ISSN 1756ͳ1841 VOLUME 22 SUPPLEMENT 3 2019

International Journal of
Rheumatic
Diseases
Official journal of the Asia Pacific League
of Associations for Rheumatology (APLAR)

21st Asia Pacific League of AssociaƟons

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conjuncƟon with the Australian
Rheumatology AssociaƟon
8–11 Apr 2019
Brisbane, QLD, Australia

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 InternaƟonal Journal of RheumaƟc Diseases

21st Asia Pacific League of AssociaƟons for Rheumatology

Congress (APLAR) in conjuncƟon with the Australian
Rheumatology AssociaƟon
8–11 Apr 2019
Brisbane, QLD, Australia

Disclaimer: This abstract book has been produced using author-supplied copy. EdiƟng has been restricted
to some correcƟons of spelling and style where appropriate. No responsibility is assumed for
any claims, instrucƟons, methods or drug dosages contained in the abstracts: it is recommended
that these are verified independently.

apl_v22_s3_issueinfo.indd 1 16-Mar-19 3:54:21 PM

 InternaƟonal Journal of RheumaƟc Diseases
Volume 22 | Supplement 3 | April 2019

Contents
Oral Abstracts 3
Poster Abstracts 40
Author Index 227

apl_v22_s3_issueinfo.indd 2 16-Mar-19 3:54:21 PM

DOI: 10.1111/1756-185X.13538
ABSTR ACT
O R A L A B S TR AC T S
O-­057 | Treatment response prediction in
rheumatoid arthritis
A. Barton1,2
1
The University of Manchester; 2Manchester University Foundation Trust
The treatment landscape for rheumatoid arthritis (RA) has been
transformed since the turn of the century and there are now multiple
options available to manage chronic synovial inflammation; however,
each drug option works well in only a minority of patients and de-
cisions about which treatment to recommend in individual patients
are driven by guidelines, costs and familiarity with the drug options
available. The aim of precision medicine (also known as stratified
medicine) is to identify biomarkers to aid in the selection of the treat-
ments most likely to work in specific patient groups. Whilst a number
of large scale studies are underway to identify pre-­treatment or early
response biomarkers, a number of challenges remain. These include
understanding how we measure treatment response and confound-
ers that are present in assessing response. The latter includes adher-
ence to therapy; treatments will not be effective if not taken yet
we currently do not routinely account for adherence when classify-
ing individuals as responders or non-­responders to therapies. Some
treatments induce neutralising antibodies in some patients, which
can impact on efficacy but, again, this is not currently assessed when
Editorial material and organization © 2019 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd. Copyright of individual
abstracts remains with the authors.
Int J Rheum Dis. 2019;22(Suppl. 3):3–39. wileyonlinelibrary.com/journal/apl |  3

judging whether a drug is effective. This talk will discuss the chal-
lenges faced in identifying biomarkers to guide treatment selection
and progress that has been made with a specific focus on anti-­TNF
drugs and methotrexate treatment.
O-­0 01 | Charcot arthropathy caused by
syringomyelia and chiari-­malformation: a rare
case series
M. Behera1; S. R. Tripathy2; M. K. Parida2; R. Tripathy2; B. K.
Das2
1
Bhima Bhoi Medical College; 2SCB Medical College
Background: Charcot-­arthropathy is a rare, chronic, degenerative
and destructive neuropathic arthropathy. We report 3 cases of
Charcot-­arthropathy secondary to syringomyelia.
Case reports: Case1: 50 years, non-­diabetic, male presented with
gradual weakness and thinning of upper limbs for 2 years, painless
and deformed left elbow and wrists for 3 months. Examination re-
vealed saddle nose, short neck, non-­tender, swollen left elbow and
bilateral wrists, LMN signs of upper extremities, dissociated sensory
loss over left C4-­
D3, D6-­
D10 dermatomes, diminished vibration
sensation over left clavicle, elbow and wrist, thickened left ulnar
 
 |
4       ABSTRACTS
nerve, and nystagmus in right eye. Case2: 30 years, non-­diabetic
male presented with swelling of left elbow for 6 months, numbness,
and weakness of arms for 3 months. Examination revealed swollen,
non-­tender left elbow with crepitus, LMN signs of upper limbs, UMN
signs of lower limbs, with dissociated sensory loss over upper limbs
and chest. Case 3: 55 years, diabetic female, previously treated for
leprosy presented with numbness over upper limbs, chest and trunk,
weakness and atrophy of hands and forearms, swelling of left elbow
and bladder incontinence for 2 years. Examination revealed swol-
len, tender left elbow with crepitus, LMN signs of upper limbs, UMN
signs of lower limbs, dissociated sensory loss over upper forearms
and hands.
Investigations: Hematological, biochemical tests, viral markers, and
inflammatory markers were normal. NCV and radiological investiga-
tions are summarized in table-­1. Slit skin smears were negative.
Discussion: Charcot-­arthropathy of upper extremities is rare. The
most common cause is syringomyelia where shoulder, elbow, and
wrists are involved. All the cases had involvement of left elbow joint
and the cause was syringomyelia with Chiari-­malformation which is
rare. The thickened ulnar nerve in Case-­2 could be due to repeated
microtrauma while polyneuropathy in Case-­3 could be due to associ-
ated diabetes. None of the patients had evidence of leprosy.
Conclusion: Syringomyelia is the most important differential diagno-
sis of upper limb Charcot-­arthropathy.
O-­021 | Telehealth and rheumatology
H. Benham
Princess Alexandra Hospital and University Of Queensland
Telehealth involves the use of telecommunications and virtual
technology to deliver health care outside of traditional health-­care
facilities1. Telehealth offers the potential to provide improved ac-
cess to health care including access to specialist services that might
otherwise not be available without extensive travel. The timely and
suitable delivery of care to those living in Australia with rheumato-
logical diseases is crucial to ensuring excellent long-­term outcomes.
The Australian population is geographically spread and additionally
there is a lack of rheumatologists in rural areas. Increasing special-
ist rheumatology care through tele-­rheumatology could significantly
improve access2. For telehealth to be effective, it must increase ac-
cess to care whilst ensuring that the provision of the health services
allow for appropriate assessments including physical examination
and history taking. Patient provider communication and relation-
ships influence health care outcomes and are essential in person and
also when health care is delivered by telehealth3. We have recently
evaluated the outcomes of a new tele-­
rheumatology service in
Australia and analysed patient perspectives and acceptability of the
use of telehealth for the management of rheumatological conditions.
1
WHO https://www.who.int/sustainable-development/
health-sector/strategies/telehealth/en/
2
Poulsen K International Journal of Rheumatic Diseases 2015
Satisfaction with rural rheumatology telemedicine service
3
Hiratsuka V et al. Int J of Circumpolar Health 2013 Patient and pro-
vider perspectives on using telemedicine for chronic disease man-
agement among Native Hawaiian and Alaska Native people
O-­037 | Online approaches to the delivery of
lifestyle treatments for osteoarthritis
K. Bennell
Centre for Health, Exercise and Sports Medicine, University of Melbourne
The burden from osteoarthritis is expected to increase in coming
decades as the world's population ages, and obesity rates con-
tinue to rise. A substantial increase in demand for health services
is expected in the future to manage people with chronic joint pain.
Self-­management via lifestyle treatments, such as exercise/physical
activity and weight loss, is integral to minimizing pain and maintain-
ing physical function. However, OA care is suboptimal in Australia &
internationally with underuse of lifestyle treatments a major prob-
lem. There are numerous barriers to uptake of and adherence to life-
style treatments. One major barrier is difficulty accessing clinicians
and/or resources (due to geography, lack of clinicians, cost, incon-
venience & disability). Given the high adoption rate of computers,
mobile devices and internet globally, online approaches provide new
opportunities for delivering services remotely to people with oste-
oarthritis and supporting them to self manage. These approaches
include internet-­
mediated video conferencing, mobile phone
text messaging, web resources & online support groups. Blended
ABSTRACTS
interventions are also relatively new ways of delivering health care
whereby online resources are combined with some degree of thera-
peutic guidance. Evidence for effectiveness of such approaches will
be reviewed. Key challenges to implementation and future direc-
tions for research in the field will be highlighted.
O-­022 | The lancet low back pain series: a
call to action to address this major global health
challenge
R. Buchbinder
Cabrini Institute and Monash University
The Lancet Low Back Pain Series, which involved 31 authors from
15 countries, is a landmark series of three papers that outlines why
urgent global action is needed to halt the increasing burden from
low back pain and what actions need to be taken. The burden is
growing and the effects will become more extreme in low-­income
and middle-­income countries. The Series highlighted that much care
for back pain is low value and is making the problem worse and im-
proving clinician, patient and general public understanding of back
pain is a key issue. When the Series was published in March 2018 it
received extensive lay and professional media coverage across the
world. It was launched in Australia by the Federal Health Minister,
Hon Greg Hunt. As an indication of its reach, almost 15 million peo-
ple saw a tweet with the Series hashtag #LowBackPain within days
of publication.
This talk will outline the main messages from the three papers in-
cluding why low back pain is the top ranked cause of global disability.
It will describe the tremendous gaps between evidence and practice
in the management of low back pain that continue to exist in both
high-­income and low-­and middle-­income countries, as well as ex-
amples of effective, promising or emerging solutions. The final paper
describes what policy, public health, health-­
care practice, social
services and workplaces must jointly do to tackle the problem. This
includes development of an internationally-­agreed minimal national
dataset for low back pain that can be used to benchmark progress
within and across countries.
O-­042 | Vertebral fractures: controversies in
definition and management
R. Buchbinder
Cabrini Institute and Monash University
The lifetime risk of a symptomatic osteoporotic vertebral fracture
for a person aged 45 is 15% for a woman and 8% for a man, and the
rates may be rising. It is a common cause of both acute and chronic
pain in older populations. While most fractures heal within a few
months, some people have persistent pain and disability, and require
hospitalisation, long-­term care, or both. Management options for
|
      5
treating acutely painful osteoporotic vertebral fractures are limited
and include provision of adequate analgesia and supportive meas-
ures, physical therapy and assessment and appropriate management
of osteoporosis and risk factors for further fractures.
Vertebroplasty is the poster child for comparative effectiveness re-
search and medical reversal. While it enjoys continued use in some
settings, there is now high-­moderate quality evidence based upon
evidence synthesis that includes five placebo-­controlled trials that
it provides no benefits over placebo and these results do not differ
according to pain duration (≤ 6 vs >6 weeks). A clinically important
increased risk of incident symptomatic vertebral fractures or other
serious adverse events cannot be excluded due to small event num-
bers. Serious harms including cord compression, ventricular perfora-
tion, pulmonary embolism, infection and death have been reported.
While there are no placebo-­controlled trials of kyphoplasty there
is no high quality data to suggest that the efficacy of this treat-
ment differs from vertebroplasty. A second controversy that will be
discussed if time allows is whether the two thirds of osteoporotic
vertebral compression fractures that are diagnosed on the basis of
asymptomatic radiographic changes are truly vertebral fractures.
O-­038 | Education and exercise for knee OA:
making it work in clinical practice
K. Crossley
La Trobe University
Exercise-­therapy and education are critical components of success-
ful care for people with knee osteoarthritis. Exercise-­therapy is as-
sociated with large improvements in pain (standard mean difference
(SMD) = 0.69) and function (SMD = 0.63), more so than any other
non-­surgical treatments for knee OA(1) (supported by at least 44
randomised controlled trials (RCTs)(1)). Exercise-­therapy is also cost-­
effective from societal and healthcare perspectives.(2) People with
severe OA can also benefit from exercise-­therapy and education,
with moderate effects on pain reduction observed in people await-
ing knee replacement surgery (SMD = 0.43).(3)
In line with the evidence, national and international guidelines,(4,
5) the Australian Clinical Care Standard for knee OA,(6) and
‘Victorian Model of Care’(7), recommend exercise-­therapy and
education for knee OA.(8, 9) Yet 57% of Australians with OA do
not receive appropriate non-­
surgical treatments.(10) A survey
of 591 Australian with OA indicates <20% were completing any
structured exercise therapy, and 50% had never tried this treat-
ment.(11)
Access to evidence-­informed exercise-­therapy and education is on
barrier to its implementation. Good Life with osteoArthritis from
Denmark (GLA:D®), is an 8-­
week physiotherapist led evidence-­
based, standardised, but individualised treatment consisting of two
group education, and 12 group exercise therapy sessions for people
with OA.(12) Delivered to >30,000 Danish patients,(13) GLA:D® re-
duces pain and analgesic consumption; and improves function and
 |
6       ABSTRACTS
physical-­activity level at 1 year.(12) In 2016. La Trobe University
launched GLA:D™ Australia (a not-­for-­profit initiative).(13) We have
trained >700 physiotherapists, to develop their ability and confi-
dence to deliver appropriate non-­surgical care including education,
exercise therapy and discussion and education about weight man-
agement. GLA:D™ Australia is now implemented in >250 public and
private settings, with access in all states and territories. GLA:D™
Australia is an accessible, low-­cost treatment, that works in clinical
practice.
1. Uthman OA, van der Windt DA, Jordan JL, Dziedzic KS, Healey
EL, Peat GM, et al. Exercise for lower limb osteoarthritis: sys-
tematic review incorporating trial sequential analysis and network
meta-analysis. BMJ. 2013;347:f5555.
2. Abbott JH, Wilson R, Pinto D, Chapple CM, Wright AA, team MT.
Incremental clinical effectiveness and cost effectiveness of pro-
viding supervised physiotherapy in addition to usual medical care
in patients with osteoarthritis of the hip or knee: 2-year results of
the MOA randomised controlled trial. Osteoarthritis Cartilage.
2018.
3. Wallis JA, Taylor NF. Pre-operative interventions (non-surgical
and non-pharmacological) for patients with hip or knee osteoar-
thritis awaiting joint replacement surgery–a systematic review
and meta-analysis. Osteoarthritis Cartilage. 2011;19(12):
1381–95.
4. RACGP. Guideline for the management of hip and knee osteoar-
thritis. Melbourne; 2018.
5. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum
F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgi-
cal management of knee osteoarthritis. Osteoarthritis Cartilage.
2014;22(3):363–88.
6. Australian Commission on Safety and Quality in Health Care.
Osteoarthritis of the knee clinical care standard. Sydney:
Australian Commission on Safety and Quality in Health Care;
2017.
7. Briggs A, Page C, Shaw B, Bendrups A, Philip K, Cary B, et al. A
Model of Care for osteoarthritis of the hip and knee: Development
of a system-wide plan for the health sector in Victoria, Australia.
Healthcare Policy. 2018;14(2):47–58.
8. Australian Orthopaedic Association National Joint Replacement
Registry: Annual Report. Adelaide; 2018.
9. Ferket BS, Feldman Z, Zhou J, Oei EH, Bierma-Zeinstra SM,
Mazumdar M. Impact of total knee replacement practice: cost ef-
fectiveness analysis of data from the Osteoarthritis Initiative.
BMJ. 2017;356:j1131.
10. Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook
JI, Coiera EW, et al. CareTrack: assessing the appropriateness of
health care delivery in Australia. MJA. 2012;197(2):100–5.
11. Hinman RS, Nicolson PJ, Dobson FL, Bennell KL. Use of nondrug,
nonoperative interventions by community-dwelling people with
hip and knee osteoarthritis. Arthritis Care Res (Hoboken).
2015;67(2):305–9.
12. Skou ST, Roos EM. Good Life with osteoArthritis in Denmark
(GLA:D™): evidence-based education and supervised neuromus-
cular exercise delivered by certified physiotherapists nationwide.
BMC Musculoskelet Disord. 2017;18(1):72.
13. Roos EM, Barton CJ, Davis AM, McGlasson R, Kemp JL, Crossley
KM, et al. GLA:D to have a high-value option for patients with
knee and hip arthritis across four continents: Good Life with os-
teoArthritis from Denmark. Br J Sports Med. 2018.
O-­032 | Strategies to improve gout
management: eMed approaches
R. Day
St Vincent's Hospital, University of New South Wales
Background/purpose: Gout increases in prevalence despite effec-
tive pharmacotherapies. Barriers to management are largely edu-
cational deficiencies. Sufferers, usually men, need to overcome the
stigma attached to the diagnosis. They need to understand that
maintaining serum urate below 0.36 mmol/L will eliminate recurrent
attacks but that sub-­optimal adherence will result in a return of at-
tacks. Prescribers need to know that acute attacks are likely over the
initial months of urate lowering therapy (ULT) but these can be miti-
gated by commencing with a dose of ULT reflective of renal function
and escalating the dose every 2–5 weeks until target serum urate is
achieved. Protection against acute attacks over the initial 6 months
period of ULT can be enhanced further with concomitant colchicine
or NSAIDs.
Methods: Gout is managed in primary care largely. Rates of adher-
ence to ULT are 50% or less, worse than most other chronic illnesses.
Efforts at educating primary care physicians in order firstly, to man-
age gout successfully and secondly, to educate their gout patients
sufficiently, has not been successful. Allied health practitioners,
such as nurses, working with prescribers in primary care settings and
given the mandate to educate and manage patients with gout, have
been spectacularly effective. However, this approach is resource in-
tensive. ‘Personalised’ eHealth interventions show promise notably
in improving adherence to ULT.
Results: Apps for smart phones are now available to assist people
with chronic health conditions. Their design needs to accommodate
the barriers and enablers to adherence to ULT identified through
patient centred research. Individual feedback of serum urate may
represent an important enabler of adherence to ULT.
Conclusion: Harnessing mobile apps to support patients man-
aging their chronic illnesses represents an important opportu-
nity to enhance health outcomes. Rigorous, patient-­centred and
driven development is critical. These tools also require careful
evaluation.
ABSTRACTS
O-­058 | Rheumatoid arthritis lung and genital
tract microbiome
M. K. Demoruelle
University of Colorado Denver
Rheumatoid arthritis (RA) develops in multiple stages and through
complex interactions between the immune system and environmen-
tal factors. Prior to the onset of arthritis in RA, there is a pre-­clinical
period of autoimmunity during which RA-­related autoantibodies are
systemically elevated in the absence of synovitis. This pre-­clinical
period supports that initial interactions between the immune sys-
tem and environmental factors in RA occurs at a site outside of
the joint. However, the exact site(s) and factor(s) involved have not
been clearly identified. Many research studies have focused on the
lung mucosa as a site where RA may begin, particularly generation
of disease-­specific autoantibodies. This focus is largely based on
well-­established strong links between smoking and RA risk as well
as findings of airway inflammation in many individuals with pre-­
clinical RA-­related autoimmunity. However, emerging data suggest
that while the lung is likely important in RA development, other mu-
cosal sites are also likely involved in some individuals. Several other
mucosal sites are being studied in RA, and the female genital tract
mucosa is of particular interest because women develop RA three
times more often than men for reasons that have not been fully un-
derstood. In addition, many different environmental factors have
been associated with RA risk. One factor of emerging interest is the
microbiome as there are several mechanisms by which bacteria at
a mucosal site could trigger autoantibody generation or propagate
autoimmunity including molecular mimicry, alteration of host anti-
gens, modulation of immune reactivity, and generation of inflamma-
tion leading to bystander activation of autoreactive cells. Several
RA studies demonstrates dysbiosis in individuals with RA, but less is
known about changes in the microbiome that precede RA develop-
ment. Overall, future studies that better understand how microbes
interact with the mucosal immune systems are likely to improve our
understanding of the etiology of RA.
O-­0 02 | The revolution in cancer
immunotherapies
R. Dolcetti
University of Queensland Diamantina Institute
The last decade has witnessed an unprecedented revolution in the
field of cancer treatment due to the development and clinical appli-
cation of new strategies to boost or reactivate antitumour immune
responses. Notably, modulation of immune inhibitory pathways
using checkpoint inhibitors has produced durable clinical responses
in a sizable subset of patients, leading to their accelerated approval
for the treatment of several cancers. The clinical success of check-
point inhibitors has led to a paradigm shift in cancer treatment,
|
      7
clearly indicating that targeting the host immune system rather than
the tumour may be more effective than conventional therapies. The
2018 Nobel Prize winning work launched a new field that now goes
far beyond CTLA-­4 and PD-­1, considering the huge therapeutic po-
tential of targeting other immune inhibitory pathways. Despite the
impressive clinical benefits, however, checkpoint inhibition is asso-
ciated with a series of immune-­related adverse events, which can
mimic a broad range of autoimmune conditions and that can be life-­
threatening if not treated promptly.
Adoptive cellular immunotherapy using T cells genetically modified
with chimeric antigen receptors (CAR-­
T cells) represents another
breakthrough in personalized cancer medicine. This strategy is based
on the genetic reprogramming of patient's own T lymphocytes to rec-
ognize and kill antigen-­expressing tumour cells. CAR-­T cells have pro-
duced complete and durable responses in B-­cell malignancies that are
otherwise refractory to conventional therapies, supporting the recent
approval of two CD19-­targeting CAR-­Ts. However, efficacy of CAR-­Ts
against solid tumours is still limited due to the lack of adequate co-­
stimulatory signals in tumour microenvironment required to promote
and sustain the expansion and activation of these effectors.
Current challenges in the field of cancer immunotherapy are to un-
derstand why only a subset of patients respond to treatment and
how to better achieve sustained remissions while limiting toxicity.
Hundreds of clinical trials are ongoing to assess whether combina-
tion therapy approaches can improve the rate of clinical responses.
Oncolytic viruses and novel cancer vaccines are emerging as im-
portant components of combinatorial treatments due to their abil-
ity to generate new populations of tumour-­specific T lymphocytes.
Identification of reliable biomarkers predictive of response to im-
munotherapy may more accurately and precisely guide patients’
treatment. The next wave of revolution in the field of immuno-­
oncology will be probably guided by the emerging new concept of
normalizing rather than amplifying anti-­tumour immunity.
O-­039 | Magnetic resonance imaging markers
improve the prediction model for total knee
replacement over 13 years in older adults
B. S. E. Antony1; I. Munugoda1; D. Aitken1; P. Otahal1; J.
Martel-Pelletier2; J.-P. Pelletier2; M. Lorimer3; S. Graves4; F.
Cicuttini5; G. Jones1
1
Menzies Institute for Medical Research, University of Tasmania; 2Osteoarthritis
Research Unit, University of Montreal Hospital Research Centre; 3Australian
Orthopaedic Association National Joint Replacement Registry (AOANJRR);
4
South Australian Health and Medical Research Institute (SAHMRI);
5
Department of Epidemiology and Preventive Medicine, Monash University
Background/purpose: We aimed to describe whether knee MRI ab-
normalities are associated with total knee replacement (TKR) over
13 years and to estimate the additive effect of MRI measures for risk
prediction of TKR.
Methods: 1082 participants (62.8 years, 50% female) were randomly
recruited from Tasmania and followed over 13.3 years. A 1.5T MRI scan
 |
8       ABSTRACTS

of the right knee was acquired at baseline (n = 930). Cartilage defects O-­0 09 | Meet the experts: chronic pain
(grade 0–4), BMLs (grade 0–3), effusion-­synovitis (grade 0–3), meniscal
M.-A. Fitzcharles
tears (grade 0–3) and meniscal extrusion (grade 0–2) were scored at
Mcgill University
baseline using T1-­weighted and T2-­weighted MRI. The incidence of pri-
mary TKR was determined by data linkage to the Australian Orthopaedic
In this session there will be discussion of challenging pain manage-
Association National Joint Replacement Registry (AOANJRR).
ment problems that I have encountered as a rheumatologist working
Results: After adjustment for age, sex, BMI, and radiographic OA,
at the McGill multidisciplinary pain management clinic. The focus
baseline cartilage defects (grade 2, RR = 6.71; grade 3, RR = 11.17;
will be to consider the pathogenesis of pain generation in rheumatic
grade 4, RR = 13.2; P < 0.01) were significantly associated with TKR
conditions, discuss treatment approaches and address pitfalls in pa-
over 13 years independent of other MRI pathologies. BMLs (grade
tient care. Cases will be used to facilitate and illustrate this interac-
1, RR = 2.74; grade 2, RR = 2.64; grade 3, RR = 4.01, P < 0.05 except
tive discussion. Some cases that may be discussed include: a patient
grade 2), grade 3 effusion-­synovitis (RR = 2.74, P < 0.05) and supra-
with post-­surgical knee pain, spinal stenosis in an elderly person with
patellar effusion-­synovitis area were associated with TKR. Those who
a twist, the conundrum of Ehlers Danlos syndrome, the patient with
had TKR all had a meniscal tear at baseline, with 96% of them having
rheumatoid arthritis with ongoing pain and the nurse who has joint
a grade 3 tear.
pain and visits the emergency room seeking pain relief. Participants
Compared to the baseline model with age, sex and BMI (area under
are welcome to present interesting case scenarios
the ROC curve [AUC = 0.62]), Model 1 with the addition of ROA and
WOMAC pain performed better (AUC = 0.77). Addition of cartilage
defects to Model 1 resulted in a significant increase of AUC to 0.84.
The combination of all MRI pathologies to Model 1 resulted in a sig- O-­026 | Should rheumatologists see patients
nificant increase in AUC to 0.82. with fibromyalgia and prescribe marijuana
Conclusion: Baseline knee MRI structural pathology markers can
M.-A. Fitzcharles
predict TKR over the long-­term in the general population. Cartilage
Mcgill University
defects significantly improve the model performance for prediction
of TKR over 13 years, and hence could be utilized in prediction/deci-
Fibromyalgia (FM) has come a complete circle in the past 3 decades.
sion making of TKR.
Initially identified as a rheumatic process, neurophysiological study
Figure 1. Illustration of the Receiver operator characteristic (ROC)
has now centred the pathogenesis of FM in the nervous system. But
curves for the total knee replacement (TKR) risk prediction models.
the circle closes with the recent appreciation that FM is a prevalent
Base model – Age, sex, BMI
condition in 20–50% of persons with defined rheumatic diseases.
Model 1 – Base model + WOMAC + knee ROA
The recognition of co morbid FM in persons with an array of rheu-
Model 2 – Model 1 + Cartilage defects
matic conditions such as rheumatoid arthritis, ankylosing spondyli-
Model 3 – Model 1 + BMLs
tis, psoriatic arthritis, osteoarthritis, etc. is a critical component of
Model 4 – Model 1 + Effusion Synovitis
clinical care. So once again rheumatologists are obligated to have the
Model 5 – Model 1 + Cartilage defects + BMLs + Effusion Synovitis
ABSTRACTS
best understanding of FM, and be knowledgeable of current treat-
ment strategies for FM. In this session, the evidence for treatments
for FM, including the evidence for the effects of cannabinoids will
be examined. Clinical experience regarding drug treatments that are
not currently guideline recommended will be discussed.
O-­045 | Juvenile scleroderma
I. Foeldvari
Hamburg Centre for Pediatric and Adolescence Rheumatology
Juvenile systemic scleroderma (jSSc) is an orphan disease with a
prevalence of 3 in 1 000 000 children. In the jSSc inception cohort
(www.juvenile-scleroderma.com) (JSIC) all patients, who have SSc
according the adult classification criteria from 2013 and developed
the disease under the age of 16 and are under the age of 18 at the
time of inclusion, can be included.
In the JSIC 109 patients are currently included, 90% of them are
female, 73.4% have a diffuse subtype (djSSc). The mean disease
duration is 3.1 years at time of inclusion. The mean age at onset
of Raynaud's is 9.9 years and the mean age of onset at first non-­
Raynaud manifestation is 10.5 years. 86% receive a DMARD. 87%
are ANA positive and anti-­Scl70 positivity is between 30% and 40%
in both subtypes. Anticentromere positivity is 4.1% in djSSc and
11.1% in the limited subtype (ljSSc) (P = 0.282). The mean modified
skin score, the number of patients with Gottron papulae and his-
tory of ulceration is significantly higher in the djSSc group. In the
djSSc group is a higher rate interstitial lung disease on HRCT with
56.2% in djSSc compared to 31.6% in ljSSc (P = 0.69). Pulmonary hy-
pertension is about 7% in both groups. No patient had developed
renal crisis or hypertension until the time of inclusion. About 50%
of patients have contractures. Muscle weakness seems to be more
prominent in the ljSSc with 33.3% compared to 15.2% in the djSSc
(P = 0.09). Physician global of disease activity (P = 0.041) and of dis-
ease damage (P = 0.023) is significantly higher in the djSSc patients.
Patient global of disease activity and disease damage is similar in
both subtypes.
The differences in presentation of djSSc and ljSSc are less significant
than in adults. 73.4% djSSc subtype is significantly higher in the pae-
diatric patients compared to adult SSc population.
O-­046 | Uveitis in children
I. Foeldvari
Hamburg Centre for Pediatric and Adolescence Rheumatology
Noninfectious uveitis (NU) in childhood is most commonly associ-
ated to Juvenile Idiopathic Arthritis (JIA). About 10% of patients with
JIA develop NU, this is the most common extraarticular manifesta-
tion of JIA. It can persist into the adulthood and is still the leading
cause of blindness in the western world. The odd ratio to develop
|
      9
NU is the highest in the oligoarticular subset. ANA positivity and
younger age at onset of JIA is a high risk for development of NU.
Currently there is only Adalimumab licensed to treat NU, but new
promising therapies are in sight.
The measures to assess response, remission and damage are re-
cently defined by the Multinational Interdisciplinary Working Group
for Uveitis in Childhood (MIWGUC) but are not validated yet. The
proposal is based on the validation of the previously published out-
come measures, which incorporates the suggested outcome meas-
ures of the SUN Group. Currently a specific pediatric quality of life
instrument for JIA associated NU will be validated for all European
languages to be used in future trials. There are recent suggestions
for diagnosis and treatment for JIA associated NU based on an EU
initiative, the SHARE project and more recent German treatment
guidelines, which are just accepted for publication.
JIA associated NU is the most common extraarticular manifestation,
which still takes a severe course, if it is not controlled effectively
quite early in the disease course to prevent damage. The current
multinational and national approaches are aiming for an early diag-
nosis, stringent follow up and a “treat to target” aim of remission and
inactive disease.
O-­047 | Paediatric musculoskeletal (MSK)
triage in the community – rightpath – a pilot
study
H. Foster1,2; N. Smith2; J. Firth3; H. Light3; K. Kinsey3;
N. Snowden3; J. McNaught4; V. Mercer4; B. Stidolph5; T.
Rapley6; A. Nye3; S. Jandial7
1
Newcastle University Medicine Malaysia (NUMed), Newcastle University;
2
Institute of Cellular Medicine, Newcastle University; 3Pennine MSK Partnership
Ltd; 4Physiotherapy, South Tyneside NHS Foundation Trust; 5Quality Research
& Clinical Audit, South Tyneside NHS Foundation Trust; 6Social Work, Education
& Community Wellbeing, Northumbria University; 7Paediatric Rheumatology,
Great North Children's Hospital
Background/purpose: Rightpath is a novel community-­based model
of MSK care for children and young people (CYP) to identify CYP
with MSK pathology and triage them to appropriate services (rheu-
matology, orthopaedics, neurodisability or urgent care) or manage
those who do not need specialist referral appropriately within the
community. Triage and referral guidance was developed in partner-
ship with specialists and primary care. We tested safety, feasibility,
acceptability, and transferability of the model in two UK sites.
Methods: Mixed methods with evaluation focused on:
Implementation: focus groups with triagers and clinicians to refine tri-
age guidance. Evaluation: (i) Parent/patient questionnaire; (ii) Triager
and clinician weekly logs of experiences and training needs; (iii) Patient
flow, referral times, eventual diagnosis. Service providers were sign-
posted to self-­
directed e-­
learning (paediatric musculoskeletal mat-
ters [PMM] -­www.pmmonline.org). The study had ethical approval.
Results: Site 1: over 6 months n = 264 triaged to specialist paedi-
atric services and n = 101 triaged to Rightpath [(46% with ‘normal
 |
10       ABSTRACTS
variants’) with 95% assessed by community podiatry or physiother-
apy <4 weeks (31% <2 weeks), and 55% discharged after first visit].
Site 2: over 6 months n = 281 referrals to general paediatrics; n = 90
(32%) with an MSK focus, 25 (28%) suitable for Rightpath.
Positive feedback from Rightpath families at both sites (n = 121);
99% ‘would recommend the service’, with satisfaction scores high.
Primary care physiotherapists and podiatry described clinical work-
load to be appropriate for their professional roles with triage opti-
mally performed by those with paediatric experience.
Conclusion: Rightpath is safe, feasible and acceptable with 25% of pri-
mary care referrals being triaged quickly and managed ‘closer to home’
by an appropriate clinician. Rightpath is a transferable model of care and
if implemented widely, could reduce inappropriate attendance at spe-
cialist centres for CYP with simple MSK problems or normal variants.
O-­030 | Zika virus: epidemiology in Asia-­
Pacific, risk to Australia and incidence of
arthralgia/arthritis
F. D. Frentiu1; B. M. C. Randika Wimalasiri-Yapa2
1
Queensland University of Technology; 2The Open University of Sri Lanka
Background: Zika virus (ZIKV) has emerged in the last few years to
cause significant public alarm because infection in pregnancy can lead
to microcephaly in babies. ZIKV is a tropical virus transmitted by the
mosquitoes Aedes aegypti and Aedes albopictus. Although this arbovi-
rus was discovered in the 1940's, it has circulated in the Asia-­Pacific
region since the 1960's with minimal case numbers until recent years.
Objectives: I will review the recent epidemiology of ZIKV in the
Asia-­Pacific to better understand the risk of emergence and out-
breaks in the region, including risk to Australia. Our lab's recent work
with Australian mosquitoes will be presented. I will review common
clinical manifestations observed during recent ZIKV outbreaks, with
a particular focus on cases describing arthralgia and/or arthritis aris-
ing from infection.
Methods: The study has two main approaches. First, experimental
evaluation of the risk of ZIKV transmission by Australian mosquitoes
has been undertaken. Second, the ZIKV case report literature will be
reviewed to assess the incidence of arthralgia and arthritis associ-
ated with infection, using database searches. A meta-­analysis will be
performed to estimate the incidence of ZIKV-­associated arthralgia
and arthritis during recent outbreaks.
Results: ZIKV continues to circulate in the Asia-­
Pacific region.
Australia is at risk of a ZIKV outbreak, as the principal vector mos-
quito is found in Queensland and is highly competent for virus
strains that circulated in recent epidemics elsewhere. Arthralgia, and
in rare cases arthritis, is observed to be associated with some ZIKV
infections. Final estimates of incidence will be presented.
Conclusion: Arboviral infections such as dengue, Zika and chikun-
gunya can cause arthralgia and arthritis. Increased awareness of the
geographic distribution of ZIKV and common presentations of the
disease will enhance diagnosis and treatment.
O-­0 03 | An important differential
diagnosis of SAPHO syndrome: disseminated
nontuberculous mycobacterial infection with
neutralizing anti-­IFNγ autoantibody in apparently
immunocompetent patient
H. Furuya1; K. Ikeda1; K. Miyachi2; K. Nakamura1; K. Suzuki1;
S. Furuta1; T. Tamachi1; K. Hirose1,3; T. Sakagami4; H.
Nakajima1
1
Department of Allergy and Clinical Immunology, Chiba University Hospital;
2
Department of Rheumatology, National Hospital Organization Shimoshizu
Hospital; 3Department of Rheumatology, School of Medicine, International
University of Health and Welfare; 4Department of Respiratory Medicine, Faculty
of Life Sciences, Kumamoto University
Introduction: SAPHO syndrome is an inflammatory disease char-
acterized by cutaneous and articular manifestations frequently
ABSTRACTS
reported in Asian countries. However, it is not well known that dis-
seminated nontuberculous mycobacterial infection (dNTM) mimics
SAPHO syndrome, and it could develop in patients with neither HIV
infection nor immunosuppressive treatment, but with neutralizing
anti-­IFNγ autoantibody especially in Asian countries. We herein de-
scribe a case of anti-­IFNγ autoantibody-­positive dNTM presenting
with SAPHO syndrome-­like manifestations, which led to the initia-
tion of corticosteroid and TNFα inhibitor therapy.
Case presentation: A 55-­
year-­
old man admitted to our hospital
complaining of subacute fever, polyarthralgia and palmoplantar
pustulosis. While infectious workups were negative, MRI scan and
bone scintigraphy showed Th5-­7 spondylitis and arthritis of bilateral
sternoclavicular joints, sacroiliac joints, wrists and ankles. We diag-
nosed him with SAPHO syndrome and initiated prednisone (10 mg/
day) and TNFα inhibitor, which soon relieved his symptoms. After
discharge, his symptoms recurred a week after every administration
of TNFα inhibitor. He gradually developed a right cervical lymphade-
nopathy and was re-­admitted. The histological findings of the lymph
node and bone marrow, and the positive cultures from the lymph
node, sputum and blood led to the diagnosis of dNTM, which could
explain the symptoms assumed to be derived from SAPHO syn-
drome. While he was HIV-­negative, additional tests revealed he was
anti-­IFNγ autoantibody-­positive from the former admission. He has
been treated for 2-­years with the standard regimen for dNTM with
tapered dose of prednisone and has shown no signs of recurrence.
Conclusion: The possibility of dNTM with anti-­IFNγ autoantibody
should be considered before making the diagnosis of SAPHO syn-
drome. It can develop in apparently immunocompetent patient,
shares several clinical similarities with SAPHO syndrome, and both
diseases tend to develop in Asian countries.
O-­076 | Treat to target in SLE – comparison of
remission and lupus low disease activity state in a
multinational prospective study
1,2
V. Golder ; R. Kandane-Rathnayake ; M. Huq ; H. 1 3 K. Winthrop5; P. Taylor6; G. Burmester7; F. V. D. Bosch8; J.
Nim1; W. Louthrenoo 4; S. F. Luo5; Y.-J. Wu5; A. Lateef6;
S. Sockalingam7; S. Navarra8; L. Zamora8; L. Hamijoyo9;
Y. Katsumata10; M. Harigai10; M. Chang11; S. O'Neill12; F.
Goldblatt13,14; C. S. Lau15; Z. Li16; A. Hoi1,2; M. Nikpour3; E.
Morand1,2
1 of Oxford; 7Charité Universitätsmedizin Berlin; 8UZ Gent, Reumatologie; 9HFR
Monash University; 2Monash Health; 3University of Melbourne; 4Chiang Mai
University Hospital; 5Chang Gung Memorial Hospital; 6National University
Hospital; 7University of Malaya; 8University of Santo Tomas Hospital;
9
University of Padjadjaran; 10Tokyo Women's Medical University; 11Tan Tock
Seng Hospital; 12University of New South Wales; 13Flinders Medical Centre;
14
Royal Adelaide Hospital; 15University of Hong Kong; 16People's Hospital Peking
University Health Science Center
Background: The objective of this study was to compare the attain-
ability and effect of the Lupus Low Disease Activity State (LLDAS)
and The Definitions of Remission in SLE (DORIS) group remissions
on outcomes in a prospective multinational study.
|
      11
Methods: A prospective multinational cohort study was under-
taken in 13 centres between 2013-­2017. Time dependent Cox
proportional hazards models were used to compare LLDAS and
DORIS definitions of remission in terms of impact on disease flares
and damage accrual.
Results: 1735 SLE patients were recruited, and followed for (mean
± SD) 2.2 ± 0.9 years, totalling 12,534 visits. LLDAS was achieved
in 6922 visits (54.6%). In contrast, remission was achieved in 1.1%–
15.4% of visits. LLDAS attainment at any visit was associated with
significantly reduced subsequent flare (HR 0.65, 95% CI 0.56–
0.76, P < 0.001) and damage accrual (HR 0.55, 95% CI 0.43–0.70,
P < 0.001). In contrast, only the least stringent remission definition
was associated with reduced damage accrual (HR 0.58, 95% CI 0.39–
0.88, P 0.01). Only remission definitions including serological re-
mission were significantly associated with reduction in subsequent
flares. Patients who spent ³50% of their observed time in LLDAS
had two-­fold reduction in risk of damage accrual (HR 0.53, 95% CI
0.41–0.68, P < 0.001), while only the least stringent remission defini-
tion, or the related definition excluding serology, were significantly
protective against damage (HR 0.59, 95% CI 0.42–0.83, P 0.003; HR
0.69, 95% CI 0.48–0.99, P 0.05, respectively).
Conclusion: LLDAS was more attainable than any remission defini-
tion, whilst still conferring significant protection against flares and
damage accrual. Among the remission definitions only the least
stringent could be shown to be associated with significant reduction
in damage accrual, likely reflecting a low frequency of remission at-
tainment overall, and normal serology was required for protection
from subsequent flare. LLDAS is a valid treatment target for SLE
which is more achievable than remission.
O-­055 | Safety of baricitinib: update from up
to 6 years of treatment in rheumatoid arthritis
clinical trials
S. Hall1; M. C. Genovese2; J. S. Smolen3; M. Weinblatt4;
Dudler9; T. Rooney10; C. Dickson10; M. Issa10; T. Ishii10; C.
Saifan10; C. Walls10; P. Adhami10; T. Takeuchi11
1
Cabrini Medical Centre, Malvern; 2Stanford University School of Medicine;
3
Medical University of Vienna; 4Brigham and Women's Hospital; 5Oregon
Health and Science University; 6Kennedy Institute of Rheumatology, University
Fribourg Hospital Cantonalcantonal; 10Eli Lilly & Company; 11Keio University
Background/purpose: Baricitinib (BARI), an oral, selective inhibi-
tor of Janus kinase (JAK1 and JAK2), is approved for the treat-
ment of moderately to severely active rheumatoid arthritis (RA)
in adults in over 50 countries. This abstract provides an update on
the safety profile of BARI up to 6 years of treatment in RA clinical
trials.
Methods: Data were pooled from 8 randomised trials (4 Phase 3,
3 Phase 2, 1 Phase 1b) and 1 long-­term extension (LTE) study (data
up to 01-­April-­2017). The safety data were analysed in 3 integrated
 |
12       ABSTRACTS

datasets: placebo (PBO)-­controlled (6 studies comparing BARI 4-­mg O-­050 | Biosimilars

QD to PBO 0–24 weeks), extended BARI (4 studies with BARI 2-­and
R. Handa
4-­mg QD, including LTE data) and ALL-­BARI-­R A (all patients exposed
Indraprastha Apollo Hospitals
to ≥1 dose of BARI from 8 randomised trials and LTE). Incidence
rates (IRs, per 100 patient-­years [PY]) for safety events with 95%
While ‘Biologics’ have revolutionised the treatment of autoimmune
CIs are reported.
rheumatic diseases, ‘Biosimilars’ have expanded access to these medi-
Results: In total, 3492 patients were exposed to BARI for up to
cines. The list of biosimilars continues to increase rapidly. A biosimilar
6 years (7860 PY of total exposure; median: 2.5 years). The IRs
is defined by WHO as a bio-­therapeutic product which is similar in
for serious infections, malignancies, major adverse cardiovascular
terms of quality, safety and efficacy to an already licensed reference
events, arterial thrombotic events, and venous thromboembolism
bio-­therapeutic product. Unlike a bio-­originator, the goal of a biosimi-
did not increase with prolonged exposure. During the 24-­week PBO-­
lar is not to demonstrate safety and efficacy for a new product but to
controlled period, deep vein thrombosis (DVT)/pulmonary embolism
demonstrate biosimilarity with similarity defined as ‘the absence of a
(PE) was reported with BARI 4-­mg (n = 6/N = 997) but not with PBO.
relevant difference in the parameter of interest’. Since biosimilars are
However, this was not observed during the first 24 weeks after
complex molecules, the regulatory pathways are very different from
switch to BARI 4-­mg from PBO (n = 1/N = 928) or active compara-
generics and include a comparability exercise based on totality of data.
tor (adalimumab/methotrexate; n = 0/N = 451). At longer exposures,
Biosimilar development and regulation is an evolving landscape in
DVT/PE IRs were comparable between BARI 2-­and 4-­mg doses and
a state of transition and transformation as guidelines and norms
the overall IR was 0.53. The IRs for gastrointestinal perforation and
are refined and fine tuned in light of new knowledge. The debate
tuberculosis were 0.04 and 0.14, respectively in All-­BARI-­R A data-
on extrapolation of indications; switching, substitution and inter-
set (Table).
changeability; nomenclature and traceability; and trial design for
Conclusion: The safety profile of BARI up to 6 years of treatment
biosimilars continues to engage the attention of patient groups, in-
in RA clinical trials remained consistent with the profile previously
dustry, academia, regulatory authorities, professional medical bod-
reported and remains acceptable in the context of demonstrated
ies and governments.
efficacy.
ABSTRACTS |
      13

The need of the hour is to strike a balance between efficacy, safety, O-­027 | Genome−wide association study of
access and cost. While cutting costs, we should not cut corners.
acute anterior uveitis identifies new susceptibility
Rigorous trial design, ethical data collection, transparency in data
loci
presentation and continued pharmaco-­vigilance are the key mantras
to promote physician and patient confidence in biosimilars. Bio-­ X. Huang1; Z. Li1; P. Leo1; E. Guzman1; L. Bradbury1; Y.
originators and biosimilars can co-­exist. Indeed, biosimilars have the
Wang2; Z.-B. Jin2; H. Xu3; M. Brown1
1
Institute of Health and Biomedical Innovation, Queensland University of
power to be real game changers rather than mere name changers.
Technology; 2The Eye Hospital of Wenzhou Medical University; 3Changzheng
The interest of our patients will neither be served by outright re- Hospital
jection nor by unquestioned acceptance but by insistence on a data
driven approach that is evidence based! Background: Acute anterior uveitis (AAU) is the most common form
of intraocular inflammatory disease. AAU occurs in 30–50% of an-
kylosing spondylitis (AS) patients, implying a shared aetiology. This
O-­023 | Biologics in developing countries – study aims to employ genome-­wide association study (GWAS) to dis-
economics and infections sect the genetic associations of AAU and their overlaps and differ-
ences with the genetics of AS.
S. A. Haq
Methods: We undertook the GWAS analyses in AS patients with
BSM Medical University
AAU (cases) and AS patients without AAU (controls). A total of 2752
case and 3836 controls were recruited with Illumina CoreExome
The addition of the biologics to the rheumatology armamentarium
BeadChip.
has made achievement of therapeutic targets feasible. A large pro-
Results: 7,399,311 SNPs were available after imputation and quality-­
portion of deserving patients are being deprived of their benefits
control filtering. We identified one locus associated with AAU at
because of two major barriers: cost and infections.
genome-­wide significance: rs9378248 (P = 1.98 × 10−8, OR = 0.77),
Per capita GDP of the developing countries in Asia-­P acific ranges
lying close to HLA-­B, a known susceptibility gene for the disease.
from US $ 600 (Afghanistan) to 10,000 (Malaysia). The percentage
We also found suggestive association with SNPs in MERTK (MER ty-
of the population below the poverty line varies from 3% in China
rosine kinase) gene (rs7595574, P = 2.52 × 10−6, OR = 1.183), which
to 82% in Syria. Health budget as a fraction of total GDP is quite
is also a novel finding in our ongoing GWAS in ankylosing spondylitis
low in many of these countries. The provisions for cost reimburse-
(AS). We also examined the associations between the causal genes
ment for healthcare are meagre. The proportions of out-­of-­p ocket
of AS and AAU. Notably, suggestive association was observed with
(OOP) expenditure vary from 27% in Sri Lanka to 86% in Myanmar.
SNPs in ERAP1 (rs27529, P = 2.92 × 10−7, OR = 1.215), and NOS2
The average annual OOP expenditure for RA treatment without bio-
(rs2274894, P = 1.08 × 10−6, OR = 0.83). The SNP-­based heritability
logics in Japan was USD 2,900, with biologics it increased to USD
estimation (h2) is 0.34 in this analysis, while much higher (0.70) in the
7,700. The cost limits the access of deserving patients with chronic
comparison between cases with AS with AAU and healthy controls,
inflammatory arthropathies to biologics in European countries.
indicating the associations between phenotypic severity and genetic
There is no published statistics, but the access is lower in the de-
predispositions.
veloping countries. A Finnish study showed that the use of biologics
Conclusion: We report here the first GWAS for AAU and identi-
was not cost-­effective for the treatment of RA.
fies new susceptibility loci. The findings of association with the
Infections represent a major threat to health in developing countries.
HLA-B, ERAP1 and NOS2 loci are consistent with a strong overlap
South Asia represented 60, 38 and 35% of the global burden of lep-
in aetiopathogenesis with AS. The absence of findings at other AS-­
rosy, tuberculosis and hepatitis B respectively. Biologics increase the
associated loci indicates that cases with AS with AAU have similar
risk of infections. Odd's ratio of serious infections with biologics as
genetic makeup to cases with AS alone.
a whole was 1.5, and there are ample evidences of reactivation of
latent tubercular focii.
The cost of biologics need be reduced substantially to make it cost-­
effective. Biosimilars, similar biologic products and generic tsD- O-­040 | Novel therapies for osteoarthritis
MARDs may contribute to increased cost-­effectiveness of targeted D. Hunter
therapies. For optimum utilization of their potentialities, healthcare University of Sydney
budget has to be increased with enhanced provisions for cost-­
reimbursement. Improvement of environmental sanitation, hygienic Osteoarthritis (OA) is at the forefront of an exploding epidemic of non-­
practices including aseptic precautions, infection screening, vigi- communicable chronic diseases. It affects over 3 million Australians
lance and vaccination may contribute to optimum use of advanced and is a leading cause of disability and health service utilisation.
therapies. Development of more selectively targeted oral small mol- This presentation will focus on novel therapies for managing pain
ecules may ensure better treatment of chronic arthropathies in the (including nerve growth factor inhibition) and disease modification
coming decades.
 |
14       ABSTRACTS

(focused on trials that are in later phases). It will discuss some of
the barriers that have limited advances today and focus on some of
the methodologic improvements that have been made to overcome
these.
For the clinician interested in optimising their care using treatment
options that are currently available, we need to focus care to tailor-
ing management to the individual needs of the consumer, targeted
towards the central complaints of pain and functional limitation with
a chronic disease multidisciplinary management approach. Modern
health care systems are typically reactive and focused upon acute
care whereas the management of OA is ideally efficient, coordinated
and patient centred to support integration of evidence into practice.
O-­029 | Imaging, T2T and rheumatoid arthritis
A. Iagnocco
Academic Rheumatology Center, Università degli Studi di Torino
Rheumatoid arthritis (RA) can be a challenging disease to manage.
However, recent advances in RA treatment and development of new
diagnostic and monitoring tools, have clearly improved disease out-
come. The concepts of T2T that emerged in the last years changed
disease management and early diagnosis and stable remission are
currently the main goals in RA. In this context, imaging plays a rel-
evant role and represents a large part of RA management.
Many imaging techniques are currently available, with peculiar fea-
tures and characteristics. Modern imaging is able to support early
RA diagnosis, and when there is a diagnostic doubt, radiography, ul-
trasound and magnetic resonance (MR) can be used to improve the
certainty of RA diagnosis above clinical criteria alone. In addition,
early structural damage can be detected by X-­ray but, ultrasound
and MR can be also used at an earlier time point. In addition, in un-
differentiated inflammatory arthritis patients with joint inflamma-
tion, imaging can predict the progression to clinical RA and can be
an independent predictor of structural damage progression. Recent
studies have clearly demonstrated that ultrasound and MR are more
sensitive than clinical examination in detecting joint inflammation,
even in patients in clinical remission. Given their high accuracy in
O-­024 | A hospital based fracture liaison
service effectively reduces re-­fracture, is cost-­
effective and improves QALY
C. Inderjeeth1,2; W. Raymond1,2; E. Geelhoed2; A. Briggs3; D.
Mountain2
1
SCGH and OPH Group; 2University of Western Australia; 3School of
Physiotherapy & Exercise Science, Curtin University
Objective: Determine the economic benefits of a FLS in a Western
Australia in reducing morbidity, mortality and economic burden1.
Research within our hospital confirmed low rates of identification
and secondary prevention for patients discharged from Emergency
Department (ED) with a fracture2.
Methods: Patients over the age of fifty who presented with a frac-
ture to a tertiary Hospital Emergency Department (SCGH) were of-
fered an appointment at the FLS. A retrospective control group from
SCGH determined the historical fracture risk without an active FLS
intervention. Two other hospital sites acted as prospective control
cohorts.
Health economic analysis from the payer's perspective examined
recurrent fracture rates and quality of life (EQ-­5D). Bottom-­up cost-
ing included medication, investigations, medical care and the cost of
fracture (literature and the AR-­DRG 2013/14 prices). Mean incre-
mental cost effectiveness ratios/diagrams were derived from 5000
bootstrap iterations. Cost-­effectiveness acceptability curves were
generated and the willingness-­to-­pay was $50,000AUD.
Results: This FLS program reduced the absolute rate of re-­fractures
compared to the retrospective cohort and other tertiary hospitals by
between 9.2% and 10.2% equating to cost savings of approximately
$750,168 -­$810,400/1,000 patient-­years in the first year compared
to control cohorts. Incremental cost effectiveness ratios are listed
in Table 1. The FLS compared to SCGH retrospective cohort had a
mean incremental cost of $859 (95 CI −$4,074, $4,864) per QALY
gained at 12 months. The FLS compared to other sites had a mean
incremental cost of −$119 (95 CI −$1,665, $700) per QALY gained
Table 1

assessing musculoskeletal abnormalities, they can be used in clinical Incremental cost-­effectiveness ratio
Cost-­effectiveness
practice to assess joint damage that follows persistent inflammation.
analysis Mean Lower 95% Upper 95%
Moreover, given the improved detection of inflammation by MR and
Recurrent fracture rate
ultrasound than by clinical examination, they can be used to moni-
tor disease activity since early disease and at follow-­up, when they  SCGH FLS vs
SCGH
are able to assess disease progression and demonstrate increased
retrospective
severity of structural damage lesions. Their use for responsiveness
 Payer perspective $8,721.34 −$1,218.23 $35,044.29
make then those techniques of great value in rheumatology clinical
 Payer light $6,880.12 −$447.21 $38,511.01
practice.
 AR-­DRG 2013/14 $10,626.89 −$621.43 $46,919.41
More recently, the development of new imaging tools and the use of
 SCGH FLS vs Fremantle Hospital
hybrid techniques have shown a potential additional impact in the
clinical management of RA with interesting implications for the next  Payer Perspective $8,974.49 −$26,701.40 $69,929.37

future.  Payer Light $7,700.62 −$26,477.34 $69,074.67

 AR-­DRG 2013/14 $14,161.34 −$48,551.72 $79,808.84
ABSTRACTS |
      15

Figure 1 ICER Graphs for Fracture Risk, QALY gained (EQ-­5D) and QALY gained (ECOS-­16).

at 12 months. Figure 1 demonstrates that the FLS is cost-­effective 55.7 (SD 14.3) years and 67% were female. There was a high level
in delivering a reduction in the fracture rate at 12 months with im- of correlation and agreement between patient and clinician assess-
proved QALY. ment.1 (Table 1, Fig 1)
Conclusion: This FLS demonstrated to be effective in reducing re- There was no significant difference in PtGADA between ePRO-­
current fracture(s) with significant cost effectiveness and improved pPRO 0.56 (SD 2.85) or pPRO-­ePRO −1.19 (SD 2.03), PAAP ePRO-­
QALY. pPRO 7.4 (SD 27.9) and pPRO-­
ePRO 0.9 (SD 17.5), BRAF-­
MDQ
ePRO-­pPRO 2.0 (SD 9.5), pPRO-­ePRO -­0.9 (SD 7.4).
1. Briggs AM et al. ANZ J Public Health. Patients reported high levels of satisfaction with both PRO arms
2. Inderjeeth CA et al. MJA with only 2 patients (8.3%) reporting dissatisfaction. 88–92% re-
ported that they were either satisfied or very satisfied with either
tool. 58% of those who transitioned from ePRO to pPRO had no
preference for one over the other format whereas 67% of those
O-­0 06 | Comparing the electronic patient
who transitioned from pPRO to ePRO preferred the electronic
reported outcome (ePro) tool versus the paper
tablet.
reported outcome (pPro) tool in rheumatoid Conclusion: Both ePRO and pPRO provided consistent results and
arthritis patients demonstrated equivalence in PRO assessment. ePRO was well em-
1,2 1,2 1,2 braced by patients with only a minority reporting dissatisfaction. It
A. Inderjeeth ; W. Raymond ; C. Inderjeeth
1
SCGH and OPH Group; 2University of Western Australia may be a desirable inclusion in routine RA and potentially other dis-
ease assessments for its added reliability, consistency and increased
Background: Patient reported outcome (PRO) tools complement patient involvement.
physician's assessment of disease activity and response. Electronic 1 Inderjeeth et al. https://doi.org/10.1111/1756-185x.13364
data provides real time capture and reduces missing data and am- Table 1
biguous responses. Pearson
Methods: Patients were assigned randomly to either ePRO or pPRO correlation Assessor Nurse Patient Physician
at visit one. At visit 2, patients crossed over into the other PRO Tender Joint Nurse 1 0.83 ** 0.85 **
modality and remained in that arm for subsequent visits at week 6, Counts Patient 0.83 ** 1 0.59 *
12 and 36. Assessments include 28 swollen (SJC) and tender joint Physician 0.85 ** 0.59 * 1
counts (TJC), Patient assessment of pain (PAAP), Patient assessment
Swollen Joint Nurse 1 0.69 ** 0.66 **
of global disease activity (PtGADA) and Bristol Arthritis Fatigue Counts Patient 0.69 ** 1 0.42
Multidimensional Questionnaire (BRAF-­MDQ
Physician 0.66 ** 0.42 1
Results: 52 patients with mean RA duration 11.7 years were enrolled
*P < 0.01, **P < 0.001.
and 47 completed at least the initial crossover arm. Mean age was
 |
16       ABSTRACTS
Figure 1 Agreement of Patient-­Nurse SJC scores
O-­025 | Adaptive trials and other smart trial
designs
J. Isaacs
Newcastle University
The gold standard clinical trial design for the licensing of a novel
medicine remains the double blind randomised clinical trial (DBRCT).
This design has stood the test of time. By definition, however, at
the outset there is uncertainty around the medicine's efficacy yet,
once the trial starts, nothing can change. This means there is a risk of
failure, even for effective treatments, for example if the trial has not
been powered correctly. Such trials also tend to require large patient
numbers, are expensive and have modest power, particularly with
regard to subgroups (e.g. stratification).
In contrast, adaptive design trials take advantage of cumulative data,
and permit modification of key trial parameters according to prede-
fined rules. Therefore, each patient that completes the study pro-
vides information that reduces uncertainty regarding the medicine's
efficacy. Adaptive trials involve interim analyses and simulations,
and are more efficient than DBRCTs, requiring fewer patients and
a shorter trial duration. Consequently they tend to be cheaper and
provide an enhanced likelihood of finding a true benefit of treatment
if one exists.
A number of other ‘smart’ trial designs are appearing, with the ulti-
mate aim of improving efficiency with commensurate reduced cost.
Some of these allow the stratification of participants, for example
according to a biomarker. Such designs include the Cohort Multiple
Randomised Controlled Trial (or Trial within Cohorts), Platform Trials,
Umbrella and Bucket Trials. Each type of trial is suited to a particular
scenario and their apparent simplicity can hide a number of pitfalls.
When considering such a design it is therefore essential to involve
an appropriate team from the outset, with excellent trial design and
statistical support.
O-­051 | Rheumatoid arthritis early diagnosis
and intervention – and cure?
J. Isaacs
Newcastle University
For at least two decades it has been apparent that there exists a
‘window of opportunity’ in the management of rheumatoid arthritis
(RA). The precise duration of the ‘window’ is unclear, and its patho-
logical basis as yet undefined. Nonetheless, early treatment leads
to better outcomes in terms of less joint damage and disability, a
greater likelihood of drug-­
free remission, and a vastly improved
quality of life. Indeed, in the 21st Century, the expectation for a pa-
tient with a timely presentation to the early arthritis clinic and who
is treated to target, should be remission.
A further realisation over a similar timescale has been that RA has
a significant pre-­
clinical phase. Autoantibodies (ACPA and RhF)
can appear up to 15 years before the development of synovitis.
Furthermore, during the 2–3 years prior to clinical presentation bio-
markers of inflammation can be detected in the blood, and autoanti-
bodies undergo affinity maturation and isotype switching suggestive
of active T-­cell involvement in the disease process.
An important current question therefore is whether it is possible
to prevent RA from developing in ‘at risk’ individuals, or perhaps
to reverse it in its preclinical stages. There are clinical, societal
and ethical aspects to this question. The societal and ethical is-
sues arise because screening is expensive and, perhaps more im-
portantly, not all ACPA positive individuals ultimately develop RA.
However, prior to individuals developing synovitis, they may de-
velop joint symptoms (arthralgia), and at this point the probability
of developing RA increases significantly. Consequently, a number
of clinical trials are currently targeting individuals with ‘seroposi-
tive arthralgia’ in an attempt to intercept the disease and prevent
its progression.
If it proves possible to prevent RA then the value of screening will
clearly increase. Under these circumstance the type of intervention
offered to an individual at risk of RA, and particularly its safety, will
depend on the likelihood of progression to synovitis.
O-­061 | Genetics in scleroderma and new
disease targets
T. Kenna
Queensland University of Technology
Immune-­m ediated inflammatory diseases such as systemic scle-
rosis (scleroderma) are highly heritable, telling us that genetics
plays an important role in their pathogenesis. Large-­s cale genomic
studies have enabled significant advances in understanding the
genetic basis of scleroderma. Two recent genome-­wide associa-
tion studies in well-­characterised systemic sclerosis cohorts have
identified a number of genes that confer increased risk of disease
ABSTRACTS
development. Among these candidate genes are several that may
be targeted with existing drugs or may be targets of new drug de-
velopment programs. Here, we will discuss some of the leading
candidate genes and describe pre-­clinical studies that validate ap-
proaches to target them.
O-­0 04 | Artificial intelligence and machine
learning techniques optimising patient
management
S. Khanna
Research Team Leader – Health Intelligence, CSIRO Australian e-­Health Research
Centre
Artificial Intelligence (AI) techniques such as machine learning, pow-
ered by great computational speeds in today's digital and connected
world, offer great promise to all industries including healthcare.
There is indeed a strong case for the use of AI in health, given that
pressure on hospital systems continues to build due to ageing popu-
lations, increasing demand for services, and the growing prevalence
of chronic diseases. But the complexity of healthcare, and issues
such as trust and liability, complicate the potential of its use.
In a world where we all carry phones that are more powerful than
early supercomputers, there is no escaping the tidal wave of technol-
ogy driven disruption. The health system needs to shift focus from
treating patient illness to managing consumer health and wellbeing,
improving quality of life over every person's lifetime. Healthcare
need to employ a holistic and predictive approach and focus on
precision health solutions. Government, industry, researchers and
the community need to collaborate and work together to create the
value inherent in this shift.
While people still think about healthcare as being a stuck-­in-­the-­
past, fax-­machine-­using, slow moving machine, this is fast becom-
ing the exception. AI technology has made significant inroads into
health domains such as surgery and imaging. While there are several
examples of the success of AI in healthcare, there have also been sig-
nificant setbacks. What is needed is appropriate clinical stewardship
to guide the digital transformation of the health system.
This talk presents an overview of AI, and makes a case for its use in
healthcare. Recent successes and failures are discussed, followed by
an overview of current research efforts in the Australian context.
The talk concludes with a vision for the future of healthcare.
O-­041 | Osteoarthritis: what, and what not, to
treat
H. A. Kim
Hallym University Sacred Heart Hospital
Osteoarthritis (OA) is the most common form of arthritis and
ranked the 11th in the leading causes of years lived with disability
|
      17
(YLD) globally, with higher rank (the 6th) especially among Asian
countries. Over the years, exponential growth in the rate of total
knee replacement (TKR) surgeries is observed, and approximately
83% of these were associated with knee OA in Korea. Knee pain
derived from OA is a key symptom influencing the decision to seek
medical attention, and previous reports suggest that knee pain
is a better predictor of disability than radiographic change. The
mechanism of pain in knee OA is not well understood, although
multiple causes including biologic and psychological factors may
all play important roles. Hyaline cartilage, the main focus of inter-
est in both clinical and laboratory research of OA, is an aneural
structure, and it is unable to provide sensory nociceptive input.
Patients presenting with knee pain and advanced radiographic
knee OA represented by destruction of cartilage are more likely
to be offered joint replacement surgery, although it has been fre-
quently reported that radiographic OA changes are poorly corre-
lated with pain and physical function. Recently, we reported that a
significant number of subjects with K-­L grade 4 OA did not report
pain, suggesting that a guidance of therapeutic decision merely
based on imaging study as well as treatment option focusing solely
on cartilage engineering should be viewed with caution. While
it has been lamented that there's no definite treatment for OA,
and only symptomatic treatment is available, currently, there's not
even a consensus on what defines definite treatment. As a result,
OA patients are faced with a plethora of treatment modalities with
weak evidence of efficacy or safety. In this lecture, recommenda-
tion for OA treatment, new treatment on horizon and their evi-
dence base is reviewed.
O-­033 | Kidney protective effects of urate-­
lowering therapy in patients with gout
W.-J. Kim; J.-S. Song; S. T. Choi
Division of Rheumatology, Department of Internal Medicine, Chung-­Ang
University College of Medicine
Background: Reduced kidney function decreases uric acid excre-
tion and increases the risk of gout. Conversely, uric acid deposition
impairs kidney function. The target serum uric acid (sUA) level of
chronic gout management is generally below 6.0 mg/dL. However,
renal impact of urate-­lowering therapy (ULT) remains unclear.
Objectives: We aimed to evaluate the renoprotective effect of ULT
and the contributing factors in gout patients.
Methods: This study reviewed 719 patients with gout between
April 2006 and February 2018. We collected sUA, creatinine lev-
els and estimated glomerular filtration rate (eGFR) according to the
Modification of Diet in Renal Disease formula in 245 patients who
initiated ULT with a single agent among allopurinol, febuxostat, or
benzbromarone and continued at least 12 months. The changes in
sUA, serum creatinine, and eGFR during follow-­up period were com-
pared. P < 0.05 was considered statistically significant and data were
analyzed using IBM SPSS Statistics, version 23.
 |
18       ABSTRACTS
Results: The median treatment duration was 766 days, and 192
(78.4%) patients reached sUA level at <6.0 mg/dL. The sUA and serum
creatinine levels decreased (7.92 ± 2.01 mg/dL vs 4.92 ± 1.55 mg/
dL, P < 0.001, 1.08 ± 0.33 mg/dL vs 1.05 ± 0.41 mg/dL, P = 0.001,
respectively) and the eGFR increased significantly (77.1 ± 19.48 mL/
min/1.73 m2 vs 80.73 ± 20.98 mL/min/1.73 m2, P < 0.001). The
changes of eGFR were inversely correlated with the baseline eGFR
(r = −0.22, P = 0.001). Renoprotective effect of ULT was not dem-
onstrated in patients who failed to attain sUA level at <6.0 mg/dL
(Table). Patients who experienced acute kidney injury (AKI) (n = 8,
3.3%), specified as a 1.5-­fold increase in serum creatinine level from
baseline at any time during follow-­up, reported the mean change of
eGFR significantly lower than the remainders (P < 0.001).
Conclusion: This study suggests that efficacious ULT reaching sUA
level at <6.0 mg/dL and prevention of AKI are necessitated for im-
provement of kidney function in gout patients.
O-­077 | Getting to the bones of it: a clinical
audit of osteoporosis management in an
Australian SLE Cohort
1,2 1,2 2,3 1,2
R. Koelmeyer ; V. Golder ; A. Law ; E. Morand
Hoi1,2
1
Monash University; 2Monash Health; 3Singapore General Hospital
Background/purpose: Systemic Lupus Erythematosus (SLE) pa-
tients are at increased risk of osteoporosis, due to disease-­related
and traditional risk factors including common use of glucocorticoids
(GC). Bone mineral density (BMD) screening is important for over-
all fracture risk assessment; in Australia, it is reimbursed under the
Medicare Benefits Schedule (MBS) for specific criteria.
Objectives: To evaluate compliance with BMD testing according to
MBS reimbursement schedule.
Methods: Data on BMD testing and patient characteristics where
obtained from the Australian Lupus Registry. Descriptive statistics
were used to evaluate patient characteristics at the time of BMD
testing.
Results: Patients with at least 2 annual visits and seen in the last
5 years were included in the analysis (n = 263); 154 (58.6%) had
at least one BMD. Most (90.3%) had taken GC at some point. The
mean age at the time of undergoing the first test was 42 years. Of
the patients tested, 15.6% were identified as having osteoporosis (t
score ≤−2.5) and 46.1% were osteopenic (t score <−1). Of 273 BMD
performed, at least one of the MBS reimbursement criteria (see
Table 1) was present for 59.7% of tests. In those did not fulfil crite-
ria, 39% had at least osteopenia or osteoporosis. In 63.6% of cases,
the patient had met the cumulative prednisolone exposure definition
but was not on GC at the time of the test. Of the 154 patients who
had BMD testing, 46.7% had repeated measurements. Compliance
with testing frequency was met for 74.8% of repeat tests.
Conclusion: The majority of patients who had BMD testing had risk
factors for osteoporosis. Our audit shows that a significant propor-
tion of patients with previous GC exposure would have been missed
the strict criteria of MBS reimbursement. Since the value for re-
peated BMD testing is controversial, further studies should explore
their utility in this population.
O-­062 | Are we on the verge of cracking the
nut in systemic sclerosis?
M. Kuwana
Nippon Medical School
; A.
Systemic sclerosis (SSc) is the most difficult-­to-­treat rheumatic
disease today. There is only a few disease-­m odifying treatments
helpful in improving natural course of SSc, including cyclophos-
phamide and mycophenolate mofetil, which were proven to show
limited efficacy in interstitial lung disease (ILD). Two large trials
reported autologous stem cell transplantation superior to in-
travenous cyclophosphamide, albeit at the price of significant
procedure-­
associated early mortality. Several reasons may ex-
plain lack of fully adequate therapies in SSc patients. First, it is
difficult to identify “active” patients eligible for disease-­m odifying
treatment. The majority of patients with diffuse cutaneous SSc
(dcSSc) assigned to the placebo group in clinical trials experienced
subsequent improvement of modified Rodnan total skin thick-
ness score (mRSS). In addition, many observational studies have
revealed that only 20–30% of patients with SSc-­ILD progress to
end-­s tage lung disease, and the remaining patients show stable
lung function throughout the disease course without treatment.
Second, outcome measures that reflect long-­term outcomes have
not been established yet. In clinical trials, mRSS (for dcSSc) or
ABSTRACTS
forced vital capacity (for ILD) is used as a primary endpoint, while
ACR Provisional Composite Response Index for Clinical Trials in
Early Diffuse Cutaneous Systemic Sclerosis (CRISS) has been pro-
posed as a new composite measure. Finally, there is almost no
drug proven to prevent progression of excessive fibrosis. A much
greater understanding of SSc pathophysiology has developed by
tremendous efforts of basic researches, leading to clinically testa-
ble hypotheses. Accordingly, a number of novel therapies towards
specific molecular and cellular targets have been tested in clinical
trials. These include rituximab, tocilizumab, abatacept, nintadanib,
pirfenidone, riociguat, and lanabasum. Recent endeavors to solve
major issues in the management of SSc have successfully led to
development of potential treatment strategies. There is no doubt
that we are on the verge of cracking the nut in SSc management.
O-­010 | Assessment of chronic musculoskeletal
pain
R. Kwiatek
Northern Adelaide Local Health Network
The success of Western Medicine derives from its relentless search
for the precise elucidation of reductive disease mechanism(s) with
consequent powerful mechanism-­targeted treatments. The expe-
riential phenomenon of pain, however, appears intractable to be
reductively understood, akin to the phenomenon of mind. More
tractable might be the biological processes of nociception, and con-
siderable progress has been made in understanding these in animal
models, although translation into humans remains incomplete.
Chronic musculoskeletal pain is a major cause of human suffering.
Furthermore, diagnosis and management of musculoskeletal pain is
well recognised as a major clinical challenge. Most rheumatology pa-
tients present with pain as their primary complaint, and alarmingly
most rheumatoid arthritis patients, whose inflammation has been
well suppressed with expensive modern therapeutics, still complain
of unacceptable pain levels. A deeper understanding of mechanistic
processes in musculoskeletal pain would therefore seem highly rel-
evant to clinical practice in rheumatology.
This presentation will introduce the recently promulgated mecha-
nistic classification of human nociception into nociceptive, neuro-
pathic and nociplastic subtypes. The fact that many, if not most,
musculoskeletal pain patients have more than one of these pro-
cesses concurrently contributing to their pain will be highlighted.
Evolving practical bedside assessment tools of these processes will
be introduced.
Implications for more precise and therefore more effective
mechanism-­based therapeutic interventions will be discussed. The
resulting increased satisfaction within the clinical encounter for both
patient and rheumatologist will be emphasised.
|
      19
O-­071 | Outcomes in psoriatic arthritis – what
should we measure in the clinic?
Y. Y. Leung1,2
1
Singapore General Hospital; 2Duke-­NUS Medical School
With the advancement in treatment of psoriatic arthritis (PsA), the
need to understand how to measure outcomes in clinical trials and
clinical practice has become more important. As psoriatic arthritis
has a diversity of manifestations, the measurement of outcomes
has been challenging. Nonetheless, there has been great advance-
ment in outcome measures in psoriatic arthritis in the past decade.
The Group in Research and Assessment of Psoriasis and Psoriatic
Arthritis (GRAPPA) has collaborated with the Outcome Measures In
Rheumatology (OMERACT) to update the Core Domain Set (COS)
for PsA in 2016. This COS for PsA that covers musculoskeletal activi-
ties in peripheral joints, enthesitis, dactylitis and spine; skin, physi-
cal function, fatigue, pain, health related quality of life and systemic
inflammation are essential domains to be measured always in clinical
trials and longitudinal observational studies. There have been nu-
merous methods in assessing them, and it is relevant to understand
the principal in measurement in clinical practice. The GRAPPA-­
OMERACT working group have been working to standardize the
Outcome Measurement set for PsA since then. These processes of
consensus in “what to measure” and “how to measure them’’ have
been incorporating perspectives from both clinicians and PsA pa-
tients, making sure the standardized outcome measure sets for each
domain are relevant to patients and the intended use in clinical trials
and longitudinal studies. This helps clinicians and patients to evalu-
ate disease activity, impact and long-­term patient outcomes and se-
lect the best available for PsA patients.
O-­0 08 | Rheumatology in the digital age: can
apps and wearables support people with arthritis
to be physically active?
L. Li1,2
1
University of British Columbia; 2Arthritis Research Canada
Current guidelines for the management of arthritis emphasize an
active lifestyle, but up to 90% of people with osteoarthritis are in-
active. Recent research also found 42% of people with rheumatoid
arthritis accumulated 0 minute of moderate/vigorous physical activ-
ity, performed in bouts of 10 minutes or more, in a typically week.
Mobile apps and wearables, such as pedometers and accelerome-
ters, are popular tools for supporting an active lifestyle. The goal of
this presentation is to discuss opportunities and challenges of using
digital tools to promote physical activity.
The presentation consists of three part. First, results from a proof-­
of-­concept study evaluating a physiotherapist-­led remote physical
activity counselling program for people with knee osteoarthritis will
be discussed. This program includes the use of a Fitbit fitness band.
 |
20       ABSTRACTS
Second, I will discuss the views of health professionals and people
with arthritis on the use of physical activity apps and wearables from
a qualitative study. While health professionals tended to appreci-
ate the potential of these tools for a variety of populations, people
with arthritis felt that the tools would only benefit those who were
already motivated to be active. The findings have implications on
how apps and wearables can be applied to promote physical activity.
Third, I will address limitations, strengths, and opportunities of using
consumer wearable devices in health care and research. Results
from a systematic review of 67 studies on the accuracy of Fitbit will
be discussed.
O-­028 | GWAS of ankylosing spondylitis
identifies new, druggable, susceptibility loci
Z. Li1; N. Akkoc2; M. Mahmoudi3; A. Jamshidi3; M. Breban4;
C.-T. Chou5; M. Weisman6; L. S. Gensler7; M. Ward8; M. H.
Rahbar9; L. Diekman9; T.-H. Kim10; P. J. Leo1; H. Forsblad-
D'elia11; H. Marzo-Ortega12; J. B. A. Crusius13; I. E. van de
Horst-Bruinsma14; F. O'Shea15; J. D. Reveille9; H. Xu16,17; B.
P. Wordsworth18; M. A. Brown1
1
Translational Genomics Group, Institute of Health and Biomedical
Innovation, Queensland University of Technology at Translational
Research Institute; 2 Izmir; 3 Rheumatology Research Center, Tehran
University of Medical Sciences; 4 Hôpital Ambroise Paré, Assistance
Publique-­H ôpitaux de Paris; 5 Taipei Veterans General Hospital; 6 Cedars-­
Sinai Medical Center, Los Angeles, CA, USA; 7University of California;
8
National Institutes of Health, Bethesda, MD, USA; 9McGovern Medical
School at the University of Texas Health Science Center at Houston; 10 The
Hospital for Rheumatic Diseases, Hanyang University; 11Department of
Public Health and Clinical Medicine, Rheumatology, Umeå University;
12
NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals
Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine,
University of Leeds; 13 Deptartment of Medical Microbiology and Infection
Control, VU University Medical Cente; 14 Amsterdam University Medical
Centers, VU University Medical Centre, Department of Rheumatology;
15
St James's Hospital; 16 School of Clinical Medicine, Tsinghua University;
17
Department of Rheumatology and Immunology, Shanghai Changzheng
Hospital, Second Military Medical University; 18 Nuffield Department of
Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of
Oxford
Background/purpose: Ankylosing spondylitis (AS) is a highly herit-
able chronic inflammatory arthritis which affects primarily the sac-
roiliac joints and spine. Thus far, at least 114 AS-­associated loci have
been identified in people of European ancestry, contributing ~28%
of the heritability of the disease. To date, AS genome-­wide associa-
tion studies (GWAS) have only been published on ~4,000 Caucasian
cases and ~2,000 Han Chinese cases.
Objectives: To better characterize the genetic architecture of AS via
GWAS in large European and Han Chinese cohorts.
Methods: Sample of European-­
descent were typed on Illumina
Global Screening Array or CoreExome arrays; Chinese samples were
typed on Illumina OmniZhonghua or CoreExome arrays. All the AS
patients fulfilled the 1984 modified New York criteria. Following ex-
tensive quality control, genotypes were imputed using the HRC ref-
erence panel and shared SNPs merged in each ethnicity. Association
tests were then performed using logistic regression with PLINK1.9b.
In total, 9,322 AS cases and 31,319 controls in the European cohort
and 6,839 AS cases and 7,845 controls in the Chinese cohort were
included.
Results: In addition to HLA-B27, 29 known loci and 24 putative new
loci have been identified in the European cohort at genome-­wide
significance (GWS). Examples include granulysin (GNLY, rs1866139,
P-­value = 4.37 × 10−12, OR = 1.15, 95% CI = 1.10–1.19), protein
kinase C (PRKC, rs58730937, P-­value = 6.64 × 10−12, OR = 0.65,
95% CI = 0.58–0.74), and G protein-­coupled receptor 55 (GPR55,
rs1848728, P-­value = 2.21 × 10−10, OR = 1.14, 95% CI = 1.09-­1.18).
For the first time, NOS2 has been identified to be associated with
AS in Han Chinese at GWS along with 2p15 and ERAP1. The esti-
mated common variant heritability of AS is 48.1% and 46.3% in the
European and Chinese cohorts respectively.
Conclusion: This is the largest global ongoing GWAS study in AS and
identifies novel druggable genetic pathways. Our findings including
novel AS-­associated loci will provide further understanding of the
molecular pathogenesis of AS.
O-­063 | Current classification and management
of myositis
I. Lundberg1,2
1
Division of Rheumatology, Karolinska Institutet; 2Rheumatology, Karolinska
University Hospital
The idiopathic inflammatory myopathies (IIM), collectively named
myositis, are clinically characterized by muscle weakness and extra-
muscular manifestations are common such as skin rash, arthritis and
interstitial lung disease. Based on clinical and histopathological dif-
ferences myositis may be subclassified into polymyositis, dermato-
myositis and inclusion body myositis (IBM). More recently immune
mediated necrotizing myopathy and antisynthetase syndrome have
been identified as other distinct subgroups. To improve clinical re-
search new classification criteria including subgrouping of adult and
juvenile myositis have been developed and endorsed by EULAR and
ACR; 2017 EULAR/ACR Classification Criteria for Adult and Juvenile
Idiopathic Inflammatory Myopathies and their Major Subgroups.
Diagnosis is based on clinical features and laboratory tests includ-
ing so called myositis specific autoantibodies. Notably patients with
IIM may present with variable organ manifestations such as arthritis,
skin rash or interstitial lung disease sometimes without clinical mus-
cle weakness.
Glucocorticoids in combination with immunosuppressive drugs are
the basis of pharmacological treatment and should be combined
with exercise. New biologics are being tested in myositis and the
effect of rituximab seems to vary between serological subgroups.
Still many patients with IIM are left with impaired function and low
quality of life.
Management is based on standardized follow-­
up using clini-
cal outcome measures, as were developed in consensus by the
ABSTRACTS
International Myositis Assessment and Clinical Studies Group
(IMACS). These include a core set measure of disease activity
and a score to measure damage, myositis damage index (MDI).
These are useful tools for decision making on treatment in clini-
cal practice. To facilitate follow-­up in the clinic and in research
a web-­b ased international myositis registry has been developed,
the Euromyositis registry, www.euromyositis.eu, which includes
IMACS disease activity and damage variables. This registry is an
open-­s ource tool and we welcome new collaborators. Large inter-
national collaborations are needed to develop new therapies for
this rare condition.
O-­034 | Gout treatment strategies: is precision
medicine a valid approach
T. Major
University of Otago
Gout is the most common form of inflammatory arthritis, affecting
over 5.5 million people world-­wide. Effective preventative medica-
tions for gout are available (urate-­lowering therapies), with relatively
low frequency of serious adverse events. However, gout treatment
statistics are often poor, and many patients suffer unnecessarily.
Many factors contribute to these poor treatment statistics, includ-
ing over-­emphasis on management through environmental interven-
tions, treatment of gout symptoms instead of the underlying cause
(hyperuricaemia), and inadequate dosing of urate-­lowering drugs.
Precision medicine is defined as “the customisation of healthcare to an
individual patient by taking into account the genes, environment, and life-
style of the patient.” This medical model aims to optimise the efficiency
or therapeutic benefit of standard treatment strategies by tailoring
the strategy to the patient based on a prediction of their response.
In gout there are many potential benefits from the adoption of a
precision medicine model. Current research has identified several
precision medicine approaches to combat the current issues con-
tributing to the poor gout treatment statistics. These include the
development of tools to predict the allopurinol dose required by a
patient to achieve target serum urate levels and the identification
of individuals who are unlikely to respond well to allopurinol (either
due to the development of an adverse reaction or because they are
unlikely to achieve serum urate target on allopurinol) and so should
be using alternative urate-­lowering therapies. There is also the po-
tential to develop targeted advice for environmental interventions
or the creation of predictive genetic models to identify those at risk
of developing more severe gout.
But is precision medicine the answer? Will the development of these
strategies help improve the treatment of gout? Or will the inclusion
of a precision medicine model into the current treatment guidelines
create more problems for an already struggling system?
|
      21
O-­012 | C-­peptide of proinsulin is an
autoantigen in human type 1 diabetes
S. Mannering; M. So; T. Kay
St. Vincent's Institute of Medical Research
Background/purpose: The antigens and epitopes recognized by
CD4+ T cells in people with type 1 diabetes (T1D) remain poorly
defined. We, and others, have found that several epitopes derived
from C-­peptide are recognized by human islet-­infiltrating CD4+ T
cells implicating CD4+ T-­cell responses to C-­peptide in the patho-
genesis of human T1D. C-­peptide is excised from proinsulin during
the synthesis of insulin in beta-­cell granules and co-­secreted with in-
sulin. Here we quantified and analyzed CD4+ T cells that responded
to full-­length C-­peptide (PI33-­63) in peripheral blood of people with
and without T1D.
Methods: The CFSE-­based proliferation assay was used to detect
C-­peptide responsive CD4+ T cells in PBMC. CD4+ T cells that re-
sponded to C-­peptide were cloned by single-­cell sorting and charac-
terized as described below.
Results: CD4+ T-­cell responses to full-­length C-­peptide were de-
tected in: >60% (14 of 23) of recent-­onset (<3 months from diag-
nosis) T1D subjects, 13% (2 of 15) of long-­standing (>2 years since
diagnosis?) T1D subjects and 8% (1 of 13) of HLA-­matched healthy
subjects. A panel of 22 C-­peptide-­specific CD4+ T-­cell clones were
isolated from six individuals with recent onset T1D. These clones
recognized epitopes from the entire 31 amino acids of C-­peptide,
although most epitopes fell towards the C-­terminus. Eighty percent
(18 of 22) C-­peptide-­specific clones were restricted by high-­risk al-
leles HLA-­DQ8, -­DQ2, -­DQ8trans or -­DQ2trans. TCR sequencing
revealed that a wide variety of TCR genes were used by these clones.
Finally, titration experiments showed that full-­length C-­peptide was
a much more potent agonist of some CD4+ T-­cell clones than an
18mer peptide encompassing the cognate epitope.
Conclusion: Our findings support the notion that full-­
length C-­
peptide is important target of pathogenic CD4+ T-­cell responses in
people who develop T1D. Consequently, full-­length C-­peptide may
be useful in T-­cell assays and antigen specific therapy protocols.
O-­013 | Patient preferences in decision making
-­what are they and what is their role in clinical
practice and policy?
D. A. Marshall
University of Calgary
Methods to measure patient preferences are survey based ap-
proaches that ask respondents to express the relative desirability
or acceptability of features that differ among alternatives that re-
flects their underlying utility for that alternative. Aligning health
care policy with patient preferences could improve the effectiveness
 |
22       ABSTRACTS
of health care interventions by improving adoption of, satisfaction
with, and adherence to clinical treatments.
Patient preferences will play a key role in the future of arthritis
care: (1) supporting patient-­centered care and personalized medicine
in clinical practice; (2) informing clinical practice guidelines; (3) as
evidence informing regulatory decisions.
In clinical practice, recognising heterogeneity in patient pref-
erences is important for choosing treatment to achieve best out-
comes for that individual patient. This is a key in treat-­to-­target
strategies because patients with the same level of disease activity
have varying treatment preferences. In the development and recom-
mendations for clinical practice guidelines, we know patients often
value aspects of care differently than physicians. Incorporating
patients’ preferences into treatment recommendations is the next
step in guideline development and has been identified by Grading
of Recommendations Assessment, Development and Evaluation
(GRADE) as the standard for developing treatment recommenda-
tions. Finally, patient preferences for benefits and harms are now
being recognized as evidence by regulatory bodies. Recent guidance
from regulatory agencies on patient preference information speci-
fies that patient tolerance for risk and perspective on benefit, may
be considered in the assessment of the benefit-­risk profile of certain
devices when the information qualifies as valid scientific evidence.
In the future, it is expected that:
• Preferences of patients will be measured and reflected to inform
individual treatment decisions in clinical practice;
• Incorporating patients’ preferences is the next step in clinical
guideline development and recommendations;
• Evidence on patient's perspective will be part of the regulatory
approval processes in the future.
O-­014 | Vitamin D in human health and disease
R. S. Mason
Physiology & Bosch Institute, University of Sydney
Very low blood concentrations of the accepted marker of vita-
min D status, 25-­hydroxyvitamin D (25(OH)D) <25 to 30 nmol/L,
cause osteomalacia, rickets and marked muscle weakness, which
are reversed with vitamin D treatment. Somewhat low blood con-
centrations of 25(OH)D, <50 nmol/L are associated with elevated
parathyroid concentrations in most, though not all people, and with
accelerated bone turnover, bone loss and some degree of impaired
muscle function, with increased risks of falls and fractures, particu-
larly in the older population. On balance, treatment with vitamin D
and calcium, results in modest (up to 15%) improvements in falls
and fractures, particularly in institutionalized elderly, where base-
line vitamin D status is low and where compliance is good. There is
good and consistent evidence for a modest effect of vitamin D sup-
plementation, usually with calcium, to reduce overall mortality. The
active hormone, 1,25dihydroxyvitamin D alters the transcription
of around 2000 genes. Low vitamin D status has been associated
with impaired responses to infection, increased inflammation and
increased susceptibility to auto-­immune diseases such as rheuma-
toid arthritis. Molecular mechanisms which could explain these as-
sociations have been reported. One difficulty in studies on the links
between vitamin D status and various diseases is that people who
are ill, tend to not be outside, exposed to UV, so that low vitamin D
is likely to be a marker for ill-­health. A second difficulty, at least in
relation to auto-­immune conditions, is that UV is immune suppres-
sive in its own right, so that the latitude gradients commonly cited
for auto-­immune conditions, may reflect UV exposure and not vita-
min D status. At least some vitamin D intervention trials early in life
show that increasing vitamin D status from low to normal or higher
reduces susceptibility to some auto-­immune conditions. Mendelian
Randomization studies provide additional support. There is more to
be done.
O-­069 | Management of reactive arthritis
R. Misra
Professor and Head Clinical Immunology, S.G.P.G.I.M.S
Purpose: The management of Reactive arthritis (ReA) has several
challenges. The strict definition of ReA, requiring the need of dem-
onstrating preceding infectionof the genitourinary or gastrointes-
tinal tract is not met in 50% of cases. There is an unmet need of
having a pragmatic criteria classifying patients presenting with acute
or subacute onset of asymmetrical oligoarthritis of the lower limb
joints.
Methods: Analysis of published literature.
Results: Several patients with undifferentiated peripheral arthri-
tis having typical clinical features of ReA, do not give a preceding
history of diarrhea or urinary tract infection yet have serological
or cellular evidence of immune response to organisms known to
trigger ReA. The changing microbial and clinical profile of reactive
arthritis suggeststhat rheumatologists need to reconsider the ap-
proach to its identificationand treatment. Besides, the classical en-
teric organisms, Salmonella typhimurium, Shigella flexneri, Yersinia
enterocolitica several newer organisms have been incriminated in
triggering ReA. Though in majority the arthritis would remit in 3 to
6 months, 30% of patients would go on to develop a chronic or re-
current arthritis causing significant functional disability. Host fac-
tors such as HLA class I allele, B 27 which is associated in 60–70%
of cases could play an yet undefined role in perpetuating synovitis.
Antibiotic therapy in general do not favor in changing the course
of arthritis, however, in cases of Chlamydia induced ReA, antibiotic
treatment of partener is important to prevent relapses. In chronic
and recurrent arthritis, use of DMARDs as is used in patients with
other members of Seronegative spondyloarthropathy, such as AS
and IBS arthropathy is beneficial. There has been increasing use of
anti TNF therapy those who failed on conventional DMARD treat-
ment with beneficial effect.
ABSTRACTS
Conclusions: New insights in to the pathogenesis would suggest ap-
propriate targeted therapy early on in the course of the disease to
halt progression of chronic joint damage.
O-­052 | Prevalence and risk factors of serious
infections in rheumatoid arthritis patients
receiving the biologic/targeted synthetic
DMARDs
C. C. Mok; R. Wan; B. Fong
Tuen Mun Hospital
Objectives: To study the prevalence and risk factors for serious in-
fections in rheumatoid arthritis (RA) patients receiving the biologic/
target synthetic (b/ts) DMARDs.
Patients and methods: Data from the Hong Kong Biologics
Registry, which was established in 2007, were analyzed. Patients
who fulfilled the EULAR/ACR criteria for RA and were ever treated
with b/tsDMARDs were included. Withdrawal of b/tsDMARDs
due to serious adverse events (SAEs) and serious infections (SIs)
was analyzed. Demographic data, medical comorbidities (eg. dia-
betes mellitus, chronic lung, kidney and liver diseases) and con-
comitant use of glucocorticoids and csDMARDs were retrieved
from the database and their contribution to serious infections was
evaluated by separate logistic regression. The propensity score for
SIs was calculated and patients were stratified into 5 quintiles ac-
cording to the risk. The hazard ratios (HRs) of serious infections
with respect to individual b/tsDMARDs in each quintile were stud-
ied by Cox regression.
Results: Up to December 2017, 2355 courses of b/tsDMARDs
were used in 1355 patients with RA (83% women; mean age
54.0 ± 12.7 years). All are ethnic Chinese. The usage of various b/
tsDMARDs was as follows: adalimumab (12%), etanercept (24%), in-
fliximab (17%), golimumab (9.4%), certolizumab (0.9%), tocilizumab
(19%), rituximab (6.6%), abatacept (7.7%) and tofacitinib (2.7%). After
a follow-­up of 5056 patient-­years, 1433 courses of b/tsDMARDs
were discontinued, with major reasons being inefficacy (50%), SAEs
(22.4%) and cost (8.4%). Among those b/tsDMARD courses termi-
nated because of SAEs, 32% were due to SIs (103 episodes). The
rate of SIs was 1.17/100 patient-­years. The commonest causes of
SIs were pulmonary tuberculosis (TB) (41%), severe pneumonia
(33%), soft tissue infection (6.8%), atypical TB (2.9%), urogenital
sepsis (2.9%), septic arthritis (2.9%), hepatobiliary/gastrointesti-
nal sepsis (2.9%), central nervous infection (1%), severe viral infec-
tions including herpes zoster (5.8%), and opportunistic infections
(2.9%). A logistic regression model showed that increasing age (OR
1.02[1.001–1.04 per year]), male sex (OR 1.88[1.08–3.26]) and
concomitant chronic obstructive pulmonary disease/asthma (OR
2.55[1.05–6.23]) were risk factors significantly associated with SIs.
The rate of TB infection was highest in users of infliximab (2.32/100
patient-­
years), followed by tofactinib (1.47), adalimumab (1.27),
|
      23
etanercept (0.62) and tocilizumab (0.36). Non-­TB serious infections
occurred most frequently with infliximab (2.32/100 patient-­years),
tofacitinib (1.47) and abatacept (1.15). In the quintile of patients with
the highest propensity score for SIs, infliximab had the highest with-
drawal rate due to SIs (18%), followed by tofacitinib (10%), etaner-
cept (8%), adalimumab (6%), abatacept (2.8%) and tocilizumab (2.6%).
Cox regression revealed the following HRs for SIs with reference to
adalimumab: infliximab (2.81[0.80–9.88]), tofacitinib (HR 2.12[0.19–
23.4]), etanercept (HR 0.82[0.22–3.11]), abatacept (HR 0.41[0.04–
3.98]) and tocilizumab (HR 0.38[0.06–2.26]). Concomitant low-­dose
glucocorticoid was associated with an insignificantly increased risk
of SIs only in the three quintiles of patients with lower propensity
to SIs.
Conclusions: SIs causing withdrawal of b/tsDMARDs in patients
with RA account for one-­third of all SAEs. Increasing age, male sex
and concomitant chronic chest conditions were independent risk
factors for SIs. Infliximab was associated with the highest rates of
serious TB and non-­TB infection, and this observation was consist-
ent in all quintiles of patients with different propensity to SIs.
O-­0 05 | AL amyloidosis presenting as
inflammatory polyarthritis: a case report
M. S. M. Majumder; S. A. Haq; S. Author; M. M. Khan
Bangabandhu Sheikh Mujib Medical University
Background: Amyloidosis is a condition characterized by extra-
cellular deposition of fibril which causes a wide range of clinical
manifestation. This protein deposition can occur in any tissue, most
commonly seen in kidney, heart, skin, peripheral nervous system and
gastrointestinal tract.
Objective: Invasion to bone tissue is not often reported.
Musculoskeletal manifestations are subtle, subclinical and rarely the
patient present with symptoms that resemble rheumatic diseases.
Here, we present a case of AL amyloidosis in a 55 year old man who
presented with inflammatory polyarthritis with significant morning
stiffness along with inflammatory low back pain. Considering seron-
egative RA the patient was treated with various DMARDs including
tofacitinib with poor response.
Methods: Clinical examination revealed the patient to be anaemic,
localized soft tissue swellings over joints, macroglossia with lateral
scalloping of tongue, papules and plaques on periocular, perioral
and perinasal area, bilateral CTS, movement restricted in different
joints with flexion contracture in some joints. Rheumatoid arthri-
tis, spondyloarthropathy were excluded by serological and imaging
techniques.
Results: Amyloidosis was confirmed by tongue biopsy. The type of
amyloidosis was evaluated by serum protein electrophoresis, im-
muno electrophoresis, bence jones protein in urine, bone marrow
study and radiological survey. Immunoelectrophoresis revealed ab-
normal accumulation of lambda light chain molecule in serum.
 |
24       ABSTRACTS
Conclusions: Amyloid deposits in AL amyloidosis can involve the
synovium leading to musculoskeletal manifestations dircecting the
patient to a rheumatologist. This patient had significant symmetrical
polyarthritis that lead to misdiagnosis of RA. Such diversity of mus-
culoskeletal manifestations may be an under appreciated feature of
amyloidosis.
Keywords: AL amyloidosis, polyarthritis, macroglossia.
O-­078 | Novel biomarkers in SLE
E. Morand
Monash University
Systemic lupus erythematosus continues to challenge research and
drug discovery pipelines, with only one targeted therapy approved
worldwide and most patients still treated with approaches dating
from the 1950s.
While clinical heterogeneity and lack of agreement on trial end-
points are partly to blame, taxonomy of lupus and the autoimmune
diseases is also at fault – we continue to rely on clinician-­assigned
classification criteria that have little or not foundation in biology.
This means that targeted therapies are being trialed in patients
who we know to be biologically dissimilar – vritually guaranteeing
failure.
New technologies allowing genome wide analysis of gene transcrip-
tion have allowed identification of key modules of activity in SLE
patients, some common and some rare, that suggest a molecular
classification of autoimmune diseases could be at hand. In this pres-
entation, data leading to this conclusion will be reviewed, alongside
novel approaches to mathematical analysis that include the dimen-
sion of time, and emerging practical approaches that could find clini-
cal application in the near term.
O-­048 | Update psoriatic arthritis
P. Nash
University of Queensland
This review will focus upon the “hot” topics of PsA management
which include:
1. Latest thoughts on pathogenesis of PsO and PsA
2. Treat to target in PsA including targets and outcome measures in
PsA
3. Co-morbidities in PsA
4. Biomarkers
5. Guidelines Eular, ACR and Grappa guidelines
6. Established therapies such as csDMARDs, TNF inhib, 12/23 inhib,
and IL17 inhib
7. Novel therapies including IL23 inhib and Jakinibs.
As well as future directions.
O-­011 | Assessment and treatment of chronic
low back pain
C. Needs
Royal Prince Alfred Hospital
Globally, in 2015, there were over 550 million people affected by
activity limiting low back pain with African, Asian and the Middle
Eastern countries showing the largest increase in disability over the
last decade. As a result, chronic back low pain (CLBP) has large per-
sonal, family, economic and societal costs.
Most episodes of acute lower back pain (ALBP) settle within 6 weeks,
however some 14% will have persisting pain at 12 months, when
treatments used for acute pain are usually not effective. Prevention
of CLBP should be a priority. Assessment tools exist that help iden-
tify barriers to recovery from ALBP and when those factors are at-
tended to, there has been a demonstrable reduction in the transition
to CLBP.
Individuals with CLBP may have varying influences from Anatomical,
health co-­morbidities, Genetic, Psychosocial, Central pain process-
ing and societal factors contributing to their pain. Indeed not all
factors may be present. Identifying and treating all factors involved
while, advocating a positive health concept to people with CLBP is
recommended.
A challenge in this setting is to bring individual and family awareness
to and then establish a willingness to focus on the role psychosocial
factors play in their pain. This is in contrast to the usual readiness
to take up physical therapy and medications. Approaches to these
issues will be presented.
O-­053 | The utility of the ERS-­R A
cardiovascular risk calculator in Australian
rheumatoid arthritis patients
J. New-Tolley1,2; S. Lester1,2; J. Lee3; P. Sinnathurai3,4,5; R.
Buchbinder6,7; M. Lassere8,9; L. March3,4,5; R. J. Black1,2,10; C.
L. Hill1,2,10
1
Rheumatology Unit, The Queen Elizabeth Hospital; 2University of Adelaide;
3
Sydney Medical School, University of Sydney; 4Institute of Bone and Joint
Research, Kolling Institute; 5Rheumatology Department, Royal North Shore
Hospital; 6Cabrini Institute; 7Monash University; 8University of New South
Wales; 9Rheumatology Department, St George Hospital; 10Rheumatology Unit,
Royal Adelaide Hospital
Background: Patients with rheumatoid arthritis (RA) have an in-
creased risk of cardiovascular disease (CVD) compared to the gen-
eral population, which is partially related to inflammatory disease
activity. The Expanded cardiovascular Risk Score for RA (ERS-­R A)
is a 10-­year absolute CVD risk calculator, developed, and internally
validated in American RA patients specifically for Rheumatologists,
which utilizes traditional and RA-­specific CVD risk factors.
Objectives: To determine the utility of the baseline ERS-­R A risk for
prediction of 10-­year CVD risk in Australian RA patients.
ABSTRACTS
Methods: Longitudinal data was obtained from the Australian
Rheumatology Association Database (ARAD). CVD events were
defined as self-­reported hospitalization for angina, myocardial in-
farction, coronary artery bypass grafting, percutaneous coronary in-
tervention, stroke, transient ischaemic attack or CVD related death
in the National Death Index
Calibration of the baseline ERS-­R A risk was assessed by the stand-
ardized incidence ratio (SIR) and the Kaplan-­Meier cumulative failure
function at 10 years. The ability of the baseline ERS-­R A to discrimi-
nate between individuals of differing risk was assessed by area
under the curve (AUC) analysis at 10 years.
Results: The analysis consisted of 2,327 RA patients, and 204 CVD
events over 13,579 person-­years.
The CVD incidence rate in the ARAD cohort was 14.9/1000 person-­
years (95% CI 12.9, 17.4). Overall, the ERS-­R A under-­estimated CVD
risk (SIR 1.7; 95% CI 1.5, 1.9). While RA patients with a low ERS-­R A
risk (<10%) had, on average, a low 10-­year CVD risk (8.5%; 95% CI
6.9,10.5), patients in moderate (10–20%) or high (>20%) risk groups
were indistinguishable (23.2% 95% CI 19.1, 28.1) vs 24.5% (95% CI
18.1, 32.5)). The AUC at 10-­years was 0.714, indicating moderate
discrimination of the ERS-­R A for CVD, with the sensitivity/specific-
ity optimal at a cut-­off value of 8.8%.
The hazards ratio of a cardiovascular event was higher for patients
recruited earlier to ARAD, suggesting that cardiovascular risk de-
clined over time in our cohort.
Conclusion: The ERS-­R A underestimates CVD risk in Australian RA
patients; however, may have utility in identifying low risk patients.
Tighter disease control from treat to target protocols and the wider
availability of biologics may have contributed to a reduction in car-
diovascular risk in RA over time.
O-­072 | The characteristics, trend of
frequency and outcome of reactive arthritis in
Japanese patients with bladder cancer following
intravesical BCG therapy
1 1 1
M. Ogasawara ; Y. Taniguchi ; H. Nishikawa ; S. Inotani ; T. 1 tality and none in Australia. Previous small clinical and nationwide
Karashima1; Y. Yoshinaga2; S. Kobayashi3; Y. Terada1
1 2 3
Kochi Medical School; Kurashiki Medical Center; Juntendo-­Koshigaya
Hospital
Background/objective: Reactive arthritis (ReA) is a sterile arthri-
tis occurring in a genetically predisposed individual, secondary to
an extra-­articular infection, usually of the gastrointestinal or geni-
tourinary tract. Intravesical instillation of Bacillus Calmette-­Guerin
(iBCG) is used as an effective immunotherapy of bladder cancer.
Despite of the clinical efficacy, ReA could develop as adverse event
and the frequencies are known as about 0.5 to 1 % in Western coun-
tries. Objective is to assess the trend of frequency, HLA phenotype
and outcome of iBCG-­induced ReA in Japanese patients with blad-
der cancer following iBCG therapy.
|
      25
Methods: The clinical findings of Japanese patients who received
iBCG (n = 555) for bladder cancer from March 1997 to February
2017 were retrospectively assessed, with specific attention to fre-
quency and HLA phenotype of ReA. Because of the change of using
iBCG dosage, iBCG-­induced ReA patients diagnosed from 1997 to
2007 were also compared with ReA from 2007 to 2017 and the
trend of frequency was examined. Furthermore, we assessed out-
comes of iBCG-­induced ReA patients over the 20 years.
Results: Patients’ mean age was 72 ± 10 years and male/female ratio
was 438/117. Of the 555 cases, ReA was revealed in 11 (2.0%). 9.1%
of 11 ReA patients had HLA-­B27. Although the protocol of iBCG
therapy was not statistically different over the 20 years, but a half
dose of iBCG was used in 2007 to 2017 more than in 1997 to 2007.
Despite the increase of half dose using of iBCG in 2007 to 2017, the
overall frequency of iBCG-­induced ReA was not significantly differ-
ent between from 1997 to 2007 and from 2007 to 2017 (2.1% and
1.9%, respectively). Finally, as outcomes, all iBCG-­induced ReA pa-
tientsdid not progress to chronic peripheral arthritis type and axial
SpA, even if with sacroiliitis.
Conclusions: The 2.0% iBCG-­i nduced ReA frequency in Japanese
patients exceeds that in Western countries. Despite iBCG dosage
was different, the trend of frequency has been stable, which sug-
gested possible dose-­independent development. Furthermore,
all iBCG-­induced ReA, even if revealing sacroiliitis, did not pro-
gress to chronic peripheral arthritis type and SpA over the last
20 years.
O-­073 | Mortality in hospitalised ankylosing
spondylitis patients from Western Australia
M. Ognjenovic; W. Raymond; J. Nossent
University of Western Australia
Background: Ankylosing Spondylitis (AS) is a chronic inflammation
mainly of the spine where there is bone loss and rigidness of through
paravertebral calcification, however there is minimal data on mor-
cohort studies have shown standardised mortality ratios ranging be-
tween 1.33 and 1.80.
Methods: A retrospective cohort study of AS patients matched
to controls (Non-­
A S), is sourced from Western Australian (WA)
Department of Health's linked datasets including the WA Cancer
Registry, Emergency Department Data Collection, WA Mortality
Registry and Hospital Morbidity data between 1995 and 2016.
The controls are selected from the Western Australian Rheumatic
Disease Epidemiological Registry and matched with up to 10 indi-
viduals according to year of birth per 5-­year blocks, index hospital
contact year, gender, and Indigenous status. Ankylosing Spondylitis
patients were identified according to ICD-­9-­CM (720.0) and ICD-­
10-­AM codes (M45.X, M08.1X). We report mortality rates and rate
ratios for AS patients compared to matched controls in WA.
 |
26       ABSTRACTS

Results: Throughout 1995 to 2016, we identified 2,209 AS and 21,631 O-­043 | Stem cells and osteoporosis
Non-­AS patients. AS-­patients were 10% likely to die than NON-­
A. Pettit
AS-­patients (526, 24% vs 4729, 22%, P = 0.035, respectively), with
Mater Research Institute-­The University of Queensland
a mortality rate ratio of 1.10 (1.01, 1.20). AS-­patients died 5-­years
earlier than their matched NON-­AS-­patients (77 vs 82; P < 0.0001,
Osteoporosis pathology is due to haematopoietic-­
d erived os-
respectively). Non-­Indigenous status was mortality predictor of AS,
teoclast and mesenchymal-­
d erived osteoblast dysfunction.
being 10% more likely to die, and AS-­patients aged under 40 years of
Underlying genetic variations/mutations in and/or extrinsic im-
age were 60% more likely to die than aged 40–79 years.
pacts on either stem cell compartment can contribute to the
Conclusion: Mortality increased for all patients with AS compared to
pathogenesis of osteoporosis. Aging-­associated decline in stem
general population, overall dying 5 years earlier and Non-­Indigenous
cell fitness is one contributing factor, with aging impacts acceler-
being are a predictor of death.
ated in osteoporosis. During aging mesenchymal stem cells (MSC)
Table 1 mortality abstract data
shift their differentiation bias to adipogenesis, while haematopoi-
AS NON-­A S
etic stem cells (HSC) shift their bias toward myeloid differentia-
N = 2209 N = 21631 P-­value/MRR tion. A perfect storm that is pro-­b one loss. Whether aging is driven

Overall baseline characteristics

by intrinsic or extrinsic controls has implications for intervention
potential. Examples of modifiable intrinsic changes to the controls
 Male 1296 (58.7%) 12705 (58.7%) 0.952
of gene transcription in MSC include altered expression of microR-
 Female 913 (41.3%) 8926 (41.3%)
NAs and long non-­coding RNAs that have been implicated in MSC
Non-­IA
aging and osteoporosis pathogenesis. Impaired autophagy and low
 Indigenous 15 (0.7%) 94 (0.4%) 0.105
mitochondrial function are modifiable intrinsic changes reported
 Not died 1683 16902
in HSC aging, with no direct links to osteoporosis yet established.
 All died 526 (24%) 4729 0.035 More readily modifiable alterations to extrinsic controls in the
 Age died 77 (67, 84) 82 (74, 87) <0.0001 niches that support both MSC and HSC during osteoporosis is rel-
 Person-­ 39228 388280 atively unexplored. We have yet to harness targeting of stem cell
time years compartments to either prevent or treat osteoporosis. Deliberate
Died during follow-­up development or repurposing of therapeutics to manipulate stem
 Male 322 (61.2%) 3097 (65.5%) 0.051 cells in osteoporosis is underexplored given that treatments can
 Female 204 (38.8%) 1632 (34.5%) cause osteoporosis via switching differentiation bias in MSC and
  Non-­IA 522 4701 HSC stem cell compartments. Examples include glucocorticoid
 Indigenous 4 (0.8%) 28 (0.6%) 0.638 and thiazolidinedione switching of mesenchymal differentiation
Age-­groups bias toward adipogenesis. Additionally, cadmium-­induced osteo-

 <40 72 (13.7%) 387 (8.2%) <0.0001

porosis is characterised by increase number of HSC and elevated
myeloid differentiation bias. Whereas, HSC mobilising agents may
 40–79 440 (83.7%) 4145 (87.7%)
protect from osteoclast-­
m ediated bone loss by reducing bone
 ≥80 14 (2.7%) 197 (4.2%)
marrow availability of osteoclast precursors. The current status
Mortality rates
quo of knowledge relating to stem cells in osteoporosis will be re-
 Overall 13.41 (12.29, 12.18 (11.83, 1.10 (1.01, 1.20)
viewed and opportunities to manipulate these compartments to
14.6) 12.53)
prevent/treat this disease will be discussed.
 Female 12.42 (10.77, 9.95 (9.47, 1.25 (1.08,
14.24) 10.45) 1.44)
 Male 14.12 (12.62, 13.81 (13.33, 1.02 (0.91, 1.15)
15.75) 14.30) O-­064 | Management issues in systemic
 Indigenous 16.06 (4.38, 17.52 (11.64, 0 .92 (0.32, sclerosis
41.13) 25.32) 2.61)
S. Proudman1,2
 Non-­ 13.39 (12.27, 12.16 (11.81, 1.10 (1.00, 1.21)
1
Indigenous 14.59) 12.51) Royal Adelaide Hospital; 2Discipline of Medicine, University of Adelaide

Age-­groups
 <40 2.92 (2.29, 3.68) 1.67 (1.51, 1.85) 1.75 (1.34, 2.25) Systemic sclerosis (SSc) is a multi-­organ autoimmune disease with no
effective disease modifying therapy or cure. Among the rheumatic
 40–79 30.51 (27.72, 26.68 (25.88, 1.14 (1.03, 1.26)
33.50) 27.51) diseases, SSc has one of the greatest increases in mortality with
 ≥80 78.21 (42.76, 108.78 (94.12, 0.72 (0.39, 1.24) standardized mortality ratios ranging from 2.5 to 4.5. The chronic
131.23) 125.08) nature of the disease and the accrual of damage in multiple organ
ABSTRACTS
systems, makes SSc one of the most challenging rheumatic diseases
to manage and one of the most costly.
Pulmonary complications, pulmonary arterial hypertension (PAH)
and interstitial lung disease (ILD), are the leading cause of mortality.
Early detection and treatment of SSc-­PAH with advanced vasodila-
tor therapies have improved outcomes but PAH remains a significant
contributor to poor HRQoL and reduced survival. Not all patients
have clinically significant ILD but identifying in whom it will be pro-
gressive and hence who requires therapy, remains a challenge, al-
though the effects of current immunosuppressives are modest.
Scleroderma renal crisis is predominantly remains a major cause
of mortality and end stage renal failure despite the use of ACE-­
inhibitors. Gastrointestinal involvement is almost universal and a
common cause of poor HRQoL. Vascular manifestations and flexion
contractures can cause major disability.
Therapy is usually dictated by the organ involved. Development of
potential disease-­modifying therapies targeted to mediators of in-
flammation, fibrosis and vasocontriction has expanded recently. A
recent Phase II trial of the IL6 receptor blocker, tocilizumab, showed
promise but a trial of riociguat, a guanylate cyclase agonist, did not
meet the primary end-­point. Trials of other novel agents such as the
anti-­fibrotic, nintedanib and lenabasum, an agonist of the cannabi-
noid receptor type 2 (CB2), are underway. For patients with rapidly
progressive diffuse SSc, there has been growing interest in autolo-
gous stem cell transplantation since the SCOT trial, despite a risk of
early mortality and challenges in patient selection.
O-­019 | Using genetics and genomics to
understand behcet's disease
E. F. Remmers
National Human Genome Research Institute
Background: Behçet's disease was originally recognized by the
Turkish dermatologist, Hulusi Behçet, in patients with the triad, oral
and genital ulceration, hypopyon uveitis, and erythema nodosum.
The disease is now recognized as a multisystem inflammatory dis-
ease and has been included in the category of autoinflammatory dis-
eases, because of the recognized systemic inflammation and the lack
of recognized autoantibodies or antigen-­specific T-­cells. Behçet's
disease is genetically complex, with numerous contributing genetic
and environmental risk factors. The disease is common in Turkey,
reported 4 in 1,000 individuals, and is also relatively common in the
Far East and along the old silk routes.
Methods: Genome-­wide association studies of polygenic Behçet's
disease in populations where the disease is common are revealing
underlying genetic risk factors and leading to new insights into the
disease.
Results: The MHC class I allele, HLA-B*51, is the strongest and longest
known genetic risk factor for Behçet's disease. Association of ERAP1
and its significant interaction with HLA-B*51 suggest that peptide
production and binding to HLA-B*51, and possibly presentation, play
|
      27
important roles in Behçet's disease, despite the absence of recog-
nized antigen-­specific T-­cells. Interactions of different MHC class I
alleles and ERAP1 have also been described in ankylosing spondylitis
and psoriasis and these three diseases have been deemed MHC-­I-­
opathies. These diseases also share disease-­protective variants in
IL23R that impair IL-­23-­induced Th17 effector response, suggest-
ing that Th17 cells contribute to these diseases. Another theme to
emerge, is the disease promoting role of variants that reduce host
barrier function or lead to inadequate host response to microbes.
Conclusion: Shared genetic factors among the MHC-­
I-­
opathies
suggest shared disease pathogenesis and the possibility of shared
treatment options. The identified host response genetic risk factors
help to establish a link between genetic factors and environmen-
tal factors, such as microbial exposures, that together contribute to
Behçet's disease susceptibility.
O-­081 | Management of Sjogren's syndrome
M. Rischmueller
The Queen Elizabeth Hospital
Sjogren's syndrome (SS) is a chronic autoimmune inflammatory
disease. In addition to destructive effects upon salivary and lac-
rimal glands, causing xerostomia and keratoconjunctivitis sicca,
upwards of 30% of patients with primary SS (pSS) develop sys-
temic involvement, including a 5–10% lifetime risk of non-­H odgkin
lymphoma. Correct diagnosis of pSS is crucial in order to optimally
manage patients with respect to oral and ocular disease, detection
and treatment of systemic involvement, and monitoring for lym-
phoma. General principles of management include avoidance of ex-
acerbating factors such as low-­humidity, irritants, and medications
with anti-­cholinergic effects. Ophthalmic examination is important
to discern the integrity of epithelial surfaces, and to identify and
treat causes other than lacrimal failure which may be contributing
to dryness. Treatment of dry eyes should be tailored to the indi-
vidual, and includes a combination of environmental optimization,
tear supplementation, tear retention, tear stimulation, lid care,
anti-­inflammatories, and biological tear substitutes. Dry mouth
symptoms include sensitive oral mucosa, dry lips, tongue, inner
cheeks and palate, increased dental caries, and an increased sus-
ceptibility to oral infections. Patients may experience difficulties
with mastication, swallowing, and speech. Management strategies
include optimal oral hygiene, topical fluorides, dietary modifica-
tion, frequent sips of water, local and systemic salivary stimula-
tion, oral gels, mouthwashes, salivary substitutes, and treatment of
oral candidiasis. Disease modifying therapy is usually reserved for
patients with systemic involvement. Hydroxychloroquine is use-
ful for annular erythema and articular involvement. Methotrexate
is frequently used for inflammatory arthritis. Corticosteroids and
other immune suppressants may be required for the management
of vasculitis, pneumonitis, neuropathy, or nephritis. Rituximab,
used for the treatment of cryoglobulinaemia, in some cases results
 |
28       ABSTRACTS
in improved salivary and lacrimal function. Trials are underway to
evaluate the role of belimumab and abatacept in pSS; other poten-
tial therapeutic targets include CD22, IL6, IL17, lymphotoxin beta,
janus kinases, and Bruton tyrosine kinase.
O-­068 | The 2019 rheumatologist's back pain
handbook
L. Roberts
Monash Health
For almost everyone with back pain, an evidence-­based clinician
should recommend “keep moving”, as-­needed NSAIDs, and no imag-
ing. Although this is helpful in many, there remain large numbers of
patients with back pain who continue to suffer despite the applica-
tion of best evidence. Not surprisingly many seek additional treat-
ments outside the scope of the evidence base including a multitude
of imaging, interventions, and surgical procedures.
As the only non-­interventional specialist in back pain, the rheuma-
tologist can take the role of advisor to patients who are seeking un-
conflicted advice on non-­evidence-­based treatment options.
This presentation will use an informative, engaging, and entertaining
style to provide the tools you need to counsel your patients with
back pain:
• brief yet complete review of the evidence for interventions/surgery
so you know when to refer on, and when you don't need to
• pitfalls of imaging reports as a cause of unnecessary interventions
• tools to navigate various clinical scenarios, with worked examples
• communication tips and strategies to deliver desired outcomes
O-­035 | Colchicine prophylaxis of gout flares
when commencing allopurinol is very cost
effective
1,2 1,2 3 Methods: 26 patients (14 men and 12 women) with AAV with histo-
P. Robinson ; P. Donovan ; N. Dalbeth
1
University of Queensland; 2Royal Brisbane & Women's Hospital; 3University of
Auckland
Background/Purpose: Prophylaxis of acute gout flares when com-
mencing urate lowering therapy is recommended by international
guidelines. Whether this is a cost-­effective intervention is currently
unknown.
Objectives: To perform a cost effectiveness analysis using both a
United States cost input model and an Australian cost input model.
Methods: This cost-­effectiveness analysis was completed from
the point of view of the third-­p arty payer. We used a two arm
decision-­t ree with one arm commencing allopurinol with no col-
chicine prophylaxis and the other with colchicine prophylaxis.
Model inputs were drawn from published literature, where availa-
ble. We completed univariate and probabilistic sensitivity analysis
to confirm the robust nature of the modelling. The time frame for
the model was 6 months.
Results: The colchicine prophylaxis arm resulted in a cost of
US$1421 and 0.49 quality adjusted life-­years (QALYs). This domi-
nated the placebo arm with cost of US$2,149 and 0.47 QALYs. Cost
savings in Australia were more substantial (AU$753 in colchicine arm
vs AU$3,237 in placebo) due to lower colchicine cost. Univariate
and probability sensitivity analysis demonstrated that results were
robust to changes in input parameters. In probabilistic sensitivity
analysis, the probability of colchicine prophylaxis being the most
cost-­effective option was 93% in the US and 100% in Australian
setting.
Conclusion: Colchicine prophylaxis of gout flares whilst commenc-
ing allopurinol in gout is very cost effective.
O-­083 | Case-­control study on the
cyclophosphamide-­sparing effects of an
intensified B-­cell depletion treatment of anca-­
associated vasculitis
D. Roccatello; D. Rossi; S. Sciascia
CMID-­Center of Research of Rheumatology, Nephrology and Rare Diseases
Nephrology and Dialysis Unit Coordinating Center of the Rare Diseases Network
of Piedmont and Aosta Valley G. Bosco Hospital and University of Turin, Italy
Background: ANCA-­associated vasculitis (AAV) are systemic dis-
eases with relapsing chronic course. The management of the active
phases of the disease or of relapses requires the use of immunosup-
pressive drugs whose use is associated with potential toxicity.
Recently, two controlled randomized trials demonstrated the effi-
cacy of Rituximab (RTX) in the induction therapy of patients with
new diagnosis of AAV and in the management of relapse.
Objective: This case-­
control study aims to evaluate the
immunosuppressive-­sparing effect of RTX used in combination with
cyclophosphamide (CYC), compared to a traditional induction regi-
men based on high-­dose CYC.
logic evidence of necrotising extracapillarypauci-­immune glomerulo-
nephritis attending the Department of Nephrology and Dialysis and
Multidisciplinary Center of Immunopathology and Documentation
on Rare Diseases at the S. Giovanni Bosco of Turin were prospec-
tively enrolled. Thirteen patients (9 women and 4 men) received
the intensified protocol of B-­lymphocyte depletion therapy (IBCDT)
“4 + 2” with RTX and CYC and constituted the case-­
group. The
IBCDT “4 + 2” includes the administration of RTX (4 weekly infusions
followed by 2 monthly, 375 mg/m2) followed by oral prednisone rap-
idly tapered to 5 mg/day in 3 months. Parameter of disease activity
(ESR, CRP, ANCAtiter) and the Birmingham Vasculitis Activity Score
(B-­VAS) were measured. A major recurrence was defined on the
measurement of an increase of at least 1 point of BVAS.
Thirteen patients treated with the standard high-­dose CYC treat-
ment protocol (oral 2 mg /kg/die-­max 200 mg/die-­or intravenous
ABSTRACTS
every 3 weeks, 15 mg/kg, for at least 3 months followed by azathi-
oprine as maintenance therapy) were enrolled as controls. The se-
lection of controls was based on a match for age, severity of illness
(expressed as BVAS) and renal function at induction.
Results: In the 13 cases treated with the IBCDT “4 + 2” we observed
a statistically significant reduction in mean values of CRP, ANCA ti-
ters, and ESR (baseline mean value, 3, 6 months, 1 year, P < 0.05).
The mean serum creatinine values were 4.81 ± 6.4 mg/dL (0.6–2.4)
at baseline, 2.21 ± 3.8 mg/dL after 6 months, 2.6 ± 2.92 mg/dL after
1 year. After administration of RTX according to the “4 + 2” scheme,
a statistically significant reduction in the mean BVAS was observed
(baseline: 24, 3 months: 4, 1 year: 3). All patients had full B-­cell de-
pletion on peripheral blood after the first RTX protocol “4+2” at the
end of the annual follow-­up. No further maintenance therapy with
immunosuppressants was given to patients after RTX “4 + 2” proto-
col and oral prednisone was tapered to 5 mg/day by the end of the
third month after RTX.
In the cases, a response (complete with no new flare in the year of
follow-­up or presence of minor flare) was observed in 8 cases out
of 13. Four patients did not respond to the induction therapy and a
death was observed for cardiovascular causes.
When compared to the control group, no statistically significant dif-
ference was observed in terms of response to therapy (9 cases of
response-­complete with no new flare in the follow-­up year or pres-
ence of minor flare, 3 no responders, and a death for cardiovascular
causes, P = 0.56).
The IBCDT allows a significant reduction in the cumulative dose
of CYC to which each patient was exposed during the observa-
tion year, reaching statistical significance levels (cases, total dose
756 ± 358 mg/year vs 10693 ± 6614 mg/year, P < 0.001).
Calculated on a monthly basis, the “4 + 2” protocol allowed an av-
erage reduction in the CYC cumulative dose equivalent to 827 mg/
month.
Conclusion: In a selected sample of patients with AAV with renal
involvement, the IBCT regimen appeared to be non-­inferior in terms
of the efficacy when compared to CYC-­based standard regimens.
Moreover, the IBCDT regimen allowed a net reduction in the cumu-
lative average dose of CYC to which patients are exposed, quantifi-
able in approximately 1 g/month.
O-­065 | Effects of an intensive B-­cell depletion
treatment of severe systemic sclerosis
D. Roccatello; D. Rossi; S. Sciascia
CMID-­Center of Research of Rheumatology, Nephrology and Rare Diseases
Nephrology and Dialysis Unit Coordinating Center of the Rare Diseases Network
of Piedmont and Aosta Valley G. Bosco Hospital and University of Turin, Italy
Background/purpose: Systemic sclerosis (SSc) is a connective tissue
autoimmune disease with systemic involvement and a serious medi-
cal condition with a high rate of mortality, especially due to intersti-
tial lung disease (ILD). The exact pathophysiology is still unclear, but
|
      29
B cells seem to play a crucial role in the initiation and the progression
of the disorder. Therefore, the use of Rituximab (RTX) might have a
rational in the treatment of SSc.
Methods: We retrospectively collected data from SSc patients re-
sistant or intolerant to previous therapies, treated with intensified
B-­depletion therapy, between 2013 and 2016. Therapeutic pro-
tocol comprehends: RTX 375 mg/sm on days 1, 8, 15, 22, and two
more doses after one and 2 months, associated with two intrave-
nous administrations of 10 mg/kg of cyclophosphamide and three
methylprednisolone pulses (15 mg/kg) followed by oral prednisone
(0.8 mg/kg/day, rapidly tapered to 5 mg/day by the end of the 3rd
month after RTX).
Results: The study included 20 SSc patients (18 females and 2 males;
mean age 66.7 ± 11.0 years). Patients presented with severe mul-
tiorgan involvement: ILD (19/20, 95%), pulmonary hypertension
(12/20, 60%), and skin thickening (17/20, 85%). After a follow-­up
of 24 months, we observed a decrease in the levels of NT-­proBNP
(mean baseline: 385.4 ± 517, mean at 24 months: 283 ± 648, P <
0.05), and in the Modified Rodnan Skin Score (mRSS) (mean mRSS
baseline: 14.4 ± 10.5, mean after 24 months of follow-­up: 12.9 ± 10,
P < 0.05). Four out 19 (21%) patients experienced a significant im-
provement of ILD, as assessed by high-­resolution computed tomog-
raphy, while in 12/19 (63%) patients the intensified B-­cell depletion
therapy was associated with a stabilization of the imaging features
with no sign of progression. Three out of 19 (16%) patients showed
a deterioration of the ILD.
Patients showed no significant decrease in forced vital capacity
(FVC) (mean baseline FVC: 93.6 ± 19.3, mean after 24 months
of follow-­up: 92.2 ± 23.3), no significant decrease in forced ex-
piratory volume in one second (FEV1) (mean baseline FEV1:
89.5 ± 15.6, mean FEV1 at 24 months: 87 ± 21.2), no significant
decrease in diffusing capacity (DLCO) (mean baseline DLCO val-
ues: 58.8 ± 8.6, mean at 24 months: 60.3 ± 14), no significant
change in the ejection fraction (EF) (mean baseline EF values:
62.8 ± 6.4, mean EF values at 24 months: 58.6 ± 7.1) and in pulmo-
nary artery pressure (PAP) (mean baseline PAP: 30.2 ± 10.5, mean
at 24 months: 31.1 ± 11.05).
Conclusion: Our data suggest that the intensified B-­depletion ther-
apy protocol might represent a promising tool for the management
of SSc in terms of controlling the progression of the disease, espe-
cially when considering pulmonary and skin manifestations.
O-­015 | Presentation and recognition of
citrullinated epitopes implicated in RA
J. Rossjohn1,2; H. Reid1; N. L. Gruta1; A. Purcell1; C. Jones1;
Y. T. Tian1; T. J. Loh1; J. J. Lim1; D. Baker3
1
Monash University; 2Cardiff University; 3Janssen Pharmaceutical Companies of
Johnson & Johnson
Rheumatoid arthritis (RA) susceptibility is associated with the HLA-
DRB1 locus. Here, HLA-­DR molecules bearing the shared epitope (SE)
 |
30       ABSTRACTS
amino acid motif can present self-­peptides that have undergone spe-
cific citrullination, a post-­translational modification of an arginine →
citrulline residue. While we have a good molecular understanding of
the association between citrulline, the SE motif and RA, our knowledge
of the responding T cell repertoire and subsequent TCR recognition of
these citrullinated peptide-­HLA-­DR4 complexes remain unclear. This
presentation will focus on recent advances in the latter axis.
O-­084 | The diagnostic accuracy of PET/CT
compared with temporal artery biopsy for giant
cell arteritis (GCA)
A. Sammel1,2,3; E. Hsiao1; G. Schembri1,2; K. Nguyen1; B.
Janssen1; L. Schrieber1,3; P. Youssef3,4; R. Laurent1,3
1
Royal North Shore Hospital; 2Prince of Wales Hospital; 3University of Sydney;
4
Royal Prince Alfred Hospital
Background/Purpose: PET/CT vasculitis protocols have historically
focused on the aorta and major branches. Newer generation time-­
of-­flight scanners can also detect inflammation in the smaller tem-
poral (TA), occipital (OA), maxillary (MA) and vertebral arteries (VA).
We assessed the accuracy of a new PET/CT protocol compared with
temporal artery biopsy (TAB) for GCA.
Methods: 64 patients suspected of having acute GCA underwent
PET/CT from vertex to diaphragm within 72 hours of starting cor-
ticosteroids and before TAB. Two blinded PET experienced nuclear
medicine physicians independently assessed scans as globally posi-
tive or negative for GCA. They also reported if FDG tracer uptake
exceeded background blood pool for 18 artery segments and the
maximum uptake grade per patient (0 = none, 1 = minimal/equivo-
cal, 2 = moderate, 3 = very marked). Discordant results were re-
solved by consensus. The clinical diagnosis was made at 6 months
by consensus between the PET/CT blinded treating clinician and
external reviewers.
Results: TAB was performed in 58/64 patients and 12/58 (21%) were
positive for GCA. 21/64 (33%) patients had a clinical diagnosis of
GCA. Global PET/CT assessment had sensitivity (Sn) 92%, specificity
(Sp) 85%, positive predictive value (PPV) 61% and negative predic-
tive value (NPV) 98% against TAB for GCA. Interobserver reliability
was good (k = 0.65). PET/CT had Sn 71% and Sp 91% compared with
the clinical diagnosis. Defining an uptake grade cut-­off 1+ in any ves-
sel as a positive scan gave Sn 100% and Sp 46% against TAB while
a cut-­off 2+ gave Sn 83% and Sp 83%. Four (33%) TAB positive pa-
tients had grade 2+ uptake localized to the TA, OA, MA or VA arter-
ies and may have been missed on older PET/CT protocols.
Conclusion: This PET/CT protocol had high diagnostic accuracy. The
NPV of 98% would support its use as a first-­line test to rule out GCA.
O-­059 | ACPA glycosylation as biomarker in
rheumatoid arthritis
H. U. Scherer
Leiden University Medical Center
The B-­cell immune response directed against citrullinated protein
antigens is a hallmark of the majority of patients with established
rheumatoid arthritis (RA). Anti-­
c itrullinated protein antibodies
(ACPA), together with rheumatoid factors, represent the most
specific and clinically most relevant biomarker in this disease.
Notably, tolerance to citrullinated autoantigens is frequently bro-
ken prior to the onset of clinical symptoms. In fact, ACPA can
be observed in clinically healthy individuals several years be-
fore the development of disease. Hence, ACPA are considered
risk factors for the development of RA, but the time to onset of
arthritis is highly variable, and not all ACPA-­p ositive individuals
will eventually progress to RA. Given that targeted therapeu-
tic intervention in early arthritis increases the chance to reach
drug-­free sustained remission, a proxy for cure, it is of clinical
relevance to identify those individuals ‘at-­r isk’ for the transition
from ACPA-­p ositivity to ACPA-­p ositive disease. Recent evidence
on HLA-­a ssociations and the pre-­d isease expansion of the ACPA-­
response suggests that this transition is under the control of T
cells that presumably provide help to ACPA-­e xpressing B cells. In
this context, it is intriguing that ACPA of the IgG isotype in estab-
lished RA are heavily glycosylated in the variable (V-­) domain. In
fact, ACPA harbor so-­c alled N-­g lycosylation sites in the B cell re-
ceptor V-­d omain which they acquire through somatic hypermuta-
tion, a T cell dependent process. Therefore, we hypothesized that
the glycosylation of the ACPA-­IgG V-­d omain could be indicative
of T cell help and, consequently, low or absent in the pre-­d isease
at-­r isk phase of RA. Indeed, it appears that the glycosylation of
ACPA-­IgG is remarkably low in the phase of pre-­d isease autoim-
munity, and that a high degree of V-­d omain glycosylation strongly
predicts the transition to ACPA-­p ositive disease. Hence, the gly-
cosylation of the ACPA-­I gG V-­d omain can be seen as a surrogate
marker for T cell help to ACPA-­e xpressing B cells, which presum-
ably drives the development of RA. Eventually, these observa-
tions can improve risk assessment of future RA development in
ABSTRACTS
ACPA-­p ositive individuals and guide optimal preventive, thera-
peutic interventions.
O-­0 07 | The emotional experience of patients
with systemic lupus erythematosus-­related body
image disorder in China: a qualitative study
B. Shen1; S. Chen2; H. Chen2
1 2
The Second Affiliated Hospital of Nantong University; Nantong University
Objective: Systemic lupus erythematosus (SLE) is a chronic inflam-
matory autoimmune disease that can be disfiguring, disabling, and
debilitating. Little is yet known about the emotional experience of
patients with SLE-­related Body Image Disorder (BID) in China. This
study aims to describe the experiences and perspectives of Chinese
patients living with SLE related body image disorder.
Methods: Seventeen female participants who have BID with SLE
took part in semi-­structured interviews. Their ages ranged from 22
to 31 years and disease duration ranged from 1 to 7 years. Interviews
were audio recorded and transcribed verbatim. Data were analysed
using interpretative phenomenological analysis.
Results: Analysis revealed four themes that are presented set
within the overarching concept: Self-­
e steem reduced, involves
lack of charm, loss of function and weakness. Increased anxi-
ety and depression which reduces the patients’ quality of life;
Concerns about long-­term use of medication, side effects like get-
ting fat and alopecia are most commonly mentioned; the fear of
amphoteric intimacy.
Conclusions: Body image is very important for SLE patients, medi-
cal staff should be early intervention in patients with SLE-­related
BID, concerning their emotional experiences. Formulating indi-
vidualized care measures for the patients to help them understand
themselves correctly and establish correct body image cognition,
thus enhancing confidence, relieving patient's psychological pres-
sure and pain. Carrying out quality care services, including health
education, regular follow-­up, the development of pediatric manuals
and online establishment of medical care exchange group, to pro-
mote the transformation of the biomedical model to the biological-­
psychological social model.
Keywords: SLE, body image disorder, emotional experience, qualita-
tive study
O-­044 | New advances for the treatment of
glucocorticoid induced osteoporosis
Y.-K. Sung
Hanyang University Hospital for Rheumatic Diseases
Glucocorticoids (GCs) are very effective drugs for the treatment of
inflammatory diseases and have been widely used in various rheu-
matic diseases. However, long-­
term use of GCs has detrimental
|
      31
effects on bone microstructure, leading to a decrease in bone mass
and an increase in the risk of fracture. As evidence of fracture risk in
patients using GCs accumulates, drugs that effectively prevent frac-
tures have been developed. However, many primary care physicians
and specialists fail to recognize the severity of GIOP or determine
which patients are at greatest risk for GIOP. Therefore, many pa-
tients still do not receive treatment to prevent fractures. To address
this problem, guidelines for GIOP prevention and treatment have
recently been developed by several countries. Notably, the guide-
lines of the American College of Rheumatology (ACR) were revised
in 2017 based on the latest evidence and applied to clinical practice.
In Korea, a GIOP prevention and treatment guideline was developed
by adapting these previously-­published guidelines. This presenta-
tion will provide an updates on the CPGs developed in each country
or academic societies, and the key issues in the risk assessment, and
highlight recent data on SERMs, denosumab, and teriparitide in ad-
dition to bisphosphonate.
O-­074 | IgA nephropathy in a female patient
with spondyloarthropathy masquerading as
poncets disease (or extrapulmonary TB): a case
study
A. K. Surin; B. Panda; N. Mohapatro
Apollo Hospitals
Background: Nephropathy in female spondyloarthropathy patients
is more often due to nonsteroidal anti-­inflammatory drugs and IgA
nephropathy is a rare entity.
Methods: Case report.
Results: We report a case of 42-­year-­old female with acute pres-
entation of inflammatory oligoarthritis, bilateral lower limb edema
along with acute fever and vomiting. Her past history revealed a
case of left knee synovitis, where synovial fluid aspirate was con-
firmed to be erosive knee tuberculosis and treated with 6 months
anti-­t ubercular treatment. She was initially treated for acute kid-
ney injury (creatinine, 2.57 mg/dL; serum urea, 93 mg/dL). Once
the fever subsided with antibiotics, her pelvis X-­r ay showed grade
II bilateral sacroiliitis with prominent sclerosis, and positive PCR-­
based HLA B27. The serological investigations including P-­A NCA,
C-­
A NCA, and A-­
CCP ranges were negative. Thus, the prelimi-
nary existence of spondyloarthropathy with axial and non-­a xial
involvement was confirmed. The left knee with active synovitis
was administered an intra-­articular corticosteroid injection help-
ing to reduce the swelling and pain. The persistent features of
lower limb edema, elevated creatinine, proteinuria and hematuria
suspiciously instigated us for planning a percutaneous renal bi-
opsy. Light microscopy showed 6 glomeruli with sclerosis, 2 with
partially sclerosed tufts, 7 with fibrocellular crescents. Tubules
show patchy atrophy and interstitial fibrosis. Immunofluorescence
examination showed (Figure 1) a predominantly deposition of
 |
32       ABSTRACTS
mesangial granular IgA, while being negative for IgG, IgM. The
histological and immunofluorescence analysis confirmed the di-
agnosis of glomerulonephritis of IgA nephropathy origin. She was
effectively and conservatively managed with a precise modulation
of low dose corticosteroid followed by pulsed methylpredniso-
lone and subsequent intravenous cyclophosphamide, with a stable
prognosis.
Conclusion: This unusual renal involvement in HLA B27 positive
rheumatological cases needs to be addressed and implicated in a dif-
ferent approach from other known causes of nephropathy even if
the mildest suspicion may prompt thorough investigation to deline-
ate this uncommon association.
Figure 1 Mesangial granular deposition of IgA (Immunofluorescence
× 400)
O-­075 | Treating spondyloarthritis to target –
are we ready?
L.-S. Tam
The Chinese University of Hong Kong
Treat-­to-­target (T2T) is an emerging treatment paradigm in axial
spondyloarthritis (axSpA), originally based on evidence from other
inflammatory conditions, which aims to direct therapy to a clear
target such as disease remission or low disease activity, with the
ultimate goal of maximizing quality of life in affected individuals.
Controversy remains as to what this target should be, especially for
patients with axSpA. Another important consideration when dis-
cussing the T2T paradigm is when to intervene. Although evidence is
limited in this respect, the available data suggest that therapy should
be commenced at an early stage of the disease, when the process of
bone repair expected to occur after an inflammatory phase has not
yet started. On the other hand, for patients with psoriatic arthritis
(PsA), remission is an achievable goal as a result of the advancement
in therapeutic options. There is strong and consistent evidence that
a T2T approach to PsA management results in better patient out-
comes; however, the practicalities of incorporating this strategy into
routine clinical practice remain a challenge. The heterogeneous na-
ture of this condition and the need for validated outcome measures
have to-­date hampered consensus on a definition of remission. In
this talk, we will discuss whether rheumatologists can apply the T2T
concept in the management of patients with SpA as routine manage-
ment in the clinic.
O-­082 | Novel agents in SLE
Y. Tanaka
The First Department of Internal Medicine, University of Occupational and
Environmental Health, Japan
Systemic lupus erythematosus (SLE) is a representative autoimmune
disease characterized by multiple organ manifestations, and patho-
logically characterized by activation of autoreactive T cells and over-
production of autoantibodies by B cells. However, SLE is molecularly,
genetically and clinically heterogeneous which makes difficult to
manage every case based on one kinetic molecular theory.
Although corticosteroids and immunosuppressants are widely used
for the treatment, innovative approaches using biologics targeting
molecules involved in the pathogenesis of SLE need to be developed.
B-­cell targeted biologics have a potential for the treatment of SLE.
An anti-­CD20 antibody rituximab is known to beneficial in some pa-
tients with refractory SLE, but phase III clinical studies did not dem-
onstrate the superiority of rituximab over placebo. Recent GWASs
have shown that multiple genetic loci play roles in the pathogenesis
of SLE and many of the risk alleles are related to innate immunity
as well as acquired immunity. The activation, class switch and dif-
ferentiation of B cells and T cells are regulated by dendritic cells via
cytokines and cognate interactions. For instance, Soluble BAFF, IFN
and IL-­12 are secreted by dendritic cells and regulate B cell activation
and differentiation. Actually, an anti-­BAFF antibody belimumab was
the first approved biologic for SLE because of moderate efficacy and
good tolerability. Meanwhile, IFN-­stimulated genes, IFN signatures,
are upregulated most notably in SLE and a phase IIb clinical trial of
anifrolumab, an anti-­IFN-­alpha receptor antibody met the primary
endpoint SLE patients with high IFN gene signatures at base line.
Also, an anti-­IL-­12/IL-­23 (p40) antibody ustekinumab was signifi-
cantly effective in treatment of SLE, compared to placeb in a phase
IIb trial.
Furthermore, baricitinib, an orally available inhibitor of JAK1/2,
which is involved in signaling via IFN and IL-­12, significantly im-
proved the signs and symptoms of active SLE despite standard of
care with a safety profile. Thus, targeting interaction between innate
immunity and acquired auto-­immunity may be more beneficial that
targeting T and B cells directly. In addition, because SLE is molecu-
larly and clinically heterogeneous, precision medicine via the strate-
gic selection of different biologics based on different clinical and/or
molecular characteristics in each individual could be warranted for
the treatment of SLE.
ABSTRACTS
O-­016 | Antigen-­specific immunotherapy for
autoimmune rheumatic diseases
R. Thomas
University of Queensland
Disease modifying strategies are available for treatment of rheu-
matoid arthritis (RA), and good response rates are achieved.
However, limitations include toxicity, including infectious com-
plications in developing countries, a response rate ceiling, cost
and rationing of biologic therapies, inability to cure or perma-
nently reverse RA pathology, and inability to prevent disease.
Immunotherapies targeting checkpoint molecules are markedly
changing the landscape of clinical oncology. In autoimmune dis-
eases such as RA, dendritic cells represent an important target
for antigen-­s pecific immunotherapy for T cell tolerance. Antigen-­
specific strategies promise greater specificity and safety, without
general immune suppression, and thus the potential for inter-
vention in at-­risk subjects before disease onset. In a proof-­of-­
concept trial, delivery of autoantigenic peptides and autologous
tolerogenic dendritic cells was safe and had immunomodulatory
effects on T cells including reduction of effector T cells and a
relative increase in regulatory T cells. We have developed and are
trialling in RA patients, antigen-­s pecific immunotherapy target-
ing dendritic cells in situ with liposomes encapsulating autoan-
tigenic peptide and calcitriol with the aim of antigen-­s pecific T
cell tolerance. I will discuss the development and future potential
of antigen-­s pecific tolerance strategies and the development of
immune monitoring in clinical trials in RA and other autoimmune
rheumatic diseases.
|
      33
O-­017 | The interplay between citrullination
of self-­epitopes and HLA polymorphism that
shape peptide HLA binding affinity in rheumatoid
arthritis
Y. T. Ting1; J. Petersen1; S. Ramarathinam1; S. W. Scally1; K.
L. Loh1; R. Thomas2; A. Suri3; D. G. Baker3; A. W. Purcell1; H.
H. Reid1; J. Rossjohn1,4
1
Monash University; 2The University of Queensland Diamantina Institute;
3
Janssen Research and Development; 4Cardiff University School of Medicine
Background/purpose: A characteristic for Rheumatoid Arthritis
(RA) is the presence of anti-­citrullinated protein antibodies (ACPA)
in sera. Approximately 70% of all patients are seropositive. One of
the key inherited risk factors that contribute to ACPA positive RA is
the human leukocyte antigen class II, namely HLA-DRB1. The HLA-
DRB1 locus is strongly associated with RA susceptibility, where-
upon citrullinated self-­epitopes bind to HLA-­DR molecules bearing
the shared epitope (SE) motif, a conserved amino acid sequence
QKRAA, QRRAA, or RRRAA in position 70–74 of the β-­chain.
However, the differing propensity for citrullinated/non-­citrullinated
self-­epitopes to bind given HLA-­DR allomorphs remains unclear.
Objectives: To identify potential immunodominant self-­
epitopes
that could be presented by HLA-­DRB1 to provoke RA
Methods: We used a fluorescence polarisation assay to determine a hi-
erarchy of binding affinities of 34 self-­epitopes implicated in RA against
three HLA-­
DRB1 allomorphs (HLA-­
DRB1*04:01/*04:04/*04:05)
each possessing the SE motif. The extent to which the HLA poly-
morphisms contribute to the natural selection of peptides and /or
preferential binding of self-­epitopes was further established through
peptide elution studies and protein crystal structures of citrullinated
epitopes bound to the three DR4 allomorphs.
Results: A strong correlation between binding affinity and cit-
rullination of the bound peptide ligand was found compared to
non-­citrullinated peptides. Structure determination of eight HLA-­
DR4-­
self-­
epitope complexes revealed strict conformational con-
vergence of the citrulline and the surrounding SE motif. However,
a differing hierarchy of peptide-­binding affinities across the three
 |
34       ABSTRACTS
HLA-­
DRB1 allomorphs was attributable to the β-­chain polymor-
phisms that resided outside the SE motif and were consistent with
sequences of naturally presented peptide ligands.
Conclusion: Differences in the stereo-­chemical properties of the
peptide-­binding pockets, outside the SE motif (P4-­peptide bind-
ing pocket), of the HLA-­DR molecules, provided a structural basis
for the preferential binding of the citrullinated self-­epitope to the
HLA-­DR4 allomorphs.
O-­079 | Outcome of stroke in patients with
systemic lupus erythematosus: a nested case-­
control study
C. C. Mok; L.-K. Tsoi; Y.-P. Fu
Tuen Mun Hospital
Objectives: To evaluate the outcome of stroke in patients with sys-
temic lupus erythematosus (SLE) in comparison with age and gender
matched non-­SLE patients.
Methods: Patients who fulfilled ≥4 SLICC/ACR criteria for SLE and
had a history of cerebrovascular accident (stroke) were retrieved
from our SLE cohort database. The outcome of stroke in these pa-
tients was evaluated retrospectively and compared with a group of
randomly selected age and gender matched non-­SLE patients (in a
1:3 ratio) admitted to our stroke unit within the same time period.
The type and pattern of stroke, atherosclerotic risk factors (hyper-
tension, smoking, diabetes mellitus, dyslipidemia, atrial fibrillation,
valvular lesions) and previous history of stroke were compared be-
tween the two groups of patients. The primary outcome of inter-
est was the 90-­day functional outcome as assessed by the modified
Rankin scale (mRS) (score 0–2 = functional independence; score
3–6 = functional dependence). Secondary outcomes included all-­
cause mortality, 30-­
day stroke mortality, stroke recurrence and
stroke complications. Factors independently associated with a poor
functional outcome (mRS 3-­6) was studied by logistic regression.
Survival analysis was performed by Kaplan-­Meier's plot and com-
parison was made by the log rank test.
Results: A total of 40 SLE patients (age 53.7 ± 11.5, 87.5% women)
with stroke were identified from our database (stroke prevalence
0.39/100 patient-­year). A control group of 120 non-­SLE patients
(age 52.8 ± 14.8, 87.5% women) with stroke were randomly se-
lected from our stroke unit database. All were ethnic Chinese. The
prevalence of atherosclerotic risk factors was similar between the
two groups, except SLE patients had a higher atherogenic index (Log
serum [triglyceride/HDL-­cholesterol] (1.51 ± 0.47 vs 1.32 ± 0.31;
P = 0.005.) In SLE patients, the median time to stroke since diag-
nosis was 24 months. Ischemic stroke was more common in SLE
than non-­SLE patients (90% vs 63%; P = 0.001). Among patients
with ischemic stroke, SLE patients had more extensive infarction
(defined as diffuse white matter lesions, multiple infarcts involv-
ing >1 major vascular territory or one single major vessel >50% in-
volvement) than controls on CAT scan (69.4% vs 28%; P < 0.001).
The 90-­day mRS score was significantly higher in SLE patients than
controls (1.70 ± 1.97 vs 0.88 ± 1.36; P = 0.004). Significantly more
SLE patients had functional dependence (mRS score 3-­6) at 90 days
post-­s troke than controls (32.5 vs 8.3 %; P < 0.001; unadjusted OR
14.2). Logistic regression showed that SLE was an independent risk
factor for a poor stroke outcome after adjustment for age, sex, his-
tory of stroke, various atherosclerotic risk factors and the type of
stroke (ischemic vs hemorrhagic) (OR 10.1 [2.7–38.0]; P = 0.001).
Subgroup analysis of patients with ischemic stroke showed that
SLE was also independently associated with a poorer functional
outcome after adjustment for the same confounding covariates
and the extent of stroke (solitary vs multiple infarcts) (OR 14.0
[2.0–96.2]; P = 0.007). There was no significant difference in the
30-­day stroke mortality between SLE and non-­SLE patients (5% vs
2.5%; P = 0.43). However, SLE patients had a higher incidence of
post-­s troke epilepsy than controls (22.5% vs 3.3%; P = 0.001). Upon
a mean follow-­up time of 7.5 ± 5.2 years, SLE patients had a lower
stroke recurrence free survival (59.5% vs 85.7%; P < 0.001) and a
higher rate of all-­c ause mortality (34.6% vs 15.1%; P < 0.001). Cox
regression analysis showed that SLE was an independent risk factor
for all-­c ause mortality (HR 10.7 (3.5–32.7); P < 0.001) adjusting for
age, sex, atherosclerotic risk factors and previous stroke.
Conclusion: Stroke in SLE patients is more likely to be ischemic in
origin and more extensive than matched controls. Short-­term func-
tional outcome of stroke is poorer in SLE patients. Over 7.5 years,
stroke recurrence, post-­stroke epilepsy and all-­cause mortality is
significantly more frequent in SLE than non-­SLE patients.
O-­060 | Impact of anti-­citrullinated protein
antibody on response to abatacept and tnfi in
patients with rheumatoid arthritis in the OPAL
dataset
K. Tymms1,2; B. Butcher3,4; T. Smith2; S. Louis5; G.
Littlejohn2,6
1
Canberra Rheumatology; 2OPAL Rheumatology Ltd; 3WriteSource Medical
Pty Ltd; 4University of New South Wales; 5Bristol-­Myers Squibb; 6Monash
Rheumatology
Background: Patients with rheumatoid arthritis (RA) who are posi-
tive for anti-­citrullinated protein antibody (ACPA) have a poor prog-
nosis compared to those who are ACPA negative.
Objectives: The aim of this study was to assess whether ACPA status
impacts the treatment response of abatacept and tumour necrosis
factor inhibitors (TNFi) in patients with RA from Australia.
Methods: Patients with RA in the Optimising Patient outcomes in
Australian rheumatoLogy (OPAL) dataset who commenced treat-
ment with abatacept or TNFi between 1 August 2006 and 30 June
2017 with 12-­months of follow up were included in the study. The
primary outcome was change in clinical disease activity index score
(CDAI) from baseline to 12 ± 3 months.
Results: 2052 patients were included in the study (637 abatacept
initiators; 1415 TNFi initiators). Patients were predominantly female
ABSTRACTS |
      35

