Tender and swollen joint counts are poorly associated with disability in chikungunya arthritis compared to rheumatoid arthritis

Chronic rheumatological manifestations similar to those of rheumatoid arthritis (RA) are described after chikungunya virus infection. We aimed to compare the relevance of joint counts and symptoms to clinical outcomes in RA and chronic chikungunya disease. Forty patients with chronic chikungunya arthralgia and 40 patients with RA were enrolled in a cross-sectional study. The association of tenderness and swelling, clinically assessed in 28 joints, and patient evaluations of pain and musculoskeletal stiffness with modified Health Assessment Questionnaire (HAQ) and quality of life (QoL) assessments were investigated. Tender and swollen joint counts, pain and stiffness scores were all associated with the HAQ disability index in RA (all r > 0.55, p ≤ 0.0002), but only stiffness was significantly associated with disability in chikungunya (r = 0.38, p = 0.02). Joint counts, pain and stiffness were also associated with most QoL domains in RA patients. In contrast, in chikungunya disease, tender joint counts were associated only with one QoL domain and swollen joints for none, while pain and stiffness were associated with several domains. Our results confirm the relevance of joint counts in RA, but suggest that in chronic chikungunya disease, joint counts have more limited value. Stiffness and pain score may be more important to quantify chikungunya arthritis impact.

Rheumatoid arthritis patients with predominantly tender joints rarely achieve clinical remission despite being in ultrasound remission

Objectives Since subjective variables may reduce remission by composite disease activity scores (CDAS), the main objectives were to explore whether rheumatoid arthritis (RA) patients with mainly tender versuss mainly swollen joints had differences in patient reported outcome measures (PROMs), clinical or ultrasound assessments as well as in achieving remission defined by CDAS or ultrasound. Methods In a Nordic multicentre study, RA patients initiating tocilizumab were assessed by PROMs, clinical, laboratory and ultrasound assessments (36 joints, 4 tendons) at baseline, 4, 12 and 24 weeks. Remission was defined according to CDAI/Boolean or no Doppler activity present. Tender-Swollen joint differences (TSJD) were calculated. Statistics exploring changes over time/differences between groups included Wilcoxon, Mann–Whitney, Kruskal-Wallis and Spearman. Results 110 patients were included (mean (SD) age 55.6 (12.1) years, RA duration 8.7 (9.5) years). All PROMs, clinical, laboratory and ultrasound scores decreased during follow-up (p < 0.001). During follow-up, tender joint counts were primarily correlated with PROMs (r = 0.24–0.56 (p < 0.05–0.001)), and swollen joint counts with ultrasound synovitis scores (r = 0.33–0.72 (p < 0.05–0.001)). At 24 weeks patients with TSJD > 0 had higher PROMs and CDAI (p < 0.05–0.001) but lower ultrasound synovitis scores (p < 0.05). Remission by CDAI/Boolean was seen in 26–34% and by Doppler 53%, but only 2–3% of patients with TSJD > 0 achieved CDAI/Boolean remission. Conclusion Patients with more tender than swollen joints scored higher on subjective assessments but had less ultrasound synovitis. They seldom achieved CDAS remission despite many being in Doppler remission. If patients with predominantly tender joints do not reach CDAS remission, objective assessments of inflammation should be performed. Clinical trial identifier ClinicalTrials.gov, https://clinicaltrials.gov/, NCT02046616

FRI0450 MEASURES OF DISEASE SEVERITY PREDICT DISABILITY AND QUALITY OF LIFE DIFFERENTLY IN RHEUMATOID ARTHRITIS AND CHRONIC CHIKUNGUNYA DISEASE

Background:Chronic rheumatological manifestations similar to those of rheumatoid arthritis (RA) have been described after chikungunya virus infection. However, the clinical significance of the symptoms and disease severity in the two conditions has not been directly compared.Objectives:To compare, using identical measures of disease severity and patient outcomes, the impact of disease severity measures and symptoms on outcomes in RA and chronic chikungunya disease.Methods:Forty patients with chronic chikungunya arthralgia two years post-infection and 40 matched patients with RA were enrolled in Roraima, Brazil. Twenty-eight joints were assessed for tenderness and swelling, a pain intensity visual analogue scale, musculoskeletal stiffness questionnaire, modified Health Assessment Questionnaire and the EuroQol EQ5D-5L quality of life assessment were completed. The importance of the various measures of disease severity were analysed using Spearman’s rank correlation and regression analysis.Results:Tender and swollen joint counts, pain and stiffness were all predictive of the HAQ disability index in RA, but only stiffness was significantly associated with disability in chikungunya patients (Table 1). Tender and swollen joint counts, pain and stiffness were predictive for all EQ5D quality of life domains (except anxiety/depression) in RA patients. In contrast, in chikungunya disease, tender joint counts were predictive only of usual daily activities; pain was predictive of impaired mobility, self-care and discomfort, while stiffness was predictive for the mobility and anxiety/depression domains (Figure 1). Swollen joint counts were not associated with any of the patient outcomes in chikungunya disease. Linear regression analysis confirmed (p=0.003) that the effect of swollen joint count on the HAQ disability index depends on the underlying disease.Table 1.Association of disease severity with HAQ disability index in rheumatoid and CHIKV+ arthritisSeverity measureRheumatoid arthritisCHIKV+ arthritisr (p)r (p)Tender joint count0.56 (0.0002)0.24 (0.14)Swollen joint count0.60 (<0.0001)0.002 (0.99)Joint pain (VAS)0.55 (0.0002)0.29 (0.07)Stiffness severity0.57 (0.0001)0.38 (0.02)Figure 1.Association of disease severity with quality of life domains in rheumatoid and CHIKV+ arthritisConclusion:The value of all the disease severity measures tested in RA were confirmed, but tender joint counts may have more limited value in the assessment of chronic chikungunya disease. Joint swelling appears to have little impact for chikungunya patients, while stiffness appears to be an important metric to quantify chikungunya arthritis disease severity.Disclosure of Interests:Hugh Watson Shareholder of: Sanofi, Employee of: Sanofi, Ramão Luciano Nogueira-Hayd: None declared, Maony Rodrigues-Moreno: None declared, Felipe Naveca: None declared, Giulia Calusi: None declared, Richard Amdur: None declared, Karol Suchowiecki: None declared, Gary S. Firestein: None declared, Gary Simon: None declared, Aileen Chang: None declared

