High sensitivity cardiac troponin (hs-cTnT) is a biomarker for cardiovascular disease (CVD) in the general population. (1) Psoriatic arthritis (PsA) confers an increased risk for CVD (2) but there are no biological markers to stratify CVD risk in PsA patients.
Objectives:
To determine the level of serum hs-cTnT in a PsA cohort and controls without inflammatory disease, and further characterize the PsA cohort with detectable hs-cTnT.
Methods:
Serum hs-cTnT level was measured with a sandwich immunoassay method in a consecutive PsA cohort (n=96). The control cohort was based on apparently healthy individuals recruited during routine annual health examination, Tel-Aviv Medical Center Inflammatory Survey (TAMCIS) (n=6,052). hs-cTnT was measured in carefully matched controls (n=88), manually selected from the TAMCIS, based on gender, age, BMI, hypertension, and hyperlipidemia prevalence. Hs-cTnT ≥5 ng/L was used as a cutoff for the detectable level. Multiple regression analysis was used to determine the factors associated with hs-cTnT.
Results:
The characteristics of the PsA cohort are presented in table 1. Remarkably, in the majority of patients, both skin and joint disease were well controlled. PsA and TAMCIS cohorts had a similar range of age (51.5 vs 48 yr) but different gender representation: 47% vs 72.5% of males (p<0.001). PsA exhibited a higher prevalence of traditional CVD risk factors compared to the TAMCIS cohort: BMI 28 vs 26.5 (p=0.002), current smokers 20.8% vs 10.1% (p=0.002), hypertension 25% vs 15% (p=0.007), dyslipidemia prevalence 34% vs 27% (p= 0.101), diabetes 19.8% vs 4.6% (p<0.0001). Due to these differences, a matched control group was used for comparison of troponin. Detectable hs-cTnT was present in 29.5% of the PsA patients compared to 19.3% in the controls. (p=0.114) Factors associated with detectable hs-cTnT in PsA were consistent with traditional factors and included male gender (p=0.007), age (p=0.005), hypertension (p<0.001), and DM (p<0.001). No correlation between detectable hs-cTnT level and psoriasis/PsA duration, disease severity, treatment with DMARDs or biologics was found.
Conclusions:
This is the first study to report a detectable hs-cTnT level in up to 30% in patients with well controlled PsA, asymptomatic for CVD, warranting a special attention to monitoring CVD risk factors and manifestations in this group. Traditional CVD risk factors but not measures of disease activity were associated with detectable hs-cTnT. The latter may be explained by a potential positive impact of anti-rheumatic therapies on the cardiovascular profile. Further prospective studies addressing the predictive role of hs-cTnT for CVD events in PsA are needed.
References
1. Saunders JT, et al. Circulation2011;123. 2. Ogdie A, et al. Ann Rheum Dis2015;74.
The heterogeneous manifestations and clinical course of systemic lupus erythematosus (SLE) challenge disease activity assessment in everyday clinical practice. Multiple clinical disease monitoring instruments have been developed however, they are limited in the ability to detect changes in disease activity or too cumbersome to be utilized in daily practice. In a previous paper case pilot study, we compared the newly constructed ASSESSLE score, with the BILAG and SLEDAI scores and reported good reliability and construct validity. We aimed to apply the ASSESSLE disease activity score in clinical practice and evaluate its validity, and its ability to capture change in disease activity between visits, compared to the BILAG and SLEDAI scores.
Methods
The new instrument for assessing SLE activity is comprised of 7 visual analog scales (VAS), which separately address the physician's global assessment and 6 organ systems including mucocutaneous, musculoskeletal, cardiorespiratory, renal, neuropsychiatric systems, and others. Changes in blood count, serology, and medications are recorded and incorporated into the final score. The study was performed in 2 tertiary medical centers in Israel and included consecutive patients with SLE attending the SLE clinics. Repeated follow-up visits were scored, aiming to assess the score's ability to detect changes in disease activity between visits.
Results
Forty-five SLE patients were scored, 32 of whom had repeated visits (a total of 127 visits). When comparing the 3 scoring tools, the mean trajectories of the first 4 visits (121 of 127 visits) followed a similar trajectory for all 3 scores when looking at global disease activity, as well as activity in the domains most frequently active (mucocutaneous, musculoskeletal and renal domains) (figure 1). The ASSESSLE score correlated well with the BILAG score and with the SLEDAI score (Spearman correlation - 0.71 and 0.69 respectively).