Table 1 Baseline patient characteristics and Primary Outcome by anti-­citrullinated protein antibody serostatus in response to abatacept or
TNF inhibitor treatment.
Abatacept initiators (n = 637) TNFi initiators (n = 1415)

Outcome ACPA + (n = 445) ACPA − (n = 192) P-­value ACPA + (n = 1053) ACPA − (n = 362) P-­value

Patient age, mean (SD) 60.8 (12.5) 61.6 (12.6) n/s 58.8 (14.2) 57.5 (14.1) n/s
Female, % 78.4% 84.4% n/s 77.7% 74.3% n/s
Disease duration, months (SD) 141.1 (124.8) 105.6 (98.4) 0.008 123.6 (115.0) 90.2 (102.4) <0.001
Line of therapy
 1 41.9% 45.2% n/s 94.3% 91.9% n/s
 2 29.3% 33.0% 5.4% 6.7%
 3+ 28.8% 21.8% 0.3% 1.4%
Baseline CDAI
 Remission 8.6% 3.0% n/s 4.9% 2.9% n/s
 Low 15.2% 11.9% 7.9% 8.6%
 Moderate 25.4% 37.3% 14.4% 13.3%
 High 50.8% 47.8% 72.8% 75.2%
ΔCDAI score*, mean(SD) −19.1 (19.3) −10.8 (20.6) 0.011 −27.6 (20.0) −28.6 (17.7) 0.73

*Primary outcome was measured as a change from baseline to 12 ± 3 months. n/s = not significant, SD = standard deviation, CDAI = clinical
disease activity index

aged between 55 and 74 years. Disease duration was significantly immunosuppression remains uncertain. This study aims to exam-
longer in ACPA positive patients in both groups compared to ACPA ine characteristics and risk factors of patients on immunosup-
negative patients (Table 1). TNFi were predominately prescribed pression for systemic rheumatic diseases in a tertiary referral
first line in >90% of patients, whereas abatacept was prescribed centre.
in later lines. Severity of disease activity measured by CDAI was Methods: Records from 2011 to 2015 were reviewed via rheuma-
higher in the TNFi group than abatacept group at baseline; however, tology database (Audit 4) to obtain patient information including
no differences were observed within groups. After 12 ± 3 months rheumatologic diagnoses, comorbidities and immunosuppressive
of treatment disease activity measured by CDAI improved signifi- therapies. Positive PJP PCR results were obtained via local pathol-
cantly in patients treated with TNFi and abatacept; however, ACPA ogy database (AusLab) and cross-­referenced with the Audit 4 data.
seropositivity was associated with a greater response to treatment Patient charts were reviewed to confirm clinical diagnoses of PJP
with abatacept compared to the ACPA negative group (P = 0.011), and their subsequent management.
while no difference in response was observed between the ACPA Results: Over the 5-­year period, we identified nine PJP cases among
positive and ACPA negative groups treated with TNFi (P = 0.73; 1,092 patients with rheumatic conditions. Their rheumatologic
Table 1).
Conclusion: Baseline ACPA seropositivity was associated with a bet-
Table 1 Patients with PJP and treatment characteristics
ter clinical response to abatacept, which is consistent with previous
Patient
reports. No relationship was detected between ACPA serostatus
No. Diagnosis Corticosteroids sDMARD bDMARD
and response to TNFi in this study.
1 RA -­ MTX +  Adalimumab
LEF
2 RA Yes MTX Rituximab
O-­031 | Pneumocystis Jiroveci pneumonia is 3 RA Yes MTX +  -­
associated with rituximab and gastroeosophageal LEF
reflux disease in rheumatic disease cohort: a 4 Polymyositis Yes CSA Rituximab

retrospective study 5 Myositis/ Yes -­ -­

ILD
X. J. Wang; R. Norton; M. Soden
6 GPA -­ -­ Rituximab
The Townsville Hospital
7 SLE -­ HCQ Rituximab
8 OA -­ MTX -­
Background: The indication for prophylaxis against Pneumocystis
9 IgG4-­related Yes AZA -­
jiroveci pneumonia (PJP) in patients with rheumatic diseases on
Disease
 |
36       ABSTRACTS
diagnoses and therapies are listed in Table One. 69 patients were
on rituximab in our cohort. Four of the nine patients with PJP were
on rituximab. The odds ratio (OR) for PJP on rituximab to was 12.52
(95% CI: 3.29, 47.78). Methotrexate or corticosteroids did not ap-
pear to be associated with an increased risk of PJP. 334 patients
had gastroeosophageal reflux disease (GORD) in our cohort. Seven
of the nine patients with PJP had GORD. The OR of PJP in the pres-
ence of GORD was 8.09 (95% CI: 1.67, 39.16). Among patients with
PJP, two had interstitial lung disease (ILD), one had type 2 diabetes
mellitus, and six were lymphopenic. However, lymphopenia, ILD or
diabetes mellitus did not appear to be associated with an increased
risk of PJP.
Conclusion: PJP is a rare complication in patients on immunosup-
pression for rheumatic diseases. Rituximab appears to be associ-
ated with an increased risk of PJP. The association between PJP and
GORD requires further investigation.
O-­080 | The clinical features and genetical
pattern of primary Sjogren's syndrome in Asia
X. Wang
The First Affiliated Hospital of Wenzhou Medical University
Background/Purpose: Primary Sjögren's syndrome (pSS) is a chronic
inflammatory autoimmune disorder with broad spectrum of clinical
presentations and widely varied prevalence of pSS, which might due
to disease heterogeneity or ethnic diversity.
Objectives: To investigate the typical clinical characteristics and ge-
netical pattern of pSS in Asia, in order to enhance our understanding
of the mechanisms underlying the progression of the disease and to
discover potential biomarkers for the diagnosis or progonosis.
Methods: 534 pSS patients were included in a cross-­
sectional
study. Clinical, immunological and histological characteristics were
surveyed, and potential risk factors of disease outcomes, includ-
ing EULAR SS disease activity index (ESSDAI) and major organ in-
volvement, were examined by multivariate analysis. Logistic models
were used for outcomes prediction. The gene expression patterns in
minor salivary glands applied RNA sequencing between pSS patients
and non-­pSS controls was investigated.
Results: Different organ involvements in pSS were found to be as-
sociated with various potential risk factors. ESSDAI together with
older age, and abnormal immunity are predictors for pSS disease
prognosis. Gene-­expression changes in pSS revealed immunological
overactivation, especially with enhanced the formation of the im-
munological synapse. Differentially expressed genes (DEGs) have
good discriminatory power in identifying patients with pSS with area
under the curve of 0.92 (95% confidence interval: 0.77–1) using re-
ceiver operating characteristic curve analysis.
Conclusion: Clinal manifestation, genomic variations and gene ex-
pression differences studies of pSS in Asia not only have well ex-
plained the mechanism underlying the progression of the disease but
provide potential biomarkers for disease diagnosis and prognosis, all
of which would ultimately highlight the promising target for disease
treatment.
O-­018 | Clinical uses of synovial biopsies in
inflammatory arthritis
M. Wechalekar
1
Flinders Medical Centre; 2Flinders University
The synovium is the soft tissue lining diarthrodial joints and the pri-
mary target for several of the inflammatory arthritides, which are
characterised by hyperplasia of the lining layer, influx of inflamma-
tory cells, macrophage recruitment and change in number and be-
haviour of lining fibroblasts. Understanding synovial pathology has
been pivotal in providing insights into pathogenetic mechanisms of
disease and drug therapeutics. Synovial biopsy also has diagnostic
value in the evaluation of granulomatous disease, infection or neo-
plasia, particularly when synovial fluid is non-­contributory. Synovial
biopsy has had an enormous impact as a research tool for proof-­of-­
concept studies and identification of new and validation of existing
therapeutic targets. The heterogeneity of synovial tissue within a
particular disease, both at baseline and following treatment, also
makes it particularly relevant from the viewpoint of personalised
medicine; this heterogeneity is reflected in recent discoveries of
unique cellular subsets and an understanding of reasons for a ther-
apeutic response, or lack thereof. Indeed, the recent explosion of
research techniques including whole-­tissue and single cell RNA se-
quencing has led to hitherto unknown pathogenetic and therapeutic
insights. These findings not only provide potential explanations for
the variable response to conventional and biologic therapy, but also
pave a way towards targeted therapy, directed by synovial biopsy,
that holds the potential to optimise response and improve disease
outcomes. Furthermore, synovial biopsy in the pre-­clinical inflam-
matory arthritides holds the promise of antigen-­detection and iden-
tification of individual-­specific immune repertoire and thus possibly
disease interception prior to clinical presentation.
O-­070 | Treatment advances in axial
spondyloarthritis
J. Wei
Chung Shan Medical University
Spondyloarthritis (SpA) is a spectrum of disease including ankylos-
ing spondylitis (AS), reactive arthritis, psoriatic arthritis and entero-
pathic arthropathy. For diagnosis of AS, modified New York criteria
is still the gold standard. In year 2009 and 2011, new criteria for axial
and peripheral SpA were published, highlighting the importance of
clinical features, HLA-­B27 and MRI images. New axial and peripheral
SpA criteria may improve patient care.
ABSTRACTS
There are many advances in the treatment of axial spondyloarthritis
in recent years:
• Early diagnosis and treatment improves patient outcomes and
treatment response, esp. in patients with high risk non-radio-
graphic axial SpA.
• Physical exercise, pain control and psychosocial support are im-
portant to improve patient-reported outcomes
• NSAIDs and coxibs are the cornerstone of the pharmacological
therapy. Daily COX-2 inhibitors are recommended for syndesmo-
phyte positive patients with persistent high CRP.
• Sulfasalazine, a traditional disease-modifying anti-rheumatic drug
might benefit patients with peripheral arthritis, psoriasis, inflam-
matory bowel diseases or uveitis.
• TNF blockers should be considered in NSAID-failed axial SpA or
sulfasalazine-failed peripheral SpA patients. TNF monoclonal an-
tibodies are also helpful for SpA patients with uveitis, psoriasis or
inflammatory bowel diseases (IBD)
• IL17A monoclonal antibodies had comparable efficacy to TNFi.
However, IL17i might harm IBD.
• Switch between or within biological classes are also effective.
• IL23 inhibition by anti-p19 or p40 failed in axial SpA clinical trials
• JAK inhibitors is promising in phase II clinical trials.
O-­067 | Scleroderma and lung disease
H. Wisbey
Prince Charles Hospital
In scleroderma, the lung presents an intriguing interface between
the host, environment and immune system. Scleroderma has the
highest mortality amongst the autoimmune diseases with the lung
contributing to at least 60% of the death rate. This is solely due
to the 2 main entities encountered in clinical practice—Pulmonary
Arterial Hypertension (PAH) and Interstitial Lung Disease (ILD).
These two dread conditions have provoked therapeutic nihilism
for many years but recent publications are providing some limited
optimism.
In PAH, early screening and combination vasodilator therapies are
improving survival and quality of life. Refinements to algorithms in-
cluding biomarkers (N-­terminal pro-­brain natriuretic peptide—BNP)
are being assessed to further enhance early detection, as vascular
remodelling can occur years prior to disease presentation and be a
potential therapeutic target.
In ILD, Cyclophosphamide is being challenged as the only evi-
dence based treatment. Mycophenolate mofetil (MMF) has been
reported to show equivalent benefit with less toxicity and is now
the preferred agent for many clinicians. The faSScinate study also
has reported benefit with tocilizumab, possibly contributed to by
an antifibrotic effect with this agent. Treatment effects from all
these agents are modest however and ongoing trials with rituxi-
mab, specific antifibrotic agents, combination therapy and Human
|
      37
Stem Cell Transplantation (HSCT) are all underway. HSCT has now
been recommended for rapidly progressive scleroderma and may
play a specific role in poor prognosis early lung fibrosis. Decisions
regarding when to intervene largely depend on the extent and
pace of disease.
Despite these advances, major challenges remain for our patients
including treatment toxicity and scleroderma related comorbidities,
that preclude them being considered for heart/lung transplantation.
Some local cases will be included in this presentation to scaffold the
discussion and highlight these challenges.
O-­054 | Vaccination of patients with
autoimmune inflammatory rheumatic diseases
P. Wong1,2
1
Mid-­North Coast Arthritis Clinic; 2UNSW Rural Clinical School
Autoimmune inflammatory rheumatic diseases (AIIRD) such as
rheumatoid arthritis, psoriatic arthritis and spondyloarthritis are
associated with an increased risk of infection due to the immuno-
suppressive effects of the AIIRD, comorbidities and the immuno-
suppressive effect of conventional synthetic disease-­
modifying
anti-­rheumatic drugs (DMARDs), targeted synthetic (ts-­) DMARDs
and biologic (b-­) DMARDs. While many infections are preventable
with vaccination, vaccination is often not considered by those in-
volved in the care of AIIRD patients.
As the protective immune responses induced by vaccination may be
impaired by immunosuppression, vaccination should be considered
prior to commencement of immunosuppression. The other oppor-
tune time to review vaccination status is when planning overseas
travel, as destination-­specific vaccines are often required. While
limited data regarding vaccine efficacy in AIIRD patients makes pre-
scriptive guidelines difficult, a vaccination history should be part of
the initial work-­up in all AIIRD patients. It is hoped this talk will en-
courage those caring for AIIRD patients, especially Rheumatologists,
to regularly review vaccination status in their patients and pro-
vide appropriate advice to patients and general practitioners re
vaccination.
O-­036 | Predicting allopurinol maintenance
doses
D. Wright1; N. Dalbeth2; T. Merriman3; M. Barclay4; L.
Stamp5
1
School of Pharmacy, University of Otago; 2Department of Medicine, University
of Auckland; 3Department of Biochemistry, University of Otago; 4Department of
Medicine, University of Otago; 5Department of Medicine, University of Otago
Maintenance doses of allopurinol are commonly restricted for
patients with renal impairment based on estimated creatinine-­
clearance (CLcr). The basis for this practice is concern that
 |
38       ABSTRACTS
oxypurinol, the active metabolite of allopurinol, will accumulate in
patients with poor renal function and increase the risk of allopu-
rinol hypersensitivity syndrome (AHS), a rare and life-­t hreatening
adverse reaction. However, the evidence to support a relation-
ship between oxypurinol accumulation and AHS is not convinc-
ing. Furthermore, adherence to a CLcr-­b ased dosing guideline in
clinical practice results in an inadequate urate-­lowering response
and treatment failure. Recent evidence suggests that doses rang-
ing from 100 to 900 mg daily will be required to achieve the serum
urate target of <0.36 mmol/L, regardless of renal function. In this
presentation, we will explore the factors that determine allopuri-
nol maintenance dose requirements. We will show that allopurinol
doses are predicted primarily by body weight, diuretic use, and
ethnicity, while renal function has only a modest impact on dose-­
response. Genetic differences in urate transporters were found
to have only a small influence on allopurinol urate-­lowering effect
and are not expected to significantly alter maintenance dose re-
quirements. We will propose a revised dosing guideline to achieve
a serum urate target <0.36 mmol/L based on simulations from our
predictive model.
O-­049 | Global, regional, and national burden
of psoriatic disease estimates from the global
burden of disease 2016 study
1 2 1
D. Wu ; C. Guo ; P. Wong ; L.-S. Tam 1 controlled clinical trials, but rather on ideas from case reports, case
1
Department of Medicine & Therapeutics, The Prince of Wales Hospital, The
Chinese University of Hong Kong; 2Jockey Club School of Public Health and
Primary Care, The Chinese University of Hong Kong
Background: The last quarter century witnessed significant popula-
tion growth, aging, epidemiologic changes.
Objective: To investigate the distribution and change in burden of
psoriatic disease from the Global Burden of Disease Study 2016
(GBD 2016).
Materials and methods: Based on GBD 2016, decomposition anal-
yses were performed according to gender, age, sociodemographic
index (SDI), geography. The number and age standardized rate of
incidence, prevalence and disability adjusted life years (DALYs) with
95% uncertainty intervals (UI) were calculated.
Results: In 2016, female patients have a slightly higher all-­age num-
ber of incidence (2.10%) prevalence (3.81%) and DALYs (2.78%) than
male patients. Among 20 age groups, age 25–29, 30–34, 25–29
group has highest all-­age number of incidence, prevalence, DALYs,
respectively. The highest all-­age number and age-­standardized rate
of incidence, prevalence, and DALYs, were middle SDI region and
high SDI region in 5 SDI region, South Asia and Western Europe in
21 GBD regions, China and Norway in 195 countries and territories,
respectively. Globally, 1990–2016, the all-­age number of incidence,
prevalence, DALYs markedly increased by 66.0%, 70.6%, 69.9%
to 8,169,975 (95% UI 7,860,855–8,478,432), 65,134,951 (95% UI
62,708,355-­67,811,694), 5, 643,427 (95% UI 4,039,734-­7,377,162).
The age standardized rate of incidence, prevalence, DALYs slightly
increased by 11.21%, 9.48%, 9.80% to 110.36 (95% UI 106.16-­
114.45), 885.70 (853.63-­921.73), 76.56 (54.91-­100.05). The greatest
increase in all-­age number and age-­standardized rate of incidence,
prevalence, and DALYs were low SDI region and middle SDI re-
gion in 5 SDI region, Eastern Sub-­Saharan Africa and East Asia in
21 GBD regions, United Arab Emirates and Oman in 195 countries
and territories, respectively. The rankings of all-­age number and age-­
standardized rate of DALYs due to psoriatic disease in 309 diseases
increased from rank 146th and 142th in 1990 to 123th and 124th
in 2016.
Conclusion: The global burden of psoriatic disease is steadily in-
creased and varied substantially by level of development and
geography.
O-­020 | Treatment of adult onset Still's disease
D. H. Yoo
Hanyang University
Adult onset Still's disease (AOSD) is a systemic inflammatory dis-
order of unknown etiology, and approximately 60–70% of patients
may develop a chronic polyphasic form of the disease or a chronic
polyarthritis.
Due to the rarity of disease, treatment of AOSD is not based on
series, and extrapolation from experiences in patients with sJIA
and autoinflammatory diseases. Conventional treatment consists of
NSAIDs, corticosteroids, csDMARDs, and IVIG. Among them, cor-
ticosteroid is the cornerstone of treatment, and the most common
csDMARDs are methotrexate and cyclosporine. Recent progress in
our knowledge of pathogenesis has provided a rationale for the utili-
zation of some anti-­cytokine bDMARDs for the treatment of AOSD.
Despite limited evidence and the rarity of randomized controlled tri-
als, the use of anti-­TNF, anti-­IL-­1 and anti-­IL-­6 agents represent a
major therapeutic advance in patients with AOSD refractory to con-
ventional treatment.
Clinical data suggest that IL-­1 inhibitors may be more efficient for
systemic manifestations and IL-­6 inhibitor for both joint and sys-
temic manifestations. Anti-­TNF agents must be reserved for patients
with pure chronic articular manifestations. Recently, monoclonal an-
tibody against IL-­18 binding protein showed some positive effect in
phase II trial. Small molecules against Jak-­1/Jak-­2 may provide ad-
ditional therapeutic options for AOSD, but clinical trial is required
for confirmation.
Some patients present life threatening manifestations as the first
symptom, and approximately one thirds of AOSD patients have a
transient monocyclic pattern, and thus an initial application of bD-
MARD is not recommended.
It is very important to measure disease activity accurately during the
long term follow up. However, currently available biomarkers have
limited value for the detection of variable manifestations of AOSD.
ABSTRACTS
The development of composite biomarkers to detect disease activity
could certainly support rational decision making in the treatment of
AOSD.
O-­056 | Pregnancy and rheumatic diseases
L. Young
Redcliffe & Northside Rheumatology
Many of the rheumatic conditions affect women in childbearing
years and therefore the option to get pregnant is often raised with
the treating physician. Factors to consider include the effect on the
disease, the risk to the baby due to the disease but also the possible
treatments required that may have to be modified pre-­conception,
during the pregnancy and post-­partum. Fear for the baby can often
lead to decisions regarding therapy that may allow the disease to
worsen during these periods which is a risk to the future baby as
well. All of these considerations need careful planning to success-
fully navigate the best outcomes for all involved. We will discuss
the pregnancy and options for medications including biologics for
rheumatic diseases. Paternal exposure to medications will also be
discussed.
O-­085 | IgG4-­related vascular disease:
pathogenesis and management
W. Zhang
Peking Union Medical College Hospital
Background: IgG4-­related vascular disease, manifested mostly as
periaortitis/aortitis (PAO/PA), including retroperitoneal fibrosis
|
      39
(RPF) and inflammatory abdominal aortic aneurysm (IAAAs), was
one of the commonly involved lesions in IgG4-­RD patients. The pur-
pose was to clarify the clinical features and treatment efficacy of
IgG4-­
related periaortitis/periarteritis and comparison of patients
with/without periaortitis/periarteritis.
Methods: Among 639 patients with IgG4-­RD in PUMC form January
2011 to September 2018, followed more than 3 months enrolled in
this study. Periaoritis/periarteritis was defined as vessel wall thick-
ness or soft tissues around blood vessels with circumferential en-
hancement on contrast-­enhanced computed tomography or MRI.
Patients’ clinical characteristics, laboratory parameters and treat-
ment efficacy were analyzed.
Results: 16.9% (108 patients) the age of patients was enrolled, and
age was 57.9 ± 11.3 years, and there was a male dominance (82.4%).
The percentage of vessels affected of IgG4 related PAO/PA was
as follows: abdominal affected 76.6%, iliac artery affected 48.1%,
thoracic aorta affected 11.1%, other vessels affected 18.5%, and
13.0% patients had retroperitoneum fibrosis/sclerosing mediasti-
num and paravertebral soft tissues without vessels affected. The
most prevalent vascular affected was Type 2 (51.9%) being localized
at the infra-­renal artery portion of the abdominal aorta and iliac ar-
teries, and vessels related of type 1, type 3, type 4 and type 5 was
15.7%, 0.9%, 6.5% and 12.0% respectively, and 13.0% patients were
retroperitoneal fibrosis/sclerosing mediastinum/paravertebral soft
tissues. After treatment, 38.7% patients achieved more than 70%
reduction of soft tissues around blood vessels, 41.9% had reduction
of 31%–70% and 19.4% patients had reduction less than 30%. Of 47
patients with renal function damage, 34 patients had D-­J tube place-
ment, and D-­J tube could be removed in 24 patients, 35 patients’
creatinine returned to normal.
Conclusion: IgG4 related PAO/PA was different by comparison of
clinical characteristics and laboratory parameters which may indi-
cate typical pathogenesis different from IgG4-­RD with PAO/PA.
DOI: 10.1111/1756-185X.13545

ABSTR ACT

1-­101 | Scleroderma in Cairns: an 1-­0 08 | Formulation and characterization of

epidemiological study naproxen niosomes
S. Abbot1; L. Spargo2; C. de Costa1; Z. Ur-Rehman3; S. N. Abdolahi; A. Soltani; V. Erfani-Moghadam
Proudman2,4; D. Bossingham1 Golestan Rheumatology Research Center, Golestan University of Medical Science
1
College of Medicine & Dentistry, James Cook University; 2Rheumatology Unit,
Royal Adelaide Hospital; 3Cairns Hospital; 4Discipline of Medicine, University of
Purpose: Naproxen (NPX) is used for acute or temporary pain and
Adelaide
various chronic disorders such as osteoarthritis. However, the use
of Naproxen increases the risk of digestive, cardiovascular and renal
Background/purpose: Systemic sclerosis (SSc) refers to a group of
complications. Naproxen has low in water solubility and has low per-
progressive autoimmune fibrosing disorders that can be fatal. The
meability. Because insufficiently soluble and insoluble drugs exhibit
prevalence of 23/100,000 in South Australia (SA) is among the high-
low absorption and poor bioavailability, improvements in solubility
est documented. Anecdotally it is higher still in Cairns.
and solubility are important for developing various drug preparation
Objectives: To ascertain the prevalence of SSc in Cairns and sur-
methods.
rounding regions, and to compare the demographic and clinical char-
The purpose of the present study was to investigate the formula-
acteristics of patients with SSc in Cairns with those in SA.
tions of niosomal naproxen.
Methods: Patients with SSc in Cairns were ascertained through
Material: We prepared niosomal Naproxen from the biocompatible
Cairns Hospital records and by referral from specialists. These pa-
surfactant tween 80 (polysorbate 80) and the squalene as an ex-
tients were interviewed and completed a structured questionnaire.
cipient, through film hydration method and their potential as a drug
Their physical findings and autoantibodies were recorded. These pa-
delivery system for NPX. The prepared system was characterized for
tients were compared with the SA patients enrolled in the Australian
by Fourier transform infrared spectroscopy (FT-­IR), UV-­visible, and
Scleroderma Cohort Study.
transmission electron microscopy (TEM).
Results: 81 eligible patients were identified in Cairns, giving an es-
Result: By using this method, the percent drug loading that re-
timated cross-­
sectional prevalence of 33.7/100,000. Among 65
sulted by the encapsulation of niosomes was found to be 99.5  ±  0.2
Cairns patients interviewed, 23 were born in Cairns, 16 had mi-
% for 5% of NPX weight in total ingredients weight of niosomal
grated to Cairns to ameliorate their Raynaud's phenomenon and
vesicles (w/w). It was also seen that a slower rate of release of the
26 for other reasons. The clinical features both cohorts were simi-
NPX from the drug encapsulated noisome over 7 days, suggesting
lar, although Cairns patients had a lower prevalence of digital ulcers
stable complexation of NPX. TEM result showed the naproxen na-
(30.8% vs 46.6%; OR = 0.5035, 95% CI: 0.2839 – 0.8929, P = 0.0193)
noformulation provide relatively uniform size and spherical vesi-
and higher prevalence of reflux oesophagitis (89.2% vs 71.8%;
cles, thus the morphology and characteristic size of the niosomal
OR = 3.254, 95% CI: 1.429 – 7.411, P = 0.0026), calcinosis (29.2% vs
vesicles remain unchanged after drug loading. Cell toxicity assay
17.0%; OR = 2.005, 95% CI: 1.080 – 3.721, P = 0.0356) and depres-
was carried out by MCF-­7 breast cancer cell line and showed the
sion and anxiety (33.9% vs 21.7%; OR = 1.889, 95% CI: 1.055–3.382,
half maximal inhibitory concentration (IC 50 ) of NPX decreased
P = 0.0364). Scleroderma Health Assessment Questionnaire scores
about eight folds by nanoformulation (from 2300 µM to about
were similar in both groups.
280 µM).
Conclusion: The higher prevalence of SSc in Cairns is partly, but not
Conclusion: The niosomal vesicles of polysorbate 80 and the
completely, due to migration. Differences in clinical features are
squalene in the presence of NPX was prepared through film hydra-
not entirely explained by the warmer climate. The clinical burden of
tion method and their potential as a drug delivery system for non-
the disease is similar in both cohorts indicating the need for greater
steroidal anti-­inflammatory drug and fully characterized.
rheumatologic services in the Cairns region.

Editorial material and organization © 2019 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd. Copyright of individual
abstracts remains with the authors.

40  |  
wileyonlinelibrary.com/journal/apl Int J Rheum Dis. 2019;22(Suppl. 3):40–226.

1-­0 09 | Preparation of nano combination
naproxen-­sulfasalazin
A. Soltani; N. Abdolahi; M. Aghaei
Golestan Rheumatology Research Center, Golestan University of Medical Science
Purpose: Naproxen and Sulfasalazin use for alot of rheumatologic
disease specially seronegative spondyloartheropathy.
The goal of the present study was preparation of nano combination
product (naproxen-­sulfasalazine) to improve the antioxidant prop-
erties of and also evaluated the mechanistic aspects of its action
against free radicals produced during inflammation.
Material: Firstly, 0.05 g of sulfasalazine and naproxen in a 1:1 ratio
was dispersed in 25 mL of ultrapure water by ultrasonication to form
a red solution into a 250 mL balloon flask, while the temperature of
the water in the ultrasonic bath was kept below 50 ◦C. Results upon
the nano combination product was obtained by Field emission scan-
ning electron microscopy (FE-­SEM), respectively. The antioxidant
activities of the tested specimens including sulfasalazine, naproxen
and its combination product have been measured by diphenyl-­2-­
picrylhydrazyl (DPPH), total antioxidant capacity, and reducing
power.
Result: The obtained results indicate the effect of each of these
compounds on the reduction of oxidation, which is reported by the
concentration index required for 50% inhibitory IC50. The highest
antioxidant activity of the combination product was found to be
76.0% inhibition at concentration of 100 mg/ml. The study indicates
the combination product has a higher antioxidant capacity than
sulfasalazine and naproxen. This amount of inhibition is generally
lower than the synthetic antioxidant effect of BHT. The FE-­SEM of
the combination drug nanoparticles indicated that the mean average
size of spherical shape nanoparticles was approximately 47.82 nm.
The EDX spectrum indicates the presence of C (56.36 %), N (5.62 %),
O (17.26 %), and S (4.61 %) in the combination drug.
Conclusion: Nano combination product was successfully prepared
by the ultrasonic method, and then, these nano powders character-
ized by FE-­SEM. We demonstrated that the combination product has
a higher antioxidant capacity than sulfasalazine and naproxen.
1-­102 | QTc interval prolongation and its
correlations with skin score in systemic sclerosis
N. Abdolahi; M. Mohammadi; H.-R. Azimi; M. Aghaei
Golestan Rheumatology Research Center, Golestan University of Medical Science
Background: Ventricular arrhythmias in systemic sclerosis (SSc) pa-
tients is a result of fibrosis or ischemia of the ventricular myocar-
dium. QTc interval are electrocardiographic (ECG) indices to predict
ventricular arrhythmia and cardiovascular mortality. This indics usu-
ally neglect in SSc patients.the purpose of this study is evaluation of
QTc interval in patients with SSc and its correlation with skin score
and Autoantibodies.
|
      41
Methods: A total of 35 patients with SSc (mean age, 44.3  ±  12.0  years;
33 females) and 35 healthy controls (mean age, 43.4 ± 11 years; 33
females) were enrolled in this study. The standard 12-­lead ECG was
recorded;.QTc interval were measured. Modified Rodnan skin sever-
ity score (MR-­SSS) calculated for all SSc patients. Echocardiography
was performed for all study groups and Anti-­
Scl70 and Anti-­
centromer was mesured in SSc group.
Results: QTc interval were significantly prolonged in SSc patients
than in the control group. (438.7 ± 51.3 vs 409 ± 22.3) Pearson's
correlation analyses revealed positive correlations of MR-­SSS with
QTc (r = 603, P = 0.006). We couldn’t find any correlation between
duration of disease , type of disease and type of Antibody with QTc
interval.
Conclusions: The patients with SSc had a prolonged QTc interval
compared with normal population. skin score is one of the impor-
tant indices that correlate with QTc.so we suggest every patients
with high Modified Rodnan skin severity score (MR-­SSS) be followed
closely for cardiac arrythmia with ECG or Holter monitoring.
1-­0 02 | Refractory vasculitic leg ulcers in a
clinically quiescent systemic lupus erythematosus
patient, diagnostic and management quandary: a
case report
L. Rajagopala; D. Abeysinghe; K. P. Karunadasa; M. L.
Gunathilaka; C. T. Rosa
College of Rheumatology and Rehabilitation Medicine, Sri Lanka
Background: Multiple large refractory vasculitic ulcers are a rare oc-
currence in a clinically quiescent SLE patient and potentially fatal if
delay in initiation of treatment as ischemia of limb may subsequently
result in its amputation. We describe the first reported case of iso-
lated refractory vasculitic ulcers in SLE from Sri Lanka.
Objective: To present a case of multiple refractory vasculitic ulcers
in a SLE patient to highlight the challenges we faced while diagnosing
and managing the patient.
Method: Case report.
Result: 48 year old female diagnosed with SLE developed painful leg
ulcers of her left foot that rapidly worsened over several weeks de-
spite conventional therapy with prednisolone, hydroxychloroquine,
azathioprine, and aspirin. She had no other systemic symptoms indi-
cating a flare of lupus or suggestive of a primary vasculitis. CT an-
giography and lower limb arterial Doppler study excluded arterial
thrombosis. Skin biopsy was suggestive of a leucocytoclastic vasculi-
tis. Screens to exclude a secondary antiphospholipid syndrome were
negative. Complement levels were not done due to lack of availabil-
ity in our poor resource settings. Biochemical profile was unremark-
able. Inflammatory markers were markedly elevated. Initally ulcers
were well demarcated covered by infected exudates. They rapidly
worsened, and due to risk of osteo-­tendinous impairment, surgical
opinion was sought and patient necessitated multiple wound toilets
 |
42      

and toe amputations along with aggressive immunosuppressives Results: The disease duration ranged from 4.8 to 6.8 years male
including intravenous methylprednisolone and intravenous pulsed were dominant. Important clinical features in each subset as shown
cyclophosphamide therapy that eventually lead to gradual clinical in table (percent).
improvement. A recent study revealed the concomitant use of hy- B27+, RF B27 –VE, B27-­VE,
perbaric oxygen therapy (HBOT) for ischemic ulcers to hasten clini- B27 + RF+ –VE RF + RF –VE
cal improvement. However, due to poor resource settings we were Variables (N = 13) (N = 12) (N = 22) (N = 17)
obliged against its use. Age of symtoms 38 36 40 36
Conclusion: Refractory vasculitic ulcers are a rare occurence in clini- onset (Years)
Mean
cally disease quiescent SLE patients. Prompt diagnosis and initiation
of aggressive immunosuppressives such as intravenous pulse cyclo- Male; female ratio 8:5 9:3 14:6 9:8

phosphamide therapy is warranted to prevent fatal outcomes such Polyarthritis 92 100 90 76

as limb amputation. Literature reveals the use of HBOT as an adjunct Shoulder 53 50 68 41
therapy has a promising outcome in such patients, and further re- Wrist + hands 53 67 81 52
search is needed to study its efficacy. DIP 53 0 13 11
Knee 69 92 77 58
Ankle +MTP 76 58 77) 64
Neck 30 50 45 58
Thorasic spine 30 50 31 35
LS spine 84 100 77 88
Hip 15 25 27 5
SI joint 30 50 45 58
Enthesitis 7 17 5 11
Dactylitis 15 8 5 0
Deformity 23 25 40 35
articular
ESR (mean) 88.23 98 71 80
(Westergren, mm
in 1st hour)
CRP (mean) (mg/L) 73 68 50 47
2-­113 | Influence of RF and HLA B27 of clinical Sacroilits (imaging) 69 83 63 41
phenotype on RA-­SSA overlap: a retrospective Xray erosions 46 17 40 41
cross sectional study (hands + wrist)
Conclusion: Males are dominantly affected by RA-­
SSA overlap.
K. Adam; A. Venugopalan; A. Chopra
However the individual or combined expression of B27 and RF is not
Center for Rheumatic Diseases
associated with any specific clinical phenotype on its components in
patients clinicaly classified as RA-­SSA overlap. A bigger sample size
Background: Historically and clinically rheumatoid arthritis (RA) and
study is required for validation.
seronegative spondyloarthritis (SSA) are considered to be distinct
end of spectrum disorders. Rheumatoid factor (RF) and HLA B27
continue to rule the diagnostic/classification requirements. Is there
an distinct overlap phenotype? Does the overlap behave different in 3-­087 | Serum lipid assay in a large community
time compared to its individual components? Very little data can be based rheumatology practice: interpretation and
found in literature clinical usefulness
Objectives: To describe important features of RA-­SSA overlap with
R. Ghorpade; A. Venugopalan; A. Mohan; K. Adam; A.
reference to RF and HLA B27.
Chopra
Methods: Data was mined from a comprehensive patient database
Center for Rheumatic Diseases
maintained in CRD, pune since 1996. Standard rheumatology case
record forms are used. A RA-­SSA overlap clinical diagnosis based on
Rheumatoid arthritis (RA) is an important cause of premature ath-
coexistant charactersticphenotypic features of RA (seen as polyar-
erosclerosis and Coronary artery disease (CAD). Hyperlipidemia is
thritis, deformity typical, typical erosions & RF/ACCP) and SSA (sac-
a known modifiable risk factor but its data in RA is inconsistent and
roilitis, inflammatory LBA, HLA B27+, Enthesitis, dactylitis).
inconclusive. The current emphasis is to treat early RA aggressively
Materials: 64 of the 98 patients classified as RA-­SSA overlap with
assay results of RF & HLA B27 were chosen for clinical audit.

with DMARD with/without steroids which are likely to alter lipid sta-
tus. Data in Indian patients is sparse.
Aims: To compare serum lipid profile in early onset with late onset
RA with respect to treatment with DMARDS &/or steorids at least
6 months prior to diagnosis.
Methods: The current study is a retrospective cross-­
sectional
analysis of patients attending the outpatient clinic of Center for
Rheumatic Diseases (CRD). Among 12449 clinically diagnosed RA
patients attending the clinic between January 2008 to December
2017, records of 554 patients in whom baseline lipids were deter-
mined were screened. Patients with disease duration ≥ 5 years and
those with confounding factors such as co-­morbidity (diabetes;hyp
othyroidism;hyperlipidemia) were excluded and results on 191 pa-
tients were analysed. These patients (female = 155; male = 36) were
further classified as per disease duration.
Normal range of serum lipids is consistent with Indian studies.
Results: No effect of DMARD/steroid in lipid profile in this study of
patients of RA with disease duration of ≤ 5 years.
Similar analysis done for 0–2 years disease duration and results simi-
lar (data not shown).
Conclusions: This study shows that serum lipids are normal in pa-
tients with RA in this community and not influenced by disease du-
ration or use of DMARD/steroid. Also, in rheumatology practice a
small proportion of patients are evaluated for lipids. Possibly a ho-
listic approach rather to depend on serum lipid assay is desirable in
RA to evaluate and manage risk of IHD. Atherogenic fraction of lipid
assay may be more useful.
1-­010 | Distinctive metabolic signatures of
axial and peripheral ankylosing spondylitis
revealed by 1H NMR based serum metabolomics
L. Gupta1; D. Kumar2; A. Guleria2; A. Rawat2; A. Aggarwal1
1
Sanjay Gandhi Postgraduate Institute of Medical Sciences; 2Centre of
Biomedical Research
Background: Ankylosing spondylitis (AS) is characterized by pre-
dominant involvement of the sacroiliac joints and the spine although
|
      43
half the patients have peripheral arthritis as well. The treatments
useful in peripheral arthritis like SSZ and MTX have limited role in
axial disease, this suggests that these two phenotypes may have dif-
ferent pathogenesis.
Objective: To explore potential of metabolite profiling in serum of
AS patients as a biomarker for phenotype estimation, diagnosis and
response to therapy.
Methods: Serum of 80 AS patients (ASAS 2010 criteria) and 86
healthy controls (HC) was subjected to metabolite profiling using
H1NMR. Seventeen were followed-­
up after 3 months of stand-
ard treatment. Nine paired serum-­synovial fluid samples were also
analyzed. The serum metabolic profiles were obtained at 800 MHZ
NMR spectrometer and compared using multivariate partial least-­
squares discriminant analysis (PLS-­DA, Fig. 1A). The discriminatory
metabolites were identified based on variable importance in projec-
tion (VIP) statistics (Fig. 1B) and further evaluated for statistical sig-
nificance (P-­value <0.05, Fig. 1C).
Results and discussion: Median age was 31 years and disease du-
ration 6 years. Seventy were male and 6 had non radiographic AS.
Apart from differences in AS vs. HC, PLS-­DA plots revealed distinc-
tive metabolomics signatures between axial and peripheral disease
(Fig. 1A). Sera of peripheral AS patients were characterized by in-
creased serum levels of N-­acetyl-­glycoproteins, lactate, glutamate,
proline, arginine, phenylalanine and branched chain amino acids (i.e.
leucine, isoleucine), whereas the serum levels of lipid/membrane me-
tabolites including low/very-­low density lipoproteins (LDL/VLDL),
PUFA, choline and Glycerophosphocholine and several other amino
acids (including alanine, glutamine and histidine) were found to be
decreased significantly compared with axial AS patients. in treatment
responders, metabolite profile changed significantly post therapy
(Fig.1D). Metabolite signatures are similar between HLA B27 positive
and negative disease. There was no correlation with level of disease
activity.
Conclusion: These metabolic alterations suggested that the pe-
ripheral AS patients exhibit activated glutaminolysis, glycolysis and
membrane metabolism, irrespective of disease activity, suggesting
different pathogenesis of axial and peripheral disease subsets. These
markers may have the potential to make serum metabolic profiling as
a tool for diagnosis, prediction of peripheral disease, and treatment
response.
2-­027 | Translation of revised WHO-­ILAR-­
COPCORD Core English Questionnaire into
Bangla and its cross-­cultural adaptation and
validation
S. Ahmed
BSM Medical University
Background and objectives: Community Oriented Program for
Control of Rheumatic Diseases (COPCORD) aims to help correct the
 |
44      

information deficit about the epidemiology of rheumatic diseases, 1-­076 | Successful treatment with rivaroxaban
particularly in rural communities in developing countries. This study
for Paget-­Schroetter Syndrome masquerading as
aimed to develop a culturally adapted, valid and reliable Bangla ver-
the relapse of rheumatoid arthritis
sion of WHO-­ILAR-­COPCORD Core English Questionnaire for use
as a rheumatic screening instrument among Bangla speaking people. Y. Akiyama1,2; N. Katsuyama1,2; T. Yoshida1,2
1
Methods: The original English WHO-­
ILAR-­
COPCORD question- Setagaya Rheumatology Clinic; 2Toshin Yoshida Internal Medicine and
Rheumatology
naire were translated into Bangla and adapted in the local socio-­
cultural context, following standard international recommendations.
Background: Paget-­Schroetter syndrome (PSS) accounts for 1–4%
Content validity of the adapted Bangla version was assessed by the
of deep venous thrombosis. PSS may be misdiagnosed as relapse of
item-­level & scale level content validity indices (I-­C VI & S-­C VI). 120
rheumatoid arthritis because edematous upper extremity is judged
patients with rheumatic problems and healthy attendants were as-
as arthritis of the shoulder or tenosynovitis of the hand.
sessed in the study. Test-­retest reliability was assessed using intra-­
Objectives: To present a case of PSS and discuss etiologies, diagno-
class correlation coefficient.
sis and management.
Results: The Bangla version of the WHO-­ILAR-­COPCORD ques-
Method: Case report.
tionnaire showed excellent content validity ICVI (=1), S-­C VI (=1). The
Result: In May 20XX, a 28-­year-­old female polyarthritis patient was
test-­retest reliability also was acceptable (ICC > 0.7).
diagnosed with positive anti-­CCP antibody, and methotrexate was
Conclusions: The adapted Bangla version of the WHO-­
ILAR-­
administered.
COPCORD questionnaire demonstrated acceptable psychomet-
Before consultation, she had conducted intensive work involving
ric properties, that is, content validity and test-­retest reliability in
right upper extremity for 2–5 hours, 5 days. Edema was discovered
Bangladeshi patients with rheumatic problems and also in healthy
on her right upper limb from day 4. Intensified arthritis was diag-
attendants.
nosed and glucocorticoids administered, but condition did not im-
prove. While the entire upper limb was edematous, redness was not
observed. Venous thrombosis was suspected, and the ultrasound

of the axillary vein showed thrombus. in order to investigate com-
plication of pulmonary thromboembolism, contrast CT was taken.
Thrombosis in the axillary vein was discovered from the right sub-
clavian vein, without anomalous vessel abnormality. Since lupus an-
ticoagulant was negative, rivaroxaban was administered at 30 mg/d.
Pain and edema disappeared after 1 week. Since antiphospholipid
antibodies were negative, treatment was not changed to warfarin,
but continued with 15 mg/d of rivaroxaban. Two months after treat-
ment start, thrombus had disappeared.
Discussion: PSS, also called primary “effort thrombosis”, is caused
by compression and thrombosis of the subclavian vein. in our case,
PSS was associated with repetitive long-­time compression. Past re-
ports showed that only anticoagulant therapy for PSS is generally
not recommended, but we successfully treated only with direct oral
anticoagulant (DOAC), rivaroxaban. Treatment for PSS due to com-
pression, not anatomical abnormality, might be enough for DOAC
monotherapy.
1-­103 | Echocardiographic assessment of
asymptomatic cardiac involvement in patients
with diffuse systemic sclerosis
1 2 1 2
Md Z. Alam ; R. Ara ; A. K. M. Shaheen Ahmed ; S. Ahmed ;
A. K. M. Mohibullah1
1 2
BIRDEM General Hospital; Green Life Medical College
Background: Systemic sclerosis (SSc) is an uncommon systemic dis-
ease with multiorgan involvement. Among them cardiac involvement
indicates poorer prognosis especially when clinically evident. Our
purpose of this study was to identify the subclinical patterns of car-
diac involvement in asymptomatic patients so that early intervention
may improve the prognosis.
Materials and methods: Seventy-­three diagnosed cases of diffuse SSc
who did not have any cardiac symptoms were enrolled in this cross-­
sectional observational study conducted in BIRDEM General Hospital
from January 2016 to December 2017. Patients who had clinical car-
diac symptoms, overlap syndrome, limited systemic sclerosis, renal
impairment (serum creatinine >1.4 mg/dL), and known case of heart
disease (valvular, shunt anomaly, coronary artery disease) were ex-
cluded from this study. 2D/ M-­mode and color Doppler echocardi-
ography, including tissue Doppler imaging (TDI), was done in all cases
to assess the pattern of cardiac involvement. Data entry and analysis
were done using SPSS for windows version 22.0. Frequency and per-
centage were calculated to find out the proportion of the findings.
Results: In seventy-­three cases, mean age was 44 ± 9 years, 4 (5.5%)
were male and 69 (94.5%) were female. Results showed the most
common cardiac abnormality was tricuspid regurgitation (31.5%),
followed by mild to moderate pericardial effusion in 21.9%, grade
I and II diastolic dysfunction in 20.5%, pulmonary hypertension in
|
      45
17.8%, mitral regurgitation in 12.3%, and left ventricular hypertro-
phy in 8.2%. No patients had any form of wall motion abnormality
and any systolic dysfunction.
Conclusions: Cardiac involvements, both primary and secondary, are
not uncommon in patients with systemic sclerosis who did not have
any symptoms suggestive of cardiac disease. Long term follow up is
required to find out its clinical implications.
2-­028 | Lag time between onset of symptoms
and initiation of DMARD for rheumatoid arthritis
patients and factors responsible for the delay
Md. Z. Amin; S. Ahmed; S. A. Haq; M. R. Choudhury; Md. N.
Islam
Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University
(BSMMU)
Background: The consequences of delays in adequate therapy in
rheumatoid arthritis (RA) have well been documented in the litera-
ture and have driven the development of aggressive guidelines for
early treatment of RA. No effort was made so far in Bangladesh
to know the extent of treatment delays and possible causes of this
delay.
Objectives: To determine the lag time between onset of symptoms
and initiation of DMARD therapy in patients with rheumatoid arthri-
tis and to assess factors influencing the lag time.
Methodology: A total 154 patient aged 18 years old or more who
met 2010 ACR/ EULAR criteria for RA and demonstrated willing-
ness to participate in the study were enrolled for this cross sectional
study conducted at Bangabandhu Sheikh Mujib Medical University
(BSMMU), Dhaka, Bangladesh. Patients who had incomplete medical
record and also failed to give adequate history were excluded from
the study. The patients’ records were reviewed and for assessing fac-
tors influencing lag time both structured questionnaire and unstruc-
tured interview were done. Associations between lag time and factors
influencing it were analyzed by multivariate regression analysis.
Results: The mean lag time from symptom onset to starting of
DMARD therapy in our patients were 28.6 ± 36.1 months. Several
factors like year of RA symptom onset, predominant pattern of initial
joint involvement, distance from nearest rheumatology services, im-
proper referral by primary care physician, lack of correct information
on availability of physicians having expertise in RA treatment were
found to be significantly influencing the lag time in the fitted regres-
sion model, P < 0.05.
Summary and Conclusion: In summary, our findings indicate that
major factors leading to delayed RA treatment may stem from poor
referral efforts by primary care physicians, lack of patients’ under-
standing regarding the role of specialists in their care and difficulty
in access to rheumatologist in Bangladesh.
 |
46      

2-­039 | A patient with limbic encephalitis, CMV infections in patients with autoimmune diseases seen at a large
tertiary-­care academic medical institution in Singapore.
ear perichondritis and episcleritis – an unusual
Methods: A retrospective review of the medical records of 177 pa-
presentation of relapsing polychondritis
tients with autoimmune diseases who were diagnosed with CMV
S. Angkodjojo1,2 infections using real-­time quantitative polymerase chain reaction
1
Department of General Medicine (Rheumatology), Sengkang General Hospital; and/or CMV pp65 antigen in the blood between January 2010 and
2
Department of Rheumatology and Immunology, Singapore General Hospital
December 2014. Clinical and laboratory parameters as well as treat-
ment outcomes were analyzed.
Background: Relapsing polychondritis (RPC) and limbic encephalitis
Results: A total of 177 patients were analyzed. 40 patients had CMV
(LE) is a rare association that has been mentioned in case reports.
infections, of whom 20 developed CMV disease (viral syndrome
Whilst MRI Brain has been widely used in evaluating LE, the use of
and/or tissue invasive disease). Multivariate analysis revealed that
FDG-­PET-­C T in the detection of LE is not well established.
systemic lupus erythematosus (SLE) (Odds ratio (OR) 0.16 favour-
Methods: We describe a patient with LE, ear perichondritis and epis-
ing those without a diagnosis of SLE, 95% confidence interval (CI)
cleritis who was successfully treated with methylprednisolone and
0.04–0.53, P < 0.01), and the use of immunosuppression (systemic
cyclophosphamide.
steroids, Cyclophosphamide, and Rituximab)(OR 14.55, 95% CI
Results: Our patient is a 66-­year-­old Chinese male who presented
1.78–118.67, P = 0.01] were significantly associated with CMV dis-
with 4-­weeks of progressive forgetfulness, emotional lability, and
ease. Lymphopenia (lymphocyte number <600/mm3) (OR 3.07, 95%
hallucinations. Physical examination showed redness and swell-
CI 0.91–10.27, P = 0.06) was also noted to be associated with the
ing of his right ear and bilateral episcleritis. Lumbar puncture re-
occurrence of CMV disease.
vealed CSF lymphocytosis, total protein of >2 g/L, and negative
Conclusion: A diagnosis of SLE, use of certain immunosuppressive
results for neurotrophic viruses, bacteria, and acid-­f ast-­bacilli. MRI
therapy and presence of lymphopenia are risk factors of CMV in-
brain could not be done due to the presence of an implantable-­
fection in our South-­East Asian cohort of patients with autoimmune
cardioverter-­defibrillator device. FDG-­PET-­C T scan was done in-
diseases. These patients would therefore benefit from serial meas-
stead which revealed a focus of intense metabolic activity in the
urements of CMV-­PCR copy numbers and/or CMV pp65 antigen and
left hippocampal region, confirming the diagnosis of LE. Tests for
close observation for signs of CMV infections.
paraneoplastic/autoimmune encephalitis auto-­
antibodies were
negative. Subsequent biopsy of his right ear revealed chronic infil-
tration of inflammatory cells in the perichondrium, which led to the
diagnosis of RPC. He was started on intravenous pulse methylpred-
3-­089 | Investigation of rheumatoid arthritis
nisolone for 5 days followed by oral prednisolone and oral cyclo- patients who had received lower extremity
phosphamide. FDG-­PET-­C T scan done 3 months into his treatment surgery
showed interval resolution of the increased FDG uptake within the H. Aonuma1; T. Kashiwagura2; M. Kobayashi3; Y. Sugimura4;
left hippocampus. N. Miyakoshi5; Y. Shimada5
Conclusion: Our patient with Limbic Encephalitis, ear perichondritis 1
Dept. of Orthopedic Surgery, Ogachi Central Hospital; 2Dept. of Orthopedic
(biopsy proven) and episcleritis is most likely an unusual presenta- Surgery, Akita City Hospital; 3Dept. of Orthopedic Surgery, Hiraka General
Hospital; 4Dept. of Orthopedic Surgery, Nakadori General Hospital; 5Dept. of
tion of Relapsing Polychrondritis. This case also illustrates the effec-
Orthopedic Surgery, Akita University Graduate School of Medicine
tive utility of FDG-­PET-­C T scan in the diagnosis of LE in situations
where MRI brain cannot be done.
Background: Joint destruction of the lower extremities due to rheu-
matoid arthritis (RA) leads to pain, difficulty with ambulation, and
disability.
2-­029 | Risk factors of CMV infection in Objective: To investigate the patient background and the current
patients with autoimmune diseases in a south-­ state of medication and disease activity among RA patients with
east Asian population in Singapore prior surgery of weight bearing joints of the lower extremities
Method: A total of 2172 RA patients were registered with the Akita
S. Angkodjojo1,2
1
Orthopedic Group on rheumatoid Arthritis in 2017. Of these, pa-
Department of General Medicine (Rheumatology), Sengkang General Hospital;
2
Department of Rheumatology and Immunology, Singapore General Hospital tients receiving surgery including 181 total knee arthroplasty (TKA),
70 total hip arthroplasty (THA), 70 knee synovectomy and 96 foot

Objectives: Cytomegaloviruses (CMV) can have a significant impact and ankle surgery were evaluated.

on the prognosis of immunocompromised patients. Unlike in the Result: Mean age at the time of TKA, THA, knee synovectomy, and

transplantation and AIDS fields, only a few studies on CMV infec- foot & ankle surgery were 63.8, 61.8, 56.2 and 59.1 years, respec-

tions have been published in the field of autoimmunity. in this study, tively. Mean disease duration were 12.1, 13.3, 7.8 and 15.0 years,

we examined the risk factors associated with the development of respectively. High titer (more than 13.5 U/mL) rate of anticyclic

citrullinated peptide antibodies were 73.5, 65.7, 66.7 and 70.8%, re-
spectively. Mean age at the final survey among the four group were
63.8, 61.8, 56.2 and 59.1 years, respectively. Methotrexate and
prednisolone were administered in 56.4 and 55.2 % of patients with
TKA, 62.9 and 52.9% patients with THA, 71.0 and 49.3% patients
with knee synovectomy and 66.7 and 57.3% patients with foot &
ankle surgery. The patients with history of one or more biologics use
were including 47.0, 40.0, 61.4 and 55.2% among the four groups,
respectively. Mean DAS28-­CRP were 2.65, 2.62, 2.31 and 2.43,
respectively.
Conclusion: The lowest mean age at the time of surgery was
shown in patient with knee synovectomy and the highest was
shown in TKA. The patient with knee synovectomy showed the
lowest mean DAS28-­CRP, which was almost as well as in non-­
surgery group.
1-­123 | Glucocorticoids and damage accrual
in a cohort of lupus patients with no clinical or
serological disease activity
D. Apostolopoulos1; R. Kandane-Rathnayake1; W.
Louthrenoo2; S. F. Luo3; Y.-J. Wu3; A. Lateef4; V. Golder1;
S. Sockalingam5; S. Navarra6; L. Zamora6; L. Hamijoyo7;
Y. Katsumata8; M. Harigai8; M. Chan9; S. O'Neill10; F.
Goldblatt11,12; A. Hoi1; M. Nikpour13; E. Morand1
1
Monash University; 2Chiang Mai University Hospital; 3Chang Gung Memorial
Hospital; 4National University Hospital; 5University of Malaya, Kuala Lumpur;
6
University of Santo Tomas Hospital; 7University of Padjadjaran; 8Tokyo
Women's Medical University; 9Tan Tock Seng Hospital; 10University of New
South Wales; 11Flinders Medical Centre; 12Royal Adelaide Hospital; 13St.
Vincent's Hospital
Background/purpose: Observational studies have previously found
associations between glucocorticoid therapy and irreversible organ
damage in SLE. Glucocorticoid use and lupus disease activity are
highly correlated, thus disease activity potentially confounds analy-
sis of the contribution of glucocorticoid use to organ damage. We
studied whether glucocorticoids independently contribute to dam-
age accrual in SLE by analysing patients with no clinical or serological
lupus disease activity (SLEDAI = 0).
Objectives: To examine patients with SLEDAI = 0 in the Asia-­Pacific
Lupus Cohort (APLC), and to determine the effect of glucocorticoids
on SLE damage accrual.
Methods: APLC patients, recruited between 2013–2016 from 13
centres in eight countries, were included in the study. As per stand-
ardised protocol, disease activity (SLEDAI-­
2K), treatment details
were recorded at each visit, and organ damage measured annually
(SDI). Cox-­proportional hazards analyses were used to examine time-­
dependent associations of glucocorticoid use with damage accrual.
Results: 1707 patients with ≥2visits were studied with median (IQR)
observation period 2.2 years (1.5–3.0); 93% patients were female;
age at diagnosis 29 years (21.0–40.0); Asian ethnicity, 88%. The
median time-­adjusted-­mean (TAM)-­SLEDAI was 3.3 (1.5–5.3), and
|
      47
median baseline SDI was 0 (0–1). Eighty-­t wo percent were exposed
to prednisolone, with a median TAM-­
prednisolone dose 5 mg/d
(1.9–8.8).
276 events of damage accrual were recorded. Factors significantly as-
sociated with damage accrual-­over-­time included TAM-­prednisolone
(HR 1.05, 1.0–1.1, P < 0.01), cumulative prednisolone (HR 1.04,
1.0–1.1, P < 0.01), baseline organ damage (HR 1.6, 1.2–2.0, P < 0.01),
disease activity (TAM-­SLEDAI, HR 1.1, 1.06–1.14, P < 0.01), smok-
ing (HR 1.96, 1.3–3.0, P < 0.01), age at enrolment (HR 1.02, 1.0–1.0,
P < 0.01).
Eleven percent of subjects (n = 196) had SLEDAI = 0 for the entire
study period with median TAM-­
prednisolone 2.0 mg/d (0.0–5.0).
Prednisolone exposure was significantly associated with damage ac-
crual (TAM-­prednisolone ≥2.0 mg/d, HR 2.2, 1.0–4.9, P = 0.04), as
were TAM-­PGA (HR 3.7, 1.4–9.6, P < 0.01) and age at enrolment (HR
1.0, 1.0–1.1, P = 0.02).
Conclusions: In SLE patients with no clinical or serological lupus
activity, prednisolone exposure was associated with damage
accrual.
2-­040 | Assessment of epidemiology,
symptoms, accuracy of diagnostic examination
methods and X rays used for young patients with
patella femoral syndrome
H. S. D. Appuhamy; S. M. P. D. Munidasa
Ministry of Health
Background/purpose: Knee is a tri-­compartment joint, with patella-­
femoral compartment having unique biomechanics. Patella Femoral
Syndrome (PFS) is one of the most common problems among young
individuals. Lack of a referral study with regards to epidemiology,
symptom variability, accuracy of diagnostic examination methods and
x rays used for patients with PFS is a barrier that must be overcome.
Methods: Descriptive study included 80 patients, aged between
18–40 years, who visited Rheumatology clinics in a District General
Hospital, with retro-­patellar pain manifested during activities requir-
ing knee flexion and forceful contraction of the quadriceps. Patient
with history of significant trauma, congenital/developmental dis-
orders, other joint disorders (Rheumatoid/septic arthritis) were ex-
cluded. Interviewer administered questionnaire and a data extraction
tool was used. Each patient was examined using 4 predetermined
examination methods. X-­rays of the relevant knees were arranged.
Results: Mean age at presentation was 21.4 years with female: male
ratio of 1.35:1. Average pain severity (using VAS 0–10) was 4.72
(SD 1.36). Crepitus, feeling of knee giving-­way, swelling and morn-
ing stiffness (>30 minutes) were seen in 61.25%, 13.75%, 7.5% and
1.25%. Risk factor analysis showed history of knee overuse (sports/
occupation related) in 40% and overloading (overweight/obesity)
in 60%. Sensitivity of examination methods included Patellar ap-
prehension test, Vastus-­Medialis coordination test, Patellofemoral
 |
48      

grinding test and Waldrone's test were 38.75%, 16.25%, 57.5% and 1-­124 | Pregnancy outcomes in women with
51.25% respectively. While all these tests were normal in 11.25%
systemic lupus erythematosus in a tertiary care
of patients, majority (66.25%) had 2 or more tests positive. Only
hospital of Dhaka, Bangladesh
73.75% had X-­Ray evidence of PFS, but when clinical examination
combined, diagnosis sensitivity increased to 92.5%. R. Ara1; J. S. Roy1; S. Ahmed1; A. Malek1; Md Z. Alam3; S. A.
Conclusion: Female predominance and symptom variability was
Haq2
1
Green Life Medical College; 2Bangabandhu Sheikh Mujib Medical University;
identified. History of overusing or overloading was seen in majority. 3
BIRDEM General Hospital
All four examination methods had poor sensitivity individually and
X-­rays alone missed the diagnosis in ¼th of patients. When several
Background: Systemic lupus erythematosus (SLE) predominantly af-
examination methods and X-­rays combined, diagnosis sensitivity in-
fects women of reproductive age group. So, pregnancy and child-
creased markedly.
bearing is very important consideration for them. This study was
aimed to see pregnancy outcomes of women with SLE in resource
constraints setting like Bangladesh.
3-­045 | Study of epidemiology, symptom Methods: An observational study was conducted in Green Life
variability and knowledge assessment of knee Medical College Hospital from January 2017 to July 2018. All di-
joint osteoarthritis patients in Sri Lanka agnosed case of SLE who became pregnant and pregnant women
who diagnosed as SLE during pregnancy were included. Pregnant
S. Appuhamy; S. M. P. D. Munidasa
women who had overlap syndrome and MCTD were excluded. Data
Ministry of Health
were collected in a preformed datasheet and hospital records were
reviewed. Analysis was done using SPSS windows version 23.
Background/purpose: Osteoarthritis is the commonest articular dis-
Results: A total 36 lupus patients with pregnancy were enrolled.
ease worldwide. Lack of a referral study with regards to epidemi-
Mean age was 28.1 ± 4.3 years and 44.4% was primigravida. Among
ology, symptom variability, severity and knowledge assessment of
them, 66.6% (n = 24) had planned pregnancy with duration of re-
osteoarthritis in Sri Lanka is a barrier that must be overcome before
mission >6 months and rest (n = 12) were unplanned. All patients
improving treatment methods.
except 2 (due to side effects) were on hydroxychloroquine, 44.4%
Methods: A descriptive study was conducted in Rheumatology
was on azathioprine prior and throughout pregnancy, 16.4% was
and Rehabilitation Hospital-­R agama, Sri Lanka, where randomly
on prednisolone with average dose of 9 mg per day and 27.8% was
selected 88 patients with knee joint osteoarthritis, based on
on low dose aspirin. Lupus flare was observed in 22% cases, mostly
American College of Rheumatology-­2012 clinical classification cri-
mucocutaneous and musculoskeletal. Most (94.4%) had live births
teria were assessed. Interviewer administered questionnaire and a
with 2 fetal losses (both from unplanned pregnancy with high dis-
data extraction tool was used. X-­r ays of the relevant knees were
ease activity). Elective caesarean section was common in 91.6%
arranged.
(n==33) cases. Other maternal outcomes showed GDM (n = 6), APS
Results: Mean age of the population was 52.4 years, where 81.8%
(n = 4), premature ruptured membrane (n = 3), puerperal sepsis
were females. Average body weight and body mass index were
(n = 1), cerebral venous sinus thrombosis (n = 1), and no patient de-
63.4 kilograms (SD 13.2) and 24.7 (SD 5.42) respectively. Patients
veloped preeclampsia or eclampsia. Fetal outcomes showed IUGR
had visited their general practitioners early with a delay of only
in 28% and prematurity in 19.4%, no perinatal mortality. Baby's dis-
0.83 years (SD 1.19). Arthralgia was the commonest symptom
charged at home after mean 4.7 ± 1.6 days of hospital stay.
(100%) with an average severity of 4.72, assessed using a visual
Conclusions: Management of lupus pregnancy poses multiple chal-
analog scale of 0 to 10. Other symptoms presented were knee
lenges. A well planned pregnancy can minimize adverse fetal and
swelling (45.5%), stiffness (54.6 %), crepitations (81.8%), daily
maternal outcome especially in resource constraint setting.
activity limitations (9.1%), occupational limitations (27.2%), lei-
sure activity limitations (36.4%) and sleep problems (18.2%).
Knowledge assessment showed satisfactory knowledge for
epidemiology/etiology, non-­
p harmacological managements, 1-­125 | Anti-­Sm antibody directly decreases
pharmacological managements, surgical managements and im- tight junction protein composing blood brain
portance of follow in 32.73%, 29.87%, 42.42%, 13.64% and barrier on brain endothelial cells by MMP-­2
27.27% respectively
activation
Conclusion: Female predominance and significant symptom vari-
ability was identified among Osteoarthritis patients. Majority
Y. Arinuma; S. Hirohata; Y. Matsueda; K. Yamaoka
Kitasato University School of Medicine
were overweight and obese. Final analysis revealed symptom
diversity of knee osteoarthritis and poor knowledge of patients
in all the categories assessed, despite presenting early to general Background/purpose: Break-­down of blood brain barrier (BBB) in-

practitioners. tegrity is required for development of diffuse neuropsychiatric/


psychological manifestations in patients with SLE, causing direct
access to neurons by autoantibodies entering from systemic circula-
tion beyond BBB. A previous study demonstrated that in patients
with NPSLE, serum anti-­Sm antibody level was significantly cor-
related with breakdown of BBB integrity estimated by Q-­albumin.
However, the certain mechanism of breaching BBB by anti-­Sm anti-
body has not been clarified.
Objectives: The aim of this study is to investigate the direct effect
and the mechanism of anti-­Sm antibody on break-­down of BBB in-
tegrity in brain endothelium cells in vitro.
Methods: A human brain hemangiosarcoma cell line (ISO-­H AS)
was used as brain endothelial cells. Murine monoclonal anti-
­S m antibody, anti-­R NP antibody were used for stimulation and
staining. Immunofluorescent staining was performed, examined
by confocal microscopy. Quantification of claudin-­5 expression
was evaluated by western blot, using whole cell lysates of ISO-­
HAS. MMP-­2 and claudin-­5 mRNA expression from ISOHAS were
measured, using q-­P CR. Statistical analysis was performed by
Paired T test.
Results: Anti-­S m antibody was clearly binding to ISO-­H AS. The
level of claudin-­5 was significantly reduced in ISO-­H AS stimulated
by anti-­S m antibody than that by isotype control (P = 0.018). By
contrast, anti-­R NP stimulation rather increased claudin-­5 expres-
sion (P = 0.040) (Figure 1). Immunofluorescent staining also dem-
onstrated that signals of claudin-­5 was lower by anti-­S m antibody
stimulation, compared to that by anti-­R NP or isotype controls. The
mRNA expression of MMP-­2 was significantly increased in anti-­S m
antibody-­s timulated ISOHAS (P = 0.023) but did not increased in
|
      49
that by anti-­R NP antibody stimulation (P = 0.340). Interestingly,
claudin-­
5 expression was increased in ISOHAS stimulated by
anti-­R NP antibody (P = 0.024), unlike in that by anti-­S m antibody
(P = 0.766).
Conclusion: Anti-­Sm antibody could reduce BBB-­composing protein
by enhancing MMP-­2 expression on endothelial cells. Anti-­RNP anti-
body may play a protective role on brain endothelium cells regarding
rupture of BBB permeability.
3-­035 | The prescribing pattern of allopurinol
in current daily practice at King Chulalongkorn
Memorial Hospital
T. Assawasaksakul; S. Ukritchon; M. Osiri
Department of Medicine, Faculty of Medicine, Chulalongkorn University and King
Chulalongkorn Memorial Hospital, Thai Red Cross Society
Background: Allopurinol is a widely-­used drug for the treatment of
gout. As hyperuricemia is claimed over decades to be a risk factor
of chronic kidney disease (CKD) and other metabolic diseases, al-
lopurinol is frequently described in asymptomatic hyperuricemia.
The evidences regarding the advantages and the disadvantages of
allopurinol are lacking and needed to be verified.
Objective: To identify the prescribing pattern of allopurinol at
KCMH.
Methods: A cross-­sectional study was conducted on patients who
were newly-­
prescribed allopurinol between January and March
2017 at KCMH. All medical records were intensively reviewed for
indications for allopurinol and adverse events (AEs). The indications
are based on the 2012 ACR recommendations for urate-­lowering
therapy (ULT).
Results: Of the 252 patient charts reviewed preliminarily, 27
were excluded due to receiving combination of ULT, previously
received, and loss-­to-­follow-­u p. of the remaining 225, 56 patients
were prescribed allopurinol according to the 2012 ACR indica-
tions (group I), whilst the other 169 were not (group II). The mean
age (±SD) in group I was 59.5 (±15.5) and 61.9 (±14.1) in group II.
The median starting dose was 100 mg/day in both groups. The
estimated glomerular filtration rate (eGFR) at baseline was 69.3
(±23.2) in group I and 65.8 (±26.2) mL/min/1.73 m2 in group II.
The AEs occurred in both groups were not statistically differ-
ent. For subgroup analysis, we found allopurinol may slow the
rate of eGFR declining in patients with serum urate level ≥ 7 mg/
dL, mean difference of eGFR was -­1 .86 mL/min/1.73 m2 (95% CI,
-­3 .19, - ­0 .53, P < 0.005).
Conclusion: The appropriate indications of allopurinol is still un-
clear and the allopurinol prescribing pattern at our hospital fol-
lowed the 2012 ACR recommendations is fewer than 25%. To date,
we encountered no serious AEs of allopurinol. in additions, short
term data showed a potential benefit of allopurinol in delaying CKD
pregression.
 |
50      

3-­030 | Filariasis is the commonest cause of

musculoskeletal symptoms in Eastern India: a
single centre prospective study
S. Behera
SCB Medical College, Cuttack

Introduction: Musculoskeletal conditions are a major burden affect-

ing more than 180 million people in India. Lymphatic filariasis is one
of the causes of monoarthritis in children in India. Observing it in
many cases in our institution a systematic observation is done.
Objective: To study the prevalence of lymphatic filariasis in
Musculoskeletal Diseases.
Methods: In this prospective single centre study 100 patients of
musculoskeletal pain are randomly selected. Definite causes like
RA, Spondyloarthropathies, Osteoporosis and hypothyroidism
are excluded. From the rest patients, only non-­responders to two
weeks analgesics are selected for further evaluation. They are
given a 15 days course of Diethylcarbamazine, five days antibiotic,
analgesics and antihistaminics. We followed up and repeated two
such treatment cycle at a monthly interval, and evaluated and at
the end of three months when we administered a single combina-
tion dose of Albendazole and Ivermectin and evaluated clinically and
biochemically.
Results: Out of 100 selected cases, females (67%) outnumbered
males (33%), more common age group is 30 to 50 years. Swelling
and pain in single ankle joint is the commonest presentation (78%),
followed by pain in nape of the neck (46%), wrists (45%) and back-
ache in 40% cases. Filarial antigen test is positive in 22 cases.
Eosinophilia is observed in 62% of cases. 13 patients discontinued
after two weeks. Pain recurred in 87 patients after stopping analge-
sics. After first month empirical treatment with DEC all felt better
but after one month pain recurred again and was given the second
course DEC 80% of patients felt significant improvements. After one
month 54% complained mild pain and the third course of DEC with
 |
      51

antihistamines was given to all. Albendazole and Ivermectin were
given to all at the end and they became asymptotic as evaluated sta-
tistically after one month.
Conclusion: Musculoskeletal symptoms due to Lymphatic filariasis
is common. Antigen detection tests are less sensitive. Blood eosino-
philia is common. Patients responded well to three courses of DEC
at monthly interval.
1-­126 | Refractory thrombotic
thrombocytopenic purpura in a patient with
systemic lupus erythematosus: a case report
C. A. Boado1; C. Rosales1,2; J. J. Lichauco1,3; E. Esposo1; E.
Demerre1
1
Department of Medicine, St. Luke's Medical Center; 2Section of Hematology,
St. Luke's Medical Center; 3Section of Rheumatology and Immunology, St. Luke's
Medical Center

1-­020 | Successful treatment of refractory Thrombotic Thrombocytopenic Purpura (TTP) is a life-­threatening

Erythema nodosum with oral potassium iodide in auto-­immune disorder which leads to the development of micro-
a patient with chronic liver disease. An old drug angiopathic hemolytic anemia and severe thrombocytopenia ul-

reinvented timately resulting to a multi-­visceral ischemic syndrome. About

10–50% of patients with acquired TTP will have a disease which
S. Bhasin; P. Rath; S. Pandey
will not respond to initial treatment. We hereby describe a case of
Max Superspeciality Hospital Saket
a 48-­year-­old female, diagnosed case of SLE, presenting with fever
and bicytopenia. She was clinically diagnosed as a case of TTP and
Background: Erythema-­nodosum represents delayed hypersensi-
undewent PEX immediately upon diagnosis. The TTP was refractory
tivity reaction to variety of inciting factors including drugs and au-
after 2 PEX sessions and the patient was started on Intravenous
toimmune diseases.However in majority of patients no identifiable
Immunoglobulin (IVIg) and PEX because she developed infection in
cause is found.
the course of her hospital stay. As cases have been sporadically re-
Diagnosis is clinical but biopsy can be performed for confirmation.
ported in literature, the relative lack of the understanding between
This would reveal panniculitis of septa in subcutaneous fat tissue
the pathophysiological link between the two entities leads to an
without vasculitis.
unfavorable prognosis. The case highlights factors in a SLE patient
Treatment is self-­limiting or treatment of underlying cause. Various
that leads to a refractory disease as well as the treament armamen-
treatment options include Nonsteroidal anti-­
inflammatory drugs,
tarium that can be offered to such patients. Our case raises ques-
colchicine, heparin, steroids, Hydroxychloroquine.
tions on the link of TTP and SLE, ulitmately concluding that in a SLE
Potassium iodide is successfully used for various inflammatory
patient developing TTP, the treatment approach is complicated and
dermatoses. It has inhibitory effect on chemotaxis of neutro-
is a dilemma to clinicians.
phils and on toxic radical production by these cells which justi-
fies its use in inflammatory conditions. The mechanism of action
in Erythema nodosum is unknown but is thought it causes hepa-
rin release from mast cells which suppress delayed hypersensi-
1-­088 | Demographics and response to
tivity reactions. Dose monitoring is essential as sideeffects are treatment of rheumatoid arthritis patients to
dosedependent. synthetic and biological disease-­modifying anti-­
Objective: To demonstrate the efficacy of potassium iodide an old rheumatic drugs in Makati Medical Center
drug in treatment of refractory erythema nodosum where traditional
J. Borja-Dimal; A. Villarubin; G. Katigbak
drugs failed or could not be used because of coexisting comorbidities.
Makati Medical Center
Methods: This is a case report of 43 years old female with morbid
obesity, hypertension, Chronic liver disease and steroid induced
Background/purpose: RA is a chronic, systemic, inflammatory
diabetes mellitus with progressive weight gain with refractory
disorder characterized by symmetric, polyarticular inflammation,
Erythema Nodosum (Biopsy proven). She presented to us with pain-
which can lead to progressive joint damage and has significant
ful lesions over both shins and the abdomen. All possible secondary
negative impact on the ability to perform daily activities. Various
causes were ruled out. She was started on oral potassium iodide tab-
DMARDs are available which could be used as mono-­or combina-
lets at a dose of 300 mg thrice daily.
tion therapy.
Result: Our patient who was refractory to various possible conven-
Objectives: This study compared treatment response of RA pa-
tional drugs, responded to oral potassium iodide within one week
tients to csDMARDs versus bDMARDs, ± glucocorticoids after 6
leading to complete resolution of the skin lesions.
and 12 months of treatment, based on the DAS-­based EULAR re-
At present she is on tapering dose of potassium iodide and has lost
sponse criteria.
7 kgs weight with minimal requirement of insulin.
Methods: A retrospective cohort covered the period from January 1,
Conclusion: Potassium iodide shows promise as an inexpensive and
2010 to June 30, 2017. 60 patients were classified by the treatment
relatively nontoxic therapy for patients with refractory erythema
given to them, csDMARDs vs bDMARDs ± csDMARDs. The primary
nodosum.
 |
52      
outcome determined treatment response after 6 and 12 months
based on the DAS-­based EULAR response criteria. Comparison of
response to treatment between the two groups was done using chi-­
square analysis. Wilcoxon Signed Rank Sum Test was used to com-
pare the response within a group.
Results: For both groups, there were no significant differences in the
improvement of disease activity after 6 and 12 months (P = 0.10).
But after excluding patients given monotherapy with bDMARD,
significant difference (P = 0.020) in disease reduction between the
two groups was observed after 12 months of treatment. Results
also showed that for both groups, the median DAS28 score dur-
ing baseline is significantly different after 6 months as well as after
12 months. The median DAS28 score after 6 months is also signifi-
cantly different after 12 months.
Conclusion: The overall treatment response showed that under the
csDMARDs arm, patients responded after 6 months of treatment
but eventually became non-­responders after 12 months. As com-
pared to the bDMARD arm, majority continued to respond even
after 12 months of treatment. It was also observed that the use
of combination therapy (bDMARD plus methotrexate) resulted in
higher disease activity reduction compared to csDMARDs (metho-
trexate alone).
3-­046 | High baseline fat mass is associated
with high intensity low back pain and disability in
community based adults
S. Brady; D. Urquhart; S. M. Hussain; A. Teichtahl; Y. Wang;
A. Wluka; F. Cicuttini
Department of Epidemiology and Preventive Medicine, School of Public Health
and Preventive Medicine, Monash University
Background/purpose: Low back pain is the largest contributor to
disability worldwide. While obesity is a risk factor for back pain, the
role of body composition remains unclear. Our aim was to exam-
ine the relationship between fat mass and fat distribution on back
pain intensity and disability using validated tools over 3 years, in a
community-­based cohort.
Methods: Participants aged 25-­60 years were recruited for a study
examining musculoskeletal health. at baseline, body composition
was assessed using dual-­energy X-­ray absorptiometry (DXA). All
participants completed the Chronic Pain Grade Scale assessing back
pain and disability at baseline and 3-­year follow-­up.
Results: Of the 150 participants, 123 (82%) completed the follow-
­up. Higher baseline body mass index (BMI) and fat mass (total,
trunk, upper limb, lower limb, android and gynoid) were all as-
sociated with high intensity back pain at either baseline and/or
follow-­up (total fat mass: multivariable OR 1.05, 95% CI 1.01–1.09,
P < 0.001). A higher android to gynoid ratio was associated with
high intensity back pain (multivariable OR 1.04, 95% CI 1.01–1.08,
P = 0.009). There were similar findings for all fat mass measures
and high levels of back disability. There were no associations be-
tween lean mass and back pain.
Conclusion: Higher fat mass, but not lean mass, in different body re-
gions was associated with both high back pain intensity and disability
at baseline and/or 3 years later. Moreover, an android distribution of
excess fat was particularly associated with high pain intensity. This
study provides evidence for the important role of fat mass, specifi-
cally android fat, on back pain and disability.
3-­064 | Tumour necrosis factor inhibition
results in weight gain in patients with
inflammatory arthritis
A. Brooks1; A. Bowling2; K. Chia1; D. Freeman3; H. Bagga3; P.
Wong1,3
1
UNSW Rural Clinical School; 2School of Health and Human Sciences, Southern
Cross University; 3Mid-­North Coast Arthritis Clinic
Background/purpose: Tumour necrosis factor (TNF) was initially
called “cachectin” because of its ability to cause cachexia and muscle
protein loss. Chronic systemic TNF elevation may contribute to the
cachexia seen in rheumatoid arthritis (RA), psoriatic arthritis (PsA)
and ankylosing spondylitis (AS). We sought to determine the effect
of tumour necrosis factor inhibition (TNFi) on bodyweight (BW)
compared to non-­TNF inhibitory biologic disease modifying anti-­
rheumatic drugs (bDMARDs).
Methods: In this retrospective cohort study, the computerised
medical records of all patients who commenced a bDMARD or
targeted synthetic (ts-­
) DMARD for inflammatory arthritis (IA)
through MNCAC were reviewed. The following data were ob-
tained: age, sex, type of IA, initial bDMARD/tsDMARD com-
menced. The following data recorded at various time points
(approx. 4, 10 and 16 months) after therapy commencement were
extracted: BW, CRP, ESR, Bath Ankylosing Spondylitis Disease
Activity Index (BASDAI) or the Disease Activity Score (28 joints;
DAS28), as appropriate and oral corticosteroid dose. Regression
modelling (mixed linear models) was undertaken to ascertain the
effect of parameters on BW.
Results: A total of 343 suitable patients were identified. of these 343
patients, 288 (84%) were commenced on a TNFi, with the remain-
ing 55 (16%) on a non-­TNFi b-­/tsDMARD. in RA/PsA patients, TNFi
use was associated with a BW increase of 0.037 kg per week (95%
CI 0.027–0.048; P < 0.001) even when corrected for corticosteroid
dose. Most patients (276/343) gained weight. Non-­TNFi use was not
significantly associated with significant weight gain (P = 0.059) in the
TNFi group, increased DAS28 was associated with lower baseline BW.
However, weight gain was independent of change in disease activity.
Conclusion: TNFi use was associated with approximately 1.9 kg of
weight gain per year. Non-­TNFi use was not significantly associated
with weight gain. Weight loss may be predictive of clinical response
to a TNFi.

3-­090 | Modifiable factors associated with
response to treatment in early rheumatoid
arthritis
Z. Brown1; R. Metcalf1; T. Sullivan2; L. Spargo1; M. James1; L.
Cleland1; S. Proudman1
1
Rheumatology Department, Royal Adelaide Hospital; 2Adelaide Health
Technology Assessment, University of Adelaide
Background/purpose: There is evidence for associations of BMI,
smoking history, and dietary fish oil supplementation with RA
outcomes. An integrated examination of these lifestyle factors as
predictors of outcomes was undertaken in a single cohort from an
early RA clinic that used standardised algorithm-­directed DMARD
therapy.
Methods: Consecutive Royal Adelaide Hospital clinic patients with
recent-­onset RA according to the 1987 revised ACR criteria were as-
sessed. All patients routinely received advice to take fish oil supple-
ments at anti-­inflammatory doses. Prognostic variables for DAS28
remission and DAS28 low disease activity (LDA) at the 12 month
visit were identified using multivariable logistic regression models.
Omega-­3 status was assessed as plasma eicosapentaenoic acid (EPA)
levels.
Results: Of 286 participants, 55.9% were in DAS28 LDA and 42.7%
were in DAS28 remission at one year. Increase in plasma EPA was
associated with an increase in the odds of being in DAS28 LDA
(OR = 1.23; P = 0.003) (Table) and DAS28 remission (OR = 1.17;
P = 0.02).
There was a statistically significant interaction between smoking
status and BMI on DAS28 LDA (Table). Increase in BMI was associ-
ated with a decrease in the odds of being in DAS28 LDA in current
and former smokers, but had no impact on LDA in patients who had
never smoked.
|
      53
There were no statistically significant associations with BMI or
smoking history and DAS28 remission.
Conclusion: The results supports the role of fish oil supplemen-
tation in addition to DMARDs in early RA. The effect modifica-
tion by smoking status on the association of BMI with treatment
outcomes in early RA strongly supports counselling for lifestyle
modification in patients who are overweight and have a smoking
history. Overall, the results suggest that modifiable risk factors
may interact and remain an important factor in the treatment of
patients with RA.
2-­030 | Prevalence of rheumatic immune
related adverse events (RirAE) in patients
with metastatic melanoma treated with
immunotherapy: preliminary results
A. Bruce1,2; G. Long2; A. Menzies2; F. Joshua3
1
Royal Prince Alfred Hospital; 2Melanoma Institute of Australia; 3Rheumatology
Specialist Care, Macquarie University
Background: Immune checkpoint inhibitors (ICIs) including mono-
clonal antibodies to PD-­1 and CTLA-­4 have revolutionised the treat-
ment of metastatic melanoma and other malignancies. Rheumatic
complications have been reported and include inflammatory arthri-
tis, myositis, PMR-­like syndrome, various connective tissue diseases
and vasculitis. Retrospective studies, mostly in the form of case se-
ries, have explored the nature of de novo rheumatic disease as well
as exacerbations of pre-­existing autoimmune conditions although
these latter patients were largely excluded from the initial trials. The
prevalence and incidence of rheumatic immune complications is as
yet unknown and a prospective study is required to determine the
frequency, risk factors and character of RirAE in a specific patient
population.
Methods: Patients attending the medical oncology clinics at the
Melanoma Institute of Australia were asked to complete a question-
naire designed to capture current rheumatic symptoms, previous
history rheumatic disease, management of RirAE and nature of un-
derlying malignancy and treatment response. This includes stand-
ardised measures for rheumatic symptoms including the ‘Visual
Analogue Scale (VAS)’ and ‘Health Assessment Questionnaire
(HAQ)’. Data regarding the patient's melanoma stage, treatment and
response to treatment, immune related adverse events and rheu-
matic complaints was also recorded. The patients were consented
to complete a follow up questionnaire at 6 and 12 months (to take
place in 2019).
Results: Preliminary results from initial questionnaire will be
presented.
Conclusions: These preliminary results will inform data concerning
prevalence and patient risk factors of RirAE.
 |
54      
2-­041 | How common is imaging for low back
pain? A systematic review and meta-­analysis
A. Downie1,2; M. Hancock3; H. Jenkins2; R. Buchbinder4,5; I.
Harris6; M. Underwood7; S. Goergen8; C. Maher1
1
Institute for Musculoskeletal Health, Sydney School of Public Health,
Faculty of Medicine and Health, the University of Sydney; 2Faculty of
Science and Engineering, Macquarie University; 3Faculty of Medicine and
Health Sciences, Macquarie University; 4Department of Epidemiology and
Preventive Medicine, School of Public Health & Preventive Medicine, Monash
University; 5Monash Department of Clinical Epidemiology Cabrini Institute;
6
South Western Sydney Clinical School, University of NSW; 7 Warwick Clinical
Trials Unit, the University of Warwick; 8School of Clinical Sciences, Monash
University
Background/purpose: Overuse of imaging for low back pain (LBP)
has been reported for decades despite clinical practice guidelines
and campaigns such as Choosing Wisely warning against over-
use. Selection of imaging estimates for the purpose of health care
decision-­making is non-­systematic and often relies upon data from a
single study. We estimated the proportion of patients seeking care
for LBP who are imaged, and explored trends in the proportion of
patients receiving diagnostic imaging over time.
Methods: MEDLINE, EMBASE, and CINAHL were searched with-
out language restriction from January 1, 1995 to December 9, 2017.
Eligible studies were observational designs and controlled trials that
reported imaging for patients presenting to primary or emergency
care for LBP, in any language. Data were extracted by 2 independent
authors and assessed for risk of bias. Pooled proportions were calcu-
lated using random-­effects meta-­analysis and assessed for quality.
Trends in frequency of simple (X-­ray, ultrasound) and complex (CT,
MRI, bone scan) imaging were investigated.
Results: 45 studies representing 19,451,749 consultations, resulted
in 4,343,919 imaging referrals/events over 21 years. Primary
care: moderate quality evidence that simple imaging proportion
was 16.3% (95%CI 12.6–21.1); complex imaging was 9.2% (95%CI
6.2–13.5). Emergency care: moderate quality evidence that sim-
ple imaging proportion was 26.5% (95%CI 16.9–36.0); high qual-
ity evidence that complex imaging proportion was 8.6% (95%CI
4.1–13.1). Complex imaging increased from 7.4% (95%CI 5.7–9.6)
for imaging requested in 1995, to 11.4% (95%CI 9.6–13.5) in 2015
(relative increase of 53.5%). Between study variability in imaging
proportions was only partially explained by study-­level charac-
teristics; insufficient data were available for some pre-­specified
study-­level factors.
Conclusion: Imaging for LBP remains high, with increase in com-
plex imaging use over 21 years without associated reduction in
simple imaging despite guideline advice and education campaigns.
(PROSPERO: CRD42016041987)
1-­110 | Patients’ experience of shoulder
disorders: a systematic review and thematic
synthesis of qualitative studies
M. Page1; D. O'Connor2,3; M. Malek4; R. Haas2,3; D. Beaton5;
H. Huang6; S. Ramiro7; P. Richards8; M. Scholte-Voshaa9; B.
Shea10,11; D. van der Windt12; A. Verhagen13; S. Whittle14; J.
Gagnier6,15; R. Buchbinder2,3
1
School of Public Health and Preventive Medicine, Monash University; 2Monash
Department of Clinical Epidemiology, Cabrini Institute; 3Department of
Epidemiology and Preventive Medicine, School of Public Health and Preventive
Medicine, Monash University; 4Monash University; 5Institute of Health & Work
and the University of Toronto; 6Department of Orthopaedic Surgery, University
of Michigan; 7Department of Rheumatology, Leiden University Medical Center;
8
University of Bristol, Academic Rheumatology Bristol; 9Department of Psychology,
Health and Technology, University of Twente; 10Ottawa Hospital Research Institute,
Clinical Epidemiology Program; 11School of Epidemiology and Public Health, Faculty
of Medicine, University of Ottawa; 12Arthritis Research UK Primary Care Centre,
Institute for Primary Care and Health Sciences, Keele University; 13University
of Technology Sydney; 14Rheumatology Unit, the Queen Elizabeth Hospital;
15
Department of Epidemiology, School of Public Health, University of Michigan
Background: Exploring the lived experience and perspectives of
people with shoulder disorders can help determine which outcomes
are important to patients and improve patient-­centred care.
Objectives: To conduct a systematic review of qualitative research
describing the experiences (including symptoms and perceived im-
pacts on daily living) of people with a shoulder disorder.
Methods: We searched for eligible studies indexed in Ovid
MEDLINE, Ovid Embase, CINAHL (EBSCO), SportDiscus (EBSCO)
and Ovid PsycINFO up until November 2017. Two authors indepen-
dently screened studies for inclusion, appraised their methodologi-
cal quality, used thematic synthesis methods to generate themes
describing the experiences reported by participants, and assessed
the confidence in the findings using the GRADE-­CERQual approach.
Results: The inclusion criteria were met by eight studies, which in-
cluded 133 participants (49 females and 84 males) with either rotator
cuff disease, adhesive capsulitis, proximal humeral fracture, shoulder
instability or unspecified shoulder pain. We generated seven themes
to describe what people in the included studies reported experiencing:
pain; physical function/activity limitations (e.g. difficulties performing
activities of daily living); participation restriction (e.g. work disruption,
limited recreation); sleep disruption (e.g. difficulty falling, and sub-
sequently staying, asleep); cognitive dysfunction (e.g. poor concen-
tration and memory); (6) emotional distress (e.g. frustration, anxiety
and depression); and impairment in musculoskeletal and movement-­
related functions (e.g. loss of muscle strength). There were many inter-
actions between the themes, with particular experiences impacting on
others (e.g. pain leading to reduced activities and sleep disruption). We
considered it likely that most of the review findings were a reasonable
representation of the experiences of people with shoulder disorders.
Conclusion: Patients with shoulder disorders contend with consid-
erable disruption to their life. A better understanding of patients’
experiences is useful for clinicians who manage them and can also
inform selection of the most appropriate outcomes to measure in
clinical trials for shoulder disorders.

3-­047 | Translating a clinical care standard
for knee osteoarthritis into routine clinical
care: a systematic scoping review to inform
implementation planning
1,2 1 1,2
D. O'Connor ; J.-X. Han ; A. Fletcher ; R. Buchbinder
1
Cabrini Institute; 2Monash University
Background/purpose: The Australian Commission for Quality and
Safety in Health Care has published a Clinical Care Standard for
knee osteoarthritis. A Clinical Care Standard is a nationally-­agreed
statement on the care patients should expect to be offered or re-
ceive based on best evidence, regardless of where they are treated
in Australia. A key challenge is translating Clinical Care Standards
into routine clinical care. Strategies that aim to support research
translation should be based on a diagnostic assessment of barriers
to, and enablers of, change and empirical evidence about the effects
of research translation interventions. Our objective is to describe the
extent, range and nature of existing research about evidence-­practice
gaps, barriers and enablers, and effects of research translation inter-
ventions, relevant to the knee osteoarthritis Clinical Care Standard.
Methods: We conducted a systematic scoping review of studies pro-
viding information on evidence-practice gaps, barriers and enablers of
change, and/or effects of research translation interventions relevant to
the Standard. We searched Medline, Embase, CINAHL, PsychINFO and
PDQ-Evidence from inception to May 2018. Studies were independently
screened and abstracted by two review authors.
Results: The search identified 5290 citations. 4881 records were ex-
cluded based on being duplicates or inclusion criteria not being met
based on title and abstract. 409 full-­text articles were retrieved and
assessed for eligibility and 167 citations were included. The majority
of studies report on barriers and/or enablers and the fewest com-
prised research translation interventions. A narrative synthesis and
bubble charts will be presented to describe the extent, range and nature
of translation research relevant to the Standard.
Conclusion: Research translation strategies tailored to barriers and
enablers of change and informed by prior research translation inter-
ventions are likely to lead to greater practice change and improved
health outcomes for people with knee osteoarthritis.
2-­063 | Effects of curcumin on serum uric acid
and uric acid clearance in hyperuricemia
P. Bupparenoo; P. Asavatanabodee; P. Narongroeknawin; R.
Pakchotanon; S. Chaiamnuay
Department of Internal Medicine, Phramongkutklao Hospital
Background/purpose: Hyperuricemia leads to gout, renal complica-
tions and may increase cardiovascular risk. Curcumin inhibits xan-
thine oxidase enzyme, increases uricosuric activity and as the results,
decreasing in serum uric acid (SUA). This randomized-­controlled trial
aims to determine the effects of curcumin versus placebo on SUA,
|
      55
and urine uric acid clearance in subjects with asymptomatic hyper-
uricemia (SUA result ≥6 mg/dL in women or ≥7 mg/dL in men).
Methods: Thirty-­eight subjects with persistent hyperuricemia were
randomized to receive curcumin (500-­mg capsules twice daily) or
placebo (19 subjects in each group). The primary outcomes were
1,2
differences between SUA and urine uric acid clearance before and
8 weeks after randomization and the secondary outcomes were dif-
ferences between fasting plasma glucose (FPG), lipid profiles before
and 8 weeks after randomization and adverse events. Continuous
variables were examined by independent t-­test and paired t-­test for
the differences between groups and in the groups, respectively.
Results: Of 38 participants, there were no differences in baseline
SUA, urine uric acid clearance, FPG, lipid profiles and demograph-
ics between curcumin and placebo groups. After 8 weeks, SUA was
significantly decreased in both groups (6.9% in curcumin group,
P = 0.002 and 5.0% in placebo group, P = 0.009). Subjects in cur-
cumin group tended to have greater reduction of SUA than subjects
in placebo group with means and 95% confidence interval of −0.58
(−0.91, −0.25) and −0.44 (−0.76, −0.12), respectively; however, there
was not statistically significant.
There were no differences in urine uric acid clearance, FPG, lipid profiles
and adverse events in both groups at eight weeks after randomization.
The most common adverse event was mild diarrhea which no treat-
ment required.
Conclusion: Curcumin may be more effective than placebo in reduc-
ing SUA. More subjects are needed to increase power to determine
these effects of curcumin.
1-­057 | Childhood systemic lupus
erythematous in the Western Australian
population I: clinical and laboratory
characteristics
A. Sage; M. Cann; S.-J. Lee; N. Larkins; K. Murray
Perth Children's Hospital
Background/purpose: Systemic Lupus Erythematosus (SLE) is a seri-
ous autoimmune disease with major end-­organ damage, morbidity
and mortality. To date, minimal data exists focusing upon the pres-
entation and short term outcomes of SLE in the Australian paediatric
population.
Objectives: To describe the unique presentation and short term dis-
ease progression of childhood SLE in Western Australia.
Method: A retrospective review was conducted of children diagnosed
with SLE before 16 years from 1998–2018, resident in Western Australia.
Demographic data, clinical presentation, management and outcomes
were collected, and compared using the Systemic Lupus Collaborating
Clinics (SLICC), and Systemic Lupus Erythematosus Disease Activity
Index (SLEDAI) criteria (GEKO No. 13051, HREC: RGS0000001103).
Results: Of 42 children, 88% (n = 37) were female, and average age at
diagnosis 12.5 years 5 children were diagnosed under the age of 10.
Average time to diagnosis was 4.9 months. 38% (n = 16) were Caucasian,
 |
56      
26% (n = 11) Indigenous and 24% (n = 10) Asian, (Other n = 5, 12%).
at presentation, 40 children (95%) fulfilled SLICC criteria. Average
SLEDAI score at presentation was high (13.9) with haematological
(n = 24, 57%), and renal disease (n = 17, 40.5%) prominent. Within one
year all 42 children were SLICC criteria compliant, and average SLEDAI
had decreased to 5.7. 19 chilldren had developed biopsy proven lupus
nephritis. All were ANA positive, 34 (81%) had positive dsDNA, and
23 (55%) positive for ENA. Vasculitis/skin disease (n = 27, 64%), arthri-
tis (n = 26, 62%) were also common. Hypo-­complementaemia (n = 36,
86%) and anti-­phospholipid antibodies (n = 28, 67%) were prominent
immunological markers, with thrombocytopaenia the predominant
haematological abnormality (n = 18, 43%).
Conclusion: This is the first major review of Australian children with
SLE, and demonstrates a high prevalence of lupus nephritis, in keep-
ing with international published data. As renal disease is associated
with major morbidity and mortality, early recognition and appropri-
ate aggressive immunosuppression is paramount especially in high
risk demographics.
1-­058 | Childhood systemic lupus
erythematous in the Western Australian
population II: management and outcomes
M. Cann; A. Sage; S.-J. Lee; N. Larkins; K. Murray
Perth Children's Hospital
Background/purpose: Systemic Lupus Erythematosus (SLE) is a seri-
ous autoimmune disease often resulting in major end-­organ damage,
morbidity and mortality. To date, no data exists focusing on the long-­
term management and progression of SLE in the Australian paediat-
ric population.
Objectives: To conduct the first Australian-­based review of child-
hood SLE, focusing on response to treatment and outcomes.
Methods: A retrospective review was conducted of patients diag-
nosed with SLE before 16  years from 1998–2018, resident in Western
Australia. Detailed collection of management and subsequent out-
comes were collected (GEKO No.13051; HREC:RGS0000001103).
Results: 41 (97%) children required systemic steroid therapy.
Average prednisolone use from diagnosis was 32.5 months. 15 chil-
dren were unable to cease steroid therapy. The majority of children
received immunosuppressive agents (41; 97%), with hydroxychloro-
quine (n = 36) and mycophenolate mofetil (n = 21) the most widely
used. On final review, 12 children developed cumulative organ dam-
age as described by the SDI. 29 children had renal involvement, 27
confirmed with renal biopsy. 19 children had grade 3 or 4 lupus ne-
phritis on at least one biopsy. Intravenous Cyclophosphamide and/
or rituximab were administered to 17 (40%) and 13 (31%) children re-
spectively. 3 children (7%) progressed to autologous stem cell trans-
plant for refractory disease. Complications of treatment and disease
included steroid induced obesity (n = 6), growth failure (n = 3) and
major thrombotic events (n = 3). 21 children (n = 50%) had infections
requiring admission to hospital. 1 child died. On final review (average
4.33 years post diagnosis), 23 children were steroid dependant, the
median SLEDAI was 4 and the average SDI was 0.5.
Conclusion: This is the first longitudinal retrospective review of
Australian children with SLE. Although improving, rates of end organ
complications in paediatric SLE remain high, similar to international
cohort outcomes. Longitudinal multi-­centre Australian research is
planned to elucidate risk factors for poor outcomes, and identifying
those warranting early more aggressive therapy.
1-­0 03 | Eosinophilic granulomatosis with
polyangiitis with mononeuritis multiplex – a case
report
C. Chan Jr1,2
1
Makati Medical Center; 2Philippine Rheumatology Association
Background: Eosinophilic Granulomatosis with Polyangiitis (EGPA)
is a vasculitis characterized by eosinophil-­
rich and necrotizing
granulomatous inflammation often associated with asthma and pe-
ripheral eosinophilia. The overall prevalence of EGPA in European
populations has been estimated to range from 2 to 38 cases per
million, however it is exceptionally rare among Filipinos. The organ-­
specific manifestations of EGPA are attributable to vasculitis and
parenchymal eosinophilic infiltration. This includes peripheral nerve
involvement characterized by painful paresthesias and numbness
which may progress to motor impairment and muscular atrophy.
Objective: To present a rare case of EGPA in a 56-­year-­old Filipino
male patient with full-­blown, well-­documented EGPA with monon-
euritis multiplex.
Case: A 56-­
year-­
old Filipino male with a history of late-­
onset
asthma presented with progressive gait disturbance due to pain,
numbness, and muscular weakness of both feet. He had mononeu-
ritis multiplex manifesting as left foot drop. Diagnostics revealed
peripheral eosinophilia at 78% differential count, negative anti-­
neutrophil cytoplasmic antibodies, axonopathy with secondary
myelinopathic features of the lower extremities consistent with
mononeuriritis multiplex seen on nerve conduction test. Surgical
history included a nasal polypectomy wherein polyps demon-
strated eosinophilia on biopsy. Bone marrow aspiration and biopsy
exhibited relative increase in eosinophils at 59.7%, while leukemia
and lymphoma panel were negative. He had evidence of myocar-
dial infarction with normal coronary arteries. Sural nerve biopsy
confirmed vasculitis with infiltrating inflammatory cells admixed
with eosinophils within the vessel wall. Fulfilling the criteria set by
the American College of Rheumatology, the patient was diagnosed
with EGPA. The patient received high dose oral glucocortocoids,
improving patient's symptoms and normalizing eosinophil count.
The plan is to taper steroids over a few months. in tne event of
disease relapse or progression, further immunosuppression with
cyclophosphamide or rituximab will be done.
Conclusion: To our knowledge, this is the first reported case of a
Filipino male with full-­blown, well-­documented EGPA vasculitis.
 |
      57

3-­091 | Impact of foot and/or ankle arthritis on One of the major complications of JIA is low bone mineral density
(BMD).
clinical remission
Objectives: The objectives of this study were to evaluate BMD in
S. H. Chang1; M. I. Kang2; S. W. Lee2; M. U. Kim3 patients with JIA and to determine factors correlated with BMD.
1
Soonchunhyang University Cheonan Hospital; 2Dankook University Hospital;
3
Methods: A cross-­sectional descriptive study was conducted in pa-
Ewha Womans University Hospital
tients with JIA followed up at the Pediatric Rheumatology Clinic,
Faculty of Medicine Siriraj Hospital, Bangkok, Thailand from July
Background/purpose: To assess the effect of foot and/or ankle
2015 to January 2016. BMD lumbar spine (BMDLS) and BMD total
arthritis (FAA) on clinical remission and compare their impact on
body (BMDTB) were measured by dual-­energy X-­ray absorptiometry
DAS28-­ESR, SDAI, CDAI, and RAPID3.
(DXA) scan. BMD was adjusted for height age. BMD Z-­score ≤−2 was
Methods: Data from Korean Biologic Registry (KoBio) data were ana-
defined as low bone mass. Age, body mass index, disease duration,
lyzed. FAA defined as one or more swollen and/or tender joint among
disease parameters, daily calcium intake, 25(OH)D level, medica-
1st–5th metatarsal or ankle joints. Univariate analysis was conducted to
tions, duration of sunlight exposure and weight bearing physical ac-
determine potential risk factors for clinical remission using chi-­square
tivity were collected.
test, Fisher's exact test, or Student's t-­test, as appropriate. Variables
Results: Thirty-­eight patients (22 boys and 16 girls) with JIA were
were included as follows: gender, RF positivity, anti-­CCP positivity, dis-
evaluated. Systemic JIA was the most common subtype (39.5%),
ease duration, past or current smoking history, no current use of MTX,
followed by enthesitis-­related arthritis (31.6%) and oligoarticular
previous use of biologic DMARDs, BMI, radiographic damage (i.e. joint
JIA (10.5%). Median (IQR) age was 10.1 (8.1–13.1) years. The me-
space narrowing or bone erosion) on hand or foot X-­ray, and FAA. To
dian (IQR) of duration of disease was 23.1 (11.6–39.4) months. The
define impacting factors for clinical remission, multivariate analysis
median (IQR) of JADAS-­71 was 4 (0.1–11.1). Twenty-­six (68.4%)
was done with variables with P > 0.5 in multivariate analysis, odds for
patients had active disease. Mean BMDLS was 0.727 ± 0.15 g/
non-­remission was evaluated for interpretation convenience.
cm2 . The mean of BMDTB was 0.876 ± 0.094 g/cm2 . None had low
Results: Absence of RF or anti-­CCP antibody, no previous use of bD-
BMDLS Z-­s core whereas only 2 (5.3%) patients had low BMDTB Z-­
MARDs, short disease duration, no radiographic damage on hand x-­
score. Duration of glucocorticoid treatment and body mass index
ray, and no FAA was significantly associated with DAS28 remission.
were significantly positively correlated with both BMDLS and
SDAI, CDAI, and RAPID3 remission was significantly associated with
BMDTB (P = 0.01).
no previous use of bDMARDs and no FAA. in multivariate analysis,
Conclusion: Our study demonstrated a low prevalence of low bone
presence of RF [odds ratio, 2.46, (95% CI, 1.60–3.78)], previous use
mass among children and adolescents with JIA. Duration of gluco-
of bDMARDs [OR 4.20 (1.81–9.77)], radiographic damage on hand
corticoid treatment positively correlated with BMD.
x-­ray [OR 2.07 (1.37–3.09)], and presence of FAA [OR 3.18 (1.79–
5.65)] were significantly associated with DAS28 non-­remission. Even
in multivariate analysis, previous use of bDMARDs and presence of
FAA were significantly associated with SDAI [OR 3.97 (1.23–12.90), 1-­078 | Prevalence and patient attitudes
OR 8.59 (2.67–27.68)], CDAI [OR 6.14 (1.49–26.35), OR 7.50 (2.34– towards side effects of low-­dose corticosteroids
24.10)], and RAPID3 [OR 7.37 (2.70–20.08), OR 4.74 (2.54–8.86)] in the treatment of rheumatoid arthritis
clinical non-­remission.
A. Chen1,2
Conclusion: Although FAA are not involved, they impact on clini- 1
University of Sydney; 2Concord Repatriation General Hospital
cal remission indices. Patients with FAA are more likely to be non-­
remission in SDAI or CDAI than in DAS28.
Background: Glucocorticoids are a central component in the man-
agement of rheumatoid arthritis (RA), alongside disease modifying
anti-­rheumatic drugs (DMARDs) and newer biologic agents. Whilst
1-­059 | Prevalence of low bone mass among
many systemic adverse effects are well known and carefully moni-
children and adolescents with juvenile idiopathic
tored for (e.g. osteoporosis, diabetes, atherosclerosis, etc.), there has
arthritis is low: a study from Thailand been a growing realisation that patients frequently experience other
S. Charuvanij1; H. Malakorn1; N . Densupsoontorn2; P. side effects not screened by doctors that patients consider to be
Nakavachara3 important to their quality of life.
1
Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Objective: To assess the prevalence and patient attitudes toward
Siriraj Hospital, Mahidol University; 2Division of Nutrition, Department of
side effects of low-­dose corticosteroids in the treatment of rheu-
Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University; 3Division of
Endocrinology and Metabolism, Department of Pediatrics, Faculty of Medicine matoid arthritis.
Siriraj Hospital, Mahidol University Methods: A cross-­
sectional survey of 46 RA outpatients being
treated with low-­
dose corticosteroids (<10 mg prednisone) was
Background: Juvenile idiopathic arthritis (JIA) is a well-­recognized carried out at Concord Hospital Rheumatology Department over
common chronic rheumatic disease in children and adolescents. 6 months. The anonymous questionnaires collected information on
 |
58      
patient demographics and their corticosteroid regime in addition to
asking subjects to rate the degree to which they experienced com-
mon patient-­reported side effects in the past month and the impor-
tance of these. Statistical analyses were performed on dichotomous
variables using one-­way ANOVA, Pearson chi-­squared tests and
multiple variable regression.
Results: There were 46 subjects, with the majority being female
(59.5%) and aged between 50–75 years old (69%) whilst the mean
daily dose of corticosteroids was 5.31 mg/d (SD = 2.46). The most
common side effects experienced was easy bruising (50%) followed
by sleep disturbance (41.6%) and thinning skin (39.5%). The side
effects most frequently rated as important were confusion & mem-
ory problems (54.8%), depression (52.4%) and swollen legs (50%).
Conclusions: Many rheumatoid arthritis patients experience and are
concerned about adverse effects which may potentially be related
to their corticosteroid treatment. Factors influencing the severity &
perceived importance of these symptoms may be related to patient
gender and corticosteroid dose. Rheumatologists need to be aware
of these symptoms as well as address patient priorities and attitudes
in order to facilitate an effective patient-­doctor relationship.
3-­127 | The diversity of IGH immune repertoire
in SLE analyzed by high throughput sequencing
W. -S. Chen1,2; C.-W. Liu1; C.-O. Choy3; H.-T. Liao1; J. Han4;
S.-F. Tsai3; C.-Y. Tsai1; D.-M. Chang1
1
Division of Allergy, Immunology, & Rheumatology, Taipei Veterans General
Hospital; 2Institute of Clinical Medicine, National Yang-­Ming University;
3
Institute of Molecular and Genomic Medicine, National Health Research
Institutes; 4iRepertoire, Inc
Background/purpose: Systemic lupus erythematosus (SLE) is a
chronic multifactorial autoimmune disease characterized by protean
autoantibody production, the underlying mechanism of which is as
yet not fully understood. Aberrant immune responses are the hall-
marks of SLE.
Objectives: We monitored changes in immune repertoire (iR) of
immunoglobulin heavy chain (IGH), particularly complementarity
determining region 3 (CDR3) sequences using massively parallel se-
quencing technology.
Methods : CDR3 sequencing was carried out on clinical blood sam-
ples from SLE patients for disease progress monitoring. The iR of
each sample was obtained using next generation sequencing (NGS)
pipeline. Data analysis was done with web-­
based iRweb server.
Principal components analysis (PCA) was completed with custom-
ized statistical pipeline.
Results: We have obtained datasets from 19 patients covering VDJ
regions of IGH gene. D50, which is a quantitative measure of B cell
clonal diversity, stayed low for all cases (mean D50 = 9.4). A pattern
of common CDR3 sequences was confirmed by a clustering pattern
within PCA. D50 analysis showed clonal diversity would remain low
throughout the disease process (mean D50 = 3.4) regardless of fluc-
tuation in disease activity, as measured by SLEDAI. Individuals had
his/her own clonal variation staying stable throughout the disease
course as measured by PCA.
Conclusion: We have successfully constructed the experimental
design, data acquisition, data processing, data analysis pipeline of a
high throughput massively parallel CDR3 sequences detection to be
used for SLE disease activity monitoring.
1-­066 | Remission targets and prevention of
subclinical atherosclerosis in psoriatic arthritis –
which target should we choose?
T. H. Cheng; S. Qing; E. K. Li; P. C. H. Wong; L. H. P. Tam; M.
M. Chang; J. Lee; A. P. W. Lee; L. Tam
The Chinese University of Hong Kong
Background: Systemic inflammation contribute to the excess risk
of cardiovascular disease (CVD) in psoriatic arthritis (PsA). We have
demonstrated that achieving sustained-­minimal-­disease-­activity
(sMDA) was associated with protective effect on subclinical athero-
sclerosis (SCA) and arterial stiffness (AS)(1). Nonetheless, it's unclear
whether clinical remission needs to be achieved in order to diminish
the CV harmful effects or if stable low disease activity over time is
sufficient.
Objective: To investigate the effect of different levels of disease ac-
tivity over time, on SCA and AS progression in PsA patients.
Method: We conducted a post-­hoc analysis of the PsAMDA-­vascular
study (1). All patients received protocolized-­
treatment aiming at
MDA for a 2 years. High-­resolution ultrasound (for SCA) and AS were
assessed annually. Carotid plaque progression was defined as an in-
crease in number or region harboring plaque compared with baseline.
Four potential definitions of remission/inactive disease were used:
MDA and very-­low-­disease-­activity (VLDA)(2) were defined as 5 and
7 MDA cut-­points were met respectively. Disease Activity Index for
Psoriatic Arthritis (DAPSA) remission (DAPSA-­rem) and low disease
activity (DAPSA-­LDA) were defined as DAPSA ≤4 and DAPSA ≤14
respectively. Sustained disease control was defined as achieving
these targets at each consecutive visit from month12 till month24.
Results: 90 PsA patients [male:52(58%);age:50 ± 11] were included
in this analysis. at 24-­
months, 62 (69%) were on csDMARDs,
20(22%) were on anti-­
TNF-­
α and 8(9%) were on Secukinumab.
After intensive treatment, significant improvement in disease ac-
tivity was observed (MDA:15[17%] at baseline vs 62[69%] at 2-­
year, P < 0.001;DAPSA:19[13,32] at baseline: vs 7[4,14] at 2-­year,
P < 0.001). in terms of sustain disease control, 46%, 4%, 44% and
4% of subjects achieved sustained-­MDA (sMDA), sustained-­VLDA
(sVLDA), sustained-­DAPSA-­LDA and sustained DAPSA-­rem respec-
tively. 34(38%) of subject had plaque progression. The rate of plaque
progression was significantly lower in subject achieving sMDA when
compared to those did not. Achieving sMDA was also significantly as-
sociated with less progression in mean intima-­media thickness (IMT)
and augmentation index (AIx)(Figure 1). Using multivariate analysis,
achieving sMDA had protective effect on plaque progression, less
 |
      59

2
increase in total plaque area (TPA), mean IMT and AIX after adjust- Adjusted for age, gender, baseline BMI, VAS pain score, patient's
ing baseline covariates (Table 1). No significant association between global assessment score, plasma total triglyceride, total cholesterol,
progression of vascular parameters and other treatment targets was LDL-­C level and use of csDMARDs; 3Adjusted for disease duration,
observed. baseline CRP, Framingham risk score, use of NSAIDs and use of bD-
4
Conclusion: Achievement of sMDA was associated with protec- MARDs throughout the year; Adjusted age, gender, baseline CRP,
tive effect in SCA and AS progression but not sDAPSA-­
LDA. waist-­to-­hip ratio, plasma total cholesterol, LDL-­C level, NSAIDs use
5
Multidimensional domain of disease control is preferable for mini- and maximum IMT; Adjusted for age, gender, baseline abdominal
6
mizing CV-­risk in PsA. obesity and PWV; adjusted with age, gender, baseline AIX and

Table 1 Multivariate analysis on the change in mean/max IMT, AIX, csDMARDs use throughout the year; IMT-­intima media thickness;

PWV, any plaque progression and change TPA AIX-­

augmentation index; PWV-­
pulse wave velocity; TPA-­
total
plaque area; LDL-­C-­low density lipoprotein cholesterol; BMI-­body
Multi-­variate analysis
mass index; csDMARDs-­conventional synthetic disease modifying
OR 95%CI P-­value anti-­rheumatic drugs; bDMARDs-­biologic disease modifying anti-­
Plaque progression 1 rheumatic drugs; VAS-­visual analogue scale; CRP-­C-­reactive protein;
Age 1.069 1.009 to 1.131 0.023 NSAIDs-­non-­steroidal anti-­inflammatory drugs.

