient in the study was 90 years.

Dr. Olsson noted that the monitor used in the study had a sensitivity of 96% and a specificity of 92%.

Dr. Olsson reported having no relevant financial disclosures.

VIENNA – Handheld ECG monitors offered a practical, noninvasive solution to detecting atrial fibrillation in patients who had been diagnosed with ischemic stroke or transient ischemic attack in a retrospective hospital-based study.

The results presented at the annual European Stroke Conference showed an overall detection rate of 7.6%, which is in the same range seen in previous studies of handheld ECG monitors but was higher than in most studies that used 24-hour Holter monitoring, said study investigator Dr. Ann-Sofie Olsson of Hallands Hospital Halmstead (Sweden).

The retrospective study included data on 356 patients who had been seen at the hospital for ischemic stroke or transient ischemic attack (TIA) and who had undergone intermittent handheld ECG testing to monitor for atrial fibrillation (AF). The mean age of patients was 66 years, 53% were male, and 46% were diagnosed with ischemic stroke and 56% with TIA. The mean baseline CHA₂DS₂-VASc score was 4.2, suggesting patients were at reasonably moderate risk of subsequent AF-related stroke.

The ECG monitor used consisted of a small, lightweight plastic box that patients held by two thumb sensors for 10, 20, or 30 seconds, with measurements taken twice a day (morning and evening) for 14 days. The sensors, which provided lead I of a standard ECG, provided information on atrial movement that was transmitted to a data server and was viewed via a web browser.

“We defined a positive investigation as either atrial fibrillation for a minimum of 10 seconds or a short, irregular supraventricular arrhythmia, Dr. Olsson explained.

Overall, 27 (7.6%) of the 356 patients evaluated had a positive result, with a 95% confidence interval ranging from 5.1% to 10.1%. While there was no statistically significant difference in AF detection rates between men (8.5%) and women (6.5%), detection rates were higher if patients had had an ischemic stroke rather than a TIA (11% vs. 5%, P = .032). There was also a trend (P = .051) for better detection rates in older (≥65 years) than younger (<65 years) patients, at 8.8% vs. 4.2%, respectively.

“It is natural to ask ourselves whether we can improve the detection rates by selecting higher-risk patients,” Dr. Olsson said, commenting on the lower detection rate seen in TIA patients despite there being more TIA cases in the study cohort.

“We saw high adherence to the monitoring; only six (1.5%) patients did not complete the investigation,” said Dr. Olsson, noting that older age did not seem to be an obstacle to performing the ECG with the handheld monitor as the oldest patient in the study was 90 years.

Dr. Olsson noted that the monitor used in the study had a sensitivity of 96% and a specificity of 92%.

Dr. Olsson reported having no relevant financial disclosures.

ROME – Anti–tumor necrosis factor agents have a slight edge over conventional disease-modifying antirheumatic drugs when it comes to helping psoriatic arthritis patients who are having work issues, according to a large British observational study presented at the European Congress of Rheumatology.

Among 236 of 400 subjects working at baseline, presenteeism improved from 30% to 10% and productivity loss improved from 45% to 10% among patients who started taking anti-TNF (anti-tumor necrosis factor) agents. Gains were more modest when patients were started on DMARDs, with presenteeism improving from 30% to 20% and productivity loss from 40% to 25%. The difference in change of presenteeism between the two treatment groups became statistically significant at 2 weeks and remained so at 24 weeks.

“Work disability is a continuum,” said the presenting author, Dr. William Tillett of the Royal National Hospital for Rheumatic Diseases in Bath (England). It starts with the normal situation then graduates from presenteeism, where the individual is sick but still attends the workplace, to absenteeism, where the individual is sick and no longer attends the place of work, and eventual unemployment, he explained. “This study suggests that work disability is reversible in the real-world setting,” he added.