Conclusions
The ASSESSLE score shows a good correlation with both the BILAG and the SLEDAI scores and a similar ability to capture change in disease activity over time. The ASSESSLE tool shares the simplicity and ease of interpretation of the SLEDAI and correlates well with the BILAG, allowing its use in everyday practice.
Ursachen myogener und neurogener Myalgien Klinische Manifestation und erforderliche Diagnostik Spezielle Befunde in der Zusatzdiagnostik ausgewählter Erkrankungen Vorschlag für einen Algorithmus zur Diagnostik bei Myalgien
Systemic lupus erythematosus (SLE) is a heterogeneous, waxing, waning, multisystem autoimmune disease. The complexity and clinical unpredictability of SLE challenge the assessment of disease activity over time, especially in everyday clinical practice. Multiple clinical disease- monitoring instruments have been developed, however, they are limited in ability to detect the change in disease activity over time, too cumbersome to be utilized in daily practice, and do not include patient-reported outcomes (PROs).
Objectives
To construct a new disease activity score that will simplify and improve disease activity assessment in daily practice, and include PROs. Here we present the PRO component.
Methods
The new instrument for the assessment of SLE activity is comprised of 7 visual analog scales (VAS), which separately address the physician's global assessment and 6 organ systems. The PRO consists of 5 VAS questions that address general well-being, global disease activity, activities of daily living, medication compliance, and mood. The ASSESSLE PRO is compared to the Short Form Health Survey (SF-36), a 36-item, patient-reported survey of patient health. We applied the ASSESSLE PRO to 46 consecutive patients with SLE attending the rheumatology clinic in 2 tertiary medical centers in Israel.
Results
Psychometric evaluation of the reliability of all 5 PRO questions indicated that question 4, regarding compliance, correlated poorly with the other items and lowered the reliability (Cronbach's α=0.80 95% CI (0.74,0.85). Following the omission of question 4, Cronbach's α was recalculated, leading to increased internal reliability (Cronbach's α = 0.86, 95% CI [0.82, 0.90]). All other remaining items had a satisfactory correlation with the other items ("item-other" correlation between 0.58-0.70). Therefore, the score was computed as the mean of the 4 remaining questions. Aiming to compare the ASSESSLE PRO to the SF-36 survey, the Spearman correlation coefficient between absolute scores was computed and a strong and significant effect was found (R=0.85, p<0.0001). (Figure 1).
Conclusion
The ASSESSLE PRO is a short PRO that allows a reliable, reproducible and simple PRO form showing excellent correlation with the SF-36. Following the omission of question 4, regarding patient compliance, the ASSESSLE PRO consists of only 4 questions, as compared to the SF-36 which requires a response to 36 items. The ASSESSLE PRO seems to have significant advantages due to its intuitive VAS questions and brevity which allows use of this PRO in everyday practice and may increase the validity of disease activity evaluation of SLE when combined with the physician's assessment.
The parasympathetic system and its main neurotransmitter, acetylcholine, contributes to homeostasis of inflammation. Cholinergic dysregulation is thought to contribute to the pathogenesis of inflammatory rheumatic diseases. Cholinesterase activity in patients with psoriatic arthritis (PsA) has not been investigated.To compare the cholinesterase activity in patients with PsA and immunocompetent controls and to explore the correlation between cholinergic status (CS) and PsA disease activity.Serum acetylcholinesterase (AChE) and total cholinesterase activity were measured in patients with PsA (n=88) and matched controls (n=84). Cholinergic activity before and 3-6 months after the initiation of a biologic treatment was evaluated in seven patients with PsA.The levels of AChE and CS were similar in both PsA patients and controls. PsA patients treated with biologics had significantly lower levels of AChE and CS compared to patients treated with non-biologics: 447.4 vs. 526 substrate hydrolyzed/min/ml, P = 0.005, and 1360.9 vs. 1536, P = 0.029, respectively. We found an association between C-reactive protein levels, AChE activity (r = 0.291, P = 0.008), and cholinergic status (r = 0.247, P = 0.026) in patients with PsA but not in controls. No correlation between AChE activity, cholinergic status, and the indices of PsA disease activity was found. After initiating or switching biologic treatment in 7 patients, AChE levels remained stable.We demonstrated similar cholinesterase activity in patients with psoriatic arthritis and controls, highlighting a potential effect of biologic treatment on cholinergic activity in patients with PsA.