Physicians’ global 0.964 0.936 to 0.993 0.016 References: 1. Isaac T Cheng QS, Edmund K Li, Priscilla CH Wong,
assessment, baseline Lydia H Tam, Tracy Y Zhu, Mimi M Chang, Jack JW Lee, CK Wong,
Plasma LDL-­C , baseline 2.628 1.310 to 5.493 0.007 Alex PW Lee, Lai-­shan Tam. Can achieving sustained Minimal Disease

bDMARDs use at 0.110 0.018 to 0.652 0.015 Activity (MDA) prevent progression of subclinical atherosclerosis? A
baseline two-­year prospective cohort study in Psoriatic Arthritis. 19th Asia
Achieved sustained 0.273 0.088 to 0.846 0.024 Pacific League of Associations for Rheumatology Congress (APLAR);
MDA Dubai: International Journal of Rheumatic Diseases; 2017.
Multi-­variate analysis 2. Coates LC, Fransen J, Helliwell PS. Defining minimal disease activ-
ity in psoriatic arthritis: a proposed objective target for treatment.
  β 95%CI P-­value
Ann Rheum Dis. 2010;69:48–53.
Change in total plaque area2
BMI, kg/m2, baseline −0.428 −0.760 to −0.096 0.012
Plasma LDL-­C , baseline 2.828 0.723 to 4.932 0.009 1-­079 | The Patient Acceptable Symptom State
Achieved sustained −3.919 −7.181 to −0.657 0.019 (PASS) in Asian rheumatoid arthritis (RA) patients
MDA
P. Cheung1,2; P. Dhanasekaran1,2; D. Tan3; S. R. Wong3; A.
Change in mean IMT3
Yap3; P. Phan2; M. Lahiri1,2
bDMARDs use −0.034 −0.065 to −0.004 0.028 1
Division of Rheumatology, National University Hospital; 2Yong Loo Lin School
throughout the year of Medicine, National University; 3Department of Rehabilitation, National
Achieved sustained −0.037 −0.066 to −0.007 0.014 University Hospital
MDA
Change in max IMT4 Background/purpose: The level of acceptability of the disease sta-
Age 0.003 0.000 to 0.005 0.038 tus, the PASS, is an important patient-­reported outcome measure
CRP, baseline 0.002 0.000 to 0.005 0.036 (PROM) in RA, not evaluated in Asians. The objective is to evaluate
NSAIDs use, baseline 0.122 0.045 to 0.199 0.003 the characteristics of the PASS and its corresponding cut-­offs for
Maximum IMT, baseline −0.455 −0.646 to −0.264 <0.001 clinical outcomes and PROMs in multiethnic Asians with RA.

Change in PWV 5 Methods: RA patients in a randomised controlled trial evaluating mul-

tidisciplinary care in a tertiary academic centre in Singapore. Clinical
Age 4.953 0.919 to 8.986 0.017
measures included (i) disease activity: Disease Activity Score (DAS28-­
PWV, baseline −0.483 −0.676 to −0.289 <0.001
ESR), Clinical Disease Activity Index (CDAI), (ii) PROMs on a 0-­10 scale
Achieved sustained −71.4 −143.2 to 0.2 0.051
(10 being the worst) for pain, coping, patient global disease assess-
MDA
ment (PGA), and (iii) quality of life (QOL): modified Health Assessment
Change in AIX6
Questionnaire (mHAQ) and Euro-­QOL 5-­Dimension 3-­level (EQ5D).
Male gender 3.332 0.105 to 6.560 0.043
Cut-­off values of the PASS were estimated using the 75th percentile of
Achieved sustained −3.059 −6.067 to −0.051 0.046
the cumulative distribution for each measure rated as PASS positive.
MDA
Multivariate logistic regression evaluated predictors of PASS.
1
Adjusted for age, gender, baseline deformed joint count, physicians’ Results: 131 patients (86.3% female, 53.4% Chinese, age
global assessment score, plasma total triglyceride, total cholesterol, 54.4 ± 12.7 years) were included. Median (IQR) disease duration
LDL-­C , use of bDMARDs and presence of carotid plaque at baseline. was 5.5 (2.4, 11.0) years, DAS28 was 2.90 (2.24, 3.65) and CDAI
 |
60      

was 5.0 (2.0, 10.0). Median mHAQ was 0 (0, 0.25) and mean EQ5D
was 0.74 ± 0.28. 110 (84%) patients were in PASS and had lower
disease activity, patient reported symptom levels and better QOL
(P < 0.001). 62.5% were either in DAS28 remission or low disease ac-
tivity. PASS cut-­off for DAS28 was 3.50, CDAI was 6.5, mHAQ was
0.13, and EQ5D was 0.85. For PROMs, cut-­off for pain was 3.5, PGA
was 3.0 and coping was 4.5. in multivariate analysis, poorer levels of
coping and higher disease activity (CDAI) negatively predicted being
in PASS, with OR 0.87 (95%CI 0.76–0.99, P = 0.028) and OR 0.91
(95%CI 0.86–0.97, P = 0.002) respectively.
Conclusion: PASS is a valid tool for Asian RA patients, with cut-­offs
consistent with the literature (3.0–4.5) for PROMs on VAS. Disease
activity and levels of coping were good predictors of PASS.
response. For ACR50 response, tocilizumab 8 mg/kg remained su-
perior to lower doses of baricitinib and filgotinib. Interestingly, to-
cilizumab 8 mg/kg is superior to any dose of salirumab. There is
no significant difference in ACR70 response between Tocilizumab
8 mg/kg and other bDMARDs and JAK inhibitors.
Conclusion: All bDMARDs and JAK inhibitors have comparable effi-
cacies in RA patients with an inadequate response to TNFi. However,
Tocilizumab 8 mg/kg is better than other bDMARDs and JAK inhibi-
tors in terms of ACR20 response.

2-­093 | Comparative effectiveness of biologic

DMARDs and JAK inhibitors in patients with an
inadequate response to TNF inhibitors: a network
meta-­analysis
T. T. Cheung; M.-F. Tsoi; M.-Y. B. Cheung; C.-S. Lau
The University of Hong Kong

Background/Purpose: TNF inhibitor (TNFi) is the first biologic dis-

ease modifying anti-­rheumatic drugs (bDMARDs) available for the
treatment of rheumatoid arthritis (RA). Therefore, many studies have
compared the efficacies of other bDMARDs and Janus kinase (JAK)
inhibitors in patients with an inadequate response to TNFi. However,
head to head comparison among other bDMARDs and JAK inhibitors
is lacking. Therefore, we conducted a network meta-­analysis to com-
pare the efficacies of bDMARDs and JAK inhibitors in patients with
an inadequate response to TNFi.
Methods: Literatures were searched in MEDLINE, clinicaltrials.gov
and EMBASE. For inclusion, randomised controlled trials must in-
clude RA patients with an inadequate response to TNFi and report
proportion of patients achieved ACR20 response in week 12/24.
Results were analysed using R version 3.5.1 with ‘netmeta’ 4.9-­2.
Summary odds ratio and 95% confidence interval were estimated
using random-­effects model.
Results: 12 trials were included in this analysis.

In patients with an inadequate response to TNFi, tocilizumab 8 mg/kg

is superior to other bDMARDs and JAK inhibitors in terms of ACR20
 |
      61

1-­067 | Utility of three different psoriasis-­ 2. Tinazzi I, Adami S, Zanolin EM, et al. The early psoriatic arthritis screen-
ing questionnaire: a simple and fast method for the identification of arthri-
related screening tools to screen for psoriatric
tis in patients with psoriasis. Rheumatology (Oxford) 2012; 51:2058–63.
arthritis in an outpatient setting
3. Chiowchanwisawakit P, Wattanamongkolsil L, Srinonprasert V, et
P. Chiowchanwisawakit; L. Chularojanamontri; N. Junsuwan; al. Developing the Thai Siriraj Psoriatic Arthritis Screening Tool and
N. Silpa-archa; C. Wongpraparut validating the Thai Psoriasis Epidemiology Screening Tool and the
Faculty of Medicine Siriraj Hospital, Mahidol University
Early Arthritis for Psoriatic Patients questionnaire. Rheumatol Int
2016; 36:1459–68.
Objective: To assess the clinical utility of the Psoriasis Epidemiology
Screening Tool (PEST)1, the Early Arthritis for Psoriatic Patients
(EARP) questionnaire2, and the Siriraj Psoriatic Arthritis Screening
2-­064 | Seasonal variations and associated
Tool (SiPAT)3 as screening tools for psoriatic arthritis (PsA), and to
identify factors significantly associated with PsA. factors of gout attacks: a prospective multicenter
Method: This cross-­sectional study included adult psoriasis patients data in South Korea
who had not been previously been diagnosed with PsA who attended H. Choi1; K. W. Moon2; H.-O. Kim3; Y.-A. Lee 4; S.-J. Hong4;
the outpatient clinic at Siriraj Hospital. Participants completed the J.-Y. Jung5; H.-A. Kim5; C.-H. Suh5; Y.-J. Ha6; I. J. Kim7; J.
EARP, PEST, and SiPAT assessment tools, after which musculoskel- Lee7; E. K. Park8; S. G. Lee8; M. R. Seo1; H. J. Baek1; S. T.
etal history was taken, and examination and radiography were per- Choi9; J. Song9
1
formed. Diagnosis of PsA was based on rheumatologist evaluation Gachon University Gil Hospital, Gachon University School of Medicine;
2
Kangwon National University School of Medicine; 3Gyeongsang National
according to Classification Criteria for Psoriatic Arthritis (CASPAR).
University School of Medicine; 4Kyung Hee University Hospital; 5Ajou University
Receiver operator characteristic (ROC) curves, sensitivity, and speci- School of Medicine; 6Seoul National University Bundang Hospital; 7Ewha
ficity were used to determine assessment tool performance. Logistic Womans University School of Medicine; 8Pusan National University School of
Medicine; 9Choong Ang University Hospital
regression analysis was used to identify factors associated with PsA.
Results: Eighty-­seven patients with a mean age of 45.90  ±  14.75  years
Objectives: To evaluate the seasonality and associated factors of
were enrolled. Twenty-­six (29.88%) patients were diagnosed as PsA.
gout attacks in Korea.
According to ROC values, EARP had the best discriminative power
Methods: We prospectively enrolled patients with gout attacks at nine
(0.83) for distinguishing between psoriatic patients with and with-
rheumatology clinics and followed up for 1-­year from January 2015
out PsA (SiPAT: 0.78, PEST: 0.77). SiPAT had the highest sensitiv-
through July 2018. Demographic data, clinical and laboratory features,
ity (92.3%), followed by EARP (84.6%) and PEST (50.0%); whereas,
and meteorological data including seasonality were collected.
PEST had the highest specificity (82.0%), followed by EARP (62.3%)
Results: Two hundred five patients (male 94.1%) were enrolled. The
and SiPAT (54.1%) for detecting PsA, regardless of inflammation pat-
proportion of initial gout attack was 46.8% (n = 96). The mean of age
terns. Univariate analysis showed disease duration >10 years [odds
at the enrollment was 50.5 years, of body mass index was 26.1, of
ratio (OR): 3.03, 95% confidence interval (CI): 1.14–8.03], nail in-
duration of gout attack was 10.2 days, and of mean serum uric acid
volvement (OR: 5.02, 95% CI: 1.07–23.52), and body surface area
was 7.3 mg/dL. Gout attacks were most common in the spring season
(BSA) involvement >10% (OR: 3.58, 95% CI: 1.36–9.41) to be signifi-
(43.4%) and in March (23.4%, P < 0.001, respectively). Similar pat-
cantly associated with PsA. Multivariable analysis revealed BSA in-
tern of seasonality was shown in the group with initial gout attacks.
volvement >10% to be the only independent predictor of PsA (OR:
Alcohol was most common aggravating factors (39.0%), especially in
2.99, 95% CI: 1.09–8.21).
summer (50%). The mean diurnal change of temperatures at the day
Conclusions: SiPAT is an effective and simple to use tool for screen-
of gout attack was highest in the spring (10.3OC), followed by win-
ing PsA in psoriasis patients in an outpatient setting. Effective treat-
ter (9.1OC), summer (8.1OC), and fall (8.0 OC) (P = 0.027). The mean
ment of skin psoriasis may prevent the development of PsA.
change of humidity between two consecutive days (the day before
Acknowledgements: This research project was supported by the
and attack day) was significantly different among seasons (3.4% in
Siriraj Research Fund, Faculty of Medicine Siriraj Hospital, Mahidol
spring, 0.2% in summer, 0.4% in fall, −3.9% in winter, P = 0.015). One
University (grant no. R015935053). The authors wish to thank the
hundred twenty-­five (61%) patients completed 1-­year follow-­up (51%
study participants for their cooperation, and Dr Chulaluk Komoltri
in the group of initial attack). During follow-­up, total 51 gout flares
for statistical advice.
developed (18 flares in the group of initial attack). There was no sig-
Conflict of interest declaration: All authors declare no personal or
nificant seasonal variations among follow-­up flares.
professional conflicts of interest relating to any aspect of this study.
Conclusions: In this prospective study of Korea, the most common sea-
References: 1. Ibrahim GH, Buch MH, Lawson C, et al. Evaluation
son and month of gout attack were spring and March. Alcohol was most
of an existing screening tool for psoriatic arthritis in people with
common aggravating factor, especially in summer. Diurnal changes of
psoriasis and the development of a new instrument: the Psoriasis
temperatures at the attack day and humidity changes between the day
Epidemiology Screening Tool (PEST) questionnaire. Clin Exp
before and the attack day were associated with gout attack in our cohort.
Rheumatol 2009; 27:469–74.
 |
62      
1-­038 | The association between knee
osteoarthritis and coffee consumption in elderly
Koreans
J. H. Jung; S. J. Choi; G. G. Song
Korea University Medical Center
Background/purpose: Coffee is one of the most consumed bever-
ages globally, and coffee consumption is increasing. Osteoarthritis
(OA), the most common musculoskeletal disease in the elderly, is
also becoming more prevalent. in particular, the knee is most com-
monly affected large joint by OA which causes pain and physical
disability. Coffee is associated with various diseases, but there has
not yet been a study of the relationship between coffee and knee
OA. We investigated this relationship in elderly Koreans.
Methods: Data from 2012–2013 were collected from the Korea National
Health and Nutrition Examination Survey. We included 2302 participants
in our study: 897 men and 1405 women. Participants with knee OA were
defined as those whose knee joints exhibited radiographic change of
Kellgren-­Lawrence grade 2 or higher. Daily coffee consumption amounts
were categorized as none, <2 cups, 2–3 cups, 4–6 cups and ≥7 cups based
on self-­
reporting. Sex, age, body mass index, hypertension, diabetes
mellitus, dyslipidemia, alcohol consumption, smoking status, household
income, education level, and occupational cluster were considered as po-
tential confounding variables affecting OA risk and coffee consumption.
Results: A multiple logistic regression model, the odds ratios (ORs)
of knee OA in the <2 cup, 2–3 cup, 4–6 cup and ≥7 cup groups com-
pared to the no-­coffee group in men were 1.13 (95% CI 0.50–2.55),
1.79 (95% CI 0.81–3.97), 2.21 (95% CI 0.91–5.35), and 3.81 (95%
CI 1.46–12.45), respectively. There was no significant association
between coffee consumption and knee OA prevalence in women.
Conclusion: Daily more than 7 cups of coffee drinking was associated
with a prevalence of knee OA in Korean men, and although the ORs did
not increase significantly across consumption levels, the prevalence
of knee OA tended to increase with increasing coffee consumption.
2-­141 | Comparisons of clinical manifestations
and prognosis between giant cell arteritis
patients with or without sensorineural hearing
loss: a retrospective study
X. Chu1; D. Wang2; Y. Yin1; Y. Zhang1; M. Shen3; H. Jiang4; X.
Zeng1
1
Department of General Internal Medicine, Peking Union Medical College
Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and
Peking Union Medical College (PUMC); 2Department of Neurology, Nanfang
Hospital, Southern Medical University; 3Department of Rheumatology, Peking
Union Medical College Hospital (PUMCH), Chinese Academy of Medical
Science (CAMS) and Peking Union Medical College (PUMC); 4Department of
Otorhinolaryngology, Peking Union Medical College Hospital (PUMCH), Chinese
Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC)
Purpose: Auditory manifestations has rarely been mentioned in
studies concerning giant cell arteritis (GCA). This study explores the
prevalence of hearing loss (HL) in Chinese GCA patients and investi-
gates the differences in clinical features between GCA patients with
or without HL.
Methods: We retrospectively collected clinical data of 117 GCA
patients form Peking Union Medical College Hospital (PUMCH) be-
tween November 1998 and October 2017. Patients with obviously
incomplete data were excluded. Subgroup analysis was conducted
according to the occurrence of HL.
Results: 91 out of 117 GCA patients met the inclusion criteria; 23
patients (25.3%) had HL and 68 didn't. in HL group, there was a
higher percentage of males (P = 0.025) and patients with HL were
more likely to have symptoms such as headache, visual loss or CNS
symptoms (P = 0.011, P = 0.039, P = 0.035), or to have smoking his-
tory (P = 0.019). Moreover, they were more likely to have lower
lymphocyte count (P = 0.049), positive ANA or APS (P = 0.047,
P = 0.017) or negative biopsy results (P = 0.011). Patients without
HL were more likely to have symptoms such as myalgia (P = 0.001),
as well as comorbid disease like coronary artery disease (P = 0.024)
and hypertension (P = 0.039). No significant differences were found
in age, disease course, inflammatory markers, hemoglobin, platelet,
vascular involvement or prognosis between the two groups.
Conclusions: HL was not rare in Chinese patients with GCA.
Clinicians should consider GCA when patients present HL as well
as headache, visual loss, CNS symptoms or fever. More attention
should be paid to HL in GCA diagnosis and management.
2-­114 | Accuracy and reliability of spinal
inflammation intensity on STIR sequence
according to the SPARCC MRI Index in axial
spondyloarthritis
H. Y. Chung; C. S. Lau; T. T. Cheung
The University of Hong Kong
Objective: To determine the accuracy of detecting the intensity of spinal
inflammation on short tau inversion recovery (STIR) sequence according
to the Spondyloarthritis research Consortium of Canada (SPARCC) MRI
index by comparing with the apparent diffusion coefficient (ADC) values
of the active MRI lesions in axial spondyloarthritis (axSpA).
Methods: Fifty active lesions in STIR sequence of spinal MRI were
identified. With reference to sites of active lesions in STIR, the corre-
sponding region of interest (ROI) on ADC map was drawn to determine
the maximum ADC (ADCmax) and mean ADC (ADCmean). in addition, we
determined the background ADC to calculate the normalized maxium
(nADCmax) and mean (nADCmean). Four independent readers scored the
identified active lesions as “intense” or “not intense” according to the
SPARCC MRI index. They were compared to ADCmax, ADCmean, nAD-
Cmax, and nADCmean, for assessment of accuracy. Cohen's kappa coef-
ficient (K) was used to determine the inter-­reader agreements.
Results: There were differences in ADCmax between “intense” and
“not intense” lesions scored by 3 of the 4 readers (1365.5 ± 288.0
vs 1196.4 ± 234.1, P = 0.03; 1390.1 ± 248.9 vs 1229.6 ± 272.7,

P = 0.05; 1405.2 ± 290.2 vs 1232.6 ± 254.6, P = 0.04).
ADCmean of the lesions, differences were observed in “intense”
and “not intense” lesions scored by 1 reader only (868.1 ± 209.2 vs
720.2 ± 247.7, P = 0.04). nADCmean and nADCmax were not different
between “intense” and “not intense” lesions scored by the 4 readers.
Inter-­reader agreements were only slight to fair (K = 0.08–0.34).
Conclusion: SPARCC MRI index has the ability to differentiate de-
gree of spinal inflammation but its reliability is only fair.
1-­111 | Clinical predictors of disease relapse
and mortality in immunoglobulin G4-­related
disease from a retrospective cohort in Hong
Kong
H. Y. Chung1; R. C. P. Tang2
1 2
The University of Hong Kong; Pamela Youde Nethersole Eastern Hospital
Background/purpose: There is limited data on disease relapse and
mortality in immunoglobulin G4-­relarted disease (IgG4-­RD).
Objective: To describe and determine the clinical predictors of dis-
ease relapse and mortality retrospectively in a cohort of IgG4-­RD.
Method: Patients with an expert diagnosis of IgG4-­RD were re-
cruited from 4 rheumatology centers in Hong Kong. Clinical data,
duration of follow up, time to initial relapse, and time to mortality
were recorded. Data was analyzed using univariate and multivari-
ate Cox regression models to determine clinical predictors of relapse
and mortality. Kaplan-­Meier log survival curves were plotted for
variables stratified by use of immunosuppressant therapy.
Results: One hundred forty-­t hree patients with IgG4-­R D were re-
cruited. One hundred and six (74.1%) were male patients. Mean
age of disease onset was 62.3 ± 12.7 years and average disease
duration was 3.8 ± 3.5 years. Multivariate Cox regression showed
that combined surgery and steroid induction therapy (HR 2.46;
95% CI 1.39–4.35; P < 0.01) was positively associated with ini-
tial relapse and that immunosuppressant therapy (HR 0.45; 95%
CI 0.23–0.86; P = 0.02) was negatively associated with relapse.
When the variable “immunosuppressant therapy” was replaced
with “steroid-­sparing immunosuppressant therapy” and “dosage of
prednisolone” in multivariate Cox regression, the steroid-­sparing
therapy showed a tendency to be negatively associated with ini-
tial relapse (HR 0.36; 95% CI 0.11–1.19; P = 0.09). in the models
on mortality, multivariate Cox regression showed that “age at di-
agnosis” (HR 1.14; 95% CI 1.02–1.27; P = 0.02), and “CRP level at
diagnosis” (HR 1.03; 95% CI 1.00–1.06; P = 0.03) were positive
predictors of mortality.
Conclusion: Based on our results, we recommend steroid-­sparing
immunosuppressant maintenance therapy in selected group of pa-
tients and careful monitoring in the elderly with IgG4-­RD.
|
      63
For 1-­128 | Good response to methylprednisolone
pulse therapy among SLE patients presenting
with psychosis
E. V. Co; E. Salido
Philippine General Hospital
Background: In a patient with Systemic Lupus Erythematosus, psy-
chosis may be due to active disease, corticosteroid use, infection, or
metabolic abnormality. These conditions have different treatment
approaches. There is also no single test available to establish the di-
agnosis of lupus psychosis.
Objective: To discuss four cases of psychosis in systemic lupus
erythematosus.
Method: Case report.
Results: We present 4 patients with active lupus who manifested with
psychosis. All four patients presented with insomnia, hallucinations,
delusions, and agitation. All had active cutaneous disease, hypoal-
buminemia, anemia, and positive anti-­nuclear antibody test. Other
lupus manifestations were arthritis (2), nephritis (2), high titers of anti-­
dsDNA, and low serum C3 (3). All of them needed hospitalization, two
had infections (pneumonia, tuberculous meningitis-­positive CSF TB
PCR). Cranial CT scans were unremarkable. All received methylpred-
nisolone pulse therapy (500–1000 mg/day for three days) and antip-
sychotic medication (risperidone). Two patients received intravenous
cyclophosphamide. Anti-­tuberculous medication was started for the
patient with tuberculous meningitis. All of them fully recovered from
the psychosis. Improvement was immediate in one patient (tubercu-
lous meningitis) but was observed within a month for the other three.
Conclusion: Our patients showed that psychosis in SLE may be
multifactorial. Investigation should consider various etiologies. in
general, in the presence of lupus activity and a good response to
methylprednisolone pulse therapy with or without other immuno-
suppressive agents, psychosis is presumed to be secondary to lupus.
3-­128 | Presumed autoimmune retinopathy
presenting as retinitis pigmentosa in a patient
with localized discoid cutaneous lupus
erythematosus
K. J. Cortez; H. B. Reyes; E. V. Co; F. M. Sy-Alvarado; D. N.
Espiritu
Philippine General Hospital
Background: Discoid lupus erythematosus (DLE) is the most com-
mon form of chronic cutaneous lupus erythematosus. Autoimmune
retinopathy (AIR), among patients with DLE, is rarely reported.
Enolase antibodies and STAT4 may be associated with the pathogen-
esis of these two disoders.
Case: We present a case of 40 year old female diagnosed wth DLE
in 2011. She received clobetasol ointment and hydroxychloroquine
200 mg daily for a year. She developed progressive blurring of vision
 |
64      
on the second year. There was no associated nyctalopia, photopsia,
and scotoma. There was no family history of blindness. On physical
examination, there were multiple active discoid lesions on the left
side of her face. Hydroxychloroquine retinopathy was initially con-
sidered. Funduscopic examination revealed a pigmentary retinopathy
with bone-­spicule formations in both eyes. Macular edema of the left
eye was noted on optical coherence tomography. at that time, oph-
thalmology service considered retinitis pigmentosa. Vitamin A and a
short course of topical NSAIDs were given. Hydroxychloroquine was
continued. For the next 7 years, her vision was stabilized and main-
tained despite active discoid lesions. She was given tacrolimus and
mometasone ointment, and oral prednisone. Ophthalmology service
reviewed the patient's case and concluded that findings are consist-
ent with the entity called autoimmune retinopathy.
Conclusion: It is vital that DLE patients with blurring of vision are
assessed for AIR, a vision threatening condition.
1-­129 | Severe tuberculosis infection following
high dose steroid treatment in SLE: a case report
1 1,2 1 1,3
I. J . Coronel ; G. Penserga ; N. N. Pajes ; V. Ramiro ; J.
Magallanes1,4; B. Lim1,5; F. Tranquilino1,3
1
UP-­Philippine General Hospital Department of Medicine; 2Section of
Rheumatology, UP-­Philippine General Hospital Department of Medicine;
3
Section of Cardiology, UP-­Philippine General Hospital Department of Medicine;
4
Section of Pulmonology, UP-­Philippine General Hospital Department of
Medicine; 5Section of Infectious Diseases, UP-­Philippine General Hospital
Department of Medicine
Background/purpose: Tuberculosis (TB) is an endemic infection in
the Southeast Asia and other developing countries with an incidence
of 554 per 100,000 population. in the Philippines, It is known to fre-
quently complicate diseases among immunocompromised such as
lupus patients. in a study conducted in 2010 among lupus patients
with concomitant TB, 74% developed pulmonary complications
leading to respiratory failure and death. at present, there is paucity
of evidence on the management of lupus patients coinfected with
tuberculosis. With this report, we aim to elucidate and review exist-
ing literature on lupus and tuberculosis coinfection, as to arrive with
new recommendations for these complications.
Method: Case report.
Results: This is case of a 19-­
year-­
old female, known lupus, not
previously diagnosed with tuberculosis, who was recently treated
with methyprednisolone pulse therapy for lupus nephritis. One
month after discharge, she developed progressive cough, difficulty
of breathing and undocumented fever for two weeks, prompt-
ing consult. Upon admission, she was started on empiric antibiot-
ics and was worked up for nosocomial pneumonia. All her cultures
were negative, however patient continued to deteriorate. Further
workup revealed an acute miliary TB and was then confirmed by
her endotracheal aspirates which were positive for acid fast bacilli.
Modified AntiKochs treatment was started but due to multi organ
failure, the patient expired.
Conclusion: Infections, often bacterial, account for the majority of
complications and mortality among patients with lupus. Considering
the high burden of tuberculosis in our country, it is important to have
a high index of suspicion, early detection and low threshold for start-
ing TB treatment. Fulminant cases of TB, if not treated early lead to
multiorgan failure and death.
2-­042 | An unusual cause of knee swelling
C. T. Quake; H. C. Chong
Hospital Melaka
Lipoma arborescens is a rare cause of monoarticular swelling,
characterized by villous proliferation of the synovial membrane.
It is a relatively chronic, slow-­growing benign intra-­articular lesion
which commonly involves the suprapatellar pouch of the knee joint.
Risk factors reported to be associated with this condition include
trauma and inflammatory arthritides such as rheumatoid arthritis
and psoriatic arthritis. We describe a case of lipoma arborescens
in a 47-­year old gentleman presenting with left knee swelling. We
highlight this condition to raise awareness of its clinical presenta-
tion with particular attention to its specific features on magnetic
resonance imaging (MRI). in our patient, MRI depicted a left knee
joint effusion with multiple frond-­like projections into the joint
arising from the synovium, which showed an increased fat signal
intensity. However, there was no significant blooming artifact
within these lesions on the gradient echo (GRE) sequence. This is
consistent with a diagnosis of lipoma arborescens. Recommended
treatment is synovectomy, either by open arthrotomy or arthros-
copy, if it causes pain and discomfort. in conclusion, although rare,
this condition should be considered in the differential diagnosis of
monoarticular swelling. Better awareness of this disease entity is
essential for early diagnosis and treatment.
1-­080 | Metabolic syndrome in rheumatoid
arthritis patient visiting tertiary care hospital,
rheumatology clinic at JPMC, Karachi, Pakistan
S. Shaikh; S. R. Arain; A. Dahani; F. Khan
Jinnah Postgraduate Medical Centre
Background: Met S is strongly associated with RA. Parameters of Met
S such as increase TG, cholesterol and LDL, low HDL, increasing blood
pressure and blood sugar significantly increases cardiovascular compli-
cations and hence morbidity and mortality. Treating Met S decreases
cardiovascular related deaths and also disease flares in RA patients.
Objective : To determine the frequency of metabolic syndrome
in rheumatoid arthritis patient visiting tertiary care hospital,
Rheumatology clinic at JPMC, Karachi, Pakistan
Methods : This was a Cross sectional prospective Study of 105 pa-
tients diagnosed with Rheumatoid Arthritis from April 2018-­August

2018, attending the Rheumatology Clinic at Jinnah Postgraduate
Medical Center Hospital Karachi, Pakistan. Disease activity of rheu-
matoid arthritis by DAS-­28 or CDAI ,RA factor, anti CCP,blood pres-
sure and waist circumference, Body mass index, (BMI) Fasting blood
sugar (FBS), triglyceride (TG), total cholesterol (TC), high density li-
poprotein (HDL) and low density lipoprotein (LDL) were determined.
Results : The mean age of patients with Rheumatoid Arthritis
33.35 ± 5.4 years. The female to male ratio in our study 9.4:1. The
mean duration of Disease was found to be 3.105 ± 4.169 years.
Out of 104 Rheumatoid arthritis patients 34n (32.7%) of patients
were found to have metabolic syndrome. However the Overall
BMI of Patients with Rheumatoid arthritis with normal 26n (25%),
Over weight was 56n (53.8%), Obese patients were 22n (21.2%).
The overall waist circumference was increased in 86n (82.7%) of
patients. Raised Blood Pressure Systolic was found in 48n (46.2%)
of patients and diastolic was raised in 38n (36.5%) of the patients.
Fasting blood sugar was raised in 36n (34.6%) out of 104 patients.
Triglycerides were increased in 18n (17.3%) of patients. LDL was in-
creased in 10n (9.6%) of patients. Total no of patients with low HDL
were 28n (26.9%).
Conclusion : We conclude that metabolic syndrome is highly preva-
lent in patients with rheumatoid arthritis. Treating Met S decreases
cardiovascular related deaths and also disease flares in RA patients.
This young population base study will help out to estimate the exact
burden of Met S in our country, after which strategies could be de-
vice to treat Met S along with the RA, so that morbidity and mortal-
ity could be prevented at an earlier stage.
Keywords: Rheumatoid Arthritis, Metabolic Syndrome,
Cardiovascular disease
2-­031 | Thyroid dysfunction in connective
tissue disorder presenting at rheumatology clinic
at JPMC, Karachi, Pakistan
A. Dahani; S. Sheikh; S. R. Arain; F. Khan
Jinnah Postgraduate Medical Centre
Background: Thyroid dysfunctions are frequently coexist in patients
with other Systemic connective tissue disorder like SLE, RA, Sjogren
Syndrome, MCTD, Vasculitis as elucidated in many previous studies.
Objective: To study the pattern of thyroid dysfunction in patients
with CTDs presenting at Rheumatology Clinic at JPMC, Karachi,
Pakistan.
Methods: This was a cross-­sectional, prospective data analysis of
100 patients diagnosed with any CTD from April 2018-­July 2018,
attending the Rheumatology Clinic at JPMC Karachi,
Pakistan. TSH, FT3 and FT4, ATGAb, TPOAb, ESR, RF, Anti CCP ANA,
Anti DSDNA, ENA Profile, APLA antibodies, C-­ANCA, P-­ANCA and
CRP were determined.
Results: Total number of patients studied were 100. The female
to male ratio was 15:1. Mean age was 35.20 years. Out of 100 pa-
tients with CTD 42% of patients had Thyroid dysfunction with 32%
|
      65
of patients had Hypothyroidism (sub clinical Hypo 26% and overt
Hypo 6%), 10% had hyperthyroidism (sub clinical hyper 1% and overt
Hyper 9%). Thyroid dysfunction was seen 41.17% in RA, 42.8% in
SLE, 33.3% in MCTD. Out of 2 patients with overlap 1 had thy-
roid dysfunction and out of 4 patients with vasculitis 1 had thyroid
dysfunction.
Conclusion: Autoimmune thyroid diseases (AITD) are the most
prevalent organ-­specific autoimmune diseases (ADs) and affect
2–5% of the general population. in our study 42% of patients with
CTD had thyroid dysfunction. Therefore these patients should be
evaluated for thyroid dysfunction clinically as well as laboratory
basis.
Keywords: connective tissue disorder, RA, SLE, thyroid dysfunction
2-­054 | Unilateral sacroiliitis due to multi drug
resistant strain of Salmonella typhi: a report of
two cases
A. Dahani; S. Arain; F. Khan; S. Shaikh
Jinnah Postgraduate Medical Centre
Pyogenic infection of sacroiliac joint is uncommon and the most
common organisms causing pyogenic sacroiliitis are Staphylococcus
aureus and Streptococci, although Pseudomonas aeruginosa may be
more common in intravenous drug abusers. Salmonella typhi is one
of the rare cause of pyogenic sacroiliitis but few cases have been
reported. Due to emergence of multidrug resitant strain of salmo-
nella typhi treatment has been challenging. We report two cases
presented in Rheumatology clinic, Jinnah Post Graduate Medical
Centre, Karachi, Pakistan
Case 1: A 14 year female presented in September 2018 with com-
plain of high grade fever of since 1 month followed by diarrhea
and pain in left buttock and thigh which was severe enough to
cause restriction of movement. Her workup showed raised ESR
and CRP with normal WBC and platelet. MRI sacroiliac joint shows
left sacroiliitis. Bone scan showed increase tracer uptake at left
sacroiliac joint. blood culture were sent which showed Salmonella
Typhi which was multidrug resistant. Initially she was started on
ceftriaxone 2gm OD and Vancomycin 1gm BD and analgesics, but
fever did not subside. Blood culture reported sensitivity to only
Imipenem and Azithromycin. So IV Imipenem 500 mg TDS was
started and continued for 1 week. And then switched to Oral
Azithromycin for 4 weeks.
Case 2: A 22 year old male Presented in March 2018 with com-
plain of fever high grade, backache and Left hip joint pain since
2 week. His workup showed raised ESR and CRP and normal WBC
and Platelet. MRI sacroiliac joint showed Left Sacroiliitis and Blood
culture showed resistant strain of Salmonella Typhi only sensitive
to Imipenem. Patient was started on Initially Emperic antibiotic
Ceftriaxone and Vancomycin in view of pyogenic sacroiliitis. But
fever did not subside, after receiving culture and sensitivity report
antibiotic was changed to Imipenem and continued for 1 week.
 |
66      
Thereafter oral Azithromycin was started for 4 weeks. Both patients
responded well.
Conclusion: Salmonella Typhi infection should be kept in mind in a
patient who presents with febrile unilateral sacroiliatis of sudden
onset.
Keywords: sacroiliitis, Salmonella typhi
2-­065 | P2X7R promotes secretion of IL-­1β in
macrophages of rats with acute gouty arthritis by
regulating NLRP3 inflammasome
X. Li; X. Dai; J. Tao; X. Fang; Y. Xia; X. Li
Rheumatology and Immunology, the First Affiliated Hospital of University of
Science And Technology of China
Background/purpose: Activation of the P2X7R signaling pathway
through changes in extracellular ATP concentrations, which leads
to the production of IL-­1β and the development of acute gouty
arthritis. The aim of this study was to examine whether P2X7R
on macrophages promotes IL-­
1β secretion by activating NLRP3
inflammasome.
Methods: 120 male Sprague-­Dawley rats were randomly divided
into 3 groups: After establishment of acute gouty arthritis model,
rats were given P2X7R agonist ATP, P2X7R inhibitor BBG and PBS,
respectively. The rats were sacrificed at 12 and 24 hours after treat-
ment, while rat spleen macrophages were extracted, and the expres-
sions of P2X7R, NLRP3 and IL-­1β mRNA in rat spleen macrophages
were detected by qRT-­PCR.
Results: At 12 hours, the expression of P2X7R, NLRP3 and IL-­1β
mRNA in ATP group were significantly higher than those in BBG group
and control group (P = 0.001, 0.008; P = 0.000, 0.012; P = 0.002,
0.034), and the BBG group was lower than the control group, but with
no statistically significant. Notably, at 24 hours, the expression of IL-­
1β was obviously higher in ATP group than in BBG group and control
group (P = 0.000, 0.001), followed by the control group (P = 0.007),
and the difference among the three groups were significant.
Conclusions: P2X7R on macrophages promotes IL-­1β secretion by
activating NLRP3 inflammasome, suggesting that P2X7R/NLRP3/
IL-­1β signaling pathway was involved in the pathogenesis of acute
gouty arthritis in rats.
1-­081 | Prevalence of coronary artery
disease in a cohort of Sri Lankan patients with
rheumatoid arthritis
C. Dandeniya1,2; M. Withana1; J. Rubasinghe1; V. Senaratne1
1 2
National Hospital of Sri Lanka; University of Peradeniya
Background: Epidemiological studies have demonstrated an in-
creased cardiovascular risk in rheumatoid arthritis. Although data is
available on the cardiovascular morbidity in rheumatoid arthritis in
the western world, surprisingly sparse data is available on the Asian
counterparts. South Asians have consistently shown a higher car-
diovascular risk compared to other ethnic groups. Coronary artery
disease (CAD) in the South Asian patient with rheumatoid arthritis
remains largely unexplored. This study attempts to provide an in-
sight to the prevalence of CAD in Sri Lankan patients with rheuma-
toid arthritis, noting the differences to known trends.
Methods: 61 consenting patients with rheumatoid arthritis, followed
up at the department of rheumatology and rehabilitation at the na-
tional hospital of Sri Lanka, were included in the study. Pregnancy,
established coronary artery disease prior to the onset of rheuma-
toid arthritis, diabetes and chronic kidney disease were considered
as exclusion criteria. An interviewer-­
administered questionnaire
was used for data collection and subsequently ECG and echocardio-
graphic assessment were done at the cardiology unit of the National
Hospital of Sri Lanka. ECG's were interpreted using the Minnesota
code and the presence of CAD was assessed using Epstein's criteria.
Results: Of the sample of 61 patients, 22 were sero-­negative and 39
were seropositive. Their age ranged from 19 to 76 years. 59 were
females while only 2 were males. 3 female patients reported symp-
toms suggestive of exertional angina consistent with Epstein's class
I probable CAD, giving a prevalence of 4.92% in the studied sample.
(95% CI 1.4% to 12.5%) This value is consistent with the observations
in published local studies for the general population. Interestingly,
none of the study group were detected to have evidence of CAD on
ECG or echocardiography.
Conclusion: While being a defined high risk group for cardiovascu-
lar disease, the studied cohort failed to demonstrate an increased
prevalence of CAD compared to general population.
1-­104 | Clinical and histological features of
necrotising myopathy: a prospective South
Australian cohort study
J. Day1,2; S. Otto2,3; K. Cash3; S. Proudman2,4; J. Hayball1; V.
Limaye2,4
1
University of South Australia; 2Royal Adelaide Hospital; 3SA Pathology;
4
University of Adelaide
Background/purpose: Differentiation of immune-­mediated necro-
tising myopathy (IMNM) from non-­
immune mediated necrotising
myopathy (NIMNM) can be difficult clinically but has important
therapeutic implications. Herein we describe a consecutive cohort
of Australian patients with necrotising myopathy (NM) and identify
patterns that allow differentiation of IMNM from NIMNM.
Methods: Muscle samples and clinical details were prospectively
collected. Necrotising myopathy was diagnosed if necrotic muscle
fibres were the predominant abnormal histological feature and mac-
rophage infiltration exceeded lymphocyte infiltration. Consecutive
muscle sections were stained using immunohistochemistry. Slides
were graded by an experienced muscle pathologist. Clinical and his-
tological subgroups of NM were defined and compared. Two group
       67|
comparisons were performed using the Mann-­
Whitney U test. Table 1 Ordinal logistic regression performed on each radiologist's
Spearman correlations were performed to analyse associations be- set of scores. Odds ratio (OR) and 95% confidence intervals (CI) pre-
tween grades and continuous or ordinal parameters. sented. AT, anterior thigh; IBM, inclusion body myositis; FR, fatty
Results: NM patients displayed marked clinical, biochemical and replacement; PT, posterior thigh; NAM, necrotising autoimmune
histological heterogeneity. Twenty-­four percent (15/63) demon- myopathy.
strated widespread muscle necrosis, with the remainder exhibiting OR for NAM (95% CI) OR for NAM (95% CI)
only mild (23/63, 37%) or moderate (25/63, 40%) necrosis. There Radiologist 1 Radiologist 2
was notable variability in creatinine phosphokinase levels (range: Pelvic Oedema 7.73 (1.96–30.51)* 12.06 (3.11–46.80)**
23–219,000 IU/L) and degrees of muscle strength. Sarcolemmal
Pelvic FR 5.01 (1.48–17.01)* 18.12 (4.0–82.11)**
and sarcoplasmic membrane attack complex (MAC) deposition was
Pelvic Atrophy 6.44 (1.76–23.62)** 14.49 (3.57–58.80)**
common and correlated with the degree of necrosis and clinical se-
Adductor Oedema 3.93 (1.27–12.14)* 7.74 (2.31–25.94)**
verity. Those who were seropositive for myositis-­specific autoanti-
Adductor FR 5.10 (1.71–15.19)** 4.07 (1.39–11.94) *
bodies (MSAs) featured higher capillary MAC deposition (P = 0.02)
Adductor Atrophy 5.10 (1.76–14.70)** 9.10 (2.85–29.07)**
and more widespread sarcolemmal MHC I expression (P = 0.04)
compared with seronegative patients. Comparison of anti-­SRP with PT Oedema 2.84 (0.99––8.12) ∆ 2.80 (0.93–8.39) ∆

anti-­HMGCR positive patients revealed more sarcolemmal MAC PT FR 2.84 (0.99–8.12) ∆ 2.80 (0.93–8.39) ∆
(P = 0.04), sarcolemmal MHC I (P = 0.04), necrosis (P = 0.07, trend) PT Atrophy 7.43 (2.30–23.94)** 3.58 (1.19–10.76)*
and CD45+ cellular infiltrate (P = 0.07, trend) in the former. OR for IBM (95% CI) OR for IBM (95% CI)
Conclusions: An immune mediated form of NM is suggested by Radiologist 1 Radiologist 2

MSA positivity, widespread MHC I sarcolemmal expression and AT Oedema 3.50 (1.01–12.11)* 8.10 (1.61–40.67)*
capillary MAC deposition. Certain MSAs are associated with spe- AT FR 7.81 (2.08–29.35) ** 49.78
cific histological phenotypes. Features which imply an autoim- (9.36–254.79)**

mune pathogenesis for subsets of NM may help guide therapeutic AT Atrophy 10.11 (2.50–40.88) ** 33.63
(6.76–167.21)**
decisions.
*P < 0.05 when compared to all remaining subjects, **P < 0.01,
∆P = 0.05–0.08 (trend)

2-­043 | Patterns of muscle oedema, atrophy

and fatty replacement in the idiopathic Results: There was low inter-­rater reliability (kappa < 0.60) for nu-

inflammatory myopathies: a retrospective
analysis of magnetic resonance imaging
J. Day1,2; N. Bajic2; S. Gentili1; S. Patel2; V. Limaye2,3
1
University of South Australia; 2Royal Adelaide Hospital; 3University of Adelaide
Background/purpose: Magnetic resonance imaging (MRI) has been
proposed as a non-­invasive tool to aid diagnosis and subtyping of
the idiopathic inflammatory myopathies (IIMs). Herein we describe
the MRI findings of a cohort of IIM patients and identify radiologi-
cal patterns that help discriminate between polymyositis (PM), der-
matomyositis (DM), inclusion body myositis (IBM) and necrotising
autoimmune myopathy (NAM).
Methods: Musculoskeletal MRIs performed on 66 IIM patients and
10 patients with non-­IIM between 2009 and 2017 at the Royal
Adelaide Hospital were retrospectively reviewed. Two musculo-
skeletal radiologists independently quantified the degree of mus-
cle oedema, fatty replacement (FR) and atrophy. Total radiological
scores were calculated by summing individual muscle compartment
grades and dividing by the number of compartments assessed.
Ordinal logistic regression was performed analysing radiological
grades for each patient subgroup. Spearman correlations were per-
formed to evaluate associations between radiological grades and
clinical parameters. Paired two-­group comparisons were performed
using a Mann-­Whitney U test.
merous muscular compartments, and a finding was only considered
convincing if it was significant for both radiologists. Compared with
other IIM, NAM patients had higher total oedema (P < 0.05) and total
FR (P < 0.05) scores. The compartments most affected in NAM were
the pelvis, adductors and posterior thighs (Table1). Conversely, IBM
was characterised by marked radiological change in the anterior
thighs (Table 1). Compared with other IIM, PM exhibited lower total
oedema scores (P < 0.05) whereas DM featured lower FR (P < 0.05)
and atrophy (P < 0.05) scores.
Conclusions: Patients with NAM and IBM patients have characteris-
tic patterns of muscle abnormalities that allow them to be differenti-
ated radiologically from other IIM subtypes. Patients with DM and
PM appear to be less profoundly affected on muscle imaging.
2-­142 | Myositis as the presenting feature of
ANCA-­associated vasculitis: a local experience
and literature review
T. De Silva1; A. Rischin1; K. L. Marshall1,2,3; A. Leung1,3; C. Hor1,3
1
Department of Rheumatology, Western Health; 2Western Clinical School,
University of Melbourne; 3Australian Institute for Musculoskeletal Science
Background: ANCA-­associated vasculitis (AAV) is a group of sys-
temic diseases that have common organ-­specific clinical features.
 |
68      
Making the diagnosis can however be difficult due to undifferenti-
ated presentations, asynchronous organ involvement and mimicking
diseases. Lower limb myositis is uncommon as the first presentation
of AAV, but should be considered to enable prompt recognition and
treatment.
Objectives: This study aimed to characterise patients with AAV that
present initially with myositis and compare our local experience to
the existing literature.
Methods: A retrospective chart review was conducted of all patients
diagnosed with AAV from 2008–2018 at Footscray and Sunshine
Hospitals (Western Health), Melbourne, Australia. AAV patients
were identified primarily using diagnostic coding. Additionally all
patients with positive ELISA tests for MPO or PR3 antigens were
identified and their records checked. The literature review was per-
formed in MEDLINE, EMBASE and CENTRAL.
Results: 2 patients presented with myositis and were subsequently
diagnosed with AAV as the primary aetiology. Both patients had
subacute onset bilateral lower limb pain, constitutional symptoms
and elevated inflammatory markers. Immunofluorescence showed
perinuclear ANCA staining with strongly positive MPO titres. MRI
had active myositis features and muscle biopsy demonstrated highly
active vasculitis. One patient also had glomerulonephritis on renal
biopsy and received high-­dose oral steroids and cyclophosphamide.
The other patient responded to intravenous methylprednisolone and
is now on maintenance azathioprine monotherapy. There are only
limited published cases of myositis in AAV patients. 2 cases described
an initial presentation of proximal myopathy and myalgia, with ANCA
positivity and vasculitis detected on muscle biopsy. A retrospective
vasculitis cohort of 144 patients found 6 patients with biopsy-­proven
myositis, but occurring throughout the disease course.
Conclusion: Myositis is an uncommon but significant presenting fea-
ture of AAV. It is likely still under-­reported in the published litera-
ture. Clinician awareness allows earlier diagnosis and treatment that
should follow current AAV management guidelines.
3-­048 | Quantifying knee joint effusions with
clinical tests, musculoskeletal ultrasound and
synovial fluid aspiration: a prospective cohort
study
T. De Silva1; C. Pham1,2; A. Rischin1; K. L. Marshall1,2; A.
Leung1; S. Vogrin1; K. Lim1,2,3
1
Department of Rheumatology, Western Health; 2Western Clinical School,
University of Melbourne; 3Australian Institute for Musculoskeletal Science
Background: Aspiration of knee joint effusions is an integral diag-
nostic and therapeutic intervention in many rheumatologic diseases.
Clinical examination has traditionally involved tests including the “pa-
tella tap” or “bulge test”. The accuracy of these tests for determining
effusion presence and size is not well established. Musculoskeletal
ultrasound (MUS) is considered better for identification and quanti-
fication of knee effusions.
Objectives: To investigate the relationship between both clinical ex-
amination and MUS to aspirated knee effusion volume.
Methods: We performed a prospective cohort study of 37 os-
teoarthritis patients with symptomatic knee effusions. Clinical as-
sessments with patella tap, bulge test and knee circumference
measurement were carried out. MUS was used to measure effusion
depth in the suprapatellar, lateral and medial parapatellar views. All
knee effusion aspirations were performed by the same experienced
clinician using a consistent, lateral approach. Linear regression anal-
ysis was used to assess the association between clinical tests, MUS
and aspiration volume.
Results: In patients with > 3 ml of fluid aspirated, patella tap and
bulge test were positive in 67% and 80% respectively. The posi-
tive predictive value for bulge test was 80%. Where larger vol-
umes > 10 ml were aspirated, patella tap and bulge test were only
positive in 52% and 65% respectively. There was a positive asso-
ciation between the measured circumference of the index and
non-­index knee and aspiration of fluid (r = 5.6, P = 0.007). The rela-
tionship between fluid depth on MUS and aspirated volume showed
a trend towards statistical significance, with a depth of 1 mm equat-
ing to 1.57 ml of fluid (r = 1.57, P = 0.06).
Conclusion: This pilot study demonstrates that a positive patella
tap or bulge test is moderately predictive of knee effusion volume.
However, this association is weaker when larger knee effusions are
present. MUS showed promise at accurately predicting knee effu-
sion volume. A larger study is underway to assess this association
further.
1-­089 | An audit on clinical use of
hydroxychloroquine (HCQ) and current practice
of screening for HCQ retinopathy
M. Gunawardena; K. Deshapriya
Teaching Hospital, Karapitiya
Background: Hydroxychloroquine (HCQ) is being widely used for
the treatment of rheumatic diseases, particularly Systemic Lupus
Erythematosus (SLE) and Rheumatoid Arthritis (RA). While it is

tolerated by many, retinopathy is the most feared complication,
which depends on duration of therapy and cumulative daily dose.
Objectives: Our aim was to audit the clinical use of HCQ and the cur-
rent practice of eye screening for HCQ retinopathy in rheumatology
clinic in teaching hospital, Karapitiya.
Methods: We assessed patients attending rheumatology clinic dur-
ing a period of 6 months, who were on HCQ and established (1) in-
dication for HCQ (2) daily dose (3) duration of therapy (4) whether
baseline eye screening was performed (5) time between start of drug
and eye screening.
Results: We assessed 156 patients (137 female and 19 male).
Indication for 133 (85.3%) prescriptions was RA and for 15 (9.6%)
it was SLE. HCQ was received by 18.6% for more than five years.
Mean duration of HCQ for RA (3.54 years) was not significantly dif-
ferent from SLE (2.55 years) (P = 0.099). Among RA patients, 88%
were on more than 5 mg/kg daily dose, while only 46.7% of SLE pa-
tients exceeded this limit. Mean weight adjusted dose was signifi-
cantly higher for RA patients (7.81 mg/kg) than for SLE (5.77 mg/kg)
(P = 0.003). Baseline eye screening had been done for 71.6%. For
patients who have had eye screening, the mean lag time between
start of the drug and eye screening was 1.25 years.
Conclusion: HCQ was being prescribed in excessive daily dosing
than recommended for 84% of all patients. The causes for the sig-
nificant difference between weight adjusted dosing among RA and
SLE patients, need to be identified. Notably, eye screening practices
were comparatively higher than the international cohorts.A repeat
audit after implementation of new guidelines on HCQ therapy and
weight adjusted prescription of HCQ is needed.
1-­105 | Antifibrosis and anti-­inflammatory
effect of physalis angulata extract in scleroderma
patients (a double blind randomized controlled
trial)
S. Dewi1; R. G. Wachjudi1; L. Hamijoyo1; A. R. Rahmadi1; E.
H. Purwaningsih2; N. Kertia3; R. Setiabudi4; S. Setiati5; H.
Isbagio6
1
Rheumatology Division, Internal Medicine Department, Hasan Sadikin Hospital,
Faculty of Medicine, Universitas Padjadjaran; 2Department of Pharmacy,
University of Indonesia; 3Rheumatology Division, Department of Internal
Medicine, Faculty of Medicine, University of Gadjah Mada; 4Department of
Pharmacology, University of Indonesia; 5Geriatric Division, Department of
Internal Medicine, Faculty of Medicine, University of Indonesia; 6Rheumatology
Division, Department of Internal Medicine, Faculty of Medicine, University of
Indonesia
Scleroderma is an autoimmune disease characterized by organ fibro-
sis, resistant to standard treatment, but it is suspected the addition
of Physalis angulata Linn (Ciplukan) extract can improve the sclero-
derma skin fibrosis by anti-­inflammatory effect. The aim at this study
was to evaluate the effect of Physalis angulata extract on skin fibrosis
based on MRSS, P1NP and CRP as inflammatory biomarkers in scle-
roderma with standard therapy.
|
      69
Double-­blind, randomized clinical trial was performed in scleroderma
patients with stable disease at RSCM and RSHS from November
2015−March 2017 who met the inclusion criteria and continued to
receive standard therapy. The subjects were randomly divided into
two groups: the study group received the Physalis angulata extract
3 × 250 mg/d for 12 weeks and the placebo group. Examination of
MRSS, CRP, P1NP were performed every 4 weeks until the end of
the study.
Fifty-­eight subjects completed the study, divided into two group: 29
subjects of the study group and 29 subjects of the placebo group,
with an average age of 38 ± 11 years, the proportion of women:
male = 9: 1. There was a significant improvement of skin fibrosis in
the study group with a relative decrease in MRSS by 35.9% com-
pared with placebo at 6.3% with P < 0.001, a relative decrease in
P1NP levels of 17.8% versus placebo 0.7% with P = 0.002, and rela-
tive decrease in CRP levels of 16.12% in study group versus relative
increase 3.29% in placebo group with P = 0.181. There was a signifi-
cant positive correlation between MRSS with P1NP levels (r = 0.236,
P = 0.036).
Giving the Physalis angulata extract with dose 3 × 250 mg for
12 weeks as adjuvant therapy on scleroderma with standard ther-
apy, clinically and statistically improvement of skin fibrosis based on
MRSS, P1NP and CRP as inflammatory biomarker.
1-­106 | Correlation between C-­reactive
protein with modified Rodnan's skin score and
N-­terminal propeptide of type 1 collagen in
scleroderma
S. Dewi1; R. G. Wachjudi1; W. Palupi2; D. Priyantini2; W.
Tresnadi2
1
Division of Rheumatology, Department of Internal Medicine, Hasan Sadikin
Hospital, Faculty of Medicine, Universitas Padjadjaran; 2Department of Internal
Medicine, Faculty of Medicine, Universitas Padjadjaran
Background/purpose: Scleroderma is an autoimmune disease char-
acterized by organ fibrosis, Modified Rodnan's Skin Score (MRSS)
had been used as clinical parameter of skin fibrosis in scleroderma.
N-­terminal propeptide of type 1 collagen (P1NP) and C-­Reactive
Protein (CRP) are potential biomarkers in assessing disease activity
of Scleroderma. The aim of this study was to determine the correla-
tion between CRP level with MRSS and P1NP serum.
Methods: Scleroderma patients at the Hasan Sadikin Hospital, were
enrolled from November 2015 to December 2017. Subjects were
performed MRSS measurement by a rheumatologist, and blood
tests. We divided subject into two group based on the disease onset.
Data were analyzed using Rank-­Spearman Correlation.
Results: Fifty eight subjects with mean age 38 ± 11 years were
analyzed. Fifty five subjects (94.8%) were women, consisted of
35(60.3%) diffuse type and 23(39.7%) limited type. The median
P1NP level was 51.05 (14.90 – 177.80) ng/mL, and median CRP
level was 0.289 (0.016 – 1.729) pg/mL. The median MRSS was 17 (4
 |
70      

– 36). We found no correlation between CRP with MRSS and P1NP
(r = −0.139, P = 0.149; r = -­ 0.104, P = 0.219) in all subjects. in the
subject ≤2 years of the disease onset, we found a positive correla-
tion between CRP and P1NP level (r = 0.575, P = 0.012), compare
with subject with disease onset > 2 years, there was a negative cor-
relation between CRP and P1NP level (r = −0.281, P = 0.034). We
found no correlation between CRP and MRSS in the different onset
of the disease.
Conclusions: No correlation found between CRP with MRSS and
P1NP in all subjects. There was a positive correlation between
CRP with P1NP in the subject less than 2 years of the disease
onset and no different correlation between CRP with MRSS in
both groups.
Further studies are needed to asses the side effects profile of low
dose Rituximab.
3-­092 | What affects joint destruction of large
joints in the lower extremities in rheumatoid
arthritis – a 4-­year longitudinal study
K. Doi1; H. Ito1; T. Tomizawa1; K. Murata1,2; K. Nishitani1,2;
M. Tanaka2; M. Hashimoto2; S. Matsuda1
1
Department of Orthopaedic Surgery, Kyoto University Graduate School of
Medicine; 2Department of Advanced Medicine for Rheumatic Diseases, Kyoto
University Graduate School of Medicine

Purpose: Rheumatoid arthritis (RA) is a chronic disease leading to joint

destruction. Destruction of the joints leads to disability of daily life.
2-­094 | Experience with low-­dose rituximab in Therefore, the key goal of treatment is to prevent joint destruction.
rheumatoid arthritis in a district general hospital The purpose of this study is to identify the factors influencing joint
of Sri Lanka destruction of large joints in the lower extremities in patients with RA
Methods: We enrolled consecutive RA patients from the Kyoto
U. D. Mudiyanselage1; C. Illangasinghe2
1 University Rheumatoid Arthritis Management Alliance (KURAMA)
District General Hospital, Kegalle; 2District General Hospital
cohort who participated both in 2012 and 2016. Clinical data in 2012
including age, duration of disease, sex, BMI, ACR class, Steinbrocker's
Rituximab is a selective B cell depleting chimeric monoclonal antibody
stage, HAQ, and TJC/SJC 28 were collected. We evaluated disease
directed against CD20 that is used in treating RA. Although the recom-
activities using SDAI/CDAI and DAS28-­CRP/ESR. The use/non-­use
mended dose is 1000 mg × 2, similar clinical efficacy has been shown
and doses of methotrexate, glucocorticoids and biological agent
at a lower dose (500 mg × 2) according to some data. It has never been
were also recorded.
assessed in Sri Lanka. However, this can result in a higher level of phar-
Standard anteroposterior radiographs of weight-­bearing joints (hips,
macoeconomic implication in a low income country like Sri Lanka.
knees, and ankles) were taken at 2012 and 2016. Radiographic pro-
Objective: To review the indications and outcomes of the low dose
gression was defined if Larsen Grade was progressed (progression
Rituximab given in the Rheumatology department in a District
from 0 to 1 was excluded) or joints were received total joint arthro-
General Hospital.
plasty or arthrodesis. The effect of baseline characteristics on the
Methods: We performed a retrospective audit of the use of low dose
incidence of radiographic progression was assessed.
Rituximab in RA patients from 2012 until the mid 2018 in a District
Results: A total of 186 patients were enrolled in this study. Forty-­
General Hospital.
three joints of 31 patients (16.7%), 75 joints of 49 patients (26.3%),
Results: 12 patients with Rheumatoid Arthritis were treated with
6 joints of 5 patients (2.7%), and 69 patients (37.1%) showed radi-
low dose Rituximab. of them 9 were females. Outcomes were known
ographic progression in hip, knee, ankle, or any joints in the lower
in all patients. The drug was not continued indefinitely.
extremities.
11/12 patient had responded to Rituximab, and only 1 patient de-
On multivariate regression models, the explanatory factors of the
veloped secondary failure. All were taking concomitant DMARDs.
presence of radiographic progression were older age, higher SJC 28,
8/12 were on Methotrexate and others were on Leflunomide. None
and lower dosage of PSL.
of them were on long term steroids.
Conclusion: Age, SJC 28, and dosage of PSL are associated with
Complete remission was observed in 11 patients and only 4 patients
radiographic progression in any joints in the lower extremities. To
were taken more than 5 doses.
examine the patients joints and treat the swollen joints and the suffi-
Adverse effects were not assessed due to unavailability of data.
cient use of PSL when needed may lead to prevent joint destruction
Conclusions: This audit suggests that low dose Rituximab can be
of large joints in the lower extremities in RA.
used effectively in Sri Lanka and non responders are very minimum.
This will have an important pharmacoeconomic benefit in a resource
poor setting.
 |
      71

1-­082 | Consolidations in the lung and 3-­049 | Inappropriate use of opioids for

mediastinal lymphadenopathy occur incident knee and hip osteoarthritis
predominantly in early anti-­citrullinated protein J. B. Thorlund1,2; A. Turkiewicz1; D. Prieto-Alhambra3,4; M.
antibody-­positive patients with rheumatoid Englund1
arthritis
1
Lund University; 2University of Southern Denmark; 3Universitat Autònoma de
Barcelona and Instituto de Salud Carlos III; 4University of Oxford
Y. Endo1; T. Koga1; S. Tsutsui2; K. Ashizawa3; M. Eguchi1; M.
Okamoto1; S. Tsuji1; A. Takatani1; T. Shimizu1; R. Sumiyoshi1;
Background/purpose: According to clinical guidelines opioids are
T. Igawa1; S. Kawashiri1; N. Iwamoto1; K. Ichinose1; M.
Tamai1; H. Nakamura1; A. Kawakami1 not appropriate as first-­line treatment for osteoarthritis (OA) as they
1 are associated with a high risk of side effects and addiction.
Department of Immunology and Rheumatology, Unit of Advanced Preventive
Medical Sciences, Nagasaki University Graduate School of Biomedical Objectives: To estimate inappropriate use of opioids in OA patients
Sciences; 2Department of Radiology, Japan Community Healthcare defined as dispensing of opioids within the first year of diagnosis.
Organization (JCHO), Isahaya General Hospital; 3Clinical Oncology Center,
Methods: We included persons aged ≥ 35 years in 2012 in southern
Nagasaki University
Sweden without any diagnosis of knee or hip OA the prior 15 years.
We defined a person as having incident knee or hip OA if newly
Background: A previous report showed that early ACPA-­positive RA
diagnosed between Nov 1st 2012 and Oct 31st 2014. The index
patients have a higher frequency of abnormalities in the lung field
date was set as the date of first OA diagnosis. For persons without
than early ACPA-­negative RA patients, suggesting that immunologi-
incident OA, the index date was randomly assigned. The outcome
cal events in the lung could contribute to the production of ACPA.
was any incident opioid prescription identified using the Anatomical
Because abnormalities in the lung may influence the choice of treat-
Therapeutic Chemical codes (N02A). To focus on new opioid use we
ments in RA, it is important for clinicians to determine a factor re-
excluded all patients with an opioid prescription in the 2 years pre-
lated to pulmonary involvement in RA patients. However, there have
ceding the index date. Furthermore, we also excluded persons with
been still few reports showing the association between lung lesions
a cancer diagnosis within the 5 years preceding the index date, or
and the positivity of ACPA.
during the 1-­year follow-­up. Difference in opioid use was estimated
Objectives: We aimed to compare clinical profiles including the
using an inverse probability weighting model adjusted for age, sex,
findings of a chest computed tomography (CT) between early
income, level of education, residential area, civil status, and country
ACPA-­negative and ACPA-­positive RA patients and to determine
of birth. Additionally, we adjusted for a wide range of comorbidities
characteristics in the lung field associated with early ACPA-­positive
to minimize the risk that opioid use was incorrectly attributed to OA.
RA patients.
Results: The study cohorts consisted of 399 670 and 414 216 per-
Methods: We enrolled 74 early RA patients within half one year
sons for incident knee OA and hip OA, respectively (Figure 1) of
of disease onset between 2014 and 2017 at our institution. All pa-
5,866 incident knee OA patients 14.7% received an incident opioid
tients were performed a power Doppler ultrasound of the joints and
prescription within the first year. The corresponding proportion was
a chest high-­resolution CT within a few months of the first visit to
20.7% for those with incident hip OA. The adjusted estimated pro-
our department. The findings of CT were reviewed independently
portion of incident OA patients with inappropriate use was 7.4% for
and at random by two experienced thoracic radiologists with good
knee OA and 12.8% for hip OA (Table). Thus, about 50% of all opioid
consensus.
use in the first year after OA diagnosis was inappropriate.
Results: HRCT imaging showed no significant difference in the ab-
normalities of airway lesion. The ACPA-­positive group had the higher
frequency of consolidation as one of abnormalities of parenchymal
lesion and mediastinal lymphadenopathy compared to the ACPA-­
negative group. Multivariate analyses showed that ACPA-­positivity
was an independent factor predicting consolidation and mediastinal
lymphadenopathy respectively in early RA patients. Interestingly,
the percentage of consolidation and mediastinal lymphadenopathy
were associated with high disease activity of RA and smoking history,
respectively among the ACPA-­positive group but not -­negative RA
group.
Conclusion: Our results indicate that consolidation in the lung field
and the mediastinal lymphadenopathy are associated with the pro-
duction of ACPA in early RA patients.
 |
72      

Table 1. Cumulative incidence of opioid prescriptions within the first year of knee or hip OA diagnosis and proportion of patients with incident
knee or hip OA with inappropriate opioid use.

Cumulative incidence (%) of opioid Without incident knee With incident knee OA Without incident hip With incident hip
prescriptions OA (n = 393 804) (n = 5866) OA (n = 410 857) OA (n = 2359)

All 4.9 14.7 5.1 20.7

 Men 4.5 13.6 4.6 20.6
 Women 5.4 15.5 5.6 20.8
Proportion (%) of patients with incident Knee OA* (95% CI) Hip OA* (95% CI)
OA with inappropriate opioid use*
All 7.4 (6.5 to 8.4) 12.8 (11.1 to 14.4)
 Men 7.4 (6.0 to 8.8) 13.8 (11.3 to 16.3)
 Women 7.5 (6.2 to 8.7) 12.0 (9.8 to 14.2)
*Adjusted for age, sex, highest education level, residential area, if born outside Sweden, marital status and comorbidities (specific back condi-
tions, intervertebral disc disorders, arthritis, OA of other joints, fracture, multi-­morbidities, headaches, neuropathies and other conditions
associated with chronic pain).

Conclusion: At least half of opioids dispensed to patients with inci-
dent knee or hip OA are inappropriate.
2-­044 | Utilization and impact of
musculoskeletal ultrasonography on rheumatoid
arthritis patients in clinical practice
L. H. Eow; N. S. Shahril
Department of Medicine, Hospital Putrajaya
Introduction: Musculoskeletal ultrasonography (MSUS) is more
sensitive in detecting synovitis compared to clinical examination.
It helps to differentiate synovitis from other causes of painful joint
and in guiding intra-­articular injections. The aim of this study was to
describe indications and impact of MSUS on Rheumatoid Arthritis
patients in clinical practice.
Methods: A retrospective cross-­sectional study of MSUS examina-
tions performed between January 2016-­December 2017 in a dedi-
cated MSUS clinic.
Results: A total of 288 MSUS examinations was performed on pa-
tients with Rheumatoid Arthritis (RA) (50%), soft tissue rheumatism
(26%), spondyloarthropathies (10.8%), osteoarthritis (6.6%), lupus
(2.8%), crystal arthropathies (2.1%) and undifferentiated arthritis
(1.7%).
The main indications for MSUS in Rheumatoid Arthritis patients
were disease activity assessment (n = 115), therapeutic (n = 32) and
diagnostic (n = 9) indications. The commonest joints assessed in
RA were hand joints [wrists, metacarpal and interphalangeal joints]
(n = 150).
In patients who had MSUS performed for disease activity assess-
ment, MSUS demonstrated active synovitis in:
• 27 out of 29 patients who had tender/swollen joints but have nor-
mal inflammatory markers
• 32 out of 37 patients who had no tender/swollen joints but have
persistent high inflammatory markers.
• 4 out of 9 patients who had no tender/swollen joints and normal
inflammatory markers.
MSUS examination did not reveal active synovitis in 11 out of 40
patients who had tender joints and high inflammatory markers.
Treatment was escalated in 59 patients who showed active synovi-
tis on MSUS. Three patients had treatment deescalated in view of
clinical remission with no sonographic evidence of synovitis. Intra-­
articular injections were performed on 78% of RA patients whom
had MSUS arranged for therapeutic indication. Five of nine patients
in whom had diagnostic MSUS examinations done for evaluation of
painful joint revealed pathologies other than synovitis.
Conclusion: MSUS is important in clinical practice for assessing dis-
ease activity in RA, guiding intra-­articular injections and establishing
causes of painful joints.
1-­0 05 | Case report: rituximab in a case of
dermatomyositis complicated by diffuse alveolar
hemorrhage
A. M. Estrella; G. Katigbak
Makati Medical Center
Pulmonary involvement in inflammatory myopathy presents in a
variety of ways. With exceptionally rare occurrence, diffuse alveo-
lar hemorrhage (DAH) is a complication that poses a high risk for
mortality. Mainstay management requires aggressive immunosup-
pression with high-­dose intravenous (IV) steroids and cyclophospha-
mide. Recently, rituximab, a CD20 antigen-­antibody has been used
as alternative therapy for life-­threatening complications of autoim-
mune diseases. This report highlights DAH in the context of der-
matomyositis with lung abscess managed with rituximab.

We report a case of a 60 year-­old female, diagnosed with paraneo-
plastic inflammatory myopathy initially presenting with proximal
muscle weakness, rashes, elevated muscle enzymes along with elec-
tromyography and skin biopsy consistent with dermatomyositis. She
was maintained on azathioprine and steroids with noted improve-
ment of symptoms and laboratory parameters. However, a month
into treatment, she developed productive cough, fever, dyspnea and
hemoptysis. These were accompanied by recurrence of muscle weak-
ness and skin changes (heliotrope rash, V sign, shawl sign). Clinical
deterioration required mechanical ventilation. Empiric intravenous
antibiotics and steroids were started. Subsequent HRCT scan of the
chest showed patches of ground glass opacities with septal thick-
ening in both upper and right lower lobes and a mass-­like opacity
in the anteromedial basal segment of the left lower lobe. Fiberoptic
bronchoscopy with bronchoalveolar lavage revealed pulmonary
hemorrhage from all endobronchial airways suggestive of intersti-
tial pneumonitis. Endobronchial biopsy of the mass showed findings
consistent with an abscess thus piperacillin-­tazobactam was con-
tinued. Due to persistent pulmonary deterioration on top of active
dermatomyositis, methylprednisolone 1 g pulse therapy for 5 days
and rituximab 500 mg for two doses (two weeks apart) were given.
After therapy, resolution of hemoptysis and stabilization of respira-
tory symptoms ensued, thus patient was weaned off the ventilator.
To our knowledge, this is the first reported case of a Filipino with
paraneoplastic dermatomyositis complicated by DAH successfully
treated using rituximab.
3-­050 | The effect of face to face education
on weight loss of overweight patients with knee
osteoarthritis
S. Fallahi; S. Z. Jazaeri; A. Dehdashtian
Tehran University of Medical Sciences
Background/purpose: Osteoarthritis (OA) is the most common ar-
thritis disorder. Obesity has been established as a major risk factor
for this disorder. Increasing awareness about nutritional habits and
lifestyle modifications may be one of the strategies for controlling
obesity.
Objectives: To examine the effect of education on weight loss in
overweight patients with knee OA.
Methods: A case-­control study was carried out on 138 partici-
pants with convenience sampling. The case group included 73
overweight subjects (BMI > 25 kg/m2) suffering from knee OA
with Kellgren-­L awrence radiographic grading ≥ 2. They were in-
formed about the effect of obesity as an exacerbating risk fac-
tor and about correct nutritional habits by face-­to-­f ace education
and brochures containing useful information. The control group
included 65 overweight patients with knee OA with similar clinical
and radiographic symptoms and they were not given any educa-
tion. The participants in both groups were matched in terms of
|
      73
age, gender, VAS pain score, radiographic grading, diabetes, hy-
pothyroidism and educational level. Individuals who used weight-­
reducing drugs were excluded. Body mass index (BMI) of patients
in both groups was calculated before education and after at least
2 months later.
Results: In control group, 46 patients and in case group, 44 patients
ended the study. in case group, BMI (mean±SD) before and after
education was 33.24 ± 3.86 and 32.38 ± 3.67, respectively which
T-­paired test showed significant decrease in BMI (P < 0.001). in con-
trol group, BMI before and after education was 32.45 ± 4.89 and
32.21 ± 4.87, respectively without significant difference (P = 0.25).
Comparison of BMI difference (before and after education) in two
groups with t-­test showed significant decrease of BMI in case versus
control group (P = 0.01).
Conclusion: Education may be effective in weight loss of overweight
patients with knee OA, although this result is not clinically strong.
Repeat this study in a higher educated level population with longer
follow-­up is recommended.
1-­011 | MiR-­326 improves Th17/Treg
imbalance in lupus nephritis of MRL/lpr mice
Y. Xia; X. Fang; N. Xiang; X. Dai; L. Jin; X. Li; J. Tao; X. Li
The First Affiliated Hospital of USTC, Division of Life Sciences And Medicine,
University of Science And Technology of China
Background/purpose: Th17/Treg imbalance plays an important role
in systemic lupus erythematous (SLE). Dysregulation of miRNAs has
been observed in SLE.we explored the effect of miR-­326 on SLE, and
investigated the correlation between miR-­326 and Th17/Treg imbal-
ance in kidney of MRL/lpr mice.
Methods: 3 groups of female MRL/lpr mice were injected with
lentivirus-­miR-­326 (LV-­326) or lentivirus-­miR-­326 specific inhibi-
tor (LV-­sponge) to increase or inhibit miR-­326 expression, respec-
tively, and lentivirus-­no-­encoding (LV-­c trl) as control, 10 mice per
group. The expression levels of miR-­326 in kidney were determined
by rt-­PCR. The percentage of Th17 cells and Tregs in kidney were
detected by flow cytometry. Immunohistochemistry labeled renal IL-­
17A and TGF-­β expression. Differences between groups were ana-
lyzed by SPSS software.
Results: Results of rt-­PCR showed that systemic administration of
lentivirus led to increase or silence of miR-­326 expression in kidney
of group LV-­326 or group LV-­sponge respectively; Results of flow
cytometry demonstrated that the percentage of Th17 cells in kidney
were significantly higher in group LV-­326 compared to group LV-­
sponge and group LV-­c trl. On the contrary, the percentage of Tregs
in kidney were lower in group LV-­326 compared to group LV-­sponge
and group LV-­c trl. Moreover, compared with group LV-­c trl, kidney
expression of IL-­17A were increased in group LV-­326, and decreased
in group LV-­sponge, TGF-­β were decreased in group LV-­326 and in-
creased in group LV-­sponge.
 |
74      

Conclusion: These findings suggest that miR-­326 improves Th17/ (SLICC) criteria were enrolled. Detailed history was taken to deter-
Treg imbalance in kidney of lupus model mouse. Implying that miR-­ mine the symptoms at the onset of disease all data was analyzed by
326 might be a candidate in lupus nephritis pathogenesis. SPSS version 23.
Result: A female predominance was observed at 95.7% (n = 22).
Mean age at diagnosis was 15 years ± 2 years in which 34.8%
(n = 8) of patients were between ages of 11–15 years. Majority
1-­012 | MiR-­326 regulates CD4+ T cells
i.e. 69.6% (n = 16) of patients were diagnosed with in five years of
differentiation in systemic lupus erythematous
their disease onset with a mean duration of 43 months (3.5 years).
X. Fang; Y. Xia; N. Xiang; X. Dai; L. Jin; J. Tao; X. Li; X. Li Consanguinity present in 56.5% (n = 13) of patients. Fever and
The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, hair loss were the most common symptoms at the onset i.e. in
University of Science and Technology of China
73.9% (n = 17) followed by oral ulcers and arthritis present in
65.2% (n = 15). Nephritis was present in 21.7% (n = 5) of patients
Background/purpose: CD4+T cells play a major role in systemic
in which all has class IV lupus nephritis at renal biopsy. ANA by IFA
lupus erythematous (SLE) pathogenesis. Many aberrations in miR-­
was positive in all patients while Anti dsDNA was positive in 87%
326 expression have been described as related to abnormal T cell
(n = 20) of patients.
activation in SLE.The aim of this study was to investigate the effect
Conclusion: Following the global known pattern there was a female
of miR-­326 expression on the differentiation of CD4+T cells and se-
preponderance in cSLE. Fever and hair loss were the most common
cretion of pro-­inflammatory cytokines in MRL/lpr mice.
initial symptoms at presentation. in developing countries fever is one
Methods: In vivo silencing or increasing of miR-­326 in MRL/lpr mice
of the cause of hospital visits due to underlying infections, in our
to estimate the effect of miR-­326 expression on CD4+T cells differ-
study fever is also the most common presenting complain, there for
entiation and pro-­inflammatory cytokines secretion. Differences be-
it is an important reminder to keep cSLE as an important differential
tween groups were analyzed by SPSS software.
of PUO.
Results: The results demonstrated that, compared with control mice
and miR-­326 silenced mice, miR-­326 overexpressed mice had higher
percentage of Th17 cells in splenic CD4+T cells. in contrast, the per-
centage of Tregs and Th1 cells were decreased significantly com-
pared with control. Moreover, serum levels of IL-­17A and IFN-­γ were
significantly increased in miR-­326 overexpressed mice compared
with control mice and miR-­326 silenced mice, and levels of IL-­2 were
significantly decreased compared with control mice.
Conclusion: These findings suggest that miR-­326 regulates CD4+T
cells differentiation and pro-­inflammatory cytokines production in
lupus model mouse. Implying that miR-­326 might be a candidate in
SLE pathogenesis.

1-­060 | Childhood onset systemic lupus

erythematosus: pattern of initial clinical
manifestations in a Pakistani population
R. Shamim1; S. Farman2
1
Rheumatology Department, Fatima Memorial Hospital Lahore; 2Division of
Rheumatology, Department of Medicine, Fatima Memorial College of Medicine &
Dentistry (FMHCM&D)
Objective: To determine the pattern of initial clinical manifesta-
tions of child hood-­onset systemic lupus erythematosus (cSLE) in a
Pakistani population.
Methods: Cross sectional observational study conducted at
Rheumatology department of Fatima Memorial Hospital, Lahore. A
total of 23 patients diagnosed with cSLE before and at the age of
18 years irrespective of their current age, of either gender, fulfilling
criteria of 2012 Systemic Lupus International Collaborating Clinics
1-­113 | Six months results of tofacitinib
versus lower dosage etanercept in patients
with refractory spondyloarthritis: a study from
Bangladesh
N. Islam1,2; N. Ferdous2,3; A. U. Zaman2; F. B. Nazrul2,4; Y.
Khatun2; M. A. Rahman2; F. Mahmud2
1
Department of Rheumatology, Bangabandhu Sheikh Mujib Medical
University (BSMMU); 2Modern One Stop Arthritis Care and Research Center®
(MOAC&RC®); 3Department of Medicine, MH Samorita Hospital and Medical
College; 4National Heart Foundation Hospital and Research Institute
Objective: To determine the efficacy and safety of tofacitinib in re-
fractory spondyloarthritis (SpA) patients.
Methods: A total 60 refractory SpA patients of both genders attend-
ing a tertiary care rheumatology center of Dhaka were enrolled in

tofacitinib group. in etanercept group, 87 cases were enrolled. The
study period was from December 2016 to September 2018. The
dose of tofacitinib was 10 mg/d and etanercept was given 50 mg
weekly in first month, then 2 weeks interval in 2nd and 3rd month
then every 3 weeks interval. All patients were screened for TB by X-­
ray chest, TST and QuantiFERON-­TB Gold test at baseline.
Results: Among the 60 patients of tofacitinib group, 17 missed fol-
low up and 5 were treatment failure. For severe adverse events 6
was excluded from analysis. Results of 32 patients (25M/ 7F) have
shown. Fifty patients (39M / 11F) of etanercept group had com-
pleted 6 months. Twenty seven patients lost follow up and 10 pa-
tients didn't respond to protocol.
Mean disease duration (years) of tofacitinib group versus etanercept
group was 12.53 ± 7.77 and 12.15 ± 7.57 respectively. TST was posi-
tive in 14 patients, 7 in each group but all were QuantiFERON-­TB
Gold test negative. There were significant changes in mean Hb (gm/
dl), ESR, CRP, morning stiffness, patient global assessment, BASDAI,
BASMI, BASFI, ASDAS-­CRP and ASDAS-­ESR at 6 month in each
group (P = 0.00 in all parameters).
The frequency of adverse events in tofacitinib versus etanercept
group were; gastroenteritis (53.1% vs 6%), dyslipidaemia (43.8% vs
0%), UTI (21.9% vs 0%), URTI (18.8% vs 14.7%), anaemia (12.5% vs
0%).
Sever adverse events (pneumonia, cellulitis, severe UTI, severe
anaemia, HEV infection) was observed in tofacitinib group only.
None of the study subjects developed TB.
Conclusions: At 6 months evaluation both the tofacitinib and etaner-
cept were found effective. Infection and dyslipidaemia were preva-
lent in tofacitinib group.
1-­090 | Socioeconomic differences in opioid
use by people with inflammatory arthritis: data
from the Australian rheumatology association
database (ARAD)
A. Fletcher1,2; M. Lassere3; L. March4,5; R. Buchbinder1,2; S.
Lester6,7; C. Barrett8; G. Carroll9; R. Black6,10; B. Richards3;
C. Hill6,7,10
1
Cabrini Institute; 2Monash University; 3University of New South Wales;
4
Northern Clinical School, Institute of Bone and Joint Research, Kolling Institute,
University of Sydney; 5Department of Rheumatology, Royal North Shore
Hospital; 6The University of Adelaide; 7The Queen Elizabeth Hospital; 8Redcliffe
Hospital, University of Queensland; 9University of Notre Dame; 10Royal
Adelaide Hospital
Background/purpose: Internationally, prescription opioid use is
often higher among patients of lower socioeconomic status (SES).
in addition, despite improved treatments for inflammatory arthritis,
opioid use remains high among patients with inflammatory rheu-
matic diseases. The aim of this study was to determine the effect
of lower SES on opioid use in people with inflammatory arthritis.
Methods: ARAD is an observational database that collects outcome
data for people with inflammatory arthritis. Participants complete
|
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semi-­annual then annual questionnaires. Longitudinal analysis was
performed on all data (2001–2018). The Index of Relative Socio-­
economic Advantage and Disadvantage (IRSAD) was determined,
using patient postcodes, from Socio-­Economic Indexes for Areas
(SEIFA) data from the 2011 Australian census, and grouped into
Australian population-­derived quintiles (Q1-­5).
Results: For 5634 participants (median follow-­up 4 years, mean age
52.7 years and 66.3% female; 70% rheumatoid arthritis/13% psori-
atic arthritis/13% ankylosing spondylitis/4% juvenile idiopathic ar-
thritis) there are 47,134 questionnaires where 29.3% indicated use of
opioids and 52.7% of participants have taken an opioid at least once.
Opioid use was more prevalent in more disadvantaged participants
(IRSAD Q1: 31.8%, Q5: 26.1%, OR 2.17; 95%CI 1.59–2.96)). Other
predictors of opioid use were a high HAQ score, current smoking
and being permanently unable to work. When these were included
as covariates, the IRSAD Q1:Q5 comparison was no longer signifi-
cant (OR 1.36; 95%CI 0.98–1.87)). The prevalence of opioid use did
not change significantly over time, and remained higher in IRSAD
Q1, compared to Q5, participants (P < 0.05). The most commonly
used opioid was paracetamol/codeine, and use of more potent opi-
oids (oxycodone and morphine) was higher in more disadvantaged
participants.
Conclusion: Opioid use is higher in ARAD participants with the
greatest socioeconomic disadvantage. Future research into the rea-
sons for this may include further exploration of factors including ac-
cess to care, predictors of cessation and prescriber characteristics.
1-­068 | Prevalence of PsA amongst
secukinumab treated PsO patients in the
Australian setting: a sub analysis from the phase
IV HOPE study
P. Foley1; M. Walsh2; E. Mate2
1
Skin & Cancer Foundation Inc.; 2Novartis Pharmaceuticals, Australia Pty
Limited
Background/purpose: Secukinumab (SEC) is a fully human monoclo-
nal antibody that selectively neutralises IL17A and has shown sus-
tained efficacy with a favourable safety profile in psoriasis (PsO),
psoriatic arthritis (PsA) and ankylosing spondylitis.Wide-­
ranging
prevalence estimates of PsA in patients with PsO have been re-
ported.Here we describe patients’ characteristics and prevalence of
PsA among PsO patients with concomitant PsA in HOPE study.
Objectives: Primary objective of HOPE study was to demonstrate
change in patient-­reported outcomes using Dermatology Quality of
Life Index (DLQI) tool in patients treated with SEC for moderate to
severe plaque psoriasis at 14 weeks.
Methods: HOPE study is a prospective, open label, single arm,
multi-­centre, non-­interventional, exploratory trial in patients with
moderate to severe psoriasis in the Australian setting, investigating
their change in QOL in response to SEC. SEC was administered as
300 mg s.c. weekly for 4 wks followed by monthly over 58 wks as
 |
76      
in the approved prescribing label.The study recruited adult subjects
presenting with moderate to severe plaque psoriasis and eligible for
government reimbursed SEC.Analysis set was stratified into patients
with or without a PsA diagnosis.
Results: 17 of the 58 enrolled patients (29.3%) had documented
history of PsA at time of enrolment.Of the 17, 12 had PsO nail in-
volvement.Mean time since first diagnosis of PsA was 6.3 years.
Mean absolute PASI and DLQI scores at BL for patients with con-
comitant PsA was 21.3 and 16 respectively compared to 22.6
and 15.9 for those without PsA.PASI 75/90/100 at week 14 was
100/60.0/33.3% respectively for those with concomitant PsA com-
pared to 97.5/77.5/42.5% for those without.Mean change in DLQI
score from BL to week 14 was −9.8 for those with concomitant PsA
compared to −13.3 for those without.
Conclusion: The reported prevalence of PsA among PsO patients is
in line with what has been reported in existing literature.SEC treat-
ment was equally effective in psoriasis patients with or without a
history of PsA.
1-­108 | Prevalence and clinical association of
the presence of anti-­neutrophilic cytoplasmic
antibody in systemic sclerosis: a review of the
literature
C. Foocharoen; A. Mahakkanukrauh; S. Suwannaroj; R.
Nanagara
Khon Kaen University
Background: Anti-­
neutrophilic cytoplasmic antibody (ANCA) has
been reported in systemic sclerosis (SSc). Some clinical features of
SSc can also be presented with ANCA associated vasculitis.
Objectives: To determine the prevalence and clinical associations
with ANCA among Thais SSc.
Method: A cross-­sectional study of Thai adult SSc patients, followed
up during November 1, 2016-­November 30, 2017 at the Scleroderma
Clinic, Khon Kaen University, Thailand was conducted. According to
the sample size calculation, 185 patients were included.
Results: The female to male ratio was 2:1. Majority had diffuse SSc
subset (71.2%). The respective prevalence of having a) at least 1 se-
rological test for ANCA (viz., perinuclear-­ANCA, cytoplasmic-­ANCA,
anti-­myeloperoxidase, or anti-­proteinase3), b) positive for either p-­
ANCA or c-­ANCA, c) positive for either anti-­MPO or anti-­PR3, d) p-­
ANCA and anti-­MPO and e) c-­ANCA and anti-­PR3 was 21.6% (95%CI
15.9–28.3), 11.9% (95%CI 7.6–17.4) and 13.0% (95%CI 8.5–18.7) and
1% (95%CI 0.1–3.9). By multivariate analysis, the erythrocyte sedi-
mentation rate elevation was significantly associated with the pres-
ence of the antibody (OR 11.36: 95%CI 1.44–83.65), while elevation
of high sensitivity cardiac troponin-­T (hs-­cTnT) was significantly as-
sociated with the presence of either p-­ANCA or c-­ANCA (OR 4.25:
95%CI 1.41–15.34). Clinical features like small vessel vasculitis in-
cluded proteinuria and neuropathy were not associated with ANCA.
None of the patients had clinical features of systemic vasculitis.
Conclusion: Around one-­fifth of Thai-­SSc patients have detectible
ANCA without any features of vasculitis. The presence of ANCA is
associated with inflammation and myocardial injury. Long-­term clini-
cal follow-­up is suggested to elucidate the clinical implications.
1-­109 | Prevalence and predictors of
proton pump inhibitor partial response in
gastroesophageal reflux disease in systemic
sclerosis: an open label study
C. Foocharoen; K. Chunlertrith; P. Mairiang; A.
Mahakkanukrauh; S. Suwannaroj; S. Namvijit; O. Wantha; R.
Nanagara
Khon Kaen University
Background: Proton pump inhibitor (PPI) twice daily dosing is a
standard therapy for gastroesophageal reflux disease (GERD) in sys-
temic sclerosis (SSc) but there is no data on its response rate or the
predictors of PPI-­partial-­response (PPI-­PR) GERD.
Objectives: To determine the prevalence of PPI-­PR GERD in SSc and
to define its predictors.
Methods: An open label study was conducted in SSc patients with
GERD. The patients were treated with omeprazole 20 mg twice
daily for 4 weeks. The severity of symptom-­grading by visual ana-
logue scale (VAS) and frequency of symptoms by frequency scale for
symptoms of GERD (FSSG) were assessed at baseline and 4 weeks
after treatment. PPI-­PR GERD was defined as less than 50% im-
provement in the VAS for severity of symptom as well as acid reflux
score by FSSG after treatment.
Results: According to the sample size calculation, 243 SSc-­GERD pa-
tients were enrolled; of whom 116 (68.3%) had the diffuse SSc sub-
set. PPI-­PR GERD was found in 131 SSc patients (prevalence 53.9%;
95%CI 47.4–60.3). The univariate analysis revealed that dysphagia,
high baseline dysmotility score by FSSG, and high baseline severity
of regurgitation by VAS were associated with PPI-­PR GERD; how-
ever, only dysphagia was a predictor the PPI-­PR GERD in the multi-
variate analysis (OR 1.82; 95%CI 1.01–3.29).
Conclusion: Half of the SSc patients were PPI-­PR GERD. Dysphagia
was the only predictor of PPI-­PR GERD in SSc patients. Initial treat-
ment with a prokinetic drug PPI supplement might improve GERD
symptom and the PPI response rate in SSc-­GERD patients with co-
existing dysphagia.
The trial registration in ClinicalTrials.gov number: NCT03561233.

1-­061 | Globalisation of paediatric
musculoskeletal matters
H. Foster1,2; N. Smith2; R. Wyllie3; C. English4; B. Davies4;
R. Khubchandani5; M. Chan6; J. Munro7; V. Ferriani8; C. S.
Magalhães9; R. Russo10; J. Yan11; C. Scott12; S. Charuvanij13;
K. Khawaja14; J. Vojinovic15; C. Foley16; T. Rapley17; S.
Jandial3
1
Newcastle University Medicine Malaysia (NUMed); 2Institute of Cellular
Medicine, Newcastle University; 3Paediatric Rheumatology, Great North
Children's Hospital; 4Department of Nursing, Midwifery and Health,
Northumbria University; 5Department of Paediatrics, Jaslok Hospital
and Research Center; 6Paediatric Rheumatology, University of Alberta;
7 the immunophenotypic characterization of MCTD patients by flow
Paediatric Rheumatology, Royal Children's Hospital; 8Department of
Paediatrics, Ribeirão Preto Medical School, University of São Paulo;
9
Department of Pediatrics, UNESP; 10Service of Immunology/Rheumatology,
Hospital de Pediatría Garrahan; 11Paediatric Rheumatology, Starship
Children's Health; 12Department of Paediatrics, University of Cape
Town; 13Department of Pediatrics, Siriraj Hospital, Mahidol University;
14
Department of Immunology/Rheumatology, Al-­M afraq Hospital;
15
Paediatric Rheumatology, Faculty of Medicine, University of Nis; 16The
National Centre for Paediatric Rheumatology, Our Lady's Children's Hospital
Crumlin; 17Social Work, Education and Community Wellbeing, Northumbria
University
Background/purpose: ‘Paediatric musculoskeletal matters’ (PMM–
www.pmmonline.org), launched 2014, is a free, evidence-­
based
and peer-­reviewed open e-­resource for paediatric musculoskeletal
(MSK) medicine targeting non-­MSK specialists. PMM is endorsed by
the Paediatric Rheumatology European Association (PRES) and NICE
(National Institute for Health and Care Excellence) as an educational
resource. Here we describe feedback and the process to develop
new content for application in global health care contexts.
Methods: Data from Google Analytics, e-­surveys and 1-­1 interviews
was analysed using mixed-­methods.
Results: Since launch (Nov-­
2014) PMM has reached 200 coun-
tries with >133,300 users, >367,800 hits. Users register to access
the video materials and are mainly non-­
MSK specialists (mostly
from general paediatrics and primary care) and trainees with “oc-
casional exposure to paediatric MSK medicine”. PMM was viewed as
“very useful” (75.93%) or “useful” (20.37%) for many (96.3%) survey
respondents and most (96%) deemed PMM “had impact on clinical
practice”. Most useful aspects of PMM reported; videos (particu-
larly joint examination), clinical cases, red flags for concern and
referral pathways. Feedback from users requested further content
to reflect international healthcare systems; this resulted in ‘PMM
International’ (launched Sept 2018), with content contributions from
our global partners, predominately focused on infection-­
related
MSK presentation.
Conclusion: Data supports wide reach of PMM and positive uptake
from the target audience. Rapid globalisation of PMM necessitated
further content to reflect international healthcare contexts. PMM
International is now live (www.pmmonline.org), remains a free and
open resource to raise awareness and early recognition of childhood
onset MSK pathology. Formal evaluation of PMM International on
clinical practice is in progress. A PMM app is planned to facilitate
access where Internet capacity is limited.
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1-­013 | Alterations of immune cell subsets in
patients with mixed connective tissue disease
J. Maeda1; T. Okamura1; Y. Iwasaki1; Y. Nagafuchi1; M. Ota1;
Y. Takeshima1; K. Yamamoto2; K. Fujio1
1
University of Tokyo; 2RIKEN
Background/purpose: Mixed connective tissue disease (MCTD) is
a disease entity of unknown etiology characterized by overlapping
clinical features of two or more connective tissue diseases and by
elevated anti-­U1RNP antibodies. in this study, we aimed to assess
cytometry (FCM).
Methods: Peripheral blood samples were obtained from 16 MCTD
patients and 51 healthy controls (HC). Immunophenotypes were
analyzed by FCM. Each one patient evolved to SLE and overlap syn-
drome was excluded.
Results: Among 26 immune cell subsets, the proportion of naïve B
cells and monocytes, especially CD16-­negative monocytes, was sig-
nificantly higher in MCTD patients than in HC. Moreover, circulating
plasma cells tend to increase in MCTD patients.
Conclusion: The increased CD40 expression on CD16-­
negative
monocytes, and the increased number of plasma cells in the active
stage of MCTD have been reported. Our results suggest that the
increased number of CD16-­negative monocytes, as well as plasma
cells, is important for the pathogenesis of MCTD, indicating the pe-
ripheral blood compartment reflects the inflammatory milieu of the
affected organs. We are currently investigating the molecular basis
of these changes by using next generation sequencing techniques.
1-­014 | The gene expressions of various
key molecules are influenced by Fas ligand in
rheumatoid synovial fibroblasts
K. Fukuda1; Y. Miura2; T. Maeda1; S. Hayashi1; R. Kuroda1
1
Department of Orthopaedic Surgery, Kobe University Graduate School of
Medicine; 2Division of Orthopedic Science, Department of Rehabilitation
Science, Kobe University Graduate School of Health Sciences
Background: Fas ligand (FasL) is a member of tumor necrosis factor
superfamily (TNFSF6) and reported to be involved in synovial hyper-
plasia of rheumatoid arthritis (RA). Apoptosis through Fas/FasL path-
way of RA synovial cells was inhibited by pro-­inflammatory cytokines
present within the synovium. We previously reported that decoy re-
ceptor 3 overexpressed in rheumatoid synovial fibroblasts (RA-­FLS)
stimulated by TNFα protects the cells from Fas-­induced apoptosis.
Objectives: In this study, we investigated the gene expression pro-
files regulated by FasL in RA-­FLS to reveal how FasL is involved in
the pathogenesis of RA.
Methods: RA-­FLS were incubated with either recombinant human
FasL protein or phosphate buffered saline as unstimulated control
diluted with Opti-­MEM reduced serum medium for 12 hours. Gene
expressions were detected by microarray assay.
 |
78      

Results: Microarray data analysis revealed that FasL up-­regulated Therapy with IV ganciclovir was started followed by valganciclovir.
or down-­regulated the expression of various genes in RA-­FLS. CMV viral load was undetectable upon completion of treatment with
The most up-­
regulated 3 genes by FasL were dual specificity ganciclovir. Thereafter, corticosteroid, prednisolone was tapered
phosphatase 6 (DUSP6), epiregulin (EREG) and interleukin11 (IL-­ and immunosuppression was continued with azathioprine.
11). DUSP6 regulates CD4+ T-­cell activation and differentiation
by inhibiting the T-­cell receptor-­d ependent extracellular signal-­
regulated kinases 1 and 2 activations. EREG is increased in patients
with RA and associated with the development of cytokine-­induced
arthritis. IL-­11 regulates the growth and development of hemat-
opoietic stem cells and decreases the pro-­inflammatory cytokines
and nitric oxide productions. The most down-­regulated 3 genes
by FasL were angiopoietin-­
like 7 (ANGPTL7), protein inhibitor
of activated STAT2 (PIAS2) and growth differentiation factor 5
(GDF5). ANGPTL7 is pro-­
angiogenic factor and promotes pro-­
inflammatory responses through the P38 signaling pathway. PIAS
proteins inhibit the activated STAT and are involved in the patho-
genesis of RA. GDF5 is associated with joint destruction of pa-
tients with OA and RA.
Conclusions: FasL regulates the expression of various genes in RA-­
FLS and may affect the pathogenesis of RA.

Conclusions: Current guidelines for treatment of CMV infection

while receiving immunosuppressive therapy are targeted to solid
2-­143 | Cytomegalovirus colitis (CMV) organ transplant patients and patients with inflammatory bowel dis-
following cyclophosphamide therapy in a patient ease. This case report highlights the need to consider screening for
with polyarteritis nodosa (PAN) CMV infection prior to immunosuppression in rheumatologic condi-
tions especially in vasculitides and even more so in PAN, where as-
A. F. M. Salleh; E. Chong YY2
sociation with CMV is known.
1
Hospital Queen Elizabeth, Ministry of Health, Malaysia; 2Gleneagles Kota
Kinabalu

Background: PAN is a necrotizing arteritis of medium or small arter-
ies that is treated with immunosuppressive therapies such as glu-
cocorticoids. Opportunistic infections such as CMV are potential
complications of immunosuppression and ensuing immunosuppres-
sion is hampered by the possibility of viral replication. Screening for
latent CMV is not advocated prior to immunosuppressive therapy in
rheumatologic conditions.
Objectives: To discuss the relationship between CMV, PAN and
immunosuppression.
Methods: We report a case of CMV colitis following cyclophospha-
mide therapy in a patient with PAN and the subsequent choice of
immunosuppressive therapy.
Results: 26 year old lady who presented with hypertension, on and
off headache with discolouration and ulceration (ischaemia) of the
left 2nd finger and pulseless left radial artery.
The diagnosis of PAN was made based on micro-­aneurysms seen on
CT angiogram of the renal arteries. CT angiogram of the left upper
limb showed faint opacification of the left ulnar artery and stenosis
of the left radial artery.
She was started on high dose prednisolone and a dose of cyclophos-
phamide at 15 mg/kg. Two weeks later, she developed persistent
diarrhoea, following which; the diagnosis of CMV colitis was con-
firmed based on histopathology as well as positive CMV IgG.
2-­066 | Effectiveness of febuxostat in the
management of gout – the Kuala Lumpur hospital
experience
S. G. Ong1; S. P. Gan1,2; W. H. Han1; H. J. Ding1
1
Rheumatology Unit, Department of Medicine, Kuala Lumpur Hospital, Ministry
of Health Malaysia; 2Rheumatology Unit, Department of Medicine, Selayang
Hospital, Ministry of Health Malaysia
Background/purpose: Achieving target serum uric acid (SUA) level
of <360 µmol/L is key to quality management of gout. Febuxostat
was recently approved by Ministry of Health Malaysia for treat-
ment of gout. We aimed to evaluate the efficacy and safety of fe-
buxostat in gout patients who were intolerant or non-­responders
to allopurinol.
Methods: This is a retrospective study. Medical records of all 20 pa-
tients who had received febuxostat at the Rheumatology Clinic were
examined. Febuxostat was initiated at 40 mg daily, and up-­titrated
to 80 mg daily (maximal dose) when target SUA was not achieved.
Results: Indication for febuxostat in 19 patients was hypersensitiv-
ity reaction to allopurinol, while one was non-­response to allopuri-
nol. Two patients developed hypersensitivity reaction to febuxostat.
Therefore only 18 patients were analysed. Mean age was 67.3 years
with standard deviation (SD) of 10.2. Twelve (67%) patients were
 |
      79

men. Seventeen (94%) had chronic kidney disease (CKD), whereby
11 (61%) were in CKD stage 3. Mean baseline SUA was 601.2 µmol/L
(SD = 102.5). Sixteen (89%) patients achieved target SUA. Median
time to achieve target SUA was eight months with interquartile range
of 9. Eight (50%) patients achieved target SUA within six months of
febuxostat treatment. Equal proportion of patients achieved target
SUA with febuxostat 40 and 80 mg daily, respectively. There were
no significant changes (P > 0.05) in serum creatinine, estimated
glomerular filtration rate and alanine transaminase, at baseline and
upon achievement of target SUA.
Conclusion: Febuxostat is an effective and relatively safe urate-­
lowering drug in allopurinol-­intolerant patients with CKD.
than HIV infection with lupus-­like manifestation. The diagnostic
difficulties may be explained by autoantibodies cross reactivity or
broadly neutralizing antibody in SLE patients with co-­existing HIV
infection.
1-­083 | Factors for development of
connective tissue disease in idiopathic
pulmonary fibrosis
B. Ghang1; J. Lee2; Y.-G . Kim2; B. Yoo2; W. S. Jeong1; J .
Kim1; C.-K. Lee2
1
Jeju National Unversity Hospital; 2Asan Medical Center

Background/purpose: Connective tissue disease (CTD) may be ob-

2-­055 | Systemic lupus erythematosus in a
patient with hiv infection: a diagnostic dilemma
S. P. Gan; I. S. Lau; N. Zainudin
Rheumatology Unit, Department of Medicine, Selayang Hospital, Ministry of
Health
Background/purpose: The co-­
existence of Systematic Lupus
Erythematosus (SLE) and Human Immunodeficiency Virus (HIV) in-
fection is rare. The unclear immunopathogenesis, with overlapping
clinical features and common laboratory findings between these
conditions often raise diagnostic challenges.
Methods: We report a case of HIV infection with co-­existing SLE and
describe the diagnostic dilemmas we encountered.
Results: A 30-­year-­old Indian man presented with a week history
of facial rash, oral ulcers, joint pain and vasculitic rashes over the
soles, and a month history of fever and diarrhoea. He was diagnosed
with antiphospholipid syndrome in 2009, chronic immune throm-
bocytopenic purpura in 2013 and HIV infection in 2011 which was
naïve to highly active antiretroviral therapy (HAART). in view of his
HIV ribonucleic acid (RNA) viral load was undetectable with clus-
ter of differentiation (CD4) counts of 227 cells/μL, he was referred
to rheumatology for a possibility of SLE with a false positive HIV
antibody.
Initial laboratory investigations revealed leucopenia, thrombocyto-
penia, low complements (C3 and C4) and a positive direct Coombs
test. Urinalysis was normal. However, anti-­nuclear antibody (ANA)
was negative. The diagnosis of HIV infection was confirmed with
a positive HIV Immunoblot test. Our impression was HIV infection
served during the disease course of idiopathic pulmonary fibrosis
(IPF). However, clinical factors associated with the development of
CTD in patients with IPF have not yet been identified. We aimed to
investigate factors of IPF associated with development of CTD.
Methods: We retrospectively reviewed the records of 526 patients
initially diagnosed with IPF between January 2007 and March 2014.
The time to development of CTD after the first visit was investigated
in these patients.
Results: CTD developed in 15 IPF patients at a median of
2.1 years (range 1.2–4.8) after their first visit (7 patients with
rheumatoid arthritis, 1 undifferentiated connective tissue dis-
ease, 2 Sjögren syndrome, 1 polyarteritis nodosa, and 4 micro-
scopic polyangiitis).
Independent risk factors for development of CTD in IPF patients
included, male sex (hazard ratio [HR] 0.23, P = 0.021), malignancy
(HR 6.49, P = 0.003), immunomodulator use (HR 5.560, P = 0.017),
and titers of rheumatoid factor (RF, HR 1.006, P = 0.016), titers of
anti–citrullinated protein antibody (ACPA, HR 1.007, P = 0.006),
and titers of anti-­
myeloperoxidase (MPO) antibody (HR 1.02,
P < 0.001).
Conclusion: In IPF patients, RF, ACPA, and anti-­MPO antibody may
be important for the development of CTD
Table 1 Multivariable Cox regression analysis of connective tissue
disease development in idiopathic pulmonary fibrosis patients
Characteristic HR (95% CI) P value
Male 0.234 (0.069–0.801) 0.0207
Malignancy 6.488 (1.891–22.253) 0.0029

with lupus-­like features. Immunomodulator use 5.597 (1.368–22.9) 0.0166

We repeated the ANA and it was positive with a titre of 1:640 with Rheumatoid factor 1.006 (1.001–1.011) 0.0158
homogenous pattern. Anti-­double stranded DNA (anti-­dsDNA) was Anti–citrullinated protein 1.007 (1.002–1.013) 0.0055
positive with a titre of 77 IU/mL. Skin biopsy of facial rash was sug- antibody

gestive of cutaneous lupus. We revised our diagnosis to HIV infec- Anti-­myeloperoxidase 1.02 (1.011–1.029) <0.0001
tion with co-­existing SLE. antibody

Conclusion: This case highlights the challenges of a patient pre-

sented with lupus-­like illness in HIV infection. Our patient eventu-
ally was found to have HIV infection with co-­existing SLE rather
 |
80      
2-­103 | Prevalence of restrictive lung disease
in systemic sclerosis patients in rheumatology
outpatient clinic in Cipto Mangunkusumo
General Hospital
A. Ginting; S. Anggoro; B. Setyohadi
Departemen Ilmu Penyakit Dalam – Divisi Reumatologi RSUPN Cipto
Mangunkusumo
Background/purpose: Systemic sclerosis (SSc) is a generalized dis-
order of connective tissue affecting skin and internal organs. Lung
involvement has been long shown to be associated with reduced
survival. Pulmonary function testing (PFT) are cornerstone test in
detection of pulmonary involvement in patients with SSc. Patients
with interstitial lung involvement will demonstrate restriction of
lung function test. Spirometry typically utilized in clinical practice
provides a good estimation of restriction. This aim of the study was
to describe spirometry findings in patients with SSc in our rheuma-
tology outpatient clinic.
Methods: A retrospective cross-­
sectional, descriptive study was
conducted in 29 patients with confirmed diagnosis of SSc, who un-
derwent spirometry. According to spirometry results, we categorized
the patients into normal, restrictive, obstructive, and mixed groups.
Restrictive lung disease was defined as combined of forced vital ca-
pacity (FVC) < 70% and forced expiratory volume at 1s (FEV1)/FVC
>70%. Patients with restrictive lung disease was categorized as mild,
moderate, moderately severe, severe and very severe based on FVC
prediction.
Results: Twenty-­nine patients were included in this study. Spirometry
findings showed mean FVC 1.87 ± 0.85 Liters, mean FVC prediction
62.8 ± 33.44%, and FEV1/FVC prediction 98.76 ± 14.76%. Based on
combination FVC and FEV1/FVC, normal lung function was present
in 13.8% of patients, restrictive in 72.4%, obstructive in 6.9%, and
mixed in 6.9%. Within the restrictive group, 14.3% was mild, 14.3%
moderate, 19% moderately severe, 33.3% severe, and 19% very
severe.
Conclusion: The spirometry findings of patients with systemic scle-
rosis showed high prevalence of restrictive lung diseases (72.4%).
Within the restrictive group, 33% of patients had severe restriction
and 19% very severe restriction.
1-­135 | Treat to target in SLE -­prospective
validation of the lupus low disease activity state
endpoint
V. Golder1,2; R. Kandane-Rathnayake1; M. Huq3; H.
Nim1; W. Louthrenoo 4; S. F. Luo5; Y.-J. Wu5; A. Lateef6;
S. Sockalingam7; S. Navarra8; L. Zamora8; L. Hamijoyo9;
Y. Katsumata10; M. Harigai10; M. Chan11; S. O'Neill12; F.
Goldblatt13,14; C. S. Lau15; Z . Li16; A. Hoi1,2; M. Nikpour3; E.
Morand1,2
1
Monash University; 2Monash Health; 3University of Melbourne; 4Chiang Mai
University Hospital; 5Chang Gung Memorial Hospital; 6National University
Hospital; 7University of Malaya; 8University of Santo Tomas Hospital;
9
University of Padjadjaran; 10Tokyo Women's Medical University; 11Tan Tock
Seng Hospital; 12University of New South Wales; 13Flinders Medical Centre;
14
Royal Adelaide Hospital; 15University of Hong Kong; 16People's Hospital Peking
University Health Science Center
Background: Adoption of treat to target approaches for Systemic
Lupus Erythematosus (SLE) requires the definition of a target state
validated for improved patient outcomes. The Lupus Low Disease
Activity State (LLDAS) has been shown in multiple retrospective and
cross-­sectional studies to have face, content, construct and criterion
validity and be associated with better quality of life. We report on a
multinational prospective study undertaken to determine whether
LLDAS attainment is associated with protection from flare and dam-
age accrual.
Methods: A prospective multinational cohort study was undertaken
in 13 centres between 2013–2017. Patients with SLE were recruited,
SLEDAI-­2k, SELENA flare index, PGA, and medication data collected
at every visit, and damage (SLICC-­ACR damage index (SDI)) collected
annually. Time-­dependent Cox proportional hazards models were
used to assess the association of LLDAS at any time point, as well
as the effect of the proportion of time spent in LLDAS, with disease
flare and damage accrual (increase in SDI).
Results: 1735 patients were followed for (mean 
± 
SD)
2.2 ± 0.9 years, totalling 12,717 visits. LLDAS was achieved in
54.6% of visits. Attainment of LLDAS at any timepoint was pro-
tective against subsequent flare (HR 0.65, 95%CI 0.56–0.76,
P < 0.001) and damage accrual (HR 0.55, 95%CI 0.43–0.70,
P < 0.001). Similarly, patients who spent ≥50% of their observed
time in LLDAS had reduction in risk of flare (RR 0.41, P < 0.001)
and damage accrual (RR 0.59, P < 0.001), compared to those
with < 50% of observed time in LLDAS. Increased durations of
sustained LLDAS were associated with incremental reduction in
risk of damage accrual.
Conclusion: LLDAS attainment provides significant protection
against disease flare and damage accrual. Our findings support the
use of LLDAS as a treatment target in SLE, and as an outcome meas-
ure for clinical trials and treat-­to-­t arget strategies.

1-­049 | Australian osteoporotic treatment
trends over five years
R. Gunawardana; M. Terrill; P. Vecchio
Rheumatology Department, Princess Alexandra Hospital
Background: Osteoporosis treatment is proven to prevent fractures
and increase bone density. in Australia different treatment options
are available, in which uptake of use has differed in the last 5 years.
Objectives: This study compared the number and trend of
Pharmaceutical Benefit Scheme prescriptions processed within
Australia over a five-­year period, of the following medications for os-
teoporosis: Alendronate, Risedronate, Zoledronic acid, Denosumab,
Raloxifine and Teriparatide.
Method: Using the item numbers listed for Osteoporosis through
the publicly accessible Pharmaceutical Benefits Schedule (PBS) item
reports, the yearly number of all PBS and RPBS prescriptions of
Alendronate, Risedronate, Zoledronic acid, Denosumab, Raloxifene
and Teriparatide over the period of July 2012–2013 versus 2017–
2018 was assessed.
Results: Over a 5-­year period; from July 2012–2013 to 2017–2018,
the amount of Denosumab prescriptions have increased dramati-
cally, from 61,601 to 590,584 (859% increase), while Teriparatide
prescriptions have slightly increased 7080–10,040 (42% increase).
All bisphosphonate prescriptions have decreased; Zoledronic acid
33,635 to 13,288 (60% decrease), Alendronate 395,080–112,156
(72% decrease), Risedronate 6041–3634 (40% decrease). Raloxifine
has also decreased from 179,140 to 80,851 prescriptions (55% de-
crease). Please refer to graph 1.
Conclusion: This review shows that the use of denosumab for os-
teoporosis has increased dramatically within Australia in the last
5 years, with a small increase in the use of Teriperatide. On the other
|
      81
hand, this coincides with a decrease in the prescriptions of all bis-
phosphonates and use of Raloxifine.
This study reveals that Denosumab has become the favoured treat-
ment option for use in osteoporosis within Australia.
1-­136 | Clinical and immunological
manifestation in 62 SLE patients in Nepal
A. Gupta
Norvic International Hospital
Objectives: Though SLE is rare disease in the world and having is
a wide variation of presentation among different ethenic and geo-
graphical groups.There is no information and clinical picture of SLE
among Nepalese nations.This study aim to delineate the clinical and
immunological manifestation of systemic lupus erythematosus in
Nepali populations.
Methods: This was hospital base prospective studied conduct in
one tertiary care hospitals and specialized Arthritis Care Center in
Kathmandu Nepal over Seven years (September 2011-­2018 sep-
tember). Subjects were diagnosed using the American college of
Rheumatology (ACR) criteria for SLE.
Results: Total 62 SLE patients were identified. The patients were
from all parts of Nepal.The female and male Ratio was 6.5:1.The
mean age of disease duration was32.10 months.The peak age of
diagnosis was between 5 and 55 years. The mean duration of fol-
low up was 16 months. The spectrum of clinical manifestations were
malar rash, 86.6%; photosensitivity, 83.3%; oral ulcer, 86.3%; alope-
cia,73.3%; discoid rash, 3.3%; reynaud's phenomenon, 73.3%; subcu-
taneous nodules, 3.3%, arthralgia, 83.3%; myalgia, 60%; fever, 70%;
fibromyalgia syndrome, 16.6%; lupus nephritis,13.3%,Polyserositis
30.3%; lymphoadenopathy, 10.3%; hepatospleenomegaly, 13.3%.
The frequency of haematological and immunological findings were
Autoimmune Hemolytic Anemia 3.3%; anemia, 40%; pencytopenia
56%; Erythrocyte Sedimentation Rate, 69.26%; antinuclear antibod-
ies (ANA), 100%; antidsDNA antibodies, 83.3%, low complement pa-
tients of SLE. All our patients received corticosteroid,Antimalarialand
immunosupressive agents at some stage and according to severity of
their disease.
Conclusion: The clinical and immunological characteristic of our pa-
tients with SLE are largely comparable to other studies from Asia and
developed countries.In our study main observation included high
frequency of mucocutaneous manifestation and high prevalence of
serological markers in Nepali SLE patients.
Keywords: Systemic Lupus erythematosus, Nepal
82       |

2-­104 | Role of ultrasound in skin and end-­ Table 1. Intra-­rater reliability of US

organ disease in scleroderma Assessor 1 - Visit 1

Agreement
Assessor 1 - Visit 2
Assessment Site ICC (95%CI) LCI UCI ICC LCI UCI
1 1 2 1,3
P. Habib ; J. Roddy ; W. Raymond ; H. Keen Face 0.659 0.256 0.870 0.914 0.652 0.978
Chest 0.754 0.415 0.910 0.913 0.724 0.976
1
Department of Rheumatology, Fiona Stanley Hospital; 2University of Western Abdomen 0.822 0.552 0.936 0.887 0.641811803 0.96809
Australia; 3School of Medicine and Pharmacology, University of Western Australia Right finger 0.853 0.625 0.948 0.943 0.790191615 0.9856
Left finger 0.777 0.468 0.919 0.557 -0.019 0.857
Right hand 0.365 -0.146 0.727 0.908 0.705 0.974
Left hand 0.365 -0.166 0.731 0.703 0.191 0.912
Background: The modified Rodnan skin score (mRSS) is limited by Right forearm 0.715 0.338 0.894 0.526 -0.154 0.860
Left forearm 0.508 0.008 0.803 0.856 0.556 0.959
inter-­observer variability and measures skin tethering rather than Right arm 0.676 0.280 0.877 0.75 0.332 0.925

thickness. Left arm

Right thigh
0.829
0.888
0.559
0.700
0.939
0.961
0.844
0.888
0.540
0.635
0.955
0.969

Objectives: Evaluate intra-­and inter-­rater reliability ultrasound (US); Left thigh 0.851 0.615 0.947 0.631 0.129 0.882
Right Leg 0.795 0.490 0.926 0.908 0.708 0.974
assess whether US can detect temporal progression of skin disease Left Leg 0.806 0.509 0.931 0.7 0.236 0.908
Right Foot 0.379 -0.162 0.739 0.605 0.024 0.877
and correlate progression with organ complications. Left Foot 0.634 0.185 0.862 0.609 0.067 0.876
Cumulative Score 0.919 0.726 0.979 0.966 0.813 0.995
Methods: Participants attending Fiona Stanley Hospital from 2010 Abbreviations: ICC, intra-class coefficient; LCI, lower confidence interval;
to 2017 underwent skin assessments with mRSS and US. US meas- UCI, upper confidence interval

urements were performed with an Esaote Mylab 70 XVG using a Abbreviations: ICC, intra-­class coefficient; LCI, lower confidence in-
linear probe set at 18 MHz, and stand-­off pad at 17 mRSS sites. terval; UCI, upper confidence interval
Skin thickness definition: distance between interface of skin stand-­
Table 2. Inter-rater reliability of US
off pad and dermis. Data was collected on clinical characteristics, Visit 1 Visit 2
Assessor 1 vs Assessor 2 Assessor 1 vs Assessor 2
medications and organ damage. Two rheumatologists trained in US Assessment Site ICC lci uci ICC lci uci
Face 0.776 0.468 0.918 0.917 0.707 0.979
recorded 2 measurements at baseline and 2 years. Chest 0.754 0.383 0.912 0.541 0.006 0.847

Statistics: Intra-­class coefficients for intra-­and inter-­rater reliability; Abdomen 0.815

0.162
0.444
-0.254
0.939
0.579
0.713
0.568
0.214
-0.043
0.915
0.864
Right finger
Wilcoxon Signed-­Rank test for progression of skin thickness (dif- Left finger 0.033 -0.363 0.482 0.135 -0.547 0.672
Right hand -0.273 -0.664 0.252 0.795 0.419 0.940
fuse disease only, n = 6) and Mann-­Whitney U test for correlation Left hand 0.111 -0.333 0.554 0.342 -0.260 0.763
Right forearm 0.256 -0.237 0.660 0.506 -0.118 0.848
between US thickness and organ complications. Left forearm 0.361 -0.090 0.713 0.68 -0.026 0.915
0.562 0.083 0.828 0.366 -0.235 0.774
Results: Sixteen participants (10 limited disease, 6 diffuse disease), Right arm
Left arm 0.511 0.003 0.808 0.443 -0.106 0.804

81% females, median age of 65 years and median disease duration Right thigh 0.658 0.261 0.869 0.769 0.137 0.940
Left thigh 0.773 0.451 0.917 0.749 0.245 0.928
of 9 years. Overall, ENA profiles were: 12.5% SSA, 18.8% Scl-­70, Right Leg 0.307 -0.224 0.691 0.834 0.471 0.953
Left Leg 0.526 0.060 0.809 0.78 0.389 0.935
6.3% SSA/centromere/RNP/histone while 62.5% had a negative Right Foot 0.172 -0.289 0.599 0.139 -0.395 0.645
Left Foot 0.222 -0.267 0.638 0.273 -0.253 0.717
ENA. Figure 1 illustrates those patients on immunosuppressants Cumulative Score 0.739 0.395 0.903 0.862 0.495 0.970

and pulmonary arterial hypertension (PAH) therapy. Primary aim: Abbreviations: ICC, intra-class coefficient; LCI, lower confidence interval;
UCI, upper
l confidence interva
Tables 1 and 2 show the intra-­r ater and inter-­r ater reliability for
US (respectively). Secondary aims: Improvement in thickness was
measured in 2 (33%) patients (Patient 1: 12/17 sites, P < 0.039; Abbreviations: ICC, intra-­class coefficient; LCI, lower confidence in-
Patient 2: 16/17 sites, P < 0.001). Both were previously on metho- terval; UCI, upper confidence interval
trexate, 1 was on mycophenylate. No correlation was found be-
tween US measurements of progression and organ complications.
Conclusions: US had good intra-­and inter-­rater reliability at the ab- 3-­093 | Using treat-­to-­target strategy by
domen and thigh. US could detect improvement in thickness in the determining physical disability and glucocorticoid
thickness at the abdomen at the abdomen in diffuse patients. There
reduction strongly influence functional remission
was no correlation between US measured skin thickness and organ
complications.
in rheumatoid arthritis
T. Hagiwara; N. Namura; K. Kamada
Takarazuka City Hospital
9
DSSc LSSc
8
7 Background: Te final target is to maximise long-­term health-­related
No. paents

6
5 quality of life (HRQoL) through arthritis control, joint damage pre-
4 vention, function normalisation and social participation.
3 Objectives: We aimed to determine the factors that inhibit the
2
achievement of functional remission (FcR) in terms of HRQoL.
1
0 Methods: A total of 227 patients with RA who had underwent
Previous Current PAH therapy first treatment between October 2014 and December 2017 and
immunosuppressant immunosuppressant
had not changed/added another DMARDs for 12 weeks before

the observation day were examined. We evaluated the HAQ-­DI as
daily-­life functional assessment and EQ5D-­5L for health status with
considerable potential assessment. FcR was defined in this study as
HAQDI ≤ 0.5 and EQ5D ≥ 0.867. We investigated their onset age,
sex, Stage and Class, HAQ-­DI, disease activity, RF, ACPA at the first
consultation, age, disease activity, HAQ-­DI, EQ5D, and status of
MTX, glucocorticoids (GCs) and b/ts-­DMARD use at the last obser-
vational day. The odds ratio for FcR was examined using multiple
logistic regression analysis for the statistically significantly different
factors and risk factors.
Results: The differences in disease duration, Stage, Class and HAQ-­DI
at the time of the first interview; state of MTX, GCs and b/ts-­DMARD
use; and age at the last observational day for the achievement of FcR
were statistically significant. Odds ratios were 1.034 (P = .202) for
disease duration (per 1 year), 1.576 (P < .001) for HAQ-­DI at first in-
terview (per 0.5), 0.615 (P = .232) and 4.943 (P < .01) for GCs state,
and 1.164 (P < .05) for age at last observational day.
Conclusions: Our results indicated the importance of functional
assessment at first interview and demonstrated how to use GCs
for the treatment of RA. Aging always contributes to patients’
frailty, and it is unavoidable it. To achieve FcR, functional as-
sessment should be performed during the first interview and
short-­term use of GC is useful for prompt functional recovery, in
consideration of aging.
1-­114 | Certolizumab pegol versus standard
care in treating non-­radiographic axial
spondyloarthritis: results for Asia-­Pacific versus
rest of the world from C-­axSpAnd
A. Deodhar1; L. S. Gensler2; J. Kay3; W. P. Maksymowych4;
N. Haroon5; R. Landewé6,7; M. Rudwaleit8; S. Hall9; J. Wei10;
L. Bauer11; B. Hoepken11; N. de Peyrecave12; T. Kumke11; D.
van der Heijde13
1
Oregon Health and Science University; 2University of California; 3University
of Massachusetts Medical School and UMass Memorial Medical Center;
4
University of Alberta; 5University Health Network, University of Toronto;
6
Amsterdam Rheumatology & Clinical Immunology Center; 7Zuyderland
Medical Center; 8Department of Internal Medicine and Rheumatology,
Klinikum Bielefeld; 9Cabrini Medical Centre, Cabrini Private Hospital;
10
Chung Shan Medical University, Institute of Medicine; 11UCB Pharma;
12
UCB Pharma; 13Department of Rheumatology, Leiden University Medical
Center
Background/purpose: In Australia and Taiwan (Asia-­Pacific [APAC]),
certolizumab pegol (CZP) is approved for treatment of active anky-
losing spondylitis but not for non-­radiographic axial spondyloar-
thritis (nr-­axSpA). C‑axSpAnd is the first study to address questions
regarding the presumed high rate of spontaneous remission of nr-­
axSpA, the limitations of conventional, non-­biologic axSpA thera-
pies, and the long-­term efficacy and safety of CZP over a one-­year,
placebo-­controlled period.
Methods: C-­axSpAnd (NCT02552212) is a 52-­week (wk), phase 3,
multicenter, double-­
blind, placebo-­
controlled study conducted
|
      83
in Europe/North America (rest of the world [RoW]) and APAC.
Recruited patients were adults with diagnosis of axSpA meeting
Assessment of SpondyloArthritis international Society (ASAS) (but
not modified New York) classification criteria, symptom duration
≥12 months, elevated C-­reactive protein/positive MRI of sacroiliac
joints, who have failed ≥2 non-­steroidal anti-­inflammatory drugs.
Patients were randomized 1:1 to placebo or CZP (400 mg at Wks
0/2/4, then 200 mg every 2 weeks), and could adjust concomitant
medication or switch to open-­label biologics at any point. The pri-
mary variable was Ankylosing Spondylitis Disease Activity Score
Major Improvement (ASDAS-­MI) at Wk52.
Results: Of 317 patients, 29 were in APAC (placebo:15; CZP:14;
Table 1). 60.8% placebo-­
treated patients switched to open-­
label
CZP (APAC:73.3%; RoW:59.4%) vs 12.6% CZP-­
treated patients
(APAC:28.6%; RoW:11.0%). at Wk52, 47.2% CZP-­treated patients
(APAC:42.9%; RoW:47.6%) achieved ASDAS-­MI vs 7.0% placebo-­
treated patients (APAC:6.7%; RoW:7.0%) (Table 2). Adverse events
for the entire study population were consistent with those reported
for CZP and other anti-­TNFs.
Conclusion: A considerably larger proportion of placebo-­
treated
patients switched to open-­label CZP, indicating that conventional
therapy provides inadequate nr-­axSpA disease control. A substan-
tially higher proportion of CZP-­treated patients demonstrated major
improvement in nr-­axSpA disease activity. No major differences in
response to placebo/CZP between APAC and RoW patients were
found; however, these results should be treated with caution given
the small APAC sample size.
1-­091 | Upadacitinib impact on individual/
composite disease measures in rheumatoid
arthritis patients with inadequate response to
conventional synthetic or biologic DMARDs
R. van Vollenhoven1; R. Dore2; K. Chen3; H. S. Camp3; J.
Enejosa3; T. Shaw3; J. L. Suboticki3; S. Hall4
1
Amsterdam Rheumatology and Immunology Center ARC; 2Univ of California;
3
AbbVie Inc.; 4Department of Medicine, Monash University, Cabrini Health and
Emeritus Research
Background/purpose: Efficacy evaluations at Wk 12 are an impor-
tant assessment point according to T2T recommendations. Here we
 |
84      
assess impact of UPA, a JAK1 selective inhibitor, at 12 weeks on in-
dividual and composite measures of RA disease activity.
Methods: Patients received UPA 15 or 30 mg once daily (QD) or
PBO for 12 weeks in two phase 3 trials. SELECT NEXT and SELECT
BEYOND enrolled csDMARD-­and bDMARD-­IR patients, respectively.
Responses at Wk 12, were defined as ≥ 50% improvement in ACR com-
ponents. Among ACR50 responders, proportions of patients achiev-
ing ≥ 50% improvement in all 7 ACR components were assessed (Table).
Differences in cumulative distributions of CDAI, DAS28-­CRP, and SDAI
between baseline and Wk 12 were assessed. Data are as observed.
Results: Patients, on average, had moderate to severe RA at baseline,
with (mean) disease durations of 7.3 and 13.2 years, CDAI of 38.2
and 40.9, in csDMARD-­IR and bDMARD-­IR, respectively; 53% of
bDMARD-­IR patients had exposure to ≥2 bDMARDs. Significantly
more patients on UPA vs PBO achieved ≥50% improvements in each
ACR component at Wk 12 (Table). Among patients who achieved
ACR50 at Wk 12, approximately one-­half of csDMARD-­IR and one-­
third of bDMARD-­IR patients achieved ≥ 50% improvement in all
7 ACR components. While there were no differences at baseline,
cumulative distributions of CDAI, DAS28-­CRP, and SDAI separated
by treatment at Wk 12(P < 0.001); the lowest quartiles for UPA 15
and 30 mg vs PBO, CDAI levels dropped to 6.2 and 5.1 vs 12.5 in
csDMARD-­IR; and 7.2 and 8.2 vs 13.1 in bDMARD-­IR.
Conclusion: In patients with insufficient responses to csDMARDs
or bDMARDs, responses at 12 weeks were observed in significantly
higher proportions with UPA vs PBO. Favorable effects with UPA
were seen in composite scores and individual parameters, including
PROs and acute-­phase reactants.
2-­032 | Psychosocial burden of rheumatic
disease in adolescents & young adults
M. Hamid1,2; L. Cummins1,2; B. Whitehead1; H. d'Emden3,4; J.
Halloran2; C. Corias2; B. McDermott5
1
Mater Hospital Brisbane; 2University of Queensland; 3Mater Research Institute;
4
Diabetes Queensland; 5James Cook University
Background: Adolescents and young adults (AYA) face distinct psy-
chosocial challenges. The psychosocial burden amongst AYA with
rheumatic diseases is unknown. A greater understanding of its im-
pact on AYA is needed to better inform their care.
Objective: To characterise the psychosocial health of adolescents
and young adults with rheumatic diseases, and to compare this to
other chronic diseases. 
Methods: A prospective, single-­
centre study was conducted of
patients aged 15–25 years old who attended our public hospital's
clinics from December 2015 to December 2017. The rheumatol-
ogy cohort included: rheumatoid arthritis, psoriatic arthritis, anky-
losing spondylitis, systemic lupus erythematous, mixed connective
tissue disease, juvenile idiopathic arthritis and Sjögren's Syndrome.
The comparator cohort included: inflammatory bowel disease (IBD),
cystic fibrosis (CF), phenylketonuria (PKU) and craniomaxillofacial
deformities (CMFD). 
Eight validated patient-­
reported question-
naires were administered. Data were analysed using Independent
Student t-­tests for normally-­distributed, Mann-­Whitney U-­tests for
non-­parametric, Pearson's chi-­squared for categorical and ANOVA
for ordinal variables.
Results: Data from 34 rheumatology patients were compared to 171
other patients including: 55 IBD, 33 CF, 25 PKU and 58 CMFD. The
cohorts were similar in gender distribution, housing, employment
and education (P > 0.05), but the rheumatology cohort was more
multicultural (P < 0.004).
Clinical psychologic distress was reported by 72% of rheumatology
patients, compared to 42% of the comparator disease cohort. of
the rheumatology cohort, 31% reported severe symptoms of psy-
chological distress. Furthermore, rheumatology patients reported
reduced quality of life (P < 0.000) and felt less in-­control of their
disease (P < 0.05) than the comparator group. However, there was
no significant difference in their perception of stress, resilience and
social supports.
Conclusion: Psychosocial distress affects the majority of AYA with
rheumatic disease, and is significantly more prevalent compared to
other chronic disease patient cohorts. Given this significant illness
burden, psychosocial screening and targeted interventions should
be provided for these patients.