The study is from the Long-term Outcomes in Psoriatic ArthritiS (LOPAS II) working group, a 2-year, multicenter, prospective, observational cohort study of work disability in psoriatic arthritis. The group has previously reported that unemployment in psoriatic arthritis is associated with older age, disease duration of 2-5 years, and worse physical function, but that employer awareness and helpfulness enabled patients to stay on the job. Higher levels of global and joint-specific disease activity and worse physical function were associated with greater levels of reporting to work sick (presenteeism) and productivity loss (Rheumatology 2015;54:157-62).

The latest study by Dr. Tillett and his team is a follow-up to see how treatment affects work performance. At baseline, before treatment with anti-TNF or DMARDs, the LOPAS II team of investigators found that 164 (41%) of their 400 subjects were unemployed. Unemployed patients tended to be older (median of 59 years vs. 49 years) and to have worse physical function (a median score of 1.4 on the Health Assessment Questionnaire vs. 1.0). Subsequent treatment with anti-TNFs or DMARDs didn’t change overall employment levels.

Patients who started on anti-TNFs tended to have longer disease duration (median of 11 vs. 5 years) and a greater median number of tender (16 vs. 11) and swollen (7 vs. 5) joints, but otherwise there were no significant differences in demographic or clinical measures between the two treatment groups.

Median scores on the Disease Activity Index for Psoriatic Arthritis (DAPSA) improved over 24 weeks from 53 to 14 among anti-TNF patients, which is considered a good response, but only improved from 39 to 30 in the DMARD group, which is considered a poor response. All of the findings were statistically significant.

The results revealed a “surprisingly poor clinical response to synthetic DMARDs on clinical outcomes … as opposed to good response amongst patients commenced on TNF inhibitors,” Dr. Tillett said in an interview. The improvement in work disability and disease activity seen also was greater and more rapid among those who started on anti-TNF rather than synthetic DMARD.

Dr. Tillett reported receiving grant/research support from AbbVie and speaker or advisory board fees from UCB, Pfizer, and AbbVie. The other authors said they have no disclosures.

ROME – Anti–tumor necrosis factor agents have a slight edge over conventional disease-modifying antirheumatic drugs when it comes to helping psoriatic arthritis patients who are having work issues, according to a large British observational study presented at the European Congress of Rheumatology.

Among 236 of 400 subjects working at baseline, presenteeism improved from 30% to 10% and productivity loss improved from 45% to 10% among patients who started taking anti-TNF (anti-tumor necrosis factor) agents. Gains were more modest when patients were started on DMARDs, with presenteeism improving from 30% to 20% and productivity loss from 40% to 25%. The difference in change of presenteeism between the two treatment groups became statistically significant at 2 weeks and remained so at 24 weeks.

“Work disability is a continuum,” said the presenting author, Dr. William Tillett of the Royal National Hospital for Rheumatic Diseases in Bath (England). It starts with the normal situation then graduates from presenteeism, where the individual is sick but still attends the workplace, to absenteeism, where the individual is sick and no longer attends the place of work, and eventual unemployment, he explained. “This study suggests that work disability is reversible in the real-world setting,” he added.

The study is from the Long-term Outcomes in Psoriatic ArthritiS (LOPAS II) working group, a 2-year, multicenter, prospective, observational cohort study of work disability in psoriatic arthritis. The group has previously reported that unemployment in psoriatic arthritis is associated with older age, disease duration of 2-5 years, and worse physical function, but that employer awareness and helpfulness enabled patients to stay on the job. Higher levels of global and joint-specific disease activity and worse physical function were associated with greater levels of reporting to work sick (presenteeism) and productivity loss (Rheumatology 2015;54:157-62).

The latest study by Dr. Tillett and his team is a follow-up to see how treatment affects work performance. At baseline, before treatment with anti-TNF or DMARDs, the LOPAS II team of investigators found that 164 (41%) of their 400 subjects were unemployed. Unemployed patients tended to be older (median of 59 years vs. 49 years) and to have worse physical function (a median score of 1.4 on the Health Assessment Questionnaire vs. 1.0). Subsequent treatment with anti-TNFs or DMARDs didn’t change overall employment levels.