Marked fatigue is common in patients with systemic lupus erythematosus (SLE). This study aimed to assess the association of sleep disorders, including obstructive sleep apnea (OSA), with SLE. Forty-two consecutive patients with SLE and 20 healthy controls were recruited and underwent a one-night ambulatory sleep examination. They completed questionnaires, including the Pittsburgh Sleep Quality Index (PSQI) and Functional Assessment of Chronic Illness Therapy (FACIT). SLE disease activity and damage were assessed by the SLE Disease Activity Index 2000 (SLEDAI-2K) and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index (SDI). A significantly increased apnea/hypopnea index was noted in the SLE group compared to healthy controls (p = 0.004). SLE patients had higher rates of moderate-to-severe OSA (p = 0.04), PSQI (p = 0.001), and FACIT scores (p = 0.0008). Multivariate analysis revealed that the SDI was associated with OSA (p = 0.03). There was a positive association between SLEDAI-2K and moderate-to-severe OSA (p = 0.03). Patients with SLE had an increased prevalence of OSA and poorer quality of sleep compared to healthy controls. Our findings suggest that active disease and accumulated damage may be associated with OSA. These findings highlight the importance of identifying the presence of OSA in patients with SLE.
The assessment of global disease activity by patients (PGA) and evaluators (EGA) is an essential outcome measure in psoriatic arthritis (PsA). However, a discordance between PGA and EGA poses a challenge in evaluating disease activity in PsA. Several clinical and sonographic factors could influence this discordance.
Objectives:
We aimed to evaluate the magnitude and extent of the discordance between PGA and EGA in PsA patients, and identify clinical, patient reported outcomes (PRO) and ultrasound (US) variables associated with this discordance.
Methods:
Consecutive PsA patients who fulfilled the CASPAR criteria were prospectively recruited. Each patient was evaluated by a comprehensive clinical, PRO questionnaires and sonographic assessment. The clinical evaluation was performed by senior rheumatologists blinded to the PGA and to US measures. PGA and EGA were rated with a 0–10 numerical rating scale, and delta of ≥3 was considered a clinically significant discordance. The US assessment included 52 joints, 40 tendons, and 14 points of entheses (according to the MASEI index plus lateral epicondyles), performed on the same day by an experienced sonographer blinded to the clinical data. The US scores calculation was based on the MAdrid Sonography Enthesitis Index (MASEI) scoring system for enthesitis, EULAR synovitis score for synovitis, and gray scale and Doppler scoring for tenosynovitis. The clinical, PRO and sonographic factors of the concordant and discordant groups were compared using a t-test for normally distributed data, otherwise, a non-parametric test was applied. Fisher's exact test was used to compare categorical variables. Factors associated with discordance were evaluated through univariate and multivariate regression analyses.
Results:
158 PsA patients (mean age 52.3±13 years, 88 (55.7%) females) were included. The mean difference between PGA and EGA was 3.30 (±2.75) and 88 (55.7%) patients were considered discordant (difference ≥3), while 68 (43.0%) patients were considered concordant (+3 to -3). The discordant group had significantly higher tender joint counts, SPARCC scores, CRP levels, and lower occupation rates compared with the concordant group (p<0.05) (Table 1). Grey scale and Doppler US scores of synovitis, tenosynovitis and enthesitis were similar between the groups. Disease activity scores (including MDA, DAPSA, CPDAI and PASDAS) were significantly higher in the discordant compared to the concordant group. In addition, patients with discordance had higher proportion of fibromyalgia (p<0.001) and significantly worse PRO, including pain, depression, fatigue and different measures of quality of life (SF-36 physical and mental, HAQ and PsAID12, p<0.05) (Figure 1). On multivariate regression, depression, higher tender joint counts and lower swollen joint counts were associated with higher discordance (OR 1.05, p=0.019; OR 1.07, p=0.017 and OR 0.85, p=0.046, respectively).
Conclusion:
The discrepancy between patients' and evaluators' global assessments in PsA is characterized by worse disease activity scores and physical and psychological/mental patient reported outcomes, but not sonographic measures. Depression was associated with higher discordance and, therefore, screening for this comorbidity and appropriate treatment are required. Table 1. Comparison of demographic, clinical and sonographic characteristics between concordant and discordant patient