1-­137 | Mycobacterial infection and acetylator
status among systemic lupus erythematosus
patients in tuberculosis endemic area in
Indonesia
E. Sahiratmadja1,2; L. Hamijoyo3,4; S. Candrianita4; I. A. Rini2;
E. Sutedja4
1 1
Division of Biochemistry and Molecular Biology, Department of Basic Medical
Science, Faculty of Medicine, Universitas Padjadjaran; 2Centre for Clinical
Genetic, Faculty of Medicine, Universitas Padjadjaran; 3Rheumatology Division,
Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran/
Dr Hasan Sadikin General Hospital; 4Lupus Study Group, Immunology Study
Center, Faculty of Medicine, Universitas Padjadjaran
Background: In tuberculosis endemic area such as Indonesia myco-
bacterial infection is common, since this country ranks second glob-
ally for tuberculosis (TB) prevalence. Systemic Lupus Erythematosus
(SLE) patients are prone to this infection due to given SLE therapy.
Slow acetylator status may worsen the TB therapy outcome, espe-
cially due to drug induced liver injury. This status is determined by
various haplotypes of NAT2 gene that encodes N-­acetyltransferase2
enzyme, an enzyme that metabolizes one of primary TB drugs isonia-
zide. This study explored the NAT2 acetylator status in SLE patients
with TB.
Methods: In as subset of SLE patients with TB registered from March
2016-­March 2018 at Rheumatology Clinic, Dr Hasan Sadikin General
Hospital Bandung, Indonesia, acetylator status were determined by
NAT2 sequencing and correlate with the outcome of TB therapy to
assess whether acetylator status might have impact on pharmaco-
logical benefit in TB treatment.
Results: In total, 34 of 260 SLE patients (13.1%) had TB after SLE was
diagnosed of whom the TB therapy was categorized as recovered
(n27), relapsed (n5), failed therapy (n1) and died (n1). The acetylator
status of these SLE patients were fast (n8; 23.5%), intermediate (n21;
61.7%) and slow (n5; 14.7%).
Conclusion: The most prevalent acetylator status in this study is
intermediate acetylator status (61.7%), and together with the slow
acetylators, this may have impact in drug induced liver injury, how-
ever, most of TB patients recovered. Further study is needed to con-
firm the pharmacological dynamic effect of SLE patients with TB.
Keywords: acetylator status, systemic lupus erythematosus, tuber-
culosis, Indonesia
|
      85
1-­035 | N-­acetyltransferase 2 (NAT2)
acetylator status and organ involvement among
systemic lupus erythematosus patients from
Indonesia
L. Hamijoyo1,2; E. Sahiratmadja2,3,4; S. Candrianita2; I. A.
Rini3; E. Sutedja2,5
Rheumatology Division, Department of Internal Medicine, Faculty of Medicine,
Universitas Padjadjaran/ Dr Hasan Sadikin General Hospital; 2Lupus study
group, Immunology Study centre Faculty of Medicine Universitas Padjadjaran;
3
Centre for Clinical Genetic, Faculty of Medicine, Universitas Padjadjaran;
4
Division of Biochemistry and Molecular Biology, Department of Basic Medical
Science, Faculty of Medicine, Universitas Padjadjaran; 5Division of Immunology,
Department of Dermatology, Faculty of Medicine, Universitas Padjadjaran/Dr
Hasan Sadikin General Hospital
Background: NAT2 gene that encodes N-­acetyltransferase 2 en-
zyme, may predispose as genetic factor in systemic lupus erythema-
tosus (SLE) development. This study aimed to analyse the acetylator
status and organ involvement among SLE patients.
Methods: Cross-­
sectional study was performed among SLE pa-
tients at Rheumatology Clinic, Dr Hasan Sadikin General Hospital
Bandung, Indonesia from March 2016-­March 2018, Genomic DNA
was isolated from blood of SLE patient and NAT2 gene was ampli-
fied and sequenced, for further determination of NAT2 haplotypes
and the acetylator status. Organ involvement over the time was re-
corded in the SLE registry.
Results: There were 260 SLE patients involved, with median age
was 32 years old, and most were female (96.2%). The most preva-
lent mutation was G590A (59.2%), while others were ranging around
10.5% (C481T) to 31.5% (C282T). Analysis of haplotype showed that
next the wild type NAT2*4 (21.5%), haplotype NAT2*6B (25.8%) and
NAT2*6A (12.7%) were the most prevalent in our SLE patients. The
acetylator status were detected in trimodale mode as fast acetyla-
tors status (22.7%) consisted of NAT2*4 wild type and NAT2*12A,
intermediate status (65.4%) and slow acetylator status (11.9%). The
most organ involvement among SLE patients were musculoskeletal
210 (80.8%), mucocutaneous 190 (73.1%) and nephritis 118 (45.5%).
However, no significant difference among acetylator status and
organ involvement.
Conclusion: The most SLE patients from West Java Indonesia harbor
G590A and NAT2*6B haplotype, leading to intermediate acetylators
status, however no difference in organ involvement.
Keywords: NAT2, acetylator, systemic lupus erythematosus,
Indonesia
 |
86      

2-­095 | Maintenance of low disease activity
after stopping concomitant methotrexate
during tocilizumab treatment in patients with
rheumatoid arthritis (T-­Rex study)
1 2 3 2
M. Hanabayashi ; S. Asai ; M. Hayashi ; Y. Kuwatsuka ; M.
Ando2; N. Takahashi4; N. Ishiguro4; T. Kojima4
1
Ichinomiya Municipal Hospital; 2Nagoya University Hospital, Center for
Advanced Medicine and Ckinical Research; 3Nagano Red Cross Hospital;
4 for HLA presentation, supports the involvement of a unique arthrito-
Nagoya University Graduate School of Medice
Background: Currently, how to safely maintain disease activity
after achieving a therapeutic goal is a major topic for RA treatment.
Little trial on stopping of concomitant MTX during biologics treat-
ment after achieving the therapeutic goal have been conducted.
Objectives: To investigate how the low disease activity was maintained
after stopping concomitant MTX during treatment with tocilizumab (TCZ)
Methods: A multicenter prospective single arm interventional trial
was conducted at 17 centers. Primary endpoint was the mainte-
nance rate of low disease activity (CDAI ≦ 10) at the 24th week after
stopping MTX in RA patients with remission or low disease activ-
ity by TCZ and MTX combination therapy. The expected number
of cases was set to 43 cases when the expected response rate was
80%, the threshold response rate was 60%, the significance level
(both sides) 0.05, and the statistical detection power was 80%. We
also investigated changes in physical functions (HAQ – DI), gastroin-
testinal symptoms (FSSG score), QOL (EQ – 5 D).
Results: The patients analyzed for primary endpoint were 49 cases, and
the required number of cases set up was satisfied. The mean age, dis-
ease duration, CDAI, and MTX dose of enrolled patients were 62.2 years,
11.4 years, 2.7, 8.2 mg/wk, respectively, and 83.7% of females. At
24 weeks after stopping MTX, the maintenance rate was 75.5% (95%
confidence interval 61.1–86.7), which significantly exceeded the as-
sumed threshold response rate. After stopping MTX, the FSSG score im-
proved and the proportion of patients with clinically significant symptoms
(FSSG ≥8) clearly decreased from 27.1% at week 0 to 18.4% at 12 weeks
(P = 0.025). There was no significant change in HAQ-­DI and EQ-­5D.
Conclusion: This study showed the possibility of stopping MTX as
an option for treatment after achieving low disease by TCZ and MTX
combination therapy.
1-­015 | An immunosequencing approach to
interrogating the T-­cell receptor repertoire in
ankylosing spondylitis patients
A. Hanson1; T. Kenna2; K.-A. Le Cao3; M. Brown2
1
University of Queensland Diamantina Institute; 2Institute of Health and
Biomedical Innovation, Queensland University of Technology; 3Melbourne
Integrative Genomics, University of Melbourne
inflammatory bowel disease. AS is associated with the HLA-B*27 allele,
encoding a cell-­surface complex that displays endogenous peptides to
CD8+ T-­cells. T-­cells screen peptide-­HLA ligands using hypervariable T-­
cell receptors (TCRs), enabling distinction of infected cells and targeted
killing. Autoreactive T-­cells in AS patients are hypothesised to retaliate
against HLA-­B*27-­restricted self-­derived peptides, driving cytotoxicity
against host tissue. Disease-­associated polymorphisms in the endoplas-
mic reticulum aminopeptidase ERAP1, an enzyme which trims peptides
genic peptide in AS. We aimed to interrogate the peripheral blood T-­cell
repertoire in AS patients and HLA-B*27 matched healthy controls (HCs)
to identify expanded CD8+ T-­cell populations with a putative role in
autoantigen recognition.
Methods: Immunosequencing was used to profile the complementarity-­
determining region of the TCRβ gene in ~120,000 CD4+ and CD8+ T-­
cells from each of 47 AS patients and 38 HCs. Differences in repertoire
diversity and abundance of TCR clones was assessed.
Results: The CD8+ T-­cell repertoire of HLA-B*27 +ve AS patients is
distinct from HLA-B*27 +ve HCs, driven by T-­cell populations exclusive
to HLA-B*27 +ve disease. These populations are expanded in patient
blood, suggesting clonal proliferation in response to an immunogenic
peptide, and exhibit distinct TCR motifs. ERAP1 polymorphisms have
discernible effects on the HLA-B*27 +ve T-­cell repertoire, implicating
altered peptide processing in sculpting T-­cell populations. Intriguingly,
patients exhibited deficiencies in CD4+ T-­cell expansion, implying per-
turbed immunological responses to infectious stimuli throughout life.
Conclusions: Expanded CD8+ T-­cells unique to HLA-B*27 +ve AS
can be detected in patients. Reduced CD4+ T-­cell expansions sup-
port the proposal that sustained inflammation in AS may be initially
triggered by microbes that permeate the gut lining and are ineffi-
ciently cleared from the circulation.
3-­094 | Impact of glucocorticoid use on
functional ability in patients with rheumatoid
arthritis after achieving clinical remission
R. Hara1,2; T. Fujimura3; M. Hashimoto 4; K. Murata4; W.
Yamamoto 4,5; K. Nagai6; H. Amuro7; Y. Son7; T. Hirano8; K.
Ebina9; A. Onishi10; K. Akashi10; M. Katayama11; T. Kira1,2; N.
Shimmyo1; A. Kido1,2; Y. Akai1; T. Fujimoto1; Y. Tanaka1,2
1
The Center for Rheumatic Diseases, Nara Medical University; 2Department of
Orthopaedic Surgery, Nara Medical University; 3Department of Internal Medicine,
Takanohara Central Hospital; 4Department of Advanced Medicine for Rheumatic
Diseases, Graduate School of Medicine, Kyoto University; 5Department of Health
Information Management, Kurashiki Sweet Hospital; 6Department of Internal
Medicine (IV), Osaka Medical College; 7First Department of Internal Medicine,
Kansai Medical University; 8Department of Respiratory Medicine and Clinical
Immunology, Graduate School of Medicine, Osaka University; 9Department
of Orthopaedic Surgery, Osaka University, Graduate School of Medicine;
10
Department of Rheumatology and Clinical Immunology, Kobe University
Graduate School of Medicine; 11Department of Rheumatology, Osaka Red Cross
Hospital

Background/purpose: Ankylosing spondylitis (AS) is the prototypic

spondyloarthropathy, characterised by severe spinal disease. Up to Purpose: To investigate the effect of the use of glucocorticoids (GCs)
60% of patients present with subclinical gut inflammation, ~10% with in RA patients with sustained remission on functional ability.

Methods: Among 2649 patients with RA who achieved DAS-­
ESR < 2.6 in the multi-­center cohort, 1171 patients who had main-
tained DAS-­
ESR < 2.6 were included. Clinical and demographic
characteristics were collected at baseline. We calculated odds ratio
(OR) (95% confidence interval) of the use and dose of GCs to predict
the yearly progression of HAQ-­DI score adjusted for potential con-
founders in multiple logistic regression model.
Results: Characteristics of patients at baseline were as follows
(median, proportion). The age was 61 years, female was 70.6%, dis-
ease duration was 4.5 years, RF-­positive was 64.4%, ACPA-­positive
was 70%, DAS28-­E SR was 2.0, HAQ-­DI score was 0.125. of the
1171 patients, 235 (20.1%) patients had been treated with oral
GCs when achieved remission. CRP (0.06 vs 0.03 mg/dL), MMP-­3
(106.1 vs 49.5 ng/mL), SDAI (2.9 vs 2.6), DAS28-­CRP (1.6 vs 1.5),
patients’ global assessment (mm) (15 vs 11 mm), physicians’ global
assessment (6 vs 5 mm) and HAQ-­DI (0.38 vs 0.13) were signifi-
cantly higher and disease duration was significantly longer (8.9 vs
4.1 years) in the GCs group compared to the non-­GCs group. One
hundred and fifty-­eight (67.2%) patients had been treated with GCs
during follow up, and median dose was 4.5 mg/day. Two hundred
and eighty-­seven (24.5%) patients’ yearly change of HAQ-­DI score
increased. The adjusted OR of the use of GCs at baseline was 2.06
(1.21–3.51). in the group of continuous GCs use after achieving re-
mission, the adjusted OR of the daily dose of GCs < 5 mg was 1.61
(0.73–3.56), whereas that of GCs ≥ 5 mg was 2.65 (1.11–6.34).
Conclusions: Continuous use of GCs in stable remission worsened
functional ability dose-­dependently.
1-­069 | Comorbidities in psoriatic arthritis
patients in the UAE
H . Badsha; G. Harifi; H. Ali
Humeira Badsha Medical Center
Aim: The objective of this study was to look at the prevalence of
comorbidities such as smoking, hypertension, diabetes, hypercho-
lesterolemia, and hyperuricemia, in psoriatic arthritis (PsA) patients
in the United Arab Emirates (UAE). The secondary objectives were
to check for a potential difference between Arabs and non-­Arabs,
males and females, in the prevalence of these comorbidities.
Methods: This is a retrospective study of 166 PsA patients from a
Rheumatology clinic in the UAE. Comorbidities were assessed in
the medical records after diagnosis of PsA. The data regarding cho-
lesterol and serum uric acid levels were retrieved from 70 and 119
patients respectively (out of the 166). A chi-­square test was used
to compare the prevalence of these comorbidities between groups.
Results: A total of 166 patients, 79 (47.6%) female, were included.
The mean age for both genders was 45. Twenty-­six of the 166
(15.7%) patients were smokers. Thirty of the 166 (18.1%) patients
had hypertension and 11 (6.6%) of the patients had diabetes.
Hypercholesterolemia was present in 38.6% (27/70) of the patients.
Hyperuricemia was present in 21.8% (26/119) of the patients. The
|
      87
PsA patients with hyperuricemia were predominantly male (83.3%,
P-­value:.004). The prevalence of these comorbidities did not seem to
be statistically different between genders, except for hyperuricemia,
which was more common in males. There also did not seem to be a
significant difference between 32 Arabs (19.3%) and non-­Arabs in
the prevalence of these comorbidities.
Conclusion: The most prevalent co-­morbidities among PsA patients in
our study were Hypercholesterolemia and hyperuricemia. The preva-
lence of these co-­morbidities and this did not seem to vary between
ethnicity and gender, except for hyperuricemia as mentioned above.
2-­067 | Correlation between hight sensitivity
C-­reactive protein levels with carotid intima
media thickness in asymptomatic hyperuricemia
R. Y. Hellmi1,2; A. S. Hardhani2; B. Suntoko1,2
1
Ira; 2Kariadi Hospital
Background: The role of uric acid in atherosclerotic pathophysiology
is still controversial and not yet fully known. Several studies report
an increased risk of cardiovascular events in asymptomatic hyper-
uricemia patients. This study aimed to determine the initial process
of atherosclerosis in asymptomatic hyperuricemia patients, which
was characterized by an increase in hsCRP levels and the carotid
Intima Media Thickness (cIMT).
Objective: To prove the correlation between of hsCRP levels with
carotid Intima Media Thickness on asymptomatic hyperuricemia
patients.
Methods: This study was an analytic observational study with a cross
sectional approach, conducted in Rheumatology Clinic in Kariadi
Hospital. Asymptomatic hyperuricemia patients were tested for fast-
ing blood sugar, trigliserides, LDL cholesterol and hsCRP, whereas
cIMT measurements using Doppler Ultrasound. Statistical analy-
sis was performed using Shapiro-­Wilk normality test, followed by
Spearman nonparametric correlation test and Mann Whitney test.
Results: This study followed by 20 respondents included 75% men
and 25% women with mean age 37.45 ± 8.61 (range 26–56 years)
mean uric acid 7.8 ± 1.37 (range 6.1–11.7 mg/dL), the mean level
of hsCRP was 4.29 
± 6.14 (range 0.17–23.80 
mg/L) the aver-
age total cIMT was 0.08 ± 0.07 (range 0.04–0.38), atherosclerotic
plaque was found in two study respondents. The statistical analy-
sis, Spearman correlation test showed that there was no correlation
between hsCRP levels with total cIMT average, right and left cIMT.
Correlation between confounding variables and cIMT, there was a
significant correlation between LDL serum levels with right cIMT
(r +0.474, P = 0.03), and total cIMT (r = 0.542, P = 0.013). By Mann
Whitney test, there was a significant correlation between athero-
sclerotic plaque and right cIMT (P = 0.023) and total cIMT (P = 0.044)
Conclusion: There was no correlation between levels of hsCRP with
cIMT in asymptomatic hyperuricemia patients. LDL cholesterol lev-
els had significant correlation with cIMT.
 |
88      

2-­144 | Systemic vasculitis in a patient with
primary biliary cirrhosis: lessons from a case
report
M. Hng; A. M. Ismail
Hospital Raja Perempuan Zainab II
Background: Presentation of systemic vasculitis with autoimmune
liver disorders (AILD) is rare and scarcely reported. There are 14
published case reports in English literature of systemic vasculitis
with AILD [Table 1].
Objectives: A 36-­
year-­
old woman with primary biliary cirrhosis
(PBC) who developed systemic vasculitis is described.
Method/Results: She had a 4-­year history of PBC presented with
cholestatic jaundice, hepatosplenomegaly, positivity for anti-­nuclear
antibody (ANA), anti-­mitochondrial antibody (AMA) and anti-­liver-­
kidney-­microsomal (anti-­LKM) antibody. The hepatitis B and hepa-
titis C serology, caeruloplasmin and double stranded DNA (dsDNA)
were negative. Serum immunoglobulin IgG, IgA and IgM level were
normal. She developed liver cirrhosis Child-­Pugh score B with portal
hypertension. Her symptoms were controlled with ursodeoxycholic
acid, propranolol and diuretics. She presented with nasal pain, fever,
seizure and ulcer at right leg over 6 weeks’ duration. Examination
showed saddle nose deformity, bluish discoloration of toes and ulcer
at right shin. Nasal tissue biopsy showed non-­specific inflamed nasal
mucosa. Skin biopsy of the ulcerated lesion showed perivascular

Table 1. Previously reported cases of systemic vasculitis associated with autoimmune liver diseases (AILD)

Other
Autoimmune Extrahepatic autoimmune
No. Author Year Age Sex liver disease Vasculitis Organ involved Biopsy ANCA disease

1 Conn DL 1982 49 F PBC EGPA Temporal artery, optic Skin, muscle, Not Polychondritis
nerve rectum specified
2 Terkeltaub R 1984 39 F PBC s/o GPA Skin, muscle, upper Skin, muscle No a)
respiratory tract specified
3 Yoshimoto T 1989 60 F PBC GPA Lower respiratory tract, Lung Not –
sclera specified
4 Bissuel F 1992 41 F PBC s/o MPA Lower respiratory tract, Renal, skin Positive Sjögren’s
renal, skin syndrome
5 Iannone F 2003 54 F PBC MPA Lower respiratory tract, Renal Positive –
renal
6 Nakamura T 2004 72 F PBC s/o MPA, Renal Renal Positive –
ANCA
associated
RPGN
7 Amezcua-­ 2006 61 F PBC MPA Lower respiratory tract, Renal Positive Sjögren’s
Guerra LM renal syndrome
8 Sinico RA 2006 39 M PSC EGPA Upper and lower Bone Negative Crohn disease
respiratory tract, marrow
peripheral nerve
9 Yüksel l 2006 35 M PSC GPA Skin, upper and lower Skin Negative –
respiratory tract,
arthritis, penile, sclera
10 Tovoli F 2014 77 F PBC GPA Mammary, nasal, lower Breast, nasal Negative Sjogren
respiratory tract syndrome
11 Tovoli F 2014 27 M Type 1 AIH EGPA Gallbladder Gallbladder Negative –
12 Tovoli F 2014 73 M PBC MPA Renal Renal post Positive –
mortem
13 Tovoli F 2014 36 F PBC EGPA Cardiac, skin, lower Right Negative –
respiratory tract ventricular,
skin
14 Yamashita H 2015 76 M PBC MPA Renal, peripheral nerve Nil Positive –
15 Current case 2018 36 F PBC systemic Skin, cerebral vessels, Skin Negative –
vasculitis nose

M: male; F: female; PBC: primary biliary cirrhosis; PSC: primary sclerosing cholangitis; AIH: autoimmune hepatitis; EGPA: eosinophilic granulo-
matosis with polyangiitis; s/o: suspected of; GPA: granulomatosis with polyangiitis; MPA: microscopic polyangiitis; RPGN: rapidly progressive
glomerulonephritis

lymphohistiocytic cells infiltration and fibrinoid change of vessel
wall [Figure 1]. Immunofluorescence study showed deposition of
IgG, IgM and C3c on the blood vessels walls. Magnetic resonance
imaging/magnetic resonance angiography of brain showed features
suggestive of chronic small vessels ischemia. Laboratory test showed
low complements level and raised inflammatory marker. Systemic in-
fection and infective endocarditis had been excluded. Cytoplasmic
anti-­
neutrophil cytoplasmic antibody (c-­
ANCA), perinuclear anti-­
neutrophil cytoplasmic antibody (p-­ANCA) were tested negative.
Extractable nuclear antigen showed positive for SSA/Ro antibody.
She was diagnosed with systemic vasculitis associated with PBC. In
view patient refused cyclophosphamide which is the preferred treat-
ment of choice, she was given antibiotic, oral glucocorticoid and col-
chicine. Unfortunately she succumbed at home 4 months later.
Conclusion: The association between systemic vasculitis and AILD
is uncommon but possible. Immunosuppressive therapy namely cy-
clophosphamide and high dose corticosteroid is the treatment of ch
oice.
Figure 1 shows presence of superficial perivascular lymphohistio-
cytic cells infiltration with occasional neutrophils and eosinophils.
There is fibrinoid change of the vessels wall associated with extrava-
sation of the red blood cells.
1-­016 | Autoimmune rheumatological
disorders and mutation profile of concomitant
myelodysplastic syndrome
L. En Hong1; D. Singhal2,3; A. Wee3; R. Chhetri3; M.
Wechalekar4,5; D. Hiwase2,3,7; S. Proudman2,6
1
School of Medicine, University of Adelaide, Rheumatology Unit, Royal Adelaide
Hospital; 2School of Medicine, University of Adelaide; 3Department of
Haematology, Royal Adelaide Hospital; 4Rheumatology Unit, Flinders Medical
Centre; 5Flinders University; 6Rheumatology Unit, Royal Adelaide Hospital;
7
Cancer Theme, South Australian Health and Medical Research Institute
Background: Association of autoimmune rheumatological disorders
(AIRD) with myelodysplastic syndrome (MDS) and therapy-­replated
myeloid disorders (t-­MN) have been reported with the prevalence
|
      89
of AIRD ranging from 10% to 48%. Immunosuppressive treatment
of AIRD could cause therapy-­related myeloid neoplasm (t-­MN) or
confound the secondary diagnosis of MDS. This study aims to in-
vestigate two large multi-­institutional databases – Royal Adelaide
Hospital Rheumatology Database (RAH-­RD) and South Australian
MDS (SA-­MDS) registry to describe the association of AIRD and
concomitant MDS.
Methods: Demographic, clinical, laboratory and treatment data
of 2663 patients from RAH-­RD and 1157 patients from SA-­MDS
were analysed. Patients with persistent cytopenia (>6 months) were
defined as follows: haemoglobin <100 g/dL, absolute neutrophil
<1800/mm3 and platelet <100,000/mm3.
Results: From RAH-­RD database, 36 (1.3%) patients had at least one
cytopenia with anaemia (19/36) being the most common, followed
by neutropenia (8/36), thrombocytopenia (4/36) and bi-­cytopenia
(5/36). 23 patients had bone marrow examination, with 7 being con-
sistent with MDS and 16 being non-­diagnostic. Interestingly, 5 pa-
tients diagnosed with MDS and 11 patients with cytopenia did not
receive any cytotoxic agents.
Analysis of the SA-­MDS database revealed that 69 patients (5.4%)
were diagnosed with AIRD. Among the 69 patients, 24 had low risk
MDS and 15 had higher risk MDS, 19 had t-­MN, 8 had MDS/MPN
and 3 had AML. Overall, in a combined population of RAH-­RD and
SA-­MDS, 76 (2%) had concomitant MDS and AIRD.
The cytogenetic and mutational profile of MDS patients with (n = 20)
or without (n = 217) AIRD were compared. There is higher frequency
of IDH1 mutations in MDS patients with AIRD compared to MDS
without AIRD (30% vs 3%, P = 0.04).
Conclusions: 1.3% patients developed persistent cytopenia with
0.3% diagnosed with MDS. This finding is higher than the incidence
of MDS in the general population (0.03–0.05%). Our findings war-
rant further study and may have implications for conventional treat-
ment options for AIRD.
1-­138 | Class transformation in class V
lupus nephritis: increased risk in patients with
tubulointerstitial inflammation
O. C. Kwon; J. S. Oh; S. Hong; C.-K. Lee; B. Yoo; Y.-G. Kim
Asan Medical Center
Background/purpose: In lupus nephritis, class transformation to an-
other class can occur during the course of the disease. Risk factors
for class transformation from membranous lupus nephritis (class V
lupus nephritis) to proliferative lupus nephritis (class III±V or class
IV±V lupus nephritis) are not known to date. We aimed to investigate
the risk factors of class transformation from membranous lupus ne-
phritis to proliferative lupus nephritis.
Methods: Biopsy-­
proven pure membranous lupus nephritis pa-
tients diagnosed between January 2005 and September 2017
were included. We assessed and compared clinical and pathological
 |
90      

parameters at the time of membranous lupus nephritis diagnosis 3-­129 | Impact of stringent complete renal
between patients who transformed and those who did not trans-
response on long-­term renal outcomes in
form to proliferative lupus nephritis. To identify risk factors of class
proliferative lupus nephritis
transformation, Cox proportional hazard regression analysis was
performed. Class transformation free survival rates were analyzed S. Hong; J. Won; J. S. Lee; J. S. Oh; Y.-G. Kim; C.-K. Lee; B.
using Kaplan–Meier analysis.
Yoo
Asan Medical Center, University of Ulsan College of Medicine
Results: Fifty pure membranous lupus nephritis patients were eval-
uated. During a median follow-­up of 78.1 (37.9 – 159.6) months,
class transformation occurred in 7 patients but did not occur in 43. Background/purpose: Favorable long-­term prognosis in prolifera-

Significantly more patients in whom class transformation to prolif- tive lupus nephritis (LN) is associated with achievement of complete

erative lupus nephritis occurred had tubulointerstitial inflammation renal response (CR), which is defined as urine protein/creatinine

at baseline (85.7% vs 41.9%, P = 0.045). in the multivariable Cox ratio (UPCR) of less than 0.5. However, it is not clear whether it is

proportional hazard regression analysis, the presence of tubuloint- better to set a more stringent cutoff for proteinuria (normal value of

erstitial inflammation at baseline was significantly associated with proteinuria; UPCR < 0.15) than CR.

an increased risk of class transformation to proliferative lupus ne- Objectives: We aimed to evaluate the effect of stringent CR, defined

phritis (adjusted hazard ratio 9.482, 95% confidence interval 1.136 as UPCR < 0.15, on long-­term renal outcomes including the risk of

– 79.170, P = 0.038). Kaplan–Meier analysis revealed a significantly chronic kidney disease (CKD) in LN.

higher rate of class transformation in the patients with tubulointer- Methods: We included 87 patients with LN class III or class IV who

stitial inflammation (P = 0.026). achieved CR at 1 year after induction therapy. Laboratory data and

Conclusion: Tubulointerstitial inflammation in membranous lupus renal pathologies were compared between stringent CR group and

nephritis is associated with an increased risk of class transformation non-­stringent CR group. Logistic regression analysis was performed

to proliferative lupus nephritis. to identify factors associated with achievement of stringent CR. Risk
factors for renal flare and CKD development were analyzed by Cox
analysis.

Table 1 Risk factors of class transformation in pure membranous lupus nephritis patients
Univariable analysis Multivariable analysis

Unadjusted HR 95% CI P value Adjusted HR 95% CI P value

Female 0.711 0.137–3.692 0.685

Age 0.983 0.916–1.053 0.621
uPCR 1.077 0.933–1.242 0.312
Albumin 0.455 0.163–1.276 0.134 0.745 0.245–2.261 0.603
GFR 1.000 0.968–1.032 0.984
C3 0.997 0.969–1.026 0.847
C4 1.014 0.929–1.107 0.758
Anti-­dsDNA Ab 0.993 0.977–1.010 0.432
Lupus anticoagulant 3.627 0.699–18.813 0.125 1.092 0.137–8.677 0.934
SLEDAI 1.131 0.908–1.409 0.271
Tubulointerstitial inflammation 7.690 0.924–64.039 0.059 9.482 1.136–79.170 0.038
Tubular atrophy 3.086 0.690–13.797 0.140 1.855 0.306–11.241 0.501
Interstitial fibrosis 2.720 0.607–12.192 0.191
Glomerulosclerosis 1.009 0.944–1.079 0.785
Hydroxychloroquine 0.643 0.077–5.361 0.684
Cyclophosphamide 1.042 0.513–2.114 0.910
Mycophenolate mofetil 0.963 0.846–1.095 0.563
Glucocorticoid 1.011 0.974–1.048 0.573

HR; hazard ratio, CI; confidence interval, uPCR; urine protein/creatinine ratio, GFR; glomerular filtration rate, anti-­dsDNA Ab; anti-­double-­
stranded DNA antibody, SLEDAI; systemic lupus erythematosus disease activity index.
 |
      91

Results: The stringent CR group included 58 patients, and the non-­ Table 1 Factors associated with deterioration of tubulointerstitial in-
stringent group included the remaining 29 patients. The two groups flammation, tubular atrophy and interstitial fibrosis
showed no significant baseline differences in terms of clinical, labo- Multivariate Cox proportional hazard regression analysis
ratory and pathological findings. Intravenous cyclophosphamide in-
Adjusted HR 95% CI P value
duction therapy (HR: 0.130 [0.023–0.737], P = 0.021) and chronicity
index (HR: 0.531 [0.313–0.901], P = 0.019) were significant predic- Tubulointerstitial inflammation
tors for stringent CR. The rates of sustained CR during 5 years were C3 0.977 0.959 – 0.995 0.012
87.5% and 36.8% (P = 0.001) in the non-­stringent CR and the strin- Chronicity index 1.081 0.774 – 1.509 0.649
gent CR group, respectively. in multivariate analyses, achievement of Hydroxychloroquine 0.359 0.159 – 0.813 0.014
stringent CR was associated with lower risk of 5-­year renal flare rate Tubular atrophy
(hazard ratio (HR): 0.196 [0.075–0.511], P < 0.01) and CKD develop- Female 0.609 0.281 – 1.319 0.209
ment (HR: 0.267 [0.071–0.995], P = 0.049).
C3 0.983 0.967 – 0.999 0.033
Conclusion: Achievement of stringent CR predicted lower risk of
Hydroxychloroquine 0.346 0.158 – 0.754 0.008
renal flare and CKD development in proliferative LN. These findings
Interstitial fibrosis
suggest that stringent CR can be a more valuable target in the treat-
Female 1.550 0.433 – 5.546 0.500
ment of LN.
C3 0.983 0.963 – 1.004 0.112
Anti-­Sm Ab 2.029 0.894 – 4.602 0.091
Activity index 1.049 0.959 – 1.148 0.295
1-­139 | Tubulointerstitial damage in lupus
Hydroxychloroquine 0.314 0.114 – 0.865 0.025
nephritis: factors associated with deterioration
O. C. Kwon; J. S. Oh; S. Hong; C.-K. Lee; B . Yoo; Y.-G. Kim
Asan Medical Center

1-­017 | CCL17 in synovial fluid and plasma of

Background/purpose: Deterioration of tubulointerstitial damage
in lupus nephritis (LN) is an important predictor of renal prognosis.
Given this importance of deterioration in tubulointerstitial damage,
we investigated the factors associated with deterioration in tubu-
lointerstitial damage in patients with LN.
Methods: Patients with LN, who underwent repeated renal biopsy at
a tertiary referral hospital between 1997 and 2017 were identified.
patients with active rheumatoid arthritis
C. Hor1,2,3; A. Achuthan2,3; K. Lim1,2,3; J. Hamilton2,3
1
Western Health Rheumatology; 2Australian Institute of Musculoskeletal Science
(AIMSS); 3University of Melbourne
Objectives: Despite the advancements in management of rheu-

Clinicopathologic and laboratory data were collected. Factors asso- matoid arthritis (RA) in the last two decades, there are still a sig-

ciated with deterioration in tubulointerstitial inflammation, tubular nificant number of patients who cannot achieve low disease states

atrophy, and interstitial fibrosis, were evaluated using Cox propor- or remission with the current available therapy. Granulocyte

tional hazard regression analysis. macrophage-­colony stimulating factor (GM-­C SF) has emerged as

Results: Of the total 53 LN patients, 29 (54.7%), 34 (64.2%), and a novel therapeutic target in RA but potential adverse side effects

36 (67.9%) patients experienced deterioration in tubulointerstitial warrant further investigation of a more specific target. Chemokine

inflammation, tubular atrophy, and interstitial fibrosis, respectively. (C-­C motif) ligand 17 (CCL17) is a downstream mediator of GM-­C SF

in multivariate Cox proportion hazard regression analysis, C3 lev- and has recently been shown to be regulated by GM-­C SF in human

els (adjusted hazard ratio [HR] 0.977, 95% confidence interval [CI] monocytes. Significantly, CCL17 has a non-­redundant role in inflam-

0.959–0.995, P = 0.012) and use of hydroxychloroquine (adjusted matory arthritis and pain. We investigated the expression levels of

HR 0.359, 95% CI 0.159–0.813, P = 0.014) were inversely associated CCL17 in synovial fluid and plasma from RA patients.

with deterioration in tubulointerstitial inflammation. C3 levels (ad- Methods: We recruited RA patients with symptomatic swollen

justed HR 0.983, 95% CI 0.967–0.999, P = 0.033) and use of hydrox- joints, who require joint aspiration for diagnostic and/or therapeutic

ychloroquine (adjusted HR 0.346, 95% CI 0.158–0.754, P = 0.008) purposes. Synovial fluid and plasma were collected and CCL17 pro-

were also inversely associated with deterioration in tubular atrophy. tein levels were determined by ELISA.

in regard to interstitial fibrosis deterioration, only the use of hydrox- Results: CCL17 protein was measured in synovial fluid and plasma

ychloroquine (adjusted HR 0.314, 95% CI 0.114–0.865, P = 0.025) samples from our cohort of RA patients. Levels of secreted CCL17

had an inverse association. were higher in plasma [median 240 (40–580) pg/ml] compared to

Conclusion: Lower C3 levels at first biopsy were associated with in- synovial fluid [median 100 (30–300) pg/ml] P < 0.05.

creased risk of deterioration in tubulointerstitial damage, whereas Conclusion: Significant levels of CCL17 were detected in RA syno-

the use of hydroxychloroquine was associated with decreased risk vial fluid and plasma. This is a novel study which demonstrates and

of deterioration. compares the presence of CCL17 in synovial fluid and plasma from
 |
92      
matching RA patients. The expression of CCL17 in plasma can make
it a useful potential biomarker for RA, while its expression in synovial
fluid suggests that CCL17 may be a therapeutic target for treating RA.
1-­140 | Identifying secondary fibromyalgia
in systemic lupus erythematosus using patient
reported outcomes
F. Huang; R. Fang; M. Nguyen; K. Bryant; K. Gibson; S.
O'Neill
UNSW/Liverpool Hospital/Ingham Institute
Background/purpose: Fibromyalgia (FM) is overrepresented in pa-
tients with systemic lupus erythematosus (SLE), but often underdiag-
nosed on a background of classical SLE symptoms. The objective of the
study was to identify FM in patients with SLE using patient reported
outcome scores from the Multi-­
Dimensional Health Assessment
Questionnaire (MDHAQ), in comparison to the 2016 ACR FM Criteria.
Methods: Patients with SLE completed an MDHAQ and the
Fibromyalgia Survey Questionnaire (FSQ), which elicits the 2016
ACR FM Criteria. An index known as the Fibromyalgia Assessment
Screening Tool (FAST3 and FAST4) was derived from the MDHAQ.
Scores and indices from the MDHAQ were compared between those
with FM and those without FM (by FSQ) using t tests and Receiver
Operating Characteristic (ROC) curves.
Results: Of the 87 patients with SLE studied, 23 (26%) had second-
ary FM. SLE patients with secondary FM reported significantly greater
bodily pain, fatigue, painful joint counts, and number of symptoms on
a symptom checklist. The Area Under the Curve (AUC) for the FAST3
was 0.90 and a cut-­off of ≥1 out of 3 demonstrated a sensitivity and
specificity of 91% and 70% respectively. The AUC for the FAST4 was
0.93, with a cut-­off of ≥2 out of 4 giving a sensitivity and specificity of
91% and 85% respectively. The symptom checklist alone gave an AUC
of 0.92 and a sensitivity/specificity of 96%/78% using a cut-­off of ≥14
out of 60 symptoms. The two most discriminating symptoms between
the non-­FM and FM groups were ‘difficulty thinking’ and ‘dry mouth’.
Conclusions: Secondary FM is prevalent in the SLE population and
can significantly affect patient reported outcome scores. The FAST3
and FAST4 index serves as a useful and diagnostic aid for FM in SLE,
although a simple symptom checklist component of the MDHAQ is
just as effective.
1-­062 | The role of 5-­methoxytryptophan (5-­
Mtp) in pediatric systemic lupus erythematosus
with nephritis
J.-L. Huang1,2
1
Chang Gung Memorial Hospital; 2Chang Gung University
Background: This clinical study investigates the role of
5-­
methoxytryptophan (5-­
MTP) in pediatric systemic lupus
erythematosus (SLE), with a particular interest in lupus nephritis
(LN).
Patients and methods: One hundred ten children with SLE were
enrolled in the cohort study. Among the patients, seventy-­seven
(70%) had active LN and thirty-­three (30%) were not present with
LN during their first visit to the clinic. The diagnoses of LN were
biopsy-­proven. Serum samples were collected before and after ad-
ministration of immunosuppressive medications to evaluate 5-­MTP
levels and regular laboratory data. Data were analyzed longitudinally.
Results: Before any treatment started, patients with active LN had
significantly higher 5-­MTP levels as compared to patients with no
LN (1.021 ± 0.709 vs. 0.719 ± 0.606, P = 0.0456). Also, in patient
with active LN, 5-­MTP level was significant decreased after treat-
ment, compared with the levels before treatment (1.021 ± 0.709 vs.
0.802 ± 0.597, P = 0.0484). Patients who reached complete remis-
sion also had significantly higher initial serum 5-­MTP levels than
that in patients with no remission (1.244 ± 0.784 vs. 0.846 ± 0.556,
P = 0.0488). There was an overall reduction in 5-­MTP levels after
six months of immunosuppressive treatment, regardless of the dis-
ease outcome. Subgroup analysis further revealed a significantly
higher 5-­MTP level during the active stage of LN (1.127 ± 0.149 vs.
0.742 ± 0.092, P = 0.0384).
Conclusion: We demonstrated that serum 5-­MTP level is positively
correlated to the disease activity, prognosis, and remission status of
pediatric LN in vivo.
3-­052 | The prevalence and distribution of
fabella determined by radiographs in Koreans
J. Hur1; S. Lee2; J. Jun3
1
Department of Internal Medicine, Eulji University College of Medicine;
2
Department of Radiology, Hanyang University Hospital for Rheumatic Diseases;
3
Department of Rheumatology, Hanyang University Hospital for Rheumatic
Diseases
Background: The fabella is a sesamoid bone present at the tendinous
origin of the lateral head of the gastrocnemius muscle. The incidence
and bony nature of fabella which has been associated with patho-
logic conditions, causing pain and osteoarthritis in human adults has
been found to various among different studies.
Objectives: The purpose of this study is to examine the prevalence of fa-
bella in knee radiographs of Koreans, comparing it with other countries
or races, and to examine the effects of differences in gender and age.
Methods: From June 2016 to August 2017, a total of 1000 patients
who visited the Rheumatism Center at Eulji University Hospital were
recruited consecutively. Two independent examiners observed the
anteroposterior and lateral view of the knee.
Results: The average age of enrolled 1000 patients was
60.1 ± 16.4 years. The number of men and women was 225 and 775,
respectively. The mean age of men was 50.6 ± 19.8 years, women
was 62.9 ± 14.1 years. The prevalence of fabella was 56.5% in our
study population. Among the patients with fabella, 79.3% had fa-
bella at both knees and 20.7% at unilateral knee. The ratio of men

with fabella was 52.0% and that of women was 57.7% and there was
no statistically significant difference.
Conclusion: the prevalence of fabella in our population was rela-
tively lower than that in other Asian regional studies but higher than
that in non-­A sian region. In terms of research methods, the method
we determined the presence of fabella was a simple radiographic,
which is thought to have a low prevalence rate compared to the dis-
section or MRI used in other studies. In the future, it is thought that
more extensive research and anatomical analysis will be needed.
Keywords: Fabella, prevalence, Knee
2-­033 | Australian patient preferences
for targeted synthetic and biologic disease
modifying antirheumatic drugs: a discrete choice
experiment
K.-A. Ho1; M. Acar2; A. Puig2; S. Fifer1; G. Hutas3
1 at initiation of JAK inhibitor. 2 mg/d of JAK inhibitor (baricitinib) was
Community and Patient Preference Research Pty Ltd; 2Real World Evidence,
Janssen-­Cilag Pty Ltd; 3Medical and Scientific Affairs, Janssen-­Cilag Pty Ltd
Background/purpose: Incorporation of patient preference into the
1
treatment discussion can lead to better patient care . However, no
study has assessed the preferences of Australian patients for tar-
geted synthetic and biologic disease modifying antirheumatic drugs
(tsDMARDs, bDMARDs) that are currently reimbursed in Australia.
Objectives: To understand treatment attributes that patients value
to assist in shared treatment decision making.
Methods: A discrete choice experiment (DCE) was administered to
patients with rheumatoid arthritis, ankylosing spondylitis and psori-
atic arthritis. The DCE presented patients with a treatment choice
experiment based on eight treatment attributes (clinical efficacy,
slowing disease progression, mild-­
moderate side effects, severe
side effects, dosing frequency, real-­world product evidence, man-
agement of related conditions and patient support program). These
attributes were derived from patient interviews and the clinical
characteristics of tsDMARDs and bDMARDs. The DCE data were
modelled using a latent class model.
Results: The latent class model revealed two classes of decision
makers with different preferences for treatment attributes. Class 1
decision makers valued clinical outcomes, placing the greatest im-
portance on clinical efficacy, stopping disease progression and the
risk of mild-­moderate side effects.
Class 2 decision makers valued attributes more evenly; while they val-
ued similar clinical outcomes to Class 1 decision makers, they also val-
ued non-­clinical outcomes including injection frequency and patient
support programs. Across both classes, it was found that patients who
were experienced with bDMARDs were more likely to prefer injection
treatments compared to those not experienced with bDMARDs.
Conclusions: Overall, not all patients value the same treatment at-
tributes. Further, previous experience with bDMARDs may influence
patients’ treatment preferences. These findings have important im-
plications for involving patient preference in shared decision making.
|
      93
1. Say, E. and Thomson, R. (2003). The importance of patient preferences
in treatment decisions – challenges for doctors, the BMJ, 327:542–5.
2-­096 | A case of examining the association of
pain transition and musculoskeletal ultrasound
findings after oral administration of JAK inhibitor
H. Ikai; T. Arai; H. Yoshida; Y. Nakamura; F. Kitamura;
T. Watanabe; M. Yamamoto; Y. Murai; W. Kokuryo; K.
Takasugi; N. Takizawa; Y. Fujita
Chuburousai Hosipital
Case: An 82-­year-­old man who had been suffering from rheuma-
toid arthritis (RA) for 39 years. Prior treatment with several types
of biological antirheumatic drugs resulted in secondary failure.
He was treated with prednisone, 2 mg/d, and salazosulfapyridine,
1000 mg/d, disease activity was DAS-­28CRP 4.73 and m-­HAQ 2.12
administered for his refractory RA. We evaluated the Visual Analog
Scale for Pain (VAS Pain) and synovitis of painful joints by using
ultrasound before and after starting treatment with baricitinib, and
repeated evaluations of VAS and over time the ultrasound findings
were completed. All exams were performed by a sonographer cer-
tified by the Japan College of Rheumatology (JCR). We evaluated
his joints 3, 6, 12, 24 and 48 hours after starting oral administra-
tion of baricitinib. After 24 and 48 hours, the VAS of the both wrist
joints showed remarkable improvement of 10 → 5 → 2 respectively.
Other joints improvements were as follows. Right 2 MCP joint: 10
→ 7 → 4, and Ankle joints: 10 → 6 → 2. However, PDUS findings
did not show any improvement throughout the course. During that
period, we did not increase prednisone dose nor use analgesic.
Conclusion: JAK inhibitors are known to improve joint pain of pa-
tients with RA by reducing inflammation. The studies which focused
on the association of pain transition and musculoskeletal ultrasound
findings after oral administration of JAK inhibiters were scarce. in this
case it is suggested that treatment with JAK inhibitors for RA may
improve pain considerably earlier than PDUS improvement. The use
of JAK inhibitor may be useful for improving patient's QOL earlier.
1-­084 | bDMARDS reduce osteoporosis by
supressing inflammation and disease activity
through increasing bone formation markers and
reducing bone resorption markers
A. Inderjeeth1,2; C. Inderjeeth1,2
1
SCGH and OPH Group; 2University of Western Australia
Background: Bone loss is accelerated in inflammatory diseases in-
cluding Rheumatoid Arthritis and Spondyloarthritis:
• Systemic: osteoporosis (resorption exceeds formation).
 |
94      
• Periarticular: Characteristic of RA - inhibition of formation (cyto-
kines effect on local immune cells).
• Focal: Erosions - activation of osteoclasts and invasive synovial
pannus in RA.
A PubMed search was completed on April 2016 for all published
reports with the following search terms used: disease modifying
OR DMARD OR methotrexate OR sulphasalazine OR leflunomide
OR hydroxychloroquine OR plaquenil OR cyclosporin OR glucocor-
ticoids OR prednisolone OR etanercept OR adalimumab OR goli-
mumab OR tocilizumab OR abatacept OR infliximab OR rituximab)
AND (bone remodelling OR bone turnover markers OR bone health
OR bone deficiency OR bone density OR osteoporosis) along with a
search of all related articles and manual search of retrieved articles’
references.
Objectives: Review the evidence for the effect of DMARDS on os-
teoporosis and bone markers.
Methods: Systematic review: PubMed search all published re-
ports with the following search terms used: disease modifying
OR DMARD OR methotrexate OR sulphasalazine OR lefluno-
mide OR hydroxychloroquine OR cyclosporin OR glucocorticoids
OR prednisolone OR etanercept OR adalimumab OR golimumab
OR tocilizumab OR abatacept OR infliximab OR rituximab) AND
(bone remodelling OR bone turnover markers OR bone health
OR bone deficiency OR bone density OR osteoporosis). Search
of all related articles and manual search of retrieved articles’
referenced.
Results: Compared to standard care/placebo bDMARDS treat-
ments increased bone formation markers (P1NP and BAP) and
reduced resorption markers (NTX and CTX) in published studies
with bDMARDS and bone outcomes. BMD at the lumbar spine
and hip improved or at least remained stable with most bD-
MARD studies reporting bone effects. Table summarises effect
of TNF on BMD.
Conclusion: bDMARDS preserve or improve BMD better than
standard care. Whether it is due to disease control or direct effect
on bone needs clarification.
1-­050 | GARVAN fracture risk calculator
without BMD is accurate and reduces reliance on
BMD in older people with poor access
C. Inderjeeth1; W. Raymond2
1
SCGH and OPH Group; 2University of Western Australia
Background: Fracture risk calculators (FRC) can guide osteoporosis
(OP) management in the absence of dual X-­ray absorptiometry (DXA).
Objectives: Determine the accuracy of age-­stratified Garvan FRC
thresholds without DXA to manage OP.
Methods: Cross-­sectional study of 935 participants, ≥70 years old,
who underwent DXA and had Garvan FRC scores with and without
DXA calculated. Age-­stratified Garvan scores without DXA, gener-
ated low (no action), moderate (order DXA) or high (treat without
DXA) risk thresholds of OP. Accuracy of our thresholds were as-
sessed against DXA confirmed OP.
Results: Age-­
specific GARVAN thresholds resulted in the cor-
rect decision in 85–88% of cases; “over-­t reated” OP in 7–8%; and,
missed OP in 5–8%. 256 (48%) DXAs were unnecessary. Using
the proposed method of clinical thresholds for GARVAN HF risk
scores compared to NOF guidelines we increased the specificity
(+47%), PPV (+39%), NPV (+1%) and accuracy (+31%), for a reduc-
tion in sensitivity (−14%). Furthermore, for GARVAN MOF risk
scores compared to NOF guidelines, we gain sensitivity (+29%),
specificity (+13%), PPV (+60%) and accuracy (+12%), for a reduc-
tion in NPV (−3%).
Conclusions: Age-­specific FRC score thresholds successfully identi-
fied who required treatment or DXA, with potential to reduce unnec-
essary DXA and costs and inconvenience associated with screening.
This screening method has clinical utility in areas that lack DXA re-
sources and could potentially reduce unnecessary use of DXA.
Figure 1 GARVAN hip and major osteoporotic fracture risk score
thresholds
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      95

Table 1 Sensitivity, Specificity and Predictive values derived from Area under the curve

Raw scores Our proposed thresholds

Test result variable(s) AUC (95%CI) Sensitivity Specificity PPV NPV Accuracy

GARVAN 10-­year hip fracture risk with BMD 0.93 (95%CI 0.91, 0.95)
GARVAN 10-­year hip fracture risk without BMD 0.72 (95%CI 0.67, 0.77) 70% 91% 72% 90% 85%
FRAX 10-­year hip fracture risk 3% cut-­off (19) 0.65 (95%CI 0.59, 0.70) 84% 44% 33% 89% 54%
GARVAN 10-­year major osteoporotic fracture 0.90 (95%CI 0.87, 0.93)
risk with BMD
GARVAN 10-­year major osteoporotic fracture 0.71 (95%CI 0.66, 0.75) 81% 90% 68% 95% 88%
risk without BMD
FRAX 20-­year major osteoporotic fracture risk 0.51 (95%CI 0.45, 0.56) 52% 77% 8% 98% 76%
20% cut-­off (19)
AUC, area under the curve with 95% confidence interval; NPV, negative predictive value; PPV, positive predictive value.

1-­018 | Osteoporosis and dementia
common pathways and targets: a mouse mode
investigating the effect of acetylcholine esterase
inhibitor Donepezil on bone
C. Inderjeeth1,2; D. Teguh2; S. Li3; J. Tickner2; J. Xu2
1
SCGH and OPH Group; 2University of Western Australia; 3Sun Yat-­sen University
Purpose: Alzheimer's disease (AD) and osteoporosis (OP) frequently
co-­exist in an ageing population. A recent study published in the
Journal of Alzheimer's Disease linked low BMD with increased risk
of AD (Zhou et al., 2011). Reductions in levels of ACh have also been
implicated in bone loss. Acetylcholine receptor (AchR) subunits and
Acetylcholinesterase (AchE) are expressed in bone.
A recent publication has demonstrated a correlation between treatment
with AChEI Donepezil and Rivastigmine and reduction in hip fracture in
osteoporotic AD patients (Tamimi et al., 2012, J Bone Miner Res). We
previously reported that in vitro cholinesterase inhibitor Donepezil re-
duces osteoclast activity (ASBMR 2013). Methods: the age of mice was
6 weeks (before injection of AD drugs). We did experiments with 10
mice per AD drug (5 mice for low-­dosage and 5 mice for high-­dosage of
each drug). The intraperitoneal injection of AD drugs was two times per
week and for a total of two months. We compared these to sham OVX
and OVX mice. We did Micro-­CT at end of dosing at 14 weeks of age.
In this sub study in healthy mice we compared sham OVX (4) and
OVX (4) against low (4) and high dose (5) Donepezil. MicroCT scan-
ning was utilised to assess femur and Tibia bone quality parameters
including BV/TV, TbSp, TbTh, TbN, cortical bone area, cortical thick-
ness and marrow area.
Results: We present results for Donepezil. at both femur and tibia
as expected OVX mice showed deterioration in most parameters
compared to sham. Donepezil treated mice showed trend to main-
tenance or improvement in these parameters. This was not dose de-
pendent. The results are illustrated in Table 1 and Figure 1.
Conclusions: Osteoporosis and dementia may share some common
pathogenesis and potential therapeutic targets.

Table 1

TA (mm2) BA (mm2) CtTh (mm) BA/TA (%) Ma.A

Sham Sham (N) Average 1.079465 0.906163 0.228265 0.839128 0.173303

SD 0.10559 0.093927 0.011181 0.005202 0.012017
OVX Control OVX (C) Average 0.950616 0.780653 0.198777 0.820533 0.169963
SD 0.077732 0.072114 0.014327 0.011326 0.007764
vs sham ttest 0.044312 0.033777 0.006503 0.013766 0.584599
Don 1 ug/g Donepzil 1 μg/g ip (D1) Average 1.032085 0.855548 0.209205 0.828961 0.176538
SD 0.012996 0.010157 0.005235 0.003247 0.004626
vs sham ttest 0.407378 0.325139 0.02145 0.01609 0.633247
vs OVX control ttest 0.072487 0.074199 0.201792 0.187879 0.161624
Don 5 ug/g Donepzil 5 μg/g ip (D5) Average 0.978634 0.807726 0.20603 0.825068 0.170908
SD 0.045317 0.045318 0.011318 0.008295 0.002599
vs sham ttest 0.092393 0.075556 0.021596 0.021804 0.673051
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96      

1-­051 | Osteoporosis in dementia patients: if

poorly managed results in high morbidity and
mortality
A. Inderjeeth1,2; N. Mughal1; C. Inderjeeth1,2
1
SCGH and OPH Group; 2University of Western Australia
Objective: Assess the Morbidity, Mortality and treatment of people
with osteoporosis (OP) with and without dementia
Setting: Data collected on 502 consecutive Orthogeriatric admis-
sions for fracture. Fisher's Exact Chi-­square was used to compare
treatment stratified by dementia status.
Results: 226 (45%) had dementia and 281 (56%) had osteoporosis
diagnosed pre-­fracture. Dementia patients were more likely to have
a prior diagnosis of OP but less likely to be on optimal treatment.
There was a significant improvement in discharge vs. admission
rates of OP treatment of patients diagnosed with OP with or with-
out dementia: Calcium; Vitamin D; antiresorptive treatment (ART);
combined therapy. However, those with dementia were less likely to
be treated with ART (36% vs. 59%, P < 0.001) or combined therapy
(32% vs. 56%, P < 0.001) and had double the 90 day mortality (17.3
vs 9.6%) and 6 times the 30 day mortality (6.4 vs 1.6%).
Conclusions: Dementia patients with OP are less likely to receive
preventative OP treatment despite higher risk of recurrent fractures
and higher mortality. Assessment and treatment of osteoporotic
fracture risk in this high risk group is imperative to reduce morbidity,
mortality and costs in and aging population.
1-­0 07 | Patients enrolled in an ankylosing
spondylitis (AS-­P) patient centred education
program had improved disease activity outcomes
up to 12 months
C. Inderjeeth1,2; E. Boland1; J. Mcquade3; W. Raymond1; C.
Connor3; K. Briffa4; J. Edelman1
1
SCGH and OPH Group; 2University of Western Australia; 3Arthritis and
Osteoporosis WA; 4Curtin University
Background: In chronic disease patient centered education and
care is important1. After a needs assessment and Plan, Do, Study,
Act (PDSA) model, we developed a multidimensional Ankylosing
Spondylitis Education Program (AS-­
P) to patients with Ankylosing
Spondylitis (AS).
Objectives: To examine the benefits of AS-­P for people with AS in
regards to health status, quality of life and disease activity.
Methods: 134 people were enrolled. Exclusion criteria: Participants
attended a weekly 2.5 hour patient centered education session facil-
itated by same two health professionals over 6 weeks. The scripted
content included multidimensional strategies including stretches;
self-­efficacy and self-­management constructs and optional 7th week
supervised exercise class.
Data collection included demographic, AS disease management
characteristics, medication patterns, and outcomes, measured at
baseline, 6 weeks, 3 months, 6 months and 12 months using GLM
repeated measures ANOVA. Additional outcomes included the:

Table 1 Osteoporosis treatment at discharge

No osteoporosis (n = 221) Osteoporosis (n = 281)

Dementia status Dementia status

No dementia Dementia No dementia Dementia

Treatment status (n = 151) (n = 70) P value (n = 125) (n = 156) P value

No treatment 19 (13%) 10 (14%) 0.831 2 (2%) 8 (5%) 0.193

Calcium 117 (77%) 49 (70%) 0.245 117 (94%) 125 (80%)* 0.002
Vitamin D 127 (84%) 59 (84%) 1.00 122 (98%) 143 (92%)* 0.002
ART 50 (33%) 17 (24%) 0.210 74 (59%) 56 (36%)* 0.000
Combination 44 (29%) 16 (23%) 0.417 70 (56%) 50 (32%)* 0.000
*The Chi-­square statistic is significant at the.05 level.

BAS-­G , BASDAI, AS-­Qol, BASFI, back pain (VAS), PDGA, anxiety
(HADs), health distress (HDQ), quality of life (EASIQol), perceived
health (GPH), pain (PSEQ), MAFs and SF-­36.
Results: 66 people completed 12 month assessments. 56% were
male and the mean age was 46 ± 15 years. The mean duration of dis-
ease was 8 ± 10 years. There only significant change in medication
usage occurred after month 3 months (P = 0.018).
Results are presented in Table 1. The BAS-­G , BASDAI and Nocturnal
and total back pain had improved between baseline and 12 months
(all P < 0.05). However BASFI, AS-­QoL, PDGA, HDQ anxiety (HADs),
health distress (HDQ), quality of life (EASIQol) did not improve.
Conclusion: AS-­P for AS is effective in improving AS specific disease
activity and pain but not QOL scores for up to 12 months in this
program.
References: 1. Vermaak V, Briffa K, Langlands https://bmc-
musculoskeletdisord.biomedcentral.com/ar ticles/10.1186/
s12891-015-0663-6 B, Inderjeeth C and McQuade J. https://bmc-
musculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-
015-0663-6 Evaluation of a disease specific rheumatoid arthritis
self-­management education program, a single group repeated meas-
ure study.
2-­045 | Clinical utility of ultrasonography in
diagnosing and monitoring disease activity of
relapsing polychondritis
S. Inotani; Y. Taniguchi; H. Nishikawa; E. Amano; S.
Nakayama; Y. Terada
Kochi Medical School Hospital
Background/purpose: Relapsing polychondritis (RP) is a rare sys-
temic inflammatory disorder, and the diagnosis and treatment evalu-
ation are often difficult. Therefore, the discovery of more convenient
imaging modality than contrast-­C T, MRI and FDG-­PET/CT would be
required on diagnosis and treatment. To assess the clinical utility of
ultrasonography (US) in diagnosing and monitoring disease activity
of relapsing polychondritis (RP).
Methods: Auricular and nasal chondritis of patients with RP (n = 6)
were initially assessed by US before and after treatments. Secondly,
|
      97
the changes of US findings and serum inflammatory markers were
compared in RP. Finally, the auricular and nasal US findings between
patients with RP (n = 6), repeated trauma (n = 6) which finding is sim-
ilar to RP, and healthy subjects (n = 6) were examined comparatively.
Results: In all cases of RP, US finding before treatment showed low-­
echoic swollen auricular and nasal cartilage with increased power
Doppler signals (PDS), corresponding to biopsy findings. After treat-
ment with prednisolone (PSL) combined with methotrexate, the
swollen ear and nose completely resolved. Then, swollen cartilage on
US also dramatically reduced with the decrease of PDS. When serum
inflammatory markers completely improved, but PDS remained in 2
of 6 cases, and these cases showed flare due to early PSL tapering.
Finally, the cartilage of RP on US could be apparently differentiated
from repeated trauma and healthy subject due to thickness of carti-
lage, PDS and subperichondrial serous effusion. 
Conclusion: Assessment of RP lesions by US possibly facilitates
evaluation of cartilaginous lesions and monitoring of disease activity,
especially when we consider the treatment response and the timing
of drug tapering.
2-­145 | Mortality in Thai patients with anti-­
neutrophil cytoplasmic antibodies (ANCA)-­
associated vasculitis
P. intapiboon; B. Siripaitoon
Division of Allergy and Rheumatology, Faculty of Medicine, Prince of Songkla
University
Background/purpose: ANCA-­
associated vasculitis (AAV) is rela-
tively rare but associated with high mortality. Survival depends on
early diagnosis, treatment strategies and prognostic factors. This
study aimed to evaluate overall mortality and factors related mortal-
ity of the AAV patients in a resource-­constrained country.
Methods: Thai patients aged 18 years or older and diagnosed AAV
according to either the American College of Rheumatology 1990
classification criteria or the 2012 Chapel Hill Consensus Conference
disease definitions were enrolled from Songklanagarind hospital
during 2007 to 2017. They were excluded if having only one organ
involvement, HIV infection or malignancy. We compared data be-
tween survival and non-­survival group, analyzed by univariate and
multivariate logistic regression. Overall survival was estimated by
using Kaplan-­Meier analysis.
Results: Sixty AAV patients were included. Their mean (SD) aged
46.4 (16.2) years old. Microscopic polyangiitis was the main diag-
nosis (30%). AAV mostly affected their kidneys (65%), and half of
which presented with rapidly progressive glomerulonephritis (32%).
Pulmonary involvement was the second common (58%) and 18%
suffered from pulmonary hemorrhage. Mean (SD) initial Birmingham
Vasculitis Activity Score (BVAS) was 20.4 (7.1). Median (IQR) du-
ration before diagnosis was 3 (1–4) months. Their short term out-
come showed 30-­day and 6-­month mortality rates of 10% and 18%.
Overall Mortality rate was 37%, with a median survival time of
 |
98      
30 months. One-­, 3-­and 5 -­year mortality rates were 33%, 52% and
68%, respectively. A significant factor related mortality was initial
BVAS 20 (adjusted OR = 7.08, 95%CI = 1.47–34.08, P = 0.007).
Conclusion: Despite of diagnostic improvement of AAV in the last
decade, the mortality rate of Thai AAV patients was still quite high.
It was strongly related to their high initial disease activity. Early
recognition of AAV and early referral might improve the outcome.
Education focused on this potentially life threatening disease is ne
eded.
2-­105 | Trabecular bone score in thai systemic
sclerosis patients: is it a better tool for predicting
fractures?
N. Intarasattakul1; A. Mahakkanukrauh1; C. Foocharoen1;
S. Suwannaroj1; R. Nanagara1; C. Pongchaiyakul1; P.
Thammaroj2
1
Internal Medicine, Khon Kaen University; 2Radiology, Khon Kaen University
Background: Systemic sclerosis (SSc) is at risk of osteoporosis and
fragility fractures. Trabecular bone score (TBS) is a new analytical
tool which demonstrate bone microarchitecture. The study on TBS
in SSc patients is still limited.
Objectives: To compare TBS in Thai SSc patient with healthy control,
to determine prevalence of low TBS and to examine the association
of clinical risk factors with osteoporosis, low TBS and spinal fracture
in Thai SSc patients.
Methods: A prospective study was conducted in SSc adult patients
at Scleroderma Clinic, Khon Kaen University. The 130 SSc patients
were enrolled in November 2012-­November 2013. All patients were
evaluated for bone mineral density (BMD), TBS, vitamin D, calcium,
phosphate, parathyroid hormone level, thyroid function test and in-
flammatory markers at the date of enrollment. Radiographic study
was performed for evaluation of osteoporosis fracture 5 years after
enrollment. Low TBS was defined by TBS less than 1.35
Results: Among participant, majority were diffuse cutaneous SSc
(80.8%) with female to male ratio 2.7:1. Low TBS was revealed in 53%
in SSc patients. The mean TBS was significant lower in SSc patients
than in control (1.35 and 1.38, respectively; P < 0.001). Female gender,
age >60 years, body mass index <18.5 kg/m2, high erythrocyte sedi-
mentation rate and menopause were factors associated with low TBS
by univariate analysis. After adjusted binary logistic regression, only
age >60 years was an associated factor with low TBS in SSc patients
(Odds ratio 5.39, 95%CI 1.41–20.63). Overall spinal fracture rate in SSc
was 43.8%. Spinal Fracture could occur in normal BMD and TBS.
Conclusion: SSc patients had significant lower TBS than normal
population. Half of SSc patients had abnormal TBS and elderly SSc
patients are at risk for low TBS.
Keyword: bone mineral density, osteoporosis, systemic sclerosis,
trabecular bone score
2-­034 | Translation, cross-­cultural adaptation
and validation of short-­form patient satisfaction
questionnaire (PSQ-­18) into Bengali
S. S. Trina1; Md. N. Islam1,2; M. M. Hasan1; A. K. Ahmedullah1
1
Department of Rheumatology, Bangabandhu Sheikh Mujib Medical
University (BSMMU); 2Modern One Stop Arthritis Care and Research Center ®
(MOAC&RC®); 3Department of Psychology, Health and Technology, University
of Twente
Background: Use of native language Patient Satisfaction Questionnaire
(PSQ-­18) to assess level of satisfaction may give higher yield.
Objectives:
• To translate and validate the original English PSQ-18 into Bengali
• To test the psychometric properties of the Bengali version of
PSQ-18
Methods: This two phased study was carried out in the Department
of Rheumatology, BSMMU from September 2016 to March 2018.
The Beaton et al. 2000 recommended methods were followed for
translation and cross-­cultural adaptation. The understandability and
pretest of the prefinal Bengali version was tested on 20, grade 6
level students and 40 adult rheumatic patients respectively. The
psychometric properties were assessed on 130 rheumatic patients.
The content validity was assessed using item-­
level (I-­
C VI) and
scale-­level content validity index (S-­C VI). Internal consistency was
assessed using Cronbach's alpha value. The construct validity was
assessed using Spearman's rank correlation coefficients (r) (indica-
tive item was item 3). The agreement between the test retest data
was shown by Bland and Altman analysis.

Results: Two Bengali words were not understood by any children
and items 3, 4, 7, 8, 10 needed explanations. The item response rate
of pretest was 100%. Adapted English words were medical tests, ap-
pointment and doctor's chamber. The Cronbach's alpha score was
ranged from 0.95 to 1.00. The Spearman's rank correlation coeffi-
cient of item 3 was 0.98 and the mean r value of the rest of the
items was 0.97. By Bland and Altman analysis limits of agreement
was between −0.25 to 0.24. The level of general satisfaction, techni-
cal quality, interpersonal manner, communication, financial aspects,
time spent with doctor as well as accessibility and convenience were
75.4%, 75.4%, 81.8%, 80.5%, 63.8%, 75.7% and 61% respectively.
Conclusions: The psychometric properties of the Bengali version of
PSQ-­18 were well maintained and useable to assess the level of sat-
isfaction of Bangla speaking rheumatic patients.
1-­085 | What affects functional disability of
the elbow joint in rheumatoid arthritis?
H. Ito; T. Tomizawa; K. Murata; K. Nishitani; M. Hashimoto;
K. Murakami; M. Tanaka; S. Matsuda
Kyoto University Graduate School of Medicine
Background: The elbow joint is specifically affected in rheumatoid
arthritis (RA), and the joint destruction still progresses in a certain
percentage of RA patients, despite of advanced medication. The aim
of this study was to clarify risk factors contributing to functional dis-
ability of the elbow joint from a large cohort of RA patients.
Methods: A total of 558 patients was sequentially recruited from
a large cohort. We collected a functional score of patient-­reported
disability of the elbow joint, PREE, as well as demographic data in-
cluding age, sex, duration of the disease, medication, and disease
activity. The risk factors affecting PREE were statistically analyzed.
Results: The age, the ratio of female, and the duration of the dis-
ease were 63.8 years in average, 82.4%, and 13.4 years in average,
respectively. The averages of DAS28-­ESR and HAQ-­DI were 2.76
and 0.61, respectively. Univariate analysis for PREE being the objec-
tive variable showed that older age, female sex, longer duration of
the disease, higher stage of joint destruction, higher DAS28, more
swollen and tender joint counts, higher HAQ, and elbow pain were
significant factors. Multivariate analysis showed that DAS28, swol-
len joint counts, HAQ, elbow pain, and range of motion of the elbow
were significant explanatory variables.
Conclusion: To lessen functional disability of the elbow, it is impor-
tant to suppress systemic disease activity and to control pain and
range of motion of the joint.
|
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1-­021 | Serum aldolase: a useful marker of
diagnosis and disease activity in patients with
adult-­onset still's disease
S. Izuka
National Center for Global Health and Medicine
Background/purpose: Adult-­onset Still's disease (AOSD) is a rare
systemic inflammatory syndrome that is diagnosed with Yamaguchi's
criteria. AOSD is difficult to diagnose and determine whether it is ac-
tive or inactive. Very few studies have reported that serum aldolase
increases in AOSD patients. But the specific relationship between
AOSD and serum aldolase has not been clarified.
Objectives: The aim of our study was to address its possible role as a
biomarker for differential diagnosis and disease activity for patients
with AOSD.
Methods: Blood samples and symptoms were collected from 8 pa-
tients with AOSD, 28 patients with rheumatic arthritis (RA) and active
arthritis with positive CRP, 34 patients with Sjogren syndrome (SjS)
who did not take glucocorticoids nor immunosuppressants, 19 patients
with systemic lupus erythematosus (SLE) whose SLEDAI were higher
than 8, and 12 patients with systemic sclerosis (SSc) who did not take
glucocorticoid nor immunosuppressants. Follow-­up samples of all pa-
tients with AOSD were collected after resolution of disease activity.
Results: Serum levels of ALD in AOSD patients were higher than
in control groups (RA, SjS, SLE and SSc patients; all P values were
<0.001) (Fig.1). The sensitivities and specificities for diagnosis for
AOSD were 87.5%/100%, 88%/95%, 87.5%/100%, and 87.5%/100%
respectively. All cutoff values were 8.9 U/L. Serum ALD was found
to be decreased after disease activity was resolved in follow-­up of
AOSD patients (P = 0.02). in addition, serum aldolase was correlated
with Pouchot's score and ferritin among AOSD patients (r = 0.71,
P = 0.003: Fig. 2 and r = 0.6, P = 0.02).
Conclusion: The data suggest that serum aldolase may be a useful bi-
omarker for diagnosis and evaluating activity in patients with AOSD.
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100      
2-­046 | Detecting hand joint subluxation in
radiographic images using deep learning: toward
the development of automatic evaluating system
for bone destruction
K. Izumi1,2; M. Hashimoto1; K. Suzuki3; T. Endoh3; K. Doi4; Y.
Iwai4; M. Jinzaki1; S. Ko1; T. Takeuchi1
1
Keio University School of Medicine; 2National Tokyo Medical Center; 3Fujitsu
Laboratories Ltd.; 4Fujitsu Ltd.
Background/purpose: In order to develop an artificial intelligence-­
aided automatic radiographic evaluating system for quantitating
degree of bone destruction, as a first step we have recently devel-
oped a deep learning-­based model to automatically detect hand joint
ankyloses in radiographic images [1]. As a next step, we aimed to
develop a deep learning-­based model to automatically detect hand
joint subluxation in radiographic images.
Methods: A total of 216 radiographic images of hands were ran-
domly obtained from patients who had visited our Rheumatology di-
vision at Keio University Hospital in 2015. Twenty-­five images were
identified as having subluxation in hand joints including wrist joints,
MP joints and PIP/IP joints in agreement with a well-­trained rheu-
matologist and radiologist. in learning phase, images were randomly
divided into five sets (fold No. 1 to 5) for 5-­fold cross validation. We
utilized ResNet[2], a deep learning model for classification of images,
to predict hand joint subluxation. The ROC analysis was performed
to evaluate performance of the model.
Results: As a performance of detecting hand joint subluxation, our
model presented accuracy of 0.95, recall value of 0.95, precision
value of 0.80, and F-­measure value of 0.87. Mean area under the
ROC curve was 0.96 (Fig. 1).
Conclusion: A model based on deep learning to automatically detect
hand joint subluxation in radiographic images was developed with
relatively small samples, which suggests that the predictive perfor-
mance may increase by collecting more training dataset. Our devel-
oped model needs to be validated in an independent set of images
and tested against other experienced doctors. in the next step of
development, we are elaborating a plan for a deep learning-­based
system to automatically detect joint location and evaluate erosion
and joint space narrowing.
References: 1. K Izumi et al. Arthritis Rheumatol. 2018; 70 (suppl 10).
2. HE Kaiming et al. Proceedings of the IEEE conference on com-
puter vision and pattern recognition. 2016.
Figure 1
2-­035 | Nutritional status in patients with
rheumatic diseases: a study from Bangladesh
S. Jahan1; Md. N. Islam1,2; N. Ferdous1,3; F. B. Nazrul1,4
1
Modern One Stop Arthritis Care And Research Center ® (moac&rc®);
2
Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University
(BSMMU); 3Department of Medicine, MH Samorita Hospital and Medical
College; 4National Heart Foundation Hospital and Research Institute
Objectives: The aim of the study is to evaluate the current state of
nutrition in patients with different rheumatic patients.
Methods: After informed written consent consecutive diagnosed
patients with different rheumatic diseases were enrolled in a tertiary
care rheumatology center of Dhaka, Bangladesh from April 2016 to
September 2018. Demographics, dietary habit evaluated by using
24 hours recall methods and anthropometric measurements were
recorded. Values were expressed in number, percentage, mean and
standard deviation.
Results: Among 339 rheumatic patients, mean age 44.88 ± 12.96,
male and female were 108 (31.9%) and 231 (68.1%) respectively.
Literacy level up to secondary were 163 (48.1%) followed by higher
secondary and above 162 (47.8%). Housewife and sedentary job
were 192 (56.6%) and 86 (25.4%) patients respectively. Tobacco
usurer was 69 (20.4%) patients. (Based on BMI; overweight and
obese were 42 (12.4%) and 232 (68.4%) patients respectively.
Daily intakes of calories were 1261.94 ± 521.35 kcal (carbohydrate
174.04 ± 84.60, fat 14.26 ± 13.74, protein 52.07 ± 29.81), calcium
319.1 ± 312.91 mg/dL, and vitamin D 0.98 ± 1.26 μg/dL. Waist
circumference was 90.07 ± 11.18 cm, waist-­hip ratio 0.87 ± 0.09.
Among the rheumatic diseases, 203 patients were suffering from
spondyloarthritis, 54 from rheumatoid arthritis, 127 from osteoar-
thritis and 10 from osteoporosis.

Conclusions: More than half of the patients suffering from rheu-
matic diseases are overweight and obese.
2-­115 | Correlating ASDAS and BASDAI in
ankylosing spondylitis
N. Jain; D. Shukla; P. Srivastava; S. Pandya
Smt NHL Municipal Medical College
Background/purpose: To study correlation and agreement between
the Ankylosing Spondylitis Disease Activity Score (ASDAS) with
Bath Ankylosing Spondylitis Activity Index (BASDAI) and their trend
on follow up.
Methods: Prospective longitudinal study including all consecutive
patients of Ankylosing Spondylitis (AS) (November 2017 to August
2018) visiting the government medical college OPD after informed
consent.
Baseline and follow-­up demographic data with ESR, CRP, BASDAI,
ADSAS, Patient and physician global assessment (PTGA, PHYGA)
was noted and appropriate statistical analysis performed using SPSS
software.
Results: The sample consisted of 134 patients, mostly men (80%),
with a mean age of 30 ± 12 years (Median = 27 years) and disease
duration of 3.5±5.2 years.
• Correlation coefficient between ASDAS CRP and BASDAI is
r = 0.75
• The cutoff point of ASDAS with the best agreement with BASDAI
was 3.5 (global agreement 82%, kappa 0.54).
• Convergent validity shows a higher correlation of BASDAI with PT
GA than with PhYGA (0.82 vs 0.7)
• ASDAS had a similar correlation with PTGA and PhyGA (r = 0.74).
• The discriminant validity analysis showed that both indices were
able to discriminate patients above and below the median PTGA
(>4.5) (Cohen δ 1.3 vs 1.1)
• On followup study of 52 patients with mean follow-up duration
of 4.2±2.1 months, both ASDAS CRP and BASDAI were sensitive
to change but ASDAS CRP showed better results as measured by
effect size (δ 0.8 vs 0.6)
• Baseline and follow-up data along with comparison with other na-
tional and international data shown in Table 1 and 2.
|
      101
Conclusion:
• Both ASDAS and BASDAI correlate well with each other and show
similar trend on follow-up.
• Agreement of BASDAI (>4) was more with high ASDAS in our
study.
• ASDAS has higher effect size on follow-up compared to BASDAI
1-­141 | Reproductive health in SLE
N. Jain; D. Shukla; S. Pandya; P. Srivastava
Sheth V S General Hospital and Smt Nhl Municipal Medical College
Background/purpose: Our aim is to study menstrual irregularities
in lupus patients and factors associated with sustained/secondary
amenorrhea (defined as amenorrhea >12 months duration).
Method:
• Prospective observational study.
• Study period: 10 months (Nov 2017-Aug 2018).
• All patients attending Government Hospital OPD were enrolled
after informed consent.
• Baseline data was collected along with Rheumatoid arthritis pa-
tients as disease controls. For healthy controls the nursing staff
was interviewed.
• Hormonal levels (LH/FSH) were done for sustained amenorrhea
(>12 months).
Results:
• Total 82 patients of SLE with disease controls, RA = 87 and
healthy controls (HC) = 41.
• Lupus patients were younger as compared to RA (Mean age
32 ± 11 vs 41 ± 9, P = 0.001).
• Lupus patients had more oligo-menorrhea or temporary
amenorrhea as compared to RA [35% vs 16% (P = 0.004)]
and HC [35% vs 0 (P = 0.001)] and more secondary infertility.
(Table 1).
• Both lupus and RA patients had more sustained amenorrhea
(>12 months) which was significant when compared to HC (P = 0.002).
• On comparing lupus and RA patients with sustained amenor-
rhea, although onset in lupus patients was earlier [35 ± 5 years vs
42 ± 6 years, P = 0.007], none had FSH >40. (Table 2).
• Factors associated with sustained amenorrhea in lupus included
early onset of SLE [19.4 ± 5.2 years vs 24.4 ± 6.2 years, P = 0.006]
with higher SLEDAI score [12.5 ± 4 vs 5.6 ± 5.4, P < 0.001] (Table
2).
Conclusion:
• More of lupus patients had oligo menorrhea or temporary amen-
orrhea and secondary infertility as compared to RA patients and
healthy controls.
 |
102      

Table 1 Baseline comparison

SLE RA Healthy control P (SLE
N = 82 N = 87 P N = 41 vs HC)

Mean Age (Median) years 32 ± 11(30) years 41 ± 9(40) years 0.001 26 ± 13(24) years .008
Mean TDI years 3.4 ± 2.3 years 5.2 ± 4.6 years 0.05 -­ -­
Mean Menarche 13.8 ± 2.3 years 14.3 ± .1.8 years 0.06 14 ± 2 years 0.3
Irregular cycle 28(35%) 21(24%) 0.11 3(8%) 0.01
Oligo menorrhea or 28(35%) 14(16%) 0.005 0 0.001
temporary amenorrhea
Menorrhagia 8(10%) 7(8%) 0.65 2 0.7
Infertility 40(39%) 20(23%) 0.0004 0 0.001
Primary infertility 11(14%) 7(8%) 0.2 0 0.02
Secondary infertility 20(25%) 13(15%) 0.002 0 0.001
Sustained Amenorrhea 13(24%) 17(29%) 0.64 1 0.002
(>12 months)
Hypothyroidism 8 (10%) 19(20%) 0.06 1 0.13

Table 2 Sustained Amenorrhea in SLE vs RA • Early onset of lupus with high SLEDAI score are associated with
sustained amenorrhea.
SLE RA P

Sustained Amenorrhea 13 17 0.64

(n)
Mean Age of Menopause 35 ± 5  42 ± 6  0.007
3-­053 | Association of age with the rate of
(Sustained amenorrhea years years change in knee cartilage volume: a 10.7 year
>12 months)
longitudinal cohort study
Mean SLEDAI/ DAS28 12.5 ± 4 3.1 ± 2.6 -­
ESR M. Jiang1,2; G. Q. Cai2; G. Jones2
1
LH 6.2 ± 4.2 19.3 ± 8 0.001 Royal Hobart Hospital; 2Menzies Institute for Medical Research

FSH 4.08 ± 2.8 23 ± 28 0.001

Background: Osteoarthritis is a slowly progressive disease and the
FSH >40 0 5 0.001
prevalence increases with age. However, it has been suggested that
Factors associated with Sustained amenorrhea in SLE
radiographic progression is very slow and only occurs in few sub-
Amenorrhea jects. This may be true or may reflect inaccuracies with radiographs
>12 months Others over time. Magnetic resonance imaging (MRI) assessment of carti-
  N = 13 N = 69 P
lage is much more accurate and sensitive thus, the aim of this study
Mean Age 35 ± 5 years 28 ± 8 years 0.003 was to describe the association between age and the rate of change
Mean Duration of 5.2 ± 4.3 years 3.4 ± 6.4 years 0.2 of tibial knee cartilage volume in participants followed up over a
illness 10.7-­year period.
Mean age of onset of 19.4 ± 5.2  24.4 ± 6.2  0.006 Methods: A total of 481 participants (49% female, mean age
SLE years years
60.8 years [range 50–80]) had MRI of the right knee performed at
Number of pts with 2 10 0.92
baseline and 10.7 year follow-­up. Tibial cartilage volume was as-
abortion history
sessed on T1-­weighted fat suppressed MRI. The association be-
APLA 1 2 0.5
tween age and change in tibial cartilage volume was analysed using
Mean SLEDAI 12.5 ± 4 5.6 ± 5.3 <0.001
linear regression models with adjustment for potential confounders.
Number of pts 5 15 0.18 Interaction between age and sex was also investigated.
received
Results: The average rate of loss of cartilage volume was 1.2% pa
Cyclophosphamide
(range −3.9% to −0.2%) with all participants losing total cartilage
Number of pts with 5 21 0.6
Lupus Nephritis volume over the study period. in multivariable analysis, there was a
significant association between age and the rate of change of tibial
cartilage volume in medial (−0.019%/year, 95% confidence inter-
• SLE patients with sustained amenorrhea (>12 months) did not val [CI] −0.031% to −0.007%, P = 0.002) and total tibial cartilage
have hormonal ovarian failure as compared to RA patients who volume (−0.015%/year, 95% CI −0.024% to −0.007%, P < 0.001).
had true menopause. This association was independent of radiographic osteoarthritis.
 |
      103

When analysed by gender, females lost more lateral tibial cartilage 3-­054 | Pro-­and antioxidative balance and
with age.
osteoarthritis in Korean adults: the Korea
Conclusions: Knee cartilage volume declines at a faster rate with in-
National Health and Nutrition Examination
creasing age suggesting that osteoarthritis is relentlessly progressive
and the X-­ray based studies may not be an accurate reflection of
Survey (2014–2015)
what is happening in the joint. With increasing age, females may lose K.-H. Jung1; J.-H. Lee2; Y. B. Joo3; K.-S. Park3; B. Y. Yoon2; S.
cartilage at a faster rate compared to males. R. Kwon1; W. Pakr1
1
Division of Rheumatology, Department of Internal Medicine, Inha University Hospital;
2
Department of Rheumatology, Inje university Ilsan Paik Hospital; 3Department of
Rheumatology, St. Vincent's Hospital, The Catholic University of Korea
1-­063 | Third degree AV block in an adolescent
with acute rheumatic fever: a case report Background and purpose: Osteoarthritis is the most common form
of arthritis, caused by a combination of systemic and local factors. Its
M. F. Carmel Jocson; C. Tee; L. Dans
multifactorial etiology includes oxidative stress and the overproduc-
Philippine General Hospital
tion of reactive oxygen species.
Objectives: This study aimed to investigate the association between
Introduction: Acute Rheumatic fever (ARF) is still the most com-
oxidative balance score (OBS) and osteoarthritis, and between OBS
mon acquired heart disease especially in developing countries.
and quality of life in patients with osteoarthritis.
And one of its major criteria is carditis commonly presenting as
Methods: Using the Korea National Health and Nutrition Examination
valvular lesion. Although, rhythm disturbances may occur, its in-
Survey (KNHANES) VI (2014–2015) program, OBS was calculated
cidence remained low. in the study of Hubail Z and Ebrahim IM
by combining 10 pro-­and antioxidant factors through baseline nu-
(2016), they reported incidence of advanced AV block varying only
tritional and lifestyle assessments. OBS was divided into quartiles,
from 0% to 1.6%.
considering the lowest quartile, Q1 (predominance of pro-­oxidants),
Objective: To report a case of a Filipino female adolescent present-
as the reference. Multivariable logistic regression was used to esti-
ing as 3rd-­degree AV block during the acute stage of ARF.
mate the adjusted odds ratios (ORs) for osteoarthritis and EQ-­5D
Description: A 13-­year-­old female had 3-­week history of fever,
was used in patients with osteoarthritis after adjusting for demo-
cough, nasal catarrh and dysphagia which spontaneously re-
graphic factors and comorbidities.
solved. One week prior to admission, she had recurrence of fever
Results: Among the 14,930 participants in the KNHANES 2014 and
associated with chest pain and difficulty of breathing, followed
2015, 296 patients with osteoarthritis and 1309 controls were included
by arthritis of right ankle, right knee, bilateral wrists and elbows.
in the analysis. Patients with osteoarthritis had lower OBS than that of
Initial electrocardiogram result revealed 3rd degree AV block but
controls (17.04 ± 0.22 and 17.08 ± 0.12, respectively), although there
normal echocardiographic findings. Based on the findings of car-
was no statistically significant difference between the groups. Especially,
ditis, polyarthritis, elevated acute phase reactants (ESR 22 and
patients with osteoarthritis had significantly lower antioxidant OBS than
CRP >12) and high Anti-­s treptolysin O titer of >400, the patient
that of controls (P < 0.01). The OR of dietary antioxidant OBS was 0.92
was diagnosed as Acute Rheumatic Fever. Intravenous Penicillin
(95% confidence interval [CI], 0.87–0.97) and that of non-­dietary life-
was given and shifted to oral penicillin VK to complete 10 days
style antioxidant (physical activity) OBS was 0.82 (95% CI, 0.71–0.94).
together with Aspirin therapy at 90 mg/kg/d. On the 3rd hospital
In a logistic regression model to assess the association of OBS with
day, electrocardiogram showed conversion of 3rd degree AV block
osteoarthritis, the adjusted OR for osteoarthritis was 0.95 (0.91–
to 1st degree AV block. Patient was then discharged after 5 days
1.00). Moreover, the adjusted OR for higher EQ-­5D was 1.17 (1.06–
of hospital stay with normal electrocardiogram and monthly peni-
1.30) in patients with OA.
cillin injections.
Conclusion: Anti-­oxidative status was associated with a lower risk of
Discussion: Cardiac inflammation involving the three layers of the
osteoarthritis and better quality of life in patients with osteoarthri-
heart is believed as characteristic findings in Rheumatic Fever. Of
tis, suggesting possible role of oxidative stress in the pathogenesis of
which, valvular endocarditis is the more common, but this patient
osteoarthritis.
presented as rhythm disturbance.
Conclusion: Although complete AV block is rare, herein we report a
case of 3rd-­degree AV block as one of the cardiac findings in ARF.
1-­142 | Connective tissue diseases with rare
associations: nightmare for rheumatologists
V. Joshi
Deenanath Mangeshkar Hospital

Background : Management of connective tissue disorders (CTD)

like systemic lupus erythematosis (SLE) , scleroderma is always a
 |
104      
challenge for rheumatologists.There are varied multisystemic mani-
festations sometimes CTDs show rare associations with macrophage
activation syndrome (MAS) ,thrombotic thrombocytopenic purpura
(TTP) ,neuromyotonia and become a nightmare for management.
Objective: • To share experience of 3 cases, 2 of SLE, one
presented with TTP, 1 with MAS. 1 case of scleroderma presented
with neuromyotonia.
• To discuss management of the conditions.
Methods: CASE 1: 39 YR female known SLE on HCQS ,leflunomide
for her arthritis presented with generalised weakness, anemia and
jaundice, initially thought of leflunomide toxicity but after evaluation
turned out to have TTP. She underwent plasmapheresis and rituxi-
mab infusions and showed a significant recovery.
CASE 2: 26 year male known case of SLE presented with high grade
fever, cytopenia and splenomegaly. He was extensively worked up
for infections finally was diagnosed to have MAS secondary to SLE
and treated with high dose steroids and rituximab.He responded
dramatically. He remained in remission for 3 years however showed
a relapse and managed on same line.
Case 3: 44 year male diagnosed as systemic sclerosis presented
with severe backache and myalgia followed by spontaneous
persistent muscle twitching of calves, thighs and arms.He de-
veloped severe insomnia and restlessness. EMG confirmed it to
be neuromyotonia and he had voltage gated potassium channel
(VGKC) antibodies. He responded well to plasma exchanges and
immunosuppression.
Results and conclusions: The literature shows few case reports and
series sharing CTDs with those rare associations.Although aetiolo-
gies are elusive certain autoimmune mechanisms may be shared and
provide basis for their associations.
Timely diagnosis and aggressive treatment are needed as they can
be life threatening.
Keywords: SLE,TTP,MAS,neuromyotonia,scleroderma
1-­086 | Dry eye in Indian rheumatoid arthritis
patients and association of dry eye with disease
activity
V. Joshi
Deenanath Mangeshkar Hospital
Background: Rheumatoid arthritis (RA) has articular as well as extra-­
articular manifestations. From rheumatologist perspective, extra-­
articular features warrant early detection and monitoring. Ocular
involvement, dry eye (DE) is reported very often.
Objective: To study prevalence of DE and its association with RA
disease activity variables.
Method: A cross-­sectional study was conducted in a cohort of 100
RA patients at tertiary care hospital in Pune. Detailed standard of
care rheumatology evaluation and ophthalmic examination were
done for all patients. McMonnies dry eye questionnaire (MDQ),
Schirmer (Sch) and tear breakup time (TBUT), slit lamp examination
using fluorescence stain were done to assess symptoms, tear secre-
tion and stability. Patents with MDQ >20 plus Sch <5 mm &/or TBUT
<10 seconds were defined as Dry Eye.
Results: There was female dominance (84%), median age 53.5 years
and mean disease duration 6.4 years. Seventeen patients showed
MDQ >20, 12 showed Sch <5 mm, 71 abnormal TBUT and 29 had
corneal abnormalities. Only 15% satisfied DE definition. 54 patients
were symptomatic for ocular symptoms; out of these 20 (37%) had
corneal abnormalities, 11 (20.4%) had positive Schirmer and 43
(79.6%) had abnormal TBUT and 14 (25.9%) had MDQ score ≥ 20.
There was a significant association of DE and RA disease duration,
DAS28 and HAQ. 66.7% patients with DE had disease duration
>5 years. The patients of DE showed significantly (P < 0.005) high
DAS 28 (>5.2) and moderate functional disability by HAQ (30–60)
than non DE patients. There was no statistical significant associa-
tion of DE with RF, Anti CCP, ANA positivity and pain VAS.
Conclusions: Dry eye symptoms should be asked to all RA patients.
All symptomatic patients and those with disease duration >5 years,
high DAS28, HAQ, ESR scores must be evaluated in detail for DE.
Keywords: Rheumatoid arthritis, Dry Eye, Ocular manifestation,
Keratoconjunctivitis sicca, Schirmer, Tear break-­up time, India
1-­072 | Systematic review of depression and
anxiety in psoriatic arthritis
N. Kamalaraj1,2; C. El-Haddad1,3; P. Hay1,3; K. Pile1,3
1
Campbelltown Hospital; 2University of Edinburgh; 3Western Sydney University
Background/purpose: Depression and anxiety are often comorbid
with rheumatic diseases. in psoriatic arthritis (PsA), the combination
of inflammatory arthritis and psoriasis may contribute to a greater bur-
den of depression and anxiety, however, the extent remains unclear.
Treatments for PsA may also benefit these psychiatric conditions.
Methods: We performed a systematic review examining point preva-
lence of depression and anxiety in PsA as well as putative reductions
in these comorbidities with PsA treatment. MEDLINE, EMBASE,
EBM Reviews and Cochrane, and PsycINFO were searched from
inception to October 2017. Quality of studies was assessed using
the Joanna Briggs Institute Checklist for Prevalence Studies. Study
and population characteristics were extracted and entered into an
electronic database for subsequent descriptive and meta-­analysis of
point prevalence.
Results: Three studies matched inclusion criteria with significant
statistical heterogeneity. The prevalence of depression ranged be-
tween 9–22% and anxiety between 15–30% in patients with PsA.
One study matched inclusion criteria for treatment effect analysis,
albeit with a high risk of bias, suggesting a benefit of etanercept
on prevalence of depression (9% vs 16%) and anxiety (14% vs 30%)
after 24 weeks of treatment. 
Conclusion: This is the first systematic review of point prevalence
of depression and anxiety in patients with psoriatic arthritis. There

is a moderate point prevalence of both depression and anxiety in
patients with psoriatic arthritis, which is similar or slightly higher
than the general population and comparable to that seen in other
rheumatic diseases. The effects of treatment for psoriatic arthritis
on comorbid depression and anxiety remain unclear.
1-­052 | Serum Interleukin 17 (Il-­17) levels
correlated with nuclear factor–kappa B
ligand (rankl) in patients with systemic lupus
erithematosus
G. Kambayana; Tonny; T. R. Putra; P. K. Kurniari
Rheumatology Division, The Faculty of Medicine Udayana Univercity
Background: Inflammation process involved in the pathogenesis of
SLE, affect the differentiation of osteoclast and osteoblast, and also
may lead to osteoporosis. Interleukin-­17 (IL-­17) is a pro-­inflammatory
mediator which produced due to systemic inflammatory process.
The increase of pro-­inflammatory cytokine resulted in impairment
of RANKL regulation.
Objective: Determine the correlation between serum IL-­17 concen-
tration with RANKL in patients with SLE.
Method: This was an observational analytical cross-­sectional study
conducted at outpatient clinic and inpatient ward of Internal Medicine
of Sanglah Hospital Denpasar, Bali, Indonesia from January to March
2018. Samples were female SLE patients with age more than 18 years,
not menopause and agree to participate. Patients with diabetes mel-
litus, malignancy, coronary heart disease, stage V chronic kidney dis-
ease with hemodialysis, obesity, infection, menopause and refuse to
participate were excluded. High sensitivity ELISA (Enzyme-­linked im-
munosorbent assay) performed to analyze serum IL-­17 levels. RANKL
measured with Human sRANKL (TOTAL) ELISA method.
Result: A total of 68 subjects were involved in this study with median
of age was 31.32 (17–54). The IL-­17 levels in all subjects was 0.435
(0.23–30.65). The result of multivariate analysis obtained serum IL-­
17 correlated with RANKL (B = 35,025, SE(B) = 13,385, P = 0.011).
Conclusion: There was correlation between serum IL-­17 with RANKL
in patients with SLE.
Keywords: SLE, inflammation, cytokine, IL-­17, RANKL
2-­082 | Assessment of disease-­specific
knowledge of patients with rheumatoid arthritis
A. K. M. Kamruzzaman; M. R. Choudhury; M. N. Islam;
A. Shahin; S. Ahmed; I. Sultan; M. Alam; T. Mahmood; S.
Yesmin; A. K. Azad; H. Masduul; S. A. Haq; N. Sazzad; I.
Ariful
Bangha Bandhu Sheik Mujib Medical University
Background: Rheumatoid arthritis (RA) is a chronic, painful, disa-
bling, systemic inflammatory disease. in order to achieve better
|
      105
management outcome, patient's knowledge about their disease is
important. This study was designed to assess the knowledge status
of rheumatoid arthritis (RA) patients with their disease.
Objectives: The purpose of the study was to estimate the knowl-
edge level of patients with rheumatoid arthritis (RA).
Methodology: A total of 168 RA patients were included in the study.
Study was done From March 2013 to September 2014, in outpa-
tients and inpatients department of rheumatology, Bangabandhu
Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh.
Bangla version of Patient knowledge questionnaire (PKQ) was used
to assess knowledge level of RA patients regarding their disease.
Descriptive statistics i.e. mean and standard deviation (SD) was
used where applicable. Correlation between patient knowledge
questionnaire (PKQ) score and clinical-­
demographic data were
compared using Pearson's correlation coefficient. Analysis of vari-
ance (ANOVA) test was used to test the significance difference
between demographical, clinical and socioeconomic variables. For
statistical analysis, SPSS statistics version 20 was used.
Result: The mean PKQ score was 9.84 from a possible maximum of 30,
scores ranging from 1.00 to 20. The mean time for answering the ques-
tionnaire was 24.33 minutes (15–34 minutes). The low score was ob-
served in all domains but lowest in etiology, and ways of joint protection
and energy conservation. Knowledge level was high who got education
regarding RA before enrollment. PKQ showed statistically significant
positive correlation with number of completed years of formal educa-
tion (r = 0.338); and negative correlation with HAQ (r = −0.146).
Conclusion: The knowledge of patients with rheumatoid arthritis
in Bangladesh about their disease was poor in all domains. These
results can be used for advancing RA patients education in future.
Keywords: rheumatoid arthritis, patient knowledge questionnaire,
health assessment questionnaire, education.
2-­106 | Clinical constellation of anti-­RNP
positive patients in Korea
M. I. Kang1; S. W. Lee2; S. H. Chang2
1
Dankook University College of Medicine; 2Soonchunhyang University, College
of Medicine
Backgrounds/Purpose: Anti-­R NP antibody is autoantibodies tar-
geting the U1 small nuclear riboncleoprotein particle. Although
high titers of anti-­R NP antibodies are associated with mixed con-
nective tissue disease overlap syndrome, the presence of anti-­
RNP antibodies with any titers is observed in patients with upto
30% of patients with SLE and upto 61% of SSc. in the majority of
cases, anti-­R NP positivity was analyzed in terms of SLE or SSc. The
aim of current study is to investigate initial clinical manifestations
of anti-­R NP positive patients and their association with particular
disease predisposition.
Methods: We reviewed medical records of patients visited at
Soonchunhyang University Cheonan Hospital and Dankook
University Hospital since April of 1990.
 |
106      
Results: A total of seventy-­three patients with anti-­RNP positive pa-
tients were identified (female n = 65, 89%). The most common initial
clinical symptoms were musculoskeletal symptoms including muscu-
loskeletal symptoms arthritis, arthralgia, myositis, myalgia, and puffy
hands (n = 29, 39.7%), followed by cytopenia including hemolytic
anemia, leucopenia and thrombocytopenia (n = 36, 49.3%), mucocu-
taneous symptoms including photosensitivity, malar rash (n = 29,
39.7%), Raynaud's phenomenon (RP, n = 24, 32.9%), renal involve-
ment (n = 12, 16.4%), serositis (n = 12, 16.4%), and enteritis (n = 3,
4.1%). Average 8.1 ± 7.1 years of follow-­up duration, 80.8% of pa-
tients were diagnosed SLE (n = 59), 9.6% of patients were diagnosed
SSc (n = 7), and 9.6% of patients were diagnosed MCTD (n = 7).
Patients who had RP at the beginning were significantly associated
with diagnosis of MCTD or SSc than SLE (P < 0.01, Risk ratio 13.0
95% confidential interval 3.1–53.5), while patients with cytopenia
at the beginning were significantly associated with diagnosis of SLE
than MCTD or SSC (P < 0.05, relative risk 4.7, 95% CI 1.2–18.4).
Conclusions: In patients with anti-­
RNP positive, patients with
Raynaud's phenomenon have increased risk of developing systemic
sclerosis even without SSc specific autoantibodies, while patients
with serositis, cytopenia, enteritis, or renal involvement have higher
probability to have SLE.
2-­083 | Extrapulmonary tuberculosis in two
rheumatoid arthritis cases during treat-­to-­target
therapy
H. Kataoka; M. Kondo; M. Mukai
Sapporo City General Hospital
Background: Biologic and JAK inhibitor use is a mainstay in treat-­
to-­t arget therapy for active rheumatoid arthritis (RA), but can be a
serious risk for mycobacterium tuberculosis (TB) infection.
Objectives: We thoroughly reviewed a clinical course of two RA pa-
tients who recently developed extrapulmonary TB.
Case presentation: Case 1: An 85 year-­old woman recently devel-
oped active RA and her family doctor gave her methotrexate (MTX)
and bucillamine, but her RA remained active. To know whether
anti-­TNF therapy was safely introduced, chest X-­ray and interferon
gamma release assay (IGRA) were done to exclude current TB in-
fection. As IGRA was positive but CXR showed only old organized
lesion, her family doctor judged to be able to rule out active TB, and
then anti-­TNF α therapy was introduced. One and a half year later,
her right forearm got swollen and was resistant to antibiotics. She
was referred to our hospital, and after admission, she developed
acute pneumonia and TB was found in her sputum specimen. Leaked
fluid from the opening of subcutaneous abscess was positive for TB.
Case 2: A 63 year-­old woman treated with MTX+JAK inhibitor found
a solid tumor in her right axilla. Her husband had lung TB history
and her IGRA test was positive before initiating target therapy. Her
family doctor consulted us about whether it was lymphoma. PET-­C T
scan revealed high FDG accumulation in the axillary lymph nodes
and it did not shrink much even after ceased MTX. Lymph node bi-
opsy showed cold abscess and its culture was positive for TB. She
also had uterine TB infection, but no lung lesion.
None of these two cases had been given isoniazid.
Conclusion: Extrapulmonary TB infection may develop if IGRA is
positive, suggesting that prophylactic anti-­TB drug should be recom-
mended even if old TB lesion is not found.
2-­107 | Scleroderma renal crisis: observations
from the South Australian Scleroderma Register
(SASR)
Y. Khadra; J. G. Walker; P. Roberts-Thomson
Flinders Medical Centre
Aim: To investigate epidemiological, serologic and clinical fea-
tures of all patients with scleroderma renal crisis (SRC) listed on
the population based SASR and to examine possible factors in
aetio-­pathogenesis.
Method: A case note review was performed on all SRC patients with
relevant data extracted to determine incidence, clinical phenotype,
presence of autoantibodies and survival. Possible precipitating and
aetio-­pathogenic factors were also examined. Data from the SASR
was sourced for comparative purposes.
Results: Over the 30 year period 1988–2018, 33 patients (24 fe-
males, 9 males) presented with SRC giving a South Australian state
adjusted incidence of 0.65/106/year. Thirty of these patients had
diffuse cutaneous scleroderma, one limited and two overlap scle-
roderma. The mean age at first symptom of scleroderma was
51.2 + 15.9 (mean + SD) with SRC occurring 3.2 + 4.9 years later
(range 0.1–20 years). Possible precipitating factors for SRC were
identified including high dose steroids in five patients. Twelve of the
patients had the autoantibody RNAP3, two with topoisomerase 1
and two with RNP. Renal outcome was poor with 13 patients re-
quiring renal replacement therapy (RRT) and two proceeding to renal
transplantation. The mean age at death was 61.2 + 11.6 years with
SRC patient survival being significantly shorter than patients with
diffuse scleroderma without renal involvement. (P = 0.002). There
was no significant difference in survival between the 1988–2002
and the 2002–2018 SRC cohorts (P = 0.2). Nailfold capillaroscopy
(NFC) performed in 10 patients revealed extensive microvascular
damage with prominent capillary drop out.
Conclusion: SRC is a rare occurrence but continues to have a se-
vere adverse outcome with frequent requirement for RRT and poor
survival. NFC revealed evidence of extensive capillary damage. No
improvement in survival was observed over the study period.
 |
      107

2-­108 | A rare case of adult onset stills disease Methods: All consecutive outpatients with Rheumatoid arthritis
requiring disease modifying anti rheumatic drugs (DMARDs) for
with dermatomyositis: a diagnostic challenge
at least 2 years were included in this cross-­s ectional study. The
S. Shaikh; S. Arain; A. Dahani; F. Khan; S. Mumtaz primary end point was to assess the frequency of remission.
Jinnah Postgraduate Medical Centre
Secondary end points were to compare the disease activity score
(DAS 28) with functional ability (clinical HAQ), ACR 20, 50 &70
Adult Still's disease (ASD) is a rare inflammatory disorder character- response rates.
ized by quotidian (daily) fevers, arthritis, and an evanescent rash. Results: A total of 300 patients were enrolled. Data analysis showed
First described in children by George Still in 1896, “Still's disease” that n = 162/300 (54%) of patients had consulted a rheumatolo-
has become the eponymous term for systemic juvenile idiopathic gist after 2 years of onset of symptoms. Majority of patients were
arthritis. Whereas Dermatomyositis (DM) is idiopathic inflammatory treated with conventional DMARD with only 15/300 patients re-
myopathies, characterized by the proximal skeletal muscle weakness ceiving biological DMARDs (Rituximab).
and by evidence of muscle is associated with a variety of charac- Remission was observed in n = 38 /300 (12.7%) patients out of
teristic skin manifestations. A form of DM termed amyopathic is a which n = 9 (60%) received Rituximab. Moderate disease was found
condition in which patients have characteristic skin findings of DM in n = 142/300 (47.3%) while n = 102/300 (34%) were having severe
without weakness or abnormal muscle enzymes. disease.
Many autoimmune diseases are associated with each other. A
Number of Disease activity DAS ACR
literature review showed only 3 cases of polymyositis with ASOD. patients 28 HAQ response
But no case has been reported on the simultaneous presentation of
56 Remission + low (<3.2) <0.5 70
ASOD with DM.
142 Moderate (3.2–5.1) 0.5–1.5 50
We report a case of 19 year old female presented in February
102 Severe (>5.1) >1.5 20
2015 in Rheumatology clinic, Jinnah Post Graduate Medical Centre,
Karachi, Pakistan with two year symptoms of fever on/off high Conclusion: Majority of patients were having moderate to severe

grade, salmon color , maculopapular rashes which started from fin- disease with a high DAS 28 score, clinical HAQ score had ACR 20 re-

ger webs-­followed by bilateral arms – trunk and then to legs. Her sponse despite on maximal DMARDs. Remission was achieved more

face was spared. Along with multiple joint pain including small and frequently with the use of biological DMARDs. Timely consultation

large joint with knee joint swelling. Patient was noticed to have he- with a rheumatologist and frequent use of biological DMARDs can

liotrope rash increase pigmentation on neck and trunk. Her workup result in more patients achieving remission and having a better func-

showed increase ESR and CRP with leukocytosis and markedly raised tional outcome.

Ferritin level of 56,600 ng/mL. with negative dengue serology, ma-

larial Parasite, Blood C/S, ANA, Anti DS DNA, ENA Profile and nega-
tive Rheumatoid Factor. Patient was fulfilling the Yamaguchi Criteria. 2-­146 | Subcutaneous tocilizumab in refractory
And she was started on steroids. But again after one year patient had giant cell arteritis: a case report
similar complain as she stopped medication. That time she had proxi-
H. Khan; N. M. Ahmed; S. Batool; S. F. Raja
mal muscle weakness and skin Rash. Her CPK levels were normal and
Rheumatology Department Fatima Memorial Hospital
again serum Ferritin was markedly raised 6015.23 ng/mL (10–150).
Her Skin biopsy showed Perivascular inflammatory infiltrate repre-
Introduction: Giant cell arteritis (GCA) is a form of vasculitis affect-
senting dermatomyositis. Patient was again started on steroids and
ing medium to large-­size arteries, characterized by granulomatous
methotrexate and was improved clinically. Treatment with metho-
inflammation in the wall of the arteries. It presents with constitu-
trexate resulting in improvement in both ASOD and Dermatomyositis.
tional symptoms, headache, visual symptoms and jaw claudication.
A high index of suspicion is needed in order to diagnose such a rare
Glucocorticoids remain the mainstay of treatment. Various data
association which has relevant prognostic and therapeutic implications. 
about the role of Tocilizumab (TCZ), an interleukin 6 receptor anti-
Keywords: adult onset stills disease, dermatomyositis
body, in the treatment of giant cell arteritis has been published. We
report a case of a patient 60 year-­old woman with GCA treated with
tocilizumab a humanized anti interleukin-­6 receptor antagonist.
1-­092 | Remission rate in Pakistani rheumatoid Case presentation: A 60-­year-­old woman presented with complaints
patients: where do we stand? of sudden pain in the shoulders, headache accompanied by fever
H. Khan and malaise and loss of vision. Initial laboratory findings showed

Rheumatology Department Fatima Memorial Hospital increased

C-­
reactive protein level at 72 
mg/dL (<5), ESR 121 
mm/h,

Objective: To evaluate the frequency of clinical remission in patients Haemoglobin of 9.2 g/dL. Glucocorticoids were started. Her tem-

with Rheumatoid arthritis. poral artery biopsy showed granulomatous inflammation with giant
 |
108      
cells. Patient was steroid dependent on prednisone 20 mg/d, symp-
tomatic having raised ESR and CRP despite maximal dosage of meth-
otrexate. Tocilizumab (TCZ) 162 mg subcutaneously every 2 weeks
was started. After 3 doses, serum CRP lowered to 0.1 mg/L, haemo-
globin levels raise to 12 g/dL and her symptoms resolved.
Discussion: Gold standard for diagnosis of GCA is temporal ar-
tery biopsy. Our patient fulfilled the criteria of Giant cell arteri-
tis, with a biopsy proven diagnosis. Response to treatment with
Glucocorticoids was quick in our patient and complications included
diabetes mellitus and cataract formation. Interleukin-­6 (IL-­6) has a
well-­documented role in inflammation and is raised in patients with
GCA. Hence Tocilizumab, can be used in refractory GCA.
Conclusion : Glucocorticoids are the drug of choice in GCA but
are associated with long term side effects. Patients who are unre-
sponsive to conventional immunosuppressive or require high dose
(>10 mg per day) of prednisone should be treated with newer agents
such as tocilizumab.
2-­147 | Utilizing combined pulsed dye and
Nd:YAG laser in the treatment of connective
tissue diseases: case series
H. Kim; J.-S. Park; H. Kim
Soonchunhyang University Seoul Hospital
A variety of connective tissue disease (CTD), including dermato-
myositis (DM), discoid lupus erytheromatosus (DLE), and systemic
sclerosis (SSc), are commonly associated with skin manifestations,
which are refractory to topical and systemic treatments. These skin
lesions from CTD are often a major source of psychological distress,
disfigurement and body image dissatisfaction, even after disease re-
mission (1). DM is an inflammatory myopathy with specific rashes
that include a symmetric violaceous macular erythema progressing
to poikiloderma and induration (2). DLE is characterized initially by
erythematous, indurated plaques with adherent scale that progress
to peripheral hyperpigmentation, central hypopigmentation, and
atrophic scar (3). Skin involvement is a nearly universal feature of
SSc that is characterized by proximal skin thickening, and Raynaud's
phenomenon. in patients with limited cutaneous SSc, telangiecta-
sias on the face are also appeared (4). Currently laser therapies have
been shown to provide symptom improvement in patients with vari-
ous skin lesions. Therefore, our case series estimate the efficacy of
combined pulsed dye laser (PDL) and neodymium-­doped yttrium
aluminum garnet (Nd:YAG) laser in the treatment for CTD. The com-
bined PDL and Nd:YAG laser device used was a Cynergy (Cynosure
Inc., Westford, MA).
Case 1: A 60-­
year-­
old female diagnosed with DM before
20 years was referred with skin rash on her forehead, both cheeks
and nose (Fig. 1-­A ,B). Muscle function and disease activity were
well-­controlled with medication, but her cutaneous symptoms per-
sisted with fixed redness. As the penetration of PDL is low, we added
Nd:YAG laser in association with the PDL to treat both the deep and
superficial capillary networks of the skin lesions (5). After five ses-
sions of treatments, the generalized erythematous scaled patches
were nearly disappeared and no recurrence with concomitant dis-
ease controlling medication (Fig.1-­C ,D).
Case 2: A 35-­year-­old female diagnosed with DLE before 7 years
was referred with a 5-­year history of an erythematous skin lesion
and circularly contracted scars on the face (Fig. 2-­A ,B). The patient
received five sessions of the PDL combined Nd:YAG treatment to
the DLE lesions of the face at 4-­week intervals. The depressed round
patch ear before occurred 7 years ago were partially response but
remain. However, 3 cm sized annular patches occurred 1 year ago
were nearly disappeared. (Fig. 2-­C ,D).
Case 3: A 40-­year-­old male diagnosed with SSc before 3 years
was referred with diffuse telangiectasias on the face (Fig. 3-­A ,B).
During the first 2 treatment sessions of the PDL combined Nd:YAG
laser, telangiectasias on the left cheek was improved but recurred
after repeated laser therapy (Fig. 3-­C ,D). He was under immunesup-
pressant therapy for the reason of progrressive skin hardening and
delayed bowel transit time.
 |
      109

Table 1. Summary of basic demographics and treatment course

1 2 3

Diagnosis Dermatomyositis Discoid lupus erythematosus Systemic sclerosis

Sex/Age F/60 F/35 M/40
Disease duration (year) 20 7 3
General treatment None Hydroxychloroquine 200 mg After cyclophosphamide pulse therapy
(total dose 5250 mg), he had the
medication of MMF 1500 mg/d
Laser therapy
 Location Face Face Face
 Times (n) 5 5 5
 Inverval (w) 4 4
 Wavelength, PDL/Nd:YAG (nm) 585/1064 585/1064 585/1064
 Energy, PDL/Nd:YAG (J/cm2) 7–8/40 7–8/40 7–8/40
 Pulse duration, PDL/Nd:YAG (ms) 6/40 6/40 6/40
 Spot size, PDL/Nd:YAG (mm) 7/7 7/7 7/7
 Additional therapy Tacrolimusoint 0.3% Elidel cream 1% None
 Response Patches were nearly plaques on the cheek had completely Partially response but remain
disappeared resolved, the other lesion also improved

Clinically, the PDL has been used for the treatment of vascular
lesions such as hemangiomas, nevus flammeus, and other vascular
proliferations. The PDL can target blood vessels because the wave-
length corresponds to the absorption spectrum of hemoglobin and
penetrates to the level of the dermis, while the pulse duration can
be set to be shorter than the thermal relaxation time of a small cu-
taneous blood vessel (6). Also, it can be used to target the vessels in
cutaneous inflammatory diseases that has characteristic of vascular
dilation and/or perivascular inflammation as a prominent feature (7).
The PDL also showed superior clearance for facial vessels compared
with other lasers (8). The Nd:YAG laser emits light in the 1064 nm
wavelength (near-­infrared range), which is only moderately absorbed
by melanin. The Nd:YAG laser allows for treatment of a broad range
of vessel diameters in most skin types. Combined PDL and Nd:YAG
laser is an effective means of reducing vascular inflammation (7, 9).
There was separate reports that showed good efficacy of the PDL in
telangiectasias, poikiloderma, or Gottron's papules (4, 10). Another
report presented the improvement in recalcitrant lesions like ery-
thema and scaling in DLE, after treatment with PDL. However, it
showed little effect in the scarring, dyspigmentated and longstand-
ing atrophis lesion, which suggests that early intervention may be
optimal to protect from these sequelae (7). Telangiectasis, clinical
marker of microvascular features in SSc, is dilated small blood ves-
sels near the surface of the skin. According to previous studies, PDL
is also effective in treatment of telangiectasia (4, 10). However, the
formation of new telangiectasias is to be predicted, when the pa-
tient's underlying condition is not well controlled. Therefore, clini-
cians should expect the treatment of telangiectasias related to these
CTD to involve recalcitrance and recurrence (10).
Further clinical studies are needed to optimize the treatment
protocol for single sessions for both PDL and Nd:YAG lasers in
patients with CTD. With more optimal parameters it would be pos-
sible that higher rates of clearance can be achieved. Furthermore,
combination of laser treatment with accepted topical therapies may
offer higher cure rates (9).
Keywords: pulsed dye laser, Nd:YAG laser, dermatomyositis, discoid
lupus erythematosus, systemic sclerosis
References: 1. Ennis H, Herrick AL, Cassidy C, Griffiths CE, Richards
HL. A pilot study of body image dissatisfaction and the psychologi-
cal impact of systemic sclerosis-­related telangiectases. Clinical and
Experimental Rheumatology. 2013;31(2 Suppl 76):12–7.
2. Callen JP. Cutaneous manifestations of dermatomyositis and their
management. Current Rheumatology Reports. 2010;12(3):192–7.
3. Kuhn A, Sticherling M, Bonsmann G. Clinical manifestations of cuta-
neous lupus erythematosus. Journal der Deutschen Dermatologischen
Gesellschaft = Journal of the German Society of Dermatology: JDDG.
2007;5(12):1124–37.
4. Black CM. Scleroderma-­
-­
clinical aspects. Journal of Internal
Medicine. 1993;234(2):115–8.
5. Chen JK, Ghasri P, Aguilar G, van Drooge AM, Wolkerstorfer A,
Kelly KM, et al. An overview of clinical and experimental treatment
modalities for port wine stains. Journal of the American Academy of
Dermatology. 2012;67(2):289–304.
6. Anderson RR, Parrish JA. Microvasculature can be selectively
damaged using dye lasers: a basic theory and experimental evidence
in human skin. Lasers in Surgery and Medicine. 1981;1(3):263–76.
7. Han G. Applications of lasers in medical dermatology. Cutis.
2014;94(5):E20–3.
8. West TB, Alster TS. Comparison of the long-­pulse dye (590–
595 nm) and KTP (532 nm) lasers in the treatment of facial and leg
telangiectasias. Dermatologic Surgery: Official Publication for American
Society for Dermatologic Surgery [et al]. 1998;24(2):221–6.
 |
110      
9. Jalian HR, Avram MM, Stankiewicz KJ, Shofner JD, Tannous Z. Combined
585 nm pulsed-­dye and 1064 nm Nd:YAG lasers for the treatment of
basal cell carcinoma. Lasers in Surgery and Medicine. 2014;46(1):1–7.
10. Brauer JA, Gordon Spratt EA, Geronemus RG. Laser therapy in
the treatment of connective tissue diseases: a review. Dermatologic
Surgery: Official Publication for American Society for Dermatologic
Surgery [et al]. 2014;40(1):1–13.
Figure 1
(A) Before laser therapy, it showed the generalized erythem-
atous scaled patches on the whole face in patient with DM. (B) It
showed an erythematous skin lesion and circularly contracted scars
on the face in patient with DLE. (C) It showed the hypopigmented
persistent telangiectasia around the left cheek in patent with SSc.
(D) After 5 sessions of the initial PDL combined Nd:YAG laser treat-
ment, it showed the improvement of the skin lesions can be seen as
complete remission. (E) After 5 sessions of laser treatments, the de-
pressed round patch near the ear, that occurred 7 years before, was
partially improved but remain (arrows). However, 3 cm sized annular
patch that occurred 1 year before were nearly disappeared. (F) After
laser treatments, telangiectasias on the left cheek was remain and
rash was recurred.
2-­084 | Interleukin-­6 receptor inhibition and
tumor necrosis factor-­alpha inhibition therapies
increased the body weight of patients with
rheumatoid arthritis
I. A. Choi1; J. H. Kim1; S. Akira2; E. Y. Lee3; E. B. Lee3; Y. W.
Song3
1
Division of Rheumatology, Department of Internal Medicine, Chungbuk
National University Hospital; 2Sagawa Akira Rheumatology Clinic; 3Division of
Rheumatology, Department of Internal Medicine, Seoul National University Hospital
Background/purpose: We sought to investigate the effects of bio-
logic therapies on body weight and profiles of serum leptin, resistin,
and adiponectin in patients with rheumatoid arthritis (RA).
Methods: the study population consisted of three groups:
infliximab-­treated RA (n = 66), tocilizumab-­treated RA (n = 130), and
methotrexate-­treated RA (n = 51).
Results: Baseline leptin showed a positive correlation with base-
line body mass index (BMI) in all three groups: tocilizumab-­treated
RA (r = 0.442, P = 0.004), infliximab-­R A (r = 0.643, P < 0.001), and
methotrexate-­treated RA (r = 0.507, P < 0.001). Baseline adiponec-
tin showed negative correlation with baseline BMI in the infliximab-­
treated RA (r = −0.349, P = 0.004).
In the tocilizumab-­treated RA group, mean body weight increased
from 55.1 (±9.4) kg at baseline to 55.6 (±9.3) kg at 24 weeks (20.8 g/
wk, P = 0.032). Among the patients, 41 were available for additional
cytokine analysis. Serum IL-­
6 decreased significantly (P = 0.004),
while serum adiponectin (P < 0.001), leptin (P < 0.001), and resistin
(P = 0.003) increased significantly in this group. in the infliximab-­treated
RA patients, mean (±SD) body weight increased from of 71.81 (±16.51)
kg at baseline to 72.69 (±15.91) kg at 30 weeks (29.3 g/wk, P = 0.025
by Wilcoxon signed rank test, but serum adiponectin (P = 0.478), leptin
(P = 0.478), and resistin (P = 0.930) did not significantly change.
In the other hand, mean body weight did not significantly decrease in the
methotrexate-­treated RA group: 57.8 (±9.9) kg at baseline to 57.7 (±10.2)
kg at 24 weeks (−4.2 g/wk, P = 0.755). Although serum IL-­6 decreased
significantly (P = 0.002), adiponectin (P = 0.081), leptin (P = 0.682), and
resistin (P = 0.070) did not. Baseline BMI or EULAR response in RA did
not affect the tendency of weight change in any of the groups.
Conclusion: IL-­6 receptor inhibition and TNF-­alpha inhibition ther-
apies increased the body weight of patients with RA. Weight gain
seems to be independently of baseline BMI and serum leptin, resistin
and adiponectin.
2-­069 | Predictive factors of increased vascular
stiffness in patients with gout and hyperuricemia
J. Kim1; J. H. Choi1; W. S. Jeong1; C. Choi2
1
Department of Internal Medicine, Jeju National University Hospital; 2Jeju
National University School of Medicine
Background: Gout is the most common form of inflammatory ar-
thritis and its prevalence is increasing in more affluent countries
in recent decades. Many studies have reported that gout and hy-
peruricemia are associated with an increase in all-­cause mortality
and cardiovascular mortality. Increased arterial stiffness is an inde-
pendent marker of cardiovascular diseases and risk predictors. Many
studies have shown a significant correlation between uric acid levels
and arterial stiffness. Augmentation Index (AI) is an indirect measure
of arterial stiffness.
Objectives: The aim of this study is to evaluate the predictors of
increased arterial stiffness in gout and hyperuricemia patients.
Methods: Between June 2017 and October 2018, AI was measured
using SphygmoCor for patients who visited Jeju National University
Hospital in South Korea with gout or hyperuricemia. Medical re-
cords, laboratory and AI data were retrospectively analyzed and
multivariate analysis was performed.
Results: One hundred twenty two patients participated in the study
and AI was measured. Most (96.7%) of the patients were male. at the

time of the examination, 99 patients (81.1%) were treated with uric acid
lowering agent and the mean duration of the disease was 6.9 years.
When the patients were divided into two groups according to the pres-
ence or absence of Tophi, the average age (60.2 ± 11.6 vs 53.4 ± 13.2,
P = 0.023) of the patients with Tophi was significantly higher, dura-
tion of disease (13.0 ± 6.5 vs 5.4 ± 5.4, P = 0.000) was longer and the
AI (28.7 ± 7.8 vs 20.7 ± 10.4, P = 0.001) was higher. When univariate
regression analysis was performed, tophi was able to predict high AI
(b = 7.99, 95% CI 3.50–12.49, P = 0.001). Tophi was a predictor of high
AI when multivariate regression analysis was performed to exclude the
effects of DM, HTN, hyperlipidemia, age, BMI, total cholesterol, and
creatinine. (b = 6.10, 95% CI 0.43–11.79, P = 0.035)
Conclusions: This study suggests that the presence of tophi is an
independent predictor of increased arterial stiffness in patients with
gout and hyperuricemia.
1-­064 | Long term safety and efficacy of
etanercept in juvenile idiopathic arthritis: a
single-­center experience in Korea
K. N. Kim
Hallym University Sacred Heart Hospital
Background: Etanercept is a fully human, soluble, TNF inhibitor
that binds soluble TNF, which prevents it from interacting with cell-­
surface TNF receptors, thereby blocking the physiologic effects that
lead to inflammation and joint damage in JRA. For treating JIA were
dramatically improved by the introduction of etanercept, a biologic
response modifier recently.
Objectives: To investigate the long term safety and efficacy of
etanercept in children with JIA.
Method and materials: Total 90 JIA patients were given Etanercept
between Janunary 2004 through December 2017.
Characteristics of patients: Male: Female = 38:52.
Age at start of etanercept was 9 years of age (3–18).
sJIA 15, Extended oligo JIA 41. RF(+) poly JIA 14, RF(-­) poly JIA 18
and ERA 2. Patients.
The duration of etanercept was 6 years (0.5–13 years).
Results: The number of active joint decreased after 3 month of
etanercept. ESR decreased after 3 month. CRP decreased after
3 month, remained elevated until 1 year. Highest discontinuation
rates were observed in systemic onset JIA, compared to other sub-
types. After 5 years of etanercept treatment, 27% of systemic JIA
patients have discontinued, while 11% of extended oligoarticular
and 7% of rheumatoid factor negative subtype patients have discon-
tinued. After 10 years, 39% of systemic JIA patients have discontin-
ued, while 16% of extended oligoarticular and 20% of rheumatoid
factor negative subtype patients have discontinued.
Adverse event: The non-­serious adverse events were 8 cases and
the serious adverse events were 6 cases. The SAE were 5 case of
uveitis and 1 case of recurrent cellulitis. There were no TB and no
malignancy.
|
      111
Conclusion: Highest discontinuation rates were observed in sys-
temic arthritis. And Etanercept has safety and efficacy for JIA pa-
tients. This is the first report of long term safety and efficacy in
Korea.
2-­014 | Mitochondrial reactive oxygen
species induced by NADPH oxidase 2 deficiency
enhances Th1/Th17 immune responses through
SHP1/JAK/STAT signaling
M. Kim1; G.-T. Kim2; S.-I. Lee1; S.-H. Lee3; Y.-H. Cheon1
1
Gyeongsang National University Hospital; 2Kosin University College of
Medicine; 3Korea Advanced Institute of Science and Technology (KAIST)
Nicotinamide adenine dinucleotide phosphate (NADPH) oxidase is
a professional reactive oxygen species (ROS) generating enzyme.
NADPH oxidase 2 (Nox2) initially identified in phagocytes is re-
sponsible for the production of ROS that kills engulfed pathogens.
Chronic granulomatous disease (CGD) is a rare hereditary disorder
caused by mutations in a component of NADPH complex.
Therefore, CGD patients are prone to be severely susceptible to
life-­threatening infections from bacteria and fungi. However, para-
doxically, CGD patients also suffer from autoimmune diseases caused
by excessive immune reactions. Despite the co-­existence of these
contradictory symptoms, the molecular mechanisms are still un-
clear and controversial. in this study, we uncovered Nox2 deficiency
in T cells promotes in vitro T cell proliferation and type 1 help T cell
(Th1) and Th17 cell-­mediated immune responses in a T cell-­intrinsic
manner. Furthermore, using Th1 and Th17-­mediated disease model,
collagen-­induced arthritis (CIA) and experimental autoimmune en-
cephalomyelitis (EAE), we clarified Nox2 deficiency enhances Th1/
Th17-­mediated inflammation through augmented mitochondrial reac-
tive oxygen species (ROS). These are due to increased mitochondrial
respiration capacity and mitochondrial biogenesis induced by lack of
Nox2. We revealed increased mitochondrial ROS diminishes tyrosine
phosphatase SHP-­1 activity and this attenuated SHP1 activity by
mitochondrial ROS promotes Th1/Th17 immune responses through
JAK/STAT signaling. Collectively, we show enhanced T cell prolifera-
tion and Th1/Th17 differentiation in Nox2 deficient CD4+ T cells via
regulation of mitochondrial ROS and exaggerated EAE phenotypes
through increased Th1/Th17-­mediated inflammation. Therefore, our
data indicate mitochondrial ROS-­induced by a Nox2 deficiency in T
cells is crucial for the Th1/Th17 inflammatory program.
Keywords: NADPH oxidase 2, autoimmune disease, Th1/Th17,
Mitochondrial ROS, SHP-­1
 |
112      
2-­015 | Synovial fluid proteomics in
inflammatory arthritides
S.-H. Kim1; C. Son1; H.-J. Jeong1; J.-N. Chae1; J.-M. Kim1; W.-
K. Baek 2; T.-H. Kim3; J.-S. Kim4
1
Division of Rheumatology, Department of Internal Medicine, Keimyung
University Dongsan Medical Center; 2Department of Microbiology, School
of Medicine, Keimyung University; 3Department of Rheumatology, Hanyang
University Hospital for Rheumatic Diseases; 4Center for RNA Research, Institute
of Basic Science
Background/purpose: The synovial fluid (SF) is a lubricant, composed
of hyaluronic acid, inflammatory cells and proteins released from
synovial fibroblasts, synovial membrane and inflammatory cells. The
purpose of this study was to identify those proteins relatively more
abundant in the SF of patients suffering from rheumatoid arthritis
(RA), gout, ankylosing spondylitis (AS) and osteoarthritis (OA) using
mass spectrometry.
Methods: Approximately 2 mL of the synovial fluid samples were
aspirated from the affected knees of 10 RA, 10 gout, 10 AS and 10
OA patients. We identified differentially expressed protein (DEP) in
SFs of various arthritides using LC-­MS/MS, and analyzed molecular
component and biological process.
Results: We have identified 984 proteins out of which 139 pro-
teins were found to be differentially expressed by ≥2-­fold in the
SF of RA, 134 proteins were found to be differentially expressed
by ≥2-­fold in the SF of gout, 23 proteins were found to be dif-
ferentially expressed by ≥2-­fold in the SF of OA, and 19 proteins
were found to be differentially expressed by ≥2-­fold in the SF of
AS. Up-­regulated DEPs in AS compared with other three arthriti-
des were HP, MMP1, MMP3, APCS, CFHR5, FAH, C9, C4A, and
MBL2.
Conclusion: Mass spectroscopy based proteomics could identify
many proteins in synovial fluid of various inflammatory arthritides.
Further investigations are needed to replicate these DEPs in western
blot analysis or enzyme-­linked immunosorbent assay.
2-­070 | Association between smoking and
serum uric acid in Korean population: data from
Korea National Health and Nutrition Examination
Survey 2016
S. Kim; J.-Y. Choe
Catholic University of Daegu
Objective: The aim of this study was to identify any association be-
tween serum uric acid and smoking status using data from the Korea
National Health and Nutrition Examination Survey (KNHANES VII-­1)
2016 of the Korean population.
Methods: This study used a cross-­
sectional design and analyzed
5609 subjects aged ≥19 years among 8150 participants enrolled in
the KNHANES VII-­1 2016. Smoking status was classified into current
smokers, never smokers, and ex-­smokers. Serum uric acid was assessed
by uricase calorimetry. Multivariate regression analysis was performed
to identify the association between smoking and serum uric acid.
Results: A significant difference in serum uric acid according to smok-
ing status was identified. The mean serum uric acid level was 5.70 (SE
0.05) for current smokers, 5.56 (SE 0.04) for ex-­smokers, and 5.56 (SE
0.04) for never smokers (P < 0.001). Serum uric acid in female subjects
was markedly different according to smoking status (P < 0.001), but a
significant difference was not identified in male subjects (P = 0.069).
In multivariate regression analysis, serum uric acid level in ex-­smoker
demonstrated a significant association (odds ratio 0.414, 95% confi-
dence interval 0.076–0.753, P = 0.017), but current smoker level did
not (P = 0.512). Neither ex-­smoker nor current smoker status was as-
sociated with serum uric acid in male subjects.
Conclusion: This study revealed that serum uric acid had a weak as-
sociation with only ex-­smoking status in female but not in male sub-
jects in Korean population.
Keywords: uric acid, smoking, female, male, epidemiology
2-­121 | Mortality in autoimmune rheumatic
diseases with anti-­Ro/SSA antibody in Korea:
single center-­based retrospective study
S. Kim; J.-Y. Choe
Catholic University of Daegu
Aim: The clinical importance of the anti-­Ro antibody has not been
completely understood. This study investigated to identify the asso-
ciation between mortality and clinical features in patients with auto-
immune rheumatic diseases and detectable anti-­Ro antibody titers.
Methods: We retrospectively analyzed a total of 336 patients with
autoimmune rheumatic diseases and positive anti-­Ro antibody titers
from January 2012 to January 2015. Clinical manifestations and
other autoantibodies detected during the follow-­up period were
identified. Cumulative survival rates were assessed by Kaplan-­Meier
analysis. Differences between survival curves for each risk factor
were analyzed by log-­rank test. The relative risk of mortality was
assessed using standardized mortality ratios (SMRs).
Results: There was no difference in the mortality rates of patients
with autoimmune rheumatic diseases with or without detectable
anti-­Ro antibody (SMR 1.373, 95% CI 0.539–2.791). Six patients (four
with systemic lupus erythematosus [SLE] and two with Sjögren's
syndrome [SS]) died during the follow-­up period. In the whole study
population, the mortality rate of patients with lymphopenia was
higher than those without lymphopenia (P = 0.023). In a sub-­group
of patients with both SLE and SS, Kaplan-­Meier analysis showed that
lymphopenia and interstitial lung disease were associated with in-
creased mortality (P = 0.024 and P = 0.023, respectively).
Conclusion: This study demonstrated that presence of the anti-­Ro
antibody was not associated with increased mortality in patients
with autoimmune rheumatic disease. Conversely, we found that lym-
phopenia was independently associated with mortality in patients
with autoimmune rheumatic disease.
 |
      113

1-­039 | Impact of FRAX-­based osteoporosis we assayed for candidate circulating miRs using qPCR in samples
from the patients with AS (n = 65), RA (n = 25), and healthy controls
treatment in patients with osteoarthritis
(n = 31). All clinical values were also evaluated at the time of RNA
S.-S. Kim1; B. Y. Kim1; S.-H. Lee2; S.-J. Hong3 isolation.
1
Ulsan University College of Medicine; 2School of Medicine, Konkuk University;
3
Results: A total of 887 miRNAs were screened. After normaliza-
School of Medicine, Kyung Hee University
tion of the raw data, we noted that the expression copy number of
serum miR-­214 were significantly lower than HC and RA. Correlation
Background: Osteoarthritis (OA) is often associated with increased
studies showed that copy numbers of miR-­214 was significantly as-
bone mineral density (BMD). However, the increase in BMD does
sociated with ASDAS_CRP (r = 0.299, P = 0.02). However, all others
not indicate a reduction in fracture risk.
variables were no statistical significance [gender (P = 0.286), periph-
Objective: The purpose of this study was to evaluate the clinical
eral arthritis (P = 0.634), enthesitis (P = 0.464), dacylitis (P = 0.750),
impact on osteoporosis treatment decisions in patients with OA
psoriasis (P = 0.552), inflammatory bowel disease (P = 0.369), family
through FRAX criteria.
history (P = 0.235), HLA-­B27 presence (P = 0.473), NSAIDs use for
Methods: 239 subjects who visited 5 medical centers for knee pain
last 3 month (P = 0.448), use of TNF-­blocker (P = 0.505).
and met the American College of Rheumatology criteria for symp-
Conclusion: miR-­214 may serve as noninvasive biomarkers for diag-
tomatic OA of the knee were evaluated. After matching for age, sex
nosis of AS. in addition, the expression level of miR-­214 was associ-
and body mass index, 478 subjects (239 subjects in OA group and
ated with the disease activity.
239 subjects in control group) included for this study.
Results: Mean FRAX major osteoporotic fracture probabilities cal-
culated without femur neck BMD were significant different be-
tween OA group and control group (7.96% vs 6.83%, P < 0.0001).
Mean FRAX hip fracture probabilities calculated without femur neck
BMD were also significant different between OA group and control
group (2.97% vs 2.35%, P < 0.0001). The FRAX calculator uses data
for clinical risk factors to estimate fracture probabilities. Among the
clinical risk factors of FRAX, previous fracture was significant differ-
ent between OA group and control group (15.9% vs 0%, P < 0.001).
From calculations of FRAX, 99 (41.6%) subjects in OA group would
receive recommendations for osteoporosis treatment, compared
with 85 (35.71%) subjects in control group (P = 0.008). However,
osteoporosis according to WHO criteria was detected 96 (40.17%)
subjects in OA group, and 87 (36.4%) subjects in control group; these
2-­085 | Audit of antihypertensive and
difference were not significant.
Conclusion: Patients with OA had increased fracture probabilities
cholesterol lowering therapy usage in patients
from calculations of FRAX. The use of FRAX may support clinical with inflammatory arthritis attending an
decision for osteoporosis treatment in patients with osteoarthritis. inflammatory arthritis clinic
R. Kirupananther; H. Keen
University of Western Australia
2-­116 | Serum miR-­214 as a noninvasive
biomarker for ankylosing spondylitis Background/purpose: Rheumatoid arthritis is associated with an
M. S. S.-H. Jin; M. S. H. Kook; M. S. P.-R. Park; S.-J. Lee; J.-H. increased risk of cardiovascular morbidity and mortality. Most
Kang; D.-J. Park; Y.-W. Park; S.-S. Lee; T.-J. Kim guidelines recommend management of cardiovascular risk factors,
Chonnam National University Medical School and Hospital including consideration of antihypertensive and cholesterol lower-
ing therapy, in patients with inflammatory arthritis.
Introduction: Recently, the discovery of miRNAs (miR) has paved a Objectives: To assess cardiovascular risk factor management, in
new way for the diagnosis of cancers and other diseases, However, terms of antihypertensive and cholesterol lowering therapy usage,
the global serum miR pattern in AS patients has rarely been deter- in patients with inflammatory arthritis, attending an outpatient in-
mined. So, the aim of this study was to find AS specific miR in the flammatory arthritis clinic.
sera of patients with AS. Methods: We performed a cross sectional audit of antihypertensive
Materials and methods: Total RNA was isolated from whole sera in and cholesterol lowering therapy usage in adult (>18 years of age) pa-
AS patients, in patients with RA and in healthy controls (HC) using tients, with inflammatory arthritis, who attended the inflammatory
miRNA microarray. Subsequently, differential expression of miRs arthritis clinic, at a single tertiary hospital, between October 2017
was validated by Real Time PCR. To verify the microarray results, to October 2018. Patient electronic medical files were reviewed in
 |
114      

retrospect. The first study visit within the audit period was assessed
and diagnosis, age, gender, medications, blood pressure measure-
ment and blood results were extracted and input into Excel. Analysis
was performed using Excel and SPSS Statistics.
Results: A total of 128 patients were included (96 with rheumatoid
arthritis, 24 with psoriatic arthritis, 8 with other diagnoses), with a
median age of 60 years. Overall 22.7% (29/128) and 14.8% (19/129)
were on antihypertensive and cholesterol lowering therapy at the
study visit.
Given the Australian population level of uncontrolled/unmanaged
hypertension and dyslipidaemia was noted as 23.0% and 32.8% re-
spectively, in our specific cohort, who are at a higher risk of cardio-
vascular disease, these results likely represent an under treatment of
these risk factors, particularly cholesterol.
Conclusions: The data suggests an underutilisation of antihyper-
tensive and cholesterol lowering therapy in our study cohort, rep-
resenting suboptimal cardiovascular risk factor management. This
indicates a need for increased assessment and management of pa-
tient cardiovascular risk factors.
1-­115 | Efficacy and safety of secukinumab in
Japanese patients with ankylosing spondylitis:
52 week results from MEASURE 2-­J
M. Kishimoto
St. Luke's International University and St Luke`s International Hospital
Background: Secukinumab has been approved for the treatment of
ankylosing spondylitis (AS) in Europe and the US based on MEASURE
1 and MEASURE 2 studies. An open-­label, single arm design study,
MEASURE 2-­J, was conducted to evaluate secukinumab treatment in
Japanese AS patients to support secukinumab registration in Japan.
Objectives: To assess the efficacy and safety of secukinumab subcu-
taneous injections up to 52 weeks in Japanese patients with active
AS.
Methods: Thirty Japanese patients with active AS fulfilling modi-
fied NY criteria, with a score ≥4 on BASDAI and ≥4 cm spinal pain
score on a VAS despite current or previous treatment with NSAIDs
and/or anti-­TNF-­α (TNFi) agents, were included. Patients received
open-­label secukinumab 150 mg at week 0, 1, 2, 3, and 4, followed
by treatment every 4 weeks. The primary outcome was ASAS 20 re-
sponse rate at Week 16. Overall safety and tolerability were also
assessed.
Results: Twenty-­five patients completed treatment up to Week 52.
The proportion of patients with ASAS 20 responses at Week 16 was
70.0%. All efficacy variables/response rates were similar or slightly
higher than those seen with secukinumab 150 mg in MEASURE 2
study (Table 1). Secukinumab was efficacious in both TNFi naïve pa-
tients and those who failed prior TNFi therapy. These improvements
were maintained throughout the study period. ASAS 20 response
rate at Week 16 in HLA-­B27 positive and negative patients were
64.3% and 75.0%, respectively. AE rate during the entire reporting
period was 86.7% among which 3 were SAEs. The most frequent AE
was nasopharyngitis (50%). The cumulative secukinumab exposure
was 25.5 patient-­years.
Conclusions: Secukinumab treatment improved the signs and symp-
toms of active AS in Japanese patients with a similar safety profile as
seen in past global studies, showing that secukinumab is a beneficial
treatment option for Japanese AS patients.