Patients who started on anti-TNFs tended to have longer disease duration (median of 11 vs. 5 years) and a greater median number of tender (16 vs. 11) and swollen (7 vs. 5) joints, but otherwise there were no significant differences in demographic or clinical measures between the two treatment groups.

Median scores on the Disease Activity Index for Psoriatic Arthritis (DAPSA) improved over 24 weeks from 53 to 14 among anti-TNF patients, which is considered a good response, but only improved from 39 to 30 in the DMARD group, which is considered a poor response. All of the findings were statistically significant.

The results revealed a “surprisingly poor clinical response to synthetic DMARDs on clinical outcomes … as opposed to good response amongst patients commenced on TNF inhibitors,” Dr. Tillett said in an interview. The improvement in work disability and disease activity seen also was greater and more rapid among those who started on anti-TNF rather than synthetic DMARD.

Dr. Tillett reported receiving grant/research support from AbbVie and speaker or advisory board fees from UCB, Pfizer, and AbbVie. The other authors said they have no disclosures.

ROME – Anti–tumor necrosis factor agents have a slight edge over conventional disease-modifying antirheumatic drugs when it comes to helping psoriatic arthritis patients who are having work issues, according to a large British observational study presented at the European Congress of Rheumatology.

Among 236 of 400 subjects working at baseline, presenteeism improved from 30% to 10% and productivity loss improved from 45% to 10% among patients who started taking anti-TNF (anti-tumor necrosis factor) agents. Gains were more modest when patients were started on DMARDs, with presenteeism improving from 30% to 20% and productivity loss from 40% to 25%. The difference in change of presenteeism between the two treatment groups became statistically significant at 2 weeks and remained so at 24 weeks.

“Work disability is a continuum,” said the presenting author, Dr. William Tillett of the Royal National Hospital for Rheumatic Diseases in Bath (England). It starts with the normal situation then graduates from presenteeism, where the individual is sick but still attends the workplace, to absenteeism, where the individual is sick and no longer attends the place of work, and eventual unemployment, he explained. “This study suggests that work disability is reversible in the real-world setting,” he added.

The study is from the Long-term Outcomes in Psoriatic ArthritiS (LOPAS II) working group, a 2-year, multicenter, prospective, observational cohort study of work disability in psoriatic arthritis. The group has previously reported that unemployment in psoriatic arthritis is associated with older age, disease duration of 2-5 years, and worse physical function, but that employer awareness and helpfulness enabled patients to stay on the job. Higher levels of global and joint-specific disease activity and worse physical function were associated with greater levels of reporting to work sick (presenteeism) and productivity loss (Rheumatology 2015;54:157-62).

The latest study by Dr. Tillett and his team is a follow-up to see how treatment affects work performance. At baseline, before treatment with anti-TNF or DMARDs, the LOPAS II team of investigators found that 164 (41%) of their 400 subjects were unemployed. Unemployed patients tended to be older (median of 59 years vs. 49 years) and to have worse physical function (a median score of 1.4 on the Health Assessment Questionnaire vs. 1.0). Subsequent treatment with anti-TNFs or DMARDs didn’t change overall employment levels.

Patients who started on anti-TNFs tended to have longer disease duration (median of 11 vs. 5 years) and a greater median number of tender (16 vs. 11) and swollen (7 vs. 5) joints, but otherwise there were no significant differences in demographic or clinical measures between the two treatment groups.

Median scores on the Disease Activity Index for Psoriatic Arthritis (DAPSA) improved over 24 weeks from 53 to 14 among anti-TNF patients, which is considered a good response, but only improved from 39 to 30 in the DMARD group, which is considered a poor response. All of the findings were statistically significant.

The results revealed a “surprisingly poor clinical response to synthetic DMARDs on clinical outcomes … as opposed to good response amongst patients commenced on TNF inhibitors,” Dr. Tillett said in an interview. The improvement in work disability and disease activity seen also was greater and more rapid among those who started on anti-TNF rather than synthetic DMARD.

Dr. Tillett reported receiving grant/research support from AbbVie and speaker or advisory board fees from UCB, Pfizer, and AbbVie. The other authors said they have no disclosures.