Effectiveness of an Outreach Model of Care for Rheumatology Specialty Clinics to an On-Reserve First Nations Community

A model of care consisting of rheumatology specialty services embedded in the primary care system on a First Nations reserve was instituted to reduce barriers to care and improve inflammatory arthritis outcomes for patients. We assessed the effectiveness of this model of care on disease activity measures and patient-reported outcomes over 7 years. Patients were enrolled in a longitudinal cohort at the Siksika Nation in Alberta. Clinical characteristics, treatment recommendations and disease activity measures were systematically recorded over follow-up. Mixed-model regression was performed to determine rates of change for continuous measures. 59 participants (78% female; M = 47 years, SD = 13), predominantly with rheumatoid arthritis (RA; n = 36), were followed for an average of 29 months (SD = 23). Swollen and tender joint counts decreased significantly (change per month: -0.20, 95% CI -0.29 to -0.10, and -0.20, 95%CI -0.34 to -0.06, respectively) but pain, physician global and function scores did not significantly improve (all p > 0.05). Patient global evaluation scores worsened over time (change per month 0.08, 95%CI 0.029 to 0.131, p = 0.002). Inflammatory markers improved at a slower rate in patients with incident compared to incident disease. Disease-modifying agents were escalated for moderate or high disease activity at 64% of RA visits, with justifications for not escalating or application of local treatment approaches in all but one instance. Despite improvement in swollen and tender joint counts and adherence to current treatment paradigms, patient-reported outcomes did not significantly improve during follow-up. Further innovation is required to meet relevant outcomes.

Psoriatic Nail Changes Are Associated With Clinical Outcomes in Psoriatic Arthritis

Background: Nail changes are common in psoriatic arthritis (PsA), with varying relationships existing between skin, nail, and joint disease. Objective: To further characterize relationships between nail changes, psoriasis, and joint involvement in PsA patients. Methods: One hundred eighty-eight PsA patients had skin, fingernail, and rheumatological assessments completed. Hand and fingernail photographs were taken and reviewed by a dermatologist. Results: Higher swollen joint counts were associated with distal interphalangeal (DIP)/periungual psoriasis ( P = .001), more splinter hemorrhages ( P = .006), and any nail bed change ( P = .03). Higher tender joint counts were associated with rough onychorrhexis ( P < .001), DIP/periungual psoriasis ( P = .03), red lunula ( P = .001), nail crumbling ( P = .046), any nail matrix ( P = .03), and nail bed change ( P = .03). Joint involvement was associated with same-digit nail changes; strongest association was swollen or tender DIP with subungual hyperkeratosis, odds ratio = 26.6 (95% CI, 5.1-139.1). Conclusion: The DIP/periungual psoriasis and specific nail changes were associated with higher joint counts and certain nail changes with same-digit joint involvement.

Systematic Review and Metaanalysis of Patient Self-Report versus Trained Assessor Joint Counts in Rheumatoid Arthritis

Objective.Patient self-report outcomes and physician-performed joint counts are important measures of disease activity and treatment response. This metaanalysis examines the degree of concordance in joint counts between trained assessors and patients with rheumatoid arthritis (RA).Methods.Studies eligible for inclusion met the following criteria: English language; compared patient with trained assessor joint counts; peer-reviewed; and RA diagnosis determined by board-certified or board-eligible specialist or met 1987 American College of Rheumatology criteria. We searched PubMed and Embase to identify articles between 1966 and January 1, 2008. We compared measures of correlation between patients and assessors for either tender/painful or swollen joint counts. We used metaanalysis methods to calculate summary correlation estimates.Results.We retrieved 462 articles and 18 were included. Self-report joint counts were obtained by a text and/or mannequin (picture) format. The summary estimates for the Pearson correlation coefficients for tender joint counts were 0.61 (0.47 lower, 0.75 upper) and for swollen joint counts 0.44 (0.15, 0.73). Summary results for the Spearman correlation coefficients were 0.60 (0.30, 0.90) for tender joint counts and 0.54 (0.35, 0.73) for swollen joint counts.Conclusion.A self-report tender joint count has moderate to marked correlation with those performed by a trained assessor. In contrast, swollen joint counts demonstrate lower levels of correlation. Future research should explore whether integrating self-report tender joint counts into routine care can improve efficiency and quality of care, while directly involving patients in assessment of RA disease activity.