Table 1 Primary and secondary endpoints at Week 16 on FAS

Measure 2-­J Measure 2 Measure

Secukinumab s.c.150 mg Secukinumab s.c.150 mg 2Placebo

N = 30 N = 72 N = 74

ASAS 20 response with NRI, (%) 70.0% 61.1% 28.4%

ASAS 40 response with NRI, (%) 46.7% 36.1% 10.8%
BASDAI 50 response with NRI, (%) 36.7% 30.6% 10.8%
hsCRP, geometric mean of post-­BSL/BSL ratio* 0.247 0.550 1.13
ASAS 5/6 response with NRI, (%) 46.7% 43.1% 8.1%
BASDAI, mean change from baseline −3.09 −2.19 −0.850
SF-­36 PCS, mean change from baseline 6.31 6.06 1.92
ASQoL, mean change from baseline −3.40 −4.00 −1.37
ASAS partial remission with NRI, (%) 20.0% 13.9% 4.10%

ASAS, Assessment of SpondyloArthritis International Society; ASQoL, Ankylosing Spondylitis Quality of Life; BASDAI, Bath Ankylosing
Spondylitis Disease Activity Index; hsCRP, high sensitivity CRP; NRI, Non-­responder imputation; PCS, Physical Component Summary; s.c.,
subcutaneous; SF-­36, MOS 36-­Item Short-­Form Health Survey.
*Observed case.

1-­036 | Next-­generation sequencing of the
whole Mediterranean fever gene in 266 Japanese
patients with familial Mediterranean fever: a
case-­control association study
T. Koga1; S. Sato1; H. Mishima1; K. Migita1; Y. Endo1; M.
Umeda1; R. Sumiyoshi1; F. Nonaka2; S. Fukui1; S. Kawashiri1;
N. Iwamoto1; K. Ichinose1; M. Tamai1; H. Nakamura1; T.
Origuchi1; Y. Ueki3; J. Masumoto 4; K. Agematsu5; A. Yachie6;
K. Yoshiura1; K. Eguchi3; A. Kawakami1
1
Nagasaki University; 2Sasebo City General Hospital; 3Sasebo Chuo Hospital;
4
Ehime University Graduate School of Medicine and Proteo-­Science Center;
5
Shinshu University; 6Kanazawa University
Background: Numerous mutations/polymorphisms have been iden-
tified in the region of Mediterranean Fever (MEFV), mutations in
exon 10 reportedly correlate with disease severity and prognosis.
Accordingly, genetic diagnostic testing is important in the diagnosis
and treatment of familial Mediterranean fever (FMF).
Objectives: We aimed to identify the whole nucleotide sequence of
the MEFV gene in FMF and reveal novel single nucleotide polymor-
phisms (SNPs) associated with the onset of FMF.
Methods: Two hundred SNPs in the whole region of MEFV, includ-
ing promoter regions and intron regions, were genotyped using
next-­generation sequencing in 266 Japanese patients with FMF
and 288 ethnically matched controls. We performed an association
analysis using these SNPs to identify genetic variants that predis-
pose to FMF.
Results: We identified the two most significant SNPs [rs28940578;
M694I in exon 10, odds ratio (OR) = 153, P = 2.47 × 10−21 and
rs3743930; E148Q in exon 2, OR = 1.65, P < 0.0005]. Stratified anal-
ysis identified rs28940578 as a risk allele in typical FMF. Haplotype
AG, defined by rs401298 and rs28940578, was the most significant
and prevalent among patients with typical FMF compared with
controls (22.4% vs. 0%, respectively; OR = 137, P = 1.44 × 10−31).
Haplotype TGT, defined by rs11466018, rs224231, and rs401877,
was the most significant among patients with typical FMF without
the rs28940578 mutation compared with controls (15.9% vs. 6%, re-
spectively; OR = 12.4, P = 0.004).
Conclusions: rs28940578 is associated with the highest risk in typi-
cal FMF cases. This is consistent with results from previous studies in
Japan. We found novel disease-­related SNPs that confer susceptibil-
ity to the onset of FMF among typical FMF without the rs28940578
mutation. There were no relevant SNPs identified in MEFV among
the atypical FMF group.
|
      115
1-­073 | Persistence of biologics in teatment of
psoriatis arthritis patients – the first data from
Moscow unified register of arthritis (MUAR)
K. Lytkina1; G. Lukina2; E. Schmidt3; E. Koltsova5; E.
Zhilyaev4
1
City State Hospital #4; 2Clinical Scientific Center; 3City Clinical Hospital 1
(named after N.I. Pirogov); 4CJSC European Medical Centre; 5Research Institute
of the Organization of Health and Healthcare Management
Background: Early started therapy of psoriatic arthritis can slow the
joint damage progression. Data concerning the persistence of bio-
logics in psoriatic arthritis (PsA) treatment in real clinical practice are
insufficient.
Objective: To analyze the retention of biological therapy of PsA and
identificate possible predictors of persistence of biologics.
Methods: PsA patients from Moscow Unified Arthritis Registry (MUAR)
with biologics or scheduled for the bDMARDs were included in study.
Unadjusted survival analysis was performed by the Kaplan-­
Mayer
method. The search for independent risk predictors of the therapy dis-
continuation was carried out by the multivariate Cox regression.
Results: We analyzed 236 treatment episodes in 141 PsA patients
enrolled in MUAR, 61 men (43%), 50.1 ± 11.5 years old. The age of
disease onset was 37.4 ± 13.0.
The patients received etanercept (71), infliximab (51), adalimumab
(50), Ustekinumab (35), golimumab (11), cerolizumab pegol (7).
In unadjusted analysis mean treatment persistence was longer with
etanercept, adalimumab and infliximab. Significant independent pre-
dictors for the risk of therapy discontinuation associated with pa-
tients (confounders) were education, heel pain at the disease onset,
clinical form of PsA, intumescence of shoulder joints and neck pain
at the disease onset.
After the adjusting data for cofounders there was no significant dif-
ference in risk of withdrawal between different biologics. Neither
the year of onset of the case of treatment nor the number of previ-
ous bDMARDs didn't show a significant influence on the risk of drug
withdrawal.
Conclusion: Our analysis of PsA treatment persistence in real clini-
cal practice detected several factors associated with withdrawal risk.
These data can provide specialists with a tool for tailor-­maid therapy.
3-­066 | Switching from etanercept in patients
with rheumatoid arthritis. Data from Moscow
Unified Arthritis Registry (MUAR)
E. Koltsova1,2; G. Lukina2; E. Shmidt3; K. Lytkina4; E.
Zhilyaev5
1
Research Institute of the Organization of Health and Healthcare Management;
2
Moscow Clinical Scientific Center; 3City Clinical Hospital 1 named after N.I.
Pirogov; 4City Clinical Hospital №4; 5CJSC «European Medical Center»
Background: The probability of achieving target activity with
the first targeted DMARD (tDMARD) in rheumatoid arthritis (RA)
 |
116      
patients is 50–60%. The data about results of switches tDMARDs
are scars and controversial.
Aim: To evaluate the results of switching from etanercept (ETA) to
other tDMARDs in patients with RA.
Materials and methods: In the analysis were included RA patients
from the Moscow Unified Arthritis Registry (MUAR) who fulfill
criteria EULAR (1987) or ACR/EULAR (2010) and receiving target
therapy. The analysis includes patients who were using etanercept
and have stopped it for any reasons and then switched to another
target DMARD. Switching was successful if tDMARD was using
during 6 months and the remission or low disease activity (DAS28
(ESR) < 3.2) was achieved.
Results: 195 of 757 included in registry patients received ETA.
Among 33 patients who were switched to another tDMARD 4 pa-
tients had 2 switches after ETA discontinuation. 16 patients were
switched to another TNF inhibitor (TNFi), 16 patients were switched
to other classes of bDMARDs and 5 to tsDMARD (tofacitinib). The
mean duration of etanercept treatment -­732-­571 days.
The reasons for ETA discontinuation were: side effects 4 (10.5%),
inefficacy -­23 (60.5%) and others -­11 (29%). Among the patients
with ETA inefficacy switching to other classes of tDMARD was more
common 16 (66.7%). in the group of cancellation the ETA for other
reasons the switching to another TNFi occurred in 10 of the 18 cases
(P = 0.086).
Among the patients who were switched from ETA to non-­TNFi the
probability of success was higher (P = 0.001). Among the patients
who were switched to TNFi, remission wasn't observed.
Conclusion: The results of the study give grounds to prefer switch-
ing to drugs of other classes in the case of cancellation of etanercept
for any reason.
2-­097 | Use of tofacitinib (TOFA) in patients
with rheumatoid arthritis (RA) in Moscow:
analysis data from Moscow Unified Arthritis
Registry (MUAR)
E. Shmidt1; E. Koltsova2,3; G. Lukina2; K. Lytkina4; E.
Zhilyaev5,6
1 with AS and 45 patients (47 samples) with RA who suffered from
City Clinical Hospital#1, N.a. N. I. Pirogov; 2Moscow Clinical Scientific Center;
3
Research Institute of the Organization of Health and Healthcare Management;
4
City Clinical Hospital #4; 5Russian Medical Academy of Continuing Professional
Education; 6CJSC «European Medical Center»
Background: Moscow Unified Arthritis Registry (MUAR) started at
01 DEC 2012. By 01 DEC 2017, 829 RA patients were included in
the register.
Objectives: The aim of the study was to evaluate the effectiveness
and treatment survival of TOFA and identify predictors of the ef-
fectiveness of TOFA.
Methods: The inclusion criteria were diagnosis of RA, established
at any time according to ACR (1987) or ACR/EULAR (2010) criteria;
persons receiving or planning to receive targeted therapy for RA;
signed informed consent to participate in the study. All episodes of
treatment with TOFA in which there was at least 1 visit not earlier
than 6 months since the start of the drug were included.
Results: Data of 48 patients treated with TOFA were extracted
from the registry. Women were 41 (85.4%), mean age was
55.1 ± 12.4 years; age at the disease beginning was 44.3 ± 14.0;
6 (12.5%) of patients were smokers; mean time on TOFA was
552 ± 259 days. Treatment survival on TOFA as the 1-­
s t and
the 2-­n d line of targeted therapy seems to be one of the best.
Treatment survival on TOFA as the 3-­rd and the 4-­t h line of tar-
geted therapy seems to be the best. One of the independent pre-
dictors of achieved DAS28 was sex – 0.49 lower in men (P < 0.001).
There was no correlation of achieved disease activity with num-
ber of previous failures with biologics. Patients seropositive for
rheumatoid factor achieved significantly lower activity (P = 0.015).
There was also a trend towards lower achieved activity in patients
with rheumatoid nodules (P = 0.059).
Conclusions: The effectiveness and treatment survival of TOFA
does not depend on the number of previous failures with biologics;
the best results of TOFAcan be expected in men and seropositive
patients; the presence of rheumatoid nodules can be considered as a
special indication for TOFA.
1-­116 | Changes in the level of cytokines in
synovial fluid affected by drugs in patients with
ankylosing spondylitis
B. S. Koo1; I. Sung2; T.-H. Kim3
1
Inje University Seoul Paik Hospital; 2Department of Orthopedics, Hanyang
University Hospital for Rheumatic Diseases; 3Department of Rheumatology,
Hanyang University Hospital for Rheumatic Diseases
Background/purpose: This study aimed to evaluate the levels of
tumor necrosis factor alpha (TNF-­α), interleukin (IL)-­17, IL-­23 in the
synovial fluid in patients with ankylosing spondylitis (AS) and rheu-
matoid arthritis (RA) and elucidate he effect of biologics on the level
of cytokines from synovial fluid in AS.
Methods: Synovial fluid was obtained from 34 patients (42 samples)
active arthritis of the knee; and the levels of the cytokines were
measured. The differences in their levels between patients treated
with and without biologics (biologics group and non-­biologics group)
were analyzed in AS and RA. The correlations between cytokines
were examined in non-­biologics group and biologics group in AS.
In addition, we divided AS samples according to the use of disease
modifying anti-­rheumatic drugs (DMARDs) and biologics group to
identify the effect of drugs.
Results: The level of TNF-­ɑ in AS were significantly lower than
those in RA (P = 0.016). IL-­17 and IL-­23 levels were not different
between AS and RA (P = 0.409 and P = 0.562). In AS, TNF-­a , IL-­17,
and IL-­23 showed good correlation between each other in non-­
biologics group. However, there was no significant correlation in

biologics group. In some patients of AS group, the level of IL-­17 or
IL-­23 were markedly elevated in the biologics group according to
the use of DMARDs.
Conclusion: Treatment with biologics affects the association of cy-
tokines in inflammatory synovial fluid in patients with AS. In addi-
tion, IL-­23 and IL-­17 cytokine may be an important factor in some
patients who do not respond to treatment with biologics in AS.
2-­110 | Anti-­PL-­7 antibody-­positive
dermatomyositis complicated with rapid
progressive interstitial lung disease and colon
cancer successfully underwent laparoscopic
colectomy after triple-­immunosuppressive
therapy
1 1 2 1 1 1
T. Kuga ; M. Koyama ; T. Kon ; Y. Abe ; K. Tada ; K. Yamaji ;
N. Tamura1
1
Department of Internal Medicine and Rheumatology, Juntendo University
School of Medicine; 2Juntendo University Nerima Hospital
A 70-­year-­old woman presented with 2-­week history of dysp-
nea, arthralgia and red papules. Physical examination showed red
papules on her hands, forearms and lower back consistent with
Gottron's sign, bilateral fine crackles on the lower lung field. No
muscle weakness was present. Laboratory survey showed white
blood cell count 5600/μL, C reactive protein (CRP) 1.4 mg/dL,
LDH 287 U/L, KL-­6 583 U/mL and Ferritin 201 ng/mL. Antinuclear
antibody test was positive at 1:160 with a speckled pattern. Anti-­
SS-­
A antibody and anti-­
PL-­
7 antibody were positive. CT scan
showed ground-­glass opacities in both lungs. Spirometry showed
decreased vital capacity (%VC 78%). Biopsy of the skin confirmed
clinically amyopathic dermatomyositis (CADM). As her oxygena-
tion worsened in 2 days after admission, intravenous methylpred-
nisolone pulse (1000 mg/d for 3 days) was started, followed by
oral prednisolone 50 mg/d (1 mg/kg/d), bi-­
weekly intravenous
cyclophosphamide (IVCY; 750 mg), oral tacrolimus targeting rapid
progressive interstitial lung disease (RP-­ILD). AS colonoscopy re-
vealed stenosing adenocarcinoma of the descending colon indica-
tion for surgery, prednisolone was tapered weekly after 2 weeks
of initial dose and reduced to 40 mg/d. Although RP-­
ILD got
worse after tapering prednisolone to 35 mg/d and intravenous
methylprednisolone pulse was added, treatment response was
good and her %VC improved to 96%. After 6 courses of IVCY and
tapering prednisolone to 17.5 mg/d, she successfully underwent
laparoscopic colectomy. RP-­ILD was stable during perioperative
period and adjuvant chemotherapy was started. In our hospital,
4/11 (36.4%) anti-­PL-­7 antibody-­p ositive dermatomyositis patient
complicated with malignancy. No correlation between anti-­PL-­7
antibody and malignancy has been reported but malignancy may
not be uncommon complication of anti-­
PL-­
7 antibody-­
p ositive
dermatomyositis.
|
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2-­086 | Clinical problems of elderly onset
rheumatoid arthritis patients in Japan
T. Kurasawa; Y. Okada; A. Shibata; K. Chino; H. Takei; T.
Kondo; K. Amano
Department of rheumatology and clinical Immunology, Saitama Medical Center,
Saitama Medical University
Background/purpose: Japan is the ultra-­aging society ahead of any
other country in the world, which aging rate (the ratio of the popula-
tion aged 65 and older to the total population) was reported to be
27.7% on October 1, 2017. The rate of aged patients in our outpa-
tient clinic have exceeded 40% and onset age of rheumatoid arthritis
(RA) is getting older than before. The aim of our study is to reveal
recent clinical features and problems of elderly onset RA (EORA) pa-
tients who developed RA after 65 years old, for better management.
Methods: We retrospectively collected clinical informations of 212
EORA patients from medical records, who had been followed up at
our hospital from April 1 to September 30, 2017.
Results: Female were 129 (60.8%). Mean observation period was
56.4 months (995.9 person-­years). Rheumatoid factor positive/anti-­
CCP antibody-­positive rate was 65.8/67.2%. At the time of diagno-
sis, respiratory complications were seen in 50 cases, diabetes in 32,
hypertension in 78, hyperlipidemia in 38, cerebrovascular or car-
diovascular events in 22, and malignancy in 14. Infectious adverse
events occurred in 35 patients, which was 3.51 /100 person-­years
(PY) and newly developed malignancy in 15 cases (1.51/ 100 PY).
Corticosteroids were prescribed in 30.7%, csDMARDs 85.8%, and
biological DMARDs (BIO) 43.4%. of 92 EORA patients treated with
BIO, 12 severe adverse events occurred (infection in 7 cases; 1.38/
100 PY, and malignancy in 3; 0.59/ 100 PY).
Conclusion: RF/anti-­CCP antibody positive rate was similar to past
reports in Asia. The frequency of infection and malignancy was
higher in EORA patients. However, those frequency of BIO-­treated
EORA was similar to other large cohort. We should be careful to fol-
low up EORA patients.
1-­0 06 | A case of systemic lupus
erythematosus with enchepalitis anti-­NMDAR
induced by teratoma
P. K. Kurniari; G. Kambayana
Rheumatology Division, Internal Department Udayana University
Background: Systemic Lupus Erythematosus is an autoimmune
disease that can affect many organ. Anti-­
N-­
methyl-­
D-­
aspartate
receptor (anti-­NMDAR) encephalitis is a form of autoimmune en-
cephalitis involving anti-­NMDAR antibodies, which is specific to the
NR1/NR2 heteromers of the NMDAR. About half of cases are as-
sociated with tumors, most commonly teratomas of the ovaries, while
the cause in others cases is unclear. The correlation between anti-­
NMDAR encephalitis and SLE is yet to be clarified. The treatment for
 |
118      

SLE-­associated anti-­NMDAR encephalitis has not been established
conclusively. The conventional recommended treatment for anti-­
NMDAR encephalitis is methylprednisolone plus immunoglobulin or
plasma exchange as the first-­line therapy, and rituximab, cyclophos-
phamide, or their combination as the second-­line therapy.
Case: A young female, 15 years old, Javanese, presented to our hos-
pital with decreased of consiousnes with history of seizure before
she got unallert. Vital sign within normal limit. No deficit neurologis
was found. There is teratoma on ovarii sinistra. Laboratory finding,
ANA IF positive 1:1000 speckle pattern. Antibody anti-­
NMDAR
serum and cerebrospinal liquid was positive. Head MRI show no ab-
normality. She was successful treated with pulse dose metylpred-
nisolon 1000 mg daily in 3 days, rituximab 1 g at day 1 and day 6,
Cyclophospamid 500 mg iv, plasmapharesis, intravena immunoglob-
ulin and surgery for teratoma.
Conclusion: SLE with seizures could lead to a diagnosis of NPSLE
and also of anti-­NMDAR encephalitis. This case reports suggest that
SLE is an indicator in the development of anti-­NMDAR encephalitis.
Keyword: SLE, Antibody anti-­NMDAR, teratoma
analysed and reported here. MRS glutathione normalised to water
at OCC in FMS was mean 2.81 (SD 1.08) i. u. and in HC 3.10 (1.50)
[P > 0.05], and at ACC in FMS was 1.94 (1.97) and in HC 2.59 (3.07)
[P > 0.05].
Conclusion: Both at the ACC and OCC, cortical levels of the anti-
oxidant glutathione appear to be normal in FMS. However, a recent
brain PET study reporting activated cortical glial cells in FMS (Brain
Behav. Immun. doi.org/10.1016/j.bbi.2018.09.018) suggests that
the voxels for glutathione investigation in this pilot study were in-
correctly located.
2-­122 | Increased possibility of
antiphospholipid syndrome in pseudo-­pseudo
Meigs syndrome
S. Y. Lee; W. Park; M. J. Lim; K.-H. Jung; S.-R. Kwon
Inha University
Pseudo-­pseudo Meigs syndrome (PPMS) is a rare manifestation
of systemic lupus erythematosus (SLE) and defined as pleural

3-­032 | Neuroinflammation in fibromyalgia effusion, ascites, and elevated cancer antigen 125 in the serum.
Antiphospholipid syndrome (APS) is characterized by thrombotic
assessed by proton magnetic resonance
event or obstetrical morbidity with antiphospholipid antibody
spectroscopy – a pilot study (aPL). Among about 10 reported cases of PPMS there was no diag-
R. Kwiatek1; B. Crouch2; B. True3; S. Whittle 4; A. Wall5; V. nosis of APS. In our first case a 61-­year-­old woman was admitted
Sherwood6 complaining of abdominal pain on her right upper quadrant started
1
Northern Adelaide Local Health Network; 2Royal Adelaide Hospital; 3Wakefield three days ago. SLE was diagnosed with serositis, renal disorder,
Rheumatology; 4Queen Elizabeth Hospital; 5Clinical and Research Imaging
hematologic disorder, antinuclear antibody (ANA), and immuno-
Centre, SAHMRI; 6Siemens Ltd, Australia and New Zealand
logic disorder including positive result of lupus anticoagulant and
also classified as having PPMS. On the 103th day of admission,
Background: Whilst traditionally viewed as a non-­inflammatory dis-
her consciousness got in comatous state with abrupt onset of
order, at least a subgroup of individuals with the prevalent fibromy-
dyspnea. Brain CT revealed newly appeared hemorrhagic lesions
algia syndrome (FMS) have elevated inflammation-­related proteins
in genu of corpus callosum and right frontal lobe suggesting em-
peripherally. Evidence is accumulating for similar changes in the cer-
bolism most likely. On the 116th day, she died due to uncontrolled
ebrospinal fluid, suggesting central neuroinflammation may play an
SLE activity and the resulting complications of CMV pneumonia.
important pathogenetic role in FMS. Consistent with this hypoth-
Though this case didn`t fit the criteria of APS completely, the pa-
esis, Shungu DC et al. have recently reported preliminary evidence
tient died without enough time to retest aPL. In our second case
using proton magnetic resonance spectroscopy (MRS) that brain
a 33-­year-­old woman visited our hospital with abdominal pain,
ventricular lactate is elevated in FMS (J Pain 2015;16:1211-­9). The
diarrhea and vomiting started five days ago. She experienced a
current pilot study aims to confirm and extend these findings.
spontaneous abortion at eight month of pregnancy five years ago.
Methods: Subjects with primary FMS on no centrally acting medica-
She was diagnosed with SLE due to serositis, hematologic disor-
tions and healthy controls (HC) were recruited. All undertook the
der, immunologic disorder, and ANA and concurrently PPMS. The
Structured Clinical Interview of DSM-­5 to exclude psychiatric co-­
follow-­up results of anti-­c ardiolipin IgG with interval of at least
morbidities and completed validated self-­reported questionnaires.
twelve weeks were positive. In this case the classification of APS
All underwent at 3.0-­Telsa multi-­slice PRESS MRS imaging of ven-
was completely met. In PPMS, there is increased probability of oc-
tricles and MEGA-­PRESS (TE = 130 ms, 384 signal averages) MRS
currence of APS. Therefore, when treating PPMS, we should keep
of voxels centred on occipital cortex (OCC) and pregenual anterior
APS in mind with confirming the presence of aPL and the history
cingulate cortex (ACC), analysed for lactate and glutathione levels,
of obstetrical morbidity or thrombotic manifestation and monitor-
respectively, using Gannet 3.0 software.
ing carefully whether symptoms related to thrombosis happen.
Results: Ten FMS (mean age 43.4, mean BMI 25.3, mean Fibromyalgia
Impact Questionnaire Revised 56.8) and 9 HC (mean age 37.3, mean
BMI 26.8) have been enrolled, but to date cortical glutathione only

3-­095 | Quality of life and its determinants in
established rheumatoid arthritis
M. Lahiri1,2; P. Cheung1,2; P. Dhanasekaran2; P. Phan2
1
Division of Rheumatology, University Medicine Cluster, National University
Hospital; 2Department of Medicine, Yong Loo Lin School of Medicine, National
University of Singapore
Background/purpose: Health related quality of life utility (HRQOL)
measures such as the European Quality of Life (EQ5D) index are
country specific and have not previously been well described in
Asian rheumatoid arthritis (RA) patients. We assessed the EQ5D-­
index, its determinants, predictors and changes over time in RA pa-
tients in Singapore (SG).
Methods: Data from participants of a randomised controlled trial
of a multidisciplinary RA clinic were analysed. Data were collected
by face-­to-­face questionnaires, review of medical records and joint
counts by a standardised assessor.
Results: 131 patients (86.3% female, 53.4% Chinese, age
54.4 ± 12.7 years) of median (IQR) disease duration 5.5 (2.4, 11.0)
years were followed for 6 months. The mean (SD) baseline EQ5D-­
SG-­index was 0.74 (0.28) (SG population mean 0.95) and the median
(IQR) EQ5D visual analogue scale (VAS, 0–100) for overall health-­
state was 65 (50, 80) (Figure 1B). Pain was the biggest driver of the
EQ5D (Figure 1A). There was a strong correlation between EQ5D-­
SG-­
index and pain VAS (r = −0.53), physical function as meas-
ured by the modified health assessment questionnaire (mHAQ)
(r = −0.66) and patient global VAS (r = −0.43), all P < 0.001, confirm-
ing face validity of the EQ5D-­SG-­index. Disease activity (DAS28-­
ESR) (OR = 1.7, 95%CI = 1.14–2.61, P < 0.01) and coping VAS (0–10,
10 being worst) (OR 1.50 95%CI = 1.22–1.86, P < 0.001) were sig-
nificant predictors of poor baseline EQ5D-­
SG-­
index. Age, race,
gender, education level, smoking status, body mass index (BMI)
and disease duration were not predictors. EQ5D health-­s tates and
EQ5D-­VAS improved after 6 months (Figure 1C, D). On multivariate
analysis, the strongest predictors of a minimum clinically significant
improvement of 0.1 in the EQ5D-­SG-­index and of 20 points on the
EQ5D VAS were a low baseline index (OR 0.61, 95% CI = 0.47–0.79,
P < 0.001) and VAS (OR 0.86, 95% CI = 0.81–0.91, P < 0.001),
respectively.
|
      119
Conclusion: HRQOL in patients with established RA is impacted by
modifiable factors such as disease activity and coping, and can im-
prove over time.
1-­117 | Efficacy outcomes in certolizumab
pegol-­treated patients with axial
spondyloarthritis in Asia: results from part A of
C-­OPTIMISE
R. Landewé1,2; D. van der Heijde3; M. Dougados4; X.
Baraliakos5; F. Van den Bosch6; J. Wei7; B. Hoepken8; L.
Bauer8; K. Thomas8; L. S. Gensler9
1
Amsterdam Rheumatology & Clinical Immunology Center; 2Zuyderland Medical
Center; 3Department of Rheumatology, Leiden University Medical Center;
4
Rheumatology Department, Paris-­Descartes University and Cochin Hospital;
5
Ruhr-­University Bochum; 6Department of Internal Medicine, Ghent University
Hospital; 7Institute of Medicine, Chung Shan Medical University; 8UCB Pharma;
9
University of California
Background/purpose: Part A of the C-­OPTIMISE study assessed
certolizumab pegol (CZP) response in patients with early axial spon-
dyloarthritis (axSpA; ankylosing spondylitis/radiographic axSpA and
non-­radiographic axSpA) to identify patients in sustained remission
who may be able to reduce/discontinue treatment (Part B). Here, we
report Part A post-­hoc analyses results in patients from Asia and
other regions (OR).
Methods: Up to Wk48, C-­O PTIMISE (NCT02505542) was open-­
label (Part A – completed), followed by 48-­
w k parallel-­
group,
double-­
b lind, placebo-­
controlled treatment (full dose and half
dose) to Wk96 (Part B – ongoing). Patients from Asia (Taiwan
and Turkey) and OR (Europe/North America) with adult-­
onset
axSpA of <5 years’ symptom duration, fulfilling Assessment of
SpondyloArthritis international Society (ASAS) classification cri-
teria, were recruited. Part A: patients received CZP 400 mg at
Wks0/2/4, then 200 mg every 2 weeks; patients achieving sus-
tained remission (Ankylosing Spondylitis Disease Activity Score
[ASDAS] <1.3 at Wk32 and <2.1 at Wk36 [or vice versa], and <1.3
at Wk48) were eligible for Part B. Additional efficacy outcomes
were also collected. Missing values were imputed using non-­
responder imputation (NRI) and last observation carried forward
(LOCF).
Results: Part A: of 736 patients, 75 were from Asia and 661 from
the OR (Table). at Wk48, 42.7% of patients from Asia achieved
sustained remission (OR: 44.0%). at Wk48, 58.7% of patients from
Asia achieved ASAS40 response (OR: 73.4%). ASDAS clinically im-
portant improvement was achieved by 72.0% of patients from Asia
(OR: 77.0%) (Table). 4.5% of all patients discontinued CZP due to
treatment-­related adverse events. The safety profile across all re-
gions was consistent with previous reports for CZP and other
anti-­TNFs.
Conclusion: A large proportion of CZP-­treated patients in Asia and
OR demonstrated improvements in disease activity and achieved
sustained remission by Wk48.
 |
120      
Acknowledgements: the study was funded by UCB Pharma, medical
writing by Costello Medical, UK.
3-­139 | Atypical presentation: spontaneous
subcapsular renal hematoma and autoimmune
hemolytic anemia in microscopic polyangitis
N. Zainudin; S. Ch'ng; I. S. Lau; H. M. Yusof; A. Rosman; M.
M. Zain
Hospital Selayang, Selangor, Malaysia
Introduction: Microscopic Polyangitis (MPA) is Antineutrophil
Cytoplasmic Antibody (ANCA) related small vessel vasculitides and it
distinct from Polyarteritis Nodosa (PAN) even though has similar mani-
festations. This case report presents a case with spontaneous subcap-
sular renal hematoma which is not uncommon in PAN but rare in MPA.
Case presentation: A 66 year old, lady with one month history of
constitutional symptoms admitted for acute autoimmune hemo-
lytic anemia (AIHA), required blood transfusion. Erythrocyte
Sedimentation Rate and C-­Reactive Protein were high. Initial blood
tests, cultures and radiological findings were not significant except
for bilateral pleural effusion and ground glass appearance in the
lungs. Work up for tuberculosis, multiple myeloma and viral hepati-
tis were negative. Rectal ulcer biopsy showed inflammatory colitis.
She had multiple episodes of AIHA and it was steroid responsive.
ANCA and anti MPO later were positive. Abdominal ultrasound was
repeated due to progressive renal impairment and microscopic he-
maturia. It showed large left renal subscapular mass represented
early abscess. Two weeks after empirical antibiotic, the ‘abscess’ was
partially liquefied but with no change in size with a similar lesion
developing in the right kidney. Drainage of the subscapular mass
yielded blood only. Patient's condition deteriorated with multiple
episodes of pulmonary edema secondary to acute cardiomyopathy.
Angiogram showed multiple liver infarcts and multiple aneurysms
in the small to medium size of renal arteries. Subscapular hema-
toma likely secondary to ruptured renal parenchymal hematoma.
Atypical presentations delayed the diagnosis. Patient passed away
due to massive bleed from the renal subscapular hematoma despite
Metylprednisolone.
Discussion: Spontaneous subcapsular hematoma is life threatening
and relatively common in PAN; about 4–13% of cases. It is very rare
in MPA but is possible due to rupture of microaneurysm of the small
vessels. Autoimmune hemolytic anemia is not uncommon and is as-
sociated with severe form of MPA.
2-­123 | SLE patients with cerebral lupus in a
Malaysian Rheumatology Centre
R. Nasadurai1; S. C. Suyin1; N. Zainuddin1; A. Rosman1; L. I.
Soo1; M. M. Zain1; H. Yusoof1; H. Baharuddin2
1
Hospital Selayang; 2Faculty of Medicine UiTM
Background/purpose: To determine the prevalence, clinical mani-
festations, autoantibody profile sensitivity and radiological features
of cerebral lupus in a Malaysian Rheumatology centre.
Methods: This retrospective study was conducted in a Malaysian
Rheumatology centre over one year. Records of 314 patients with
SLE were analyzed.
Results: In this study 49 (16%) out of 314 SLE patients had cere-
bral lupus during their course of illness. 47 (16%) out of 300 female
SLE patients and 2 (14%) out of 14 male SLE patients had cerebral
lupus respectively. Cerebral lupus occurrence among the different
ethnic groups were 36 (16%) out of 221 Malays, 9 (12%) out of 75
Chinese, 2 (18%) out of 11 Indians and 2 (29%) out of 7 other ethnici-
ties. Manifestations of cerebral lupus were seizures (43%), cognitive
dysfunction (37%), headache (10%), psychosis (8%) and transverse
myelitis (2%). Anti-­nuclear antibody (ANA) was positive in 48 (98%),
anti-­double stranded DNA antibody (anti-­dsDNA) was positive in 29
(64%) , anti-­RNP antibody was positive in 23 (59%) and anti-­Sm was
positive in 17 (47%) cerebral lupus patients. MRI brain was done in
39 cerebral lupus patients and CT brain in 38 cerebral lupus patients.
In patients who had done MRI brain 15 (38%) showed normal find-
ings, 12 (31%) infarcts, 11 (28%) vasculitis and 1 (3%) hyperintensity
signals. In comparison CT brain showed 24 (63%) normal studies, 10
(26%) infarcts and 4 (11%) cerebral atrophy.
Conclusion: Prevalence of cerebral lupus was 16% in this study
cohort. Similar to other studies seizures and cognitive dysfunction
were the most common manifestation seen. Patients with cerebral
lupus were very likely to have positive ANA and anti-­dsDNA. MRI
and CT brain showed higher percentage of normal findings in this
study cohort of cerebral lupus patients.
 |
      121

2-­124 | National data based analysis of 3-­067 | Demyelination amongst patients

malignancy in Korean Sjogren's syndrome exposed to Tumour Necrosis Factor-­Alpha
patients Inhibitor (TNFi): a case series
C. H. Lee1; J. S. Park1; H. Lim2; H. Pak 2 H. J. Lee1; A. Salonga1; L. Cummins2,3
1 1
Divison of Rheumatology, Department of Internal medicine, NHIS Ilsan Hospital; Greenslopes Private Hospital; 2Mater Hospital Brisbane; 3University of
2
Research and Analysis Team, NHIS Ilsan Hospital Queensland

Background: Patient with systemic autoimmune rheumatic disease,
are known to have a high risk of malignancy. Among these, Sjogren's
syndrome (SS) which characterized by lymphocytic infiltration of
exocrine glands and caused sicca symptoms is associated with devel-
opment of lymphoma. However, prevalence of SS was too low; most
studies about lymphoma and malignancy were done on a small-­scale.
For more large-­scale research about development of malignancy
and mortality in SS, we analyzed these with whole Korean National
Health Insurance data.
Method: We compared the incidence of malignancy and mortality
in newly diagnosed SS patients from 2004 to 2015 with age-­sex
matched controls and calculated hazard ratio (HR) with multiple
Cox's model.
Results: The number of total study population including SS was
52,663. Among this, the number of SS was 8826. Therefore the ratio
of control vs. SS patient group was 4.97:1 (43,837:8826). Total study
population's malignancy rate was 3.23% (1699/52,663). SS's malig-
nancy rate was 4.06% (358/8826). The duration from diagnosis of SS
to development of malignancy was 5.4 year and their mean age was
52.3 years old. The risk of overall malignancy was not higher than
that of the control. However, the incidence of thyroid cancer (HR;
1.75, 95%CI; 1.15–2.65) and lymphoma (HR; 4.8, 95%CI; 1.40–16.42)
were higher than that of control (Table1). Total study population's
mortality rate was 2.70% (1422/52,663). SS's mortality rate was
2.93% (259/8826). Presence of SS did not increase the mortality rate
(HR; 1.09, 95%CI; 0.81–1.45). However among SS, mortality rate was
higher in man, elderly, low income, smoker, and malignancy group.
Conclusion: This is one of the largest epidemiologic study about SS
including 8826 patients of SS. SS patients’ overall malignancy risk
was not higher than control group. However, risk of lymphoma in-
cluding non-­
Hodgkin lymphoma was higher than control group.
Mortality rate of SS was not higher than control group.
Background: In the recent years, the use of tumour necrosis factor-­
alpha inhibitors (TNFi) has increased dramatically as a result of its
efficacy in the management of various autoimmune conditions.
Demyelinating conditions such as Multiple Sclerosis (MS) are one of
the important side effects of TNFi to consider and recognise.
In 2017, the McDonald Criteria have been revised to increase the
sensitivity for the diagnosis of MS. We herein report a case series of
4 patients who developed demyelinating disease after the initiation
of TNFi and consider if they meet the revised criteria.
Objective: To report a series of cases of demyelination associated
with TNFi use and thereby increase awareness of this association.
Methods: We performed a retrospective review of clinical and ra-
diological parameters of 4 patients who received TNFi and subse-
quently developed demyelinating disease.
Results: The table below describes the characteristics of our pa-
tients. All patients had only partial neurologic recovery after cessa-
tion of TNFi.
Conclusion: Clinicians should have a low threshold of suspicion for
considering demyelination when patients who are receiving TNFi
present with new neurologic signs and symptoms.

Patient (age, TNF-­α Onset of demyelination (from Fulfills 2017

gender) Diagnosis inhibitor Previous DMARD first dose of TNFi) McDonald criteria

1. AR (32, Male) Ankylosing Spondylitis Adalimumab Sulfasalazine 8 weeks Yes

2. SN (39, Psoriatic arthritis Adalimumab Methotrexate 8 weeks No
Female) Mesalazine
3. DB (61, Male) Sero-­positive Adalimumab Methotrexate 12 weeks (symptoms developed Yes
Rheumatoid Arthritis Leflunomide 4 weeks after treatment
Hydroxychloroquine ceased due to infection)
4. KS, (27, male) Crohn’s disease Infliximab Azathioprine 2.5 yrs No
 |
122      
2-­036 | Burden of disease in a national sample
of women in childbearing years with rheumatic
diseases in Korea
J. Lee; M. K. Chung; J.-Y. Shin; E.-H. Ha
Ewha Womans University College of Medicine
Background/purpose: Many rheumatic diseases occur in women in
their reproductive years which have significant impact on childbear-
ing. We aimed to investigate the burden of rheumatic diseases (RD)
among Korean women in childbearing years in terms of prevalence
and incidence of the diseases, prevalence of comorbidities, preg-
nancy rate, and medication dispensing during pregnancy.
Methods: From National Health Insurance Service-­National Sample
Cohort (NHIS-­NSC) data during 2010–2013, 210,328 women be-
tween 20–44 years of age were identified. Among these women,
the prevalence and incidence of RD including rheumatoid arthritis
(RA), systemic lupus erythematosus (SLE), and ankylosing spondy-
litis (AS) were estimated. Prevalence of chronic diseases (CD) in-
cluding cancer (Ca), hypertension (HT), hyperlipidemia (HLD), and
diabetes mellitus (DM) was compared in women with or without
RD. Pregnancy rate was estimated in women with RD or CD and
compared with the control without RD or CD. Seventy-­one women
with RD who had delivered a child were identified and prevalence
of medication dispensing during pregnancy were estimated.
Result: Prevalence of RD in childbearing years was 0.43% and inci-
dence was 9.37 cases per 10,000 person-­years during 2010–2013.
CD were significantly more prevalent among women with RD com-
pared with those without (28.38% vs 10.19%, P = <0.001). in par-
ticular, risk for HT (OR 3.24, P < 0.001) and HLD (OR 3.25, P < 0.001)
were increased significantly in women with RD. Pregnancy rate was
significantly lower in women with RD compared with the control
(12.60% vs 18.69%, P < 0.001). Likelihood of becoming pregnant in
women with RD (OR 0.55, P < 0.001) was comparable with women
with CD (OR 0.64, P < 0.001). During pregnancy, 54.9% of women
with RD had taken at least 1 RD related medications. The prevalence
of DMARDs dispensing during pregnancy was 23.9%, CSs 43.7%,
and NSAIDs 38.0% respectively.
Conclusion: Rheumatic diseases are prevalent in women in child-
bearing years causing significant burden in Korean women resulting
in increased rate of comorbidity, reduction in pregnancy rate, and
high prevalence of medication use during pregnancy.
2-­071 | Gout revisited: clinical characteristics
and treatment outcomes in a tertiary state
hospital
S. H. Chua1; K. K. Yap1; H. S. Sulaiman1; K. H. Lee2; S. C. Gun2
1
International Medical University; 2Hospital Tuanku Jaafar Seremban
Background/purpose: Gout is a common inflammatory arthritis.
Global epidemiological studies have shown that its incidence is on a
rising trend. Despite widely available safe and effective treatments,
significant disparities in quality of care exist. We aim to determine
the epidemiology, clinical characteristics and treatment outcomes of
gout patients followed-­up in a rheumatology clinic in a tertiary state
hospital.
Methods: This is a retrospective study. Case notes of all gout pa-
tients attending the clinic from December 2017 to March 2018 were
reviewed. Demographic data, clinical characteristics, co-­morbidities
and treatment outcomes were obtained.
Results: 138 gout patients were identified. The male to female
ratio is 8:1 with a mean age of 56.1 ± 13.1 years with a dura-
tion of illness of 15 ± 10.7 years. Majority of the patients were
Malays (63.8%), followed by Chinese (30.4%) and Indians (5.1%).
54% of these patients have a positive family history of gout.
Co-­
m orbidities identified were hypertension (77.5%), obesity
(44.9%), dyslipidaemia (44.2%), chronic kidney disease (37%),
diabetes mellitus (27.5%) and ischaemic heart disease (18.8%).
The mean lag time between symptom onset to appropriate treat-
ment was 11 ± 9.4 years. Tophi (68.8%) and urolithiasis (15.2%)
were known complications. The baseline serum uric acid level
was significantly higher (P = 0.005) among tophaceous patients
compared to the non-­tophaceous group. Only 25.4% of patients
achieved treatment target with a mean treatment duration of
2.9 ± 3.7 years. Mean Allopurinol dose required to achieve this
target was 317.7 ± 143.5 mg.
Conclusion: A strong family history and a varying prevalence
among different ethnic group suggest an environmental-­genetic
interaction in gout patients. Delay in receiving treatment contrib-
utes to complications. The overall low success rate of treatment and
prolonged duration to achieve target serum uric acid level remains
a cause of concern. Reinforcement on gout education for patients
are needed.
2-­072 | How much do patients know about
gout and its treatment?
S. H. Chua1; F. B. H. Yeoh1; K. M. Lew1; K. H. Lee2; M. N.
Nadiah2; C. K. Cheah2; S. C. Gun2
1
International Medical University; 2Hospital Tuanku Jaafar
Background/purpose: Active patient involvement is crucial in the
management of gout. They need sufficient knowledge regarding im-
pact of lifestyle, diet and medications on their condition. We aim to
examine patient's gout knowledge and its treatment to identify bar-
riers to effective management.
Methods: From December 2017 to March 2018, self-­administered
questionnaires were given to gout patients followed up in a rheuma-
tology clinic in Hospital Tuanku Ja'afar, Seremban. Addition data on
disease characteristics and treatment outcomes were obtained from
patients’ case notes.
Results: 111 gout patients participated in the study. Majority
were male (88.3%) of Malay ethnicity (65.8%), with mean age

55.8 ± 13.76 and duration of illness of 16 ± 11.6 years. 81.1% of
patients received at least a secondary level education. All were
prescribed with at least 1 urate lowering therapy (ULT). Higher
educational level and longer disease duration were significantly
associated with higher knowledge score. Majority of patients
were aware of common high purine food such as red meat (90.1%),
organ meat (89.2%), seafood (87.4%), alcohol (84.7%) and beans
(92.8%). Although they had good knowledge pertaining to gout,
there were sub-­optimal comprehension regards to its long term
treatment. Patients were unaware of the desired serum uric acid
target level (45.9%), the risk of short-­term gout worsening with
ULT (59.5%) and the requirement of long term treatment (61.3%).
The latter was significantly associated with higher serum uric acid
level (P < 0.05). Only 22.5% of patients achieved target treatment
level and the remaining who did not, had poorer knowledge on
long term treatment.
Conclusion: Sub-­optimal knowledge on long term treatment of
gout leads to poor treatment outcome. More attention is needed
on patient education. Furthermore, with overall low treatment
target achievement, other aspects of patient care should also be
explored.
2-­0 08 | Real life experiences on practices
of soft tissue infiltrations and intra-­articular
injections
1 1 2 1
K. H. Lee ; C. K. Cheah ; S. H. Chua ; H. L. Tan ; N. M.
Noor1; S. C. Gun1
1
Hospital Tuanku Ja'afar Seremban, Malaysia,; 2International Medical University,
Seremban, Malaysia
Background/purpose: Soft tissue infiltrations and intra-­
articular
injections are common diagnostic and therapeutic rheumatologi-
cal procedures. It allows provision of targeted therapy thus reduces
the need of exposing patients to high dose systemic therapies.
Traditionally, the treating physicians determine efficacies of such
procedures. However in daily practice, discrepancies occurred be-
tween patient-­
reported outcomes (PROs) and physician's assess-
ment to what is perceived as efficacious.
We intend to (1) explore the utility of PROs on soft tissue infiltra-
tions and intra-­articular injections as an indicator of clinical efficacy;
(2) describe the safety and potential complications following soft tis-
sue infiltrations and intra-­articular injections.
Methods: Our study recruited both in and outpatient, from 1st
January to 31st December 2017. Information was collected using a
specified case review form from the time of recruitment till 12 weeks
post procedures for outcome data. Outcome was measured at base-
line, 6 and 12 weeks. PROs parameters are: pain, swelling and func-
tional improvement. Complications encountered were recorded in
similar manner, with parameters of: worsening pain, infection, and
skin hypopigmentation/ atrophy. Data was analysed using SPSS ver-
sion 23.0.
|
      123
Results: 245 patients were recruited, with 195 (79.6%) female. 93
(38%) has rheumatoid arthritis. 137 (55.9%) underwent intra-­articular
injection, 55 (22.4%) had intra-­lesional injection and 53 (21.6%) re-
ceived hydro-­
dissection. 76.3% of procedures were ultrasound-­
guided. Mean baseline pain score was 6.11 (95%CI: 5.90–6.40),
reduced significantly to 2.83 (95%CI: 2.58–3.09) at 6 weeks, and
2.25 (95%CI: 1.89–2.61) at 12 weeks post procedure, P = 0.005.
Baseline functional score was 5.13 (95%CI: 4.72–5.55). Significant
increment was seen at 6 weeks (mean 5.50, 95%CI: 5.13–5.86)
and sustained even at 12 weeks (mean 5.98, 95%CI: 5.61–6.35),
P = 0.005 respectively. 8 patients (3.3%) experienced worsening of
pain. None develop infection.
Conclusion: Soft tissue infiltrations and intra-­articular injections are
effective and safe in pain management and functional rehabilitation
among patients with musculoskeletal disorders.
1-­053 | A regulatory role of ANTXR1 in
RANKL-­induced osteoclast differentiation and
function
M. S. Lee1; C. L. Lee1; S. J. H. Hong2; J.-Y. Kim3
1
Wonkwang Univ. Hospital; 2Kyung Hee University School of Medicine; 3School
of Medicine, Wonkwang University
Background: Anthrax toxin receptor 1 (ANTXR1) has been known to
have relationship with extracellular transmembrane protein deeply
associated with the process of bone formation and exert important
role in angiogenesis. However, there have been no reports to prove
the effects of ANTXR1 on bone metabolism mediated by two types
of bone cells, osteoclasts and osteoblasts. The aim of this study is
to reveal the role of ANTXR1 in the differentiation and function of
osteoclasts and osteoblasts.
Methods: To determine the effect of ANTXR1 on osteoclastogen-
esis or osteoblast differentiation, we examined TRAP staining, F-­
actin staining and Pit assay, or ALP and Alizarin Red-­mineralization
staining, respectively. The mechanism of ANTXR1 by transfection
of retrovirus or siRNA analyzed using real-­t ime PCR and western
blot analysis. Also, the effect of ANTXR1 on osteoclast-­m ediated
angiogenesis of endothelial cells assessed by in vitro vascular
tubule formation assay of human umbilical vein endothelial cells
(HUVECs).
Results: Through performing gain-­and loss-­
of-­
function studies,
we found that ANTXR1 positively regulated receptor activator of
nuclear factor kappa B ligand (RANKL)-­induced osteoclast differ-
entiation and bone resorption with no effects on osteoblast differen-
tiation. During ANTXR1-­mediated regulation of osteoclastogenesis,
phosphorylation of early signal transducers, c-­jun N-­terminal kinase
(JNK), Akt, and inhibitor of kappa B (IkB) was affected, which in turn
alteration of mRNA and protein levels of c-­Fos and nuclear factor
of activated T cells cytoplasmic 1 (NFATc1). in addition, genetic ma-
nipulation of ANTXR1 in bone marrow macrophages (BMMs) modu-
lated the capillary-­like tube formation by HUVECs via two kinds of
 |
124      

angiogenic factors, matrix metalloproteinase-­9 (MMP-­9) and vascu- 2-­117 | Remission of paradoxical skin lesions by
lar endothelial growth factor-­A (VEGF-­A). These results explained
Tripterygium wilfordii hook f treatment in SAPHO
the important role of ANTXR1 in osteoclast differentiation and
syndrome: a case report
functional activity, as well as, osteoclast-­mediated angiogenesis of
endothelial cells. Q. Lei; C. Li; X. Shi
Conclusions: Taken together, it was proposed that ANTXR1 might be Peking Union Medical College Hospital

a promising candidate for gene therapy related with bone metabolic

diseases and further, have potential to be served as an important
biomarker in the research fields of bone metastasis associated with
vascularization.
Keywords: ANTXR1, bone, osteoclast, osteoporosis, angiogenesis
2-­087 | Development and validation of PET/
CT-­based tool for the evaluation of joint counts
and disease activity in patients with rheumatoid
arthritis
S. J. Lee; Y. M. Kang
Background: Synovitis, acne, pustulosis, hyperostosis and osteosis
(SAPHO) syndrome is a rare disease with no standardized treatment.
Anti-­TNF-­α is effective for osteoarticular manifestations but may
induce severe psoriasiform lesions paradoxically in part of SAPHO
syndrome patients. Traditional Chinese medicine Tripterygium wilfor-
dii hook f (TwHF) is used as a potent treatment for chronic inflam-
matory diseases.
Methods: A 58-­year-­old female patient noted swelling and pain
at the anterior chest wall, left shoulder and back with pustular
lesions with limited physical activity of axial joints and scattered
erythematous maculopapular rashes covered with silvery-­w hite
scales around the whole body. Based on dermatological and os-

Division of Rheumatology, Department of Internal Medicine, Kyungpook National teoarticular manifestations and the classic “bull's head” sign by
University Hospital, Korea whole body bone scintigraphy using 99mTc-­MDP as well as palmo-
plantar pustulosis by skin lesions biopsy, the diagnosis of SAPHO
Objective: Clinical joint count assessment is important for detecting syndrome was made
synovitis but its reliability is controversial. This study assessed the Anti-­TNF-­α (Etanercept) was given for 4 weeks at 25 mg/wk dos-
correlation of positron emission tomography (PET)-­derived param- ing, after which pain was remitted while paradoxical skin lesions
eters in 68 joints with disease activity and compared the reliability
of joint counts between PET/computed tomography (CT) and clinical
assessment in rheumatoid arthritis (RA).
Methods: We enrolled 91 patients with active RA who underwent
fluorine-­18-­fluorodeoxyglucose PET/CT and disease activity evalu-
ation at the same time. This two-­step study involved a development
(n = 69) and validation (n = 22) group. PET-­derived parameters were
compared with clinical disease activity. Subsequently, we developed
a disease activity score (DAS) using PET-­positive joints and validated
it in an independent group.
Results: The number of PET-­positive joints in 28 and 68 joints was
significantly correlated with the swollen (SJC) and tender (TJC) joint
counts and DAS28-­erythrocyte sedimentation rate (ESR). Intra-­and
inter-­observer reliabilities of PET for the affected joint counts were
excellent. Inter-­observer reliability between nuclear medicine phy-
sicians and rheumatologists was good for SJC and TJC in both 28
and 68 joints. After multivariate analyses including ESR and patients
global assessment (PGA) in addition to PET-­
derived parameters,
PET/DAS was derived as 0.063 × number of PET-­positive joints in
28 joints +0.011 × ESR + 0.030 × PGA. A significant correlation be-
tween PET/DAS and DAS28-­ESR was confirmed in the validation
group (P < 0.001).
Conclusions: PET/CT could serve as a sensitive and reliable method,
complementing clinical assessment for evaluating disease activity in
RA patients. PET-­derived parameters may subsequently replace ex-
perienced joint assessors.
 |
      125

appeared as psoriasiform lesions. Considering the autoinflammatory (5 mg/day) are reached. Patients with PMR are more likely to have
nature of SAPHO syndrome, TwHF was administered tentatively to loss of weight and shorter symptom duration than patients who are
exert its anti-­inflammatory function with a priming dose of 20 mg eventually given an alternate diagnosis.
3 times per day and a gradual dose reduction of 20 mg per day in
every 3 months.
Table 1. Clinical presentation according to diagnosis
Results: Three weeks later, patient's symptoms were improved re-
markably, especially the rashes. Four months later, a remarkable Alternate
PMR diagnosis P value
remission of symptoms was achieved and inflammatory condition
parameters and disease activity indexes decreased progressively Total number 55 20

during the whole period. And the patient reported that she strictly Symptom duration 7.5 (2–28) 51 (1–156) <0.005
adhered to the medication and no adverse effects were noted. (weeks)

Conclusion: This is the second case of SAPHO who benefits from Shoulder pain 55 (100) 13 (65) <0.005

TwHF. Symptoms including skin lesions and osteoarthritic pain and Hip pain 46 (84) 10 (50) 0.005
inflammatory indexes were both significantly improved after TwHF Thigh pain 17 (31) 3 (15) 0.139
therapy. Further clinical trial is needed to test efficacy and safety of Knee pain 21 (38) 5 (25) 0.218
TwHF in SAPHO syndrome treatment. Neck pain 11 (20) 6 (30) 0.268
Back pain 15 (27) 2 (10) 0.099
Hand pain 19 (35) 6 (30) 0.469
3-­140 | Real-­world experience of polymyalgia Foot pain 4 (7) 2 (10) 0.511
rheumatica managed in a single tertiary centre Fatigue 31 (56) 6 (30) 0.039
1,2 1 1,2 1,2 Fever 5 (9) 1 (5) 0.489
J. L. Leung ; P. Shamdasani ; C. E. Owen ; D. F. Liew ; R.
R. C. Buchanan1,2 Loss of weight 24 (44) 1 (5) 0.001
1
Austin Health; 2The University of Melbourne Duration of stiffness 120 (0–480) 0 (0–360) 0.067
(mins)

Background/purpose: Polymyalgia rheumatica (PMR) is the most ESR 43 (3–140) 25 (2–90) 0.008

common inflammatory rheumatic disease of the elderly, but remains
under-­researched and poorly understood. To date, there have been
no published descriptions of PMR patients’ presentation or disease
trajectory in Australia. At Austin Health there has been a dedicated
PMR clinic in operation since early 2016. This represents a unique
opportunity to study this patient population in routine clinical
practice.
Objectives: To examine the real-­world experience of PMR patients
seen in a single tertiary centre in Australia.
Methods: A retrospective chart review was conducted of all patients
seen in the Austin PMR clinic since inception until 16th March 2018.
Differences between patients with PMR and those with an alternate
diagnosis were assessed by the Fishers Exact Test for categorical
variables, or the Mann-­Whitney U test for non-­parametric continu-
ous variables.
Results: 92 patients were seen and included in the study. The diag-
nosis was PMR in 59, giant cell arteritis (GCA) in 6, both PMR & GCA
in 4, and an alternate diagnosis was made in 23. Differences in clini-
cal presentation between patients diagnosed with PMR and those
with an alternate diagnosis are shown in Table 1.
Of 59 PMR patients, 32 (54%) were male, and the median age was 70
(range 56–87). During an average follow-­up of 44 weeks, 61% experi-
enced at least one relapse. The median prednisolone dose at the time
of relapse was 5 mg (range 0-­15 mg). A steroid-­sparing agent, either
methotrexate or leflunomide, was commenced in 9 (15%) patients.
Conclusion: Most patients with PMR experience at least one relapse
of disease whilst weaning prednisolone, usually once lower doses
CRP 35 (2–200) 6.5 (0.7–104) 0.024
Data presented as n (%) or median (range)
2-­073 | Cohort of allopurinol severe cutaneous
adverse reaction – gene testing might be better
than “go low go slow” strategy
M. A. Leung; J. Chan; R. Ng
Queen Elizabeth Hospital
Background/purpose: Allopurinol is known to cause severe cutane-
ous adverse reaction (SCAR) and gene testing is a valid preventive
measure. This study explores the significance of allopurinol among
other drug induced SCAR and gene positivity.
Methods: Patient data of a tertiary internal medicine and rheumatol-
ogy referral centre of catchment population around 800,000 was
retrieved and reviewed for the period January 2008 to December
2017.
Results: Of 75 patients with diagnosis of Stevens-­J ohnson syn-
drome or Toxic Epidermal Necrolysis, allopurinol was implicated in
18 (24%) and was the single commonest drug culprit among other
drug groups (Table). of these 18 patients with SCAR related to
allopurinol, half were male and the mean age was 74 years ± 16
(SD). Ten patients had clinical gouty arthritis and 3 was crystal-­
proven. Co-­m orbdities were common: all except 2 patients had
raised baseline serum creatinine (range 76–844 µmol/L, average
 |
126      
201 µmol/L) and mean eGFR (MDRD equation) was 39.1 mL/min.
Ten patients had hypertension, six diabetes mellitus and three is-
chaemic heart disease. Allopurinol was started at dosages ranging
from 100 to 300 mg daily (mean 170 mg) and SCAR occurred at
5–121 (mean 40) days in all except one patient who developed
the reaction at 1419 days. Fever occurred in 11 (61%) patients,
raised ALT in 6 (33%) and eosinophilia in 3 (17%). HLA-­B*5801 was
checked in 8 patients and all were positive. Steroid was given in
10 patients and IVIG in 4. The average length of hospital stay was
25 days (range 3–52) and eventually 4 (22%) patients died within
the same hospitalisation, all due to sepsis including pneumonia
and E coli septicaemia.
Conclusion: Gene testing before starting allopurinol has the poten-
tial to reduce one-­quarter of drug-­induced SCAR. Renal failure pa-
tients are at risk. “Go low go slow” strategy may not be valid.
3-­036 | P2X7R regulates the uptake of YO-­
PRO-­1 by macrophages in rats with acute gouty
arthritis
X. Dai; J. Tao; X. Fang; Y. Xia; X. Li; X. Li
Rheumatology and Immunology, the First Affiliated Hospital of University of
Science and Technology of China
Background/Purpose: ATP may be the second causative signal for
the onset of gout, which acts on P2X7R to regulate the develop-
ment of acute gouty arthritis. P2X7R has the ability to form a non-­
selective membrane pore, which is sufficient in macrophages to
allow passage of substances with a molecular weight of 900 kDa.
The aim of this study was to investigate the effect of P2X7R on the
uptake function of macrophages in rats with acute gouty arthritis.
Methods: 120 male Sprague-­Dawley rats were randomly divided
into 3 groups: After establishment of acute gouty arthritis model,
rats were given P2X7R agonist ATP, P2X7R inhibitor BBG and PBS,
respectively. The rats were sacrificed at 6, 12, 24, 48 and 72 hour
after treatment to obtain the spleens. The expression of P2X7R on
macrophages and the ability of macrophages to uptake YO-­PRO-­1
were detected by flow cytometry.
Results:
1. The expression of P2X7R on macrophages of each group in-
creased first and then decreased, and reached their highest
at 12 hours; at 12 and 24 hours, the expression of P2X7R in
ATP group was obviously higher than that in BBG group and
Control group(P = 0.000,0.019; P = 0.000,0.001), and BBG group
was lower than Control group(P = 0.012,0.004).
2. The ability of macrophages to uptake YO-PRO-1 in ATP and
Control groups was highest at 12 h, while the BBG group was re-
versed. At 12 and 24 hours, the ability of ATP group macrophages
to uptake YO-PRO-1 was significantly higher than that of BBG
group and Control group(P = 0.000,0.023; P = 0.001,0.031), fol-
lowed by Control group (P = 0.01), but at 24 h, there was no differ-
ence between BBG group and Control group(P > 0.05).
Conclusions: The expression of P2X7R on macrophages of rats with
acute gouty arthritis affected the ability of macrophages to uptake
YO-­PRO-­1, and the activation of P2X7R promoted the formation of
membrane pores in macrophages.
2-­075 | Patient perception of psoriatic arthritis
treatment and communication with physicians in
Australia: results from a patient survey
I. Lim1; K. Steinberg2; J. C. Cappelleri3; H. Ng4; D.
Witcombe 4; L. Fallon5
1
BJC Health; 2The Harris Poll; 3Pfizer Inc; 4Pfizer Australia; 5Pfizer Canada
Background/purpose: Psoriatic arthritis (PsA) is a complex disease
affecting multiple domains. A patient's perception of disease may
differ from their physician.
Objectives: To analyse patient perception of treatment and satisfaction
with physician communication among Australian patients with PsA.
Methods: A global patient-­based online survey was conducted (2
Nov 2017 to 12 Mar 2018). Eligible patients (≥18 years) had PsA
for >1 year, visited a rheumatologist/dermatologist in the past
12 months and reported using ≥1 synthetic/biologic DMARD for
PsA. Descriptive statistics are reported for patient demographics,
and satisfaction with treatment and physician communication for
Australian patients with PsA.
Results: In total, 152 patients from Australia responded: mean age
and time since diagnosis was 45.7 and 8.5 years respectively (Table).
 |
      127

Most patients considered a rheumatologist (76%) their main physi-
cian (dermatologist, 24%). Most (75%) were satisfied with their cur-
rent medication and 85% always/often took their PsA medication
as directed. However, most still experienced symptoms (previous
12 months, 97%), reported their overall health as poor/fair (on pre-
sent day, 71%), and would change something about their medica-
tion (93% [wanted fewer medications, 43%; change how well their
medication relieved musculoskeletal symptoms, 42%]). For patients
who visited a rheumatologist/dermatologist in the last 12 months,
most were satisfied (very/somewhat) with the communication with
their physician (rheumatologist, 85%; dermatologist, 94%), and be-
lieved that their physician worked well (very/somewhat) with them
to make treatment decisions (rheumatologist, 74%; dermatologist,
68%). However, most agreed (strongly/somewhat) that they wished
to discuss their treatment goals more with their physician (rheu-
matologist, 59%; dermatologist, 62%), and many were worried that
asking too many questions would make them appear difficult and
affect the quality of their care (rheumatologist, 48%; dermatologist,
49%).
Conclusion: Most patients with PsA in Australia were satisfied
with their medication and the communication with their physician.
However, many still experienced symptoms and wanted better com-
munication regarding their treatment.
Table. Demographics, disease characteristics and treatment satis-
faction of Australian patients with PsA
Respondents
(N = 152)a
Age (years), mean (SD) 45.7 (13.7)
Male, n (%) [N1]b 23 (59) [39]
In employment, n (%) [N1]b 27 (70) [39]
Time since PsA diagnosis (years), mean (SD) 8.5 (8.2)
Patients diagnosed with PsA before PsO, 6 (45) [12]
n (%) [N1]b
Overall current health – poor/fair, n (%) [N1]b, c 27 (71) [39]
Self-­reported PsA severity, n (%) [N1] b specificity in a US population of SLE patients. We sought to deter-
DMARD, disease-­
modifying antirheumatic drug; NSAID, non-­
steroidal anti-­inflammatory drug; PsA, psoriatic arthritis; PsO, pso-
riasis; SD, standard deviation; WB, weighted base.
All n numbers and percentages are shown to the nearest integer.
a
N represents the unweighted sample size of respondents, which re-
flects the total number of patients who completed the survey, while
all reported percentages are calculated based on the weighted base.
b
N1 represents the weighted base, which was used to bring raw data
for Australia in line with the proportion of the global population sur-
veyed. The weighted percentage is based on the relative size of the
general adult population in Australia compared with the global total
adult population of all countries surveyed.
c
Overall health on the present day.
d
This is the percentage of patients who experienced symptoms in
the last 12 months.
2-­125 | Assessment of a multiplex
autoantibody test, SLE-­KEY®, to rule out
systemic lupus erythematosus in Chinese
subjects
H. Ding1; N. Shen1; S. You2; R. Sorek3; S. Wallace 4; I.
Gluzman3; P. Lipsky5
1
Renji Hospital, Shanghai JiaoTong University School of Medicine; 2Kindstar Global
Co. Ltd; 3ImmunArray, Ltd.; 4ImmunArray, Inc.; 5RILITE Research Institute
Background/purpose: SLE diagnosis and classification can be chal-
lenging. Although a positive anti-­nuclear antibody test result (ANA)
is a classification criterion for SLE, recent data suggest the test is not
uniformly positive in subjects with established SLE. Furthermore,
different testing platforms can yield widely differing results. SLE-­
key®, a 160-­feature multiplex autoantibody test analyzing both IgG
and IgM antibodies against a diverse array of autoantigens was vali-
dated to rule out a diagnosis of SLE with 94% sensitivity and 75%

 Mild 11 (28) [39] mine whether SLE-­key® could effectively exclude a diagnosis of SLE
in the Chinese population.
 Moderate 24 (61) [39]
Methods: SLE samples (N = 202) from subjects meeting ACR clas-
 Severe 4 (11) [39]
sification criteria and Healthy Individual (HI) samples (N = 100) were
Current medication, n (%) [N1]b
obtained from the Shanghai Institute of Rheumatology, Shanghai,
 Biologic DMARD only 7 (19) [39]
PRC. Testing was performed in a clinical testing lab in Wuhan China
 Oral DMARD only 14 (36) [39]
using a 160 feature iCHIP® array. Images were obtained with the
 Biologic and oral DMARD 6 (16) [39] Agilent SureScan Dx Microarray Scanner and analyzed using the
 NSAID/steroids only 10 (27) [39] SLE-­key® Analyzer software.
 Satisfied with current PsA medication regimen, 28 (75) [38] Results: The US reference SLE cohort (N = 50) included Afro
n (%) [N1]b
Americans (53%), Caucasians (22%), White Hispanics (20%), Asians
 Still experience symptoms despite treatment, 37 (97) [38] (2%) and others (4%). Mean time post diagnosis was 1.0±1 year.
n (%) [N1]b, d
Mean disease duration of the Chinese cohort was 3.9 ± 0.5 years.
 Always/often take PsA medication exactly as 32 (85) [38]
100% had a documented positive ANA some time during the course
described by physician, n (%) [N1]b
of disease. The SLE-­key® test yielded a sensitivity of 87% and a spec-
 There is something they would change about 35 (93) [38]
ificity of 95% in this population (table 1). Results suggest that SLE-­
current PsA prescription medication, n (%) [N1]b
key® can effectively rule out SLE in Chinese subjects. Some Chinese
128      |
subjects with established SLE might require additional evaluation to
confirm SLE classification.
Conclusion: The SLE-­key® multiplex test can be used to rule out a
diagnosis of SLE in the Chinese patient population. The relatively
high specificity is very important since it can help rule out lupus,
reducing unnecessary referrals to already overburdened Chinese
rheumatologists.
Table 1
2-­0 09 | Opioid burden is reduced in lower back
pain inpatients admitted under rheumatology,
but not general medicine
B. Liu1; C. McMaster1,2; D. Liew1,2; A. Frauman1,2; E. Su1; E.
Joules1; P. Aminian1; R. Buchanan1,2
1
Austin Health; 2The University of Melbourne
Background: Low back pain is a common hospital presentation and
a strong indication for prescription of opioid-­based analgesia, with a
significant economic burden to Australian adults. Interventions for
patients presenting with low back pain varies according to a combi-
nation of underlying pathology and patient factors.
Objectives: We explored the trajectory and determinants of inpa-
tient opioid use for patients admitted for lumbar back pain.
Methods: We examined admissions to our hospital under rheuma-
tology and general medicine units between 1st July 2012 and 1st
July 2018, coded for lower back pain. Admissions less than 2 days
and those with fewer than 2 recorded pain scores were excluded.
Opioid doses were converted to oral morphine equivalent (OME).
Mixed-­effects models with bootstrap confidence intervals were
used to examine the time-­dependent trajectory of daily OME and
its relationship with patient factors and admitting unit. Model
selection was performed using analysis of variance. The paired
Wilcoxon test was used to test for unadjusted change in opioid use.
Results: 294 inpatient admissions were analysed (Table 1). Average
daily OME was 13.3 mg higher in rheumatology patients (95% CI
4.1–22.3). Whilst general medicine patients experienced no reduc-
tion in OME (95% CI −0.20 to 0.03), the rheumatology cohort had a
daily reduction of 1 mg/d (95% CI 0.6–1.4), or 7 mg/d by the end of
an average 7-­day admission. Higher pain scores (P < 0.01) and longer
length of stay (P < 0.01) were correlated with greater average OME,
but not age and gender. The unadjusted analysis revealed no change
in OME (Figure 1).
Conclusion: Rheumatology patients, but not general medicine pa-
tients, admitted for lower back pain experienced a reduction in opi-
oid burden through their inpatient admission. Demographics (age
and sex) were not correlated with opioid burden, however patients
with higher opioid burden had a longer length of stay.
2-­016 | Liposomes encapsulating calcitriol and
antigenic peptide modulate dendritic cells to
expand antigen-­specific regulatory T-­cells in vivo
and ex vivo
X. Liu; M. Talekar; H. Nel; N. Stone; R. Galea; R. Thomas
University of Queensland – Diamantina Institute
Background/purpose: Loss of immune tolerance is a key feature of
Rheumatoid Arthritis (RA). Dendritic cells (DCs) are regulators of in-
nate and adaptive immunity, and represent a target for induction of
antigen-­specific tolerance. 1α,25-­dihydroxyvitamin-­D3 (Calcitriol) is
a metabolite of Vitamin D3, which selectively suppresses RelB to
promote regulatory T-­cell (Treg) differentiation. Liposomes encapsu-
lating Calcitriol and RA autoantigen peptide (DEN-­181) are currently
in clinical trials.
Objectives: To determine the phenotype of liposome-­t argeted DCs
and their capacity to induce antigen-­specific Tregs.
Methods: For in vivo Treg expansion, OVA-­specific DO11.10 splenocytes
were transferred to BALB/c mice, and immunized subcutaneously (s.c.)
with OVA/QuilA 2-­days later. Liposomes (empty, OVA323 or OVA323/
Calcitriol) were administered s.c. on the day of priming and 1-­week later.
On day 12, Treg differentiation (CD4+CD25+Foxp3+) and T-­cell anergy
(CD4+Foxp3-CD73+ and IFNγ) were measured in the spleen and drain-
ing lymph nodes (dLNs) by flow cytometry (FACS). For ex vivo Treg ex-
pansion, mice were immunized with DiI-­labelled liposomes 3-­days after

OVA/QuilA prime. After 24 hours, DCs (CD19-MHCIIhiCD11c+) were
assessed phenotypically by flow cytometry, or sorted from dLNs and
co-­cultured with naïve or primed DO11.10 CD4+ T-­cells. Five days later,
Treg expansion was enumerated by flow cytometry.
Results: Fewer OVA-­specific T-­cells and significantly more OVA-­
specific Foxp3+ Tregs were recovered from OVA-­primed mice ad-
ministered with OVA323/Calcitriol liposomes compared to controls.
Treg induction required inclusion of Calcitriol in liposomes. A high
proportion of residual cells became anergic (increased CD73 expres-
sion and decreased IFNγ production). DCs taking up liposomes were
CD11b+PD-­L1hiCD80 hi. Calcitriol reduced their expression of MHC
class II and CD40. DCs isolated from OVA323/Calcitriol liposome-­
treated mice expanded significantly more antigen-­specific Tregs ex
vivo than control DCs.
Conclusion: Peptide/Calcitriol liposomes target myeloid PD-­
hi hi
L1 CD80 DCs in dLNs to promote antigen-­specific Treg expansion
in vivo and ex vivo. These Treg further regulate the expansion and
function of effector T-­cells.
3-­037 | Serum uric acid and serum bilirubin and
their association in Thai patients with Parkinson's
disease
C. Songsomboon1; S. Tanprawate2; A. Soontornpun2; C.
Wantaneeyawong2; W. Louthrenoo1
1
Division of Rheumatology, Faculty of Medicine, Chiang Mai University; 2Division
of Neurology, Faculty of Medicine, Chiang Mai University
Background: Low serum uric acid (SUA) is well known in Parkinson's
disease (PD) patients, but the association between serum bilirubin
and PD was inconclusive.
Objective: To determine the association between SUA and serum
bilirubin in Thai PD patients aged over 60 years.
Methods: This cross section study was performed between September
2015 and December 2016. The PD stage was determined by the
Hoehn-­Yahr (H&Y) scale, and motor and non-­motor function by the
Unified Parkinson's Disease Rating Scale (UPDRS). Clinical examina-
tion and laboratory tests were performed simultaneously.
Results: Sixty-­one PD patients (disease duration 5.62 ± 4.19 years)
and 135 controls participated. The PD patients were slightly older and
had more co-­morbidities. No difference in SUA was found between
the PD patients and controls, but serum uric acid/serum creatinine
(SUA/SCr) ratio was significantly lower (6.12 ± 1.34 vs. 6.82 ± 1.54,
P = 0.003) in the PD patients. Serum total and indirect bilirubin were
significantly higher in the PD patients than in controls (0.46 ± 0.21
vs. 0.38 ± 0.16 mg/dL, P = 0.003 and 0.26 ± 0.14 vs. 0.19 ± 0.11 mg/
dL, P < 0.001, respectively). No significant association was found be-
tween SUA, the SUA/SCr ratio, serum total or indirect bilirubin and
the H&Y scale, PD disease duration, or motor and non-­motor symp-
toms in the UPDRS. No significant correlation was found between
SUA or SUA/SCr ratio and serum total or indirect bilirubin.
|
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Conclusion: The SUA/SCr ratio associated negatively with Thai
PD patients aged over 60 years. The positive association between
serum total bilirubin and indirect bilirubin and PD is of interest and
needs further investigation.
2-­088 | Mild cognitive impairment in elderly
patients with rheumatoid arthritis
E. Maeshima1; K. Furukawa2; S. Maeshima3
1
Osaka University of Health and Sport Sciences; 2Kainan Iryo Center, 3Kinjo
University
Background: As the number of elderly patients with rheumatoid ar-
thritis (RA) increases, their cognitive decline is a growing concern.
This study aimed to determine the prevalence of mild cognitive im-
pairment (MCI) in elderly RA patients and to identify factors affect-
ing their cognitive functions.
Methods: This study included 31 RA patients aged 65 years or older
(RA group) and 64 local residents participating in the health promo-
tion program of our university (control group). The median age was 72
and 70.5 years, respectively, and the level of education was 12 years
in both groups. Cognitive functions were evaluated with the Japanese
version of the Montreal Cognitive Assessment (MoCA-­J). The preva-
lence of MCI was compared between the RA and control groups. In
the RA group, we also examined whether cognitive functions were
associated with age, disease duration, DAS28-­CRP, JHAQ score, the
Frenchay Activity Index (FAI), and treatment with PSL or DMARDs.
Results: The prevalence of MCI was 61.3% in the RA group and
87.5% in the control group, and it was significantly lower in the RA
group than in the control group (P = 0.033). Between patients with
and without MCI in the RA group, no significant differences were
observed in age, disease duration, DAS28-­CRP, JHAQ score, or FAI.
The total MoCA-­J scores were not correlated with age, disease du-
ration, DAS28-­CRP, or JHAQ scores, but were correlated with FAI
(ρ = 0.3955, P = 0.0411). Although the total MoCA-­J scores signifi-
cantly differed between patients treated with and without oral PSL,
no significant differences were observed between those treated
with and without oral MTX or bDMARDs.
Conclusion: Cognitive function was better preserved in the elderly
RA patients than in the local residents. The cognitive function of RA
patients were revealed to be affected by instrumental activities of
daily living and treatment with oral PSL.
1-­041 | Osteoarthritis in a community based
rheumatology practice: pattern, secular and
temporal trends 2007–2017
B. Manchanda; M. Saluja; K. Adam; R. Ghorpade; A.
Venugopalan; A. Chopra
Center for Rheumatic Diseases
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130      
Introduction: Osteoarthritis (OA) is often neglected and shunned in
hospital based rheumatology practice. About 30% of all musculo-
skeletal pains were attributed to OA and 4% to rheumatoid arthri-
tis (RA) in a COPCORD population survey in the Pune region (West
India); adjusted prevalence was urban 4.01 and rural 6.25 (Chopra et
al. J Rheumatol 2009). CRD Pune is a community center.
Objectives: To study the clinical pattern of community OA over time.
Methods: Patient records of OA (clinically classified) were extracted
from the CRD database. This was a cross-­sectional retrospective
study design with data pertaining to first rheumatology examination
(January 2007 to December 2017). The standard CRD case record
form used during the initial patient visit captures comprehensively
clinical, laboratory, radiological, functional and management data.
Standard Statistical software (SPSS v 9) was used.
Results: 43,913 patients’ records were scrutinized. OA was classified
in 21.6% subjects (male: female = 1:31): RA in 31 % subjects. Amongst
the OA, the dominant pattern was OA knees 94%, OA spine 67%, OA
hand (mostly DIP) 19.1%, primary generalized OA 18.7% and OA hip
0.2% (considered infrequent in oriental communities). The mean for
ESR (Westergren) and C-­reactive protein was 40 mm 12.7 mg/L. 7.2%
OA subjects belonged to age group 25–44 years (male: female = 1:25).
Co-­morbidity (OA) was hypertension 18%, diabetes 11.8 %, ischemic
heart disease 3.7%. The mean annual proportion of OA in the total
database was 23% during the period 2007–2009 and 26% during
2014–2017; correspondingly 30% and 34 % for RA.
Conclusion: This community based rheumatology practice
study showed a substantial burden of OA which was close to the
COPCORD report from the region. There was a modest rise in the
OA over time. The large number of young subjects and a somewhat
inflammatory nature (OA) needs further research. We need to deter-
mine risk factors.
3-­038 | The fury of gout remains unabated:
A large retrospective cohort analysis of indian
patients managed in a Community Rheumatology
Centre
B. Manchanda; M. Saluja; A. Mohan; N. Kulkarni; A.
Venugopalan; A. Chopra
Center for rheumatic diseases
Background/purpose: Data on gout in the Indian context is sparse.
A COPCORD India population survey reported a modest prevalence
(0.06 urban, 0.13 rural).
Objectives: To comprehensively study the clinical profile of gout in
the Indian community.
Methods: Data was extracted from a large patient database in CRD
(West India) created in 1996. CRD is a popular community center.
This was a cross-­sectional retrospective design study. The study
period was from January 2007 to December 2017. Asymptomatic
hyperuricemia was excluded. The diagnosis was clinical and study
data pertained to first rheumatologic examination.
Results: 585 patients’ records (male: female ratio = 12:1) were re-
trieved [45% rural, mean age 48 years (range 16-­92), mean disease
duration 78 months (range 3 days to 63 years): 5.8% family history
of gout. 10.4% patients consumed regular alcohol. 10-­15 % subjects
(Hindu ethnic) who were vegetarian since birth. 51% patients re-
ported classical podagra. 8.7% showed tophi -­common sites knee,
ankle, feet; ear was infrequent. The articular pattern was: 46% pol-
yarticular, 47% oligoarticular and 7% monoarticular: in 80% patients
with supporting radiological picture. 8.5% showed renal calculi and
renal derangement was found in 5% subjects: Other co-­existing dis-
eases were Hypertension 21.7%, Diabetes 5.6%, Hyperlipidemia
58.2% and ischemic heart disease 2.9%. An unusual co-­occurrence
of gout and RA was diagnosed in 22 patients. 35% subjects showed
hyperuricemia (8 mg% or more). Acute attacks were mostly managed
with NSAID and/or oral colchicines; steroids were infrequent. ~70%
patients required long term allopurinol; Febuxostat use was infre-
quent (<10%). Limitations include retrospective design and some
missing data (such as body mass index).
Conclusion: Though seemingly familiar, this study shows phenotypic
differences-­gender, clinical presentation, articular pattern, tophi and
co-­morbidity from classic text and published literature. We ought to
research and treat modifiable risk factors.
1-­118 | Remission in spondyloarthritis-­2 year
prospective study in a teaching hospital, South
India
A. Manivannan; D. Thiyagarajan; M. Murugan; S. Nallasivam
Velammal Medical College Hospital and Research Institute
Background: Spondyloarthritis (SpA) is a spectrum of inflammatory
arthritides in which ankylosing spondylitis (AS) is common, others
being uveitis, inflammatory bowel disease and psoriasis. Anti TNF
inhibitors, in addition to disease modifying drugs (DMARDS) have
transformed the treatment paradigm in SpA and help to maintain
good quality of life with disease remission.
Objectives: To study the clinical profile and remission of patients
with Spondyloarthritis and long term follow up with disease activity
indices.
Methods: All patients diagnosed with Spondyloarthritis, by
Assessment of Spondyloarthritis Society (ASAS) criteria, were
included in this prospective study, in two different centres of
Rheumatology over 2 year period. Clinical characteristics, MRI of
Sacroiliac joints, disease activity using BASDAI, BASFI (BATH AS
disease activity indices) and treatment response were assessed.
Other investigations like ESR, CRP, and screening for biologics were
done. Treatment included DMARDS, biosimilar DMARDs, NSAIDs,
physiotherapy and counselling. Compliance to treatment and regular
 |
      131

2-­037 | Willingness to avail of private

outpatient musculoskeletal health and wellness
services among elderly in an urbanized city in
Manila, Philippines
E. Manlulu1,2; Ma. E. Silva2
1
Philippine Rheumatology Association; 2Department of Health Policy and
Administration, College of Public Health, University of the Philippines Manila

Background/purpose: Ageing is associated with chronic pain due to

joint and bone diseases. Metabolic diseases among the aged height-
ens their experience of debilitating musculoskeletal pain. Joint and
bone (musculoskeletal) health and wellness involve promotive and
preventive strategies that lessen the impact of metabolic diseases
on musculoskeletal pain. The study described characteristics of the
elderly population from a highly urbanized city in terms of their joint
and bone health as well as their willingness to avail of musculoskel-
etal health and wellness outpatient services at a private hospital.
Methods: This research was a cross-­sectional study that utilized
quantitative techniques. A modified WHO-­ILAR COPCORD ques-
tionnaire was administered in Filipino to 84 elderly persons in a
highly urbanized city in the Philippines. Descriptive and analytical
statistics were generated.
review every 3 months was insisted. Remission is defined as low dis-
Results: Majority of the elderly respondents identified themselves to
ease activity and job retention.
be in a poor state of health. They shared that they experienced acute
Results: We studied 55 patients with mean age 32 years. M:F = 48:7
and chronic body pains. Consequently, most of them had limitations
(19 patients excluded due to lost to follow up). All had MRI spine and
in performing daily activities. Despite this, results showed that ma-
sacroiliac joints showing inflammation. HLA B27 was positive in 9/18
jority had good health-­seeking behavior and had access to healthcare
and raised ESR/CRP in 22/36. Low disease activity in 21/36, over
services. Results also suggested that there was unmet and urgent
the mean follow up of 1 year (as in Image1).Treatment modalities as
need for musculoskeletal health and wellness services. Although
in Table1.
half of them were unsatisfied with their experience as patients, 7
Extraskeletal manifestations such as panuveitis, dactylitis, iridocycli-
out of 10 indicated that they were still willing to avail of outpatient
tis, were observed in 20/36 patients. Those on biosimilar DMARDs
musculoskeletal health and wellness services in a pre-­identified pri-
showed very good disease remission with mean BASDAI 1.8 and
vate hospital within their locality. Their primary consideration was
BASFI 2.1 at the end of 12 months.
the hospital's location and affordable price. Awareness regarding the
Conclusion: Spondyloarthritis invariably manifest with inflamma-
availability of musculoskeletal health and wellness services was a sig-
tory back pain and radiological sacroileitis. Though they respond to
nificant factor associated with their willingness to avail (P-­value 0).
NSAIDs and DMARDs, biosimilars are very effective. Remission is
Conclusion: The elderly in a highly urbanized city in the Philippines
good with good quality of life in our cohort.
reported willingness to avail of musculoskeletal health and wellness
outpatient services in a private hospital within their locality and they
should be made aware of its availability.
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132      
2-­038 | The Australian arthritis & autoimmune
biobank collaborative (A3BC) & the Australian
rheumatology association database (ARAD)
L. March1,2; J. Munro3; C. Hill4; S. Lester4; C. Jackson1; M.
Xue1; M. Wechelakar5; T. Kenna6; H. Benham7; H. Keen8;
C. Willers1; C. Perera9; M. Lassere10; R. Buchbinder11; C.
Barrett12; G. Carroll8; D. Singh-Grewal13; J. Chaitow13; G.
Hassett14; I. Lim15; B. Richards16; R. Thomas7; M. Brown6;
W. Walter1; D. Chessman14; S. Oakley17; P. Sinnathurai1,2; P.
Youssef16; E. Coiera18; S. Chatfield19; J. Cobb3; P. Gowdie3; M.
Inouye20; C. Boros21; J. Ninan4; E. Pontifex5; S. Proudman22;
M. Rischmueller4; N. Adib23; P. Kubler24; J. Ng25; K. Murray26;
P. Walsh26; A. D. Raj9; R. Hannan9; A. Kelly9; K. Khoo9; T.
Tsai9; K. Tymms9; R. Black4; M. Cross1,2; T. Lynch1; L. Bereza-
Malcolm1; V. Chand27; A. Fletcher27; F. Marine28
1
Institute of Bone and Joint Research, University of Sydney; 2Royal North
Shore Hospital; 3Murdoch Children's Research Institute and the Royal
Children's Hospital, Murdoch Children's Research Institute (MCRI) and the
Royal Children's Hospital; 4Rheumatology Research Group, Basil Hetzel
Institute and the Queen Elizabeth Hospital; 5Rheumatology Unit, Flinders
Medical Centre, Flinders University; 6Institute for Health & Biomedical
Innovation, Queensland University of Technology; 7Rheumatology
Department, Princess Alexandra Hospital, Diamantina Institute; 8Harry
Perkins Institute of Medical Research, Royal Perth Hospital, Fiona Stanley
Hospital; 9Rheumatology Unit, Canberra Hospital and Health Services,
Australian National University; 10Department of Rheumatology, St
George Hospital, University of New South Wales; 11Department of Clinical
Epidemiology, Cabrini Medical Centre; 12Department of Rheumatology,
Redcliffe Public Hospital; 13Paediatrics and Paediatric Rheumatology, Sydney
Children's Hospitals Network; 14Rheumatology Department, Liverpool
Hospital and Ingham Institute of Applied Medical Research; 15BJC Health;
16
Rheumatology Department, Royal Prince Alfred Hospital and University of
Sydney; 17Department of Rheumatology, John Hunter Hospital; 18Australian
Institute of Health Innovation, Macquarie University; 19Walter & Eliza Hall
Institute of Medical Research; 20Systems Genomics, Baker Heart and Diabetes
Institute; 21Department of Paediatrics, Women's & Children's Hospital,
Robinson Research Institute, University of Adelaide; 22Rheumatology Unit,
Royal Adelaide Hospital, University of Adelaide; 23Paediatric Medicine and
Rheumatology, Wesley Hospital & Queensland Rheumatology Services;
24
Department of Rheumatology, Royal Brisbane and Women's Hospital;
25
Paradise Arthritis & Rheumatology, Gold Coast University Hospital;
26
Department of Paediatric Rheumatology, Perth Children's Hospital & Sir
Charles Gardiner Hospital; 27Department of Epidemiology and Preventive
Medicine, School of Public Health and Preventive Medicine, Monash
University; 28Arthritis Australia; 29Department of Rheumatology, Royal
Melbourne Hospital; 30Royal Perth Hospital, University of Western Australia
Background/purpose: A3BC is developing a national rheumatology
research network with biobanking infrastructure across eight state
nodes linked by a common registry – the new ARAD. It will create
and integrate a broad range of data from children and adults with
MSK and autoimmune diseases and aims to increase research out-
put into safer, more effective diagnostic and treatment strategies for
sufferers of MSK conditions.
Methods: The A3BC protocol was developed in consultation with
leading national and international stakeholders. The initial focus
is on people with RA, JIA, PsA, AS and PMR/Vasculitis, recruited
at 40 + sites, with blood/tissue/fluid/faeces collected at multi-
ple time-­points and stored at 8 nodes as plasma/serum/PBMCs/
DNA/RNA. Sjogren's, Scleroderma, SLE, Gout, OA and others are
intended for future. Participation is open to all. At a patient-­centric
level, biospecimens are integrated with multi-­
omic data, ARAD
questionnaires/PROMs (including diet/environmental), electronic
medical records, Commonwealth health (e.g. PBS, MBS), registries
(e.g. cancer), longitudinal/lifecourse data (e.g. ANZ CLARITY) and
consumer entry (My Health Record). The A3BC network, through
the founding philosophy of collaboration, increased recruitment
power, free on-­line data-­base, laboratory infrastructure nodes and
highly integrated data-­linkage capabilities, will enable the conduct of
multiple investigator-­initiated focussed research questions. Stored
data will provide a valuable resource for future researchers and en-
able big-­data and artificial intelligence mining for as yet unknown
associations.
Results: The A3BC protocol provides best-­practice, quality-­assured
methods to advocate for MSK research towards a cure. Current re-
view of recruitment experiences and positive support from patients,
consumer groups and participating rheumatologists, scientists and
orthopaedic surgeons demonstrates the protocol is fit-­for-­purpose.
Conclusion: The A3BC protocol will result in new dataset integration
systems, new multidisciplinary collaborations, and identification of
new risk factors, biomarkers and predictors of treatment responses.
It will improve patient outcomes by enabling innovative research
questions, faster translation and facilitating decision-­making in pre-
cision and preventive medicine.
2-­017 | Synergistic enhancement of IL-­
6 production by human peripheral blood
monocytes by anti-­Sm and anti-­RNP antibodies
Y. Matsueda; S. Hirohata; Y. Arinuma; T. Nagai; S. Tanaka; K.
Yamaoka
Kitasato University School of Medicine
Background/purpose: The present study was designed in order to
elucidate the roles of serum anti-­Sm antibodies in the pathogenesis
of systemic lupus erythematosus (SLE).
Methods: Highly purified peripheral blood monocytes obtained
from healthy donors were cultured in the presence of monoclo-
nal anti-­
S m antibody (anti-­
S m mAb), monoclonal anti-­
U1-­
R NP
antibody (anti-­R NP mAb) or control murine IgG1 or IgG3. After
various periods of incubation, levels of IL-­6 and TNF-­α in the cul-
ture supernatants were measured by ELISA and the expression of
mRNA for various molecules in monocytes was determined using
RT-­P CR.
Results: Flow cytometry analysis confirmed the bindings of anti-­Sm
mAb and anti-­RNP mAb on viable human monocytes. Both anti-­Sm
mAb and anti-­RNP mAb significantly increased the production of
IL-­6 and TNF-­α of human monocytes in a dose-­dependent manner,
although the latter was more potent than the former. of note, anti-­Sm
mAb synergistically enhanced the production and mRNA expression
of IL-­6 and TNF-­α of human monocytes in the presence of anti-­RNP
mAb. Finally, anti-­Sm mAb still upregulated the IL-­6 production of

monocytes in the presence of anti-­RNP mAb under the influence
of N-­acetyl cysteine that totally abrogated the IL-­6 production pro-
voked by anti-­Sm mAb alone in the absence of anti-­RNP mAb.
Conclusion: These results demonstrate that anti-­Sm and anti-­RNP
antibodies synergistically upregulate the expression of IL-­
6 and
TNF-­α in human monocytes. The data also suggest that the effect
of anti-­Sm in the synergy with anti-­RNP might not involve NFkB
activation.
1-­065 | Moyamoya syndrome in a 16 year old
Filipino female with active SLE: a case report
M. G. Mejia; C. Bernal
Cardinal Santos Medical Center
Background/purpose: Moyamoya Disease is a rare progressive
stenosis of the intracranial internal carotid artery or the proximal
anterior and middle cerebral artery. It has been associated with
some autoimmune diseases but very few reports on systemic lupus
erythematosus. This is the first case report on a Filipino SLE patient
with Moyamoya Syndrome.
Methods: This is a case report on a 16 year old, right handed, female,
with SLE, who had a sudden onset of left sided body weakness. She
was conscious, coherent, with no cognitive dysfunction. She had a
motor deficit on the left upper and lower extremities, accompanied
by sensory deficit on the left upper extremity. She showed evidence
of SLE flare with malar rash and oral ulcers.
Results: Cranial MRI showed multiple acute infarctions involving the
right frontal and parietal lobes, while cranial MRA revealed severe
narrowing of the intracranial segments of the internal carotid arter-
ies, anterior and middle cerebral arteries bilaterally. There was an
absence of flow across the left middle cerebral artery, with multiple
prominent collateral vasculatures bilaterally. Cerebral angiography
confirmed the presence a tuft of abnormal tiny vasculature adjacent
to the right and left internal carotid arteries, consistent with the
Moyamoya. Workup showed neither the presence of antiphospho-
lipid antibodies nor a concomitant cardiac pathology.
She was started on low dose Aspirin and Steroids plus
Hydroxychloroquine to control the disease flare. One month later,
she underwent Indirect Encephaloduroarteriopial Synangiosis, right,
which she tolerated well, with no new neurological deficit or residu-
als. She is scheduled to have the same type of procedure on the left
three months later.
Conclusion: This case presented a vasculopathy as a cause of a
neurological manifestation of SLE in a young female. Although the
course of the disease may be variable, immediate imaging and inter-
vention is of outmost importance on the onset of an ischemic attack.
|
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3-­055 | Infliximab for the treatment of
refractory Kawasaki disease in children: a meta-­
analysis
A. Melicor1; H. G. Agosto2; L. Dans1; L. P. Plucena1
1
University of the Philippines Philippine General Hospital; 2University of the
Philippines-­Manila College of Public Health
Background/purpose: Refractory Kawasaki Disease (KD) charac-
terized by persistent or recurrent fever after intravenous immuno-
globulin administration is associated with increased risk of coronary
artery aneurysm. Infliximab, an antibody specific for TNF-­alpha, is
one of many treatments currently being employed in refractory KD.
Objectives: To evaluate the efficacy and safety of Infliximab for re-
fractory Kawasaki Disease.
Methods: Extensive search of MEDLINE, EMBASE, Cochrane
Database of Systematic Reviews and Cochrane Register of Controlled
Trials, Clinicaltrials.gov, WHO ICTRP and Google scholar was done.
Randomized control trials comparing infliximab with intravenous im-
munoglobulin (IVIG) as second-­line treatment for KD were included.
Two authors did screening, quality assessment and data extraction.
Using Review Manager 5, the odds ratio and mean difference were
estimated with a 95% confidence interval in a fixed effects model.
Results: Three trials were included with a total of 98 participants. A sig-
nificant reduction in the incidence of treatment resistance was found
with Infliximab when compared to intravenous immunoglobulin. (OR
0.18, 95%CI: 0.06, 0.55, I2: 0%) with decreased number of adverse events
(OR 0.28, 95%CI: 0.09, 0.83, I2: 0%). However, there was no significant
difference in the over-­all incidence of coronary artery abnormalities (OR
0.44 95%CI: 0.08, 2.29, I2: 0%) between infliximab and intravenous im-
munoglobulin. Other outcomes including duration of clinical symptoms
(MD: −16.66, 95%CI: −35.35, 2.03) and length of hospital stay (MD: −1,
95%CI: −3.73, 1.73) were only reported by one study with no significant
reduction between infliximab and intravenous immunoglobulin.
Conclusion: Moderate-­quality evidence shows that infliximab is ef-
fective and safe in refractory Kawasaki Disease with decreased inci-
dence of treatment resistance and adverse effects. More studies are
needed to determine the effect of infliximab on coronary artery aneu-
rysms. Further studies are recommended with different interventions
to determine standard treatment for refractory Kawasaki Disease.
2-­048 | Safety of arthrocentesis in patients
receiving therapeutic anticoagulation with
warfarin and direct oral anticoagulants – a
retrospective study
M. Mian1; S. Shan2; P. Ramaraj1; C. McMaster1; R. R. C.
Buchanan1
1
Austin Health; 2University of Melbourne
Background: Arthrocentesis is commonly performed for diagnostic
indications and is often an investigation that needs to be performed
 |
134      
in a timely fashion. There is, however, often reluctance by health
professionals to perform this procedure in patients who are on anti-
coagulation at therapeutic levels. Our study aims to assess the safety
in patients on warfarin and direct oral anticoagulants (DOACs) at the
time of this procedure.
Methods: We conducted a retrospective review of arthrocentesis
procedures from May 2012 to May 2017 performed at Austin Health,
Melbourne, Australia. Data including demographic details, joint site
aspirated, coagulation studies, discharge diagnosis and aspirate cell
counts were collected. We assessed the incidence of early and late
clinically significant bleeding in or around the joint, infection, or any
re-­hospitalisations within 1 month of the procedure. We further com-
pared differences in joint aspirate cell counts in patients on DOACs
and warfarin.
Results: There were no immediate or late post-­procedure compli-
cations of the 108 patients who had an arthrocentesis procedure
while on therapeutic anticoagulation. 71 (65.7%) of patients were
male. The median age was 77 (IQR 66–84). 81 (75%) of these pa-
tients were taking warfarin with a median INR of 2.0 (IQR 1.5–2.6).
Crystal arthropathy was the principle diagnosis in 54% of patients,
while septic arthritis was successfully diagnosed in 16% of cases
following joint aspirate. There were no statistically significant dif-
ferences in aspirated erythrocyte cell count between warfarin and
DOACs (P = 0.06).
Conclusion: There were no immediate or late complications post ar-
throcentesis in patients on therapeutic anticoagulation highlighting
its safety in this invasive investigation. There were no significant dif-
ferences between joint aspirate erythrocyte cell counts.
1-­037 | Fine-­mapping of the NPEPPS
locus associated with ankylosing spondylitis
susceptibility in a European cohort
1,2 2 2 1 2
W. Midwinter ; Z. Li ; P. Leo ; J. Knight ; M. Brown
1
Wellcome Trust Centre for Human Genetics, University of Oxford;
2
Translational Genomics Group, Institute of Health and Biomedical Innovation,
Queensland University of Technology
Background/purpose: Ankylosing spondylitis (AS) is a chronic inflam-
matory arthritis primarily affecting the joints of the spine and pelvis. AS
affects ~1/200 individuals of European ancestry and its prevalence is
highly correlated with the HLA-B*27 allele but not all of the genetic risk
for this complex disease is explained by this association. at least 115
other susceptibility loci have been identified, with the NPEPPS locus
at 17q21 being implicated by multiple high impact studies. NPEPPS, a
cytosolic enzyme involved in the trimming of precursor-­peptides for
MHC class I presentation, is a likely candidate gene for this signal.
We aim to fine-­map the disease association signal at the NPEPPS
locus using computational methods to identify the potentially causa-
tive gene and variants for experimental validation.
Methods: Genotyping was performed on Illumina Infinium
CoreExome BeadChips for ~8000 AS cases and ~14500 controls
of European descent. Genotypes covering Chr17:45,000,000–
46,000,000 bp (GRCh37/hg19) were analysed in a case-­
control
manner using logistic regression in PLINK1.9. Conditional analysis of
the genome-­wide significant (GWS) SNPs was performed to assess
residual signal and prioritise variants controlling this association.
Subsequent annotation of functional elements from publically avail-
able databases was performed to identify overlaps with GWS SNPs.
Results: At the NPEPPS locus 96 SNPs were identified at genome-­
wide significance (P < 5 × 10−8), with rs4794057 as the lead SNP (risk
allele=T, OR = 0.88, P = 2.43 × 10−11). From a minimal residual set of
41 SNPs (P < 4.86 × 10−10), conditional analysis prioritised 5 SNPs
for further investigation; synonymous variant rs4794057, 5` variants
rs67919208 and rs8070463 (associated with multiple sclerosis), and
intergenic variants rs9901869 and rs11651766.
Conclusion: The key variants responsible for the signal at the NPEPPS
locus can be identified by computational analysis using a combina-
tion of statistical methods and genomic annotation. The variants
identified by these computational approaches require experimental
validation before their potential contribution to AS disease progres-
sion can be fully assessed.
1-­112 | The restoration of cellular proliferation
and characteristics of human tenocytes by
vitamin D
K. Min1; Y.-S. Choi2; J. M. Lee2; M. J. Kim2; D. G. Lee3
1
Rehabilitation Medicine, CHA University School of Medicine; 2Biotechnology,
CHA University; 3Rehabilitation Medicine, Yeungnam University
Background: Vitamin D (Vit D) increases calcium absorption in the
intestine after binding to the Vit D receptor (VDR). The VDR has also
been identified in muscle cells. Vit D supplementation resulted in
improved muscle strength. However, there is a paucity of studies of
the role of Vit D on tenocytes. We investigated the effects of Vit D
on damaged tenocytes.
Methods: Human tenocytes were treated with dexamethasone
(Dex) to induce cell injury. Expression of the tenocyte-­related mark-
ers tenomodulin (Tnmd), tenascin C (Tnc), scleraxis (Scx), mohawk
(Mkx), and collagen (Col) 1 and 3 were measured. Then, tenocytes
were cotreated with Vit D. 1-­α-­Hydroxylase and VDR were explored
in tenocytes.
Results: With 10 μM Dex, the growth of tenocytes was signifi-
cantly inhibited, and the gene expression of Tnmd, Tnc, Scx, Mkx,
Col 1 and 3 also decreased. When tenocytes were cotreated with
Vit D, cell proliferation recovered in a dose-­d ependent manner,
and the expression of TNMD and Col 1 improved. When study-
ing the mechanisms of the effects of Vit D on tenocytes, reactive
oxygen species produced by Dex decreased with Vit D, and the
phosphorylation of ERK and p38 was stimulated by Vit D cotreat-
ment. 1-­α-­Hydroxylase and VDR were found in tenocytes, indicat-
ing that the cells have the ability to use an inactive form of Vit D
and interact with it. Conclusion:

Vit D is known to perform diverse actions and its supplements or
exposure to sunlight might be a simple way to manage tendinopathy.
2-­089 | The associated factors for falls and
fear of falls in indian patients with rheumatoid
arthritis
P. Mishra
Era's Lucknow Medical College, Era University, Lucknow, India
Purpose: The Patients with rheumatoid arthritis (RA) have an in-
creased risk of fractures and falls compared to healthy controls. This is
because of the systemic effects of the disease, poor muscle and bone
strength and multiple deformities. Limited data exist in the literature
concerning the risk factors for falls in RA patients. We attempted to
determine factors associated with falls in Indian patients with RA.
Method: There were about 2000 (250 male, 1750 females, median age
50 years) patients enrolled in our study and were sent a uniform ques-
tionnaire as related to falls in the previous year. Logistic regression was
used to determine the association between variables and falls.
Results: Two Hundred (10%), 40 (2%), and 400 patients (20%) re-
ported at least one fall, multiple falls, and fear of falling, respec-
tively. Those who fell tended to report incident fractures during the
same 6 months compared to those who did not (15% versus 1.5%,
P < 0.001). In multivariate models, DAS 28 scores (odds ratios [OR]
1.52, 2.49, and 3.88), tender joint counts (OR 1.39, 1.72, and 1.36),
patient-­reported visual analog scale (VAS) for general health (OR
1.08, 1.16, and 1.20) and body mass index (BMI) (OR 1.05, 1.08, and
1.04) were associated (P < 0.05) with at least one fall, multiple falls,
and fear of falling, respectively. Other clinical variables (swollen joint
counts) and medications (methotrexate, leflunomide, methylpredni-
solone and hydrochloroquine sulfate were also associated with falls
and fear of falling. (Detailed results in table format will be presented)
Conclusion: DAS 28 score, tender joint counts, and impaired general
health appear to be associated with falls in Indian patients with RA
as previously reported in other ethnicities. BMI appears to be related
to falls and fear of falling in Indian patients with RA. This study de-
sign may not have been adequate to evaluate the efficacy of medi-
cations; further randomized controlled or prospective observational
studies are needed to conclude the associations.
3-­018 | The role of low socio-­economic status,
education and occupation in patients with
rheumatoid arthritis
P. Mishra
Era's Lucknow Medical College, Era University, Lucknow, India
Background: There are few studies evaluating community poverty
association with RA especially in an emerging economy like India.
In other chronic diseases, the poverty rate of one's community was
|
      135
found to be associated with disease prevalence and health status
outcomes independent of a person's education level.
Purpose: The aim of this study is to critically evaluate associations
between education, occupation, and community poverty with rheu-
matoid knee symptoms and radiographic knee RA parameters.
Method: A cross-­sectional analysis was conducted on 500 patients
with RA who resided in a district setting comprising of low income
and high income groups. Education (less than High School) and occu-
pation (physically demanding or not) were used as individual meas-
ures. The annual income of 1000 USD is used as defining criteria for
community poverty with about 250 patients selected with < 1000
USD annual income and rest 250 above it. Covariates included age,
gender, number of dependents and current smoking. Three out-
comes were assigned as a finding in one or both knee joints: r RA
defined as Larsen grade 2 and rheumatoid knee symptoms (pain,
swelling and stiffness). Multivariate analyses were also performed
adjusting for the covariates.
Results: In bivariate analyses with education and the covariates, less
than High School was significantly associated with r RA (OR equal to
1.3, CI 1.3, 1.5), symptoms (OR equal to 1.6, CI 1.5,1.9), and symp RA
(OR equal to 1.6, CI 1.3,2.0). In an urban group with > 20% poverty
was significantly associated with r RA (OR equal to 1.8, CI 1.3, 2.5)
and symp RA (OR equal to1.5 CI 1.1, 2.1) in bivariate analyses.
Conclusion: The community and individual Socio-­economic status
(SES) measures were independently associated with knee RA in this
population-­based study of individuals from a urban community.
1-­054 | The study of predictors of osteoporotic
fracture in rheumatoid arthritis
P. Mishra
Era's Lucknow Medical College, Era University, Lucknow, India
Purpose: Osteoporosis and osteoporotic fractures are commonly
associated with Rheumatoid Arthritis (RA). We assessed the as-
sociation between osteoporotic fractures and RA clinical fea-
tures, other organ damage and the impact of treatment, especially
corticosteroids.
Method: This is a large prospective cohort study of 500 RA pa-
tients, there were 200 osteoporotic fractures. Variables evaluated
were sociodemographic data, disease variables, clinical features,
Uveitis, the use of corticosteroids and other complications. Clinical
associates of fractures were determined by univariate and multi-
variate analyses.
Results:
In the best multivariable model, More than 3 major joint involve-
ment, smoking ever, uveitis, prednisone ever, pulse steroid ever and
obesity remained significant.
Conclusion: This study identified multiple risk factors for osteo-
porotic fracture in RA. Corticosteroid use (ever, current, pulse) was a
strong risk factor. This new study also identifies smoking, Uveitis and
polyarticular involvement as additional risk factors.
 |
136      

Factor Fracture Present No Fracture P-­value Odds Ratio (95% CI)

Smoking ever 45% 37% 0.0092 1.38 (1.09, 1.76)

More than 3 major joint involvement 65% 49% <0.0001 1.93 (1.51, 2.47)
Uveitis 23% 16% 0.0051 1.54 (1.15, 2.06)
Prednisone ever 91% 83% 0.0001 2.15 (1.43, 3.22)
Prednisone use currently 64% 53% 0.0004 1.54 (1.21, 1.97)
Pulse steroid ever 47% 33% <0.0001 1.79 (1.41, 2.28)
Obesity 50% 38% <0.0001 1.66 (1.30, 2.10)

1-­0 01 | The use of complementary and 3-­141 | NMR based serum metabolomics

alternative medicine by rheumatoid arthritis revealed distinctive metabolic Patterns of ANCA-­
patients in a University Hospital Clinic in India associated vasculitis
P. Mishra; V. Trivedi R. Misra1; G. G. Ekbote2; L. Gupta1; A. Jain1; U. Kumar3; R.
Era's Lucknow Medical College, Era University, Lucknow, India Raj3; A. Guleria3; R. Gupta2; D. Kumar2
1
S.G.P.G.I.M.S; 2The Medanta Hospital, Medicity; 3Centre for Biomedical
Research
Background: There is a paucity of data regarding the use of and
attitudes toward complementary and alternative medicine (CAM)
Background: Metabolomics, a hypothesis free approach, is an under
among rheumatoid arthritis (RA) patients in Asia, especially India
explored area to study pathogenesis of rheumatic diseases. In this
where these practices are highly prevalent. This study was per-
study we explore if there are any characteristic metabolomics ab-
formed to evaluate the pattern of utilization of CAM, related de-
normalities in sera of patients with ANCA associated vasculitis.
mographic and clinical factors, and attitudes among Indian RA
Objective: To identify if the serum metabolic perturbations associ-
patients. We focused on the CAM systems utilizing oral drugs and
ated with AAV patients are specific and different compared to other
acupuncture.
autoimmune inflammatory conditions such as TA and SLE.
Methods: We conducted a survey of patients in rheumatology
Methods: Sera of 54 AAV, 98 TA, and 49 SLE patients and 77
clinics affiliated with a university hospital. 250 patients suffer-
healthy controls (HC) were collected for metabolomics analysis.
ing from rheumatoid arthritis (RA), satisfying American College
The serum metabolic profiles were measured using 1D 1H-­CPMG
of Rheumatology (ACR) criteria were interviewed for the modali-
NMR experiments at high resolution 800 MHz NMR spectrometer
ties of therapy and drugs used. All patients have been diagnosed
and compared using multivariate partial least-­squares discrimi-
with RA more than 5 years back. We analysed prescriptions of
nant analysis (PLS-­DA, Figure 1A). The discriminatory metabolites
both conventional and CAM practitioners. Direct questionnaires
were identified based on variable importance in projection (VIP)
regarding CAM were avoided. Fifty two percent (130 patients)
statistics and further evaluated for statistical significance (P-­
had used CAM drugs and 60% of them had used more than two
value < 0.05). To access the degree of metabolic perturbation and
modalities.
phenotyping discrimination, we also performed the Random forest
Results: Ayurveda, homeopathy, Persian medicine and acupunc-
(RF) analysis (Figure 1B).
ture were the four common CAM utilized by the patients in that
order. About 80 percent patients using CAM believed conven-
tional medicine has no cure for RA and adverse reactions were
rare in CAM. These factors predominantly influenced their deci-
sion to use CAM. Family income, urban and rural living did not
influence usage of CAM. The use of CAM significantly increased
as the duration of disease increased. (Detailed results will be
presented).
Conclusion: The knowledge of CAM is essential to avoid drug inter-
actions, recognise their reactions and also appreciate their risks and
Figure 1: (A) PLS-­DA and (B) RF analysis of 1D 1H CPMG NMR spec-
benefits. ‘Alternative treatments’ play an important role as self pre-
tra of serum samples obtained from AAV, TA and SLE patients. The
scribed therapy in rheumatoid arthritis and their use should not be
RF analysis in (B) also involves normal control group for which the
ignored nor underestimated. A scientific scrutiny to these practices
error rate is coinciding with the overall error rate (in red line). The
and utilizing them carefully, if beneficial is needed.
different colors represent different study groups as labelled along
with their demographic characteristics in the inset table.

Results: An exquisite separation in the 2D score plot of PLS-­DA
between AAV (n = 54, mean age 46.5 years), TA (n = 98, mean age
27 years) and SLE (n = 49, mean age 33 years) patients clearly re-
vealed that the metabolic disturbances associated with AAV are
specific and different to TA and SLE (r2,0.8 and q2, 0.71) (Figure 1A).
Sera of AAV patients were characterized by increased serum lev-
els of N-­acetyl-­glycoproteins, lipid/membrane metabolites including
low/very-­low density lipoproteins (LDL/VLDL), PUFA, choline and
Glycerophosphocholine whereas, the serum levels of glucose and
various amino acids (including glutamate, histidine, valine, leucine
and isoleucine) were found to be decreased significantly compared
with both TA and SLE. Randon Forest (RF) classification analysis re-
vealed that the serum metabolic perturbations in AAV significantly
differed from SLE w.r.t TA (Figure 1B).
Conclusion: Sera of AAV patients had distinctive metabolomics
signature.
1-­022 | A comparative study of vitamin D
serum levels between patients with recurrent
aphthous stomatitis and normal subjects
N. Moghimy1; M. M. Jahrom2
1
Kurdistan University of Medical Sciences; 2Sina Hospital Rheumatology
Research Center Tehran University of Medical Sciences
Background: Recurrent aphthous stomatitis (RAS) is one of the most
painful inflammatory ulcerative conditions of oral mucosa that af-
fect the childhood and adolescent. According to a pilot study in Iran
the life time prevalence is 25.2%. Despite the high prevalence and
detailed investigation the etiopathogenesis of RAS is still unclear.
Because of expression of the VDR in immune cells and its immu-
nomodulatory effect, the aim of this study is to compare vitamin D
status in RAS patient and investigate the relationship of vitamin D
level with RAS severity.
Objectives: In this cross-­
sectional study, 110 Kurdish people in
which 54 patients with recurrent idiopathic aphthous stomatitis and
56 sex and age matched healthy controls were included.
Methods: Patients with more than three minor, major and herprti-
frm oral ulcers in a year without any known cause were deter-
mined as IRAS. The severity of RAS was assessed by, frequency of
episodes in month, number of ulcers in each attack and the healing
times of IRAS. 25-­hydroxy vitamin D level was measured by ELISA
method in patient and control groups. Demographic character-
istics and BMI of each person was recorded. Comparison mean
of quantitative variables between the independent groups is per-
formed by using unpaired t-­tests and one-­way analysis of variance
(ANOVA) test. A P-­value of less than 0.05 was considered to be
statistically significant.
Results: In present study the mean of vitamin D level in patient was
lower than control groups. (17.9 ± 8.87 vs. 20.35 ± 11.75) but it was
not significant. There was no correlation between, frequency of epi-
sodes, number of ulcers in each attack and the healing times of IRAS
|
      137
and vitamin D status. The BMI of control group was significantly
higher than patient group.
Conclusion: The present study suggests that vitamin D deficiency
and insufficiency is not a trigger factor of RAS onset and severity.
3-­019 | Relationship between BMI and quality
of life of with the severity diseases activity in
people with rheumatoid arthritis
N. Moghimy
Assistant Professor of Rheumatology, Kurdistan University of Medical Scienses
Background: Rheumatoid arthritis is a chronic and progressive dis-
ease of the joints that exhibits its systemic and joint symptoms, lead-
ing to functional, physical, psychological and social consequences.
For this reason, recent attention has been paid to the quality of life
of chronic diseases and research in this field. Improvement in treat-
ment has increased.
Objectives: The aim of this study was to determine the quality of life in
physical aspects, social relationships and environmental effects in pa-
tients with rheumatoid arthritis and the effect of body mass index on se-
verity of diseases activity based on DAS28 and quality of life in patients.
Methods: This descriptive-­analytical study was performed in 2017.
A total of 195 rheumatoid arthritis patients were selected using con-
venience sampling method at tohid Hospital of sanandaj, Iran. The
data collection tools included demographic and clinical factors, and
36-­Item Short Form QOL questionnaires. Data were analyzed by
SPSS 22 using univariate and multivariate regression analyses.
Results: The findings showed that the quality of life score of peo-
ple with rheumatoid arthritis in the field of health changes was
the highest score and the role of limitation of role was the lowest
due to physical health. There was also a significant relationship be-
tween education, severity of disease and BMI with quality of life
(pv = 0.0001), but there was no significant relationship between BMI
and severity of disease (pv = 0.35).
Conclusion: The findings suggested the impact of contextual factors
associated with the disease on patients’ quality of life. Therefore,
they can be applied in designing training programs to improve pa-
tients’ quality of life.
2-­127 | Anti-­C1q antibodies in Malaysia's lupus
nephritis and non-­lupus nephritis patients: a
single centre experience
M. S. M. Said; S. W. Yi; A. A. Nordin; S. N. Kamaruzaman; A.
N. Azman; S. N. A. M. Ayob; A. A. Wahab; R. Mustafar; H.
Ismail
University Kebangsaan Malaysia
Background and aims: The objective of this study is to determine the
levels of anti-­C1q antibodies in Lupus Nephritis (LN) and Non-­Lupus
 |
138      
Nephritis (Non-­LN) with relation to the disease activity, target or-
gans damage and various treatments conferred to the patients.
Materials and Methods: Blood samples and information were ob-
tained in a prospective case control study from 74 SLE patients taken
from clinics and ward. Patients who were aged less than 18 years
old, positive family history, HIV positive, pregnant, and having acute
infections was excluded. The samples were then analysed for anti-­
C1q antibodies level using ELISA.
Results: The median anti-­C1q antibodies level for the study popu-
lation was 0 U/mL, there were 38 LN and 36 non-­
LN patients.
However, there were no statistical significance comparing anti-­
C1q antibodies between LN and non-­LN (P = 0.105). The median
anti-­C1q antibodies levels for LN was 0 U/mL (IQR 8.39) while for
non-­LN was 0.58 U/mL (IQR 13.99). In LN group, anti-­C1q antibod-
ies showed statistical significant association with disease activity
(P = 0.028) and organ damage index (P = 0.017). While in non-­LN,
anti-­C1q antibodies showed no significant association with disease
activity (P = 1.0) and organ damage index (P = 0.502). In both LN
and non-­LN, treatments with various immunosuppressants, ethnics
group and gender showed no statistical significance (P > 0.05).
Conclusion: Serum levels of anti-­C1q antibodies showed statistical
significant association with severity of disease and end organ damage
index in LN patients. However, we did not see the associations in non-
­LN patients. Thus, anti-­C1q antibodies may have a role in assessment
of severity of disease and end organ damage index in LN patients.
Keywords: C1q, complements, lupus nephritis, medications, sys-
temic lupus erythematosus
3-­039 | Cross sectional study of carotid intima
media thickness in gouty arthritis patients with
low framingham risk score
1 2 1 1
M. S. M. Said ; H. Aziz ; S. S. Shaharir ; O. Masakon ; S.
Majedah1
1 2
University Kebangsaan Malaysia; Kementrian Kesihatan Malaysia
Introduction: GA has a strong association with metabolic syndrome,
obesity, insulin resistence, hypertension and dyslipidaemia (1,2).
Objective: To compare the CIMT in gouty arthritis (GA) patients with
low Framingham risk score, with normal control.
Methodology: Study design: Comparative Cross Sectional Study.
Study population: GA patients attending Rheumatology Clinic
Pusat Perubatan Universiti Kebangsaan Malaysia. Age and gender-­
matched healthy control with similar inclusion and exclusion criteria
will be recruited.
Inclusion criteria: GA patients whose age should be older than
18 years old but younger than 55 years old. The Framingham Risk
score is less than 10% risk of cardiovascular disease in 10 years,
under low risk category.
Exclusion criteria: Coronary heart disease, heart failure, inflamma-
tory diseases, chronic kidney disease, cerebrovascular events and
peripheral artery disease.
Results: There was no significant difference of CIMT between
gouty arthritis patients and healthy controls. The median of CIMT
for gout was 0.50 mm (IQR 0.20), and healthy controls was 0.55 mm
(IQR 0.16) (p value 0.79). In this study, the measured CIMT were
not thickened for both patients and controls. Gouty arthritis pa-
tients had significantly higher diastolic blood pressure of 80 mmHg
(IQR 12) as compared to the healthy controls, 72 mmHg (IQR 14) (p
value 0.01). Apart from that, the body mass index, total cholesterol,
serum high density lipoprotein (HDL) and serum uric acid were also
higher among gout patients as compared to the healthy controls (all
P < 0.05). On univariate analysis, age and Framingham scores had
significant correlation with CIMT among gouty arthritis patients.
Conclusion: It can be concluded that gouty arthritis was not associ-
ated with subclinical atherosclerosis in patients with low Framingham
risks.
References: 1. Kuo CF, See LC, Luo SF, Ko YS, Hwang JS, Lin CM,
Chen HW, Yu KH. Gout: an independent risk factor for all-­cause and
cardiovascular mortality. Rheumatology 2010; 49:141-­6.
2. Abbot RD, Brand FN, et al. Gout and Coronary Heart Disease: the
Framingham Study. J ClinEpidemiol1988; 41(3):237-­242.
3. Tzou WS, Douglas PS, et al. PrevCardiol 2007; 10:181-­9.
2-­076 | Pattern and profile of psoriatic arthritis
in a community based referral practice over a
decade (2007–2017)
A. Mohan1,2; A. Jain1; K. Adam1; N. Nahar1,3; A.
Venugopalan1; A. Chopra1
1
Center for Rheumatic Diseases; 2Caritas Hospital; 3Arham Rheumatology
Center
Introduction: Data on psoriatic arthritis (PsA) in the Indian commu-
nity is sparse. Very few population surveys (COPCORD) reported
PsA (Chopra A. Ind J Rheum 2015) We decided to study the clinical
phenotype of PsA in patients examined in CRD which is a community
based popular rheumatology centre.
Methods: This was a cross-­sectional retrospective design study of
patient records from 01 Jan 2007–31 Dec 2017. Data was extracted
from a comprehensive referral database in CRD, maintained since
1996. Data on first examination was considered.
Results: Psoriatic arthritis was classified in 0.9% (male: female ra-
tion = 12 :1) of the total patient records (n = 58,439). The mean
age was 45.1 years (range 14–97) and the mean duration of dis-
ease was 6 years (range 15 days to 45 years). 14.8% used tobacco.
The phenotypic pattern seen were: 20% oligoarticular, 58% pol-
yarticular, and 7.2% axial only, 14.7% axial plus peripheral arthritis.
Substantial DIP arthritis was evident in 18% patients. The follow-
ing co-­m orbidities were seen: hypertension in 59.7%, diabetes in
32.3%, hypothyroidism in 12.2%, ischemic heart disease in 6.4% &
dyslipidemia in 15.82. Over 80% had plaque skin psoriasis (diffuse
lesion in <30%). Psoriasis of Scalp and other sanctuary sites were
often missed by referring doctors. Co-­m orbidities were mostly

associated with peripheral arthritis; only 10.1% patients with
Spondyloarthritis (Axial) showed co-­m orbidities. Further data on
nail disease/DIP disease and IHD and hyperlipidemia, serum (RF,
anti-­CCP) and other lab parameters (ESR, serum uric acid) will be
presented. 
Conclusion: There is a substantial burden of PsA in routine rheu-
matology practice and patients show a wide phenotype spectrum.
Psoriatic patients need to screened for cardiovascular morbidity and
metabolic disorders.
2-­018 | Vitamin D supplementation improves
disease severity, suppresses interferon-­α in SLE:
a longitudinal study
1 1 2 3
S. Mohapatra ; R. Tripathy ; A. K. Panda ; R. Patro ; S. R.
Tripathy1; M. K. Parida1; B. K. Das1
1 2 3
Scb Medical College, Cuttack, Odisha, India; Khallikote University; Institute
of Life Sciences
Background: Role of Vitamin D has been demonstrated in treatment of
various autoimmune diseases for its immunomodulatory effect, includ-
ing SLE. In the present investigation, we enrolled patients from Odisha,
India, assessed vitamin D status and scored different clinical and bio-
chemical phenotypes before and after vitamin D supplementation.
Methods: SLE patients (n 
= 83), reported to Department of
Rheumatology, SCB Medical College, Cuttack and fulfilled SLICC
criteria, were enrolled. All patients were treated with standardized
treatment protocol and along with received oral cholecalciferol
60,000 IU/wk for 3 months followed by 2000 IU/d for 3 months.
Patients were advised to report at 3 and 6 months. Disease activity
was measured by SLEDAI and ACR/SLICC damage index. Vitamin D
levels were measured by ELISA. Other biochemical parameters (C3,
C4 and anti-­ds DNA) were quantified by standard laboratory proce-
dure. Expression of IFNα gene was measured using QT-­PCR on blood
samples of first 25 SLE patients compared (using the delta-­delta Ct
method) at baseline and at 2nd follow-­up (6 months) and in 25 age
and sex-­matched healthy controls.
Results: The mean 25 (OH) vitamin D level of patients sig-
nificantly elevated in 3 
months (48.5 
± 28 
ng/mL) (P < 0.0001)
and 6 months (37.2 ± 25.1 ng/mL) (P < 0.0001) compared with
baseline (21.6 
± 12.6 
ng/mL). Interestingly, SLEDAI scores sig-
nificantly reduced in 3 
months (1.85 
± 2.5) (P = 0.0009) and
6 months (1.5 ± 2) (P < 0.0001) of therapy compared with base-
line (3.19 ± 2.5). Furthermore, C3 significantly elevated during
follow-­up time (3 months: 116.9 ± 55.4 mg/dL; P = 0.005 and
6 months: 118.6 ± 50.2 mg/dL; P = 0.002) compared to baseline
(93.1 ± 40.5 mg/dL). The expression for IFNα was higher in SLE
baseline samples compared to healthy control and 2nd follow-­up
subjects (Vit-­D treated) samples (P = 0.0489).
Conclusion: Vitamin D supplementation significantly increases
plasma levels of vitamin D, reduces IFNα and improves clinical con-
dition (SLEDAI) of SLE patients.
|
      139
1-­023 | An interdisciplinary diagnostic
challenge: a case of atypical Cogan's syndrome
D. M. Suahilai; M. H. Mustapha; N. Zainudin; M. Mohd Zain;
A. Ahmad
Hospital Selayang
Background: Cogan's syndrome is a rare presumed autoimmune
disorder characterized by interstitial keratitis with progressive vesti-
buloauditory dysfunction and symptoms of systemic disease. While
atypical Cogan's syndromes include other forms of inflammatory eye
and inner ear disease.
Objectives: To describe a case of atypical Cogan's syndrome in a
35-­year-­old woman who developed bilateral sensorineural hearing
loss accompanied by panuveitis and renal impairment.
Methods: Retrospective case report.
Results: A previously well 35-­year woman presenting with 4 weeks
history of fever, cervical lymphadenopathy and weight loss sought
treatment at the otolaryngology clinic. Tuberculosis and malignancy
have rule out by excision biopsy of the lymph node. She was treated
for lymphadenitis which responded well to a course of antibiotic.
3 months later, she developed redness over bilateral eyes with blur-
ring of vision. She also complained of skin nodules and arthritis. Eye
examination confirm present of bilateral panuveitis. Skin biopsy was
inconclusive. at that time, a deterioration of her hearing ability was
also diagnosed. Audiometry confirmed present of moderate bilateral
sensorineural hearing loss.
Investigations revealed normocytic, normochromic anaemia with
haemoglobin 9.0 g/dL (11.5–15.5 g/dL), elevated white count of
16 × 109/L (86% neutrophils), ESR 117 mm/h (0–15 mm/h), CRP
20 mg/L (<5 mg/L) and creatinine 190 mmol/L (30–90 mmol/L).
Workup for infections was negative, including negative screen-
ing for: HIV, EBV, CMV, adenovirus, Mycoplasma pneumonia and
Mycobacterium tuberculosis. The following tests were also nega-
tive: ANA, ANCA and Rheumatoid factor. An ultrasound scan of the
kidneys and chest X-­ray were normal.
The diagnosis of atypical Cogan's syndrome was arrived at the basis
of clinical presentation. The treatment with systemic corticosteroids
was started. She responded well to treatment and her repeat audi-
ometry at 6 months post treatment was normal. Her renal function
normalized, and the uveitis remained in remission.
Conclusion: Prompt recognition and treatment with corticosteroids
may result in functional hearing and renal improvement as in this case.
2-­129 | Effect of the metabolic syndrome on
incident vascular events and mortality in four
rheumatic diseases: an 8-­year longitudinal analysis
C. C. Mok; C. S. Chu; L. Y. Ho; K. Chan; S. M. Tse; C. H. To
Tuen Mun Hospital
Objective: To study the effect of the metabolic syndrome (MetS) on
incident vascular events and mortality in four rheumatic diseases.
 |
140      

Design: A longitudinal 8-­year study.
Patients and methods: Consecutive patients who fulfilled the
1997 ACR criteria for systemic lupus erythematosus (SLE), 2010
EULAR/ACR criteria for rheumatoid arthritis (RA), ASAS criteria
for spondyloarthritis (SpA) and the CASPAR criteria for psoriatic
arthritis (PSA) were recruited in a 10-­month period in 2009/2010.
at baseline, recruited patients had the following measurements:
body weight, height, waist circumference, blood pressure and
fasting blood for assay of glucose and lipid (total cholesterol, HDL
and LDL cholesterol, triglyceride). The MetS was defined by the
updated joint consensus criteria, using the Asian criteria for cen-
tral obesity, when ≥3 of the following components were present:
(1) Increased waist circumference to ≥90 cm in men or ≥80 cm in
women; (2) Elevated blood pressure to ≥130/85 mmHg or requiring
drug therapy; (3) Elevated serum triglyceride level to ≥1.7 mmol/L;
(4) Reduced serum high density lipoprotein (HDL)-­cholesterol to
≤1.0 mmol/L in men and 1.3 mmol/L in women; and (5) Elevated
fasting glucose level to ≥5.6 mmol/L. Patients were followed lon-
after adjustment for the same covariates. Factors independently
associated with all-­cause mortality were increasing age (HR 1.12
[1.10–1.14] per year; P < 0.001), ever smoking (HR 3.26 [1.82–5.84];
P < 0.001) and a diagnosis of SLE (HR 3.18 [1.88–5.37] vs non-­SLE;
P < 0.001).
Conclusions: MetS is common in patients with rheumatic diseases.
The presence of the MetS increases the risk of new cardiovascular
events in these patients over 8 years, which is independent of the
underlying rheumatic disease and other risk factors. The MetS is
not independently associated with mortality in these four rheu-
matic diseases.
2-­0 01 | A case of IgG4 related disease with
vasculitis
K. W. Moon
Kangwon National University Hospital

gitudinally for the occurrence of new vascular events and mortal-

ity. Comparison was made between those with and without the A 73-­y ear-­o ld man visited our clinic due to general weakness, fa-
MetS at baseline. Cox regression analysis was performed for the tigue, and anorexia since 3 months ago. He reported weight loss
effect of MetS on incident vascular events and mortality adjusted by 14 kg during last 2 months. He has no history of thromboem-
for other confounding factors. bolic events. His laboratory results showed ESR and CRP were
Results: 1497 patients were studied (693 RA, 577 SLE, 121 elevated, ANA and lupus anticoagulant were positive. Serum IgG
SpA and 106 PSA). The mean age at baseline was highest in RA and IgG4 level were also elevated. Abdominal computed tomog-
(53.4 ± 12.0 years) and lowest in SpA patients (39.0 ± 11.9 years). raphy (CT) revealed that peripancreatic fatty infiltration, dilated
Disease duration was longest in SLE (9.3 ± 7.2 years) and shortest in bile duct, wall thickening of infrarenal abdominal aorta and both
PSA patients (3.6 ± 3.2 years) at entry. The MetS was present in 137 common iliac arteries (Fig. 1). Gastroscopic biopsy was done and
RA (20%), 85 SLE (15%), 13 SpA (11%) and 39 PSA (37%) patients, some IgG4 positive inflammatory cells were noted in lamina pro-
respectively. Patients with arthritis were followed for 96 months pria at duodenum. He was diagnosed as IgG4 related disease
whereas SLE patients were followed for 90 months. New cardio- with vasculitis. So we initiated oral prednisolone (40 mg/d) for
vascular (acute coronary syndrome or angina) and cerebrovascular 4 weeks. Then the dosage of oral prednisolone is reducing by
(ischemic stroke or transient ischemic attack) events developed in 51 5 mg every 1 week, and now he takes prednisolone 5 mg/d. His
and 29 patients, respectively. The incidence of new vascular events
(per 100 patient-­years) was highest in RA patients (0.84), followed
by PSA (0.71), SLE (0.67) and SpA (0.62). There were 99 deaths, of
which 12 were directly due to vascular events (vascular deaths). The
mortality rate (per 100 patient-­years) was highest in RA patients
(1.04), followed by SLE (0.93), PSA (0.24) and SpA (0.21). Patients
with the MetS at entry had significantly higher rates of vascular
events (9.5% vs 4.8%; P = 0.003), all-­cause mortality (11.4% vs 5.6%;
P < 0.001) and vascular mortality (2.2% vs 0.5%; P = 0.004) than
those without MetS. Cox regression analysis showed that the MetS
was independently associated with new cardiovascular events (HR
1.98 [1.08–3.63]; P = 0.03) or any vascular events (HR 1.64 [1.01–
2.66]; P = 0.04), after adjustment for age, sex, duration of underlying
disease, ever smoking, LDL >2.6 mmol/L and underlying disease (SLE
vs non-­SLE). A diagnosis of SLE (vs non-­SLE) was independently as-
sociated with new cerebrovascular events in a separate Cox regres-
sion model (HR 4.66 [1.80–12.1]; P = 0.002). The MetS, however,
was not significantly associated with new cerebrovascular events
(HR 1.74 [0.76–3.97]; P = 0.19), all-­cause mortality (HR 1.33 [0.85–
2.07]; P = 0.21) or vascular mortality (HR 2.91 [0.89–9.51; P = 0.08) Figure 1. Direct comparison of CT with after steroid therapy
 |
      141

symptom was improved, and subsequent CT showed that de- 2-­111 | Discrepancies in clinical characteristics
creased volume of pancreas and slightly decreased wall thicken-
between cancer-­and non-­cancer associated
ing of aorta.
anti-­melanoma differentiation-­associated
CT images conducted at diagnosis showed diffuse mild peri-
pancreatic infiltration around the whole pancreas (A), diffuse wall
gene 5-­associated dermatomyositis in a Thai
thickening of infrarenal abdominal aorta (B). Interval decreased University Hospital
volume of the pancreas and slightly decreased extent of mild peri- S. Muennuch; P. Ngamjanyaporn
pancreatic fat infiltration, Interval decreased extent of bile duct Ramathibodi Hospital
dilatation (C, D).
Background: Dermatomyositis (DM) with anti-­
M elanoma
Differentiation-­
A ssociated Gene 5 (MDA5) antibody has dis-
3-­068 | Expression of antidrug antibodies to tinct clinical characteristics including clinically amyopathic DM
adalimumab monotherapy has no influence on (CADM), skin ulcerations, and rapidly progressive interstitial lung
improvement of joint inflammation: subanalysis disease (RP-­ILD). Previous report showed low incidence of cancer

of the CHANGE study in CADM. This study aimed to characterize the differences be-
tween anti-­MDA5-­associated DM in patients with and without
D. Furtner1; Y. Hasegawa2; T. Mosch2
malignancy.
1
Abbvie Pty Ltd; 2Abbvie GK
Methods: Twelve DM patients with positive anti-­MDA5 antibody by
immunoblotting assay, who were followed-­up at Ramathibodi hos-
Background/purpose: Clinical factors associated with the occur-
pital, Mahidol University between December 2015 and April 2018
rence of anti-­drug antibodies (ADAbs) to anti-­TNF-­alpha monother-
were retrospectively identified. Demographic data, clinical presen-
apy have been insufficiently described to date.
tation, diagnosis of cancer, and outcome were collected.
Objective: To identify clinical and treatment related factors of ADAb
Results: Two female patients (16.7%) (average age 42.0 years) were
expression before and after treatment with adalimumab monother-
diagnosed with stage I cervical adenocarcinoma and stage IIIa breast
apy in Japanese patients with rheumtoid arthritis.
cancer in concurrent with DM. Skin ulcers were exclusively found
Methods: Subanalysis of the previously published phase 2b/3
in 4 non-­cancer patients (40%). Six non-­cancer patients (60%) had
CHANGE study. Positivity of any ADAbs was analyzed using
amyopathic and hypomyopathic DM. of the cancer patients, one had
Pearson's chi-­square test. The relationship between baseline CRP
grade 2 Medical Research Council (MRC) muscle strength with cre-
levels and ACR responses was analyzed using logistic regression
atinine kinase (CK) level 11,454 U/L, while another had grade 4 mus-
analyses. Improvements in CRP levels, TJC, and SJC after treatment
cle strength and CK level 109 U/L. The mean CK level was 265.3 U/L
were analyzed using the Wilcoxon rank-­sum test.
in non-­cancer group. Both cancer patients recieved cancer specific
Results: In the CHANGE study 44.0% of patients in the 40-­mg
treatment along with corticosteroid, resulted in recovery of muscle
adalimumab monotherapy dose group and 26.4% in the 80-­mg adal-
strength. No ILD was found in cancer patients, while it was found in 8
imumab group tested positive for any ADAb at least once through-
(80%) of non-­cancer patients. Five (62.5%) of ILD patients died from
out the observation period. The baseline CRP level (P = 0.0117) and
RP-­ILD, with the mean survival time of 2 months after DM diagnosis.
adalimumab dose were identified as general factors related to the
The mortality rate was 0% in cancer group and 50% in non-­cancer
development of ADAbs, with patients on adalimumab 80-­mg hav-
group.
ing lower ADAb positive ratios than those on adalimumab 40-­mg
Conclusion: Anti-­M DA5 associated DM patients with coexisting
(P = 0.0075). A higher number of SJC and TJC at baseline was asso-
cancer share clinical characteristics of classic DM and demon-
ciated with an increased risk of ADAbs. ADAb expression did not af-
strated better prognosis. The incidence rate of cancer in anti-­
fect the improvement in joint symptoms for the 80 mg group (SJC:
MDA5 associated DM is indispensable; hence, cancer screening
P = 0.9131 and TJC: P = 1.000) and for the 40 mg group in regards
should be implemented regardless of antibody subtypes.
to TJC (P = 0.0556).
Nonetheless, active detection and management strategy for life-­
Conclusion: CRP level and a high number of swollen and tender
threatening RP-­ILD should be emphasized in anti-­M DA5 associ-
joints at baseline are related to ADAb expression. The improvement
ated DM patients.
of tender joints through adalimumab monotherapy is not affected by
ADAb expression.
 |
142      
2-­019 | Human mesenchymal stem cells
induce the expression of CD4+ CD25+ FoxP3+
programmed cell death-­1+ regulatory T cells
1,2 1,2 1,2
C. H. Mun ; Y. D. Shin ; Y.-B. Park
1
Division of Rheumatology, Department of Internal Medicine, Yonsei University
College of Medicine; 2Brain Korea 21 PLUS Project for Medical Science, Yonsei
University College of Medicine
Background: Mesenchymal stem cells (MSCs) have profound im-
munomodulatory properties. Using their properties, MSCs-­based
therapies have been applied in several inflammatory diseases. The
immune modulation of MSCs is related to inhibition of immune cell
proliferation and activation. T cells are critical effe12ctor immune
cells in affecting and regulating immune response and can differ-
entiate into one of several subtypes, including TH1, TH2, TH17 or
regulatory T cells (Tregs). In this study, we investigated the immu-
nomodulatory property of MSCs on T cells.
Methods: We co-­cultured human bone marrow-­derived MSCs (BM-­
MSCs) and mouse CD4+ T cells directly. The effect of BM-­MSCs on
T cell differentiation was assessed by T cell subtype markers by flow
cytometry, and supernatants for induced production of cytokines.
Gene and protein expressions were analyzed by qRT-­PCR and west-
ern blot, respectively. in addition, immunohistochemistry and Tregs
suppression assay were performed in inflammatory tissues in col-
lagen induced arthritis (CIA) mice.
Results: The expressions of CD4+CD25+FoxP3+PD-­1+ Tregs were
highly induced in co-­culture condition. Human BM-­MSCs signifi-
cantly induced the Tregs by increasing programmed cell death-­1 (PD-­
1) and Neuropilin-­1 (Nrp-­1) expressions in vitro. However, human
BM-­MSCs did not induce the FoxP3+ Tregs in the splenic CD4+ T
cells from PD-­1-/- mice. Moreover, immunohistochemical analysis of
inflamed tissues in BM-­MSC treated CIA mice showed significant im-
munopositive staining for PD-­1 on T cells. And, PD-­ligand 1 (PD-­L1)
expression was increased in BM-­MSCs.
Conclusion: Our data showed that MSCs had immune modulatory
effect of CD4+ T cells, induced the CD4+CD25+FoxP3+PD-­1+ Tregs
both in vitro and in vivo.
This study was supported by a grant of the Korean Health
Technology R&D Project, Ministry of Health & Welfare, Republic
of Korea (HI13C1270 and HI14C0324) and Basic Science Research
Program through the National Research Foundation of Korea (NRF)
funded by the Ministry of Education (NRF-­2013R1A1A2058120 and
2016R1D1A1B03933603).
Keywords: mesenchymal stem cells, regulatory T cells, programmed
cell death-­1, immune modulation
1-­024 | Usefulness of tacrolimus for adult-­onset
still's disease: single-­center historical cohort study
H. Nakamura; T. Watanabe; T. Horita
Tomakomai City Hospital
Background/purpose: Adult-­
o nset Still's disease (AOSD) is a
systemic inflammatory disorder in which T cells and subse-
quently activated macrophages play a pathophysiological role.
Treatment for AOSD has centered on corticosteroids, although
corticosteroid-­r esistant/dependent AOSD is often encountered
in clinical setting. Tacrolimus, a calcineurin inhibitor, is expected
to be a reasonable therapeutic medication for AOSD since it
downregulates T cell activation by inhibiting IL-­2 transcription
and signal transduction. Nevertheless, only a few case series
have indicated effects of tacrolimus for AOSD. This study was
conducted to evaluate the efficacy and safety of tacrolimus in
patients with AOSD.
Methods: This is a single-­centre historical cohort study comprised
of the consecutive patients with AOSD according to Yamaguchi
classification criteria, who were attending our clinic between May
2008 and August 2018. The endpoints were set as event-­free sur-
vival from the initiation of treatment and safety. Event is defined
as death of any cause or relapse of AOSD requiring an increase of
corticosteroid dose. Event-­free survival was estimated by Kaplan-­
Meier method and was evaluated using Cox regression model. All
potential confounding factors were adjusted by summarizing into
propensity score.
Results: Twenty-­five patients were enrolled in this study. Mean age
was 51 year-­old, and median follow-­up period 34 months. Seven pa-
tients were treated with therapeutic regimen including tacrolimus,
and 18 patients were treated with the conventional therapy without
tacrolimus. After adjustment, the tacrolimus group had significantly
longer event-­
free survival than the conventional group (Figure 1,
P = 0.03). Serious infection occurred in two patients (29%) in the tac-
rolimus group, whereas in four patients (22%, P = 0.61) in the conven-
tional group (Table 1). No deaths were found during the observational
period.
Conclusion: Our study suggested that tacrolimus could be a useful
option for treating AOSD in spite of the small-­size and retrospective
design.
 |
      143

Figure 1 Methods: All patients who had Biosimilars for Rheumatoid, Psoriatic
arthritis, Ankylosing spondylitis or SLE under Rheumatology were
reviewed. All patients should satisfy ACR criteria for diagnosis,
failed classic DMARDs, screened for Biologics and also had 3, 6, and
12 months follow up and under review.
Results: 91 patients are in the biologic database and 34 excluded.
Mean duration of follow up-­24 months. 57 patients studied, of which
Rheumatoid arthritis-­30, SpondyloArthritis-­17, Psoriatic arthritis -­5,
Polymyositis-­1, Systemic lupus erythematosus-­4. (Details in Table 1)
RA group- 26 F: 4 M. Different biosimilar drugs were used to treat
and list is given in the table 2.
Patients are in sustained remission with DAS 28 is now 2.74. (Sept 2018).
SpA Group- 13 M: 4 F. HLA B27 was positive in 6/11. Eleven patients
had Adalimumab (Exemptia) biosimilar and six had others. All had
achieved good remission and still maintaining.
Psoriatic arthritis-­5 patients had adalimumab biosimilar for periph-
eral arthritis and now in remission. 3 are on demand Biosimilar and
2 on methotrexate.
Table 1 SLE group-­4 patients had Rituximab biosimilar for SLE and nephritis. 3
patients had avascular necrosis of hips and had failed cyclophospha-
mide. All are currently on mycophenolate and hydroxychloroquine.
ALL patients came off steroids before biosimilar therapy.
Adverse effects: 2 patients on Intascept had cutaneous allergy, one
developed lung TB and 2 patients with Ritux developed lung TB and
recurrent impetigo.
Conclusion: Biosimilar DMARDs are safe and effective in achieving
long term remission in RA, SLE, Psoriatic arthritis, spondyloarthritis
3-­069 | Biosimilars in rheumatology – real life
and myositis.
experience over 3 years
S. Nallasivan; B. Nirmal; A. Sangeetha; R. Rajendran
Velammal Medical College Hospital and Research Institute

Background: Biosimilar drugs are increasingly being used in different

Rheumatological diseases in Asia and especially in India. Compared
to innovator biologics, these biosimilar drugs are effective, economi-
cal and readily available in India.
Objectives: To evaluate the effects of Biosimilar drugs in common
rheumatic diseases in South India.

Table 1: Use of Biosimilars in Rheumatological conditions-Disease activity before and after Bio drugs
Mean No of Mean Disease activity Disease activity -­3 months after Disease activity -­24 months
Diagnosis age patients Pre-­Biosimilar Biosimilar after Biosimilar

Rheumatoid arthritis 48.8 yrs 30 DAS 28 ESR-­5.35 DAS 28-­3.10 DAS 28 2.74

Psoriatic arthritis 39 yrs 5 DAPSA-­3 4 DAPSA-­ 14 DAPSA-­9
SLE 29 yrs 5 SLEDAI-­31 SLEDAI-­8 SLEDAI-­5
Spondyloarthritis 30 yrs 17 BASDAI-­5.61-­ BASDAI-­2.1 BASDAI-­2.4
BASFI-­5.4 BASFI-­ 2.8 BASFI-­2.1

Table 2: Biosimilar drugs used for patients with Rheumatoid arthritis

Biosimilar INTASCEPT (ETN) ADFRAR (ADA) EXEMPTIA(ADA) ADELIEL (ADA) RITUX

No of patients 12 2 7 2 7
144       |

3-­096 | Health-­related quality of life in patients
with rheumatoid arthritis
W. Katchamart1; P. Narongroeknawin2; W. Chanapai3; P.
Thaweeratthakul1
1
Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Tha;
2 associated with EQ-­5D (adjusted R 2 0.376, P < 0.001) and EQ VAS
Division of Rheumatology, Department of Medicine, Pramongkutklao Hospital,
Pramongkutklao College of Medicine; 3Division of Clinical Trials, Research
Department, Faculty of Medicine Siriraj Hospital, Mahidol University
Background: Rheumatoid arthritis is a chronic systemic autoimmune
disease that primarily affects joint with extraarticular involvement. If
left inappropriately treated, it usually results in persistent joint pain,
irreversible deformities, and functional disability, leading to poor
quality of life.
Objective: To evaluate health-­related quality of life (HRQoL) and its
related factors in patients with rheumatoid arthritis (RA).
Methods: A total of 464 patients from Rheumatoid Arthritis registry
of 2 academic centers, Siriraj and Phramongkutklao hospital were
enrolled. Sociodemographics, clinical and laboratory data were col-
lected. HRQoL was assessed using the Thai version of EuroQol five
dimensional questionnaire (EQ-­5D) and EQ global health (EQ VAS).
Univariate and multivariate analyses were employed to model the
association between HRQoL and patient characteristics.
Most of them was female (85%) with mean age 
± SD of
59.2  ±  11.4  years and mean disease duration±SD of 11.5  ±  8.3  years.
The mean duration of follow-­up±SD was 4.3 ± 2.3 years. Almost
half was unemployed (47%). They had moderate disease activity
(mean cumulative DAS28 ± SD 3.5 ± 0.8) and mild functional im-
pairment (mean HAQ ± SD 0.70 ± 0.68). Depression and anxiety
were recognized in 8.4% and 9.3%, respectively. The mean EQ-­
5D ± SD (0–1) was 0.87 ± 0.13 and mean EQ VAS ± SD (0–10) was
7.94 ± 1.7. Based on the EQ-­5D domain, 49%, 83%, 65%, 30%, and
61% reported that they had no problem with mobility, self-­c are,
usual activity, pain or discomfort, and depression or anxiety, re-
spectively. In multivariate analyses, high cumulative disease activ-
ity, functional disability, depression, and anxiety were negatively
(adjusted R 2 0.189, P < 0.001).
Conclusion: Disease severity and psychological disturbance have a
negative impact on quality of life in patients with RA. All these fac-
tors should be considered in daily practice to improve standard of
care.
1-­093 | Efficacy of baricitinib compared
with adalimumab and placebo in patients with
rheumatoid arthritis: post-­hoc analyses from RA-­
BEAM and RA-­BEYOND trials
P. Nash1; J. Pope2; J. Smolen3; M. Weinblatt4; P. C. Taylor5;
E. Keystone6; A. Cardoso7; B. Zhu7; L. Xie7; I. Stoykov7; P.
Durez8; Y. Tanaka9
1
University of Queensland; 2University of Western Ontario; 3Medical
University of Vienna; 4Brigham and Women's Hospital; 5Kennedy Institute of
Rheumatology, Botnar Research Centre Nuffield Department of Orthopaedics,
Rheumatology and Musculoskeletal Sciences, University of Oxford Botnar
Research Centre Oxford; 6The Rebecca MacDonald Centre For Arthritis, Mount
Sinai Hospital; 7Eli Lilly and Company; 8St-­Luc, Avenue Hippocrate; 9The First
Department of Internal Medicine, School of Medicine, University of Occupational
and Environmental Health
Background: RA-­BEAM was a Phase 3 study of baricitinib-­4 mg
(BARI) in rheumatoid arthritis (RA) patients with an inadequate re-
sponse to methotrexate (MTX-­
IR), in which BARI demonstrated

Table: Multivariate analysis of relationship between EQ-5D, EQ global health (VAS), and patient characteristics

EQ-­5D score EQ Global health (VAS)

95% CI OF BETA 95% CI of beta

Variables Beta SE t Lower Upper P value Beta SE t Lower Upper P value

Age 0.001 0.0001 1.930 0.0001 0.002 0.054 −0.051 0.072 −0.701 −0.192 0.091 0.484
Unemployed −0.014 0.011 −1.313 −0.306 0.007 0.190
Education −1.105 1.641 −0.673 −4.329 2.120 0.501
> 6 years
Disease 0.472 1.457 0.324 −2.392 3.335 0.746
duration ≥
10 years
DAS28 −0.014 0.006 −2.150 −0.027 −0.001 0.032 −1.889 0.937 −2.017 −3.730 −0.048 0.044
HAQ −0.090 0.008 −11.315 −0.106 −0.075 <0.001 −8.088 1.178 −6.866 −10.403 −5.773 <0.001
DM 0.017 0.016 1.002 −0.016 0.049 0.317
CAD −0.033 0.031 −1.050 0.294 −0.094 0.029
Dyslipidemia 2.109 1.546 1.364 −0.929 5.146 0.173
Depression −0.077 0.019 −3.965 −0.115 −0.039 <0.001 −7.563 2.826 −2.676 −13.117 −2.008 0.008
Anxiety −0.087 0.019 −4.632 −0.124 −0.050 <0.001 −5.921 2.734 −2.166 −11.293 −0.548 0.031
Constant 1.124 0.041 27.343 1.043 1.205 <0.001 108.626 6.083 17.857 96.971 120.58 <0.001

statistically superiority in ACR20 responses and DAS28-­CRP mean
change at Week 12 compared to adalimumab (ADA). We studied the
effects of BARI on disease activity compared to placebo (PBO) and
ADA utilizing CDAI, which uses only clinical measures. In addition,
we analyzed disease activity, pain, physical function (HAQ-­DI), and
safety in patients who continued BARI treatment or switched treat-
ment from ADA to BARI after entering a long-­term extension (LTE)
study (RA-­BEYOND).
Methods: In RA-­BEAM, 1305 patients were randomized 3:3:2 to
PBO, BARI 4-­mg, ADA. Disease activity (CDAI) was evaluated at
Week 12 and 24. At Week 52, patients were allowed to enter the
LTE, where all patients received open-­label BARI 4-­mg. CDAI, SDAI,
HAQ-­DI, and DAS28-­ESR were evaluated in patients who were not
rescued in RA-­BEAM and entered the LTE ≥48 weeks. Missing val-
ues were imputed using modified last observation carried forward.
Results: In RA-­BEAM, BARI resulted in significantly lower mean
disease activity at Weeks 12 and 24 than PBO, and ADA (P ≤ 0.05;
Table 1). Among patients who completed RA-­BEAM without rescue,
381/394 (97%) BARI (continued BARI), and 238/241 (99%) ADA
(switched to BARI) patients entered the LTE for ≥48 weeks. Patients
|
      145
who switched from ADA to BARI and continued on BARI maintained
disease control (Table 2, Figure 1). Of patients with CDAI >10 at
the time of switch, approximately half reached low disease activity
(CDAI ≤10) by Week 48 (54% [BARI]; 50% [ADA]). Safety was con-
sistent in both groups.
Conclusion: In MTX-­IR RA patients with moderate to severe disease
activity, BARI significantly reduced the overall disease activity com-
pared to PBO and ADA. Switching from ADA to BARI without ADA
washout, maintained disease control.
2-­077 | Efficacy of ixekizumab in different
phenotypes of patients with active psoriatic
arthritis: results from the SPIRIT trials
F. Behrens1; P. Nash2; L. Gossec3; S. Liu-Leage 4; I. de la
Torre 4; C. Sapin4; M. Kurzawa4; G. Burmester5; J. Smolen6
1
Department of Rheumatologly & Fraunhofer Institut IME-­Translational Medicine
and Pharmacology Goethe-­University; 2University of Queensland; 3Sorbonne
Université and Hôpital Pitié Salpêtrière; 4Eli Lilly and Company; 5Department of
Rheumatology and Clinical Immunology, Universitatsklinikum Charite; 6Division
of Rheumatology, Department of Medicine 3, Medical University of Vienna
Background/purpose: Ixekizumab (IXE) is approved for the treat-
ment of moderate-­to-­severe psoriasis and more recently for active
psoriatic arthritis (PsA).
Objective: To describe the efficacy of IXE at week 24 in PsA patients
with different disease manifestations and characteristics.
Methods: Biologic naïve patients (SPIRIT-­P1) were randomized to
80-­mg IXE (initial dose 160 mg) every 4 (Q4W; N = 107) or 2 weeks
(Q2W; N = 103), to adalimumab 40-­mg IXE (Q2W; N = 101), or pla-
cebo (PBO; N = 106). Patients with an inadequate response or intol-
erance to TNF inhibitors (SPIRIT-­P2) were randomized to IXE Q4W
(N = 122) or Q2W (N = 123), or PBO (N = 118). Patients had active
disease with ≥3TJC and ≥3SJC and were classified according to the
following phenotypes of PsA: polyarthritis (≥5TJC and/or ≥5SJC),
oligoarthritis (<5TJC and <5SJC), DIP joint only, enthesitis and dac-
tylitis. in each phenotype ACR 20, 50 and 70 response criteria,
Minimal Disease Activity Psoriasis Area Severity Index (MDAPASI),
and Disease Activity Psoriatic Arthritis (DAPSA) remission and low
disease activity (LDA) response criteria were assessed to evaluate
IXE effect at week 24 combining both doses. For each phenotype
with a sufficient sample size, IXE-­and PBO-­treated patients’ base-
line characteristics were assessed. Treatment effects of IXE and
PBO were compared using Chi-­square tests (or Fisher's exact tests)
within each phenotype.
 |
146      
Results: The largest phenotypes were polyarthritis (N = 662), en-
thesitis (investigator: N = 459; LEI > 0: N = 403), and dactylitis (inves-
tigator: N = 220; LDI-­B > 0: N = 155). Too small sample sizes due to
inclusion criteria or low frequency were observed for “DIP joint only”,
oligoarthritis and arthritis mutilans phenotypes (N = 22, N = 17 and
N = 15). Baseline patient characteristics were generally balanced be-
tween treatment arms and similar between the 3 largest phenotypes,
with no difference in disease activity and duration. Response rates
were consistent to overall efficacy reported with IXE in SPIRIT trials.
Conclusion: Treatment responses with IXE at week 24 were consist-
ent across all phenotypes evaluated.
2-­130 | Clinical features and risk factors for
mortality among Pakistani patients with SLE
N. Nasir
Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
Background: SLE is a chronic, multisystemic autoimmune disease.
Outcomes are distinct in different ethnic groups and emerging data
from developing countries highlight the need for more data to better
understand clinical phenotype and outcomes.
Objective: To describe clinical presentation, SLE Disease activity
pattern and risk factors for mortality.
Methods: Demographic, clinical and laboratory data were collected
and analyzed on patients with SLE who attended the Aga Khan uni-
versity Hospital, Karachi from 2012 till 2017. Demographical data
included age, gender, ethnicity, disease duration and socioeconomic
status. SLE disease activity was assessed with SLEDAI-­
SELENA
modification and PGA. Univariate and multivariate analyses were
done to assess factors associated with mortality.
Results: Two hundred and one patients (185 female) were included,
whose mean age was 35.3 ± 14.7 years and mean disease dura-
tion 8 ± 2 years. Systemic fever was common in 86 (53.4%) of the
patients, followed by mucocutaneous, musculoskeletal and renal
involvement manifested as follows: oral ulcers 57 (35.4%), alopecia
52 (32.3%), arthritis 57 (35.4%), proteinuria 69 (43%), hematuria 43
(26.7%), renal insufficiency 35 (21.7%) and requiring hemodialysis
21 (13%). in the multivariate analysis, we identified that independ-
ent risk factors for mortality included high SLEDAI composite score
OR 1.09 (95%CI 1.04–1.14) P < 0.001, serositis OR 11.17 (95% CI
3.05–40.08) P < 0.001, lupus nephritis OR 7.1 (95%CI 2.28–21.1)
P = 0.001, high score on physician global assessment (PGA) OR 5.03
(1.32–19.06) P = 0.017, and lupus myocarditis OR 10 (95% 1.07–92.2)
P = 0.043.
Conclusion: Like other published studies from Indo-­A sian region,
there was predominant mucocutaneous, musculoskeletal and renal
involvement. High SLEDAI score, lupus nephritis, lupus myocarditis,
serositis and moderate to severe disease on PGA were indepen-
dently associated with mortality.
Univariate analysis

2-­090 | Impact of comorbidities in patients
with rheumatoid arthritis: a study from a tertiary
care center in Pakistan
N. Nasir; M. Riaz; S. Awan; S. Hirani
Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
Background: Rheumatoid arthritis (RA) is an inflammatory arthritis
and a leading cause of disability worldwide. Assessing co-­morbidities
is a crucial part of the clinical evaluation of patients with RA as they
have a major impact on the clinical outcomes of patients with rheu-
matoid arthritis.
Objectives: To determine the frequency and outcomes of comor-
bidities in patients with Rheumatoid arthritis.
Methods: We undertook a cross-­sectional study. Medical records
of patients registered with diagnosis of rheumatoid arthritis, hos-
pitalized from January 1st 2008 till December 30th 2013 were ac-
cessed through a computerized retrieval system and subjected to
structured review. Demographic information, duration of disease,
co-­morbid conditions as well treatment profile and clinical outcomes
including mortality and length of hospital stay were noted. Weighted
prevalence and odds ratio of co-­morbidities were determined and
their 95% Confidence Intervals (CI) were estimated using logistic re-
gression. Multivariate analysis was performed to identify independ-
ent predictors associated with poor outcomes.
Results: A total of 330 medical records were selected for analysis.
The mean age of cohort was 57.1 years with female predominance.
The most frequently associated co-­morbidities included hyperten-
sion (67.9%), diabetes (37.6%), pulmonary disease (29.1%), sepsis
(27.9%), coronary artery disease (21.5%), chronic kidney disease
(14.2%), stroke (9.1%), chronic liver disease (6.1%) and malignancy
(6.1%). After adjusting for age, duration of disease and associated co-­
morbidities, factors predictive of poor outcomes were sepsis (OR,
2.55 [ 95% CI 1.12–5.80], P < 0.001), heart failure (OR 13.22 [95%
CI 3.18–55], P < 0.001), pulmonary disease (OR 4.001 [95% CI 1.80–
8.85] P = 0.001), chronic kidney disease (OR 4.47 [95% CI 1.82–11],
P = 0.001), chronic liver disease (OR 3.92 [95% CI 1.13–13.58],
P = 0.03), and dyslipidemia (OR 5.80 [95% CI 1.40–24], P = 0.01).
Malignancy, smoking status and disease modifying therapy were not
significantly associated with mortality.
Conclusion: Cardiovascular disease and risk factors portend poor
prognosis in RA. Heart failure, pulmonary disease, sepsis, chronic
liver and kidney disease were independently associated with
mortality.
|
      147
2-­0 02 | A case report on antiphospholipid
antibody syndrome: first baby after 4 pregnancy
loss with thrombocytopenia
F. B. Nazrul1,2; Md. N. Islam2,3; A. U. Zaman2; N. Ferdous2,4
1
National Heart Foundation Hospital And Research Institute; 2Modern One
Stop Arthritis Care and Research Center ® (MOAC&RC®); 3Department of
Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU);
4
Department of Medicine, MH Samorita Medical College and Hospital
Case report: A 34-­year-­old woman had history of 4 pregnancy loss
prior to visit us. All pregnancies were spontaneously aborted within
1st trimester. Gynecologist referred her to our center in the year
2007 for a positive Antiphospholipid Antibody (APA) IgG test. Other
than history of pregnancy lost nothing was abnormal with her. The
ANA and anti-­ds DNA test were negative. She was prescribed aspi-
rin 75 mg daily and hydroxycloroquine sulphate (HCQ) 300 mg daily.
After 3 years in 2010, two consecutive (3 month's interval) APA
IgG and IgM test were found negative. She was advised to try for
pregnancy.
She became pregnant in the year 2012.
She was put on regular heparin 10,000 IU 2 mL bid and aspirin 75 mg
daily from 6th week of pregnancy. After 2 weeks, for thrombocyto-
penia (36,000) both the drugs were stopped. at 10th week aspirin
75 mg/d was restarted. From 11th week injection enoxaparin 60 mg
daily was added. Three weeks later she again developed thrombocy-
topenia (60,000). Aspirin was stopped and the dose of enoxaparin
was lowered to 40 mg/d. For lack of improvement (platelet count
35,000), from 19th week she was put on HCQ 400 mg daily and
prednisolone 55 mg daily. The dose of prednisolone was tapered
to 15 mg/d in 8 weeks’ time. At 21st week the dose of enoxaparin
was increased again to 60 mg daily (platelet count 1,35,000) and
continued till delivery. The platelet count was persisted ≥1,30,000
till delivery with the mentioned medications. Aspirin was stopped
5 days before the elective caesarean section at 34 weeks. Lastly
she became a mother of a male baby after an exhausting course of
pregnancy period. Fortunately there was no flare of APS after de-
livery. She came back 4 years later in 2016 with the baby for other
complaints.
1-­025 | Aggressive NK cell leukemia
masquerading as Behçet's disease
K. J. Ng1,2; N.-S. Lai1,2
1
Division of Allergy, Immunology and Rheumatology, Dalin Buddhist Tzu Chi
Hospital; 2Department of Medicine, Tzu Chi University
Behçet's Disease (BD) is a complicated inflammatory disorder in-
volving mucous membrane manifestation (oral aphthosis and genital
aphthosis), skin, ocular, pathergy phenomenon and lastly, vascular
manifestations. Several studies have found significant increase in
NK cells numbers in peripheral blood of BD patients, particularly in
active phase of the disease. These dysfunction NK cells may permit
 |
148      
persistent viral infections, leading to chronic inflammatory response
related to BD.
Aggressive NK-­cell Leukemia (ANKL) is a very rare form of NK cell
neoplasm, which has a distinct geographic distribution mostly involv-
ing Asian. Patients often presented with a fulminant and aggressive
clinical course. Interestingly, Epstein-­Barr virus (EBV) was frequently
detected in these leukemia cells and is proposed to contribute to the
pathogenesis of ANKL.
Here we report a case of ANKL masquerading as Behcet disease in
an old male, presented with oral and genital aphthae, fever, pancy-
topenia and hepatosplenomegaly. Blood sampling showed EBNA IgG
positive. Both bone marrow and liver biopsy revealed positive CD 56
and EBER in the neoplastic cells. Flow cytometry showed 78.4% of
CD 56 positive cells, which was compatible to Aggressive NK Cell
Leukemia.
Given the close relationship between BD and ANKL, we hypoth-
esized that, the dysfunction of NK cells might lead to chronic EBV
infection, which lead to ANKL, and also contribute to the manifesta-
tions of BD in this patient.
2-­091 | Correlation of rheumatoid arthritis
impact of disease (RAID) score with depression
and anxiety among rheumatoid arthritis patients
1,2 1,2 1,2 1 1
K. J. Ng ; K.-Y. Huang ; C.-H. Tung ; B. Hsu ; C.-H. Wu ;
M.-C. Lu1,2; N.-S. Lai1,2
1
Division of Allergy, Immunology and Rheumatology Dalin Buddhist Tzu Chi
Hospital; 2Department of Medicine, Tzu Chi University
Objectives: To evaluate the association of Rheumatoid Arthritis
Impact of Disease (RAID) score with depression and anxiety among
patients with rheumatoid arthritis (RA)
Methods: This cross-­sectional observational study was conducted
at rheumatology outpatient clinic from August of 2017 to April of
2018. A total of 625 RA patients were included in this study. RA
disease activity was measure with Disease Activity Score over 28
joints based on erythrocyte sedimentation rate (DAS28–ESR) and
Rheumatoid Arthritis Impact of Disease (RAID) score. Depression
and anxiety were measured with Hospital Anxiety and Depression
Scale (HADS). Logistic regression modelling was apply to evaluate
the associations between RAID score and HADS.
Results: A total of 96 subjects (15.4%) and 65 subjects (10.4%) were
classified as having depressive and anxiety symptoms, respectively,
based on HADS-­D > 8 and HADS-­A > 8. in the univariate analysis,
RAID was significantly associated with depression (ß = 2.23; CI 95%
1.84–2.63, P < 0.001), anxiety (ß = 2.16; CI 1.67–2.64, P < 0.001),
DAS-­28 (ß = 0.95; CI 0.86–1.04, P < 0.001), CRP (ß = 0.15; CI 0.03–
0.28, P = 0.016), female (ß = 0.60; CI 0.23–0.98, P = 0.002), retired
(ß = 0.45; CI 0.09–0.81, P = 0.015), low income (ß = 0.96; CI 0.48–
1.44, P < 0.001), religious belief (ß = 0.85; CI 0.15–1.56, P = 0.018),
and comorbidities (ß = 0.73; CI 0.40–1.06, P < 0.001). After adjust-
ing for all confounders, multivariate analysis showed depression
(ß = 1.22; CI 0.88–1.56, P < 0.001), anxiety (ß = 0.98; CI 0.58–1.38,
P < 0.001), and DAS28–ESR (ß = 0.82; CI 0.74–0.91, P < 0.001)
remained significant. Secondary analysis of RAID questionnaire
showed the strongest correlation between the emotional well-­being
NRS and depression (ß = 2.44; CI 1.97–2.90, P < 0.001) and also anx-
iety (ß = 2.33; CI 1.77–2.88, P < 0.001).
Conclusions: This study suggests that RAID questionnaire, particu-
larly the sixth question, is strongly correlated with depression and
anxiety among RA patients. Further investigations are warranted to
validate the usefulness of RAID in evaluating depression and anxiety.
1-­119 | Pulmonary sarcoidosis occurring during
golimumab treatment for ankylosing spondylitis
K. J. Ng1,2; K.-Y. Huang1,2
1
Division of Allergy, Immunology and Rheumatology, Dalin Buddhist Tzu Chi
Hospital; 2Department of Medicine, Tzu Chi University
We presented a patient with ankylosing pondylitis, initially presented
with low back pain, HLA-­B27 was positive and plain film revealed
bilateral grade 2 sacroiliitis. He had been under PRN Celecoxib with
relatively stable disease activity. Until recent two years, where
persistent low back pain was reported with elevated inflammatory
markers. He agreed to receive Golimumab injection for ankylosing
spondylitis. After 6 months of Golimumab injection, low back pain
hardly improved and inflammatory markers remained high. Follow
up chest film showed widening mediastinum. at the same time, bi-
lateral lower extremities edema developed. Computed tomography
was performed which revealed multiple lymphadenopathy over
cervical, mediastinum and inguinal area. Excisional biopsy of cer-
vical lymph node revealed non-­
caseating granulomatous lesions.
Sarcoidosis was highly impressed after exclusion of other infectious
diseases. Methylprednisolone 500 mg pulse therapy were prescribe
for three consecutive days. Patient described drastic improvement
of edema and low back pain.
Discussion: There are scanty case reports reporting co-­existence of
ankylosing spondylitis and sarcoidosis. Like our patient, most of the
cases initially presented with typical sacroiliitis and a positive HLA-­
B27. Considering the relatively high prevalence of both diseases in
Taiwan, it is possible to have them co-­existing in one patient. A na-
tionwide case–control study in Taiwan also suggested that sarcoido-
sis patients tends to have a higher risk of autoimmune comorbidities
than general population. Given the critical role of tumor necrosis
factor (TNF) in both inflammation and granuloma formation in sar-
coidosis patients, anti-­TNF has been listed as one of the treatment
options for sarcoidosis. However, there are cases reporting a para-
doxical effect of anti-­TNF, where sarcoidosis occurred despite anti-­
TNF treatment. Thus, clinicians should be more aware when patient
has a relatively poor response to treatment despite typical clinical
presentation.

3-­040 | Survey on the healthcare practitioners’
knowledge, practice and illness perception in
managing patients with gout in Kelantan State,
Malaysia
K. L. Ng; M. K. H'ng; A. M. Ismail
Raja Perempuan Zainab II Hospital
Background/purpose: Gout is the commonest inflammatory ar-
thropathy encountered at outpatient or general practitioner clinics.
Yet the overall care for patients with gout is still suboptimal that
many suffer from its complications. The global burden of gout is in-
surmountably substantial.
This study aimed to ascertain the gout management among health-
care practitioners in Kelantan State, Malaysia.
Methods: A cross-­sectional questionnaire survey was carried out
among doctors attending gout workshop series from March to July
2018.
Results: A total of 128 questionnaires were analysed. 78.9% of re-
spondents were medical officers and the median years of practice
was 7.6. The median score for familiarity with gout was 5.5/10.
60.2% perceived gout is curable. 91.4% would diagnose gout based
on frequency of typical monoarthritis in a year; 60.9% if the serum
uric acid (SUA) level > 420 μmol/L or upper limit of normal. Joint
aspiration was, however, only practised or considered in 23.4%. in
acute gout treatment, most would give colchicine and/or NSAID (up
to 68%). About 15-­19% would prescribe steroid.
The decision for urate-­lowering therapy (ULT) was mostly guided
by frequency of gouty attack in a year (84.4%) and presence of
tophi (60.2%). 21.9% would treat asymptomatic hyperuricemia
though. 99.2% were familiar with allopurinol as ULT and 150 mg
daily was the usual starting dose (57.8%), prescribed commonly
at 2-­4 weeks after a flare (68%). However, only about 50% knew
about the target SUA of < 360 μmol/L and 51.6% were unaware of
mobilisation flare. Many failed to identify important comorbidities
(except renal impairment) associated with gout too. Generally, the
median score of disease impact on patients as perceived by prac-
titioners was 7.8/10.
Conclusion: The care for gout is still suboptimal in our study popula-
tion. The lacking was still evident in term of diagnosis, ULT initiation,
target SUA and identification of comorbidities.
3-­056 | Scurvy, a disease not to be forgotten in
the 21st century
S. K. Ng1; Y. L. Teo2; S. C. Lim3; B. S. Koay1; S. P. Tang1
1
Selayang Hospital; 2Putrajaya Hospital; 3UITM Selayang
Background: Scurvy, a nutritional disorder caused by Vitamin C
deficiency should be a disease of the past. Common presentations
of scurvy include bone and joint pains, gum hyperplasia, anemia
and skin lesions. We highlight 3 children with scurvy presenting
|
      149
with musculoskeletal pain mimicking other rheumatological
conditions.
Results: Case 1: A 7-­year old autistic boy presented with a 3-­week
history of lower limb pain, refusal to walk and painful gum swelling.
Since the age of 4 years, he ate only instant noodles & plain rice por-
ridge. Clinically he was thin, pale, and had perifollicular hyperkerato-
sis, skin purpura, gum hyperplasia with gingival hematoma. Both his
lower limbs were tender and he had soft tissue swellings over the
right suprapatellar region and distal right tibia. Knees radiographs
showed metaphysical sclerotic lines at both femurs. MRI demon-
strated subperiosteal collections over both distal femurs.
Case 2: A 3.6 years old autistic girl presented with a limping gait,
refusal to walk for 2 weeks with easy bruising. She only ate plain
bread and water for 7 months prior. Clinically she was small, thin,
with multiple skin purpura and corkscrew hairs, gingival swelling,
with multiple scalp and chest wall hematomas.
Case 3: A 4-­year old developmentally normal girl but extremely
picky eater, presented with lower limb pain for 1 month and gross
haematuria for 4 days. Clinically she was small, with friable gums
and tenderness on palpation of both lower limbs with no joint swell-
ing. Radiograph of the knees showed early sclerotic changes of right
femur metaphysis. All 3 patients had scurvy confirmed with low
serum ascorbic levels (<5 umol/L). All showed improvement as early
as 1 week after starting vitamin C treatment.
Conclusion: Always remember scurvy in children with musculoskel-
etal complaints especially in special groups who have dietary restric-
tions. Treatment is simple, cheap and yet highly effective.
3-­057 | Vaso-­occlusive retinal vasculitis in
childhood-­onset systemic lupus erythematosus:
clinical associations and outcomes
S. C. Lim1,2; S. K. Ng2; S.-P. Tang2
1
Universiti Teknologi MARA (UiTM); 2Selayang Hospital
Background/purpose: Vaso-­occlusive retinal vasculitis is uncommon
in children and adolescents with childhood-­onset Systemic Lupus
Erythematosus (cSLE); and published data is scarce. Although un-
common, it is crucial not to miss this condition as it can potentially
lead to irreversible visual loss. The objective of this study is to as-
sess the clinical associations and outcomes of vaso-­occlusive retinal
vasculitis in cSLE.
Methods: Data was collected retrospectively from medical records
of all cSLE patients with proven vaso-­occlusive retinal vasculitis from
January 2004 to May 2016. Demographic data, clinical features at
presentation and progress at intervals up to 12 months after diag-
nosis were analysed.
Results: Of the 192 cSLE cases who had ophthalmological examina-
tions, 6 patients (3.1%) had vaso-­occlusive retinal vasculitis present-
ing at a mean age of 11.6 years (range 9.5-­12.9 years). Five presented
at diagnosis of SLE and one developed it 12 months later. All except
 |
150      

one patient had visual complaints predominantly blurring of vision
(4/6) and red eyes (2/6). Bilateral eye involvement was universal with
severe visual impairment at diagnosis seen in 5 patients. All patients
had concomitant active disease (mean SLEDAI score 33.5, range 13–
64) with multi-­organ involvement and the severity of eye disease ap-
peared to mirror the overall disease activity. Central nervous system
involvement was seen in 5 patients. The commonest fundoscopic
findings were retinal whitening followed by retinal haemorrhages,
and fluorescein angiography showed significant vaso-­occlusive retin-
opathy in all cases. Visual acuity improved for most patients with sys-
temic corticosteroid and immunosuppressive therapies, but all were
still left with residual visual impairment at 1 year post diagnosis.
Conclusions: Vaso-­occlusive retinal vasculitis although rare has a
poor visual prognosis. All cSLE patients should be carefully assessed
especially those with high disease activity and central nervous sys-
tem involvement.
(r = −0.03) but none achieved statistical significance. There was
no significant difference in serum Prolidase levels with duration of
disease.
Conclusion: Serum Prolidase is significantly higher in patients with
Ankylosing Spondylitis. It correlates positively with markers of in-
flammation and disease activity. Larger multi-­centric studies can
elaborate exact role of serum Prolidase.
1-­026 | Dyskeratotic cells in persistent pruritic
skin lesions are apoptotic and associated with
high levels of serum IL-­18
H. Nishikawa1; Y. Y. Taniguchi1; N. Maeda-Aoyama1; S.
Inotani1; M. Ogasawara1; K. Nakajima2; K. Arii3; Y. Terada1
1
Department of Nephrology and Rheumatology, Kochi Medical School Hospital;
2
Department of Dermatology, Kochi Medical School Hospital; 3Department of
Internal Medicine, Kochi Red Cross Hospital

2-­020 | Serum prolidase – a novel biomarker of Purpose: To assess the clinical significance of dyskeratotic cells
ankylosing spondylitis (DCs) in skin lesions of adult-­onset Still's disease (AOSD).
Methods: We assessed clinical characteristics, serum markers, out-
J. Niari; S. K. Rath; R. Tripathy; M. K. Parida; S. R. Tripathy;
B. K. Das comes and histology of skin lesions in Japanese patients with AOSD

Scb Medical College, Cuttack (n = 15). Moreover, we comparatively studied the histological find-
ings of AOSD, dermatomyositis (DM) (n = 6), drug eruptions (DE)
(n = 7), and graft versus host disease (GVHD) (n = 6).
Background: Ankylosing spondylitis (AS) is characterized by the
Results: AOSD with persistent pruritic skin lesions (n = 10) histologi-
presence of simultaneous inflammation induced bone destruction
cally showed DCs only in upper layer of epidermis and horny layer
and bone formation. Bone matrix contain 90% type-­
I collagen,
without inflammatory cells infiltrations, indicating dyskeratosis.
25% of which contains proline and hydroxyproline. Prolidase is an
AOSD with evanescent rash (n = 5) histologically showed no DCs.
enzyme that degrades imido-­dipeptides with proline or hydroxy-
in contrast, the histology of DM, DE and GVHD demonstrated that
proline at C-­terminal end. We hypothesize that in active AS serum
DCs existed in all layers of epidermis with inflammatory cells infil-
Prolidase levels will be increased to match the increase in collagen
trations. DCs in AOSD were positive by ssDNA staining, suggest-
recycling.
ing apoptotic cells. Serum IL-­18 showed significantly higher in AOSD
Objectives: To measure serum Prolidase levels in patients with AS
patients with DCs (n = 10) than without DCs (n = 5). The majority of
and correlate with inflammatory markers (ESR and CRP), disease ac-
AOSD patients with DCs required higher doses of glucocorticoids,
tivity (BASDAI) and functional state (BASFI).
immunosuppressants and biologic agents than without DCs. 2 of 10
Methods: Sixty patients with AS fulfilling the modified New York
AOSD patients with DCs died because of infectious complications or
criteria, 1984 and 30 healthy, age and sex matched controls were
hemophagocytic syndrome.
recruited. Patients with concomitant inflammatory disorders, dia-
Conclusions: Persistent pruritic skin lesions in AOSD are specific by
betes, hypothyroidism, chronic renal or hepatic disorders, malignan-
prominent epidermal apoptosis involving the upper layers of epider-
cies, cardiovascular diseases, infections and pregnancy or lactation
mis, and hyper IL-­18 is significantly related with dyskeratosis. The ap-
were excluded. ESR and CRP were measured and BASDAI and BASFI
pearance of DCs in AOSD seems to be associated with poor prognosis.
were calculated for each patient. Serum Prolidase was assessed
using sandwich ELISA (PEPD ELISA Kit). Statistical analysis was done
using GraphPad Prism 7.
Results: The mean age of patients was 33.7 ± 10.3 years. There were
58 males and 2 females in cases and all males in controls. The mean
ESR (69.6 ± 38.5 mm 1st hour) and CRP (78.1 ± 61.4 mg/L) in cases
was high compared with controls (P < 0.01). The mean BASDAI was
5.8 ± 1.1 and mean BASFI was 6.0 ± 1.4. The mean serum Prolidase
in cases (13.7 ± 5.3 ng/mL) was higher than in controls 9.5 ± 2.8 ng/
mL) (P < 0.0001). Serum Prolidase correlated positively with BASDAI
(r = 0.05), ESR (0.13) and CRP (0.91) and negatively with BASFI
 |
      151

2-­049 | Forefoot synovitis should be evaluated Methods: A 63-­year-­old woman with RA was admitted with high
fever and shortness of breath. She had demonstrated stable RA ac-
independently of global assessment of disease
tivity after taking MTX 12.5 mg/wk in addition to leflunomide 10 mg
activity in patients with rheumatoid arthritis
daily for RA; however, about 5 months ago, she stopped taking low
H. Nishimura1; R. Hara2; Y. Ozaki3; T. Kira2,4; N. Shimmyo2; dose prednisolone. Computerized tomography (CT) of the chest
A. Kido2,4; Y. Akai2; T. Fujimoto2; Y. Tanaka2,4 demonstrated diffuse ground glass opacities in bilateral middle and
1
Center for Postgraduate Training, Nara Medical University; 2The Center for
lower lung fields. Laboratory examinations showed β-­D-­glucagon
Rheumatic Diseases , Nara Medical University; 3Department of Orthopaedic
Surgery, Matsusaka Chuo General Hospital; 4Department of Orthopaedic 140.2 pg/mL. Bronchoalveolar lavage (BAL) fluid did not reveal
Surgery, Nara Medical University Pneumocystis carinii (PC) by Grocotto staining. However, a polymer-
ase chain reaction (PCR) assay of BAL fluid showed PC. MTX and
Purpose: We correlated the US evaluation of synovitis in the fore- leflunomide were immediately discontinued. High dose trimetho-
foot with the clinical and functional evaluations, after categorizing prim/sulfamethoxazole (TMP-­SMX) and methylprednisolone pulse
data for the hand and foot in patients with rheumatoid arthritis (RA). therapy were administered. Following treatment, clinical and radio-
Methods; Forty-­t wo RA patients (6 men, 36 women) were included. graphic improvement were noted.
Semiquantitative evaluation for bilateral interphalangeal (IP), proxi- Results: The risk factors for RA-­PCP have been reported by several
mal interphalangeal (PIP), metacarpophalangeal (MCP), wrist, and studies. However, in this case, the patient had not taken predniso-
metatarsophalangeal (MTP) joints was conducted using gray-­scale lone for more than 5 months before the occurrence of PCP and was
(GS) and power Doppler (PD) techniques. Each summation was de- considered low risk for PCP. Early diagnosis and adequate therapy
fined as Hand GS and PD, Foot GS and PD, and Total GS and PD is critical for treatment of PCP. in the RA patient, with or without
scores. We determined the accuracy of US based on the physical
examination for the foot, and correlated the US scores of the hand
and foot, composite measures, patient global assessment scores, C-­
reactive protein (CRP) level, matrix metalloproteinase-­3 (MMP-­3)
level, and MHAQ scores.
Results: Based on swelling and tenderness of bilateral MTP joints,
for both GS score and PD sore ≥1, the positive predictive value
(PPV) were extremely low (GS: 16.4%, 15.2% and PD: 15.2%, 21.3%).
Hand GS and PD scores showed a significant correlation with SDAI
(r = 0.487 and 0.482), CRP level (r = 0.378 and 0.376), and MMP-­3
Figure 1 Chest X-­ray and computerized tomography (CT) demon-
level (r = 0.613 and 0.661); however, Foot GS and PD scores showed
strated diffuse ground glass opacities and reticular shadows in bilat-
no correlation with any factor.
eral middle and lower lung fields
Conclusions: The composite measures of disease activity cannot de-
tect lesions in the forefoot. Synovitis in the forefoot requires US,
especially PDUS, for accurate disease stage evaluation.

2-­0 03 | Pneumocystis jiroveci pneumonia

in rheumatoid arthritis patient treated with
methotrexate but without prednisolone: a case
report
J. Noh; S. T. Han
Department of Internal Medicine, Hankook Hospital

Background/purpose: Methotrexate (MTX) is an anchor drug for

rheumatoid arthritis (RA) if there is no contraindication. However,
MTX can increase the risk of opportunistic infections including
Pneumocystis jiroveci pneumonia (PCP) if combined with other im-
munosuppressive drugs such as prednisolone. Risk factors for PCP in
patients with RA may include age, high dose prednisolone and MTX,
disease activity of RA, and number of concomitant immunosuppres-
sant medications. Herein, we report a case of an RA patient who de-
veloped PCP during MTX treatment without prednisolone. Figure 2 After treatment, infiltration and shadows were disappeared
 |
152      
risk factors, PCP should be considered in the differential diagnosis
for respiratory infection and interstitial pneumonitis, including MTX-­
induced pneumonitis.
Conclusion: PCP prophylaxis in the RA patient is often controversial,
however, MTX should be considered an important risk factor of PCP.
3-­076 | Elevating the role of carers in the
patient journey can potentially improve RA
management
1 1 2
R. Norager ; M. Skillecorn ; K. Pile ; K. A. Gibson ; S. 3 Preen4
Elderton4; W. Favorito5; Z. Li6; R. Mu6; H. Nakahara7; M.
Kishimoto8; S. Hirata9; Y. Kaneko10; C.-S. Lau11; L.-S. Tam12;
Y.-H. Chen13; P. Chen1; B. Wahking1
1 Australia
Janssen Asia Pacific, a division of Johnson & Johnson Pte Ltd; 2Department
of Medicine, Western Sydney University; 3Department of Rheumatology,
Liverpool Hospital; 4Carers Australia; 5Arthritis Australia; 6Department of
Rheumatology and Immnunology, Peking University People's Hospital; 7Division
of Allergy, Rheumatology and Connective Tissue Diseases, Department of
Internal Medicine, NTT West Osaka Hospital; 8Immuno-­R heumatology Center,
St Luke's International Hospital; 9Department of Clinical Immunology and
Rheumatology, Hiroshima University Hospital; 10Division of Rheumatology,
Department of Internal Medicine, Keio University School of Medicine;
11
Department of Medicine, The University of Hong Kong; 12Department of
Medicine and Therapeutics, The Chinese University of Hong Kong; 13Division of
Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital
Background/purpose: Clinical decision-­making in RA typically in-
corporates patient and clinician input, but patients may minimize
symptoms or under-­report medication non-­adherence. Carers are
often keenly aware of patients’ physical and emotional states as they
invest time caring for RA patients. It is possible that incorporating
carer perspectives into treatment decision-­making can provide clini-
cians with a more complete perspective of the patient's medication
adherence and treatment outcomes. This is a first-­of-­its-­kind re-
gional, multi-­stakeholder study conducted to enrich our understand-
ing of the roles and potential impact of carers on RA management.
Methods: This study used a two-­phase sequential mixed methods
approach involving three key stakeholder groups: rheumatologists,
RA patients (≥18 years of age) and carers across Japan, China and
Australia. The first phase was an in-­depth qualitative exploratory
study (n = 30) used to inform the development of the second phase,
a quantitative validation survey (n = 908).
Results: Carers in all three countries provided significant physical,
health and treatment, emotional, and financial support to their patients.
Patients with moderate and severe disease received more support than
those with mild disease. Eighty-­six percent of rheumatologists, 62%
patients and 94% carers felt that carers’ insight into patients’ physi-
cal and emotional conditions were useful and should be considered in
clinical decision-­making. Two-­thirds of rheumatologists thought it was
‘extremely important’ for carers of severe patients to actively participate
in clinical consultations and treatment decision-­making.
Conclusion: There is general agreement that carers provide input
which may give clinicians greater insight into the patients’ physical
and emotional states and into treatment adherence. The inclusion of
carer reported outcomes during clinical consultations may improve
RA management. However, patients and carers may not always
agree on the value or veracity of the carers’ input and this warrants
further evaluation.
2-­059 | Hospital presentation with infection
in children with IgA vasculitis before and after
diagnosis
J. Nossent1,2; W. Raymond1; C. Inderjeeth1,2; H. Keen1,3; D.
1
School of Medicine, University of Western Australia; 2Departent of
Rheumatology, Sir Charles Gairdner Hospital; 3Departent of Rheumatology,
Fiona Stanley Hospital; 4School of Population Health, University of Western
Background: Clinical evidence suggests that infections can trigger
IgA vasculitis (IgAV) in genetically susceptible individuals, but con-
sistent evidence is lacking on the etiologic role of specific types of
infection.
Objective: To compare state-­wide rates, types and associated micro-
organisms for hospital-­based infections before and after the diagno-
sis of childhood (<17 years) IgAV.
Methods: IgAV paediatric patients (n = 523, median age 5 years, 58.7%
males) and non-­exposed age-­matched controls (n = 1353, median age
6 years at study commencement, 65% males) were identified using
observational (1980–2015) population-­level linked data on hospital
admissions and ED visits. Serious infections (SIs) (as per Tektonidou,
2015) and organ-­based infection (as per Weiss 2010 and Riganti 2013)
were defined through relevant ICD-­codes. Time-­zero (T0) was the time
of IgAV diagnosis or equivalent date in controls. Rates for infection are
given per 1000 patient months with conditional maximum likelihood
of Rate Ratio estimate (RR) (95% CI) analysed by Fisher's exact test.
Results: No SIs were observed before T0 in childhood IgAV patients,
but postT0 their risk of SI was increased (RR = 8.7, 4.2–19.7, P < 0.01)
compared with non-­IgAV controls. Throat infections before T0 oc-
curred only in IgAV patients at a low rate (0.18/1000 months) but
after T0 the rates for throat infections (RR 25.7, 4.1–57, P < 0.001),
pneumonia (RR 22.1, 3.4–50.6, P < 0.001) and skin/soft tissue infec-
tion (RR 10.4, 3.5–37.1, P < 0.001) rates were increased compared
to controls. The post diagnosis infection rate with Gr A streptococci
was lower than pre-­diagnosis in IgAV patients (RR 0.12, 0.03–0.5,
P < 0.001), but compared to controls post-­diagnosis Gr A strepto-
cocci (RR 8.6 ; 2.8–31.5, P < 00.1) and Parainfluenza virus infections
(RR 3.6: 1.3–11.4, P = 0.027) were more frequent in in IgAV patients
who also had patients had twice the rate of ED presentations seen
in controls (2.26; 2.02–2.5, P < 0.01).
Conclusions: The substantial rise in the overall rate of SI and organ
specific infections following the diagnosis of IgAV in childhood sug-
gests that disease specific and/or iatrogenic factors rather than ge-
netic factors predispose to the increased long-­term risk of infection
in childhood IgAV.
 |
      153

Table 1 Characteristics of the study cohorts with rates of serious infections by age at diagnosis and observation period before and after diag-
nosis (t0)

IgAV (n = 523) Controls (n = 1353) Rate ratio P value

Male (%) 307 (58.7) 892 (65.9) 0.89 0.03

Age at t0 (median-­IQR) 5 (3–7) 6 (4–9) -­ <0.01
Indigenous background (%) 20 (3.8) 11 (0.8) 4.75 <0.01
Before t0 (total nr/rate per 1000 patient months)
 Observation time (months) 16,890 54,275
 Total SI 0 3
 SI per 1000 patient months -­ 0.05 NA –
 Total nr ED visits 73 -­ NA –
After t0 (total nr/rate per 1000 patient months)
 Observation time (months) 105,511 332,508
 Total SI 25 9
 SI per 1000 patient months 0.24 0.03 8.7 (4.2–19.7) <0.001
 Total nr ED visits 484 686 2.26 (2.02–2.5) <0.001
SI Serious infections – Tektonidou, 2015:

Table 2. Observed rates and rate ratio for various types serious infections by affected organ system

IgAV (n = 523) Controls (n = 1353) Rate ratio P value

Before t0 (total nr/rate per 1000 patient months

 Infection site
 Larynx/Pharynx 3 (0.18) – – –
 Pneumonia – – – –
 Skin/soft tissue – – – –
 Urinary tract – – – –
 Sepsis/bacteremia – 1 (0.02) – –
After t0 (total nr/rate per 1000 patient months
 Infection site
 Larynx/Pharynx 8 (0.48) 1 (0.02) 25.7 (4.1–575) <0.001
 Pneumonia 7 (0.42) – –
 Skin/soft tissue 13 (0.8) 4 (0.07) 10.4 (3.5–37.1) <0.001
 Urinary tract 3 (0.18) 4 (0.07) 2.4 (0.4–11.6) 0.23
 Sepsis/bacteremia – –

SI : Organ infections (Tektonidou, 2015, Weiss et al, 2010)

 |
154      

Table 3. Observed rates and rate ratio for infections by microorgan- Epstein-­Barr virus (075), B27.9 , B02.1-­B03, B25.9
ism identified Viral inducers (EBV, zoster, CMV, parvovirus) herpes zoster (053),
cytomegalovirus (078.5),
IgAV Controls
candidiasis (112.4, 112.5, B37.0-­ B38.0
(n = 523) (n = 1353) Rate ratio P value
112.81, 112.83),
n/16.8 /54.3
toxoplasmosis (130), B58.2-­ B59.0
Months 16,890 54,275
pneumocystosis (136.3), B59.0
observed
cryptococcosis (117.5), B450, B457, B459
Before t0 (number/rate per1000 months)
listeriosis (027.0), A32.0-­A33.0
 Gr.A 2 1 6.4 (0.5–189) 0.28
Streptococcus nocardiosis (039), L08.1, A42.0-­A42.3, A428-­A43.0,
A43.9 B47.1, B47.9
 Staphylococcal 5 6 2.7 (0.8–9.1) 0.19
aspergillosis (117.3), B44.9
 H. influenza – 4 NA –
coccidioidomycosis (114), B38.0-­B38.5, B38.8-­B39.0,
 Mycoplasma – – NA –
histoplasmosis (115), B39.2-­B39.6, B39.9, Go2, H32,
 Parainfluenza – 6 NA –
I32, I39, J17
 RSV 2 – NA –
blastomycosis (116.0). B40.9
 Viral inducers – 2 NA –
 Mycobacterium – – NA –
ICD-­9CR diagnosis ICD 10 (AM?)
tub
Group A ß-haemolytic Streptococcus J02.0, J03.0
After t0 (number/ rate per 1000 months)
034.0 Streptococcal sore throat
 Gr.A 11 4 8.6 (2.8–31.5) <0.001
035 Erysipelas A46.0
Streptococcus
038.0 Streptococcal septicemia A40.3, A40.9
 Staphylococcal 4 4 3.1 (0.7–13.9) 0.20
041.00 Streptococcus infection NOS B95.5
 H. influenza – 1 NA –
320.2 Streptococcal meningitis G00.2
 Mycoplasma 1 1 3.2 (0.08–139) 0.84
482.31 Pneumonia due to Streptococcus, Group A J15.4
 Parainfluenza 8 7 3.6 (1.3–11.4) 0.027
Methicillin-sensitive S. aureus (MSSA) A41.2
 RSV 1 – NA –
038.10 Staphylococcal septicemia, NOS
 Viral inducers 1 1 3.2 (0.08–139) 0.84
038.11 MSSA septicemia A41.0
 Mycobacterium 1 – NA –
041.10 Staphylococcus, NOS infection in B95.8
tub
condition elsewhere classified
 months 105,511 332,508
041.11 MSSA infection in condition elsewhere B95.61
Infections (Tektonidou, Weiss, 2010/Riganti 2013) classified
320.3 Staphylococcal meningitis G00.3
Suppl Table 1. Diagnostic codes used to classify infections in IgAV
482.41 MSSA pneumonia J15.211
patients and controls
695.81 Staphylococcal scalded skin syndrome L00

Tektonidou SLE 2015 Methicillin-resistant S. aureus (MRSA) A41.02

038.12 MRSA septicemia
ICD-­9 CR ICD10-­AM
041.12 MRSA infection in condition elsewhere B95.62
pneumonia J85/A02.2/J12-­J18.9
classified
003/481.0/513.0/480/482/
483/485/486 482.42 MRSA pneumonia J15.212

sepsis/bacteremia R78.8/A22.7/A32.7/A02.1/ Parainfluenza virus J12.2

038/790.9/ 790.7 A40-­A41.9) 480.2 Parainfluenzal pneumonia

urinary tract infection
590/595.0/599
skin and soft tissue
infections
040.0, 569.61, 681, 682,
785.4, 728.86, 035,785.4
opportunistic infections
Tuberculosis 010–018
nontuberculous mycobacte-
ria (031)
N39.0 /N30.0/N30.9/A54.0 Influenza virus 487.0 Influenza with pneumonia J11.0
487.1 Influenza with other respiratory J10.1, J11.1
A48/I96/M60.0/M72.6/ manifestations
A46.0/’L00.0-­L08.9 487.8 Influenza with other manifestations J11.2-­J12
Adenovirus A87.1
049.1 Meningitis due to adenovirus
A15.0, A15.4-­A15.9, A17.0-­A17.2,
077.3 Acute adenoviral follicular conjunctivitis B30.1
A17.8-­A18.9, A19.2, A19.8-­
A20.0, A46.0A31.0-­A31.3, 079.0 Adenovirus infection, NEC B97.0
A31.8, A31.9 480.0 Pneumonia due to adenovirus J12.0
008.62 Enteritis due to adenovirus A08.2
 |
      155

Objective: To investigate the rate, type and time course of hospital

ICD-­9CR diagnosis ICD 10 (AM?)
presentations for infection in adults (≥17 years) with IgAV compared
Respiratory syncytial virus (RSV) B97.4
to controls.
079.6 RSV infection in condition elsewhere
classified
Methods: IgAV patients (n = 284, median age 59 years, 49%
male) were age and gender matched with non-­exposed controls
480.1 Pneumonia due to RSV J12.1
(n = 1381) from a state-­wide register containing linked health data
466.11 Acute bronchiolitis due to RSV J21.0
on hospital admission and ED presentation. We defined serious
infections (SI) (per Tektonidou, 2015), organ-­b ased infection (per
Suppl Table 2. Diagnostic codes used to classify infections in IgAV Weiss 2010) and rarer infections (per Riganti, 2013). Baseline was
patients and controls (Weiss 2010) defined as time of IgAV diagnosis or equivalent date in controls.
Bacteria ICD 9 ICD10 Infection rates per 1000 patient months were calculated during
179.920 months before and 223.920 months after t0 as was the
Group A beta-­hemolytic See Weiss See Weiss
Streptococcus pyogenes prevalence of associated microorganisms. Conditional maximum
[13–20] likelihood estimates of Rate Ratios (95% CI) were analysed by
Neisseria meningitidis [21] Fishers exact test.

Mycoplasma pneumoniae 483.0/041.81 J15.2/J20.0/ Results: The rate of SI cohort was significantly increased in the
22–24] A49.3/B96.0 IgAV (6.2 vs 0.9/1000 months; RR 7.5; 6.1–9.5, P < 0.001) pre-­
Hemophilus Influenzae 041.5, 320.0, A49.2, B96.31, diagnosis and rose further post-­diagnosis to 18.3/1000 months
485.2, B96.38, (RR 4.6; 4.1–5.1, P < 0.001). Skin/soft tissue infections had the
487.1 + 041.5, B96.39, G00.0, highest RR (10.4; 3.6–37.2, P < 0.001) pre-­diagnosis followed by
711 + 041.5 J14, J201.1
urinary tract infections (RR 7.7; 5.2–11.5, P < 0.001), while sepsis
Helicobacter pylori [28–30]
(0.96/1000 months) had the highest RR (8.0; 4.4–14.6, P < 0.001)
Salmonella enteritidis [31] See Tektonidou See Tektonidou post diagnosis. Infections with Gram positive cocci were the most
Mycobacterium tuberculosis 010–018.6 A15-­A19 frequent type of infection both pre-­(1.3/1000 months) and post
[32,33]
diagnosis (3.3/100 months).
Staphylococcus aureus [34] See Weiss See Weiss Conclusions: The increased rate of infections, especially with gram-­
Chlamydophila pneumoniae positive cocci in skin/soft tissue and urinary tract before a diagnosis
[35]
of adult IgAV suggest a specific activation pathway for adult IgAV.
Campylobacter jejuni [36]
Post diagnosis infectious rates remain elevated in adult IgAV pa-
Kingella kingae [37] tients, while the microbial spectrum widens.
Viruses
 Parvovirus B19 [39–45] See Tektonidou See Tektonidou
 Hepatitis B virus [46,47]
2-­132 | The importance of tubuloreticular
 Hepatitis A virus [48–50]
inclusion bodies in lupus nephritis
 Hepatitis C virus [51,52]
J. Nossent1,2; W. Raymond1; M. Ognjenovic1; A. Kang3; D.
 Varicella-­zoster virus See Tektonidou See Tektonidou
Wong3; A. Chakera1,4
[38,53–55]
1
University of Western Australia; 2Department of Rheumatology, Sir Charles
Rigante 2013 review: Main pathogens associated with Henoch– Gairdner Hospital; 3Path West Laboratory Medicine, Anatomical Pathology;
Schönlein purpura 4
Department of Nephrology, Sir Charles Gairdner Hospital

Background: Tubuloreticular inclusion bodies (TRI) are intracellular

2-­060 | Infection rates in adult patients with structures within the cytoplasm of endothelial cells that inconsist-
IgA vasculitis before and after diagnosis ently have been associated with autoimmune and viral diseases. We

J. Nossent 1,2 1 1,2

; W. Raymond ; C. Inderjeeth ; H. Keen ; D.
Preen4
1 2
School of Medicine, University of Western Australia; Department of
Rheumatology, Sir Charles Gairdner Hospital; 3Department of Rheumatology,
Fiona Stanley Hospital; 4School of Population and Global Health, University
Western Australia
Background: IgA vasculitis (IgAV) in adults is less frequent than in
childhood but runs a more severe course. There is little data on in-
fections as potential triggers for adult IgAV.
1,3 investigated the clinical and prognostic relevance of detecting TRI in
patients with Lupus Nephritis (LN).
Methods: A single centre cohort study of patients (n = 84) with
biopsy evidence of LN. Clinical assessment included demograph-
ics, SLEDAI score and autoantibody profiling, while histological
evaluation included TRI presence, ISN classification with NIH ac-
tivity and chronicity indices, immunofluorescence and EM findings.
Comparison of clinical and histological findings between patients
with and without TRI was by non-­parametric statistical methods.
 |
156      

Results: TRI were detected in 37 patients (44%) that were younger
(28.4 vs 34.3 years, P = 0.02) and more often from Asian background
(37.8% vs 19.1%, P = 0.04) compared to patients without TRI. SLEDAI
score (11 vs 12), eGFR and amount of proteinuria (370 vs 340) were
similar in both groups, but TRI + patients had increased frequency
of anti-­SSB antibodies (16 vs 2%, P = 0.01), full house immune com-
plex deposition (85 vs 58%, P = 0.04) and presence of subendothelial
EDD (83% vs 65%, P = 0.07). Patient and renal survival were not in-
fluenced by TRI status.
Conclusions: TRI were observed in nearly half of all LN patients
but had little bearing on disease presentation or outcome in LN. As
anti-­SSB antibodies interfere with SSB protein function to regulate
mRNA transcription, these data suggest that TRI may reflect non-­
functional mRNA transcripts.
Conclusions: CTGF is able to mediate activation signal against
Notch-­1 which has been recently postulated as important factor of
angiogenesis in RA. CTGF is considered to play an important role
for aberrant angiogenesis of RA in combination with Notch-­1. CTGF
may become a novel target molecule for treatment of RA as CTGF
blockade may ameliorate RA by multiple therapeutic mechanisms in-
cluding suppression of aberrant angiogenesis.
3-­070 | Comparison of efficacy of first versus
second-­line golimumab in Japanese patients with
rheumatoid arthritis
K. Oh1; K. Ikari1; K. Yano1; K. Okazaki2
1
Institute of Rheumatology, Tokyo Women's Medical University; 2Department of
Orthopedic, Tokyo Women's Medical University

2-­021 | Aberrant angiogenesis is mediated by

connective tissue growth factor through notch-­1
activation in patients with rheumatoid arthritis
1 1 1 1
K. Nozawa ; T. Hirai ; H. Tsushima ; K. Yamaji ; I. Sekigawa ;
N. Tamura1
1
Department of Rheumatology Juntendo University; 2Department of
Rheumatology Juntendo Urayasu Hospital
Objective: Aberrant angiogenesis has been considered as one of
important factors for pathogenesis of rheumatoid arthritis (RA).
Among angiogenetic mediators, Notch-­1 has been reported as one
of important angiogenetic mediators in RA. A series of our previ-
ous studies have demonstrated that connective tissue growth fac-
tor (CTGF) was highly expressed in synovial tissue of RA. CTGF is
known as strong mediator for angiogenesis. CTGF interestingly has
also been reported as a potent angiogenetic mediator in other dis-
eases. Therefore, this study was conducted to clarify whether CTGF
associates with angiogenesis of RA.
Methods: Synovial tissue samples of RA patients were used for
immunohistochemical analysis. CTGF association for angiogen-
esis was evaluated by tube formation assay and Boyden chamber
assay using human umbilical vein endothelial cells (HUVECs) in
vitro. CTGF-­mediated Notch-­1 activation were evaluated by immu-
nofluorescence, immunoblotting, and quantitative RT-­PCR analysis
in HUVECs. Therapeutic efficacy of CTGF blockade for preven-
tion of increased angiogenesis was evaluated in collagen induced
arthritis (CIA) mice by administration of the neutralizing anti-­C TGF
antibodies.
Results: Synovial tissues of RA patients showed upregulation
of Notch-­
1 pathway indicated by strong expression of Notch-­
1,
Notch-­1 transmembrane domain (NICD), and DLL-­4. CTGF func-
tioned as angiogenetic mediator and was able to activate Notch-­1
signaling pathway in vitro. Administration of neutralizing anti-­C TGF
antibodies prevented the development of angiogenesis through in-
hibition of Notch-­1 expression in CIA mice.
Background: About 30–40% of treated patients show a primary no
response to golimumab. To clarify the factor of the difference be-
tween 1st and 2nd line golimumab should be needed.
2 Objectives: the aim of study was to assess the efficacy and the pa-
tients characteristics of first versus second-­line of golimumab (GLM).
Methods: We analyzed the efficacy of golimumab comparing be-
tween first-­line (44patients) and second-­line (66patients) in a total
of 110 Japanese RA patients
Results: Patients in 2nd line were significantly higher stage
(Steinbrocker classification), and higher HAQ scores compared to 1st
line. In 1st line, rates of DAS28-­remission at 52 weeks were 32.2%
while 22.3% in 2nd line (P = 0.02). A normal HAQ score (HAQ ≤ 0.5)
was achieved in 43.2% after 52 weeks in 1st line versus 28.5% in
2nd (P < 0.05). Discontinuation due to lack of efficacy was lower in
1st line (30.5 vs. 44.7%, P < 0.0001). Rates of adverse events were
almost similar.
Conclusion:
The efficacy of 1st line golimumab is better response than 2nd line. :
3-­033 | Application of a real-­time pain
monitoring system in Korean fibromyalgia
patients: a pilot study
M. Oh; J. Lee; S.-H. Park; J. H. Ju; J. H. Cho
Seoul St Mary's Hospital, College of Medicine, the Catholic University of Korea
Objectives: Chronic pain is a debilitating condition that should be
managed with integrated multidisciplinary approaches. To this end,
accurate pain assessment should be the first step, and self-­reporting
pain assessment systems using smartphones or wearable devices
are being introduced. The aim of the study was to evaluate the util-
ity and efficacy of a real-­time pain monitoring system using a wear-
able device, referred to as the Pain Assessment and Analysis System
(PAAS), in patients with fibromyalgia, which is characterized by
widespread chronic pain.

Methods: In this pilot study, adult fibromyalgia patients were ran-
domly assigned to use or to not use PAAS. Changes in the visual
analogue scale (VAS) were examined by rheumatologists at baseline
and after three months, and correlations between conventional pain
VAS or PAAS VAS and clinical parameters were investigated.
Results: A total of 24 fibromyalgia patients were enrolled in the
study, with 14 patients assigned to the PAAS group, and 11 patients
assigned to the control group. All patients completed the three-­
month study. The reduction of pain on the VAS in patients who used
PAAS for three months was significantly greater than that in the
control group. The mean pain VAS calculated by PAAS showed good
correlation with clinical parameters, including the score of the fibro-
myalgia impact questionnaire.
Conclusions: The proposed real-­time pain monitoring system can
be utilized for pain assessment in Korean fibromyalgia patients.
Moreover, the system accurately reflects pain status and may help
to alleviate pain.
Keywords: fibromyalgia, chronic pain, E-­health, mobile-­health
2-­133 | Soluble Siglec-­5 is a novel salivary
biomarker for primary Sjogren's syndrome
J. Lee; M. Y. Kim; S.-K. Kwok; S.-H. Park; M. Oh
Seoul St Mary's Hospital, College of Medicine, the Catholic University of Korea
Background/purpose: Despite advances in the understanding of
the pathogenesis, disease-­
specific biomarkers have not been in-
cluded in the classification criteria for Primary Sjogren's syndrome
(pSS). Based on the microarray of peripheral blood mononuclear
cell (PBMC) of pSS patients, we aimed to investigate whether sialic
acid-­binding immunoglobulin-­like lectin (siglec)-­5 might serve as a
biomarker for pSS.
Methods: Microarray of PBMCs obtained from 26 pSS patients and
10 healthy control (HC)s was performed to screen potential bio-
markers for pSS. The concentration of siglec-­5/14 in saliva and sera
was determined by ELISA. Clinical parameters related with pSS were
obtained from pSS registry and correlation with salivary siglec-­5/14
level was evaluated. Receiver operating curve (ROC) analysis was
performed to determine cut off value. A separate validation cohort
consisted of subjects with suspicious pSS was evaluated to deter-
mine the performance.
Results: The level of salivary siglec-­5/14 was significantly higher in
pSS patients compared with HCs or sicca patients (1346.8 [202.8–
4280.0] pg/mL, 6.08 [0–134.0] pg/mL, and 0 [0–385.3] pg/mL,
median [interquartile range], P < 0.001), meanwhile the serum
level was not different between the groups. Clinical parameters
were available in 170 patients in pSS registry. Salivary siglec-­5/14
level negatively correlated with salivary flow rate (spearman's rho:
−0.420, P < 0.001), and positively correlated with ocular surface
score (rho: 0.331, P < 0.001) and serum immunoglobulin G level
(rho = 0.202, P = 0.008). However, the level of salivary siglec-­5/14
was not correlated with ESSDAI or focus score. On ROC analysis,
|
      157
area under the curve was 0.835 (0.782–0.888). With cut off value
200 pg/mL, sensitivity and specificity was 0.75 and 0.75 respec-
tively. In validation cohort where patients without sicca symp-
tom but have 1 or more positive items in ESSDAI were included,
sensitivity and specificity of siglec-­5/14 was 68.2% and 71.7%,
respectively.
Conclusion: The level of soluble siglec-­5/14 is significantly in-
creased in the saliva of pSS patients and reflects the severity of
hyposalivation and ocular surface damage. Although the mecha-
nism of the contribution to gland dysfunction is unclear yet, this
easily obtainable salivary biomarker may add benefits on the di-
agnosis of pSS.
2-­112 | Audit of the management of digital
ulcers secondary to Raynaud's phenomenon
in patients with scleroderma at Fiona Stanley
Hospital
D. Olsson-White1; H. Keen1,2; J. Roddy1
1
Fiona Stanley Hospital; 2Medical School, the University of Western Australia
Background: 50% of scleroderma patients report digital ulcers
(DU). DU are often complicated by infection, which can lead to
osteomyelitis (OM). Management of Raynaud's Phenomenon (RP)
includes pharmacological measures, with phosphodiesterase-
­5 inhibitors and IV prostanoids shown to both heal and prevent
new DU. Management and investigation of infectious complica-
tions and OM in scleroderma is largely empiric, with no current
guidelines. With this audit, we aim to assess the prevalence and
management of severe DU in scleroderma patients, assess rates
of complication with infection and osteomyelitis, and the manage-
ment of these complications.
Methods: Patients with scleroderma and severe DU from Fiona
Stanley Hospital scleroderma outpatient clinic were reviewed ret-
rospectively from January–December 2017. Patients were assessed
for number and duration of DU, therapy for RP and DU, presence of
infection +/-­OM, investigation and management of OM, and num-
ber of admissions and clinic appointments.
Results: 28 scleroderma patients with severe DU were identified.
The median number of DU was 2 (1–5/multiple). Median time to
healing was 5.76 months (3–10 months, with some DU ongoing).
36% had recurrent new ulcers within the same year. 46% appeared
to have infection and 21% confirmed OM, though 32% overall had
OM suggested by imaging +/-­culture and clinical signs. Antibiotic
choice and duration of therapy was variable. 54% of all patients re-
ceived iloprost, and 86% were on sildenafil. 43% required admission
for DU, and 2 (7%) had amputations secondary to complications of
DU.
Conclusion: There is a high burden of DU amongst scleroderma pa-
tients. The majority of patients are on sildenafil and iloprost, in keep-
ing with standard of care. A high number of patients had infected
 |
158      

DU, with a significant number diagnosed with OM. Treatment of OM
was variable, with no standardised protocol.
2-­134 | Multidimensional Health Assessment
Questionnaire in systemic lupus erythematosus:
comparison with the short form 36 version 2
R. Fang; F. Huang; M. Nguyen; K. Gibson; S. O'Neill
UNSW/Liverpool Hospital
1-­027 | Clinical characteristics of patients with
remitting seronegative symmetrical synovitis
with pitting edema compared to patients with
elderly-­onset rheumatoid arthritis
T. Origuchi1; M. Umeda1; T. Koga1; S. Kawashiri1; N.
Iwamoto1; K. Ichinose1; K. Arima1; M. Tamai1; H. Nakamura1;
T. Tsukada2; T. Miyashita3; N. Iwanaga4; T. Aramaki5; Y.
Ueki5; A. Kawakami1
1
Nagasaki University; 2Aino Memorial Hospital; 3Miyashita Rheumatology
Clinic; 4Nagasaki Medical Center; 5Sasebo Central Hospital

Background: The Multidimensional Health Assessment

Background/purpose: We often experience difficulties in distinguish-
Questionnaire (MDHAQ) can provide quality of life and prognostic
ing remitting seronegative symmetrical synovitis with pitting edema
information for patients with rheumatoid arthritis and other rheu-
(RS3PE) from elderly-­onset RA (EORA). We statistically compared the
matic conditions. There are limited studies confirming its role in the
clinical characteristics between RS3PE syndrome and EORA.
assessment of patients with systemic lupus erythematosus (SLE).
Objectives: To compare clinical features of patients with RS3PE
Objectives: To evaluate the clinical utility of the MDHAQ and its
syndrome and patients with EORA, and to explore the association
summary score RAPID3 in SLE patients in comparison with the Short
between RS3PE syndrome and the complications.
Form 36 version 2 (SF-­36) quality of life tool.
Methods: We performed a retrospective chart review of 47 RS3PE
Method: Patients completed the MDHAQ and SF-­36 at a routine
syndrome patients and 50 EORA patients between January 2003
clinical visit before seeing their rheumatologist. The RAPID3 was
and December 2017. EORA patients were fulfilled 2010 ACR/
compared with the SF-­
36 physical component summary (PCS)
EULAR classification criteria for RA and developed RA after 60 years
and mental component summary (MCS) scores through two-­tailed
old. Outcomes assessed were clinical characteristics of disease and
Spearman rank-­order correlations. Patients with secondary fibromy-
associated complications.
algia were identified using the Fibromyalgia Survey Questionnaire
Results: Patients with RS3PE syndrome were more likely to be male
for stratification of analysis.
compared to the EORA group (60% vs 24%; P = 0.0004). Serum
Results: 64 patients with complete MDHAQ and SF-­36 were in-
C-­
reactive protein (CRP) concentration of RS3PE syndrome was
cluded for analysis. 17 patients (27%) with secondary fibromyalgia
higher than that of EORA (7.6 mg/dL vs 2.3 mg/dL, P < 0.0001).
were identified. There was a strong correlation between the RAPID3
Fever was more common in the RS3PE syndrome group (51% vs
and the PCS of the SF-­36 (rho = −0.712, P = 0.001), and a moder-
6%; P < 0.0001). Initial prednisolone dose of RS3PE syndrome was
ately strong correlation with the MCS (rho = −0.595, P = 0.001).
higher than that of EORA group (16.5 mg/d vs 6.9 mg/d, P < 0.0001).
These correlations weakened slightly upon removing patients with
Methotrexate was used in only 4 patients with RS3PE syndrome.
fibromyalgia: PCS (rho = −0.628, P = 0.001) and MCS (rho = −0.503,
The RS3PE syndrome group was more complicated with cancer at
P = 0.001). Weak but not statistically significant correlations were
entry (32% vs 12%, P = 0.0255) and with osteoporosis after one year
found in patients with fibromyalgia: PCS (−0.381, P = 0.131) and
treatment (40% vs 20%, P = 0.0449). On the other hand, the rate of
MCS (rho = −0.273, P = 0.288).
interstitial pneumonia in the RS3PE syndrome was less than that in
Conclusion: The RAPID3 is a useful indicator of the patient's experi-
the EORA group (0% vs 20%, P = 0.0012).
ence of disease in SLE that correlates strongly with the validated
Conclusion: Compared to patients with EORA, RS3PE syndrome
SF-­36 research questionnaire. It is feasible for routine use in clinical
patients were more likely to be male. Inflammatory signs were rela-
care. The presence of concomitant fibromyalgia has an impact on pa-
tively high and high dose corticosteroids might induce osteoporosis.
tient reported outcome measures and needs to be considered when
Although malignancy was frequently complicated as mentioned in
interpreting RAPID3 and SF-­36 results in people with SLE.
earlier studies, we suggested that interstitial pneumonia was not a
frequent complication in RS3PE syndrome.
 |
      159

2-­0 04 | Novel multiple heterozygous NUDT15 Methods: Fifty-­five outpatients with RA before tight control were
enrolled. Clinical and demographic characteristics were collected
variants caused an azathiopurine-­induced severe
at baseline. in addition to mTSS, we evaluated radiographic fore-
alopecia, tongue ulcer and leukopenia in a
foot deformities using bilateral hallux valgus angle (HV), 1st to 2nd
systemic lupus erythematosus patient metatarsal angle (M1M2) and 2nd to 5th metatarsal angle (M2M5),
M. Otsuka; T. Koga; R. Sumiyoshi; M. Okamoto; Y. Endo; and we defined the sum of these angles as total forefoot deform-
S. Tsuji; A. Takatani; T. Shimizu; T. Igawa; S. Kawashiri; N. ity score (TFDS). Predictors of clinically relevant radiographic pro-
Iwamoto; K. Ichinose; M. Tamai; H. Nakamura; T. Origuchi; gression (CRRP; ΔTFDS/year more than the small detectable change
A. Kawakami
(SDC = 5.19)) were analyzed using multivariate logistic regression
Nagasaki University
models.
Results: At baseline, the mean age of patients was 60.3 years and
The efficacy of azathioprine (AZA) has been demonstrated for the
the mean disease duration was 12.9 months. The mean simplified
treatment of autoimmune diseases including systemic lupus ery-
disease activity index (SDAI) and modified health assessment ques-
thematosus (SLE). However, common and serious adverse events
tionnaire (mHAQ) at baseline was 21.7 and 0.39. The mean CRP and
of treatment with AZA are leukopenia and hair loss. Recent stud-
MMP-­
3 was 1.97 mg/dL and 152.6 ng/mL. Twenty-­
four patients
ies have shown that NUDT15 R139C was strongly associated with
(43.6%) were treated with glucocorticoids (GCs) and mean dose of
thiopurine-­induced leukopenia among Asian populations.
GCs was 5.49 mg/day. Thirty-­one (75%) patient achieved SDAI re-
A 57-­years-­old Japanese man presented a tongue ulcer and slight
mission after tight control. TFDS was significantly increased 90.0
fever 4 weeks after the introduction of AZA 50 mg/d for the treat-
points at baseline to 98.0 points at final follow up (mean 2.2 years)
ment of SLE. He was admitted to our department since laboratory
(P < 0.001). Multivariate logistic regression analysis showed GCs use
data showed severe neutropenia (50/μL) and high level of CRP. After
was an independent predictive factor for CRRP of TFDS (OR 5.12;
admission, we discontinued AZA and initiated daily injection of G-­
95%CI 1.09–24.1; P = 0.04).
CSF, but his tongue ulcer was not improved, and severe neutropenia
Conclusions: Forefoot deformities progressed even if clinical remis-
had been sustained for 3 weeks. in addition, although hair loss of
sion was achieved. The usage of low dose GCs was an independent
the patient was not clear at admission, it progressed a total alopecia
predictive factor for forefoot deformities in early RA.
3 weeks after admission. Because his activity of SLE was stable dur-
ing the admission, we thought that immunological mechanisms did
not cause these clinical manifestations.
A genetic analysis revealed multiple heterozygous mutations in exon 3-­098 | An initial attempt of use of a composite
3 of the NUDT15 gene (R139Y). Homozygous mutation of R139C Disease Activity Score (DAS) for Extra Articular
in the NUDT15 gene is known to result in severe neutropenia and Manifestations in Rheumatoid Arthritis (EAM-­
total hair loss similar to this case, but with heterozygous mutation RA)
of R139C, a clinical course is relatively mild. This case suggests that
P. Padhan; B. Thakur
genetic testing of NUDT15 is useful for predicting the severity of
KIMS, KIIT University
AZA adverse events and that NUDT15 R139Y heterozygous muta-
tions associated with higher AZA-­induced toxicity than a NUDT15
Background: Rheumatoid arthritis is a chronic multisystem disease
R139C heterozygous mutation.
predominantly involving synovial joints. Extra articular involvement
is common in various stages of the disease. DAS-­28 scoring is used
to monitor disease activity in RA. However till date there is no tool to
3-­097 | Predictive factor for forefoot deformity access the severity of extra articular manifestations in RA.
in early rheumatoid arthritis Objective: The aim of the study was to use a composite score to ac-
1 2,3 4 2,3 2 cess the severity of EAM-­R A using various parameters.
Y. Ozaki ; R. Hara ; H. Nishimura ; T. Kira ; N. Shimmyo ;
A. Kido2,3; Y. Akai2; T. Fujimoto2; Y. Tanaka2,3 Methods: 226 patients with RA were included in this cross sectional
1
Department of Orthopaedic Surgery, Matsusaka Chuo General Hospital; study. A composite score was obtained using 28 extra articular dis-
2
The Center for Rheumatic Diseases, Nara Medical University; 3Department ease parameters in RA. DAS-­28 score and DAS EAM-­R A score were
of Orthopaedic Surgery, Nara Medical University; 4Center For Postgraduate obtained in each patient at the same visit. The score was defined as
Training, Nara Medical University
mild if ≤3, moderate if between 3 to 8 and severe if >8. The agree-
ment between DAS-­28 and EAM-­R A Score was accessed.
Background: Many kinds of factor possibly associate with various
Results: Among RA, increasing age and longer duration of disease
forefoot deformity in patients with rheumatoid arthritis (RA). The
had significantly higher DAS EAM-­R A score. Presence of RF and/
aim of this study is to determine the risk factors of forefoot deform-
or Anti-­CCP did not influence DAS EAM-­R A score. There was no
ity in early RA.
influence of gender on DAS EAM-­R A score. The agreement between
 |
160      

DAS-­28 and DAS EAM-­R A Score is 46.08% (Kappa = 0.07) with P 3-­099 | Comparison between Rapid 3 and
value 0.029 indicates slight agreement between two scores.
Clinical Disease Activity Index (CDAI), as a
Conclusion: DAS EAM-­R A can be a useful tool to monitor extra ar-
measure of disease activity in Indian population
ticular disease severity in RA. Prospective validation for the same is
warranted for future clinical use.
with rheumatoid arthritis
S. Pandey; P. D. Rath; S. Bhasin
Max Superspeciality Hospital Saket

3-­105 | An interesting case of pulmonary

Type of study: Observational analytical study.
hypertension in elderly female
Background: DAS28, CDAI and SDAI are already validated outcomes
S. Pandey; P. D. Rath; S. Bhasin to assess disease activity in Rheumatoid arthritis. RAPID3 is a ques-
Max Superspeciality Hospital Saket tionnaire which is very easy and simple, which a patient can fill sit-
ting outside in OPD mostly within 3 minutes.
Aim: To highlight a case of systemic sclerosis sine scleroderma pre-
senting as isolated pulmonary hypertension. Objectives:
Introduction: Systemic sclerosis sine scleroderma (ssSSc) is a rare
• To asses RAPID3 in rheumatoid arthritis patients
entity. in study by DIAB et al. ,only 4.0% were identified as having
• Correlate RAPID 3 and CDAI in same patient
ssSSc. Only 3 cases with PAH as predominant symptom of ssSSc in
Methods: Clinically diagnosed 200 patients of Rheumatoid arthritis
the absence of lung disease has been published.
as per ACR/EULAR 2010 criteria were selected including patients
Case description: 70 year old female with no comorbid illness came
with comorbid illness like Osteoarthritis knee, fibromyalgia, other au-
with history of progressive shortness of breath since 2 years with-
toimmune disorders were included. Patients were then divided in to
out cough with expectoration.Echocardiography demonstrated high
two groups based on presence or absence of comorbid illness. RAPID
estimated RVP with a TR gradient of 75 mm Hg, with severe PAH ,
3 and CDAI were correlated in 103 patients at time of submission.
RVSP 88 mm of hg with RV systolic dysfunction. Patient didn't con-
Results: Mean age was 52, 84.46% were females. Median score of
sented for right heart catheterisation. HRCT chest didn't showed
RAPID-­3 was 8 (IQR 18-­10) while of CDAI was 14.5 (IQR-­21-­6.6).
any evidence of ILD.
Spearman rank-­order correlation coefficients for CDAI with RAPID3
History of Raynaud's phenomenon was present since 10 years. She
was 0.757(P < 0.001).In subjects with no comorbid illness it is slightly
had no dysphagia, or arthralgia. On reassessment, there were no
higher 0.817 , P value < 0.0001 in comparison to with comorbid ill-
other clinical features of CTD, including no skin thickening. Nail fold
ness 0.677.Overall 61.17% of patients who met CDAI moderate/
capillaroscopy showed multiple giant capillaries. She had a positive
high activity criteria met similar RAPID severity criteria(k: 0.260,
ANA, 1:320 titre with centromere pattern on IF. ANA by line immu-
P < 0.001).Only 1 patient (0.97%)with moderate activity had low se-
noassay was positive for CENP.
verity in RAPID 3.18 % who met CDAI remission/low activity crite-
Patient was diagnosed as case of scleroderma sine sclerosis with
ria also met similar RAPID criteria. While 21.3% who had remission
isolated pulmonary hypertension with Raynaud's phenomenon. She
or low activity in CDAI were in moderate to high severity group in
was started treatment with sildenafil, ambrisentan and diuretics.
RAPID3.While in group with no comorbid illness (38 patients) only
Discussion: German and Spanish groups of ssSSc patients,
13.16% (0.41, P < 0.001)who had low activity in CDAI were in mod-
Esophageal dysmotility was shown in 73% and 45% of the patients,
erate to high severity group in RAPID 3.
while interstitial lung disease was found in 73% and 64%, respec-
Conclusions: RAPID 3 and CDAI both correlate well in all patients, cor-
tively. PAH was reported in 23% of their ssSSc patients. Most cases
relation is slightly better in group with no comorbid illness. We observed
of PAH have been reported with underlying ILD, isolated PAH can
moderate strength of agreement in group with no comorbid illness.
also occur in ssSSc All three cases were associated with persistent
RP. Autoantibodies directed either against centrioles or against RNP
were present in two of these cases.
Take home message: In case of pulmonary hypertension, thorough 2-­118 | Interesting case of ankylosing
clinical history is important. NFC can sometime be clue to systemic spondylitis with scleroderma overlap
sclerosis sine scleroderma.
P. D. Rath; S. Pandey; S. Bhasin
Max Superspeciality Hospital Saket

Aim: To highlight an interesting overlap case of ankylosing spondy-

litis with scleroderma.
Background: Systemic sclerosis (SSc) is a multisystem disorder char-
acterized by fibroblast dysfunction, microvascular disease, immune
 |
      161

activation that leads to fibrotic changes in the skin and some inter-
nal organs (1). Patients with SSc frequently have painful arthralgias,
but seldom have arthritis (2) Joints involved in SSc were reported
as: wrist 13%; carpometacarpal-­interphalangeal joints9%; foot11%;
knee 4%; hip, 2%; and shoulder 1%.(3). There are rare case reports
suggesting that sacroiliac involvement could also be associated with
SSc. Sacroiliitis is an important feature of spondyloarthritis; is rarely
reported as a complication of connective tissue diseases
Case history: 28 year old male presented with Bluish discoloration
of fingers since 2 years. During examination there was difficulty
in rotating in bed. Patient revealed that he had inflammatory back
ache, alternating over buttocks. Severe in intensity so that he has to
wake up from sleep. o/e: skin tightness was present over face, neck,
arm and legs. Digital pits and gangrene present. B/L sacroiliac joint
Figure 1 SWE of the deltoid muscle in a healthy individual showing
tenderness was present. Inflammatory markers high, liver and renal
SWS for the region of interest (ROI)
functions were normal. ANA IF was positive 1:320 speckled. Anti
Scl-­70 was positive. Additionally HLA B27 by PCR was positive will be used as a comparator to SWE. All patients (n = 40) will re-
Diagnoses: Ankylosing spondylitis with scleroderma overlap. ceived B mode grey scale US, power Doppler US and SWE (Figure 1)
Discussion: We found a single controlled study on sacroiliac joint over the deltoid and vastus lateralis performed by sonographers
involvement in SSc (9). In the SSc group sacroiliitis was found in experienced in SWE. All patients (n = 40) will have routine clinical
13 patients (23%) and was significantly different from RA patients assessments -­Manual Muscle Testing, patient and physician's Visual
(4%), P = 0.003; and the healthy control group (2%) P < 0.001. The Analogue Scale, Health Assessment Questionnaire score, laboratory
SSc patients with sacroiliitis and with inflammatory back pain (8/57 assessment (FBC, U&E, LFT, CK, ESR, CRP for healthy controls and
patients, 14%) were regarded as axial spondyloarthritis overlap. an additional myositis serology, HMG Coa reductase enzymes for
Male gender, diffuse subtype, inflammatory back pain and high C-­ the IIM group) and MRI of the vastus lateralis and deltoid muscles
reactive protein levels were found to be the significant risk factors for the IIM cohort only. The initial data analysis is descriptive, with
for sacroiliitis. non-­standardly distributed data being analysed with non-­paramet-
Take home message: Male gender, diffuse subtype, inflammatory ric tests. Linear regression analysis will be used to determine the as-
back pain and high C-­reactive protein were found to be the signifi- sociation between SWS and other commonly measures of disease.
cant risk factors for sacroiliitis in a patient with systemic sclerosis. Logistic regression will be used to determine the sensitivity and
specificity of SWS for distinguishing between diseased and control
participants.
2-­050 | Preliminary validation of shear wave Results: Pending, to be finalised prior to APLAR-­ARA 2019.
elastography in the diagnostic evaluation of Conclusion: SWE may have a role in both the research and clinical
setting when managing patients with IIM.
muscle disease
S. Paramalingam1,2; M. Needham1,2,3; H. Keen1,3,4
1
Fiona Stanley Hospital; 2University of Notre Dame Australia; 3Murdoch
University; 4University of Western Australia 1-­120 | Real world experience with infliximab
biosimilar (BOW015®) in ankylosing spondylitis
Background: Idiopathic inflammatory myopathies (IIM) is a rare, het- – a sub-­group analysis of the East India cohort
erogeneous group of acquired muscle diseases characterised by pro-
S. Mohammed1; J. R. Parida2
gressive muscle weakness. Shear wave elastography (SWE) is a novel 1
Sun Pharma Laboratories; 2IMS and SUM Hospital
ultrasound (US) modality that uses acoustic radiation force impulse
to generate shear wave which estimates shear wave speed (SWS)
Background: Due to dearth of data on infliximab biosimilar
and ultimately tissue elasticity of muscle.
(BOW015®), a pan India registry was planned to capture the ef-
Objective: The objective of this study is to begin validation of SWE
ficacy and safety in real world clinical settings. Here, we analyzed
as an outcome tool in muscle disease.
the subgroup data in ankylosing spondylitis (AS) from the east India
Methodology: This is a pilot cross-­sectional study looking at healthy
cohort.
controls and an incident group of IIM using US (grey scale B mode
Objectives: To determine efficacy and safety of BOW015 in AS
and power Doppler) and SWE in the evaluation of IIM. Incident IIM
patients.
patients (n = 10) and healthy controls (n = 30) will be recruited. The
incident IIM patients will have routine clinically indicated MRI's that
 |
162      

Methods: Data were collected from multiple regions across eastern

region of India. Patients diagnosed with AS, having 4–6 months of
follow up data during the last one year, were included in the study.
Patients who were given BOW015 for other indications, prior in-
novator infliximab or other biologics were excluded out of the study.
Primary variable, major clinical improvement, was defined as Δ
ASDAS >2 from the baseline to 4–6 months of follow up. For analy-
sis, statistical tests were applied as appropriate.
Results: The cohort consisted of 149 patients, predominantly male
(69.8%), with mean age of 36.75 ± 11.11 years and mean body weight
of 58.26 ± 154 kgs. of the treated patients, 91(61.1%) patients ad-
ministered four doses, 10 (6.7%) patients administered three doses,
37(24.8%) patients administered two doses and 11(7.4%) patients
administered single dose of BOW015. in the final analysis set, 81
up and the clinical benefits were apparent as early as first dose of
patients had baseline and visit-­4 data. Among them 74 (91%) pa-
BOW015.
tients achieved major improvement, 5(6%) patients achieved clini-
cally important improvement and 2(3%) were non-­responders at visit
4. Bifurcation of cohort according to disease activity from baseline
to visit-­4 and trends in BASDAI measurements were also computed.
1-­094 | Bifidobacterium bifidum ATT
Five patients reported infusion related reactions. attenuates autoimmune arthritis by regulation of
Conclusions: BOW015 showed significant improvement in ASDAS Th17 and Treg balance
and BASDAI in patients with AS at the end of 4–6 months of follow J.-Y. Jhun1; S.-Y. Lee1; J.-G. Ryu1; J.-W. Choi1; J.-Y. Ryu1; Y.
Jeong4,5; S. J. Park5; B. Kwon4; G. E. Ji4,5; M.-L. Cho1,3; S.-H.
Park1,2
1
The Rheumatism Research Center, Catholic Research Institute of Medical
Science, the Catholic University of Korea; 2Division of Rheumatology,
Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine,
the Catholic University of Korea; 3Impact Biotech; 4Research Institute, BIFIDO
Co., Ltd; 5Department of Food and Nutrition, College of Human Ecology, Seoul
National University

Background: Rheumatoid arthritis (RA) is the most common inflam-

matory arthritis which is known as systemic autoimmune disorder.
Recently, the development of RA was mediated gut environment.
Probiotic bacteria have been known as significant factors in rheu-
matoid arthritis (RA), but there is no proof of Bifidobacterium bifidum
ATT effect in RA. We investigated whether B. bifidum ATT improve
CIA development and helper T (Th) 17 activation.

Method: To examine the effect of the B. Bifidum ATT on CIA, the
probiotic B. Bifidum ATT was administered orally once on day 14
after CIA induction. Histological analysis of the joints was conducted
using immunohistochemistry. Serum level of IgG isotypes and type
II collagen specific IgG were measured by ELISA. Th17 cells and Treg
cells of the spleen tissue were examined by confocal microscopy
staining. Flow cytometric analysis (FACS) was used to evaluate Th17
cells and Treg cells.
Results: The B. bifidum ATT was reduced CIA severity and IgG and
IgG2a autoantibody. Joint inflammation, bone destruction and car-
tilage damage was improved by B. bifidum ATT. The expression of
tumor necrosis factor (TNF)-­
α , interleukin (IL)-­
1β, IL-­
6 and IL-­
17
in synovium tissue was decreased by B. bifidum ATT. The balance
between Th17 cells and regulatory T (Treg) cells was controlled
reciprocally.
Conclusion: These findings suggest that the B. bifidum ATT can
ameliorate development of CIA through the reciprocal regulation of
Th17 and Treg.
3-­077 | Gut microbiome profiling of
rheumatoid arthritis patients reveals a Novel
Bifidobacterium strain for development of
pharmabiotics
J.-W. Kim1; M. Y. Kim1; H. K. Min1; Y. Jeong2; G. E. Ji2; S.
Lee1; J. Y. Jhun1; M.-L. Cho1; J. Lee1; S.-K. Kwok; J. H. Ju1;
S.-H. Park1
1
College of Medicine, the Catholic University of Korea; 2Seoul National
University, BIFIDO CO., Ltd.
Background/purpose: Gut dysbiosis is found in patients with rheu-
matoid arthritis (RA) and murine studies have revealed that modula-
tion of gut microbiota can suppress the severity of arthritis.
Objective: To investigate the gut microbiota from patients with RA
and to develop pharmabiotics for treatment of RA.
Methods: Fecal samples were obtained from healthy controls,
patients who are at risk of developing RA (pre-­R A), and patients
with RA. RA patients were classified into 4 groups: those who
newly diagnosed as RA (DMARD-­n aive group), those who well re-
sponded to conventional DMARD (cDMARD group), those who
responded to the first biologic DMARD (biologics-­1 group), and
those who did not responded to the first biologic DMARD (bio-
logics-­2 group). Pre-­R A was defined if individuals suffered from
arthralgia and/or had seropositivity, without fulfilling 2010 ACR/
EULAR classification criteria for RA. We characterized the mi-
crobial communities of subjects through the 16S rRNA Illumina
sequencing. Analysis of diversity and community structure was
conducted using Quantitative Insight Into Microbial Ecology
(QIIME). Candidate microbial strains isolated from fecal samples
were treated to RA animal model.
Results: Fecal samples from 30 healthy controls and 134 patients
with pre-­R A or RA were analyzed in this study. The profiles of gut
|
      163
microbiota in patients with pre-­R A or RA were different from those
of controls. The relative abundance of Actinobacteria phylum was
decreased in RA patients compared with healthy controls. The rela-
tive abundance of Proteobacteria phylum was increased in RA pa-
tients compared with healthy controls. Bifidobacterium genus, the
lower level of Actinobacteria, decreased according to the RA group,
showing markedly decreased in biologics-­2 group. Prevotella copri
was increased in DMARD-­naïve RA patients compared with other
RA groups and healthy controls. We treated a selected novel strain
of Bifidobacterium to RA animal model and observed the suppres-
sive effect on arthritis score and IL-­17 secretion.
Conclusion: Patients with RA lacked Bifidobacterium in their gut mi-
crobiota, particularly from those with poor treatment response. We
found a novel strain of Bifidobacterium which might be applied as
pharmabiotics in RA treatment.
3-­106 | Echocardiographic profile in systemic
sclerosis patients in rheumatology outpatient
clinic Cipto Mangunkusumo General Hospital
Jakarta
F. Parlindungan; S. Anggoro; B. Setyohadi
Departemen Penyakit Dalam Divisi Reumatologi RSUPN Cipto Mangunkusumo
Background/purpose: Systemic sclerosis (SSc) is a connective tis-
sue disease characterized by thickening of the skin and involve-
ment of multiple internal organs, including the heart. Doppler
echocardiography is essential to detect the presence of valvular
abnormalities or left ventricular (LV) systolic or diastolic dysfunc-
tion, as well as assessing the probability of pulmonary hyperten-
sion. This study aims to describe echocardiographic profiles of
SSc patients and the echocardiographic probability of pulmonary
hypertension.
Methods: This is a retrospective cross-­sectional, descriptive study in
SSc patients from January to September 2018 that underwent rou-
tine echocardiography. The patients were referred to cardiologists in
our heart center to obtain the echocardiographic assesments.
Results: Thirty three patients were included in this study.
Echocardiographic findings showed preserved left ventricular
systolic function in all of the patients, mean ejection fraction of
67.9 ± 7.1%, interventricular septum 8.76 ± 3.7 mm, left ventricular
dimension 42.02 ± 4.6 mm. Normal left ventricular diastolic function
was found in 81.8% of patients, grade 1 in 12.1% and grade 2 in 3%.
Mean left atrium dimension was 27.6 ± 5 and mean left ventricular di-
mension was 42 ± 4.6. Normal right ventricular systolic function was
found in 97% patients and mean tricuspid annular plane systolic ex-
cursion (TAPSE) was 21.5 ± 3.6. Peak tricuspid regurgitation velocity
was more than 3.4 m/s in 7% of the patients. The presence of other
echocardiographic signs of pulmonary hypertension was observed in
7% of the patients.The probability of pulmonary hypertension was
low in 87.9% patients and intermediate in 12.1 patients. None of the
patient had pericardial effusion or significant valve disease.
 |
164      
Conclusion: The echocardiographic profile of SSc patients showed
normal LV systolic function in all patients. We found low prevalence of
LV diastolic dysfunction, increased peak tricuspid regurgitation veloc-
ity, and presence of echocardiography signs of pulmonary hyperten-
sion. Most patients had low probability of pulmonary hypertension.
3-­107 | Seeking evidence of chromosomal
damage in scleroderma
K. Patterson1; J. Walker2; P. Roberts-Thomson2; C. Bull3; M.
Fenech4
1
Rheumatology Unit, Flinders University; 2Department of Immunology, Flinders
Medical Centre; 3University of South Australia; 4CSIRO Health and Nutrition
Aim: To test evidence of chromosomal damage in systemic sclerosis
(scleroderma).
Background: Scleroderma is an uncommon heterogeneous con-
nective tissue disease that is generally considered to have an au-
toimmune origin. It is currently subdivided into several variants
dependent on the extent of skin hardening (limited cutaneous,
diffuse cutaneous) and/or the presence of specific autoantibodies
(CENP, Topo1, RNAP3 and others). Cancer occurs more commonly
in scleroderma with a standardised incidence ratio (SIR) of 2 or more
suggesting chromosomal instability.  and skin lesions that varied from papules, pustules, nodules and vas-
Method: Chromosomal damage was measured in peripheral blood
lymphocytes in 62 well characterised scleroderma patients and 28
well-­matched controls using the well-­validated cytokinesis-­block mi-
cronucleus cytome (CBMNcyt) assay.
Results: Scleroderma patients identified with the CENP antibody
(n = 24) had significantly higher frequency of micronuclei (MN) and
nuclear buds (NB) than controls (P = 0.02) or patients with other au-
toantibodies (P = 0.002). A strong trend was observed in the CENP
subgroup between MN and NB (R = 0.39, P = 0.06). Other sclero-
derma serological subgroups showed no differences in CBMNcyt
assay variables as compared with controls and there were no dif-
ferences between patients with limited and diffuse scleroderma.
Furthermore, no significant correlations were observed between
elevated MN frequency in the CENP positive patients and various
nutritional variables that are known to influence biomarkers in the
CBMNcyt assay (e.g.serum B12, folate and homocysteine).
Discussion: The CENP positive scleroderma subgroup is the more
benign clinical variant compared with the diffuse/Topo1 and RNAP3
sub-­group, hence the finding of evidence of enhanced chromosomal
damage in the former was not anticipated. However, an Italian study
in 2002 reported similar findings to those in our study. The explana-
tion of the increased MN frequency in the CENP subgroup is ob-
scure and a central question is whether the CENP antibody reflects
this chromosomal damage (as a consequence of other causes) or is,
in contrast, a causative factor in its own right? Furthermore it is in-
triguing that as >70% of micronuclei in females contain inactivated X
chromosome it raises the possibility of a causal association with the
known striking female predominance of CENP positive scleroderma.
Conclusion: We have observed high levels of MN and NB in the CENP
positive scleroderma subgroup which does not appear to be related
to micronutrient deficiency. The results support the hypothesis that
a high frequency of MN and/or NB may be a risk factor for autoim-
munity in women.
1-­028 | Calf pain as a prominent feature of
Behcet's disease: four case reports
G. Penserga; E. Salido
Section of Rheumatology, Department of Medicine, University of the Philippines-­
Philippine General Hospital
Background/purpose: Behcet's Disease (BD) is a chronic, relaps-
ing systemic vasculitis. The most common manifestations are oral
ulcers, genital ulcers, uveitis, and skin lesions. In their presence, the
diagnosis is straightforward. BD can also present with a combina-
tion of less common symptoms, like severe calf pain, unremitting
fever and headache. Coupled with normal or nonspecific laboratory
results, diagnosis can present a challenge and is often delayed. We
hope to increase awareness of the spectrum of disease presentation
of BD, improve care, and reduce patient distress and cost of illness.
Methods: We present four patients with severe, recurrent calf pain
culitic ulcers over the legs. Disease presentation, diagnostic evalua-
tion, treatment and outcomes
Results: Three patients had recurrent high-­grade fever, one had sore
throat, and one had acute asymmetric arthritis of the wrist and two
fingers of one hand (Table 1). In three of them, the diagnosis of BD was
delayed for 1–7 years. Two patients had recurrent hospitalizations and
intravenous antibiotics that did not relieve them of fever and pains. All
patients had recurrent oral ulcers; onset is more than 10 years before
other symptoms of BD in two, at about the same time in one, and a year
after first symptom of BD in one. All considered the ulcers innocuous
due to their spontaneous resolution. None had genital ulcers, neuro-
logic, vascular, or ophthalmologic involvement. All responded well to
Colchicine and corticosteroids; two patients also received Azathioprine.
Conclusion: BD should be considered as a differential among pa-
tients with unilateral or bilateral calf pain, especially when there is
fever, skin rash, asymmetric arthritis, or sore throat.
1-­029 | Concurrence of Behcet's disease,
incontinentia pigmenti and ectopic kidney in a
young Filipino woman
G. Penserga; E. Salido; E. Penserga
Section of Rheumatology, University of the Philippines-­Philippine General Hospital
Background/purpose: Behcet's disease (BD) is a relapsing vasculi-
tis characterized by recurrent oral and genital aphthae, cutaneous
lesions, and ophthalmic, neurologic, or articular manifestations.
 |
      165

Incontinentia Pigmenti (IP) is an X-­linked disorder of the skin, teeth, showed anemia, elevated transaminases, high sedimentation rate,
eyes, and central nervous system. It presents with alopecia, a neona- C-­reactive protein, positive anti-­thyroglobulin and anti-­nuclear an-
tal vesicular rash, and hyperpigmentation of skin following the lines tibodies (1:640 speckled pattern), hence the diagnosis of SLE. The
of Blaschko. The concurrence of BD and IP has been reported in case following tests were normal or negative: urinalysis, thyroid function
studies, with defective chemotaxis of the PMNs as a possible com- tests, creatine kinase, serum c3, anti-­dsDNA, anti-­Sm, anti-­Ro, anti-­
mon mechanism. Kidney ectopia is a more common condition. We RNP, anti-­L a. On further history, we found that he has had bilateral
discuss a case of unusual concurrence of these three conditions to hearing loss for 3 years. Pure tone audiometry showed moderate
increase awareness of the phenomenon, facilitate early treatment sensorineural hearing loss. He responded well to corticosteroids
and improve the quality of life of patients. with immediate resolution of arthritis, weakness, transaminitis, and
Methods: Disease history, diagnostic evaluation, treatment and out- anemia and subjective improvement in hearing.
comes of a young woman with BD, IP and unilateral kidney ectopia Conclusion: Multiple systemic manifestations like anemia, inflam-
are discussed. matory arthritis, and unintentional weight loss in a patient with
Results: We present the case of a 19-­year old woman referred to uveitis and/or sensorineural hearing loss warrant investigation for
the Rheumatology service for recurrent vulvar and oral ulcers, as autoimmune diseases, like SLE, even in supposedly less-­predisposed
well as recurrent urinary tract infections, for 5 years. She was diag- individuals. This paper serves to remind physicians of the diverse
nosed with ectopic left kidney at age 8 and Incontinentia Pigmenti presentation of lupus.
at age 9. Early laboratory tests included negative anti-­
HIV 1+2,
reactive HSV IgG-­1-­ELISA (2.005 COI) and non-­reactive HSV IgG-­
2-­ELISA. Biopsy of the vulvar ulcer twice done showed chronic in-
1-­043 | The lack of association between knee
flammation with granulation and no microorganisms. On physical
effusion size and radiographic severity in knee
examination, there was marble-­like pattern of hyperpigmentation
on her trunk and limbs, and multiple oral and vulvar ulcers. She was
osteoarthritis
classified as Behcet's Disease by Revised International Criteria for C. Pham1; C. Dabare1,3; S. Vogrin1; A. Leung1,2,3; C. Page2; K.
Behcet's Disease. She improved with Colchicine 500 μg per day and Lim1,2,3
1
Prednisone (1 mg/kg/d), which was eventually tapered. Kidney func- Western Health Hospital; 2St Vincent Hospital; 3AIMSS (Australian Institute of
Musculoskeletal Science)
tion remained normal on last clinic visit.
Conclusion: BD should be considered as a differential among pa-
Background: Knee effusion, a common finding in knee osteoarthritis
tients with recurrent oral and vulvar ulcers. The link between DB, IP
(OA), is poorly understood in relation to the disease severity and its
and ectopic kidney is an area for further investigation.
response to intra-­articular (IA) corticosteroid treatment.
Objectives: To evaluate the relationship between the knee effusion
size, radiographic grades in different knee compartments and IA cor-
2-­0 05 | Systemic lupus erythematosus ticosteroid response in symptomatic knee OA patients.
presenting as bilateral sensorineural hearing loss
and uveitis in an elderly male
G. Penserga; C. Filarca; E. Osio-Salido
Table 1 The relationship between lateral, combined lateral/ patella-­
Philippine General Hospital
femoral and medial compartment radiographic severity (KL score 3
or more) and knee effusion volume in the sub-­analysis of 120 posi-
Background: Sensorineural hearing loss occurs in 8 to 57.5% of pa-
tive knee OA effusion population
tients with systemic lupus erythematosus (SLE), whether with ac-
tive disease or in remission. However, it is uncommon as the initial Missing data (N) P-­value Median (IQR)
symptom of lupus. Uveitis is another uncommon manifestation of Medial 26 0.97
lupus occurring in 0.1 to 4.8%. The presence of blurring of vision and KL 0-­2
hearing loss may not lead one to suspect lupus in an elderly male.
KL 3-­4
Through this case, we hope to increase awareness about less com-
Lateral 26 0.01
mon manifestations of lupus.
KL 0-­2 6 (3, 10)
Method: Case report
KL 3-­4 12 (8, 15)
Results: We report a case of a 63-­
year old male whose illness
Lateral/ Patella-­ 26 0.03
started as unilateral uveitis and gradual onset of other symptoms
femoral
over 6 months. He also had low-­grade fever, body malaise, unin-
KL 0-­2 7 (3, 11)
tentional weight loss of 10 kg, non-­scarring alopecia, painful and
KL 3-­4 12 (9, 15)
multiple oral ulcers, and bilateral inflammatory knee and shoulder
arthritis. Laboratory investigations done over a period of 10 months KL, Kellgren-­L awrence score.
 |
166      

Methods: A retrospective, longitudinal study of 216 symptomatic of patients had improvement in VAS (51.4%), analgesic use (58.8%)
knee OA patients who attended a dedicated OA clinic in a Melbourne and subjective assessment scale (51.1%). in patents who had
tertiary health centre between January 2014 -­December 2015. positive aspiration volume, lateral and combined lateral/ patella-­
When the patients presented to the clinic, the knee effusion size femoral, but not medial compartment severity (KL score 3 or
was measured by knee aspiration volume. The radiographic sever- more), were positively associated with aspiration volume (P = 0.01,
ity of knee OA was assessed using modified Kellgren-­L awrence (KL) 0.03 and 0.99 respectively).
score. The response of knee aspiration and IA corticosteroid treat- Conclusion: Knee aspiration and IA corticosteroid treatment can be
ment was evaluated by the change in Visual Analog Scale (VAS), effective for up to 4 months. Knee effusion size was not associated
subjective assessment scale and analgesic use. in the sub-­analysis with medial compartment disease. However, it appears to be corre-
of patients who have positive knee aspiration volume, KL score was lated with the lateral and combined lateral/ patella-­femoral compart-
graded separately in medial, lateral and patella-­femoral compart- ment disease.
ments. Regression Analysis and Mann-­Whitney U test were used to
investigate their relationships.
Results: This population had the mean age, BMI and female pro- 3-­078 | Fatigue and its associated factors in
portion of 75, 31 and 68% respectively. Knee aspiration volume
a multi-­ethnic cohort of Malaysian rheumatoid
was not associated with modified KL score (Coefficient −0.14,
P = 0.82). After 4 months follow-­up post treatment, the majority
arthritis patients
H. J. Lee1; J. Raja1; C. M. Ng2; S. Sockalingam1; F. Yahya1; Y.
C. Tee1; L. S. L. Pok1
Table 2 The relationship between knee effusion volume and the 1
Division of Rheumatology, Department and Faculty of Medicine, University of
response to knee aspiration and IA corticosteroid treatment after Malaya; 2Institute of Mathematical Sciences, Faculty of Science, University of
Malaya
4 months follow-­
up in 216 symptomatic knee OA using Mann-­
Whitney U test
Background: Fatigue is highly prevalent yet infrequently evaluated
Non-­ complaint in patients with rheumatoid arthritis (RA) which can im-
Missing P-­ Response response
pact quality of life (QOL). RA related factors such as disease activity,
data (N) value rate N (%) rate N (%)
pain and anaemia may contribute to fatigue.
VAS 79 0.18 71 (51.4%) 67 (49%)
Objectives: This study aims to describe the factors associated with
MAPT 89 0.85 77 (60.2%) 51 (39.8%)
fatigue in a single-­centre study on RA patients.
Exercise 112 0.94 105 (41.0%) 43 (59%) Methods: A cross-­sectional study was performed in a Malaysian ter-
Tolerance
tiary hospital, University Malaya Medical Centre from April to October
Subjective 27 0.42 97 (51.1%) 93 (48.9%)
2018 in patients diagnosed with RA. Electronic clinical records were
Assessment
reviewed for demographic data and clinician-­assessed DAS-­28 score
Analgesic use 1 0.19 127 (58.8%) 89 (41.2%)
was recorded for each patient. Patients completed questionnaires for
MAPT, Multiple Attributable Prioritisation Tool; VAS, Visual Analog fatigue FACIT-­F, functional disability HAQ-­DI and QOL EQ5D.
Scale. Results: 131 patients participated in this study with a mean age of
Subjective assessment (improvement versus no improvement).
60.5 10.9 years with age range 29 to 85 years. 115 (87.8%) were fe-
male. in terms of ethnicity, 59 (45%) were Indians, 42 (32.1%) were
Chinese and 30 (22.9%) were Malays. 71 (61.2%) patients were sero-
positive and the mean duration of illness was 11.0 8.9 years. Mean
DAS28 score was 2.99 1.07 and mean HAQ score was 0.66. The mean
total FACIT-­F score was 62.1 58.4. For each FACIT-­F components,
the mean for FACIT-­4 (physical well-­being GP) was 20.08 ± 5.58,
FACIT-­4 (social/family well-­being GS) 20.2 ± 6.06, FACIT-­4 (func-
tional well-­being GF) 19.12 ± 6.04 and FACIT-­4 (additional concerns)
34 ± 10.83. After adjustment for potential confounding variables,
FACIT-­
F score was significantly associated with age (P = 0.033),
duration of disease (P = 0.048), ethnicity Chinese (P = 0.007), BMI
(P = 0.029), HAQ-­DI (P = 0.044) and EQ5D (P < 0.001).
Conclusion: Fatigue in RA is not associated with parameters of in-
flammation such as disease activity, ESR and pain score in our RA
cohort. Fatigue has significant impact on QOL.
Table 1: Independent factors associated with FACIT-F in RA patients
 |
      167

survival for biologics at 24 months compared to other biologics

FACIT-­F (total) P value
(P = 0.025). The most common reason for treatment discontinuation
Age (years), mean ± SD 60.4 ± 10.88 0.061
was adverse effects for csDMARDs (23.9%) and financial constraints
Ethnicity 0.480  for tsDMARDs (25%) and biologics (45.7%). Presence of radiographic
BMI (kg/m2), mean ± SD 26.47 ± 6.50 0.112 erosions at baseline (OR 4.18, 95% CI 1.28, 13.6), high DAS28-­ESR
Disease duration, mean ± SD 10.97 ± 8.90 0.165 at baseline (OR 2.44, 95% CI 1.16, 5.01) and exposure to four csD-
Hb% (g/dL), mean ± SD 122.09 ± 16.59 0.048 MARDs (OR 14.12, 95% CI 2.08, 95.52) (all P < 0.05) were significant
ESR (mm/h), mean ± SD 30.82 ± 18.03 0.068 factors in initiating biologics.
VAS pain score, mean ± SD 27.45 ± 21.67 0.026 Conclusion: Conventional synthetic DMARD use may not always be

DAS score, mean ± SD 3.00 ± 1.07 0.002 effective and additional treatment is limited by cost. Presence of ra-
diographic changes, high disease activity at baseline and exposure
Remission (n) 48  
to multiple csDMARDs were significant factors in initiating biologics
Low disease activity (n) 33  
in RA patients.
Moderate disease activity (n) 37 <0.001
High disease activity (n) 6  
HAQ total score, mean ± SD 0.66 ± 0.66 <0.001 3-­071 | Impact of Adalimumab (HUMIRA®)
Mild to moderate disability (n) 96  
on Health and Disability Outcomes in Patients
Moderate to severe disability (n) 28 <0.001
with Rheumatoid Arthritis, Crohn's Disease or
Severe to very severe disability (n) 4  
Psoriasis: VITALITY study
EQD5, mean ± SD 0.76 ± 0.15 <0.001
Total number of comorbidities 0.95 (range 0–5) 0.270
R. Gearry1,2; C. Frampton2; S. Inns3; D. Poppelwell4; M.
Rademaker5; R. Suppiah6
1
Department of Gastroenterology, Christchurch Hospital; 2Department of
Medicine, University of Otago; 3Hutt Valley District Health Board IBD Service;
4
Abbvie Limited; 5Waikato Clinical School, University of Auckland; 6Department
1-­095 | Treatment patterns of disease-­ of Rheumatology, Auckland District Health Board

modifying anti-­rheumatic drugs, drug survival

and factors in initiating biologics in rheumatoid
arthritis
1,2 1 1 1
S. Mohammed ; L. S. L. Pok ; Y. C. Tee ; F. Yahya
1 2
University Malaya Medical Centre; Academic Charity Hospital
Background/purpose: The availability of biologic DMARDs (bD-
MARDs) has hailed a new era in the treatment of rheumatoid ar-
thritis (RA). However, the option of a ‘step-­
up’ therapy from a
conventional-­synthetic DMARD (csDMARD) is not always possible
in clinical practice, especially in certain healthcare settings with lim-
ited access or funding.
Objectives: To evaluate the treatment patterns of DMARD use,
drug survival and to analyze factors in initiating biologic DMARDs in
rheumatoid arthritis (RA) patients in Malaysia.
Methods: Data on RA patients who were attending University
Malaya Medical Centre, Kuala Lumpur, Malaysia and started
on conventional-­
synthetic, targeted-­
synthetic and/or biologic
DMARDs from January 2006 to December 2016 were collected ret-
rospectively from review of patients’ medical records.
Results: A total of 369 patients received csDMARDs; 325 (88.1%) fe-
males, 271 (73.4%) seropositive, mean age at diagnosis 51.9 (SD 12.5)
years. Methotrexate survival rates at 1 year (90.2%) and 5 years
(68.3%) were superior compared to other csDMARDs (P < 0.05).
Forty seven (12.7%) patients received triple combination therapy, 4
(1.1%) received tsDMARDs and 35 (9.5%) received added treatment
with biologics. Etanercept and adalimumab had the longest median
Background/purpose: The purpose of this multicentre, prospective,
observational study (NCT02451839) was to assess the effects of
adalimumab (HUMIRA®) on health and disability outcomes in indi-
viduals with moderate-­to-­severe rheumatoid arthritis (RA), Crohn's
disease (CD) or psoriasis (PsO) treated in clinical practice in New
Zealand (NZ).
Methods: Biologic-­
naïve adults initiating adalimumab under NZ
special authority regulations were recruited. The primary endpoint
was change from baseline in World Health Organization Disability
Assessment Schedule (WHODAS) 2.0 score in participants continu-
ing adalimumab at 6 months (paired t-­test). Secondary endpoints
included 2-­and 4-­month change from baseline in WHODAS 2.0,
and 6-­month change from baseline in other patient-­reported out-
comes (PROs) of work activity and well-­being (Work Productivity
and Activity Impairment Questionnaire:General Health 2.0, Kessler
Psychological Distress Scale, Flourishing Scale, Subject Vitality Scale)
and in disease-­specific outcomes, including the Health Assessment
Questionnaire-­Disability Index (HAQ-­DI) in participants with RA. NZ
ethics review was not required for a minimal risk study.
Results: 164 participants initiating adalimumab completed the
WHODAS 2.0 at baseline (n = 57/70/37 for RA/CD/PsO), of whom
114 (69.5%) completed the study at 6 months (n = 40/44/30, re-
spectively). Mean WHODAS 2.0 score decreased significantly at
6 months vs baseline in all participants (mean difference 7.9 points;
95% CI 6.4–9.4; P < 0.001) and in each specific disease, with im-
provements observed from 2 months (Figure). Other PROs also
improved significantly at 6 months. Mean HAQ-­DI score decreased
 |
168      
at 6 months vs baseline (−0.4 points; P < 0.001 [minimal clinically
important difference for HAQ-­DI: decrease ≥ 0.22]); statistically
significant reductions were seen with other disease-­specific ques-
tionnaires also. No new safety signals were observed.
Conclusion: Health and disability outcomes improved significantly
after 6 months of adalimumab use in NZ patients with RA, CD or
PsO.
3-­041 | Profile of vitamin D level among
random cohort of patients, analysis of limited
data from a laboratory
S. Rahman
Bangabandhu Sheikh Mujib Medical University
Background: Deficiency of vitamin D is very common in our clinical
practice but rarely causes symptoms. Prolong deficiency may cause
osteomalacia and rickets. Diagnosis is made by biochemical testing.
There is no statistic available in our country about the prevalence
of hypovitaminosis D. Objective of this study was to observe the
profile of vitamin D level among a cohort.
Methods: Reports of vitamin D level were randomly collected from
laboratory of a clinic irrespective of age or sex during one year.
Vitamin D levels of 542 female patients and 143 male patients were
collected from a single laboratory in a clinic. Patients’ lifestyles,
dietary habit or history of sunlight exposure were not recorded.
Parathyroid hormones were not measured. Collected data were ana-
lyzed by SPSS. Patients with vitamin D deficiency were treated ac-
cordingly with supplements. No follow up studies were done to see
the improvement in clinical or laboratory parameter.
Results: 542 female patients and 143 male patients were enrolled.
Male female ratio was 1:3.79. Mean age of the female patients were
47.24 + _ 16.70. Mean age of male patients were 27.97 + _18.10.
Vitamin D levels of female patients were Mean ± SD = 19.65 ± 13.92.
Vitamin D levels of male patients were Mean ± SD = 56.66 ± 21.02
Conclusions: Hypovitaminosis D was found to be common among
our patients. The result shows that the females are predominantly
affected. Cultural variations in lifestyles like wearing of veil and lack
of sunlight exposure could be the reasons. Dietary deficiency and
genetic factors could be other causes. This small study did not re-
flect the prevalence or cause of vitamin D deficiency in our country.
Community based study with larger cohort and more variables and
timely clinical and laboratory follow up will delineate the prevalence,
cause and effects of hypovitaminosis D.
1-­030 | Amyloidosis: a mimic of rheumatic
condition
A. H. Ramlan1; H. C. Chong2; N. S. Lau3
1
Hospital Putrajaya; 2Hospital Melaka; 3Hospital Ampang
Background: Amyloidosis is a known complication of chronic dis-
eases including rheumatic conditions. Primary amyloidosis is rare
and symptoms may be vague as it involves multiple systems.Systemic
amyloidosis may present as symptoms and signs of rheumatic condi-
tions to rheumatologists. Skin infiltration mimics scleroderma skin
tightening whilst synovial and periarticular tissue infiltration caus-
ing joint stiffness and arthritis may be misdiagnosed as rheumatoid
arthritis.
Objective: To describe a mimicker of rheumatological condition that
can present with multisystem involvement.
Methods: Retrospective case report.
Results: We report a 60-­
year old lady with hypertension, com-
plained of finger stiffness and deformities for 6 months. Relevant
history included bilateral carpal tunnel release, symptoms of heart
failure and prior otorhinolaryngologist as well as neurologist assess-
ments for swallowing difficulties and abnormal articulation of her
speech. Clinical examination revealed widespread soft tissue thick-
ening, joint contractures, muscle pseudohypertrophy, hepatomegaly
and anasarca. She had macroglossia, perioral deposits and shoulder
pad signs indicative of systemic amyloidosis. Unfortunately,she sus-
tained left femoral neck pathological fracture following a trivial ro-
tatory movement of the hip before further investigations could be
performed.
Investigations revealed anemia, elevated pro-­
b rain natriuretic
peptide with significant proteinuria. Elevated kappa light chain
paraprotein was noted and bone marrow examination revealed
presence of 20% abnormal plasma cells with positive congo red
stain on trephine biopsy. Diagnosis of multiple myeloma with con-
comitant systemic amyloidosis involving skin, musculoskeletal, car-
diac, renal, peripheral nervous system and gastrointestinal system
was clinched. Chemotherapy (Bortezumib, Cyclophosphamide,
Dexamethasone) was commenced and patient showed initial clini-
cal improvement. However, after three months of treatment, the
disease progressed as patient developed gastric outlet obstruc-
tion.Regrettably patient succumbed to sepsis after five months of
treatment.
Conclusion: Failure to recognize clinical features of systemic amy-
loidosis leads to delay in diagnosis. Rheumatologists are often con-
fronted by uncommon diseases and hence recognition of amyloidosis
as a mimic of various rheumatic conditions is crucial.

3-­058 | Acute myeloid leukemia mimicking
systemic lupus erythematosus in a Filipino female
adolescent: a case report
J. Rapacon; C. Tee; L. Dans
Philippine General Hospital
Introduction: Pancytopenias, neurolopsychiatric symptoms are a
common presentation in both systemic lupus erythematosus (SLE)
and leukemia. Here we present an unusual case of pancytopenia,
neuropsychiatric symptoms and presence of autoantibodies mimick-
ing SLE as an initial presentation of acute myeloid leukemia.
Objective: To report a case of a Filipino adolescent female with
acute myeloid leukemia who presented with lupus-­like symptoms.
Description: A sixteen year old female presented with a two day
history of fever, headache and seizure. On physical examination,
the patient had fever, hyperpigmented discoid macules over the
extremities, pertinent neurologic exam: awake, no verbal output,
unable to follow commands. CBC showed pancytopenia, elevated
reticulocyte count, peripheral blood smear showed normochromic,
anisocytosis, poikilocytosis, toxic granules, positive ANA and Anti
dsDNA. EEG showed severe diffuse slowing of the background
activity suggestive of a severe cerebral dysfunction. Assessment
was SLE. She was started on prednisone and hydroxychloroquine.
She was discharged with one follow up at the clinic. Six months
later, she was readmitted for fever. CBC revealed anemia, leuko-
cytosis, thrombocytopenia and blast cells. Bone marrow flow cy-
tometry showed acute myeloid leukemia. The patient underwent
chemotherapy.
Discussion: SLE is an inflammatory disease wherein multiple of symp-
toms can occur and almost all systems can be affected. Leukopenia,
anemia and thrombocytopenia are hematologic manifestations while
seizure and behavioral changes are part of the neurological changes
and are counted in the Systemic Lupus International Collaborating
Clinics criteria. On the other hand, other clinical conditions can pre-
sent with cytopenias and positive autoantibodies such as infections
and neoplasms. The combination of cytopenias and positive ANA, anti
dsDNA may be misinterpreted as hematological manifestations of SLE.
Conclusion: This case illustrates that when presented with a possible
SLE diagnosis based on pancytopenia, neuropsychiatric manifesta-
tion and positive autoantibodies, physicians should be aware of the
possibility of malignancy.
3-­132 | Conventional immunomodulators
achieve high remission in SLE with nephritis—a
1 year observational study in a teaching hospital
Y. V. Ravindran; S. Kumar; C. Sekaran; V. Sagar; S. Nallasivan
Velammal Medical College Hospital and Research Institute
Background: SLE is an autoimmune disorder; lupus nephritis is the
commonest complication. Average annual cost of therapy in the
|
      169
west to maintain remission is USD 772.26(Azathioprine regimen)
or 790(Mycophenolate regimen) per year. in India it is equivalent to
INR 51,827.61(Azathioprine regimen) or 53,018.09 (Mycophenolate
regimen) which is expensive for a standard patient. Hence conven-
tional immunomodulators are used to achieve remission.
Objectives: The objective of this study is to assess the systemic
manifestations of SLE, especially renal and the degree of remission
using conventional immunomodulators.
Methods: An observational study involving patients diagnosed with
SLE over the past 1 year and their clinical profile, renal biopsies, SLEDAI
score at diagnosis and at the end of 1 year with conventional immu-
nomodulators were analysed with the histopathologies of renal biopsies.
Results: 43 patients were reviewed.
Mean age—30. Female: male ratio is 18: 4.
Common features were rash, oral ulcers, nephritis and serositis.
All had positive ANA and dsDNA.
18 patients had renal biopsies, WHO class 3A was predominant.
Corticosteroids and Hydroxychloroquine for induction and
Cyclophosphamide for renal and serosal disease were given.
Maintenance regimen included steroids, Hydroxychloroquine and
Azathioprine or Mycophenolate. 3/18 patients remained dialy-
sis-dependent and 15/18 achieved complete renal remission.
At diagnosis, mean of SLE DAI score was16.64. At the end of 1 year,
it came down to 4.64.
SLE DAI score distribution at the end of 1 year
Remission Mild Moderate High Very high
SLEDAI 0 1 to 6 to 10 11 to Above 20
score 5 19
No. of 16 13 10 3 1
patients
The average annual cost of treatment per patient is USD 121.94
(Azathioprine regimen) or 412 (Mycophenolate regimen) equivalent
to INR 8183 (Azathioprine regimen) or 27,656 (Mycophenolate regi-
men) which is affordable in India.
Conclusion: Patients with SLE at diagnosis had high disease activity
and an increasing nephritic trend. Effective remission induction using
Cyclophosphamide improved the outcome in the short term (6 m). Those
who had positive DsDNA had better outcome. Thus, conventional im-
munomodulators show great benefit in maintaining remission in SLE.
 |
170      

2-­136 | Cytokines and health-­related quality of lower in MH ≤50% (228 vs 389, P = 0.01). No other cytokine, com-
plement or anti-­dsDNA Ab level was significantly different across
life in systemic lupus erythematosus (SLE)
these groups. The amount of organ damage (SDI > 0, n = 30) associ-
S. Shanmugakumar1; W. Raymond1; G. Ostli-Eilertsen2; J. ated with lower PF Scale scores (Rs −0.412, P = 0.002) and patients
Nossent1,2,3
reporting PF ≤50% more often had sustained organ damage (37 vs
1
The University of Western Australia; 2Arctic University; 3Department of
9%, P = 0.023), but organ damage scores were unrelated to cytokine
Rheumatology
levels (all P > 0.1).
Conclusion: HRQOL is reduced in most areas in SLE patients except
Background: Systemic lupus erythematosus (SLE) patients fre-
Mental Health, but this cannot be attributed to clinical disease activ-
quently report reduced Health Related Quality of Life, even with
ity or levels of proinflammatory cytokines. Organ damage accrual
clinically well-­controlled disease.
however significantly reduces Physical Functioning, providing an-
Objectives: To investigate whether subclinical inflammation as re-
other incentive to maximize damage prevention in SLE.
flected by cytokine levels associate with SF-­
36 Subscale scores
(where lower scores indicate reduced QOL) across a spectrum of
disease activity and severity in SLE.
Methods: A cross-­sectional study of SLE patients [n = 52, mean age 1-­044 | Mortality rates in patients with
47.3, 86.5% female] who completed a Short Form Health Survey-­36 osteoarthritis in Western Australia from 1995–
(SF-­36) questionnaire. Data was also collected on disease activity 2015
(SLEDAI-­2K) and organ damage (SDI). Autoantibody and cytokines
W. Raymond1; H. Keen2,3; D. Preen4; C. Inderjeeth1,3; J.
(IFN-­γ, IL-­1β, IL-­
4, IL-­
6, IL-­
10, IL-­
12, IL-­
17, BAFF, TNF-­
α , TGF-­
β1,
Nossent1,3
MIP-­1α, MIP-­1β and MCP-­1 (levels in pg/mL) were quantified by 1
The University of Western Australia; 2Fiona Stanley Hospital; 3Sir Charles
sandwich ELISA. Comparative statistics include Mann-­Whitney U-­ Gairdner Hospital; 4School of Population and Global Health
tests and Spearman's correlation (Rs).
Results: SLE patients scored significantly lower than a female refer- Background: Osteoarthritis (OA) is the commonest joint disease
ence group on Physical Functioning (PF), Role Physical (RP), Bodily worldwide, however data is limited and conflicted regarding its as-
Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF) sociation with mortality.
and Role Emotional (RE), but not on Mental Health (MH) (Table 1). Objective: Investigate all-­cause mortality in OA patients in Western
Patients with SLEDAI ≤4 (n = 18) or SLEDAI >4 (n = 52) had equiva- Australia (WA) between 1995 and 2015.
lent scores on all subscales. Across dichotomised (>50% vs ≤50%) Method: Linked state-­
level data on hospital admissions, cancer
subscale scores, IL-­12 was lower in GH ≤50% (20 vs 12, P = 0.025); development, and death identified OA patients (ICD-­9-­CM: 715.
TNF-­α was lower in RP ≤50% (70 vs 25, P = 0.005) and TGF-­β1 was XX, 721.XX, and ICD-­10-­AM: M15-­M19.XX, M47.81, M47.9X) and

Table 1 Comparison SF-­36 Summary Measures and Scales between (and within) patients in the Tromso Lupus Cohort against Norwegian refer-
ence value from 2015

Independent t-­test
Averages, Norway Low disease activity High Disease Activity
Female 2015 Overall SLE (SLEDAI-­2K ≤ 4) (SLEDAI-­2K > 4) Independent Independent
(n = 2118) (A) (n = 52) (B) (n = 18) (C) (n = 34) (D) t-­test A vs B t-­test C vs D

Mean ±  Mean ±  Mean ±  Mean ± 

Standard Standard Standard Standard
Deviation Deviation Deviation Deviation P-­value P-­value

Physical 84.9 ± 21.0 66.35 ± 24.50 72.78 ± 21.09 62.94 ± 25.76 <0.001 0.171

Functioning
Role-­physical 72.6 ± 39.6 27.88 ± 36.60 27.78 ± 40.12 27.94 ± 35.23 <0.001 0.988
Bodily Pain 66.9 ± 26.5 53.74 ± 27.38 56.44 ± 27.19 52.31 ± 27.79 <0.001 0.609
General Health 72.6 ± 22.5 44.56 ± 23.53 49.72 ± 24.17 41.82 ± 23.07 <0.001 0.253
Vitality 57.2 ± 20.6 38.94 ± 24.80 39.44 ± 25.26 38.68 ± 24.93 <0.001 0.917
Social Functioning 85.7 ± 21.6 62.98 ± 27.11 69.44 ± 26.16 59.56 ± 27.36 <0.001 0.214
Role-­emotional 87.4 ± 28.6 66.67 ± 41.22 74.07 ± 42.09 62.75 ± 40.84 <0.001 0.351
Mental Health 79.9 ± 14.8 76.00 ± 15.68 81.33 ± 13.23 73.18 ± 16.32 0.061 0.074
Physical Health   48.13 ± 21.83 51.68 ± 22.00 46.25 ± 21.83 – 0.399
Mental Health   61.15 ± 19.39 66.07 ± 19.74 58.54 ± 18.98 – 0.185
 |
      171

Table 1 Characteristics at the 1st hospital contact since 1995

Characteristics at the 1st hospital contact since 1995

Controls (n = 200,203) Osteoarthritis (n = 163,375) Comparative Statistics

MoCT or n (%) MoCT or n (%) P-­value

Age at Hospital Contact 57.00 ± 18.13 57.00 ± 17.07 0.947

Male 103,104 (51.5%) 79,926 (48.9%) OR 0.95 (0.94, 0.95)
Female 97,099 (48.5%) 83,449 (51.1%) OR 1.05 (1.04, 1.05)
Non-­Indigenous 197,546 (98.7%) 161,705 (99.0%) OR 1.17 (1.12, 1.21)
Indigenous Australia 2657 (1.3%) 1670 (1.0%) OR 0.89 (0.87, 0.92)
Prospective follow-­up to exit (years) 18.41 (9.79, 20.00) 20.00 (12.25, 20.00) <0.001
Total person-­years 2,947,699 2,589,401
Deaths during follow-­up 60,221 (30.1%) 48,314 (29.6%) OR 0.99 (0.98, 0.99)
Patient died in hospital 31,344 (52.0%) 25,805 (53.4%) OR 1.01 (1.00, 1.02)
Age at Death 82.92 ± 9.76 83.08 ± 9.93 0.007
Male 30,790 (51.1%) 21,039 (43.5%) OR 0.84 (0.83, 0.85)
Female 29,431 (48.9%) 27,275 (56.5%) OR 1.14 (1.13, 1.16)
Indigenous Australia 722 (1.2%) 574 (1.2%) OR 1.00 (0.94, 1.07)
Time to death from first hospital contact 8.73 (3.98, 13.85) 10.29 (5.29, 15.12) <0.001
Mortality Rate per 1000 person-­years 20.43 (20.27, 20.59) 18.66 (18.49, 18.82) 0.91 (0.90, 0.92)

IQR, interquartile range; MoCT, Measure of Central Tendency; n (%), frequency and percentage.

Table 2 Characteristics of OA site sub-­groups (hip, knee and spine) at the first hospital contact since 1995; deaths, mortality rates and mortality
rate ratios for the period from 1995–2015

Spinal OA / spondylosis
Hip OA (n = 35,406) Knee OA (n = 95,549) (n = 27,055)

Age at hospital contact 61.20 ± 13.85 53.08 ± 16.15 65.92 ± 15.77

Male 16,503 (46.6%) 48340 (50.6%) 11729 (43.4%)
Female 18,903 (53.4%) 47209 (49.4%) 15326 (56.6%)
Non-­indigenous 35,186 (99.4%) 94612 (99.0%) 26760 (98.9%)
Indigenous Australia 220 (0.6%) 937 (1.0%) 295 (1.1%)
Total person-­years 565865.59 1,610,813 371991
Deaths during follow-­up 11486 (32.4%) 19105 14784
Mortality rate 20.30 (19.93, 20.67) 11.86 (11.69, 12.03) 39.74 (39.10, 40.39)
Mortality rate ratio (vs controls) 0.99 (0.97, 1.01) 0.58 (0.57, 0.59) 1.94 (1.91, 1.98)

age-­and gender-­matched controls (>1:1). We estimated crude and
standardised mortality rates per 1000 person-­years (MR / SMR)
and rate ratios (MRR / SMRR) against matched controls or the 2011
Census Population in WA between 1995 and 2015.
Results: Over 20 years of follow-­up, OA patients (n = 163,375, mean
age 57 years, 51.1% female) had lower likelihood of mortality than
controls [(MR 18.6 vs 20.4; MRR 0.91, 95%CI: 0.90, 0.92). However,
OA patients had increased mortality compared to controls, relative
to the general population [SMR (7.47 vs 6.68); SMRR 1.12 (95%CI
1.01, 1.24), P = 0.034].
Non-­surviving OA patients were more likely to be female (OR
1.14, P < 0.001). Comparing the MRs between OA sites and con-
trols, hip OA patients (n = 35,406) had comparable MRs [MRR
0.99 (95%CI: 0.97, 1.01)]; knee OA patients (n = 95,549) had a 42%
reduction in MR [MRR 0.58 (95%CI: 0.57, 0.59)]; and, spinal OA
patients (n = 27,055) had a 94% increase in MR [MRR 1.94 (95%CI:
1.91, 1.98)].
Conclusion: From 1995 to 2015 in WA, OA patients with a hospital
presentation or admission, experienced an increased likelihood of
mortality compared to the general population. However, compared
to hospitalised (matched) controls, OA patients did not exhibit an
increased likelihood of mortality.
Nevertheless, our data suggest that OA site, especially the spine,
could influence mortality outcomes. This may be due to site specific
characteristics of the disease process, management and/or associ-
ated comorbidity.
172       |

2-­137 | Principal component analysis reveals IL-­1β, IL-­4, IL-­10, IL-­12, IL-­17, IFN-­γ, MCP-­1, and TNF-­α were in the
PC1 for all groups. From controls to SLE-­HDA, PC1 changes included:
disconnect between regulatory cytokines and
increased influence of IL-­1β (from 0.58 to >0.95); HDA featured IL-­6
disease activity in systemic lupus erythematosus.
(0.76); increased influence of MIP-­1α (0.60) and MIP-­1β (0.85); and,
W. Raymond1; G. Eilertsen2; J. Nossent1,2,3 the waning effect of TGF-­β1 (0.14). PC2 changes, included: the in-
1
The University of Western Australia; 2Arctic University; 3Department of creased BAFF effect (from −0.18 to 0.88); an oppositional effect of
Rheumatology, Sir Charles Gairdner Hospital
TGF-­β1 (−0.36); and, inclusion of MCP-­1 (0.65).
Levels of cytokine profiles were equivalent between controls and
Objective: Use Principle Component Analysis (PCA) to identify
SLE patients (P > 0.18). BAFF was not associated with the cytokine
cytokines that may influence inflammation across disease activity
profiles. TGF-­β1 associated with Th1, Th1+Th17, and inversely with
states in Systemic Lupus Erythematosus (SLE).
Th17/Th2 profiles. IL-­1β associated with the proinflammatory, Th1,
Method: A cross-­
sectional study of SLE patients (n = 100) and
Th2, Th17, Th1+Th17, Th2+Treg, and inversely with the (Th1+Th17/
matched controls (n = 31). SLE patients had a median SLEDAI-­2K
Th2+Treg) and Th17/Th2 profiles (all, P < 0.05).
score of 6 (IQR 2, 11). IFN-­γ, IL-­1β, IL-­4, IL-­6, IL-­10, IL-­12, IL-­17, BAFF,
Conclusion: PCA described cytokine interactions in SLE in a manner
TNF-­α , TGF-­β1, MIP-­1α, MIP-­1β and MCP-­1 levels were quantified
congruent with the literature. Interestingly, BAFF (↑) and TGF-­β1 (↓)
by sandwich ELISA. PCA determined the principal components (PC)
levels associated with disease activity, but were not the dominant
across controls, patients in remission (SLEDAI-­2K = 0), lupus low
factors (in PC1) in the PCA. The PCA demonstrated that IL-­1β did not
disease activity state (LLDAS = SLEDAI-­2K from 1 ≤ x ≤ 4), and high
lose its regulatory function in SLE.
disease activity (HDA: = SLEDAI-­2K > 4).
Component matrices of the PCA for healthy controls (blue) vs lupus
Results: TGF-­β1 (Rs −0.27, P < 0.01) and IL-­1β (Rs −0.20, P < 0.01) in-
low disease activity state (LLDAS: SLEDAI-­2K 1 ≤ x ≤ 4) (orange)
versely correlated, whereas BAFF correlated with increased disease
(Figure 1) and healthy controls (blue) vs lupus patients in a high dis-
activity (Rs 0.46, P < 0.01).
ease activity state (SLEDAI-­2K >4) (red) (Figure 2).

Table 1 Median serum cytokine levels (pg/mL) in controls and SLE patients

Study Cohort
Independent-­
Remission Samples
Healthy Controls (SLEDAI-­2K = 0) SLEDAI-­2K = 1 ≤ x ≤ 4 SLEDAI-­2K >4 Kruskal-­ Spearman
(n = 31) (n = 20) (n = 22) (n = 58) Wallis Correlation

Median (IQR) Median (IQR) Median (IQR) Median (IQR) P-­value Rs .

BAFF 0.98 (IQR 0.75, 1.15) 1.59 (IQR 1.32, 2.28) 1.51 (IQR 1.10, 2.36) 1.78 (IQR 1.39, 2.36) <0.001 0.465
IFN-­γ 47.31 (IQR 19.60, 58.85 (IQR 19.60, 82.02 (IQR 19.60, 57.82 (IQR 19.60, 0.930 0.048
113.90) 131.36) 108.31) 144.36)
IL-1β 17.90 (IQR 17.90, 17.90 (IQR 17.90, 17.90 (IQR 17.90, 17.90 (IQR 17.90, 0.004 −0.199
268.97) 17.90) 17.90) 17.90)
IL-­4 7.00 (IQR 7.00, 7.00) 7.00 (IQR 7.00, 7.00) 7.00 (IQR 7.00, 7.00) 7.00 (IQR 7.00, 8.82) 0.644 0.094
IL-­6 14.00 (IQR 14.00, 14.00 (IQR 14.00, 14.00 (IQR 14.00, 14.00 (IQR 14.00, 0.453 0.095
15.73) 14.00) 20.53) 24.35)
IL-­10 5.90 (IQR 5.90, 17.59) 5.90 (IQR 5.90, 7.43) 5.90 (IQR 5.90, 20.81) 5.90 (IQR 5.90, 27.70) 0.290 0.093
IL-­12 40.40 (IQR 12.60, 35.79 (IQR 12.60, 30.21 (IQR 12.60, 14.71 (IQR 12.60, 0.266 −0.168
86.20) 87.73) 61.82) 58.40)
IL-­17 28.40 (IQR 28.40, 28.40 (IQR 28.40, 28.40 (IQR 28.40, 28.40 (IQR 28.40, 0.643 0.037
94.92) 29.81) 71.03) 72.89)
MCP-­1 102.36 (IQR 45.34, 158.37 (IQR 86.57, 169.78 (IQR 69.81, 124.47 (IQR 80.82, 0.310 0.111
195.66) 209.47) 228.36) 208.65)
MIP-­1α 18.51 (IQR 15.00, 15.00 (IQR 15.00, 15.00 (IQR 15.00, 0.547 −0.020
255.84) 69.81) 55.35)
MIP-­1β 204.29 (IQR 146.12, 223.01 (IQR 168.06, 195.07 (IQR 163.85, 0.909 −0.031
307.74) 282.52) 291.65)
TNF-­α 35.89 (IQR 21.40, 25.96 (IQR 21.40, 33.69 (IQR 21.40, 41.18 (IQR 21.40, 0.843 0.060
92.30) 77.06) 81.16) 92.96)
TGF-β1 746.71 (IQR 606.76, 769.56 (IQR 581.06, 454.29 (IQR 306.18, 559.76 (IQR 312.97, 0.005 −0.266
921.68) 934.56) 775.29) 848.18)
 |
      173

86 (39%) of patients assigned a triage category did not receive an

initial evaluation.
130 patients were seen. Of those seen, 66 (51%) were overtriaged,
9(7%) were undertriaged and 55 were exactly triaged.
Referrals varied widely in the information provided. Quantity of in-
formation provided did not have a significant influence on probabil-
ity of exact triage or risk of overtriage (φ < 0.25).
Conclusion: Undertriage was uncommon in the clinic, but overtriage
was common among those seen. More information in referrals was
not associated with appropriate triage categorisation.

Figure 1 Principal Component Analysis of healthy controls vs lupus

patients in a high disease activity state (SLEDAI-­2K >4)
Describes for 11 cytokines in healthy controls and 13 cytokines in 1-­096 | A phase 3, randomized controlled trial
SLE patients with different levels of disease activity (listed in Table 1), comparing upadacitinib monotherapy to MTX
the first two principal components, i.e., PC1 (x-­axis) and PC2 (y-­axis). monotherapy in MTX-­naïve patients with active
The graphs provide quantitative information on the role of variables rheumatoid arthritis
as determined by the PCA: 1) the distance of the cytokine (factor)
R. van Vollenhoven1; T. Takeuchi2; A. L. Pangan3; A.
to the null represents the correlation of that factor to the system,
Friedman3; M. F. Mohamed3; S. Chen3; M. Rischmueller4; R.
i.e., disease activity status. 2). The closer the two or a cluster of cy- Blanco5; R. M. Xavier6; V. Strand7
tokines, the more similar their effects are on disease activity. 1
Amsterdam Rheumatology and Immunology Center ARC; 2Keio University
School of Medicine; 3AbbVie Inc; 4The Queen Elizabeth Hospital and University
of Adelaide; 5Hospital Universitario Marques de Valdecilla; 6Universidade
Federal do Rio Grande do Sul Porto Alegre; 7Stanford University
3-­020 | How urgent is the issue? Triage in a
busy public rheumatology clinic Background/purpose: Upadacitinib (UPA) is an orally-­
administered
J. Riley; D. Edwards JAK1-­selective inhibitor. Here we compare safety, efficacy and inhibition
Hunter New England Health of structural damage with UPA monotherapy vs methotrexate (MTX).
Methods: In SELECT–EARLY, MTX-­naïve patients at high risk for dis-
Background/purpose: The rheumatology clinic at the Royal ease progression received once-­daily UPA 15 mg, 30 mg, or weekly
Newcastle Centre receives an average of 71 referral letters per month MTX. Primary endpoints were ACR50 at Wk12, or DAS28CRP<2.6
but currently has capacity to provide only 60 initial consultations. at Wk24. Secondary endpoints included change from baseline in
Referrals are triaged with the aim of ensuring timely treatment where modified Total Sharp Score (mTSS) and patients with no radiographic
indicated. This triage process can lead to inappropriately urgent cat- progression (mTSS ≤ 0) at Wk24.
egorisation (overtriage) or insufficiently urgent categorisation (un- Results: 945/947 randomized patients received study drug;
dertriage). A high rate of undertriage could necessitate increasing 840(88.7%) completed Wk24. ~50% had RA diagnosis <6 months
the proportion of initial appointments allotted to individuals triaged and RA symptoms <2 years. 874/945 (92.5%) had no prior MTX
into low-­urgency categories.
We aimed to estimate the rates of overtriage and undertriage in the
rheumatology clinic and to determine if more information included in
referrals was associated with higher triage accuracy.
Methods: A retrospective audit of all referrals received in the first
quarter of 2016 was performed. Information included in the referral
letters was recorded, along with the triage category received.
The clinician who performed the initial assessment assigned to each
patient a retrospective urgency category. The clinician was blinded
to the initial triage categorisation.
Rates of overtriage and undertriage were found, and the association
between referral information and triage accuracy calculated using a
2-­sided phi statistic on dichotomised referral information data.
Results: In the first quarter of 2016, there were 216 referrals to the
clinic. Most were triaged into the urgent or semi-­urgent (30-­day and
90-­day) categories.
 |
174      
exposure; 706(74.7%) had no prior csDMARD exposure. Significantly
more patients receiving UPA15 and UPA30 vs MTX achieved Wk12
ACR50 and Wk24 DAS28CRP<2.6 (Table 1). All secondary endpoints
were met. at Wk24, for UPA15 and UPA30 vs MTX, ΔmTSS were sig-
nificant in favor of UPA vs MTX (0.14 and 0.07 vs 0.67); significantly
fewer patients had radiographic progression on UPA15 and UPA30
vs MTX (87.5 and 89.3 vs 77.7). LDA and remission were achieved in
significantly more patients on UPA vs MTX.
Up to Wk24, adverse events AEs and serious AEs were similar on
UPA15 and MTX, and slightly higher on UPA30 (Table 2). More pa-
tients on UPA30 reported serious infections vs MTX and UPA15, and
there were more cases of herpes zoster on UPA15 and UPA30 (7 cases
each) vs MTX (1 case). Four malignancies, 4 major adverse cardiovas-
cular events (MACE), and 6 deaths were reported (Table 2). Two GI
perforations (UPA30) and two venous thromboembolic events were
reported (MTX:1, pulmonary embolism, UPA30:1 deep vein thrombo-
sis). Laboratory abnormalities were consistent with prior UPA studies.
Conclusion: In MTX-­naïve patients, UPA 15 and 30 mg QD demon-
strated significant improvements and less radiographic progression
vs MTX. Safety was consistent with prior UPA studies.
3-­059 | Systemic lupus erythematosus in
children: a 10-­year retrospective analysis of
mortality and morbidity
M. F. Rivera; L. Dans
University of the Philippine – Philippine General Hospital
Background: Systemic Lupus Erythematosus (SLE) in children com-
prises 15–20% of the disease population and considered a predictor
of mortality among adult SLE patients.
Objective: To determine the clinical profile and outcome of pediatric-­
onset SLE in the Philippines, identify risk factors for mortality, and
generate a 10-­year survival analysis.
Methods: A retrospective review of medical records of all SLE patients
age < 19 years, being seen at the Philippine General Hospital from
January 2008 to December 2017, was conducted. Clinical and laboratory
data at the time of diagnosis and subsequent follow ups were recorded.
Patients lost to follow up were also contacted for updates of their pre-
sent condition. Descriptive statistics was used to summarize clinical data.
Kaplan–Meier analysis was used to calculate the survival rates. Logistic
regression was applied to assess the risk factors for mortality.
Results: A total of 261 patients were included. Average age at diag-
nosis is 14.5 years old (±2.7), with male to female ratio of 16:1. Mean
onset of symptoms prior to diagnosis is 3 months (±2.1). Upon diag-
nosis, most patients have malar rash (88%), alopecia (82%), oral ulcers
(78%), and proteinuria (77%). Long term systemic involvement in-
cludes mucocutaneous (95.8%), hematologic (80%), and renal (79%).
Most patients received Prednisone (95%) and Hydroxychloroquine
(91%) while 71% needed IV Methylprednisolone at least once dur-
ing the course of their illness. Over-­all mortality rate was 15%, and
mostly due to infection and SLE activity. Survival rate at 1, 3, 5 and
10 years were 92%, 86%, 81%, and 79% respectively. Significant
mortality risk factors are myocarditis, pleural effusion, and seizures.
Conclusion: Most pediatric SLE patients have mucocutaneous symp-
toms upon presentation. Nephritis is persistent despite the standard
of care and a substantial cause of morbidity. Seizures and myocar-
ditis entail increased mortality. Our survival rate is comparable with
other developing countries.
1-­097 | Hepatic safety in patients with
rheumatoid arthritis treated with baricitinib:
post-­hoc analysis from clinical studies
T.-Y. Hsieh1; C. Dickson2; W.-S. Wu2; I. De La Torre2; R.
Liao2; K. Winthrop3; M. Harigai4; W.-N. Huang1; H.-P.
Tony5; A. Balsa6; B. Combe7; T. Takeuchi8; Y.-M. Chen9; J. S.
Smolen10; G. R. Burmester11; M. C. Genovese12; C. A. Little2;
E. Romas13
1
Department of Internal Medicine, Taichung Veterans General Hospital; 2Eli
Lilly and Company; 3Center for Infectious Disease Studies, OHSU-­PSU School of
Public Health; 4Institute of Rheumatology, Tokyo Women's Medical University;
5
Rheumatologie, Klinische Immunologie, Klinikum der Universität Würzburg;
6
Department of Rheumatology, Hospital Universitario La Paz; 7Départment
of Rheumatology, Montpellier University Hospital, University of Montpellier;
8
Keio University School of Medicine; 9Taichung Veterans General Hospital;
10
Medical University of Vienna; 11Charite Universitatsmedizin Berlin; 12Stanford
University, Palo Alto, United States; 13Department of Rheumatology, the
University of Melbourne
Background: Latent tuberculosis infection (LTBI) and hepatitis B
virus (HBV) reactivation are important issues in the management
of rheumatoid arthritis patients. Isoniazid (INH) plays a vital role in
 |
      175

treatment groups. of these, 175 with confirmed lab data re-

controlling TB but it may result in hepatic abnormalities. We present
hepatic safety and HBV reactivation in patients with RA treated with
baricitinib (BARI).
Methods: Hepatic safety with INH treatment was analyzed in data
from 3 placebo (PBO)-­controlled Phase 3 studies, and HBV analy-
ses included additional Phase 3 and a long-­term extension stud-
ies. Respectively, changes in alanine aminotransferase (ALT) levels
(≥1X/≥3X/≥5X/≥10X ULN) from baseline up to 24 weeks; and HBV
surface antigen, core antibody (HBcAb), surface antibody (HBsAb),
and HBV DNA at baseline or post-­baseline, were analyzed.
Results:
(1). INH: Total, 2516 patients were treated with BARI 4-mg/BARI
2-mg/adalimumab (ADA)/PBO. Background csDMARDs were
continued. Overall, 246 patients reported LTBI across all
ceived INH. Table 1 represents changes in ALT. Percentage of
patients with ALT ≥ 1XULN was higher in INH-treated patients
across all treatment groups. No BARI/ADA patients using INH
had study treatment interruption due to abnormal hepatic tests.
(2). HBV: of 2890 patients, 269 had baseline serology suggestive of
prior infection (HBcAb+/HBsAb+, n = 255; HBcAb+/HBsAb-,
n = 14; Figure 1). of these, 32 BARI-treated patients (32/269;
11.9%) later (post-baseline) tested with HBV DNA+. Out of 32
patients, 8 patients had results above the lower limit of quantita-
tion (LLQ); subsequent tests were either not detectable or below
LLQ. No patients developed clinical evidence of hepatitis; ALT
tests were within normal range.
Conclusion: Data do not suggest an increased hepatic safety risk in
patients treated with BARI and concomitant INH. Although some
BARI-­treated patients had post-­baseline detectable HBV DNA, none
developed clinical evidence of hepatitis.
3-­133 | SLEDAI-­2K-­responder index-­50
demonstrates early response in a phase-­2,
randomized placebo-­controlled study of
Ustekinumab in patients with active systemic
lupus erythematosus
Z. Touma1; M. B. Urowitz1; D. D. Gladman1; R. Gordon2; Y. I.
Gregan2; K. Fei2; S. Rose2
1
Krembil Research Institute, U of Toronto; 2Janssen Research & Development,
LLC
Background: Ustekinumab (UST), a monoclonal antibody that tar-
gets the shared p40 subunit of cytokines IL-­12 and IL-­23, is being

Table 1. Response rates over time with S2K-­RI-­50, SLEDAI-­2K, and SRI-­4

S2K-­RI-­50a SLEDAI-­2K SRI-­4

Week % USTb,c % PBOb,c Difference (%) % USTb,c % PBOb,c Difference (%) % USTb,c % PBOb,c Difference (%)

4 45.5 43.4 2.1 19.6 28.7 −9.1 17.8 29.8 −12.0

8 58.0 52.3 5.7 42.6 41.7 0.9 40.2 37.1 3.1
12 72.2 58.9 13.3 57.0 44.8 12.3 50.4 42.9 7.5
16 74.7 57.2 17.5* 63.5 46.0 17.5 60.4 44.2 16.2
20 86.2 62.1 24.1* 69.3 54.1 15.2 65.9 51.1 14.8
24 83.4 58.9 24.5* 76.3 46.9 29.4* 69.2 42.8 26.4*

S2K RI-­50 uses partial response definition of ≥50% improvement for each individual SLEDAI-­2K descriptor.
a
Response threshold is 4-­point decrease from baseline.
b
Values for subjects meeting treatment failure criteria are set to missing from point of treatment failure forward.
c
Response based upon multiple imputations for missing data from Wk16 to Wk24, where Markov chain Monte Carlo method is used to make
missing pattern monotone & serial logistic regression is used to impute monotone missing. The imputation model includes treatment group,
baseline SLEDAI-­2K, and SLE medications as covariates.
*P < 0.05, where test for greater treatment effect in UST over PBO (alternative hypothesis) is based upon logistic regression with treatment
group, baseline SLEDAI-­2K, baseline medication use for SLE, and race as covariates. Firth logistic regression model using penalized likelihood
estimated is used.
 |
176      
investigated in patients with active systemic lupus erythematosus
(SLE). While traditional SLE-­Disease-­Activity-­Index-­2000 (SLEDAI-­2K)
scoring assesses complete SLE response for individual disease mani-
festations, the SLEDAI-­2K-­Responder Index-­50 (S2K-­RI-­50) evaluates
SLE responses using partial improvement (≥50%) in each domain. We
previously showed that changes from baseline in SLEDAI and S2K-­
RI-­50 scores were strongly correlated at week (wk) 24 in a Phase 2
trial of UST in SLE. A decrease from baseline of ≥4 points was deter-
mined to be an optimal threshold for assessing response to usteki-
numab at wk 24 using the S2K RI-­50 and SLEDAI-­2K indices.
Objectives: To determine whether S2K-­RI-­50 can discriminate clini-
cal responses earlier than wk24 in a randomized, placebo (PBO)-­
controlled trial of UST in patients with moderate-­to-­severe SLE.
Methods: Adults with active SLE (SLEDAI score ≥ 6 with ≥1 BILAG
A and/or ≥2 BILAG B scores) despite standard-­of-­care therapy were
randomized (3:2) to UST ~6 mg/kg or PBO IV at wk0, then UST 90 mg
q8w or PBO SC beginning at wk8, both added to standard of care.
Proportions of patients with S2K-­RI-­50 response were compared
with SLEDAI-­2K and SLE-­Responder Index-­4 (SRI-­4) responses in
patients receiving UST (n = 62) vs PBO (n = 40) through wk24.
Results: S2K-­
RI-­
50 captured a higher proportion of respond-
ers than SLEDAI-­2K at wk20 (S2K-­RI-­50 response: 86.2% UST vs.
62.1% PBO, P = 0.006; SLEDAI-­2K response: 69.3% UST vs 54.1%
PBO, P = 0.073). Treatment differences at wk16 and wk20 had P
values < 0.05 with S2K-­RI-­50 but not SLEDAI-­2K (Table 1). Notably,
S2K-­RI-­50 response also outperformed SRI-­4 response at the wk16
and wk20 timepoints.
Conclusions: S2K-­RI-­50 response using a 4-­point threshold can po-
tentially be used to discriminate response earlier than wk24 in pa-
tients with moderate-­to-­severe SLE disease activity.
3-­021 | Association of dietary and nutrient
patterns with osteoarthritis among Australian
adults
Y. Melaku1; T. Gill1; C. Ruediger2; C. Davis1; R. Adams1; C.
Hill1,2
1
Adelaide Medical School, the University of Adelaide; 2The Queen Elizabeth
Hospital
Background/purpose: Evidence of the impact of the whole pattern
of diet and nutrients on osteoarthritis (OA) is very limited. We hy-
pothesized that dietary (DPs) and nutrient patterns (NPs) influence
OA and assessed their association.
Methods: Data from the North West Adelaide Health Study, a
community-­based cohort study undertaken in South Australia, were
used. Overall, 1913 adults (916 males, 45.9%) aged 24–94 years had
dietary data collected using a food frequency questionnaire and had
information on self-­reported doctor diagnosed OA. Factor analysis
was used to construct the DPs and NPs based on the intake of 39
foods/food groups and 31 nutrients. Log-­binomial logistic regression
was used to assess the association of DPs and NPs with OA.
Results: Two DPs (prudent pattern – high intake of vegetables,
fruits, medium fat dairy, nut dairy, fish and legumes; and western
pattern – high intake of processed meat, snacks, take away foods,
red meat, soft drinks and beer) were identified. Patterns of animal-­
sourced nutrients including protein, cholesterol, and saturated fat;
plant-­sourced nutrients including fibre, carotene, magnesium and
phosphorous; and mixed-­source nutrients (combining plant and ani-
mal), including omega-­3 and 6, vitamin E, saturated fat, calcium and
fibre were also identified. Compared to the study participants in the
first quartile (lowest consumption) of the prudent DP, participants in
the fourth quartile had a 36% lower odds of reporting OA (adjusted
odds ratio (aOR) = 0.64; 95% CI: 0.45–0.89; P-­for trend 0.026), after
adjusting for socio-­demographic and behavioural characteristics and
chronic conditions. The odds of OA in the fourth quartile of plant-­
sourced NP was 38% lower (aOR = 0.62; 95% CI: 0.45–0.87; P-­for
trend 0.001) than those in the first. A statistically non-­significant in-
crease in prevalence of OA was found across quartiles of the animal-­
sourced NP.
Conclusion: Greater adherence to a prudent DP and a plant-­sourced
NP is inversely associated with OA.
2-­138 | Cognitive function was not correlated
with disease activity in systemic lupus
erythematosus patients
A. Saepudin1; P. A. Ong2; L. Hamijoyo1
1
Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran/
DrHasan Sadikin General Hospital; 2Department of Neurology, Faculty of
Medicine, Universitas Padjadjaran/DrHasan Sadikin General Hospital
Background: Cognitive dysfunction was found in 55–80%
Neuropsychiatry Systemic Lupus Erythematosus (NPSLE) patients.
Serious concern from clinicans was needed as its impact to patient's
quality of life. Disease activity is expected to be affecting patient's
cognitive function. Previous studies regarding correlation between
disease activity and cognitive dysfunction showed various results.
This study aimed to evaluate the correlation between disease activ-
ity and cognitive function in SLE patients.
Methods: This study is an analytical cross-­sectional study. Subjects
were SLE patients at the rheumatology clinic of Dr Hasan Sadikin
Hospital Bandung during June-­August 2017. Subjects evaluations in-
cluded disease activity assessment using SLE disease activity index-
­2K (SLEDAI-­2K) and cognitive function assessment using MoCA-­Ina
test. Data were analyzed by using Spearman Rank correlation test.
Results: Mean age of the subjects was 31 ± 8 years old, most of which
were senior high school students (65, 8%) and median length of study
was 12 years. Subject's median duration of illness was 44 months.
Their MoCA-­
Ina median score was 25, while SLEDAI-­
2K median
score was 6. Cognitive dysfunction were found in more than half of
subjects (52.63%), as memory domain (78.95%) was most frequently
impaired. Most subjects of the study were patients with active SLE
(63.2%). Correlation test result showed there was no correlation be-
tween SLEDAI-­2K score and MoCA-­Ina score (rs=0.023, P = 0.445).

Conclusion: There was no correlation between disease activity
(SLEDAI-­2K score) and cognitive function (MoCA-­Ina score).
Keywords: cognitive dysfunction, MoCA-­Ina, systemic lupus erythe-
matosus, SLEDAI-­2K
3-­072 | The profile investigating of Rheumatoid
Arthritis (RA) patients who received adalimmab
therapy in AORA (Akita Orthopedic Group on
RA)
T. Sakuraba1; T. Kashiwagura2; M. Kobayashi1; Y. Sugimura3;
N. Miyakoshi4; Y. Shimada4
1 2 3
Hiraka General Hospital; Akita City Hospital; Nakadori General Hospital;
4
Akita University Graduate School of Medicine
Objectives: The aim of this study is investigating of the profiles of
rheumatoid arthritis patients in Japan who received adalimumab
(ADA) therapy.
Methods: We evaluated 86 patients in the Akita Orthopedic Group
on Rheumatoid Arthritis (AORA) registry (mean age, 63.6 years: 24–
88) who received ADA.
Results: The mean disease period was 172 months. The cases had
Steinbrocker classification stages I/II/III/IV (16/21/19/30 patients),
classes 1/2/3/4 (33/38/14/1 patients). Seventy-­
three patients
(84.9%) received methotrexate (MTX; mean dosage, 6.2 mg/week);
and Thirty-­
three (38.4%), prednisolone (4.3 mg/day). The mean
DAS28-­CRP (4) was 3.87 in the first ADA administration. The mean
follow-­up period was 127 (6–317) weeks. The cumulative continua-
tion rates were 83% (1 year), 76% (2 years), and 64% (3 years) in the
Kaplan-­Meier analysis. Twenty-­seven patients had failure of ADA
administration. Therapy was discontinued because of primary fail-
ure in 12 cases and secondary failure in 6. The mean disease activity
score of continuable patients was 1.70, and 53 patients (91%) had
good response in the final examination according to the criteria of
the European League against Rheumatism.
Conclusion: The patients who received ADA had a high combination
rate with MTX, high continuation rate, and good results, and were
therefore appropriately selected and treated.
2-­0 07 | Awareness of drug teratogenicity and
contraception use by patients with rheumatic
diseases presenting in a tertiary care center of
Pakistan
S. Mushtaq; B. Salim; H. Gul; S. Samreen; A. Nasim
Fauji Foundation Hospital Rawalpindi
Objective: To find the level of awareness of drug teratogenicity, con-
traception and mode of contraception among patients of different
rheumatic diseases presenting in a tertiary care center of Pakistan.
|
      177
Methodology: This is a cross sectional descriptive study done at
Rheumatology department of Fauji Foundation Hospital, Rawalpindi.
Patients with rheumatoid arthritis (RA), systemic lupus erythroma-
tosis (SLE), Scleroderma (SSc) or polymyositis were included in the
study. Demographic details, duration of disease, medications taken
by the patient, marital status were asked. After that specific ques-
tions regarding counseling on medications, teratogenic potential
of the drugs and any prior counseling regarding contraception and
mode of contraception used by the patients were asked.
Results: 52 females were enrolled in the study. Results showed
mean Age ± SD (in years) 39.25 ± 5.43. Mean disease duration ±SD
(in years) was 5.69 ± 4.67. Out of these 38 (73.1%) patients had RA, 6
(11.5%) SLE, 4 (7.7%) SSc and 4 (7.7%) had other connective tissue dis-
orders like polymyositis. Around 22 (42.3%) patients were on meth-
otrexate, 11 (21.2%) on leflunomide, 7 (13.5%) on Mycophenolate
mofetil, 1 (1.9%) was on cyclophosphamide, 11 (21.2%) were tak-
ing methotrexate and leflunomide combination. Only 27 (51.9%)
patients were counseled regarding teratogenicity of drugs and 21
(40.4%) patients knew correctly the possible teratogenic drug they
were taking. Only 12 (23.1%) patients know the correct time to stop
the drug before conception. 18 (34.6%) patients were counseled re-
garding using contraception with these drugs. 29 (55.8%) patients
were using contraception and amongst these 18 (34.6%) were using
barrier methods, 4 (7.7%) employed coitus interruptus, 3 (5.8%) used
oral contraceptive pills, 3 (5.8%) have placed intrauterine device , 4
(7.7%) have undergoes tubal ligation and 1 (1.9%) have undergo hys-
terectomy. Also, 4 (7.7%) patients have used emergency contracep-
tive pill (ECP) once in their lifetime while taking medicines.
Conclusion: Disease awareness, drug teratogenicity and contracep-
tion is an under addressed aspect of the management in rheumato-
logical diseases.
3-­081 | Follow-­up frequency in patients with
rheumatoid arthritis and its association with
disease activity at a tertiary care center
S. Javed; B. Salim; S. Samreen; H. Gul; M. Mushtaq; A. Nasim
Pakistan Society of Rheumatology
Background: Rheumatoid arthritis (RA) is an autoimmune disorder
which leads to deformities. It is necessary to ensure regular treat-
ment and follow-­up. Poor follow-­up has often been associated with
active disease but local data in this context remains scarce. The ob-
jective of the study is to determine the frequency of regular follow
up in the outpatient department (OPD) with RA and its association
with disease activity.
Methodology : This is a Cross sectional study that included 93 patients
from rheumatology OPD in Fauji Foundation Hospital, Rawalpindi.
Patients of RA fulfilling the American college of Rheumatology 1987
criteria were enrolled. The frequency of outpatient visits in RA is
every month for first three months, followed by three monthly visits
 |
178      
thereafter. At each visit, the physician makes the next appointment
for each patient. The patients who regularly returned for their sched-
uled appointments on the correct date within the last 6 months were
defined as the regular follow-­up (RFU) group, while the patients who
missed their scheduled appointments as irregular follow up (IFU)
group. Data on outpatient visits, disease duration, serology and
Clinical Disease Activity Index (CDAI) were noted for analysis.
Results : The mean age ±SD (years) and mean duration of disease ± SD
(years) was 52.25 + 12.73 and 9.25 ± 6.98 respectively. About 50.5%
patients were seropositive. Around 60.2% were on methotrexate,
14% on leflunomide, 23.7% on hydroxychloroquine and 2.2% on sul-
fasalazine. Only 55.9% had RFU whereas 44.1% had IFU and. About
76.3% had their labs done on time. According to CDAI, 14%, 20.4%,
31.2% and 34.4% were in remission, low disease activity (LDA), mod-
erate disease (MDA) and high disease activity (HDA) respectively.In
patients with RFU, 15.38, 23.07, 28.84 and 32.69% had disease remis-
sion, LDA, MDA, and HAD respectively where as in the patients with
IFU about 12.19, 17.07, 34.14 and 36.58 % had disease remission, LDA,
MDA and HDA respectively. About 46.87 % of all patients with HAD
were on RFU and about 53.15% were on IFU. The association between
RFU and HAD was statistically not significant (P-­value 0.831).
Conclusion: Recognizing the associated factors and reasons for
being irregular may help to improve the attendance of patients and
the quality of medical care.
3-­100 | Importance of drug verification and
adherence to disease modifying anti-­rheumatic
drugs in rheumatoid arthritis
Q. Rukhsar; B. Salim; S. Samreen; H. Gul; M. Mushtaq; A.
Nasim
Pakistan Society of Rheumatology
Background: Rheumatoid arthritis (RA) is a chronic debilitating dis-
order which requires regular treatment. Nonetheless, compliance to
these medications is often poor in our patients. There has been no
local study done to identify these factors so far.
Methods: This study was conducted in Rheumatology department,
Fauji foundation hospital (FFH) Rawalpindi from 1st June 2018 to
30 August 2018. A total of 95 patients between ages 30 to 80 di-
agnosed RA according to American college of rheumatology 2010
criteria were selected from outpatient department. Approval for this
study was taken from Ethical review committee. Personal profile
questions were noted in the proforma. Each patient was examined to
note down the number of tender joints and swollen joints. Patient's
pain score and physician evaluation of disease were both calculated
on visual analogue scale (0–10).Disease activity status of each patient
was calculated using CDAI score. Patients were interviewed regard-
ing the DMARDs they are taking; drug verification was done based on
patient's recall, from attendants and also by showing visual samples.
Drug adherence was asked from the patients/relatives; Morisky scale
questionnaire filled and causes of poor compliance were noted.
Results: The mean age of patients was 53.26 + 10.18, mean duration
of disease was8.32 + 7.6.CDAI score showed remission in 22(23.2%),
low disease activity in 33(34.7%), moderate in 16 (16.8%), whereas
high in 24(25.3%). All 95 (100%) patients correctly verify the drugs
they are using. According to Morisky scale for adherence 28 patients
have low67 have medium drug adherence. The commonest reasons
for non-­compliance were travelling issue and patients own decision.
Conclusion: RA patients have good drug compliance and drug verifi-
cation provided they are counselled and advised properly at each visit.
3-­108 | Muscle weakness with an overlap in a
13 year old male
M. Salman; B. Salim; S. Samreen; H. Gul; M. Ahmed
Pakistan Society of Rheumatology
Childhood Polymyositis and myasthenia gravis rarely exist together
and very few case reports are found about these two diseases to-
gether especially in childhood. We reported a 13 year patient with
2 year history of proximal muscle weakness and easy fatigability
with bilateral ptosis. Clinical features, examination, laboratory find-
ings, Electromyography(EMG), muscle biopsy and acetylcholine re-
ceptor antibodies of patient was in favor that patient had overlap
of polymyositis with myasthenia gravis. The patient improved clini-
cally as well as his muscle enzymes improved with pyridostigmine
and prednisolone and methotrexate drugs which he is still receiving.
Background: Polymyositis (PM) and myasthenia gravis (MG) are two
autoimmune diseases. These diseases can rarely coexist in one person,
owing to autoimmune nature of both these diseases. Around 26 case
reports exist in literature about the co-­occurrence of both these enti-
ties. But uniqueness of this case is its existence in juvenile population.
We report this 13 year old male with features consistent with both.
Case presentation: 13 year old male, student of 9th standard has 2
siblings; 1 brother and 1 sister. His milestones were delayed since
birth. He often complaints of easy fatigue and avoid playing out-
door games. He had bilateral ptosis since birth. at age of 10 years he
started having difficulty in standing from sitting position and rais-
ing the arms above head; more pronounced at the end of the day.
Neurology department did the initial workup and patient was treated
on lines of myasthenia gravis alone, with partial response only. Later
rheumatology review was sought. On examination he had bilateral
ptosis with proximal muscle weakness of both upper and lower limbs.
Investigations: Baselines tests were normal
Creatinine kinase: 1672 IU/mL
Aldolase: 9.9 U/L
Acetylcholine receptor antibodies: Positive
Anti Jo1 antibodies: Negative
MRI thighs: Muscle edema as in Figure 1, 2, 3
EMG: Generalized myopathic disorder (affecting proximal more than
distal muscles with fibrillations and sharp waves) as in
RNS: shows decrement response more than 10 % at some points.

Figure 4, 5, 6
Muscle biopsy: Consistent with polymyositis.
Thyroid function test: Normal
CT scan chest: No thymoma
Treatment: Neurology department did the initial workup and patient
was treated on line of myasthenia gravis alone, with partial response.
Later rheumatology review was sought. We diagnosed him as a case of
polymyositis overlap with myasthenia gravis in collaboration with the
neurologist. We treated him with prednisolone 40 mg/day along with
methotrexate 15 mg/week along with folic acid and pyridostigmine.
Outcome and follow up: His muscle power improved clinically as
well as his muscle enzymes improved. He is on regular follow up
in OPD of rheumatology department of Fauji foundation hospital
Rawalpindi.
Discussion: Our case included that although myasthenia gravis and poly-
myositis are two different diseases but both are autoimmune and may
Figure 1
Figure 2
Figure 3
|
      179
mimic with each other in symptoms but they have characteristic features
and different EMG findings and lab results. Overlap of MG and PM is rare
but it is reported in case reports. It is very important to recognize these
two separately as management of both these is different slightly and
they may be associated with other autoimmune disorders like thyroid
disorders. Another important point is that in clinical practice although
dermatomyositis is seen more often than polymyositis in children less
than 15 years of age but polymyositis without any skin manifestation is
not very common and also with myasthenia gravis is very unlikely.
About 26 cases are reported in the literature about the coexistence
of these diseases together. One case like this is reported is in juvenile
population. Most of them are adults more than 40 years of age and
most of them have secondary myositis. in addition to polymyositis,
MG a number of patients mentioned in literature had a thymoma in
chest along with other features.
Learning points/take home messages::
• Overlap of polymyositis and myasthenia gravis is very rare.
• It is even rarer in juvenile population.
• Any patient with partial response with treatment of myasthenia,
overlap should be considered.
• Management of both these is different slightly and they may be as-
sociated with other autoimmune disorders like thyroid disorders.
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gravis and associated autoimmune diseases in children. J Child
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2. van de Warrenburg BP, Hengstman GJ, Vos PE, Boerman RH,
terLaak HJ, van Engelen BG. Concomitant dermatomyositis and
Figure 4
Figure 5
 |
180      
Figure 6
myasthenia gravis presenting with respiratory insufficiency. Muscle
Nerve. 2002;25(2):293–6.
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H. Concurrence of myasthenia gravis, polymyositis, thyroiditis and
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Pelissier JF, Mongin M. Association of polymyositis, myasthenia, and
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NeurolNeurosurg Psychiatry. 1995;59(5):558–9.
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12. Yoshidome Y, Morimoto S, Tamura N, Kobayashi S, Tsuda H,
Hashimoto H, Takasaki Y. A case of polymyositis complicated with
myasthenic crisis. ClinRheumatol. 2007;26(9):1569–70.
13. Paik JJ, Corse AM, Mammen AL. The co-­existence of myasthenia
gravis in patients with myositis: a case series. Semin Arthritis Rheum.
2014;43(6):792–6.
14. Santos E, Coutinho E, Martins da Silva A, Marinho A, Vasconcelos
C, Taipa R, Pires MM, Gonçalves G, Lopes C, Leite MI Inflammatory
myopathy associated with myasthenia gravis with and with-
out thymic pathology: Report of four cases and literature review.
Autoimmun Rev. 2017;16(6):644–9.
15. Kobayashi T, Asakawa H, Komoike Y, Nakano Y, Tamaki Y,
Monden M. A patient with Graves’ disease, myasthenia gravis, and
polymyositis. Thyroid. 1997;7(4):631–2.
16. Saeki S, Fukusako T, Negoro K, Nogaki H, Morimatsu M.
Polymyositis followed by myasthenia gravis.
17. Spalek P, Schnorrer M, Cibulcík F. Simultaneous occurrence of
acute myasthenia gravis and acute polymyositis in 3 patients and in
2 patients also associated with a thymoma.
1-­055 | An audit on corticosteroid management
among rheumatology patients in a tertiary hospital
A. Salonga1; H. Kim2; C. Zuo3; J. Ng2,3
1
Greenslopes Private Hospital; 2Gold Coast University Hospital; 3Griffith
University
Objective: To determine the management practices for patients on
corticosteroid treatment in the Rheumatology department at the
Gold Coast University Hospital.
Methodology: A retrospective electronic medical record review was
done on patients who attended the Rheumatology clinic between 1
January 2016 and 30 June 2016. Patients identified to be on corti-
costeroids for any rheumatologic condition were included.
Results: Between 1 January 2016 to 30 June 2016, 63 patients who at-
tended the Rheumatology clinic were identified to be taking corticos-
teroids. Rheumatoid arthritis was the most common condition (27%)
for which steroid >7.5 mg daily was prescribed, followed by systemic
vasculitis (21%) and SLE (11%). 46 patients received steroids >7.5 mg
daily for >3 months. 20 out of the 46 patients (43.5%) had bone mineral
density (BMD) while 57% (26 out of 46 patients) did not have BMD.
89% of patients were prescribed any type of treatment such as
calcium, vitamin D and bisphosphonate therapy, while 11% either
did not receive any type of management or was not documented.
Only 30% had a documented treatment with bisphosphonates,
and half of the patients who had osteopenia did not have treat-
ment recorded. There was no documentation incorporating FRAX
tool in fracture risk assessment and treatment decisions in the re-
cords reviewed.

Conclusion: This study is limited due to the small sample size
but it provides a “glimpse” of Rheumatology practices in this sin-
gle centre in terms of screening and management of glucocorti-
coid –induced osteoporosis. Following this audit, the Gold Coast
University Hospital Rheumatology department is setting up a
dedicated nursing-­led service to identify patients who are at risk
of developing osteoporosis due to long term and frequently high
dose steroids. A follow up audit will be done as soon as the osteo-
porosis nurse commences.
1-­045 | Ayurvedic drugs and Celecoxib show
superior chondroprotective effect compared to
glucosamine: a controlled radiological evaluation
in symptomatic osteoarthritis knee
M. Saluja; P. Naik; S. Sarmukaddam; A. Venugopalan; A.
Chopra
Center for Rheumatic Diseases
Background/purpose: Ayurveda is an ancient India medicinal sys-
tem. Standardized Ayurvedic herbal products (OA01 & OA03)
demonstrated a-­
priori clinical equivalence in pain reduction and
improved function to oral Glucosamine and Celecoxib in a 24 week
study (published). Knee joint space measure is a surrogate marker of
cartilage status.
Objective: To demonstrate the effect of Ayurvedic drugs on the me-
dial knee joint space in an active controlled drug trial using standard-
ized digital X-­Ray technique.
Methods: Standardized plain digital bilateral X-­R ay knee of 160
randomized patients were examined by a trained radiologist (PN)
at baseline and week 24. Standing postero-­anterior semi-­flexed
view was taken. Blinded coded paired (baseline and completion)
X-­R ay films of each subject were examined by PN. Digital Vernier
was used to measure medial tibiofemoral joint space (MJS): vertical
measurements on a fixed graphic grid at 5 mm, 10 mm and 15 mm
mark from the tibial condyle edge. Mean change (completion-­
baseline, minus is worsening), in the average of the three joint
space readings (AJS) from each knee was calculated for each drug
arm. Standard statistical software (SPSS v 12) used: significant
P < 0.05 (Kruskal Wallis statistic).
Results: At baseline, the study drug arms were well matched for AJS
for each knee; Left knee: 2.1 mm, 2.6 mm, 2.8 mm and 2.3 mm for
OA01, Glucosamine, OA03 and Celecoxib respectively; correspond-
ingly Right knee: 2.2 mm , 2.9 mm , 2.9 mm and 2.3 mm. The mean
change in AJS for left knee was −0.36 mm, −0.77 mm, −0.77 mm and
−0.29 mm (P = 0.09) for OA01, Glucosamine, OA03 and Celecoxib
respectively; correspondingly for right knee AJS was −0.44 mm,
−0.87 mm, −0.76 mm and −0.09 mm (P = 0.03). The inadequacies of
the current measurement technique need to be considered.
Conclusion: In this controlled study, Ayurvedic drugs and Celecoxib
showed lesser reduction in medial knee joint space as compared
|
      181
to Glucosamine and therefore a likely superior chondroprotective
effect.
3-­109 | Outcome of interstitial lung disease in
patients with scleroderma: a 5 year prospective
cohort study
R. Samant; A. Khune; A. Mahashur; G. Kakade
P.D. Hinduja National Hospital & Medical Research Centre
Background: Systemic sclerosis (SSc) is a multi-­system disorder char-
acterized by a disturbance in fibroblast function, microvascular dis-
ease, and immune system activation, resulting in fibrosis of the skin
and internal organs.
Objectives: To study changes in lung function in cohort with scle-
roderma with ILD on treatment followed up prospectively over a
period of 5 years.
Methodology: In this cohort, 73 patients with scleroderma with ILD
were prospectively followed up between July 2013 to July 2018.
Patients’ clinical features, investigations, treatment and complica-
tions were recorded at regular interval.
Results: Of 73 patients, 68 were females and 5 were males. 4 had
only one visit and 11 had incomplete data. Patient's characteristics
are shown in table 1. Mean PAH at baseline was 35.95 ± 14.26 mm Hg
and at end of study was 39.44 ± 14.44 mm Hg. Immunosuppressants
used were MMF in 52, cyclophosphamide in 15, azathioprine in 13,
and methotrexate in 17 patients. 61 patients received oral predni-
solone with mean dose of 6.46 ± 7.10 mg/d during maintenance and
15 ± 8.95 mg/d during exacerbation of ILD. There was no statisti-
cally significant difference in mean FVC of 59 patients at baseline
(59.76 ± 16.91) and at end of the study (57.03 ± 16.77) and in sub-
group analysis of patients who received MMF (P > 0.05).Change in
FVC in all patients and in patients on MMF shown in Figure 1 and
2 respectively. Mean 6MWD at baseline was 370 ± 58.83 m and at
end of study was 377 ± 88.96 m. Impacts of baseline factors like age,
grade of dyspnea, FVC, presence of PAH as outcome have also been
 |
182      
studied. 5 patients died because of ILD. 13 patients needed home
O2.
Conclusion: Lung function either improved or remained stable over
5 years in 78% of all patients and 83% of the patients treated with
MMF; suggesting beneficial effect of immunosuppressants, espe-
cially MMF, in reducing progression of ILD in scleroderma.
2-­139 | Less fatigue in lupus low disease
activity state (LLDAS)
R. Saputra; L. Hamijoyo; S. Andayani
Padjadjaran University
Background: Systemic Lupus Erythematosus (SLE) is an autoim-
mune disease with heterogeneous clinical manifestations includ-
ing fatigue. Previous studies aimed at proving the relationship
between fatigue and SLE disease activity showed conflicting re-
sults. in 2015, Asia Pacific Lupus Collaboration (APLC) developed
low disease activity criteria, named Lupus Low Disease Activity
State (LLDAS). Patients spend more time in LLDAS have signifi-
cantly lower morbidity.
Objective: This study aimed to evaluate the association between
disease activity based on LLDAS and fatigue.
Methods: This is an analytical cross-­sectional study. Subjects were
SLE patients at rheumatology clinic in Dr Hasan Sadikin Hospital,
Bandung during June 2017. Subjects were evaluated based on
LLDAS criteria and divided into 2 groups: LLDAS and non-­LLDAS.
Fatigue status of the subjects were assessed using Fatigue Severity
Scale (FSS). Data were analyzed by using Chi-­square test.
Results: Sixty two subjects were included in this study, divided into
30 subjects in LLDAS group and 32 subjects in non-­LLDAS group.
Twelve subjects (40%) in LLDAS group had fatigue and 22 sub-
jects (68.8%) in non-­LLDAS had fatigue. There was a significant as-
sociation between LLDAS disease activity and fatigue (P = 0.023).
Nonetheless, there are still high fatigue level in LLDAS group
since disease activity was not the only factor related to fatigue.
Fatigue might be a clinical manifestation of other factors such as
psychosocial.
Conclusion: There was a significant association between LLDAS and
fatigue showed by higher fatigue level was found in the non-­LLDAS
group than in the LLDAS group.
Keywords: systemic lupus erythematosus, disease activity, lupus
low disease activity state, fatigue
1-­074 | Total knee arthroplasty (TKA) in a
patient with malignant rheumatoid arthritis and
schizophrenia: a case report
A. Sato
Kohnodai Hospoat, National Center for Golbal Health and Medicine
Background: No reports have been found of TKA in patients with
schizophrenia and malignant rheumatoid arthritis.
Case: The patient was a 44-­year-­old female. She was diagnosed with
schizophrenia at age 28 in 1940. Bilateral knee pain appeared gradu-
ally, she had trouble walking, and she was diagnosed with malignant
rheumatoid arthritis in 2013. Range of motion was: right knee, exten-
sion −95°, flexion 120°; left knee; extension −95°, flexion 120°. Knee
Society Score: 4 points (bilateral). X-­ray grade: Larsen 5. Steinbrocker
grade: Stage 3, class 4. Before operations, she wore corrective casts,
and her range of motion was improved (extension; right −75°, left
−70°). She received TKA on her right knee in September 2013, and
on her left knee in December 2015. Post operation ROM was exten-
sion −15° and flexion 120° on bilateral knees. After operation, she
wore knee braces.
After TKA, contractions appeared on bilateral knees, and manipula-
tion was performed in 2015. After manipulation, she received re-
habilitation, and she could stand up with some difficulty. However,
she refused outpatient rehabilitation, and as a result, it became more
difficult for her to stand up. ROM became Right: extension −95°,
flexion 115°, Left: extension −75°, flexion 115°, and bilateral Knee
Society Score was 13 points.
Discussion: The illness rate of schizophrenia is about 1% for the gen-
eral population, and this is the first report to my knowledge of TKA
in a patient with schizophrenia and malignant rheumatoid arthritis.
Rehabilitation for severe contracture on knees includes wearing
braces, stretching exercises, hot packs, and “bed sheet training”.
Conclusion: I report a case of TKA in a patient with schizophrenia
and malignant rheumatoid arthritis. Rehabilitation refusal may have
influenced its prognosis.
3-­022 | What is an ‘optimal’ spinal position
during sleep? a systematic review
J. Sewell1; E. Ong1; Y. Wang2; F. Cicuttini1,2
1
Alfred Health; 2Department of Epidemiology and Preventive Medicine, School
of Public Health and Preventive Medicine, Monash University
Background: The Australian mattress industry is worth two-­billion
dollars. Mattresses are being designed based on the hypothesis that
an optimal spinal position in sleeping is akin to that in standing. This
is largely based on a theory that this minimises stress on spinal tissue.
Objectives: The aim of this review is: 1. to examine the evidence
underpinning the hypothesis that an optimal spinal position during
sleep is akin to that of standing; and 2. to ascertain whether this
posture correlates with improved sleep quality.

Methods: Medical and engineering databases were searched includ-
ing Medline, PEDro and IEEE Xplore. Studies from 1990 to 2018
were included. Studies which measured both spinal position and
sleep quality were included. A snowballing technique was performed
within each article's reference list to interrogate the evidence behind
the hypothesised optimal spinal position.
Results: Five studies were referenced in the hypotheses of this opti-
mal spinal position (table 1), three of which measured stress on spinal
tissue in an erect spine, not a supine position. All were low quality.
Four studies measured both spinal position and sleep quality (table
2), only two of which found positive associations between these
outcomes. One study found that mattresses which promoted spinal
postures similar to standing were rated as more comfortable. One
demonstrated that sleepers on a custom mattress adopted less spi-
nal displacement and rated a higher sleep quality. The two remaining
studies found no association between optimal spinal position and
objective measurements of sleep quality. The heterogeneity of out-
come measurements renders it difficult to directly compare results.
Conclusion: The optimal position for good quality sleep is unclear.
There is minimal data examining whether the optimal spinal position
in sleep is akin to that of standing. Given the importance of good
quality sleep, further work is needed to determine optimal spine po-
sition during sleep.
|
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2-­140 | Clinical significance of antiphospholipid
antibodies (aPL) among Malaysian systemic lupus
erythematosus
S. S. Shaharir1; N. Yusof2; R. Mohd1; K. W. Yen1; A. H. A.
Gafor1; N. S. Shahril3; W. R. W. Musa3
1
Department of Internal Medicine, Universiti Kebangsaan Malaysia;
2
Department of Pathology, Universiti Kebangsaan Malaysia; 3Department of
Medicine
Background: Antiphospholipid antibodies (aPL) are one of the immu-
nologic criteria in diagnosing Systemic Lupus Erythematosus (SLE).
Apart from thrombotic risk and adverse pregnancy event, the clinical
significance of these autoantibodies in other SLE characteristics is
not well studied.
Objective: To determine the prevalence of positive aPL and the as-
sociated SLE features.
Method: Consecutive SLE patients with available aPL profile from
Rheumatology and Nephrology clinic in Universiti Kebangsaan
Malaysia (UKMMC) and Putrajaya Hospital were studied. Positive
aPL was defined as: positive lupus anticoagulant (LA) test and/
or anti-­c ardiolipin IgG/IgM >20 IU/mL. Patients with and with-
out aPL were compared by univariate (Chi square or Fisher's
exact test for categorical and Student's t  or Mann-­W hitney
test for continuous variables). P values < 0.05 were considered
significant.
Results: Among 359 SLE patients studied, majority were
Malays (57.1%) followed by Chinese (36.8%) and Indians (5.0%).
A total of 143 (39.8%) patients had a positive aPL. Such pa-
tients had an increased prevalence haematological manifesta-
tion of SLE, organ damage with a higher SLICC/ACR damage
score, cerebrovascular accidents, avascular necrosis and posi-
tive anti-­d sDNA. Among 196 lupus nephritis patients who had
renal biopsies, a positive aPL was significantly associated with
presence of global sclerosis. Further stratification of subset of
aPL revealed that patients with positive LA had significantly
increased thrombotic event, organ damage with earlier onset of
damage from SLE diagnosis (3.63 ± 3.18 vs 6.77 ± 6.14 years)
and presence of crescents in renal biopsy. However, they had
reduced prevalence of muco-­c utaneous lupus manifestation.
Positive anti-­c ardiolipin was associated with a higher preva-
lence of haematological manifestation, avascular necrosis, pos-
itive anti-­d sDNA and presence of global sclerosis and crescents
in renal biopsy.
Conclusion: Our study showed that one-­third of SLE patients had
positive aPL, and that this is associated with a different clinical mani-
festation and renal biopsy pattern even in the absence of antiphos-
pholipid syndrome.
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184      
3-­113 | Predictors of disease relapse in
pregnancy among Malaysian women with
systemic lupus erythematosus (SLE)
S. S. Shaharir; R. Mohd; R. A. Cader; R. Mustafar; R. A.
Rahman; M. S. M. Said
Universiti Kebangsaan Malaysia
Background: Systemic Lupus Erythematosus (SLE) predominantly
affects women of reproductive age. Due to the heterogeneity of the
disease, the impact of pregnancy towards SLE activity may differ
across various populations.
Objective: To determine the incidence of disease relapse and predic-
tors of disease relapse in pregnancy among Malaysian women with SLE.
Methods: This was a retrospective analysis which included SLE women
who had complete pregnancy care in Universiti Kebangsaan Malaysia
Medical Centre (UKMMC) from 2000 until 2017. Information on the
disease activity and medications during pre-­pregnancy and antenatal
period were obtained from the medical records. in our centre, pre-­
pregnancy disease activity was recorded using the Systemic Lupus
Erythematosus Disease Activity Index 2000 (SLEDAI-­2K) while activ-
ity during pregnancy was recorded using the SLE-­Pregnancy Disease
Activity Index (SLEPDAI). Disease flare was defined as per SELENA-­
SLEDAI composite index and statistical analyses were performed to
determine the predictors of disease relapse.
Results: A total of 114 patients with 187 pregnancies were analyzed. A
total of 67.9% (n = 127) of the pregnancies occurred in Malays, followed
by 22.5% (n = 42) Chinese, 7.5% (n = 14) Indians and 2.1% (n = 4) in oth-
ers. The incidence of disease relapse in pregnancy was 43.9% (n = 84)
with the mean pre-­pregnancy SLEDAI score increased from 3.1 ± 2.9 to
4.2 ± 4.3 during pregnancy, P < 0.001. The highest system relapse was
renal (n = 48, 57.1%) and haematological (n = 48, 57.1%). Disease re-
lapse was significantly associated with Chinese ethnicity, pre-­pregnant
active disease, shorter duration of remission pre-­pregnancy and tem-
porarily withheld hydroxychloroquine treatment during pregnancy (all
P ≤ 0.05). Patients with musculoskeletal involvement and Malays expe-
rienced significantly less disease relapse (P < 0.05).
Conclusion: Increases in SLEDAI and relapse episodes were ob-
served during pregnancy which predominantly involved renal but
less musculoskeletal system and Malays. A tight disease control is
warranted before pregnancy to reduce risk of disease relapse in
pregnancy.
2-­010 | A trial of suprascapular nerve block for
shoulder pain in motor neuron disease
E. M. Shanahan1; K. Glaezter1; T. K Gill2; C. Hill2; S. Graf1; P.
Allcroft1
1 lationship among objective support, subjective support, use of
Flinders University; 2University of Adelaide
Background: Shoulder pain is a distressing but under-­reported and
poorly managed symptom in people with motor neuron disease (MND).
Objectives: This study aimed to quantify the prevalence of shoulder
pain in people with MND and assess the efficacy of suprascapular
nerve block (SSNB) for the management of this symptom.
Methods: The study was made up of two parts. in the first part of
the study 49 consecutive patients from a dedicated MND clinic
were surveyed as to the presence of clinically significant shoul-
der pain. The rate of shoulder pain was compared with an age
and gender matched cohort. 27 patients with significant shoulder
pain were then offered a SSNB to manage the pain. 10 of the pa-
tients had bilateral shoulder pain and both were injected making
a total of 37 shoulders. The patients were followed for a total of
3 months, or until death. Shoulder pain was measured using the
pain scale (out of 100) of the shoulder pain and disability index
(SPADI) and compared with baseline scores and a placebo control
group from an earlier study using the same methodology for the
nerve block.
Results: The prevalence of shoulder pain in the 3 months prior to
the survey was 51% (CI 37.5–64.4) compared with a rate of pain of
11.7% (CI 10.3–31.1) from the community cohort. Following the
SSNB there was a statistically and clinically significant improve-
ment of pain scores from baseline (58.4) at week 1 (20.8, P < 0.000),
week 6 (17.6, P < 0.000) and week 12 (30.4, P 0.001) and a clinically
and statistically significant improvement compared with the control
group across each time interval.
Conclusions: Approximately 50% of patients with motor neuron dis-
ease suffer from shoulder pain. SSNB is a safe, effective therapy for
the management of shoulder pain in people with this disease.
3-­0 06 | The correlations of coping style and
social support in Chinese patients with systemic
lupus erythematosus
H. Chen1; X. Du1; Q. Zhao1; Y. Zhuang1; B. Shen2
1
Nantong University; 2The Second Affiliated Hospital of Nantong University
Objectives: This study aimed to investigate the in Chinese Systemic
Lupus Erythematosus (SLE) patients. And to investigate how Chinese
patients make sense of disease diagnosis, social support and per-
ceived cultural influences within the context of their SLE.
Methods: A total of 109 Chinese patients with SLE (92.7% female,
mean t SD age, 33.0 ± 17 years) underwent standardized laboratory
examinations and completed several questionnaires. Independent
sample t-­test, Mann–Whitney U.A linear regression model was used
to study association between the health assessment questionnaire-­
disability index and other variables.
Results: More than 50% of people choose negative coping strate-
gies. Objective support and support utilization were notable re-
support and mental health.The scores of whole social support are
higher than regional normative data. It maybe had close relationship
with the tan-­moral culture background of China.

Conclusion: It is beneficial to pay attention to the coping style and
social support of patients, to understand their needs and to provide
effective and effective service for them.
Keywords: systemic lupus erythematosus, coping style, social
support
2-­0 06 | Significant response to
immunomodulatory combination therapy for
recurrent Kimura's disease: a case report
Y. Shih; S.-H. Chang; P.-C. Wu
Division of Rheumatology and Immunology, Department of Internal Medicine,
China Medical University Hospital
Kimura's disease (KD) is a rare chronic inflammatory disorder with
unknown etiology that mainly affects Asian men between 20 and
30 years of age. It presents as solitary or multiple painless subcuta-
neous masses in head and neck region and is often associated with
lymphadenopathy, marked peripheral eosinophilia and high serum
IgE level. Although surgical excision, radiotherapy, and a variety of
immunomodulating agents such as corticosteroids, cyclosporine
and leflunomide are reported to be effective, no optimal treatment
modality was proven for Kimura's disease. Furthermore, high re-
currence rate up 60% to 80% makes treatment of Kimura's disease
become a tough nut to crack. We described a case with significant
response to immunomodulatory combination therapy for recurrent
Kimura's disease.
This 25-­year-­old previously healthy young man was diagnosed
as having Kimura's disease with the presentation of right facial
and postauricular masses (Fig. 1). In the begining, he received
oral corticosteroids therapy. However, the facial mass enlarged
gradually with marked eosinophilia and progressive IgE elevation.
Thus, he received wide excision of right neck and cheek soft tis-
sue masses, followed by methylprednisolone 500 mg pulse ther-
apy for 3 days. Unfortunately, the facial mass grew rapidly after
these treatments. He then received immune modulation therapy
Figure 1 Right facial and postauricular painless masses before
surgical excision and immunomodulatory therapies
|
      185
with azathioprine, methotrexate, hydroxychloroquine, and pred-
nisolone 10 mg/d. The facial mass, serum IgE and eosinophilia
decreased for a period but another recurrence bursted out. We
prescribed Cyclophosphamide 600 mg for six times. Three years
later, Leflunomide was added for recurrence. Finally, the facial
mass decreased and the serum IgE and eosinophilia dropped to
normal range draumaticly. No more recurrence noted for almost
2 years.
3-­082 | Glucocorticoid sparing effect of
targeted therapy in rheumatoid arthritis:
real-­world data from the Korean College
Rheumatology Biologics Registry
E. E. Lee1; S.-K. Lee1; H.-A. Kim2; K. Shin1
1
Seoul Metropolitan Government – Seoul National University Boramae Medical
Center; 2Ajou University School of Medicine
Background/purpose: Glucocorticoid (GC) is one of the key agents
that helps reduce robust synovitis and improve joint mobility at the
early phase of rheumatoid arthritis (RA) treatment. Discontinuing
GC or tapering GC to use the lowest dose possible is vital to pre-
vent comorbidities in long-­term. We investigated whether targeted
therapy better facilitates this goal in Korean RA patients.
Methods: Data were obtained from Korean College of Rheumatology
Biologics Registry (KOBIO), an inception cohort for biologic and
targeted synthetic DMARDs (altogether, targeted therapy). We
selected RA patients with a DAS28-­ESR ≥ 3.2, prescribed with a
targeted therapy and GC at baseline (group 1). A propensity score-­
matched control group (treated with conventional (c) DMARDs-­only,
group 2) was included in the analysis. Sparing of GC was analyzed in
a yearly basis using the chi-­square test for trend in proportions. A
multivariable regression analysis was performed to identify possible
baseline predictors for GC discontinuation.
Results: Baseline characteristics of group 1 (N = 188) and group 2
(N = 94) groups were comparable. Improvement in disease activity
during the first 2-­years was nearly equivalent between the 2 groups
(P = 0.8250). However, the cumulative percentage of patients taper-
ing, and discontinuing GC in group 1 was significantly greater than
group 2 during this period (P = 0.001611, P = 0.01468, respectively).
The gap between the 2 groups converged with time. Younger age,
and lower disease duration were baseline factors associated with
GC discontinuation in targeted therapy recipients. Results between
first-­line and ≥ 2nd-­line users of targeted therapy were not different.
 |
186      

Conclusion: On receiving targeted therapy, RA patients with a mod- 3-­143 | Assessment and predictors of response
erate to severe disease activity were able to discontinue, or taper GC
to steroid monotherapy in patients of takayasu
earlier than those treated with cDMARDs. Nevertheless, low-­dose
arteritis in bangladeshi population: an open-­label
GC is used long term in a great deal of Korean patients, regardless of
targeted or conventional treatment.
clinical trial
F. Shumy1; A. M. Anam2; M. R. Choudhury1; A. Shahin1; S. A.
Haq1; Md. N. Islam1
1
Bangabandhu Sheikh Mujib Medical University; 2Western General Hospital
3-­073 | Retention and safety of biosimilar
CT-­P13 in patients with rheumatoid arthritis:
Background: Efficacy of steroid, as treatment of Takayasu arteritis
data from the Korean College of Rheumatology (TA), varies in different studies. According to recent studies, effi-
Biologics Registry cacy is reduced to < 20%. Different groups have different opinion
1 2 2 3
K. Shin ; H.-A. Kim ; E. Lee ; S. K. Lee ; Y.-B. Park ; Y. N. 4 regarding induction therapy, whether it should be mono-­therapy or
Lee5; H. J. Kang5 combined with immune-­suppressive. The aim of this study is assess
1 2
SMG-­SNU Boramae Medical Center; Ajou University School of Medicine; the remission rate with prednisolone in TA in Bangladeshi population
3
Seoul Metropolitan Government-­Seoul National University Hospital Boramae and to determine the characteristics of patients for further guidance
Medical Center; 4Yonsei University College of Medicine; 5Celltrion Healthcare
to choose induction therapy.
Co. Ltd.
Methodology: Twelve active TA patients were enrolled from June
2016 to March 2018. They received 1 mg/kg prednisolone initially.
Background/purpose: CT-­P13 is a biosimilar prescribed for indica-
Disease activity assessed using the Indian Takayasu Activity Score-­
tions approved for the reference infliximab (RINF) including rheu-
CRP (ITAS-­CRP). The patients were followed-­up after 1 month and
matoid arthritis (RA) and other diseases. Clinical data of CT-­P13
disease activity reassessed. The patients, not in remission at the end
analyzed in previous clinical trials demonstrated non-­inferiority of
of the first month or relapsed during tapering of prednisolone were
efficacy and equivalence pharmacokinetic profile to RINF. However,
put on methotrexate and followed-­up. All the patients were followed
there are few studies showing long-­term data of its drug survival
up to 12 months.
or safety. This study investigated the drug retention rate and safety
Results: After 1 month 45.5% (CI: 17.28–73.62) patients went into
data of CT-­P13 in Korean RA patients.
remission. However, 80% patients relapsed during tapering of pred-
Methods: Subjects were RA patients enrolled in the Korean College
nisolone and 9.1% patients were in sustained remission with predni-
of Rheumatology biologics registry (KOBIO). Data from patients who
solone. The rate of patients relapsed while on methotrexate during
received RINF and CT-­P13 were included in the analysis (Dec 2012 ~
tapering of prednisolone was 20% (CI: 44.6–19.75). Those patients
Dec 2017). Discontinuation was defined as switching or stopping the
had onset of symptoms less than 15 months prior to starting ther-
biologic agent. Kaplan-­Meier curve were used for further analysis.
apy and did not have syncope, stroke, TIA and complications like
Reason for RINF or CT-­P13 discontinuation was assessed.
aortic regurgitation and hypertension responded to prednisolone.
Results: Data from 199 RA patients (CT-­P13; 147, RINF; 52) were an-
Systemic symptoms disappeared in all patients and ITAS-­CRP re-
alyzed. The mean age of patients was 51.3 years in the CT-­P13 group,
duced significantly in all patients (P ≤ 0.001). In 3 out of 11 patients’
and 12% were males. The mean disease duration was 7.7 years.
pulses reappeared. Presence of carotidynia (P = 0.03) found as sig-
Eighty four percent of CT-­P13 treated patients were biologic-­naïve.
nificant predictor for reappearance of pulse. Although statistically
Overall drug retention rate of CT-­P13 versus RINF was comparable
not significant, the disease duration and baseline ITAS-­CRP found
(P = 0.8382), as well as the retention rates of first-­line (P = 0.6609)
lower in ‘pulse reappearance’ group than the patients whose pulse
and second or more (≥2)-­line users (P = 0.9552) of agents. The rea-
did not reappear.
sons for discontinuing were inefficacy (31.8% in CT-­P13, 34.8% in
Conclusions: The response to prednisolone is variable in different
RINF), adverse events (20.0% in CT-­P13, 23.9% in RINF), clinical
population of TA. Proper identification of baseline factors in TA
improvement (3.0% in CT-­P13, 4.3% in RINF), and others (10.4% in
might help physician to decide induction regimen: with prednisolone
CT-­P13, 4.3% in RINF). The incidence of adverse events in CT-­P13
alone or combined with immunosuppressive.
treated patients leading to discontinuation was comparable to that
Keywords: takayasu arteritis ITAS steroid monotherapy Bangladeshi
of RINF; infusion reaction (10.2%), skin eruption (2.0%), and herpes
zoster (0.68%)
Conclusion: Our study demonstrates that the drug retention rate of
CT-­P13 was similar to RINF, and CT-­P13 showed a reasonable long-­
term safety profile comparable to RINF in Korean RA patients.
 |
      187

2-­078 | Circulating adipokines and phenotype subgroups (oligo versus polyarticular, axial versus peripheral, pres-
ence or absence of dacytlitis, and presence or absence of enthesitis).
in psoriatic arthritis
The relationship between adipokines and disease activity scores was
P. Sinnathurai1,2,3,4; D. Chessman4,5; H. Lin3; M. Xue3; assessed using linear regression.
D. Sumpton4,5; M. Oliffe 4,5; F. Briggs4,5; S. O'Neill4,5; G.
Results: 39 participants were included in the analysis (Table 1).
Hassett4,5; L. March1,2,3
1 Chemerin and adiponectin were higher in polyarthritis than oli-
Rheumatology Department, Royal North Shore Hospital; 2Institute of Bone
and Joint Research, Kolling Institute, Northern Sydney Local Health District; goarthritis (mean differences (95%CI) 4167 pg/mL (722–761 pg/
3
University of Sydney; 4Rheumatology Department, Liverpool Hospital; mL); P = 0.02, and 4003 ng/mL (551–7455 ng/mL), P = 0.02 re-
5
University of New South Wales and the Ingham Institute for Applied Medical
spectively). Chemerin was lower in active dactylitis (mean dif-
Research
ference (95%CI) 436 pg/mL 1 (161–8562 pg/mL); P = 0.04), and
adiponectin was lower in active enthesitis (mean difference
Background: Adipokines are cytokines produced by adipocytes
(95%CI) 3917 ng/mL (741–7094 ng/mL); P = 0.02). Otherwise,
which may promote inflammation and disease activity in psoriatic
there were no differences in adipokine levels between any phe-
arthritis (PsA).
notypic subgroups. After adjusting for age, sex and BMI, resistin
Objectives: To measure plasma levels of adiponectin, leptin,
was positively associated with PASI (β (95%CI) 632 (122–1142);
chemerin and visfatin, tumor necrosis factor (TNF)-­α and interleukin
P = 0.02). Visfatin was also positively associated with PASI (0.63
(IL)-­6 in patients with PsA and correlate with disease activity and
(0.26–1.01); P = 0.002). There were no other significant associa-
phenotype.
tions between adipokine levels and swollen/tender joint count,
Methods: Participants were drawn from PsA cohort studies at
PASI, DAPSA or MDA status.
Royal North Shore and Liverpool Hospitals, Sydney, Australia.
Conclusion: Circulating chemerin and adiponectin were increased in
Participants with PsA had musculoskeletal and skin disease activ-
the polyarthritis phenotype compared with oligoarthritis in PsA. To
ity assessed and venous blood collected. Adipokines were assayed
our knowledge, this is the first study investigating the association
using commercially available kits. Statistical analysis performed
between phenotypic subgroups in PsA and adipokine levels.
using STATA v15.1. Chi-­squared and T-­tests used for between group
comparisons. Adipokine levels compared between PsA phenotypic

Table 1 Characteristics of participants with psoriatic arthritis by site 2-­079 | Circulating adipokines in psoriatic
arthritis: a systematic review
Site
P. Sinnathurai1,2,3; D. Sumpton3,4,5; L. March1,2,3
Royal North Liverpool 1
Rheumatology Department, Royal North Shore Hospital; 2Institute of Bone
Shore (n = 20) (n = 19)
and Joint Research, Kolling Institute, Northern Sydney Local Health District;
3
Characteristic Mean SD Mean SD University of Sydney; 4Centre for Kidney Research, the Children's Hospital
Westmead; 5Department of Rheumatology, Concord Repatriation General
Age 53.8 15.8 47.8 12.8 Hospital
BMI (kg/m2) 27.9 7.4 31.1a 7.7
Swollen joint count (0–66) 3.0 3.5 3.5 4.8 Background:
Tender joint count (0–68) 3.0 3.4 9.9 10.8 Adipose tissue secretes bioactive substances called adipokines
PASI 4.1 7.6 2.9 3.4 which may promote inflammation, contributing to increased preva-

DAPSA 15.4 7.3 23.1 18.1 lence and severity of psoriatic arthritis (PsA) in obesity.

n % n %
Objectives:
Sex (female) 12 60.0 7 36.4
Phenotype • To determine whether circulating adipokine levels are associated
 Oligoarthritis 11 55 4 21.1 with PsA, compared with healthy controls, or other rheumatic
 Polyarthrtitis 8 40 10 52.6 diseases;

 Axial involvement 0 0.0 7 36.8 • To determine whether circulating adipokine levels are associated
with disease activity in PsA
 DIP involvement 1 5.0 2 10.5
 Dactylitis 5 25 1 5.3 Methods: A systematic literature review was performed (PROSPERO
 Enthesitis 7 35 16 84.2 ID=CRD42018086425). Databases searched from their incep-
BMI, body mass index; DAPSA, Disease Activity for Psoriatic tion to 13th December, 2017: Medline via Ovid, EMBASE, Web of
Arthritis; DLQI, Dermatology Life Quality Index; HAQ, Health Sciences, Scopus (Health Sciences) and Cochrane Central Register
Assessment Questionnaire; PASI, Psoriasis Area and Severity Index; of Controlled Trials. Studies measuring circulating adkipokine lev-
SD, standard deviation. els in adults with PsA were included. Observational and interven-
a
n = 18. tional studies were included. Review articles, editorials, paediatric
 |
188      
studies, and studies not involving humans were excluded. Two inde-
pendent reviewers screened titles, abstracts, and full text articles.
Disagreements were discussed and resolved with a third reviewer.
Data from eligible studies were extracted by two independent re-
viewers, who assessed the quality of included studies using the
Newcastle Ottawa Scale.
Results: There were 161 articles identified in the database search
after de-­duplication. After screening of titles and abstracts, 29 ar-
ticles remained. After full text review, 9 were eligible for inclusion.
Variable associations were reported between circulating adipokines
in PsA compared with psoriasis alone and healthy controls. Leptin
was consistently higher in PsA, but there were conflicting results for
adiponectin, chemerin and resistin, and limited data for omentin and
visfatin. There was conflicting data regarding the relationship be-
tween adipokines and disease activity in PsA. The included studies
were heterogeneous in design and quality with inconsistent report-
ing of disease outcomes.
Conclusions: There is conflicting and limited data reported regarding
circulating adipokines and PsA. Further research is needed to inves-
tigate the relationships between PsA and adipokines to determine
whether they may be useful as biomarkers of disease.
3-­134 | Apixaban treatment failure
presenting as recurrent thromboembolism in
antiphospholipid syndrome
G. Smith; J. Eng-Frost; M. Litwin
Royal Adelaide Hospital
Background/purpose: Antiphospholipid syndrome (APS) is man-
aged with lifelong anticoagulation with warfarin, following an initial
thrombotic event. There is ongoing research into novel anticoagu-
lant (NOAC) use in these patients. We discuss a case involving multi-
ple thrombotic complications of APS despite therapeutic treatment
with apixaban.
Objectives: To explore the current place of NOACs in APS.
Methods: Following an outline of a case managed in our service we
review the current literature of NOAC treatment for thrombotic
events in APS. Relevant case reports, series and ongoing stud-
ies were identified using the Medline database with the Keywords
new or novel anticoagulant, antiphospholipid syndrome, apixaban,
rivaroxaban.
Results: A 65-­year-­old woman with a background 10-­year history of
triple positive APS, commenced warfarin in 2013, but transitioned
to apixaban in 2017. She presented with acute onset right arm pain
and arterial compromise requiring urgent brachial embolectomy.
48 hours post-­operatively she developed dysarthria, dysphasia and
left hemi-­spatial neglect and imaging was consistent with multiple
embolic cerebral infarcts.
NOACs are increasingly used in Australia however there is insuffi-
cient evidence regarding their efficacy and safety in the APS cohort
and they may even be harmful. The multi-­centre Rivaroxaban in
Antiphospholipid Syndrome (RAPS) trial and recently the Trial on
Rivaroaban in Thrombotic Antiphospholipid Syndrome (TRAPS)
were both terminated early due to excessive thrombotic events
in the rivaroxaban arm. Outcomes of the Apixaban for Secondary
Prevention of Thrombosis among patients with APS trial are pending.
Several case studies published examining the use of NOACS in APS
have demonstrated inconsistent results. The majority of case studies
have reported failure of treatment in high risk patients treated with
NOACS however a number case reviews have shown no difference
to warfarin.
Conclusion: There is insufficient evidence in current literature to
support the efficacy and safety of NOACS in long-­term treatment
of APS and increasingly convincing evidence that they are harmful.
We look forward to the results of the pending ASTRO-­APS study.
Patients with APS, especially high-­risk APS, should therefore be
treated with warfarin with a target INR of 2–3.
3-­114 | Factors associated with loss to follow-­
up among systemic lupus erythematosus patients
in Myanmar: a mixed method study
Y. M. Soe; C. Soe; K. Lin; K. Aung
Department of Rheumatology, University of Medicine
Introduction: In Myanmar, Rheumatology service is only available in
Yangon and Mandalay. The prevalence of SLE is increasing in recent
years: total number of new admission in 515 in 2014, 634 in 2015,
796 in 2016 and 913 in 2017. All these cases are organ threatening
and needs intensive immunosuppressive therapy. Among them, 20%
are failed to attend follow-­up during the induction phase and reap-
peared later with organ failure. Therefore, identification of the fac-
tors associated with loss to follow-­up (LTFU) is necessary to improve
patient outcomes.
Method: A hospital-­b ased mixed method study was conducted
from June 2018 to August 2018 at Rheumatology Department,
Yangon Specialty Hospital. in 16 LTFU cases and 32 regular
follow-­
u p controls, socio-­
d emographic characteristics, trans-
portation, trust in health care providers, social support and
stigma, knowledge on SLE, income and economic support were
determined for quantitative study. Individual-­indepth interviews
were used to understand reasons for not returning for scheduled
follow-­u p.
Results: In multivariate analysis, city transport and levels of edu-
cation were significantly associated with LTFU. Taxi-­
users (OR
0.03, 95% CI: 0.002–0.44, P = 0.01) and those used other trans-
port methods (OR 0.04, 95% CI: 0.004–0.43, P = 0.008) have lower
odds of being LTFU. Patients who have finished middle school (OR
0.04, 95% CI 0.002–0.99, P = 0.049) and high school (OR 0.04, 95%
CI 0.002–1.00, P = 0.05) have lower odds of being LTFU. Interview
revealed that financial limitation, i.e, lack of money for drugs,
 |
      189

property loss to afford medication, complicated city-­

transport 3-­0 01 | Nonradiographic spondyloarthritis: a
system, communication failure with healthcare personnel, unfa-
case report of a filipino female presenting with
miliarity of updated Rheumatology treatment among physicians in
chronic inflammatory back pain
district hospitals.
Conclusions: Main transport method and educational status were H. M. Sollano; J. P. Lorenzo
found to be independent predictors of LTFU. Qualitative findings Makati Medical Center

have revealed poverty, poor city-­

infrastructure and healthcare-­
associated factors as the underlying reasons. Catastrophic health
expenditure because of out-­of-­pocket payments is the major under-
lying problem hidden behind LTFU.
3-­110 | Subclinical Atherosclerosis in Systemic
Sclerosis
Y. Minn Soe
Myanmar Rheumatology Society
Objective: Endothelial dysfunction and inflammation are pathogenic
mechanisms common to systemic sclerosis (SSc) and atherosclero-
sis. This study was undertaken to study subclinical atherosclerosis in
systemic sclerosis, as assessed by the carotid intima media thickness
(CIMT) and conventional cardiovascular and disesase specific risk
factors in SSc patients and to determine its association with micro-
vascular nailfold capillaroscopic changes.
Methods: The study population and healthy controls were inter-
viewed by the structured questionnaire. The conventional car-
diovascular risk factors such as BP, BMI, glycemic status and lipid
profile were measured in SSc patients and their age and sex matched
healthy non-­smoking controls. The nailfold capillaroscopy was done
in SSc patients to define their NFC stage. The CIMT was measured
by B-­mode ultrasound.
Results: Seventy-­one SSc patients and 71 controls were recruited.
The patients had a mean ± SD age of 42.59 ± 12.65 years and me-
dian disease duration of 28.52 ± 25.27 years. Female to male ration
was 6:1. Compared with their controls, the SSc patients had lower
BMI. The BP and lipid profile were not significantly different. There
was a significantly higher proportion of carotid intima media thick-
ness in SSc patients compared with the controls (0.68 ± 0.10 mm
versus 0.48 ± 0.07, P < 0.01). Among the disease specific factors,
the disease duration, modified Rodnan Skin Score (mRSS), disease
subset (lcSSc and dcSSC) and antibody positivity (anticentromere
antibody, anti topoisomerase I antibody and anti RNA polymerase
III antibody). −49% of SSc patients had late stage of NFC. Regarding
the NFC and CIMT, there is no significant association between the
two variables (P = 0.70)
Conclusion: The study indicates that SSc is an independent risk fac-
tor for subclinical atherosclerosis regardless of the tradional cardio-
vascular risk factors and disease specific factors.
Background: Nonradiographic spondyloarthritis is a recent classi-
fication of axial spondyloarthritis as defined by the Assessment of
SpondyloArthritis International Society (ASAS) in 2009. This was de-
veloped to identify patients with spondyloarthritis regardless of the
lack of radiographic sacroilitis. Prevalence studies that exist inter-
estingly state that Asians have a high prevalence compared to other
ethnicities. However there has been no reported or documented
case from the Philippines.
Methods: This is a report of a 42-­year-­old female who presented
with chronic inflammatory back pain, arthritis and enthesitis, which
merited further imaging work-­up.
Results: The patient had a 1-­year history of chronic inflammatory back
pain with intermittent arthritis and enthesitis of the left heel. This
was initially responsive to non-­steroidal anti-­inflammatory medica-
tions but persistence prompted consultation with a Rheumatologist.
Initial diagnostics exposed elevated CRP and ESR. An x-­ray of the
lumbosacral spine was done which only revealed lumbar spondylo-
sis. Further imaging studies included a plain MRI of the sacroiliac
joints which showed mild, right sacro-­iliac joint inflammation.
Conclusion: In correlation to the ASAS criteria of nonradiographic
spondyloarthritis, our patient fulfills the standards set by the soci-
ety. A thorough history, proper diagnostics and a highly suspicious
clinical eye are warranted to properly document and support diag-
nostic criteria. To our knowledge, the lack of any documented case
of nonradiographic spondyloarthritis among Filipinos, until this case,
is likely due to either their rarity or lack of recognition of the disease.
Figure 1Figure 1
 |
190      
3-101 | Superb microvascular imaging com-
pared with conventional power doppler imaging
of active synovitis in rheumatoid arthritis
J.-S. Song1; G. Y. Lee1; S. Kim1; S. T. Choi1; K.-H. Lee2
1
Chung-ang University College of Medicine; 2Dongguk University College of Medicine
Background: Precise evaluation of synovial inflammation is very im-
portant for the management of rheumatoid arthritis (RA). One of the
most popular used methods to detect synovial inflammation is ultra-
sonography. The superb microvascular imaging (SMI) is a new, which
can show more sensitive vascularity excluding motion artifacts.
Objectives: This study evaluated SMI technology for detection of
active synovitis in patients with RA.
Methods: Fifty-six patients with RA (42 females; mean age,
53.2 years) underwent gray-scale ultrasound imaging, power
Doppler imaging (PDI), and SMI using Aplio TM 500 Ultrasound
(Toshiba Medical Systems Corporation) for synovitis of both wrists
and hands (total 22 joints), scored for each joint from grade 0 to 3.
The sum of grades for 22 joints was determined for gray-scale (SYN-
sum), PDI (PDI-sum), and SMI (SMI-sum). Follow-up ultrasound was
performed in 17 patients (mean interval, 251.6 days).
Results: The mean values of ESR, CRP and DAS28 were
27.13 ± 18.06 mm/h, 6.78 ± 9.14 mg/L, and 2.71 ± 1.11, respectively.
The SMI-sum (7.27 ± 4.56) was significantly higher than the PDI-sum
(4.38 ± 3.09, P < 0.001) and the SYN-sum (4.55 ± 3.72, P < 0.001),
and was significantly correlated with the ESR, CRP, and DAS28 score
(γ = 0.409, P = 0.002; γ = 0.695, P < 0.001; γ = 0.726, P < 0.001, respec-
tively). Moreover, in 28 patients with clinical remission, the SMI-sum
(4.32 ± 2.01) was greater than the PDI-sum (2.61 ± 1.60, P < 0.001). in
17 patients with follow-up US, the SMI-sum (2.35 ± 1.73) was signifi-
cantly greater than the PDI-sum (1.24 ± 1.20; P < 0.001), and was also
significantly correlated with DAS28 (γ = 0.880).
Conclusion: SMI may detect active synovitis with greater sensitivity
than PDI in RA patients, even with clinical remission, and is well-
correlated with inflammatory parameters during follow-up.
2-119 | Prevalence of and factors associated with
sarcopenia in patients of ankylosing spondylitis
R. Song1; S. W. Chung2; Y.-A. Lee2; S.-J. Hong2; H.-I. Yang2;
S.-H. Lee1
1
Kyung Hee University Hospital at Gangdong; 2Kyung Hee University Hospital
Background/purpose: Sarcopenia is characterized by progressive
and generalized loss of skeletal muscle mass and strength. Low lean
mass and sarcopenia are common in patients with chronic inflamma-
tory disease. However, the studies about sarcopenia in ankylosing
spondylitis (AS) were lack.
Objectives: The aim of this study was to evaluate the prevalence and
risk factors of sarcopenia in patients with AS.
Methods: Cross-sectional data were collected on 60 male pa-
tients with AS who fulfilled the modified New York criteria. For
measurement of body composition, dual energy X-ray absorptiome-
try (DXA) for bone mineral density (BMD) was performed. Sarcopenia
was defined by Asian working group for sarcopenia (AWGS) criteria
and by Korean criteria based on the KNHANES 2008-2009. Clinical
data and laboratory were compared for AS without sarcopenia ver-
sus those with sarcopenia
Results: The prevalence of sarcopenia by AWGS and Korea criteria was
15% and 26.7% in AS patients. The mean age of patients with sarcopenia
according to the Korea criteria was 48.8 ± 15.6 years and the sarcope-
nia occurred at a relatively young age in AS. Mean age was higher in the
sarcopenia groups both by AWGS criteria and Korea criteria (P = 0.02
and 0.004) and the level of ESR was higher in the sarcopenia group by
Korea criteria (16.8 ± 13.6 vs. 14.8 ± 6.0, P = 0.03). The patients with
sarcopenia tended to show lower BMI, lower disease duration, more
cumulative dose of glucocorticoid than the patients without sarcope-
nia, but there was no statistical significance. The older age (P = 0.007),
longer disease duration (P = 0.008) and lower BMI (P < 0.001) were sig-
nificantly associated with lower skeletal muscle mass in AS.
Conclusion: Sarcopenia occurred at a relatively young age in patients
with AS. Mean age and level of ESR were higher in patients with sar-
copenia. The older age, longer disease duration and lower BMI were
significantly associated with lower skeletal muscle mass in AS.
Table 1 Comparison of clinical and laboratory characteristics of AS
patients with and without sarcopenia
2-051 | 18F-Fluorodeoxyglucose positron
emission tomography/magnetic resonance
imaging (18F-FDG PET/MRI) correlated with the
histologic scoring system in C protein-induced
myositis model
J. Y. Kim1,2; J. W. Byun3; J. H. Shin3; J. S. Park1,2;
J. H. Lee2; D. W. Hwang3; Y.-S. Lee3; J. C. Paeng3;
E. Y. Lee2; S. Y. Wook1,2
1
Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate
School of Convergence Science and Technology, Seoul National University,
2
Division of Rheumatology, Department of Internal Medicine, Seoul National
University Hospital, 3Department of Nuclear Medicine, Seoul National University
Hospital
Background/purpose: C protein-induced myositis (CIM) is a mu-
rine model of polymyositis (PM). Muscle injury is mediated by C

protein-­reactive CD8 + T cells. The histological scoring is the reliable
way to assess the severity of CIM. However it has limitation to evalu-
ate the inflammation due to focal involvement. The aim of this study
was to evaluate the correlation of skeletal muscle inflammation and
18
F-­fluorodeoxyglucose (FDG) positron emission tomography (PET)/
magnetic resonance imaging (MRI) findings in CIM.
Methods: To induce CIM, 8–10-­week-­old female mice were immu-
nized intradermally with 200 μg C protein fragments emulsified in
200 μg of Freund’s complete adjuvant (CFA). Pertussis toxin (0.2 μg)
was injected intraperitoneally at the same time. On PET/MRI, FDG
uptake was measured in the gluteal and thigh muscle, foot pad, and
the soft tissue as a background. Maximal target-­to-­background ratio
(TBR) of the muscles was measured as the index for uptake. 18F-­FDG
PET/MRI evaluation was performed on day 12, 14 and 19 after im-
munization. Each muscle tissues were stained with hematoxylin and
eosin (H&E). Myositis was graded on a scale of 1–6 according to the
histologic severity.
Results: Mean of histologic summation score of skeletal muscles was
0.77 (P = 0.016 on day 12), 1.94 (P = 0.0014 on day 14), 0.5 (P = 0.12
on day 19) in CIM compared to control mouse. On PET/MRI, TBR
was 1.67 in control, whereas it was 4.11 (P = 0.019 on day 12) 6.34
(P = 0.004 on day 14), and 3.93 (P = 0.005 on day 19) in CIM model.
TBR was correlated with histologic summation score (Spearman’s
rho = 0.954, P = <0.0001).
Conclusion: TBR in 18F-­FDG PET/MRI correlated with the histologic
scoring system in CIM model. 18
F-­FDG PET/MRI could be an effec-
tive non-­invasive method for quantitative, longitudinal assessment
of inflammatory activity in CIM model.
Keywords: C protein induced myositis, polymyositis, inflammation,
18
[ F]FDG PET, MRI
2-­052 | The relationship between clinical
findings of low back pain and magnetic resonance
imaging results
M. Soroush1; B. Shekarchi2; N. Anari2
1
Iran Rheumatology Association; 2AJA University of medical sciences
Background/purpose: A large number of patients with low back pain
(LBP) refer to imaging evaluation in routine practice. Most of these
patients have abnormal findings on magnetic resonance imaging
(MRI). There are many reports about the poor association between
symptoms and anatomical findings in MRI.
The purpose of this study is to evaluate the relationship between
clinical findings of patients with LBP and findings in reports of MRI
in these patients.
Methods: We selected 710 patients with LBP that referred to the
imaging center for lumbar spine MRI. We did history and physical
examination for all of patients before doing MRI and after that, we
compared the reports of MRI with our clinical findings.
Results: Mean age of referred patients was 41.2 years (18–90 year).
of 79 patients with clinical diagnosis of acute lumbar disc disease,
|
      191
55 cases (69.6%) had disc protrusion in MRI report. in addition, in
18 cases (22.8%) there was not any specific findings in MRI. in 268
patients we did not find any significant clinical problems, from them
72 cases (26.9%) had report of disc protrusion in MRI and in 176 pa-
tients (65.7) no specific findings were reported in MRI.
Conclusion: This study shows that we cannot trust to results of lum-
bar spine MRI in patients with low back pain and we have to first trust
to our good physical examination, then request MRI in perfect indica-
tions and eventually check the results based on our clinical findings.
Keywords: low back pain; magnetic resonance imaging, imaging, in-
tervertebral disc
2-­061 | Septic arthritis secondary to
Streptococcus dysgalactiae subspecies
dysgalactiae bacteremia: a case report
J. Suaco; M. S. Machacon-Wong
St. Luke's Medical Center – Quezon City
Background/purpose: Streptococcus dysgalactiae subspecies dysga-
lactiae (SDSD), an alpha hemolytic streptococcus, is a zoonotic path-
ogen well-­recognized to cause pyogenic infection in animals. Human
infection is rare and has only been reported twice as an upper limb
cellulitis and as a prosthetic joint infection after total knee arthro-
plasty. Bacteremia caused by SDSD which subsequently resulted to
septic arthritis and other complications has not yet been reported in
the literature, hence management of such a case is still novel.
Objective: To discuss the first documented case of SDSD septic ar-
thritis in the Philippines and the second reported SDSD joint infec-
tion in the world.
Methods: This is a case report based on a 63-­year-­old Filipino female
who presented with acute inflammatory polyarthritis and general-
ized body weakness but no fever, cough, colds, decreased appetite,
insect bite or trauma. She has a history of degenerative osteoarthri-
tis of both knees. She was known to have cervical squamous cell
carcinoma stage IV with bone and lymph node metastases and un-
derwent a total of 4 cycles of chemotherapy, 28 fractions of radio-
therapy and 4 sessions of brachytherapy. On physical examination,
there were petechiae on both upper extremities, tenderness and
erythema on the left arm, multiple inflamed joints, anal fistula and
hemorrhoids.
Results: Streptococcus dysgalactiae subspecies dysgalactiae (SDSD)
was isolated both in the blood and the synovial fluid. She was initially
given an empiric therapy of vancomycin which was then shifted to
penicillin G and levofloxacin upon isolation of SDSD. Repeat cultures
showed no growth of microorganism.
Conclusion: Symptoms of sepsis with concurrent isolation of SDSD
in the blood and synovial fluid in an immunocompromised individual
proves that even zoonotic pathogens can cause human infection
especially in the presence of predisposing risk factors. Clinical re-
sponse to antibiotic therapy with subsequent clearance of cultures
indicates that such an infection is treatable.
 |
192      
3-­023 | New onset acute inflammatory arthritis
in hospitalized patients
Y. S. Suh1; H. Kim1; M. G. Kim2; Y. Cheon2; S. Lee2; S. Hong3;
O. Cho3
1
Division of Rheumatology, Department of Internal Medicine, Gyeongsang
National University Changwon Hospital; 2Division of Rheumatology, Department
of Internal Medicine, Gyeongsang National University School of Medicine;
3
Division of Infectious diseases, Department of Internal Medicine, Gyeongsang
National University Changwon Hospital
Purpose: We determined the clinical characteristics of hospital-­
onset acute inflammatory arthritis (HAIA) in hospitalized patients
and examined misdirected investigation and inappropriate treat-
ment when the diagnosis was delayed.
Methods: We reviewed the medical records of hospitalized patients
who underwent arthrocentesis or were seen in consultation to rheu-
matologist because of hospital onset inflammatory arthritis (defined
as onset ≥ 48 h after hospital admission) from Jan, 2015 to Feb, 2018.
We excluded non-­inflammatory arthritis, non-­specific arthralgia, and
the patient who admitted with joint symptoms already present.
Results: HAIA was diagnosed in 51 patients, gout attack in 35 (68.6%),
calcium pyrophosphate dehydrate (CPPD) arthropathies in 12 (23.5%),
aggravation of inflammatory osteoarthritis in 2, and rheumatoid ar-
thritis flare in 2. Twenty five (49%) patients were newly diagnosed with
inflammatory arthritis (gout 56%, CPPD 40%). The mean age were
70.7 years (IQR: 63.0–80.0) and 22 were female. Joint symptoms de-
veloped 5.6 days after admission (IQR: 2.0–6.0). The main causes of
hospitalization were infectious diseases (31.4%). Nine patients (17.6%)
had surgery and 16 (31.4%) used diuretics before the development of
HAIA. Fever was present in 49% patients. Polyarticular involvement
were found in 19.6% patients. Appropriate treatment started 2.1 days
after joint symptoms (IQR: 0–4.0). Eighteen patients (35.3%) received
a delayed appropriate treatment after 3 days. Four patients adminis-
trated antibiotics before the correct diagnosis for 4–5 days.
Conclusion: Fever and polyarthritis are not uncommon feature in
HAIA. A precise diagnosis will help minimize the rate of inappropri-
ate treatment and the morbidity of prolonged joint pain in hospital-
ized patients.
3-­061 | A case of juvenile dermatomyositis
(JDM) calcification successfully treated with
Abatacept
S. Sukumaran
ACH/UAMS
Introduction: The incidence of JDM varies between 2–7/1,000,000
per year. The incidents of the subcutaneous and soft tissue calcifica-
tion in JDM is estimated to range between 20 to 60% of the cases.
Case presentation: We report a 16 year old female with rash and
muscle weakness and diagnosed with JDM based on Bohan and
Peter Criteria with characteristic rash, proximal muscle weakness and
elevated muscle enzymes. Her treatment helped with the rash, muscle
enzymes and muscle weakness. Her calcification in her thighs never
subsided. She had excision of the calcum deposits and later showed
recurrence. She had quarter sized calcification in her both thighs.
She was seen in clinic in summer of 2015 and was noted to have
elevated muscle enzymes and inflammatory markers. She was also
noted to have mild symmetrical muscle weakness and fatigue and
was noted to have flare up of her inflammation. She was on cellcept,
IVIG and hydroxylchloroquine and probenecid.
She was on the Abatacept, showed normalization of her inflamma-
tory markers and muscle enzymes and complete resolution of the
calcification.
Discussion: This case report highlights the need for close monitor-
ing in JDM patients to look for calcification and the need to ex-
plore other biological options to control the calcification. Further
studies needed for Abatacept in the use of the JDM calcification.
The option of surgical treatment vs medical option for the treat-
ment of dystrophic calcification needs to be answered with fur-
ther studies.
3-­102 | Patient's expectation and satisfaction
for joint sacrificing surgery on rheumatoid
forefoot deformity
I. Sung; T.-H. Kim; J.-K. Lee; D.-W. Kim
Hanyang University Medical Center
Background: Forefoot deformity is common in rheumatoid arthritis
(RA), often demanding surgery. Patient's satisfaction has not been
well documented, following joint sacrificing operation for forefoot
deformity in RA.
Objectives: To assess preoperative patient's expectations and
postoperative satisfaction, and also factors that could affect post-
operative satisfaction following metatarsophalangeal joint (MTPJ)
arthrodesis of hallux and lesser MTPJ resection (Figure 1).
Methods: 40 RA patients were enrolled. Clinical and radiological
outcomes were investigated retrospectively. Primary expectation
for surgery was questioned and fulfillment of expectation was as-
sessed by 5-­point ordinal scale. Relationship of overall surgical sat-
isfaction with fulfillment of expectation, radiological improvements,
American Orthopedic Foot and Ankle (AOFAS) forefoot score, and
subjective Foot function index was assessed. Statistical analysis was
done using SPSS and Spearman's rho rank correlation test.
Results: Mean follow-­up was 38 months (range; 24~54). For preop-
erative expectations, improvement in pain, shoe wearable, and gross
appearance were considered in 30 (75%) patients, 7 (17.5%) and 3
(7.5%), respectively. Fulfillment of expectations for great toe /lesser
toes and overall postoperative satisfaction were showed in Table 1.
AOFAS hallux and lesser toe score were 69.7 
± 11.71 and
70.7 ± 12.26, respectively. Foot function index was 20.5 ± 12.07 at
final follow-­up. Preoperative and postoperative radiographic angular
parameters were shown in Table 2.

Correlation analysis showed that significant factors, associated with
overall satisfaction, were fulfillment of expectation on the great toe
(Spearman's rho = 0.842, P < 0.001), that of lesser toes, and AOFAS
score. Radiological severity and improvement in radiographic an-
gular parameters were not significantly associated with patient's
satisfaction.
Conclusions: Expectation from surgery on rheumatoid forefoot
deformity was diverse. Prime one was improvement in pain.
Fulfillment of patients’ particular expectations affected signifi-
cantly on postoperative satisfaction. Individualized counselling
of patients’ expectations and corresponding fulfillment should be
requisite when joint sacrificing forefoot surgery recommended in
RA patients.
2-­011 | Exploring the use and uptake of
non-­pharmacological methods for chronic
pain management: from a patient and clinician
perspective
B. Sutu; E. O'Brien; P. Morley
Melbourne Health
Background/purpose: Chronic pain is a high-­prevalence, multifac-
torial biopsychosocial issue that is difficult to manage and places a
significant strain on an already resource-­scarce healthcare system.
Non-­pharmacological treatments (NPTs), including Music Therapy,
are important adjuncts to standard pain medications. We conducted
an observational audit of knowledge and attitudes towards NPT in
chronic pain management.
Objectives:
• To explore clinician and patients’ knowledge on NPTs
• To explore how knowledge would impact upon the use of NPTs in
|
      193
the treatment of chronic pain.
Methods:
• Patients and their treating clinicians were observed in the outpa-
tient setting.
• Observations were made about frequency, duration and content
of discussion regarding NPT.
• Patients and clinicians were interviewed separately to understand
their knowledge and attitudes towards NPT.
Thematic and inductive analyses of the interviews were performed
to identify core themes and results.
Results: Observations were obtained from 10 patients and 10
clinicians.
Observation:
• Conversations about NPTs were predominantly driven by pa-
tients, but did not occur in all consultations.
• Not all consultations offered patients NPT options.
Patient interviews:
• Patients reported barriers but were open to using NPTs in chronic
pain management.
• Patients expressed a desire for collaboration with health profes-
sionals for management of chronic pain.
Clinician interviews:
• Clinicians believe that NPTs should always be used for chronic
pain, but didn't always prescribe them.
• Clinicians were exposed to minimal formal education about use of
NPTs in chronic pain management.
Conclusions: This study highlighted an apparent disempowerment
of patients and clinicians as a barrier to optimising management of
chronic pain. When explored further, we found that a lack of clini-
cian education and patient hesitancy contributed to this sense of
disempowerment. One suggestion includes addressing clinician
education as the key to breaking this sense of disempowerment: it
should happen frequently and at all stages of a clinician's profes-
sional development.
2-­074 | Evaluation of hip joint destruction in
rheumatoid arthritis during different period
K. Suzuki1; Y. Nishio1; S. Nakamura1; N. Katayama1; A.
Sagawa2; H. Ohura1
1
Hokkaido Orthopedic Memorial Hospital; 2Sagawa Rheumatoid Clinic
Introduction: Treatment for rheumatoid arthritis has changed in
these 20 years. This resulted in the decrease of the number of or-
thopaedic related surgery. This trend is extreme in large joint such
as hip joint. We also feel that operative procedures have changed.
We analyzed the destructive pattern of the hip joint at the time of
surgery in different periods.
Materials and methods: Two groups were compared in terms of
destruction pattern. Early Group (EG) consists of cases operated
before 2002, and the late group (LG) consisted of cases operated
after 2011. 28 cases with 33 joints belonged to EG and 17 cases
194      |
with 21joints belonged to LG. Joint destruction was evaluated based
on the Lowe classification. This evaluates the existence of joint nar-
rowing, protrusion, femoral head collapse, joint ankylosis, and acute
destruction.
Results: In 33 joints of EG, joint narrowing was observed in 28 joints,
protrusion in 5 joints, femoral head collapse in 11 joints, and acute
destruction in 7 joints. in 21 joints of LG, joint narrowing was ob-
served in 20 joints, protrusion in 3 joints, femoral head collapse in 3
joints, and acute destruction in 1 joint. Joint ankylosis was not ob-
served in either group.
Discussions: Treatment option for the rheumatoid arthritis for LG
has included Methotrexate and Biologics. On the other hand, EG
were treated without these agents. This indicates that joint de-
struction pattern such as the collapse and acute destruction has de-
creased with tight control of the synovitis which maybe changed the
bone and joint quality. Pattern difference may have changed not only
the number of operations, but surgical procedures needed.
Conclusions: Different destruction pattern of the hip joint in 2 dif-
ferent periods was noted along with the different treatment option
for RA.
<6); (iii) serum MMP-­3 and CRP were measured on the same day
before starting treatment with corticosteroids or anti-­
rheumatic
drugs; (iv) the final diagnosis was confirmed as PMR or RA by the
agreement between two certified rheumatologists who reviewed
the clinical data during the one-­year follow-­up. MMP-­3/CRP ratio
was compared between the two diseases.
Result: Eight PMR-­mimicking EORA patients and 29 PMR patients
who met inclusion criteria were found and analyzed. MMP-­3/CRP
ratio was significantly higher in PMR-­mimicking EORA than in PMR
(126 × 10 −4 [127 × 10−4] vs 29.2 × 10−4 [33.7 × 10−4], median [IQR],
P = 0.0021). ROC analysis for MMP3/CRP ratio demonstrated AUC
of 0.845 (95% CI: 0.641–1).
Conclusion: MMP-­
3/CRP ratio may be useful for distinguishing
PMR-­mimicking EORA from true PMR even when the classification
criteria are not met.

1-­031 | The ratio of serum MMP-­3 to CRP is

useful for distinguishing PMR-­mimicking EORA
from true PMR at the onset
T. Suzuki1; Y. Seri1; A. Suzuki2
1
Japanese Red Cross Medical Center; 2Mitsui Memorial Hospital

Background: We previously reported the differences in synovial

and extra-­synovial shoulder lesions between polymyalgia rheumat-
ica (PMR) and PMR-­mimicking elderly-­onset rheumatoid arthritis
(EORA) at the onset by semiquantitatively analyzing musculoskel-
etal ultrasound findings. in this previous study, we demonstrated
that PMR patients dominantly present extra-­synovial soft tissues
inflammation, while PMR-­mimicking EORA patients dominantly pre-
sent proliferative synovitis in the joint, bursa and tenosynovium. It
was also suggested that the ratio of serum matrix metalloproteinase-
­3 (MMP-­3) to serum CRP (MMP-­3/CRP ratio) could represent the
proportion of synovial inflammation to whole (synovial and extra-­
synovial) inflammation.
Purpose: To determine the usefulness of MMP3/CRP ratio in distin-
guishing PMR-­mimicking EORA from true PMR.
Methods: the medical records of patients who visited Mitsui
Memorial Hospital between 2010 and 2013 or Japanese Red Cross
Medical Center between 2012 and 2017 for examination of PMR-­
like symptoms were retrospectively reviewed to identify patients
who fulfilled the following inclusion criteria: (i) EULAR/ACR 2012
classification criteria for PMR were fulfilled (Score ≥4); (ii) ACR/
EULAR 2010 classification criteria for RA were not fulfilled (Score
 |
      195

1-­032 | Prevalence of antiphospholipid Table 1 Characteristics of patients tested for antiphospholipid

antibodies
antibodies in women with early onset
preeclampsia in a tertiary centre Test results, n (%)

A. Sweeney1; K. Poulsen2,3; S. Katikireddi2 Negative* Positive* Overall

1 2 3 Characteristic (N = 67) (N = 4) (N = 71)
Gold Coast University Hospital; The Prince Charles Hospital; Royal Brisbane
and Women's Hospital Pre-­eclampsia <36 weeks
 Moderate 1 (1) 0 (0) 1 (1)
Background/purpose: Preeclampsia (PEC) is a multisystem disor-  Severe 29 (43) 1 (25) 30 (42)
der triggered by a failure to develop adequate placental blood flow  PEC with cHTN 11 (16) 0 (0) 11 (15)
early on in pregnancy. If untreated it is associated with increased
 Unspecified 26 (39) 3 (75) 29 (41)
maternofetal morbidity and mortality. The link between antiphos-
Gravida
pholipid syndrome (APLS) and PEC is well documented, however
 1 29 (43) 3 (75) 32 (45)
the relationship between antiphospholipid antibodies (APL) and
 2 10 (15) 0 (0) 10 (14)
early PEC is controversial with many studies hampered by difficul-
 3 11 (16) 0 (0) 11 (15)
ties in diagnostic guidelines and lack of standardised titres for de-
tection of APL's.  4 4 (6) 0 (0) 4 (6)

Objectives: To assess whether APL's are associated with early PEC  5+ 13 (19) 1 (25) 14 (20)

in pregnant women. Parity

Methods: Cross-­sectional, retrospective study analysed 9768 re-  0 45 (67) 3 (75) 48 (68)
cords of women delivering between 1st June 2016 and 30th June  1 9 (13) 0 (0) 9 (13)
2018. Laboratory values per Sapporo criteria were used. The sta-  2 8 (12) 0 (0) 8 (11)
tistical program R was used to assess the prevalence of APL's in  3 4 (6) 0 (0) 5 (7)
women who were diagnosed with PEC at <36 weeks’ gestation.  4 0 (0) 0 (0) 0 (0)
Maternofetal outcomes were noted where pre-­eclampsia was diag-
 5 1 (1) 1 (25) 1 (1)
nosed at ≤36 weeks (n = 140).
Hypertension
Results: Of 9768 records, 140 (1.43%) patients were diagnosed
 Essential hypertension 9 (13) 0 (0) 9 (13)
with PEC at □ 36  weeks’ gestation including mild, moderate, se-
 Non-­Renal Secondary 1 (1) 0 (0) 1 (1)
vere, unspecified and PEC superimposed on chronic hypertension
Pre-­existing diabetes mellitus
(PEC cHTN). of these only 71 (51%) were tested for at least one of
the three antiphospholipid antibodies of which four (6%) had a posi-  No 61 (91) 4 (100) 65 (92)

tive result. Categorical characteristics for the overall tested group,  Yes (Type I or II) 6 (9) 0 (0) 6 (8)
as well as separated by negative and positive outcomes are listed Gestational diabetes
in Table 1. Regarding lupus anticoagulant (LAC), 73 were not tested  No 58 (87) 3 (75) 61 (86)
(NT) for APL's (52.14%), 65 were negative (46.43%) and 2 positive  Yes 9 (13) 1 (25) 10 (14)
(1.43%). Smoking
Regarding anticardiolipin antibody (ACA), 70 were NT (50%), 67  No 43 (64) 4 (100) 47 (66)
negative (47.86%), 3 positive (2.14%) including 1 case of high titre
 Yes 18 (27) 0 (0) 18 (25)
(>139 CU). of anti-­β2 glycoprotein I (β2GPI), 76 were NT (54.29%),
 Unknown 6 (9) 0 (0) 6 (8)
63 negative (45%), 1 positive (0.71%). For severe PEC (n = 38), 10
Past pregnancy conditions**
(26.32%) were NT for LAC and anti-­β2GPI each, 8 (21.05%) were
 Condition recorded 44 (66) 3 (75) 47 (66)
NT for ACA.
 No condition recorded 23 (34) 1 (25) 24 (34)
Conclusion: Four of 71 patients (6%) with early preeclampsia had
at least one positive APL (meeting the revised Sapporo classifica- Mode of delivery

tion laboratory criteria) which could suggest a possible association  Classical C-­section 14 (21) 0 (0) 14 (20)

between APLs and PEC. Statistical analysis is therefore limited by  LUSCS 47 (70) 4 (100) 51 (72)
the small number of positive subjects and further studies are re-  Non-­rotation forceps 1 (1) 0 (0) 1 (1)
quired. of severe PEC groups, 22–26% were not tested for APL's  Spontaneous vaginal 3 (4) 0 (0) 3 (4)
despite best practice guidelines, which may underestimate the  Vaginal assisted breech 1 (1) 0 (0) 1 (1)
number of patients with underlying positive APL's. The number of  Vaginal spontaneous 1(1) 0 (0) 1 (1)
patients with positive APL's were too low to compare maternofetal breech
outcomes.
 |
196      

Table 1 Continued score (OR, 1.311; 95% CI, 1.045–1.645), and stronger beliefs about
Test results, n (%) treatment effectiveness (OR, 1.298; 95% CI, 1.082–1.559) were as-
sociated with adherence.
Negative* Positive* Overall
Characteristic (N = 67) (N = 4) (N = 71) Conclusion: In this study, 14.9% of patients with RA were not ad-
herent to their DMARDs. Extra-­articular involvement was associ-
Outcome of delivery
ated with DMARDs adherence. Cognitive impairment and less belief
 Alive on discharge 57 (85) 4 (100) 61 (86)
in treatment effectiveness were identified as modifiable factors of
 Neonatal death 2 (3) 0 (0) 2 (3)
nonadherence. These factors may be strategically targeted to im-
 Post-­neonatal death 1 (1) 0 (0) 1 (1) prove medication adherence rates.
 Remaining an inpatient 3 (4) 0 (0) 3 (4) Keywords: Adherence, Disease modifying anti-­
rheumatic drugs,
 Stillborn 4 (6) 0 (0) 4 (6) Rheumatoid arthritis
HELLP syndrome
 Yes 18 (27) 0 (0) 18 (25)
*Positive: Where participant was positive on at least one of the tests 3-­034 | Investigation of pathology of
for LAC, ACLA, B2GP. Negative: Subject did not have any positive
neuroimmune disorder syndrome seen after HPV
results and was tested for at least one of LAC, ACLA, B2GP.
vaccination
**List of complications provided in Appendix A, available at request.
O. Takahiro1; K. Yoshiyuki2; Y. Shumpei3; N. Ikuro 4; N.
Toshihiro5; K. Nishioka6
1
Department of Rheumatology,Ise Red Cross Hospital; 2Stroke Center,
3-­083 | Disease modifying anti-­rheumatic Department of Neurology, University Hospital Mizonokuchi, Teikyo University
drugs adherence in Thai rheumatoid arthritis Graduate School of Medical Sciences; 3Therapeutic Center of Pediatric
Intractable Diseases,Fuji Toranomon Orthopedics Hospital; 4Japan Medical
patients: the importance of cognitive function Research Foundation; 5Department of Locomotor Science, Institute of Medical
and belief about medication Science, Tokyo Medical University; 6National Graduate Institute for Policy
Studies
N. Taibanguay; C. S. Chaiamnuay; P. Asavatanabodee; P.
Narongroeknawin
Background: The neuroimmune abnormality syndrome seen after
Phramongkutklao Hospital
HPV vaccination presents various symptoms and it can be mis-
taken for physical function expression disorder because there is no
Objective: Medication adherence is essential for the control of
obvious abnormality in general examination. However, HANS is an
symptoms and progression of rheumatoid arthritis (RA). This cross-­
immune-­mediated disease because symptoms improve with immu-
sectional study aimed to explore Thai RA patients’ adherence rates
noadsorption therapy.
and associated factors for nonadherence.
Purpose: To clarify the pathology of HANS.
Methods: A total of 175 RA patients aged 18 years old or older
Subjects and methods: The clinical symptoms of 32 HANS patients
were recruited from the Thai Army Rheumatoid Arthritis Cohort.
visiting our hospital were classified into four domains, motor system
All patient was asked to complete a set of standardized ques-
disorder, sensory system disorder, autonomic nervous system dis-
tionnaires including EuroQoL-­5D (EQ-­5D), hospital anxiety and
order, cognitive affective disorder, and were seen after vaccination
depression scale (HADS), brief illness perception questionnaire (B-­
We classified the symptoms in chronological order. We also investi-
IPQ), and Thai mental status examination (TMSE). Disease modify-
gated the presence or absence of allergy and anti-­nuclear antibody
ing anti-­r heumatic drugs (DMARDs) adherence rate was measured
positivity
by pill count. Those with adherence rates less than 80% were con-
Results: The symptoms seen within 1 month after vaccination are
sidered to be nonadherent. Disease activity score 28 (DAS28) was
many sensory disorders, many symptoms of autonomic nervous sys-
assessed by blinded rheumatologists. Univariate and multivari-
tem and endocrine system occurred from 1 to 6 months, and cogni-
ate analyses were performed to identify factors associated with
tive / emotional within 6 months to 1 year there were many system
nonadherence.
problems. The outbreak peak, where these symptoms became strati-
Results: Most of the patients were female (85.7%) with mean
fied and the social life became difficult, was often seen two or three
age ± SD of 56.9 ± 11.9 years. Mean disease duration ± SD was
years after the first vaccination. In addition, 21 patients (66%) had
7.9 ± 7.5 years and mean DAS28 ± SD was 3.2 ± 0.9. Majority of the
a history of allergy before vaccination and 12 cases (38%) showed
patients (85.1%) adhered to their medication. in univariate analysis,
anti-­nuclear antibody
employment status, level of income, extra-­articular involvement,
Conclusion: Symptoms of HANS are symptoms centered on the hy-
cognitive function, and beliefs in treatment effectiveness differed
pothalamus, symptoms stratified with the passage of time, although
significantly in adherent and nonadherent patients. in multivariate
social life became difficult in 2-­3 years after the first inoculation, it
analysis, presence of extra-­articular involvement (odds ratio [OR],
was the most frequent. There were also many cases that had allergy
2.589; 95% confidence interval [CI], 1.013–6.017), greater TMSE
 |
      197

before the inoculation, and it was thought that some form of immune
system abnormality is involved in the pathology of HANS.
3-­0 07 | Histopathological changes of synovial
tissue in rheumatoid arthritis patients treated
with TNF inhibitors
Y. Takashima1; K. Fukuda1; S. Hayashi1; T. Kamenaga1; R.
Kuroda1; K. Funahashi2; T. Matsubara2
1
Department of Orthopaedic Surgery, Kobe University Graduate School of
Medicine; 2Matsubara Mayflower Hospital
Background: Rheumatoid arthritis (RA) is a chronic inflammatory dis-
ease characterized by hyperplasia of synovial tissues, which results in
destruction of joint structures. Tumor necrosis factor (TNF)-­α is one
of pro-­inflammatory cytokines that play an important role in patho-
genesis of RA synovitis, and TNF inhibitors have brought revolution-
ary impacts on RA treatment. TNF inhibitors have reported to induce
apoptosis in TNF-­producing cells. A previous study reported that
the characteristic changes in the synovium from patients with RA
of multilayered synovial cells were found in RA patients with TNF
inhibitors. in the sections with TUNEL stain, apoptosis of lining cells
around the discoid fibrosis was detected in synovium from RA pa-
tients treated with TNF inhibitors.
Conclusions: In this study, we demonstrated the apoptosis of lining
cells around the discoid fibrosis. These results indicated that TNF
inhibitors might induce apoptosis of synovial cells (especially lining
cells) leading to suppress RA synovitis.
1-­098 | Efficacy and safety of tofacitinib with
and without methotrexate and adalimumab with
methotrexate in rheumatoid arthritis by baseline
methotrexate dose
T. Takeuchi1; Y. Tanaka2; H. Yamanaka3; K. Yamaoka1;
N. Sugiyama4; S. Toyoizumi4; N. Iikuni5; T. Hirose 4; Y.
Morishima4; N. Yoshii4; R. Fleischmann6
1
Keio University; 2University of Occupational and Environmental Health; 3Tokyo
Women's Medical University; 4Pfizer Japan Inc; 5Pfizer Inc; 6Metroplex Clinical
Research Center and University of Texas Southwestern Medical Center

who treated with TNF inhibitors was discoid fibrosis in the sublining
layers. However, the cause of discoid fibrosis has not been revealed
in detail. in this study, we demonstrated the histological changes
around discoid fibrosis in RA synovium treated with TNF inhibitors.
Methods: Synovial tissues were obtained from 20 patients with RA
during joint surgeries, including 3 patients treated with TNF inhibi-
tors (1 patient with golimumab, 2 patients with etanercept). The sec-
tions were stained by hematoxylin and eosin (HE), or TdT-­mediated
dUTP nick end labeling (TUNEL).
Results: In the sections stained with HE, the formation of discoid fi-
brosis and the other characteristic changes including hydropic degen-
eration, vacuolation, sclerosis of small vasculature, and improvement
Background/purpose: Tofacitinib is an oral Janus kinase inhibitor for
the treatment of rheumatoid arthritis (RA). ORAL Strategy, a global
Phase 3b/4 study (NCT02187055), compared the efficacy and safety
of tofacitinib 5 mg twice daily (BID) monotherapy, tofacitinib 5 mg
BID + methotrexate (MTX), and adalimumab 40 mg once every
2 weeks + MTX in patients with RA and an inadequate response to
MTX (MTX-­IR).1 This post hoc analysis assessed efficacy and safety
in ORAL Strategy stratified by baseline MTX dose.
Methods: Data were stratified by mean baseline MTX dose (be-
fore randomization): low MTX (≤15 mg/wk; N = 720) and high MTX
(>15 mg/wk; N = 426). Efficacy outcomes at Month 6 included

Table 1: Efficacy and safety outcomes in patients with RA in ORAL Strategy stratified by baseline MTX dose

Tofacitinib 5 mg BID monotherapy Tofacitinib 5 mg BID + MTX Adalimumab 40 mg Q2W + MTX

Low MTX High MTX Low MTX High MTX Low MTX High MTX
(≤15 mg/wk) (>15 mg/wk) (≤15 mg/wk) (>15 mg/wk) (≤15 mg/wk) (>15 mg/wk)
(N = 242) (N = 142) (N = 236) (N = 140) (N = 242) (N = 144)

Efficacy outcomes
 ACR20, n (%) 158 (65) 91 (64) 175 (74) 100 (71) 175 (72) 99 (69)
 ACR50, n (%) 91 (38) 56 (39) 115 (49) 58 (41) 107 (44) 62 (43)
 ACR70, n (%) 46 (19) 24 (17) 59 (25) 35 (25) 48 (20) 32 (22)
 DAS28-­4(CRP) <2.6, n (%) 50 (21) 31 (22) 70 (30) 45 (32) 60 (25) 48 (33)
 DAS28-­4(ESR) <2.6, n (%) 21 (9) 19 (13) 25 (11) 20 (14) 23 (10) 25 (17)
Safety outcomes
 AEs, n (%) 135 (56) 91 (64) 139 (59) 92 (66) 147 (61) 106 (74)
 Serious AEs, n (%) 23 (10) 12 (9) 20 (9) 7 (5) 11 (5) 13 (9)

ACR, American College of Rheumatology; AE, adverse event; BID, twice daily; CRP, C-­reactive protein; DAS, Disease Activity Score; ESR,
erythrocyte sedimentation rate; MTX, methotrexate; Q2W, every other week; RA, rheumatoid arthritis.
Patients were stratified by mean MTX dose as low (≤15 mg/wk) or high (>15 mg/wk) before randomization to active treatment.
 |
198      

American College of Rheumatology (ACR)20, ACR50 (primary Table 1. Complete Blood Count results showing Leukocytosis with
endpoint), and ACR70 responses, and rates of remission based on Eosinophilia
Disease Activity Score in 28 joints, C-­reactive protein and eryth-
rocyte sedimentation rate < 2.6. Safety was reported over the full
study duration.
Results: Across treatment arms, the mean baseline body mass index
was 27.5–27.8 and 28.0–29.3 kg/m2 in the low and high baseline
MTX groups, respectively. A summary of efficacy and safety out-
comes is provided in the Table. Efficacy outcomes within treatment
groups were generally similar at Month 6 regardless of baseline
MTX dose. Rates of adverse events (AEs) were numerically higher in
patients who received high vs low baseline MTX; however, the fre-
quency of serious AEs was similar regardless of baseline MTX dose.
Conclusion: In ORAL Strategy, efficacy within each treatment group
was generally similar regardless of baseline MTX dose. Treatment
response was likely due to the active medication as patients were
MTX-­IR. Numerically fewer AEs were reported in the low vs the high
baseline MTX groups for all treatment arms; frequency of serious
AEs was similar between groups.
Reference: 1. Fleischmann R et al. Lancet 2017; 390: 457–468.

3-­144 | Successful treatment with Table 2. Complete Blood Count showing decreasing trend of eosino-
cyclophosphamide in a patient with eosinophilic phil count post pulse steroid and cyclophosphamide therapy
granulomatosis with polyangiitis: a case report
M. B. Tanagon; M. Aquino-Villamin
De Los Santos Medical Center

Introduction: Eosinophilic Granulomatosis with Polyangiitis

(Churg-­Strauss), is a rare vasculitis of small and medium sized ves-
sels. The worldwide incidence is ~2.5 cases per 100,000 adults
per year. Incidence is unknown in the Philippines due to its few
publications. EGPA is characterized by Asthma, Peripheral blood
eosinophilia and Peripheral neuropathy. This report deals with
a rare multisystemic disease with active vasculitis that is organ
and life threatening which yielded a good clinical response to
glucocorticoid-­cyclophosphamide-­therapy.
Case presentation: A 67-­year-­old male presented with lumbar and
bilateral hip pain, weakness and paresthesia of lower extremities
for three months, not relieved by medications and therapeutic ex-
ercises. Neurologic examination showed foot drop, MMT of 0/5 on
bilateral tibialis anterior. He also has poorly controlled Bronchial
Asthma and intermittent epigastric pain. Complete blood counts re-
vealed leukocytosis and marked eosinophilia; bone marrow biopsy
showed hypercellularity with eosinophilic hyperplasia, no significant
dysplasia. Nerve conduction studies revealed severe diffuse, slightly
asymmetric, more of axonal sensory polyneuropathy, affecting lower
extremities and distal segments. Gastroscopy with biopsy showed
Eosinophilic Duodenitis. Chest CT Scan exhibited bilateral apical
and right middle lobe infiltrates, with mediastinal and hilar lymphad-
enopathies. ANCA panel was negative. With tissue infiltration by
Figure 1. Gastroscopy with Biopsy showing Eosinophilic Duodenitis
 |
      199

eosinophils, poorly controlled asthma and mononeuritis multiplex,
diagnosis of EGPA was made. With a five factor score of 2, treatment
was initiated with Methylprednisolone and Cyclophosphamide. Post
treatment showed decreasing eosinophils, symptomatic improve-
ment of the neuropathic pain, paresthesia and weakness.
Discussion: EGPA is a rare disease. This case illustrates prompt and
accurate diagnosis of EGPA, fulfilling 5 out of 6 of the ACR criteria.
Glucocorticoids are the cornerstone of therapy. Patients with life
and organ threatening disease manifestations should be prescribed
with a remission—induction regimen combining glucocorticoids and
another immunosuppressant. Use of Cyclophosphamide provides
prompt and early control of the underlying disease and significant
prolongation of survival.
disagreeing with avoiding TNFi prescriptions until after pregnancy
differed widely between subgroups (JPN-­OR: 13%−AUS-­RH: 80%,
Table 1). Safety data during pregnancy (reported by AUS-­OB: 97%
vs others: 75−82%), and for the child 5 years post-­delivery (reported
by 60−70% of AUS-­RH, AUS-­OB, JPN-­OB, JPN-­OR) would increase
clinician comfort with using TNFis in WoCBA.
Conclusions: WoCBA management and TNFi use varied between
specialties and countries. Disease control during pregnancy was
considered important, however, comfort levels with prescribing
TNFis varied across pre-­pregnancy, pregnancy, and post-­partum pe-
riods. There is need for improved clinician information and education
on safe use of TNFis in WoCBA.

3-­074 | TNFi treatments for women with

chronic rheumatic diseases: a comparison
of attitudes and perceptions of clinicians in
Australia and Japan
Y. Tanaka1; C. Barrett2,3; Y. Hirano 4; K. Ikeda5; K. Paizis6,7,8;
C. Saadoun9; A. Sameshima10 Figure 1: Clinician Level of Comfort with TNFi Treatment in WoCBA
1
University of Occupational and Environmental Health; 2Redcliffe Hospital; with CRDs
3
Faculty of Medicine, University of Queensland; 4Department of Rheumatology,
Toyohashi Municipal Hospital; 5Department of Allergy and Clinical Immunology, Question: How comfortable are you with your patients who fall into
Chiba University Hospital; 6Department of Nephrology, Austin Health; 7Mercy the following groups being prescribed a TNFi treatment: 1) All fe-
Hospital for Women; 8Western Health Sunshine; 9UCB Pharma; 10Department
male patients between the age of 18–45 years; 2) Female patients
of Obstetrics and Gynecology, University of Toyama
who may become pregnant within the next few years; 3) Female
patients who are actively trying to become pregnant; 4) Female pa-
Background/purpose: Women may choose to pursue pregnancy fol-
tients who are pregnant; 5) Female patients who are breast feeding.
lowing diagnosis of chronic rheumatic disease (CRD); adequate dis-
The number of clinician respondents were as follows: AUS-­RH: 30,
ease control before, during and after pregnancy is crucial for optimal
AUS-­OB: 30; JPN-­RH: 103, JPN-­OB: 44, JPN-­OR: 77
maternal and foetal health. Tumour necrosis factor inhibitors (TNFis)
Abbreviations: AUS: Australia; CRD: chronic rheumatic disease; JPN:
are effective treatment options; however, there are limited data on
Japan; OB: obstetrician; OR: orthopaedic surgeon; RH: rheumatolo-
how clinicians manage women with CRDs.
gist; TNFi: tumour necrosis factor inhibitor; WoCBA: women of child
Objectives: To understand clinicians’ perceptions and attitudes to-
bearing age
wards treating rheumatoid arthritis/psoriatic arthritis/ankylosing
spondylitis in women of child bearing age (WoCBA) (18–45 years) Table 1: Clinician Level of Agreement to Discontinuing/Avoiding TNFi
with TNFis in pre-­pregnancy, pregnancy and post-­partum periods. Treatment During Pregnancy and Breastfeeding
Methods: Online surveys were completed in September 2018
through Confirmit platform by Australian (AUS) and Japanese (JPN)
rheumatologists (RH), obstetricians (OB) and orthopaedic surgeons
(OR) who medically manage CRDs.
Results: Clinician subgroups completing the survey were: AUS-­RH
(n = 30), AUS-­OB (n = 30), JPN-­RH (n = 103), JPN-­OB (n = 44),
JPN-­
OR (n = 77). JPN-­
OR managed the fewest WoCBA patients
(JPN-­OR: 28% vs others: 41−80%), and the fewest WoCBA patients
with TNFi prescription (JPN-­OR: 19% vs others: 26−34%). More
1
than 60% of RH in both countries and AUS-­OB considered keep- Response to the statement: Once a woman becomes pregnant she
ing disease controlled during pregnancy their primary goal. AUS-­RH should discontinue TNFi treatment
2
were more comfortable than others in prescribing TNFis in WoCBA; Response to the statement: Women who are breastfeeding should
JPN subgroups had low comfort levels; comfort levels consistently not be on a TNFi agent
3
declined across subgroups with onset of family planning/preg- Response to the statement: Female patients aged 18−45 years
nancy (Figure 1). The proportion of clinicians strongly/somewhat should avoid TNFi therapies until after pregnancy
 |
200      
The darkest shade of colour within each stage represents the larg-
est proportion of clinicians who have a specific attitude towards the
indicated statement in the footnotes, whereas the lightest shade
represents the smallest proportion of clinicians who have a specific
attitude within the same stage
Abbreviations: OB: obstetrician; OR: orthopaedic surgeon; RH:
rheumatologist; TNFi: tumour necrosis factor inhibitor
1-­099 | Upadacitinib as monotherapy: phase
3 randomized controlled double-­blind study in
patients with active rheumatoid arthritis and
inadequate response to methotrexate
J. S. Smolen1; S. Cohen2; P. Emery3; W. Rigby4; Y. Tanaka5;
Y. Zhang6; A. Friedman6; A. A. Othman6; H. S. Camp6; A. L.
Pangan6
1
Medical Univ of Vienna; 2Metroplex Clinical Research Center; 3Leeds Inst of
Rheumatic & Musculoskeletal Medicine, Leeds NIHR BRC; 4Dartmouth College;
5 showed significant improvements in RA signs/ symptoms vs continu-
Univ of Occupational and Environmental Health; 6AbbVie
Background/purpose: Upadacitinib (UPA), a JAK1-­
selective in-
hibitorshowed efficacy in rheumatoid arthritis (RA) patients with
inadequate response to csDMARDs or bDMARDs on background
csDMARD(s). We evaluate safety/efficacy of switching to UPA 15 or
30 mg monotherapy vs continuing methotrexate in MTX-­IR patients.
Methods: Patients with active RA on stable MTX doses were ran-
domized 1:1:1 to receive once-­daily (QD) UPA 15 or 30 mg mono-
therapy or continue MTX (cMTX) at prior dose but as a blinded
study drug. at baseline all patients discontinued prior MTX without
washout. Primary endpoints at Week 14 were ACR20, and DAS28-­
CRP ≤ 3.2 (NRI).
Results: All 648 randomized patients received study drug; 598
(92.3%) completed 14 weeks. at Wk 14, significantly more patients
receiving UPA monotherapy vs cMTX achieved ACR20, and DAS28-­
CRP ≤3.2 (Table). All key secondary endpoints showed UPA 15 and
UPA 30 monotherapy to be superior to cMTX (Table). Significantly
more patients achieved CDAI ≤10 on UPA vs cMTX. Adverse events
(AEs) were reported at similar frequencies across arms. Serious
AEs were higher in UPA 15 but similar between cMTX and UPA 30
(Table). More infections were reported in cMTX and UPA 30 vs UPA
15: One serious infection each was reported in UPA 15 and cMTX,
and none in UPA 30. Herpes zoster was more frequent in UPA 30 vs
UPA 15 and cMTXmarms. Three malignancies, 3 adjudicated MACE,
and 1 adjudicated pulmonary embolism and 1 death was reported.
No TB, renal dysfunction or GI perforation was reported. Laboratory
abnormalities were consistent with prior UPA RA studies.
Conclusion: Switching to UPA as monotherapy at 15 and 30 mg QD
ing MTX. Safety observations were similar to prior UPA studies.
2-­012 | Defining the impact of topical NSAIDs
on renal function, a survey of Australasian renal
and rheumatology specialists
M. Terrill1; M. Soden1; V. Srivastava2
1
Townsville Hospital Rheumatology Department; 2Townsville Hospital Renal
Department
Background: Topical NSAIDs are a valuable analgesic for musculo-
skeletal pain, though prescribing practices and risk of causing im-
paired renal function are not well known.
Objectives: This survey investigated physician reported patient use,
prescribing practices and adverse renal events of topical NSAIDs; in
patients managed by rheumatologists and renal physicians, within
Australasia.
Method: A survey was sent to members of the Australian
Rheumatology Association and the Australian and New Zealand
Society of Nephrology.
Results: 60 physicians responded, 55% (n: 33) were nephrologists;
45% (n: 27) rheumatologists.
Nearly all (N: 56, 93.3%) had managed at least one patient using
topical NSAIDs, including those with an eGFR <45 mL/min (N: 55,
91.7%). Concern was expressed patients may use topical NSAIDs
without the physician's knowledge.
The majority (N: 40, 66.6%) have prescribed (or recommended) a
topical NSAID, slightly less in patients with a reduced eGFR <45 mL/
min (N: 35, 58.3%). Participants would advise topical NSAIDs for os-
teoarthritis and musculoskeletal pain, though be mindful to moni-
tor the renal function and blood pressure. A variance in comments
was noted in use with Chronic Kidney Disease (CKD), ranging from

avoidance in those with an eGFR <30 mL/min, to judicious use in all
patients.
Most respondents (N:55, 91.7%) had not encountered an Acute
Kidney Injury (AKI) suspected from topical NSAID use. of the 5
that did, 3 were thought to be an adverse renovascular side ef-
fect and 2 were uncertain. All patients had had an eGFR <45 mL/
min, all had recovery of their renal function with NSAID cessation
(Table 1).
Conclusion: This survey suggests patients commonly use topi-
cal NSAIDs. Most Australasian Nephrology and Rheumatology
respondents recommending their use in osteoarthritis and musculo-
skeletal pain, though caution considered in patients with CKD. While
an AKI is uncommon with topical NSAID use; it may occur, especially
in those with CKD.
3-­115 | Oxidative stress in systemic lupus
erythematosus is associated with high disease
activity and damage: a single centre study from
India
S. Shruthi; M. Thabah; B. Zachariah; V. S. Negi
Jawaharlal Institute of Postgraduate Medical Education and Research
Objectives: To explore the association of oxidative stress namely
serum malondialdehyde (MDA), oxidised LDL (OxLDL), 8-­hydroxy-­
2′-­deoxyguanosine(8-­OHdG), and total anti-­oxidant status with SLE
disease activity and damage.
Methods: Eighty SLE patients satisfying the Systemic Lupus
International Collaborating Clinics/American College
Rheumatology (SLICC/ACR) 2012 classification criteria and 80
healthy controls were studied. Exclusion criteria for SLE patients
were clinically obvious infections, renal insufficiency, other connec-
tive tissue diseases, drug induced lupus, smoking, alcohol consump-
tion. Disease activity was measured by SLE disease activity index
|
      201
(SLEDAI), damage was quantified by SLICC-­
Damage Index (SDI).
Sera was tested for OxLDL, 8-­OHdG, and total antioxidant status
(TAS) by double-­antibody sandwich ELISA; MDA was measured by
Colorimetric assay. Oxidative stress markers were compared be-
tween group1-­ controls, group 2-­mildly active SLE (SLEDAI ≤ 5),
group 3-­moderate to highly active SLE (SLEDAI ≥ 6)
Results: Mean age was 30.88 ± 10 and 31.34 ± 10.13 years in SLE
and controls respectively. Median OxLDL was 2605.6, 2494.7,
2586.5 ng/L, P = 0.726; Median MDA was 0.50, 1.73, 2.91 μM,
P < 0.001; Median 8-­OHdG was 17.28, 18.53, 20.12 ng/mL, P = 0.05;
Median TAS was 23.77, 17.44, 12.12.02 units/mL, P < 0.001; in
groups 1, group 2, and group 3 respectively. MDA positively cor-
related with SLEDAI, r 0.738, P < 0.001; TAS negatively correlated
with SLEDAI, r −0.588, P < 0.001. There was moderate positive cor-
relation of OxLDL with SDI, r 0.226, P = 0.04; moderate positive cor-
relation of 8-­OHdG with SDI r 0.257, P = 0.02.
SLE patients with vasculitis, thrombocytopenia, neuropsychiatric
SLE (NPSLE) had significantly higher levels of MDA. TAS was signifi-
cantly lower in those with vasculitis and NPSLE.
Conclusion: Indian lupus patients have high levels of oxidative stress
which was associated with disease activity, disease damage, and
manifestations such as NPSLE, vasculitis, and thrombocytopenia.
3-­0 02 | Systemic lupus erythematosus
presenting with neuromyelitis optica spectrum
disorder
M. Thabah; D. Babu; P. Rengaswamy; K. Tamilarasu
Jawaharlal Institute of Postgraduate Medical Education and Research
Background: We present the case of a patient whose first manifes-
tation of SLE was neuromyelitis optica spectrum disorder (NMOSD).
Case: An 18-­year-­old girl presented with intermittent fever for
3 weeks, headache 2 weeks, vomiting and alteration in senso-
rium 1 day. On examination she was disoriented, neck stiffness
was present. Fundus was normal. CSF was clear, TLC 40 cells with
60% lymphocytes, protein was 80 mg/dL, glucose was normal.
Empirical anti-­TB medicines and dexamethasone 0.4 mg/kg/per
day was given. By day 5 she continued to be irritable. CSF Gene-­
Xpert was negative. Since she continued to have fever, irritability,
and hemogram showed an absolute lymphocyte count of 940/dL,
SLE was suspected. On day 9 she developed urinary incontinence
and flaccid quadriplegia, motor power of upper limbs was 2/5,
lower limbs was 0/5. MRI showed extensive hyperintense signals
of cervical, thoracic cord, and brainstem (figure-­1). Intravenous
methylprednisolone (MP) 750 mg/day for 5 days was given, fol-
of lowed by oral prednisolone 1 mg/kg/day. Meanwhile ANA was
3 + positive coarse speckled pattern, Sm++, Sm/RNP++. Serum
aquaporin-­4 (AQP4) IgG was positive, CSF oligoclonal bands were
negative. Serum complements were low. Even after 1 week of MP
she did not improve hence 5 cycles of plasma exchange was given
after which muscle power improved to 4-­/5 in upper limbs and
 |
202      
4 + /5 in lower limbs. At discharge she was able to walk with sup-
port. She is on maintenance treatment with prednisolone, azathio-
prine, and hydroxychloroquine.
Discussion and conclusion: NMO is an inflammatory CNS syn-
drome associated with serum AQP4-­IgG, longitudinally extensive
transverse myelitis and optic neuritis. NMOSD includes AQP4-­IgG
positive patients with limited forms of NMO (e.g. absence of optic
neuritis). NMOSD as a presentation of SLE is rare. The highlight in
this patient is good response to early initiation of plasma exchange. A
recent report show that rituximab is beneficial in refractory NMOSD.
Figure 1. Hyperintense signals (T2) of brainstem (thick arrow) and
cervical and thoracic cord (thin arrows) spanning > 3 spinal cord seg-
ment consistent with longitudinally extensive transverse myelitis
3-­116 | Ocular and oral manifestations among
patients from the Singapore Sjogren's syndrome
study
B. Thong; Z. W. Loh; J. Kam
Tan Tock Seng Hospital
Background/purpose: The American College of Rheumatology-­
European League of Associations for Rheumatology (ACR-­EULAR)
2016 classification criteria for Primary Sjogren's syndrome (pSS) is
based on a weighted sum of 5 items, where total score of ≥4 meet
the criteria for pSS with high sensitivity and specificity. Symptomatic
dry eyes, dry mouth and their complications may impact quality of
life and health outcomes among patients with pSS.
Methods: Among patients with Computerized Clinician Order Entry
(CCOE) diagnoses of pSS between 1993 and 2013, those who ful-
filled ACR-­EULAR 2016 classification criteria were retrospectively
analyzed for their demographic profile and types of ocular and oral
manifestations.
Results: There were 102 patients who fulfilled ACR-­EULAR 2016
classification criteria. Majority were female (94.1%) and Chinese
(89.2%). The mean ± SD age was 49.3 ± 11.8 years, disease dura-
tion 9.0 ± 4.6 years. The common ocular manifestations were kera-
toconjunctivitis sicca (99.0%), uveitis (3.9%), episcleritis/scleritis
(2.9%), blepharitis (2.0%) and dacryoadenitis (1.0%). The common
oral manifestations were xerostomia (96.1%), parotid gland enlarge-
ment (27.5%), submandibular gland enlargement (2.9%), periodontal
disease (2.0%) and gingivitis (1.0%). Prednisolone was used in 64.7%,
hydroxychloroquine (88.2%), methotrexate (7.9%) and azathioprine
(6.8%). Tear lubricants (79.4%), oral lubricants (49.0%) and oral pi-
locarpine (6.9%) were used for the relief of sicca symptoms. None
required punctual occlusion.
Discussion and conclusion: Ocular and oral manifestations of pSS
were mild. Oral complications e.g. recurrent dental caries may
have been under-­reported from lack of screening, surveillance, pa-
tient awareness, access to subsidized dental care. High-­risk post-­
menopausal females with xerostomia on bisphosphonates may be
at increased risk of osteonecrosis of the jaw, making screening even
more important.
3-­042 | 2015 ACR/EULAR gout classification
criteria: application in Vietnam
H. T. Tran1; H. N. Van1,2; B. P. Thi Thanh2
1
Rheumatology Department, Bach Mai Hospital; 2Hanoi Medical University
Background: Gout is one of the most common inflammatory arthri-
tis, which can cause many serious late sequelae and complications
affecting the patient and the community. Diagnosis and early treat-
ment gout will prevent sequelae of the disease, in fact this issue was
difficult in Vietnam. Objectives
1. Describe the clinical and subclinical characteristics, using 2015
ACR/EULAR gout classification criteria. 2. Compare between the
2015 ACR/EULAR gout classification criteria with Bennett -­Wood
1968 standard
Subjects: 145 patients, diagnosed gout according to 2015 ACR/
EULAR gout classification criteria, hospitalized in Rheumatology
Department, Bach Mai Hospital.
Methods: Prospective cross-­sectional study.
Results: The proportion symptoms according to 2015 ACR/EULAR
criteria:
• Position of arthritis: 41.4% at ankle joint, 13.1% at toe joint.
• Characteristics of acute inflammation: the proportion of red joints,
cannot bear touch or pressure to the affected joint inflammation,

difficulty to move were 82.8%, 94.5% and 90.3% respectively.
• Duration of pain: the percentage of time to maximal pain  <  24  hour;
resolution of symptoms in ≤ 14 days; complete resolution (to
baseline level) between symptomatic episodes were 75.2%,
89.8% and 96.6% respectively.
• Uric acid test: 82.1% of patients had serum uric acid
levels > 360 μmol/l.
• Tophi were detected in 35.2% patients.
• the incidence of urate crystals from synovial fluid was 56.2%
• Detected ratio of double contour sign on ultrasound: 42.0%
• Detected ratio of erosions on X-ray: 21.5%.
Of 145 patients diagnosed according to the 2015 ACR/EULAR, 127
patients diagnosed according to the Bennett -­Wood 1968 with the
proportion was 87.6%. The 2015 ACR/EULAR gout classification cri-
teria diagnosed earlier than Bennett-­Wood 1968, at the acute stage.
Conclusion: The 2015 ACR/EULAR gout classification criteria should
be used for the early diagnosis of gout.
Keywords: Gout, 2015 ACR/EULAR
3-­084 | Co-­morbidities in patients with
rheumatoid arthritis treated with Tocilizumab
T. T. Huyen
Rheumatology Department
Background: New advances in treatment, especially biologic
DMARDs, have significantly improved the treatment effectiveness
and prognosis of rheumatoid arthritis (RA). However, co-­morbidities
is a factor which can affect the outcome of treatment and shorten
the life expectancy of patients with RA.
Objectives: To evaluate the proportion and the impact of co-­
morbidities in patients with RA after 4 weeks being treated with
Tocilizumab.
Subjects and research methodology: The clinical data in eighty pa-
tients diagnosed RA according to ACR 1987 criteria at Rheumatology
Department, Bach Mai Hospital, Hanoi, Vietnam from January 2017
to June 2018. The patients were divided two groups, with follow-­up
two groups in 24 weeks. The clinical intervention trial design was
applied among 40 patients treated Tocilizumab and Methotrexat
(intervention group) and 40 patients treated Methotrexat and
Hydroxycloroquin (controlled group).
Results: The popular co-­morbidities in patients with RA were ane-
mia, dyslipidemia, hypertension, osteoporosis and diabetes with the
proportions were 48.5%; 33.3%; 27.3%, 15.2% respectively. After
24 weeks treatment, the common co-­morbidities were hyperten-
sion, anemia, dyslipidemia, osteoporosis, diabetes with the rates
were 33.3%; 30.3%, 27.3%, 24.2%, 6.1% respectively. at the time of
study, the number of co-­morbidities was not different between two
groups (P > 0.05), but after 24 weeks treatment the number of co-­
morbidities was different between the intervention group and the
controlled group (P < 0.05). The posibility of anemia, osteoporosis,
hypertension, diabetes and dyslipidemia in the patients with RA in
|
      203
the controlled group increased 4.48 (1.53–13.16); 3.43 (1.04–11.33);
1.51 (0.59–3.85); 0.89 (0.22–3.60) and 0.6 (0.12–2.89) times respec-
tively with 95% CI compared to intervention group.
Conclusion: After 24 weeks treated with Tocilizumab the number
and proportion of co-­morbidities in RA patients had obviously re-
duced. The controlled group had high risk of co-­morbidities than the
intervention group.
Keywords: Co-­morbidities, rheumatoid arthritis, Tocilizumab.
3-­136 | Hydroxychloroquine increases
efferocytosis via modulating both Mertk-­GAS6/
PROS and Integrin-­TG2-­Mfge8 pathway
H. Fei-Hung1; X. Ting-Yin1; H.-Y. Peng2,3; Y. Mei-Chin4; C.
Jiunn-Horng2,3; C.-M. Huang2,3; D.-Y. Chen1,2,3; J.-L. Lan1,2,3;
G. Tsay1,2,3
1
Research and Development Center for Immunology, China Medical University;
2
Division of Immunology and Rheumatology, Department of Internal Medicine,
China Medical University Hospital; 3College of Medicine, China Medical University;
4
Department of Food Nutrition and Health Biotechnology, Asia University
Background/purpose: Impaired clearance of apoptotic cells (effero-
cytosis) plays an important role in the pathogenesis in autoimmune
diseases, especially systemic lupus erythematosus (SLE). The inges-
tion of apoptotic cells also plays a central role in the maintenance
of tissue homeostasis and in the resolution of inflammation. Drugs
enhance efferocytosis may have the therapeutic potential for auto-
immune diseases.
Hydroxychloroquine (HCQ) is a common drug for patients with au-
toimmune diseases including SLE and Sjogren's syndrome (S). The
mechanisms of HCQ for the therapy of autoimmune disease are not
well defined. The aim of the study is to investigate the effects of
HCQ on efferocytosis.
Methods: EL4 was induced apoptosis by UVB and stained with Deep
Red Mitotracker. Carboxyfluorescein succinimidyl ester (CFSE)
stained RAW 264.7 was treated with Hydroxychloroquine (HCQ) for
24 hours then co-­cultured with apoptotic EL4 for 1 hour and investi-
gate the effect on efferocytosis by flow cytometry. To measure the
mRNA expression, HaCaT was induced apoptosis by UVB, and RAW
264.7 was treated with HCQ for 24 hours, then co-­cultured with ap-
optotic HaCaT for 4 hours. The RNA was extracted by RNAzol and
then progress reverse transcription and real time PCR.
Results: In our study, we found that HCQ could enhance efferocy-
tosis with dose-­dependent manner. We investigated its molecular
pathway. We found that HCQ could increase Mfge8-­Integrin and
GAS6/PROS-­Mertk signaling pathway.
Conclusion: Our research shows that HCQ can enhance efferocy-
tosis and modulate mRNA Mfge8-­Integrin and GAS6/PROS-­Mertk
signaling pathway. We find that HCQ involves a novel molecular
pathway for the therapy of autoimmune diseases.
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204      

3-­024 | Beyond the consultation: the value of 3-­145 | The efficacy and safety of additional
personalised handwritten patient summaries in a tocilizumab in patients with polymyalgia
rural rheumatology practice rheumatica resistant to or intolerant of
O. Tvedten1,2; J. Croker1,2,3; A. Croker2; N. Perry3; M. conventional therapy
Lawrence3; K. Williams3 A. Ueno; K. Hirose; M. Hirata; Y. Yamamura; M. Yamamura
1
Hunter New England Local Health District; 2University of Newcastle; 331 Dowe
Okayama Saiseikai General Hospital
St Rheumatology

Background: Recent trials of the anti-­interleukin-­6 (IL-­6) receptor

Background: Patient communication is an important aspect of
antibody, tocilizumab (TCZ), in patients newly diagnosed with poly-
healthcare regardless of location. However, in rural areas with
myalgia rheumatica (PMR), has shown its efficacy and safety, but it
workforce shortages, high patient load and large distances, it can
remains to be determined what PMR patients should be indicated
be difficult for patients to ‘pop back’ to see the doctor to clarify
TCZ.
management. Thus it is important for rural health professionals to
Objectives: We examined the efficacy and safety of TCZ in patients
ensure that the personalised information and management plan
with active PMR who were resistant to or intolerant of glucocorti-
developed within the consultation goes with the patient when
coids (GC) plus methotrexate (MTX).
leaving the practice. As the literature tends to focus on patient-­
Methods: Eighty-­seven patients (49 females and 38 men) were diag-
centred communication within the consultation or on communi-
nosed with PMR by 2012 EULAR/ACR provisional classification cri-
cation between healthcare professionals, we identified a gap to
teria. Their average age was 72 + 9.5 years, with CRP 6.3 + 4.2 mg/L
explore the use of personalised handwritten consultation summa-
and ESR 84 + 34 mm/h at the first visit. They were treated first with
ries for patients.
GC and then, if they were resistant to or intolerant of GC, MTX was
Objective: The research explored the question: What is the value of
added. TCZ was further added to the patients with GC plus MTX-­
personalised handwritten patient consultation summaries?
resistance, and the effects of additional TCZ administration were
Method: The context of the research was a patient-­centred rheu-
determined by measuring the disease activity with PMR activity
matology practice servicing a large area in north-­west NSW for
score (PMR-­A S).
30 years. A multidisciplinary research team (rheumatologist,
Results: Relapses occurred in 42 out of 87 patients (48.2%). MTX
medical registrar, practice nurse, researcher and two patients)
was added in 34 patients, where 10 patients could discontinue GC,
used qualitative methodology. Twenty-­n ine semi-­s tructured in-
but 23 patients (26.4%) were resistant or intolerant to GC and MTX.
terviews undertaken by the medical registrar were jointly ana-
Ten of 23 patients were agreed with TCZ treatment. Before TCZ ad-
lysed with the researcher. Other members of the research team
dition, they were treated with prednisolone (PSL) at 6.0 + 2.2 mg/d
engaged with de-­i dentified segments of the data (for participants’
plus MTX at 6.0 + 3.8 mg/wk, and serum CRP levels were at
confidentiality).
10 + 9 mg/L. After 6.9 ± 4.5 months of TCZ treatment, PSL and MTX
Results: Three themes were identified: involvement relating to the
were reduced to 1.7 + 2.0 mg/d and 2.6 + 3.0 mg/wk, respectively,
role the patient plays in the consultation, including the construc-
with CRP levels of < 0.02 mg/L. GC were able to be withdrawn in 5
tion, clarification and negotiation of content; continuity enabling
patients and 4 patients reached drug-­free remission.
information and understandings from the consultation to go be-
Conclusions: TCZ may provide a therapeutic option for patients with
yond the walls of the room and be shared with other people; and
refractory PMR who were resistant to or intolerant of GC plus MTX.
security reflecting scope for storing the document in different
ways with varying accessibility, and retrieving it according to the
requirements and opportunities of diverse lived experiences with
diseases. 3-­117 | To determine the frequency of various
Conclusion: Our research highlights the potential for individualised types of infections in patients with systemic
handwritten consultation summaries to contribute to health literacy, lupus erythematosus in a tertiary care hospital
information management and medication adherence: “It's [like] a man-
H. Alam; T. P. Umer; L. Nazir; U. Erum
ual for your car, if something goes wrong, you go to the manual and it's
Liaquat National Hospital
there.”

Background: Systemic lupus erythematosus (SLE) is a chronic in-

flammatory disease that has protean manifestations and follows
a relapsing and remitting course. Infection is one of the leading
causes of morbidity and mortality in systemic lupus erythemato-
sus (SLE). Bacterial infections are most frequent, followed by viral
and fungal infections. The impaired cellular and humoral immune

functions seen in patients with SLE are predisposing conditions,
whilst disease activity, steroids and immune-­m odulator treatment
are well-­recognized risk factors for infection. Until now, no data is
available about the frequency of infections in SLE patients in our
population.
Objectives: To determine the frequency of various types of infec-
tions in patients with Systemic Lupus Erythematosus being treated
in a Rheumatology clinic in a tertiary care center in Karachi, Pakistan.
Methods: This retrospective study comprised of collected data of
patients diagnosed with SLE in the department of Rheumatology
who fulfilled the American college of Rheumatology criteria for di-
agnosis of SLE and suffered from infection during disease course.
Cultures, c-­reactive protein (CRP) and pro-­c alcitonin levels were
done to differentiate between SLE flare and infection. History,
physical examination and lab investigations were to be collected
from OPD record files and filled in a pre-­d esigned porforma. Data
will be analysed using the Statistical package for social science
(SPSS) version 20.0.
Results: A total of 139 patients were included in this study, out of
which 112 (86%) were females, while 27 (14%) were males. Skin ab-
scess/cellulitis were seen in 23%, pneumonia in 21%, urinary tract
infection in 15%, upper respiratory tract infection in 10%, oral can-
didiasis in 8%, esophageal candidiasis in 6%, CNS infections/cerebral
abscess in 4%, septicemia in 4%, acute gastroenteritis in 3%, septic
arthritis, osteomyelitis and tuberculosis in 2%, while pyelonephritis
in 1%, hepatitis A, B, C, varicella zoster, herpes simplex and other
viral infections were seen in 3% of cases. CRP was raised in 82%
total infection, while pro-­calcitonin levels was raised in 85% of total
bacterial infections. Most common isolates were E. coli, S. aureus and
S. pneumoniae.
Conclusions: Patients with SLE witness infections often in the course
of disease, sometimes being life threatening. They maybe bacterial,
viral or other opportunistic infections. Our experience working in a
tertiary care hospital in Pakistan showed that infections are mostly
due to the treatment received by the patient, lack of proper infec-
tion control by hospitals and sanitary conditions in patient's lives.
However, that being said it is often important to distinguish between
disease flare and infection. CRP and pro-­calcitonin are sensitive
markers to help determine the presence of infection.
3-­118 | Unusual clinical presentation causing
delay in diagnosis of primary Sjogren's syndrome:
our experience in rheumatology clinic in tertiary
care hospital
H. Alam; T. P. Umer; L. Nazir; U. Erum
Liaquat National Hospital
Background: Sjögren's syndrome (SS) is a chronic autoimmune disor-
der characterized by diminished lacrimal and salivary gland function,
although the clinical manifestations of SS include both exocrine gland
|
      205
involvement and extra-­glandular disease features. Patients illustrate
the wide spectrum of extra-­glandular features. SS is often diagnosed
late due to extraglandular manifestations. A study by Delalande S
showed 43% had articular manifestations, 35% raynauds phenom-
enon, 34% had cutaneous involvement, while pulmonary, hemato-
logical and lymphoproliferative involvement were seen in 20%, 20%
and 3% respectively.
Objectives: Unusual clinical presentation causing delay in diagnosis
of Primary Sjogren's Syndrome: Our experience in a Rheumatology
clinic in a tertiary care hospital.
Methods: This observational study comprised of collected data of
patients with positive serology for sjogren syndrome, i.e. anti-­Ro/
SSA, anti-­L a/SSB and various extraglandular manifestations which
caused delay in diagnosis. Patients fulfilling the criteria and meet-
ing the inclusion and exclusion criteria were included in the study.
Data was collected on a pre-­prescribed porforma. It was analysed by
using the Statistical package for social science (SPSS) version 20.0.
Extraglandular manifestations and mean duration of symptoms to
time of diagnosis of Sjogren's syndrome were noted.
Results: A total of 43 patients were included in this study, out of
which 37 (86%) were females, while 6 (14%) were males. Initial pre-
senting manifestations were musculoskeletal 14 (32.5%), fatigue 8
(18.6%), renal tubular acidosis 7 (16.2%), peripheral neuropathy 4
(9.3%), cytopenias 3 (6.9%), lymphoma 3 (6.9%), TIA/stroke 1 (2.3%),
PRES syndrome 1 (2.3%), interstitial lung disease 1 (2.3%) and
raynauds phenomenon in 1 (2.3%). Mean duration of extra-­glandular
symptoms to diagnosis were 8.4 ± 2.3 months.
Conclusions: This study shows that Primary Sjogren Syndrome has
a wide spectrum of unusual extra-­glandular manifestations, lead-
ing to delay in diagnosis. Some patients were seen to have sicca
symptoms much later in clinical course, while often subtle sicca
symptoms were ignored due to the predominant extra-­glandular
manifestations. Keen observation is necessary when coming
across unexplained extra-­glandular symptoms pertaining to SS.
3-­0 03 | Case report of a patient with refractory
systemic lupus erythematosus: when rituximab is
organ saving
A. Uz Zaman1; N. Ferdous1,2; N. Islam1,3; F. B. Nazrul1,4; M.
A. Rahman1
1
Modern One Stop Arthritis Care And Research Center® (moac&rc®); 2MH
Samorita Hospital and Medical College; 3Department of Rheumatology,
Bangabandhu Sheikh Mujib Medical University (BSMMU); 4National Heart
Foundation Hospital and Research Institute
Case report: A 42-­year-­old woman, a known case of DM and hy-
pothyroidism was diagnosed as a case of SLE (MSK, skin and mu-
cosa) in 2010. She was on hydroxychloroquine (HCQ) and oral
prednisolone till end of 2014. During early months of 2015 she
suffered from recurrent attacks of UTI. Around April 2015 she
was diagnosed as a flare of SLE and referred to rheumatologist.
 |
206      

Renal flare was diagnosed and induction of remission tried with

I/V methylprednisolone and MMF (2 gm). She improved clinically
but became refractory at around 6 weeks (oedema reappeared,
UTP 3.57 gm/24 hours), MMF dose was increased to 3 gm/day.
After 2 months she was found treatment failure (oedema increased
and UTP 6.06 gm/24 hours). The possibility of diabetic nephropa-
thy was excluded. The MMF was stopped and 2nd time induction
tried with I/V methylprednisolone and cyclophosphamide (1 gm).
at 12 days follow-­up for marked leucopenia (WBC 1.11109/L) cy-
clophosphamide was stopped. After recovery rituximab 2 gm was
given in October 2015. She was found improved at 3 months visit
both clinically and by lab test (s.creatinine 1.1 mg/dl, UTP 1.3
gm/24 hrs). Since then from February 2016 to September 2018 she
was in remission.

2-­099 | Effect of sarilumab on glycosylated

hemoglobin in patients with rheumatoid arthritis
and diabetes
M. Genovese1; G. Burmester2; O. Hagino3; H. van
Hoogstraten3; E. Mangan4; K. Thangavelu3; R. Fleischmann5;
T. Mandrup-Poulsen6
1
Stanford University Medical Center; 2Charité – University Medicine Berlin;
3
Sanofi Genzyme; 4Regeneron Pharmaceuticals, Inc; 5Metroplex Clinical
Research Center, University of Texas Southwestern Medical Center; 6University
of Copenhagen

Background/purpose: Sarilumab is a human mAb blocking the IL-­

6Rα and is approved for adult patients with moderately to severely
active RA in Australia, Canada, EU, Japan, and the US. The incidence
of Type 2 diabetes is increased in patients with RA, and elevated IL-­6
may be an independent risk factor. We conducted a post hoc analysis
into the effect of sarilumab on glycosylated hemoglobin (HbA1c) and
fasting glucose.
Methods: TARGET (NCT01709578) was a 24-­week study of sarilumab
150/200 mg q2w vs placebo (all +csDMARD) in TNFi-­inadequate re-
sponse/intolerant (IR/INT) patients; MONARCH (NCT02332590)
was a 24-­week monotherapy study of sarilumab 200 mg q2w vs
adalimumab 40 mg q2w in MTX-­IR/INT, bDMARD-­naïve patients.
There were 78/546 (14.3%) and 28/369 (7.6%) diabetic patients in
TARGET and MONARCH, respectively, per ADA criteria (baseline
fasting glucose ≥7 mmol/L or baseline HbA1c ≥6.5%).
Results: In patients with RA and diabetes, the decrease in HbA1c
at Week 24 was greater in the sarilumab-­treated groups than in the
placebo (TARGET; in combination with csDMARDs), or adalimumab
(MONARCH; monotherapy) groups (Figure). There was no interac-
tion between change in HbA1c and corticosteroid use; nor were
changes in HbA1c correlated with changes in CRP, DAS28-­CRP, or
hemoglobin level. In patients treated with sarilumab, those with
baseline IL-­6 >3 × upper limit of normal (ULN) had greater HbA1c
reductions than those with ≤3 × ULN (least squares mean difference
−0.28% vs −0.11%). Sarilumab safety profile was similar in diabetic
vs non-­diabetic RA patients.
Conclusion: Patients with RA and diabetes treated with sarilumab
had greater improvements in HbA1c than with adalimumab or pla-
cebo. in the monotherapy setting, differences between sarilumab
and adalimumab were more pronounced among patients with higher
baseline serum IL-­6 levels.
Funding/acknowledgments: Study funding and editorial support
(Helen Johns, Adelphi Communications Ltd) were provided by Sanofi
Genzyme and Regeneron Pharmaceuticals, Inc.
2-­100 | Long-­term effect of sarilumab plus
methotrexate on disease activity, physical
function and radiographic progression: a 5-­year
analysis
M. Genovese1; D. van der Heijde2; Y. Lin3; G. St John4; S.
Wang3; H. van Hoogstraten3; J. J. G. Reino5; A. Kivitz6; J. A.
Maldonado-Cocco7; G. Burmester8
1
Stanford University Medical Center; 2Leiden University Medical Centre; 3Sanofi
Genzyme; 4Regeneron Pharmaceuticals, Inc; 5Complejo Hospitalario Universitario
de Santiago de Compostela; 6Altoona Center for Clinical Research; 7School of
Medicine, Buenos Aires University; 8Charité – University Medicine Berlin
Background/purpose: In the MOBILITY study (NCT01061736),
sarilumab significantly reduced disease activity, improved physical

function, and inhibited radiographic progression at Week 52 ver-
sus placebo in patients with RA and an inadequate response to
methotrexate (MTX-­IR). Here we examine 5-­year safety, efficacy,
and radiographic outcomes of sarilumab in adults with RA and
MTX-­IR.
Methods: In MOBILITY Part B Cohort 2, MTX-­
IR patients
(n = 1197) with moderately to severely active RA were randomized
(1:1:1) to placebo, sarilumab 150 mg, or sarilumab 200 mg SC q2w,
plus weekly MTX. Completers were eligible to enroll in the open-­
label extension EXTEND (NCT01146652), where patients received
sarilumab 200 mg q2w+MTX. Dose reduction to 150 mg q2w was
allowed for abnormal laboratory findings and per investigator's
discretion.
Results: Overall, 901 patients entered EXTEND from MOBILITY.
Initial treatment with sarilumab 200 mg+MTX was associated with
reduced radiographic progression at 5 years compared with sari-
lumab 150 mg+MTX or placebo+MTX (Figure). Clinical efficacy ac-
cording to DAS28-­CRP, CDAI, and HAQ-­DI was sustained at 5 years.
An increased incidence of CDAI remission (≤2.8) at 5 years was ob-
served in patients initially randomized to sarilumab 200 mg+MTX
versus sarilumab 150 mg+MTX or placebo+MTX (39.8% vs 34.2%
and 36.4% at Week 244; 36.7% vs 32.6% and 32.9% at Week 196;
36.6% vs 30.5% and 28.1% at Week 148, respectively). The safety
profile remained stable over 5-­
year follow-­
up and was consist-
ent with IL-­6R blockade. Absolute neutrophil count (ANC) <1000/
cm3 was observed, but was not associated with increased rate of
infection.
Conclusion: Clinical efficacy, including reduction in disease activ-
ity, improvement in physical function, and inhibition of radiographic
progression with sarilumab+MTX was sustained over 5-­year follow-
­up. No new safety signals were observed.
Funding/acknowledgments: Study funding and editorial support
(Natalie Roberts, Adelphi Communications Ltd) were provided by
Sanofi Genzyme and Regeneron Pharmaceuticals, Inc.
|
      207
2-­101 | Patients switched to sarilumab
from adalimumab achieve clinically important
improvements in disease activity: results from
MONARCH trial open-­label extension
G. Burmester1; H. Amital2; A. Rubbert-Roth3; H. van
Hoogstraten4; L. Gervitz4; K. Thangavelu4; G. St John5; M.
Genovese6
1
Charité – Medical University Berlin, Free University and Humboldt University
Berlin; 2Sheba Medical Center; 3Klinik fuer Rheumatologie, Kantonsspital
St. Gallen; 4Sanofi Genzyme; 5Regeneron Pharmaceuticals, Inc; 6Stanford
University Medical Center
Background/purpose: In MONARCH (NCT02332590), sarilumab
monotherapy (200 mg subcutaneously [SC] every 2 weeks [q2w])
demonstrated superiority to adalimumab monotherapy (40 mg SC
q2w) in DAS28-­ESR, ACR20/50/70 response, HAQ-­DI, and CDAI
in patients with RA and inadequate response/intolerance to metho-
trexate. W present data from the ongoing open-­
label extension
(OLE).
Methods: Patients completing MONARCH were eligible for OLE
where they received sarilumab 200 mg SC q2w. Week 48 efficacy
and safety data (March 2017 cut-­off; n = 320) were evaluated in
patients switched from adalimumab to sarilumab monotherapy and
patients who continued sarilumab.
Results: Of 369 patients enrolled in MONARCH, 320 (87%) entered
OLE (switch: n = 155; continuation: n = 165). By safety data cut-­off,
 |
208      
patient attrition was similar in switch (25; 16.1%) and continuation
groups (24; 14.5%), as were treatment-­emergent adverse events (AEs)
(switch: 76.1%, 267.4/100PY; continuation: 70.9%, 230.2/100PY)
and infections (switch: 41.9%; continuation: 35.8%). Within 12 weeks
post-­switch, >40% of patients exceeded a minimal clinically impor-
tant difference (MCID) in DAS28-­ESR and/or CDAI, increasing to
>60% by Week 48; >50% exceeded MCID improvements in DAS28-­
CRP and/or HAQ-­DI by Week 48 (Figure). Of patients achieving CDAI
≤10 by Week 24 post-­switch, 77.4% (switch group) and 87.8% (con-
tinuation group) achieved a sustained response to Weeks 36 and 48.
In MONARCH, response rates in sarilumab-­treated patients were
higher, hence fewer patients in the continuation group achieved addi-
tional MCID during OLE (data not shown). AEs of special interest are
reported (Table). Two versus one death occurred in the switch (malig-
nancy; cerebrovascular accident) versus continuation (subarachnoid
hemorrhage) groups, respectively. No GI-­related AEs (ulcerations/
perforations/diverticulitis) were observed.
Conclusion: Patients switched from adalimumab to sarilumab expe-
rienced clinically meaningful improvements in signs and symptoms
of RA. Safety observations in OLE were generally consistent with
those in MONARCH.
Funding/acknowledgments: Study funding and editorial support
(Vicki Cronin, Adelphi Communications Ltd) were provided by Sanofi
Genzyme and Regeneron Pharmaceuticals, Inc.
3-­119 | Histopathological features of lupus
nephritis of South Indian ethnic tamil population:
10 year single tertiary center study at Chennai,
India
K. Venkataraman; S. Munirajan; M. Sethupathy
Chennai Meenakshi Multispeciality Hospital
Lupus nephritis (LN) causes morbidity and mortality in systemic
lupus erythematosus (SLE). Variability of the histological features
have been studied in different populations. This study analyses the
renal biopsy of LN in a single tertiary referral medical center in the
Tamil ethnic population of South India.
A study of Tamil ethnic SLE patients treated at Chennai Meenakshi
Multispeciality Hospital between 2009 and 2018 was done at
Chennai, India
There were 88 Tamil ethnic SLE patients in whom renal involvement
was present in 34(38.6%). They were subjected to renal biopsy and
the International Society of Nephrology/ Renal Pathology society
classification was followed. The age range was 17 and 56. The me-
dian age was 33 and the male to female ratio was 1:11
The majority of them 9/34 (26.4%) had Class IIIA + Class V LN fol-
lowed by Class V in 6/34 (17.6%), Class IVA+V LN in 5/34 (14.7%),
Class IV A alone in 5/34 (14.7%), Class IV in 3/34(8.8%), Class II in
3/34(8.8%) One patient had Class IV with crescents and another pa-
tient reported a normal
biopsy. Nephrotic Proteinuria was present in 4/34 Patients (11.8%)
and Non-­nephrotic in 6/34 (17.4%) patients.
Two patients had ESRD and died. Both of them had Class IVA with
Class V.
Our study concludes that LN occurs at a younger age in Tamil ethnic
community and the predominant type is Class IIIA with Class V war-
ranting early immunosuppressive therapy.
2-­013 | The impact of topical NSAIDs on renal
function: a review of the literature
B. Venning1; M. Terrill1; M. Soden1,2
1
The Townsville Hospital; 2James Cook University
Background: Topical NSAIDs reach minimal plasma blood levels,
thus the exact risk of topical NSAIDs on renal function is not well
defined.
Objectives: A literature review was performed to further define the
renovascular risk of topical NSAIDs.
Method: Two independent assessors searched online databases
Pubmed, Medline, Embase, Cochrane and Google Scholar for stud-
ies using topical NSAIDs. Studies were included if they mentioned
an assessment of creatinine, urea or eGFR in their safety analysis, or
mentioned adverse renovascular events.
Results: 19 Randomised Controlled Trials (RCTs) and Pooled Analysis
meet the inclusion criteria, as did 1 retrospective case-­controlled
analysis and 2 case studies.
The RCTs demonstrated that a mild treatment-­related increase in
creatinine may occur with topical NSAIDs, especially when used for
prolonged periods up to 12 months. Most of these cases showed
mild creatinine increases, ranging from 20 to 62 µmol/L and no more
than 64 µmol/L. A maximum rise to 200 µmol/L was reported, from
a baseline of 174 µmol/L. However, most studies excluded those
with baseline severe renal impairment.
A case-­controlled analysis found topical NSAIDs were not a risk
factor for an AKI when oral NSAIDs or aspirin were accounted
for. of two case studies demonstrating impaired renovascular
function; one was secondary to acute Ketoprofen use in a patient

with Polycystic Kidney Disease and CKD, the other from chronic
Benzydamine use.
Table 1 Shows the differing pharmacology of NSAIDs used within
Australia and their possibility for bioaccumulation in CKD
Active ingredient Pharmacology
Diclofenac Plasma level (compared to oral equivalent): 6%
Half-­life: 1–2 hours
Elimination: 65% renal, 35% bile
Ibuprofen Plasma level (compared to oral equivalent): 5%
Half-­life: 2 hours
Elimination: Renal
Piroxicam Plasma level (compared to oral equivalent): 3%
Half-­life: 50 hours
Elimination: 95% renal, 5% faecal
Ketoprofen Plasma level (compared to oral equivalent): 1%
Half-­life: 2 hours, Increases in CKD
Elimination: Renal
Benzydamine Plasma level (compared to oral equivalent): 1–4%
Half-­life: 13 hours
Elimination: Renal
Conclusion: The monitoring of renal function should be considered
in patients who use topical NSAIDs for prolonged periods. This is
likely to be of greater importance for those with underlying CKD.
Given the short half-­life and mixed elimination, topical diclofenac
may have less chance of bioaccumulation and renal harm, however
more research is needed into this area.
3-­137 | The alteration of regulatory t cells in
systemic lupus erythematosus with and without
lupus nephritis
S. Vilaiyuk; B. Lerkvaleekul; N. Apiwattanakul; N.
Jirapattananon; K. Tangnararatchakit; J. Yamsuwan; S. Srisala
Faculty of Medicine Ramathibodi Hospital
Background: Regulatory T cells (Tregs) abnormalities can lead to T
cells and B cells hyperactivity in systemic lupus erythematosus (SLE).
From previous studies, the levels of Tregs in active SLE patients were
still controversial.
Objective: To determine the alteration in Tregs levels in active SLE
patient.
Methods: This is a prospective cohort study. Active SLE patients
(5–18 
years), according to 2012 Systemic Lupus International
Collaborating Clinics (SLICC) criteria and SLE disease activity index
(SLEDAI) score > 3, in Ramathibodi Hospital between March 2015
and June 2018 were included in the study. Demographic data and
baseline characteristic were collected. Blood was sent for percent-
age of CD4+ CD25+ Foxp3+ T cells, which measured by flow cy-
tometry technique (FACS). Patients were followed up with Tregs
measurement and disease activity assessment by using SLEDAI
score every 3 months for 6 months. Active patients were catego-
rized into non-­lupus nephritis and lupus nephritis (LN) which based
on proteinuria > 0.5 gm/24 h or RBC > 5 cells/HPF, and renal biopsy
|
      209
confirmed of LN. Tregs measurement from 40 age-­and sex-­matched
healthy controls were performed.
Results: Forty active SLE children were enrolled. There were 24
non-­LN and 16 LN patients. Around 90% were female and median
age was 11.3 years. Median (IQR) SLEDAI score in non-­
LN and
LN group were 21 (17) and 7 (8), respectively. Mean percentage
of Tregs/CD4 in non-­LN were 6.6 + 3.7, 6.1 + 4.7, 7.5 + 3.7 at 0, 3,
6 months, respectively. Mean percentage of Tregs/CD4 in LN group
were 4.5 + 3.0, 5.4 + 3.0, 8.4 + 5.7 at 0, 3, 6 months, respectively
and mean percentage of Tregs/CD4 in LN group were statistically
increased when compared between 0, 6 months (P = 0.024).
Conclusion: The alteration of Tregs in active SLE patients were dif-
ferent depending on specific organ involvement especially renal. The
significantly increased percentage of Tregs were found in LN, not in
non-­LN.
1-­033 | Myeloproliferative neoplasm in a
36 year old female with Behcets disease: a case
report
J. G. Villo
East Avenue Medical Center
Background: Myeloproliferative neoplasm coexisting with Behçet's
disease is rare.
Summary: We report a case of 36 year old, Filipino female, presenting
with extreme leukocytosis and cough. She was diagnosed with Behçet's
disease 1 year prior to admission (PTA) after presenting with genital and
oral ulcers, arthritis, conjunctivitis and erythema nodosum. She was
started on prednisone at 1 mg/kg/d which was gradually tapered and
improvement of symptoms noted. She later presented with abdominal
pain and on CT scan, it revealed superior mesenteric vein thrombo-
sis for which she was given Azathioprine. She was admitted 4 months
PTA as due to anemia where peripeheral blood smear, esophagoduo-
denouscopy, and colonoscopy were unremarkable. 1 month PTA, the
patient had her regular follow up and complete blood count (CBC)
showed mild anemia, leukocytosis with immature cells and thrombo-
cytopenia. 3 days PTA, she had occassinal non productive cough thus
she was admitted. On physical exam, pertinent physical findings were
moon facies, tachycardia, pallor, crackles with rhonchi on auscultation.
Spleen was palpable. The patient was hydrated and antibiotics were
started. PRBC was transfused and Bone Marrow Aspiration (BMA) was
consistent with Myeloproliferative Neoplasm. She was started on hy-
droxyurea and regular monitoring of blood parameters.
Conclusion: Hematologic malignancies such as leukemia should be
considered in patients with autoimmune disease presenting with
persistent leukocytosis. Management of this rare case is a challenge.
Chemotherapy for leukemia particularly hydroxyurea has been
shown to cause flare of Behçet's Disease.
Keywords: Behçet's disease, Myeloproliferative Neoplasm, case
report
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210      
3-­0 09 | Correlation between B-­Cell Activating
Factor levels and disease activity in systemic
lupus erythematosus patient in Hasan Sadikin
General Hospital
R. Vitri; R. Wachjudi; L. Hamijoyo
Internal Medicine Department
Background: B cell hyperactivity is believed to have a central role
in the pathogenesis of systemic lupus erythematosus (SLE). B-­cell
activating factor (BAFF) is a cytokine that plays a role in accelerat-
ing maturation, differentiation, and survival of B cells. The purpose
of this study was to see if there is a significant association of serum
BAFF levels and disease activity in SLE patients.
Methods: This study uses bivariate analysis with cross sectional de-
sign. The correlation between serum BAFF levels and disease activ-
ity (SLEDAI 2K) is calculated using Pearson's correlation coefficient
test. Subjects were 44 SLE patients with active disease (SLEDAI 2K
> 2) in rheumatology clinic and in-­patient ward of Hasan Sadikin
General Hospital Department of Internal Medicine, Bandung, during
period of December 2016 -­March 2017.
Results: Forty-­four subjects of the study were women with mean
age of 28 ± 8 years. Renal and mucocutaneous involvements were
the most common manifestation (93.2%). Median disease activity
based on SLEDAI-­2K score was 8. Median serum BAFF levels was
1.218 pg/mL (0.476–10.835). Analysis showed positive correlation
with weak relation between serum BAFF levels and SLEDAI-­
2K
(r = 0.327, P = 0.015). There was also significant correlation with
weak relation found between serum BAFF levels and anti dsDNA
and complement C3 levels.
Conclusions: There is a significant correlation between serum levels
of BAFF and SLE disease activity. However, the strength of the rela-
tionship is weak. Therefore, other conditions that influence disease
activity should be considered as confounding factors.
Keywords: SLE, BAFF, SLEDAI-­2K, disease activity, Indonesia
2-­120 | A systematic review of apps for
patients with spondyloarthritis to monitor their
disease activity
W. J. Ong1; Y. H. Kwan2; M. Xiong3; Y. Y. Leung1,4,5; J. K.
Phang1; C. Wang1; W. Fong1,4,5
1
Department of Rheumatology and Immunology, Singapore General Hospital;
2
Program in Health Services and Systems Research, Duke-­NUS Medical School;
3
Department of Family Medicine, Singhealth; 4Duke-­NUS Medical School;
5
Department of Medicine, Yong Loo Lin School of Medicine, National University
of Singapore
Objective: To identify existing publicly available, high-­quality apps
for monitoring Spondyloarthritis disease activity that use validated
measurement instruments.
Methods: We did a systemic review of apps available on Apple App
store and Google Play store based on a combination of keywords,
inclusion and exclusion criteria. Validated disease activity meas-
urement instruments were identified. Information regarding app
characteristics, including the presence of validated disease activ-
ity measurement were extracted. The Mobile App Rating Scale was
used to review the apps for user experience.
Results: A total of 1253 apps were identified in the app stores,
and five apps met the criteria and were further analyzed. Two apps
(MySpA and GRAPPA App) contained some of the validated disease
activity monitoring instruments for specific spondyloarthritis sub-
types. These two apps are also rated “good” on the MARS (with total
mean scores ≥4/5), while the other apps scored poorly in comparison.
Conclusions: There are two high-­quality spondyloarthritis disease
activity monitoring apps publicly available, but they only target two
spondyloarthritis subtypes-­ankylosing spondylitis and psoriatic ar-
thritis. There is a lack of high-­quality apps that can measure disease
activity for other spondyloarthritis subtypes, and no available app
that consolidates all validated disease activity instruments across
subtypes.
Keywords: spondyloarthritis, disease activity, mHealth, mobile apps
3-­111 | Clinical presentation and incidence
of cardiopulmonary complications in Thai early
systemic sclerosis (SSc) patients comparing
between difference autoantibody profiles
S. Wangkaew1; N. Prasertwittayakit2; P. Phiriyakrit1; S.
Tungteerabunditkul1; J. Euathrongchit3
1
Division of Rheumatology; 2Division of Cardiology; 3Division of Diagnostic
Radiology
Background: Inception cohort study regarding the incidence rate
(IR) of cardiopulmonary involvement in early SSc patients comparing
among difference autoantibody profiles is limited.
Objectives: To determine the differences regarding clinical presen-
tation and IR of cardiopulmonary complication in Thai patients with
early SSc according to routine autoantibody profiles (positive anti-­
topoisomerase I antibody: pATA, negative ATA: nATA, and positive
anti-­centromere antibody: pACA).
Methods: We used an inception cohort of early SSc patients with
follow-­up duration ≥ 1 year, seen between January 2010 and June
2016.
Results: A total of 114 patients (89 dcSSc, 69 female) with mean ±
SD disease duration of 11.7 ± 8.8 months and observational period
of 3.8 ± 1.6 years, were analysed. There were 89 patients (78.1%)
with pATA, 18(15.8%) nATA, and 7(6.1%) pACA. at enrollment, the
pATA and nATA groups had significant higher prevalence of dcSSc
subtype, skin hypo-­hyperpigmentation, and interstitial lung disease
(ILD-­determined by HRCT) compared with the pACA group. in the
last visit, the pATA group had significantly more severe cumulative
organ complications consisting with digital ulcer, joint contracture
and tendon friction rub than the other groups. Interestingly, both the
pATA and nATA groups had significantly higher IR of ILD compared

to the pACA group (52.9vs.57.8vs.6.3 per 100 person-­
years,
P = 0.006). There was comparable modest IR of LVEF < 50%, right
ventricular dysfunction, and sPAP ≥ 50 mm Hg between the pATA
and nATA groups. During the study period, no suspected myositis,
sPAP ≥ 50 mm Hg and cardiac complications were observed in the
pACA group.
Conclusions: Our study cohort indicates that presence of SSc spe-
cific autoantibodies was associated with a distinctive clinical presen-
tation and internal organ involvement. In the early phase of Thai SSc,
cardiopulmonary complication was rarely seen in the pACA group;
whereas ILD complication was very common in both pATA and nATA
groups. Further study regarding the associated autoantibody in
nATA patient with ILD complication is needed.
3-­010 | Fundamental difference in macrophage
between giant cell arteritis and coronary artery
disease
R. Watanabe1; M. Hilhorst1; H. Zhang1; M. Zeisbrich1; G.
Berry1; B. Wallis1; D. Harrison2; J. Giacomini1; J. Goronzy1;
C. Weyand1
1 2
Stanford University; Vanderbilt University School of Medicine
Background/purpose: In inflammatory blood vessel diseases, mac-
rophages play a key role in vascular damage and remodeling. To ex-
amine whether inflammatory macrophages in the vessel wall display
a single distinctive effector program, we compared functional pro-
files in patients with either coronary artery disease (CAD) or giant
cell arteritis (GCA).
Methods: Patients with GCA were diagnosed based on temporal ar-
tery biopsy. Patients with CAD had at least one documented myo-
cardial infarction. Macrophages were differentiated from monocytes
with M-­C SF (20 ng/mL) for 5 days, and then stimulated with 100 U/
mL of IFN-­γ and 100 ng/mL of LPS for the indicated time periods.
Results: Monocyte-­derived macrophages from the two patient co-
horts displayed disease-­specific profiles and differed fundamentally
in metabolic fitness. Macrophages from CAD patients produced high
amount of chemoattractants (CXCL9, CXCL10), the cytokines IL-­1β
and IL-­6 and the programmed death-­ligand 1 (PD-­L1). On the other
hand, macrophages from GCA patients overproduced chemoattract-
ants (CXCL9, CXCL10) but not IL-­1β and IL-­6 and showed distinctly
low PD-­L1 expression. We also found that disease-­specific effec-
tor profiles were already imprinted in circulating monocytes. These
functional signature emokinehi cytokinehi PD-­L1hi signature in CAD
macrophages was sustained by excess uptake and breakdown of glu-
cose, placing metabolic control upstream of inflammatory function.
Conclusions: Monocytes and macrophages participate in vascular in-
flammation in a disease–specific and identifiable pattern and are de-
pendent on glucose availability in their immediate microenvironment.
|
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3-­103 | Automated multiparameter microscopy
and image analysis: next generation synovial
tissue histology
W. Murray-Brown1; H. Weedon1; A. Aloia1; S. Lester2; S.
Proudman3; M. Smith1; M. Wechalekar1
1
Flinders University; 2The Basil Hetzel Institute for Translational Health
Research; 3Royal Adelaide Hospital
Background/purpose: Histological assessment of synovial tissue
(ST) in Rheumatoid Arthritis (RA) is hampered by: 1) tissue is finite, 2)
sequential stains of single immunohistochemistry do not adequately
preserve architectural and co-­staining data, 3) image analysis and
quantification is open to interpretation/human error. Furthermore,
in RA, growing evidence implicates heterogeneous histopatho-
logical phenotypes with different disease outcomes and treatment
responses; critical, as 30–40% of patients do not respond to cur-
rent therapies and long-­term drug-­free remission is rare, reflecting
differential recruitment of inflammatory pathways and cell types.
Thus, there is an unmet need for tools providing automated multi-­
parameter cellular identification and phenotype analysis, enabling
translational research to assist with development of personalised
medicines for RA.
Methods: RA ST sections were prepared for Opal™ multispectral
imaging. Primary antibodies identifying memory T (CD45RO), B
(CD20) and macrophage cells (CD68) are stained in turn, each fol-
lowed by specific Opal™ reactive fluorophores. Primary antibody
stripping prepares the section for the next antibody. Once all Opal™
targets have been developed, DAPI nuclear staining is performed
prior to whole-­slide scanning and high-­resolution (x20 magnifica-
tion) image acquisition on the Perkin Elmer Vectra 3.0 automated
imaging system.
Results: The image analysis and machine learning software package,
inForm® was used to successfully segment individual cells, identify
and quantify cellular phenotype and distinguish regions with “fol-
licular” and “diffuse” staining patterns.
Conclusion: Due to the recent surge in interest in ST biology, in
particular in clinical trials investigating biologic therapies, there is a
need for effective, reproducible and high-­throughput technologies
for immune-­histological examination. Thus, a tool such as Opal™ can
be utilised for whole slide scanning and automated analysis of ST
infiltrates and tissue phenotype analysis. ST phenotype is thought to
influence treatment outcomes in patients, therefore, comprehensive
analysis of ST histology will result in more personalised and stratified
medicine regimes for patients.
 |
212      
3-­011 | Arthitogenic clonally-­expanded
autoantigen-­specific CD4 + T cells are a target
for prevention of autoimmune arthritis
P. Wehr1; H. Nel1; S.-C. Law1; D. Jansen1; N. La Gruta2; S.
Mannering2; H. Reid3; J. Rossjohn3; R. Thomas1
1
University of Queensland; 2University of Melbourne; 3Monash University
Background/purpose: Rheumatoid arthritis (RA) is preceded by a
prodrome in which pro-­inflammatory autoantibodies and transient
symptoms may develop. A biased T cell receptor (TCR) repertoire
in the joints of recent-­onset RA patients suggested T cell expan-
sion, but little is known about the contribution of autoantigen-­
specific CD4+ T cells to RA pathogenesis prior to autoantibody
development. We assessed clonal expansion and function of
aggrecan-­specific CD4 + T cells in the proteoglycan-­induced ar-
thritis mouse model of RA.
Methods: We induced proteoglycan-­induced arthritis (PGIA) in fe-
male BALB/c AnNCrl and FoxP3-­GFP reporter mice with rh-­aggrecan
G1. The IAd tetramer contained the immunodominant aggrecan89–103
peptide. Single tetramer+ and tetramer-­T cells were sorted at 4 time
points. CDR3α and CDR3β regions were interrogated using nested
PCR-­
TCR sequencing. Index sorting identified the phenotype of
cells of interest. PG-­specific IgG1 and IgG2a titers were determined
in sera. TRBV13 + 2 + or control CD4 + T cells were sorted from
spleen on day 22 and transferred to SCID recipients then disease
was monitored. Anti-­TRBV13 mAb were delivered before and after
induction of PGIA to deplete TRBV13 + T cells. TCRa/b derived from
expanded clonotypes were transduced into SKW3 cells to test CD69
response to peptide.
Results: Oligoclonal aggrecan 89–103-­specific CD4+ T follicular
helper (Tfh) cells expanded and Treg decreased before anti-­P G de-
velopment, concomitant with a transient flare in symptoms. As dis-
+ workshop that presented the OMERACT 2016 preliminary core do-
ease severity increased, expanding aggrecan 89–103-­specific CD4
T cells were predominantly effector-­m emory, including Tfh cells.
The aggrecan 89–103-­specific CD4+ TCR repertoire preferentially
+ + + +
used TRBV13-­1 , 13-­2 and TRBV2 TCRs. Transfer of TRBV13
T cells was sufficient to trigger arthritis in lymphopenic recipients
and depletion delayed disease onset and reduced anti-­P G titres.
Public TRBV13+ clonotypes with conserved amino acid residues
arising from convergent recombination suggest these TCRs were
antigen-­s elected.
Conclusion: Autoantigen-­specific arthritogenic CD4+ Tfh cells clon-
ally expand prior to autoantibody development, and are a target for
arthritis prevention.
3-­025 | The OMERACT core domain set for
clinical trials of shoulder disorders
S. Whittle1,2; S. Ramiro3; M. Page 4; H. Huang5; A. Verhagen6;
D. Beaton7; P. Richards8; M. Scholte-Voshaar9; B. Shea10;
D. van der Windt11; C. Kopkow12; M. Lenza13; N. Jain14; B.
Richards15,16; C. Hill1,2; T. Gill2; B. Koes17; N. Foster18; P.
Conaghan19; T. Smith20; P. Malliaras21; Y. Roe22; J. Gagnier23;
R. Buchbinder24
1
Rheumatology Unit, the Queen Elizabeth Hospital; 2The University of Adelaide;
3
Department of Rheumatology, Leiden University Medical Center; 4School
of Public Health and Preventive Medicine, Monash University; 5Department
of Orthopaedic Surgery, University of Michigan; 6University of Technology;
7
Institute for Work & Health and the University of Toronto; 8Patient Research
Partner, University of Bristol; 9Department Psychology, Health and Technology,
University of Twente; 10Ottawa Hospital Research Institute, and School of
Epidemiology and Public Health, Faculty of Medicine, University of Ottawa;
11
Arthritis Research UK Primary Care Centre, Institute for Primary Care and
Health Sciences, Keele University; 12Department of Applied Health Sciences,
Hochschule für Gesundheit Bochum (University of Applied Sciences); 13Hospital
Israelita Albert Einstein; 14Departments of Physical Medicine and Rehabilitation,
Orthopaedics, and Epidemiology (Medicine), Vanderbilt University Medical
Center; 15Royal Prince Alfred Hospital; 16University of Sydney; 17Department
of General Practice, Erasmus University Medical Center; 18Keele University;
19
Leeds Institute of Rheumatic and Musculoskeletal Medicine, University
of Leeds; 20Nuffield Department of Orthopaedics, Rheumatology and
Musculoskeletal Sciences University of Oxford; 21Monash Department of
Physiotherapy, School of Primary and Allied Health Care, Monash University;
22
Department of Physiotherapy, OsloMet, Oslo Metropolitan University;
23
Department of Epidemiology, School of Public Health, Department of
Orthopaedic Surgery, University of Michigan; 24Monash Department of Clinical
Epidemiology, Cabrini Institute and Department of Epidemiology and Preventive
Medicine, School of Public Health and Preventive Medicine, Monash University
Background/purpose: To reach consensus on the core domains to be
included in a core domain set for clinical trials of shoulder disorders
using the OMERACT Filter 2.1 Core Domain Set process.
Methods: At OMERACT 2018, the Outcome Measures in
Rheumatology (OMERACT) Shoulder Working Group conducted a
main set and its rationale based upon a systematic review of domains
measured in shoulder trials and an international Delphi involving pa-
tients, clinicians and researchers, as well as a new systematic review
of qualitative studies on the experiences of people with shoulder
disorders. After discussions in break-­out groups, the OMERACT core
domain set for clinical trials of shoulder disorders was presented for
endorsement by OMERACT 2018 participants.
Results: The qualitative review (N = 8) identified all domains in-
cluded in the preliminary core set. An additional domain, cognitive
dysfunction, was also identified but confidence that this represents
a core domain was very low. The core domain set that was endorsed
by the OMERACT participants, with 71% agreement, includes four
‘mandatory’ trial domains: pain, function, patient global and adverse
events including death; and four ‘important but optional’ domains:
participation (recreation/work), sleep, emotional wellbeing and
condition-­
specific pathophysiological manifestations. Cognitive
dysfunction was voted out of the core domain set.
Conclusion: OMERACT 2018 delegates endorsed a core domain
set for clinical trials of shoulder disorders. The next step includes
 |
      213

identification of a core outcome measurement set that passes the

OMERACT 2.1 Filter for measuring each domain.

3-­012 | DNA methylation is distinct between

AS cases and controls and in different peripheral
blood mononuclear cell types
J. Whyte1,2; L. Bradbury1,2; J. Phipps1,2; S. Song1,2; M.
Clout1,2; T. Kenna1,2; M. Brown1,2
1
Queensland University of Technology (QUT); 2Translational Research Institute,
Princess Alexandra Hospital

Background: Ankylosing spondylitis (AS) is an inherited chronic

immune-­mediated arthropathy, with a complex genetic and immu-
nological basis. Limited understanding of the fundamental biology
of AS has impeded the development of novel AS-­
specific treat-
ments. Our current study aims to describe the functional impact of
previously identified AS-­associated genetic variants by examining
transcriptional and epigenetic changes related to these genetic vari-
ants. Epigenetic and transcriptional changes are partially cell type 2-­102 | A retrospective analysis on rituximab
specific, therefore we focused on five cell types thought to mediate
for RA after three years – at a dose of 500 mg
disease in AS: CD4 T-­cells, CD8 T-­cells, γδ T-­cells, NK cells and CD14
monocytes. G. Wickrematilake
Methods: 50 AS patients and 50 HLA-­B27 matched healthy controls Rehabilitation Hospital Digana

were recruited. PBMCs were obtained and FACS sorted into the
cell types of interest. DNA and RNA were extracted from each cell
type for use in DNA methylation analysis using the Illumina Infinium
Human MethylationEPIC beadchip, and total RNAseq respectively.
Linear regression will be used to examine cell-­specific interactions
between transcription and genotype, DNA methylation and geno-
type, and interactions between all three.
Results: Recruitment and FACS sorting are complete. HLA-­B27 sta-
tus, age and sex were balanced between patient and control cohorts
(see Table 1). The cell type distribution was similar between healthy
controls and patients.
Transcription and epigenetic studies are ongoing. To date, 175 sam-
ples have successfully had DNA methylation analysis performed.
Cell type was significantly different in PC1, 2 and 3 (P < 2.2 × 10−16).
After subset by cell type, cases and controls were significantly dif-
ferent in CD4 T-­cells, γδ T-­cells and CD14 Monocytes (P < 0.05).
No difference was noted in relation to HLA-­B27 status, gender, or
smoking status. Total RNA-­seq will be performed on approximately
400 paired-­end 150 bp libraries and sequenced to a depth of 50 mil-
lion reads.
Conclusion: This study shows for the first time that DNA methyla-
tion patterns differ in AS cases and controls. We further show that
methylation patterns differ between major peripheral blood cell
types, indicating that studies must control for the cell type studied
or biases may arise due to differences in peripheral blood cell type
distributions.
Rituximab (RTX) is a chimeric monoclonal antibody that targets the
CD20 molecule expressed on the surface of B cells. It is approved
for treatment of rheumatoid arthritis (RA) in combination with
methotrexate, in patients with active RA and DMARD failure. The
optimal dosing regimen of RTX in RA has not been clearly stated.
Objectives:
• Improvement of RA by DAS-28 ESR, when rituximab is given at a
dose of 500 mg.
• Improvement by DAS 28, with age at initiation of treatment
Methods: 28 RA patients with DMARD failure, treated with 500 mg
Rituximab two weeks apart six monthly were assessed by retrospec-
tive analysis of records over 3 years. DAS-­28 ESR score was obtained
from clinic records at baseline, and after three years of therapy ini-
tiation. Patient's age at treatment initiation was documented.
Results : Out of the28 patients, one had severe anaphylaxis and
treatment was stopped. Two patients defaulted and one had poor
response requiring switching to an alternate biologic.
From the remained 24 patients, the mean age was 54 ± 9.92 years.
Baseline DAS 28 was 5.34 ± 1.25 and DAS 28 at three years was
4.10 ± 1.24. Improvement of DAS 28 at three years was significant
at P < 0.05 (P = 0.001314)
Association between remission (DAS 28 < 2.6) at three years was
statistically significant (P < 0.05) in people of ≤50 years at treatment
initiation (chi-­square statistic = 6.4. P = 0.011412).
 |
214      
Conclusions: Rituximab at a dose of 500 mg was effective in reach-
ing remission at three years; a significant positive response was seen
in patients aged ≤50 years at therapy initiation.
3-­013 | Pre-­clinical evaluation of nintedanib
for connective tissue diseases with comorbid
progressive fibrosing interstitial lung disease or
other organ manifestations
L. Wollin1; J. Distler2; E. Redente3; D. Riches3; B. Ryffel4; I.
Maillet4; S. Stowasser5; R. Schlenker-Herceg6
1
Boehringer Ingelheim Pharma Gmbh & Co. Kg; 2Department of Internal
Medicine 3, University of Erlangen-­Nuremberg; 3National Jewish Health;
4
Experimental and Molecular Immunology and Neurogenetics CNRS, University
of Orleans; 5Boehringer Ingelheim International GmbH; 6Boehringer Ingelheim
Pharmaceuticals Inc
Background/purpose: Patients with connective tissue diseases
(CTDs) can develop multiple organ manifestations. Interstitial lung
disease (ILD) is a common manifestation resulting in substantial
morbidity and mortality; however, there are no approved pharma-
cotherapies for CTD-­ILD. Some patients with CTD-­ILD develop a
progressive-­fibrosing phenotype that has similarities with idiopathic
pulmonary fibrosis (IPF). Nintedanib is an approved treatment for
IPF having been shown to reduce decline in forced vital capacity by
approximately 50%. This pre-­clinical evaluation explored the effects
of nintedanib in pre-­clinical models reflecting lung and other organ
manifestations of CTDs.
Methods: The in vitro activity of nintedanib was explored using
human cellular systems representing mechanistic aspects of organ
manifestations of CTDs, including lung and skin fibroblasts, and cells
of the immune system and the vasculature. The in vivo activity of
nintedanib was explored in diverse animal models reflecting organ
manifestations of CTDs in lung, skin, heart and liver.
Results: Nintedanib attenuated the release of immune-­stimulating
and pro-­fibrotic mediators; the migration and differentiation of fibro-
cytes; the proliferation, migration and contraction of fibroblasts and
their transformation into myofibroblasts; and functions of endothelial
cells, vascular smooth muscle cells and pericytes. In two mouse mod-
els, nintedanib reduced (bleomycin-­and silica-­induced) lung fibrosis.
In mouse models of the fibrotic and vascular manifestations of sys-
temic sclerosis, nintedanib reduced skin, lung and heart fibrosis. In a
model of rheumatoid arthritis-­associated ILD, nintedanib reduced ar-
thritis pathology and lung fibrosis. In a mouse model of hepatic injury,
nintedanib reduced inflammation and fibrosis of the liver.
Conclusion: Nintedanib attenuated fundamental processes in the
pathobiology of progressive fibrosing ILDs and improved organ
manifestations of CTDs in pre-­clinical models. Ongoing clinical trials
are exploring the efficacy and safety of nintedanib in patients with
SSc-­ILD (SENSCIS® trial; NCT02597933) and patients with progres-
sive fibrosing ILDs of various clinical diagnoses (INBUILD® trial;
NCT02999178).
3-­120 | A case report: treatment of diffuse
alveolar hemorrhage in systemic lupus
erythematosus patient with intravenous
immunoglobulin
K. T. Wong; C. P. Chan
Centro Hospitalar Conde de São Januário Macao Public Hospital
Background: Diffuse alveolar hemorrhage (DAH) is a rare but fatal
complication in SLE patients. Treatment of DAH is based on pulse
methylprednisolone, cyclophosphamide (CTX), intravenous immu-
noglobulin (IVIG), rituximab, and plasmapheresis. Currently, few
studies were published to demonstrate the results on using IVIG in
the SLE patients with DAH.
Methods: A 32-­
year-­
old Chinese woman was diagnosed SLE for
8 years, and controlled by the maintain dosage of prednisolone,
hydroxychloroquine (HCQ) and azathioprine (AZA). She presented
with recurrent chest pain without fever or hemoptysis for days, and
accompanied with sudden dyspnea and syncope. in emergency de-
partment, her vital sign and oxygen saturation are relatively stable.
However, chest x-­ray showed bilateral patchy infiltrations (figure
1), and chest CT revealed diffuse ground-­grass opacities (figure 2).
Elevation of C-­reactive protein, anti-­dsDNA, and decreased compo-
nents were noted. Bronchoscopy found diffused bloody secretion,
and bronchoalveolar lavage (BAL) also suggested DAH. The patient
was received IVIG 20 gram (400 mg/kg) daily for 5 days with anti-
biotics. Her clinical condition was improved gradually, and chest x-­
ray showed resolving when IVIG was completed (Figure 3). Systemic
steroid was administrated after the negative result of BAL culture,
HCQ and AZA were resumed gradually. Finally, the patient was
discharged on Day 12 of hospitalization, and followed up in OPD
uneventfully.
Results: DAH is a life-­threatening disease in SLE. Treatment with
pulse steroids and/or CTX may be beneficial, however, potential
risks of infection and complications (CTX to young women) should
be considered. in our case, IVIG was given initially with close moni-
tor. The illness was improved dramatically during IVIG therapy, and
Figure 1
 |
      215

1-­056 | How has treatment of osteoporotic

changed in the new decade? Our experience in a
tertiary rheumatology centre in Malaysia
P. S. Wong; C. K . Cheah; N. Mohd Nor; S. C. Gun
Ministry of Health Malaysia, Malaysia Rheumatology Association

Background: Osteoporosis (OP) is a systemic skeletal disease lead-

ing to increased risk of fragility fracture, contributed significantly to
life-­span reduction and increased health care burden. Hence optimal
management of OP is crucial in clinical practice.

Objectives:
• To describe trend of therapeutic agents prescription in the treatment
of Postmenopausal Osteoporosis (PmOP) over the past 2 decades.
• To study safety data and therapy related adverse events in our
centre.
Methods: We conducted a retrospective review on patient medical
records who received PmOP treatment in Hospital Tuanku Ja'afar
Seremban since year 2000. Data was analysed in two timed period
based on the year OP therapies were initiated (2001–2010 versus
2011–2018). Data was analysed using SPSS 23.0.
Results: 74 patients’ medical records and 105 PmOP treatment events
were analysed. All are female with Chinese prepondarence (65%),
Figure 2
followed by Indian (19.8%), Malay (11.3%) and others (3.8%). There
is increased number of PmOP patients receiving treatment over the
past two decades: 67 treatment events were documented during pe-
riod of 2011–2018, versus 38 treatment events during 2001–2010.
Approximately half had severe OP. Alendronate remained as the
main therapeutic agent used, (48/67[71.6%] vs 37/38 cases [97.4%]).
Other agents prescribed include Strontium (8/67[11.9%], Denosumab
(5/67[0.7%]), Teriparatide (3/67[0.4%]), Zoledronate (2/67[0.3%]),
and Ibandronate were the least prescribed agents, (1/67[0.1%]).
Gastrointestinal intolerance was the main reported adverse event
(2/85[2.35%]) among patients receiving Alendronate. An elderly Indian
lady developed severe eczema while receiving Denosumab. There
were no serious adverse events among patients receiving Alendronate.
Conclusion: We conclude that alendronate is the main therapeutic
agent used for PmOP in our centre, despite with increased usage of
Figure 3 other therapeutic agents. It also has good safety profile. Cost effec-
tiveness and institution policy are the main factors for alendronate
systemic steroid was administrated for further control when infec-
being the main agent used.
tion was excluded.
Conclusion: IVIG may be an effective therapy in SLE patients
with DAH, especially those have potential risk of infection or
complications.
3-­146 | The incidence of granulomatosis with
polyangiitis and takayasu arteritis in Taiwan
C.-S. Wu1; C.-J. Hsieh2; T.-H. Chang1
1
Department of Rheumatology, Far Eastern Memorial Hospital; 2Department of
Healthcare Administration, Oriental Institute of Technology

Background: Epidemiology studies of vasculitis were limited in

Taiwan.
 |
216      
Objectives: To study the incidence of granulomatosis with polyangii-
tis and Takayasu arteritis in Taiwan.
Methods: Incidences of vasculitis were derived from Taiwan National
Health Insurance (NHI) database between 1999–2012, identified ac-
cording to the ICD9 code 446.4 (granulomatosis with polyangiitis,
GPA) and 446.7 (Takayasu arteritis, TKA).
Results: A total of 128 GPA and 73 TKA were documented in the
NHI database between 1999–2012. Female to male ratios were 0.86
and 2.28 in GPA and TKA, respectively. Peak age interval of inci-
dence of GPA and MPA was 51–60 and 41–50.
Conclusion: Our study provided an estimation of the relative inci-
dence of GPA and TKA in Taiwan. Comparison of relative incidence
of GPA and TKA in different regions may shed light on the interac-
tion between genetic background and environment.
3-­026 | Burden of musculoskeletal disorders
in China, 1990–2016: findings from the global
burden of disease study 2016
1 1 2 1
D. WU ; P. Wong ; C. Guo ; L.-S. Tam
1
Department of Medicine & Therapeutics, the Prince of Wales Hospital, the
Chinese University of Hong Kong; 2Jockey Club School of Public Health and
Primary Care, the Chinese University of Hong Kong
Background/purpose: Musculoskeletal (MSK) disorders was a major
contributor to burden from non-­communicable diseases (NCDs) in
developing countries. We present the global burden of MSK disor-
ders in China based on findings from the Global Burden of Disease
Study 2016(GBD 2016).
Methods: Following the general analytical strategy used in GBD 2016,
we present prevalence and disability-­adjusted life years (DALYs) for
six MSK categories (rheumatoid arthritis[RA], osteoarthritis[OA],
low back pain (LBP), neck pain (NP), gout, other MSK disorders and
the burden arising from specific risk factor.
Results: All-­age prevalence and DALYs for RA, OA, LBP, NP, gout,
other MSK disorder increased steadily and significantly from 1990
to 2016. Age-­standardized prevalence rate increased by 11.8%,
10.2%, 0.4%, 0.4% for RA, OA, NP, gout, but decreased by 24.4%,
9.4% for LBP and other MSK disorder. Age-­s tandardized DALYs rate
increased by 10.2%, 0.5%, 0.3% for OA, NP, gout, but decreased by
8.7%, 24.4%, 10.3% for RA, LBP, other MSK disorders. High body-­
mass index account for 14.43%, 4.18%, 20.38% of DALYs from
OA, LBP, gout. Diet high in sugar-­sweetened beverages account
for 0.04%, 0.02%, 0.07% of DALYs due to OA, LBP, gout. Smoking
account for 4.76% and 5.20% of DALYs due to RA and LBP. Only
0.04%, 0.02%, 0.07% of DALYs caused by OA, LBP, gout was at-
tributed to diet high in sugar-­sweetened beverages. Occupational
ergonomic factors account for 31.32% of DALYs due to LBP and
impaired kidney function account for 8.28% of DALYS due to gout.
Compared with other 18-­
member countries of the G20 except
European Union, China ranked first for all-­age DALYs, but last for
the age-­s tandardized rate of DALYs due to musculoskeletal disorder.
Conclusion: Our result suggests that rising burden due to RA, LBP,
other MSK disorder is under effective control, but burden from OA,
NP, gout represents an ongoing challenge.
2-­080 | Effect of biologics on radiographic
progression of peripheral joints in patients with
psoriatic arthritis: a systematic review and meta-­
analysis
D. Wu1; P. Wong1; J. F Griffith2; J. Yue1; L.-S. Tam1
1
Department of Medicine & Therapeutics, the Prince of Wales Hospital, the
Chinese University of Hong Kong; 2Department of Imaging and Interventional
Radiology, the Prince of Wales Hospital, the Chinese University of Hong Kong
Background/purpose: Psoriatic arthritis (PsA) often leads to
structural damage with resultant disability and reduced quality of
life. The aims of this study are to determine the efficacy of the
following drug combinations in preventing radiographic progres-
sion in peripheral joints of PsA patients, namely 1) bDMARDs ver-
sus placebo 2) concomitant methotrexate (MTX) versus bDMARD
monotherapy 3) IL blockers in anti-­TNF-­naïve patients versus anti-­
TNF-­f ailure patients.
Methods: Randomized controlled trials (RCTs) evaluating effect of
biologics on radiographic progression in PsA patients were retrieved
in literature search. Primary endpoint was the proportion of non-­
progressors at week 24. Secondary endpoint was the mean change
in total radiographic score [modified total Sharp score (mTSS) or
modified van der Heijde–Sharp score (mvdH-­SS)] at week 24. This
study was registered with PROSPERO, CRD42018095272.
Results: Nine studies (10 RCTs, 4478 patients), 8 drugs (adali-
mumab, etanercept, infliximab, certolizumab pegol, golimumab,
secukinumab, ustekinumab, ixekizumab) and 16 treatments were
evaluated. Tofacitinib and apremilast were not included due to in-
complete radiographic data.(1) Patients treated with bDMARDs
were more likely to achieve radiographic non-­progression compared
with placebo (OR for pooled:2.41, 95%CI:2.00, 2.92; OR for TNF
blocker:2.84, 95%CI: 2.17, 3.72; OR for IL blocker: 2.15, 95%CI:1.69,
2.74), and have significantly lower radiographic progression (SMD
for pooled: −1.66, 95%CI: −2.32, −1.00; SMD for TNF blocker: −1.71,
95%CI: −2.76, −0.65; SMD for IL blocker: −1.60, 95%CI: −2.49,
−0.72). (2) in patients receiving bDMARDs, concomitant MTX use
was not superior to monotherapy (SMD: 0.01, 95%CI: −0.09, 0.12).
(3) The effect of IL blockers (ustekinuamb, secukinuamb) on radio-
graphic progression were not influenced by prior anti–TNF therapy
(SMD: −0.08, 95%CI: −0.25, 0.10).
Conclusion: Biologic DMARDs can retard radiographic progression
in PsA compared with placebo. Concomitant MTX treatment does
not improve this effect. Prior anti-­TNF therapy does not influence
the radiographic efficacy of IL blockers.

1-­100 | Patient-­reported outcomes from a
phase 3 study of baricitinib versus placebo
in rheumatoid arthritis patients: Chinese
subpopulation analysis in RA-­BALANCE
Z. Li1; Y. Yang2; J. Hu2; C. Bao3; X. Li4; X. Li5; J. Xu6; X.
Zhang7; J . Xu8; D. He9; Z. Li10; G. Wang11; H. Wu12; F. Ji12; L.
Zhan12; T. Rooney13; C. Gaich13
1
Peking University People's Hospital; 2Jiangxi Pingxiang People's Hospital; 3Renji
Hospital Shanghai Jiaotong University School of Medicine; 4Qilu Hospital of
Shandong University; 5Anhui Provincial Hospital; 6The first affiliated hospital
of Anhui Medical University; 7GuangHua Hospital; 8First Affiliated Hospital
of Kunming Medical University; 9GuangHua Hospital; 10Affiliated Hospital
of Bengbu Medical College; 11China-­Japan Friendship Hospital; 12Eli Lilly and
Company; 13Eli Lilly and Company
Background: Baricitinib, an oral selective inhibitor of JAK1 and JAK2,
was efficacious in a Phase 3 study (RA-­BALANCE, NCT02265705) in
patients with moderately to severely active rheumatoid arthritis and
an inadequate response to methotrexate.
Objectives: To evaluate effect of baricitinib on patient-­reported out-
comes (PROs) from RA-­BALANCE in Chinese sub population.
Methods: In this double-­
blind study, patients were randomized
1:1 to placebo (n = 145) or baricitinib 4-­
mg once daily (n = 145)
plus background methotrexate. PROs included European Quality
of Life-­5 Dimensions-­5 Level (EQ-­5D-­5L), Functional Assessment
of Chronic Illness Therapy-­Fatigue (FACIT-­F ), Health Assessment
Questionnaire-­
Disability Index (HAQ-­
DI), Patient's Global
Assessment of Disease Activity (PtGA), patient's assessment of pain
and Work Productivity and Activity Impairment Questionnaire-­
Rheumatoid Arthritis (WPAI-­R A). Analyses were conducted on a
modified intent-­to-­treat basis and included all randomized Chinese
patients treated with ≥1 dose of study drug (n = 115 for placebo and
n = 116 for baricitinib). Treatment comparisons were assessed with
logistic regression for categorical measures or analysis of covariance
for continuous variables.
Results: At baseline, mean HAQ-­D I was 1.47 for placebo and 1.50
for baricitinib. Compared to placebo, baricitinib showed statisti-
cally significant improvements (P ≤ 0.05) in HAQ-­D I, PtGA, pain,
FACIT-­F, EQ-­5D-­5L index scores and WPAI-­R A presenteeism and
activity impairment scores at Weeks 12 and 24. Improvements
were observed within 1–2 weeks after starting treatment for
HAQ-­D I, PtGA and pain and within 4 (the first assessment) to
16 weeks for other PROs. Improvements were maintained to
Week 52.
Conclusions: In this study, baricitinib was associated with significant
improvements compared to placebo in physical function, pain, fa-
tigue and quality of life in Chinese patients.
|
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1-­046 | Isorhamnetin ameliorates inflammatory
responses and articular cartilage damage in
the rats of monosodium iodoacetate-­induced
osteoarthritis
D.-H. Yang1,2; F.-C. Liu2; C.-C. Lu2; S.-Y. Kuo2; S.-J. Chu2; H.-
C. Chen2
1
Taichung Armed Forces General Hospital; 2Tri-­Service General Hospital,
National Defense Medical Center
Background: Osteoarthritis (OA) is a degenerative joint disease
with damage to the articular cartilage. Active production of inflam-
matory cytokine/chemokine and matrix metalloproteinases may be
found during the progression of OA. Isorhamnetin had the effects
of anti-­inflammatory, antioxidant, anti-­ischemia, anti-­atherosclerotic
hepatoprotective and anticancer activities. Our study was focused
on the effects of isorhamnetin treatment in OA.
Methods: We used monosodium iodoacetate (MIA)-­induced OA rats
to evaluate the effects of isorhamnetin related anti-­inflammatory
process. The rats in all groups were sacrificed on four weeks post-­
MIA injection. The measurements of knee joint swelling, histologi-
cal analysis, serum inflammatory biomarkers and Western blot were
evaluated.
Results: We found that isorhamnetin may reduce MIA-­
induced
knee swelling by significantly reduction of articular cartilage dam-
age.in rats. Suppression of pro-­inflammatory cytokines production
was found after isohamnetin treatment. Isorhamnetin inhibited the
production of NO and PGE2, and the expression of iNOS and COX-­
2. The production of COMP and CTX-­II were also inhibited in MIA-­
induced OA rats.
Conclusion: Isorhamnetin may modulate the inflammatory progres-
sion of OA in MIA-­induced OA rats. The prevention of cartilage
damage was found in OA after adequate isorhamnetin treatment.
Isorhamnetin may serve as a potential agent for the management
of OA.
3-­147 | A comparison of the health assessment
questionnaire-­disability index and modified
health assessment questionnaire to assess
physical function in polymyalgia rheumatica
V. Yang1; C. Owen1,2; J. Leung1,2; A. Scott1,2,3; R. Buchanan1,2
1
Austin Health; 2University of Melbourne; 3Olivia Newton-­John Cancer
Research Institute
Background/purpose: Physical function is endorsed by OMERACT
as a core domain that must be measured in all clinical trials of poly-
myalgia rheumatica (PMR). Little is known however about the de-
gree of disability experienced by PMR patients nor is there certainty
about the best instrument to measure functional status.
Objectives: To compare the Health Assessment Questionnaire-­
Disability Index (HAQ-­
DI) and Modified Health Assessment
 |
218      
Questionnaire (MHAQ) in assessing physical function and their cor-
relation with disease activity in PMR.
Methods: Data for HAQ-­DI, MHAQ and disease activity (using the
PMR-­Activity Score [PMR-­A S]) was obtained from the Melbourne
Predictors of Relapse in PMR (MPR-­PMR) study: a prospective ob-
servational cohort comprising 37 patients with newly diagnosed
PMR (2012 EULAR/ACR Classification Criteria) treated with a stand-
ardised weaning course of prednisolone for 46 weeks or until the
addition of a steroid-­sparing agent was indicated.
Differences between HAQ-­DI and MHAQ scores were assessed
using the Wilcoxon signed-­rank test, whilst Spearman's rank corre-
lation coefficient elucidated the relationship between HAQ-­DI and
MHAQ, and PMR-­A S respectively. All statistical analysis was con-
ducted using Stata 13.0.
Results: Complete data was available for 31/37 patients (83.8%). Mean
age was 69.58 ± 8.01, 55% were male and 97% Caucasian. Median CRP
was 40.2 (24.7–67.1) and ESR 48 (29–69) at diagnosis, whilst median
PMR-­AS was high (67 [51.7–98]). A statistically significant difference in
HAQ-­DI and MHAQ scores was observed at weeks 0, 4, 16, 24 and 46
(Table 1), with HAQ-­DI consistently scoring higher than MHAQ. The
HAQ-­DI correlated better with PMR-­AS at diagnosis (0.35 cf. 0.21),
however MHAQ outperformed HAQ-­DI during follow-­up.
Conclusion: HAQ-­DI appears to be a more sensitive measure of disabil-
ity than MHAQ in PMR patients. in low disease activity states, HAQ-­DI
scores were higher indicating poorer physical function, however the
clinical significance of this finding is unclear and warrants further study.
Table 1. A comparison of mean HAQ-­DI with MHAQ scores
Visit Mean HAQ-­DI Mean MHAQ P-­value
Week 0 1.78 ± 0.66 1.36 ± 0.54 <0.0005
Week 4 0.49 ± 0.59 0.27 ± 0.40 <0.0005
Week 16 0.28 ± 0.50 0.14 ± 0.31 0.0029
Week 24 0.30 ± 0.53 0.18 ± 0.35 0.0029
Week 46 0.28 ± 0.55 0.15 ± 0.35 0.0085
1-­047 | Correlation of serum MMP-­3 levels
with time course after the onset of rapidly
progressive osteoarthritis of the hip
T. Yasuda; E. Onishi; S. Ota; S. Fujita; T. Sueyoshi; T.
Hashimura
Kobe City Medical Center General Hospital
Background/purpose: Rapidly progressive osteoarthritis of the hip
(RPOH) is an unusual subset of osteoarthritis. It is characterized by
rapid joint space loss, chondrolysis, and sometimes marked femoral
head and acetabular destruction as a late finding. Although the exact
pathogenetic mechanism is unknown, potential causes of RPOH in-
clude high serum levels of MMP-­3 as biological factors. This study
was aimed to elucidate association of MMP-­3 with the time course
after the onset of RPOH.
Methods: Of female patients who visited our hospital with hip pain
from 2012 through 2018, this study enrolled female patients with
the clinical records including the onset of hip pain, a series of ra-
diographs during the period of ≥12 months from the onset of hip
pain, and hematological data of MMP-­3. We found the hip joints
of 30 patients meet the diagnostic criteria of RPOH; chondroly-
sis >2 mm with subsequent femoral head destruction in one year.
Serum MMP-­3 was measured with blood samples within one year
after the onset. This study excluded male patients because RPOH
occurs mainly in elderly females and the reference intervals (RIs) of
MMP-­3 are different between males and females.
Results: When the approximate curve obtained from the scatter
diagram of serum MMP-­
3 concentrations obtained from 30 pa-
tients with RPOH were plotted in association with the duration be-
tween the onset of hip pain and MMP-­3 determination, we found
a significant exponential decrease in MMP-­3 with time (R 2=0.304,
P = 0.002). MMP-­3 kept higher levels over >59.7 ng/mL, the upper
limit of RI, within 10 months after the onset in every patient with
RPOH.
Conclusion: In patients with RPOH, serum MMP-­3 may stay at in-
creased levels during the period of chondrolysis after the onset of
hip pain and thereafter decrease with time.
3-­121 | A multi-­centre retrospective cohort
study assessing incidence of serious infections in
lupus nephritis patients, compared to non-­renal
systemic lupus erythematosus
D. Yates1; S. Y. Mon1; Y. Oh1; M. S. Okano3; M. Soden2; V
Manickam2; P. Kubler1; D. Ranganathan1
1
Royal Brisbane and Women's Hospital; 2The Townsville Hospital; 3QIMR
Berghofer Medical Research Institute
Background/purpose: Serious infections are common in Systemic
Lupus Erythematosus (SLE) and incidence is poorly defined in lupus
nephritis (LN). The aim of this study was to determine the incidence
of serious infections in patients with SLE and LN, compared to pa-
tients with non-­renal SLE (NRSLE) and to determine factors contrib-
uting to risk.
Methods: A multi-­
centre retrospective cohort study was con-
ducted. Patients with LN at two tertiary referral centres and were
matched, where possible with up to two age and gender matched
controls with NRSLE. Serious infections were defined as any in-
fection requiring inpatient admission, six months following index
visit. Cox regression analysis determined the association between
risk of serious infection and the primary variable, LN status, and
other covariates.
Results: 178 patients were included within the analysis (n = 87 LN,
n = 91 NRSLE). 9.2% of patients with LN experienced ≥1 serious in-
fection, versus 6.6% of patients with NRSLE. Incidence was 19.5 and
13.6 infections per 100 patient-­years in LN and NRSLE patients re-
spectively (P = 0.73). Median prednisone dose (mg) was significantly

higher in LN vs NRSLE (5.0 IQR  =  3.0–15.0) vs 0.0 (0.0–5.0) P < 0.001).
Multivariate Cox regression found no significant increased risk of
serious infection in patients with LN vs NRSLE (HR = 1.12; 95% CI:
0.26–4.91), however each 5 mg increase in prednisone dose was as-
sociated with HR = 1.23 (CI: 1.06–1.42, P = 0.007). ≥2 immunosup-
pressant agents excluding prednisone did not increase infection risk
(HR 1.92; CI 0.64–5.74). SLEDAI (HR = 0.97; CI: 0.89–1.06) and co-
morbidity index (HR = 1.14 CI: 0.97–1.33) were not associated with
risk of serious infection.
Conclusion: The incidence of serious infections in this study was
comparable to previous research. Lupus nephritis alone did not ap-
pear to increase risk of serious infections compared to patients with
NRSLE. Increased prednisone dose at baseline visit independently
increased risk of serious infection.
3-­062 | Serum complement regulatory
proteins predict the therapeutic response
of cyclophosphamide in patients with lupus
nephritis
K.-W. Yeh; M.-H. Tseng; J.-L. Huang
Chang Gung Memorial Hospital
Background: Complement regulatory proteins (CRPs) are associated
the activity of systemic lupus erythematosus. The association be-
tween change of serum CRPs and the response of cyclophosphamide
pulse therapy in lupus patients of nephritis needs to be elucidated.
Method: We enrolled the pediatric-­onset lupus patients of class
III, IV and V lupus nephritis with cyclophosphamide pulse therapy
from our cohort study from 2012 to 2017. The clinical response,
laboratory data and serum levels of complement factor H (CFH), CFI,
CD46, and C5b-­9 were determined.
Results: 37 (30 female and 7 male, aged 13.9 ± 3.8 years) patients
with lupus nephritis received cyclophosphamide treatment dur-
ing study period. 16 patients reached remission of nephritis after
cyclophosphamide puls etherapy, and 21 did not respond. All en-
rolled patients exhibited lower serum C3, C4, CFH and CFI and
higher serum anti-­dsDNA and CD46, and the mean SLEDAI in the
diagnosis of lupus nephritis was 12.6. There was a significant differ-
ence in serum CFH and CD46 at 6 months between patients with
cyclophosphamide-­response and those without cyclophosphamide-­
response. Serum CFI but not CD46 level was negatively correlated
with renal SLEDAI score at 6 months phase. Compared to classical
activity markers, serum CFH was superior to C3, C4 and anti-­dsDNA
in reflecting the therapeutic response of cyclophosphamide in pa-
tients with lupus nephritis.
Conclusion: Our data demonstrated that the serum CRPs levels are
associated with the therapeutic responses of cyclophosphamide in
patients with proliferative lupus nephritis.
|
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3-­028 | Clinical audit of malignancies among
patients with chronic rheumatic diseases in
hospital Melaka (Malaysia)
Y. Jasmine; Q. CT; H. C. Chong
Melaka Hospital
Background: Improved understanding and management of chronic
rheumatic diseases (CRD) have led to a longer life expectancy of pa-
tients with these conditions. Hence, there is a real concern of higher
cancer risk with advanced age and prolonged exposure to immuno-
suppressive therapy such as methotrexate (MTX) and Azathioprine
(AZA).
Objective:
• To document incidence of malignancy among CRD patients in
Hospital Melaka
• To describe demographic characteristics of these patients diag-
nosed with malignancy
Materials and method: Medical records of 26 CRD patients with
malignancies were traced from the record office and reviewed. We
excluded one patient record as clinically relevant information was
lacking.
Results: Majority of our cohort were patients with rheumatoid ar-
thritis (RA) (n = 15) and systemic lupus erythematosus (SLE) (n = 4).
Others have scleroderma (n = 3), psoriatic arthropathy (PsA) (n = 1),
dermatomyositis (n = 1) and primary Sjogren's syndrome (n = 1).
Mean age is 61.7 ± 8.3 years and 88% are females. One patient
with lung adenocarcinoma is a smoker. Three patients had a fam-
ily history of malignancy, 2 of whom had breast carcinoma. Mean
duration of immunosuppression with MTX or AZA in patients with
non-­Hodgkin's lymphoma (NHL) is 55 and 13 months respectively.
Conclusion: Patients with CRD are at higher risks for malignancies
compared to the general population, in particular, RA patients have
increased risk of lymphoproliferative disorder. Unfortunately, it is
difficult to distinguish if chronic inflammation and disease related
mechanisms, or treatment with immunosuppressive drugs account
for this increased risk. Studies have reported associations of MTX
 |
220      

unstable group (P = 0.016). At onset, medium-­size arteries were

affected more in unstable patients (P = 0.048), and involvement
of branches below the aortic arch were more common in stable
group (P = 0.034). Higher monocytes at onset (P = 0.043), higher
lymphocytes (P = 0.014) and significantly lower erythrocyte sed-
imentation rate (ESR) after treatment (P = 0.041) were found in
stable group.
Conclusion: This study discussed factors predicting the prognosis of
GCA in a group of Chinese patients. Patients who experienced fever
and stronger inflammation at the onset of disease may have higher
predisposition toward an unstable clinical outcome. Higher mono-
cytes at onset and higher lymphocytes after treatment may indicate
the stable outcome in GCA.

and Aza with lymphoproliferative disorders. Five out of our 15 RA

patients with malignancy had NHL. All of patients with NHL were
exposed to MTX or Aza immunosuppression. But, further studies are
needed to properly understand the mechanism of differences in the
risk of certain malignancies compared to general population.

3-­148 | Factors predicting prognosis of giant

cell arteritis: a retrospective study of Chinese
patients
Y. Yin1; Y. Zhang1; D. Wang2; X. Chu1; M. Shen1; X. Zeng1
1
Peking Union Medical College Hospital PUMCH; 2Nan fang Hospital of Southern
Medical University

Background: Glucocorticoid (GC) is the most effective treatment

for giant cell arteritis (GCA). Nevertheless, patients may experience
relapses or severe complications during GC tapering. This retrospec-
tive study was to identify the potential clinical predictors that may
be associated with the prognosis of GCA.
Methods: This study retrospectively evaluated the clinical re-
cords of 91 patients with GCA in Peking Union Medical College
Hospital. Patients were followed up for an average of 86.04 months.
According to the clinical outcomes, patients were divided into stable
group (in remission) and unstable group (relapse/recurrence or with
severe complications).
Results: There were 37 patients in the stable group and 40 pa-
tients in the unstable group. Fever, tenderness and abnormal
pulsation of temporal artery and jaw claudication were more
frequently observed in unstable group (P = 0.029, 0.049, 0.043,
respectively). Fever as an onset symptom was more common in

3-­014 | 4-­phenylbutyric acid ameliorates lupus
hepatitis and nephritis through suppression of
NF-­kB activation in experimental lupus model
Y. Choi; W.-H. Y. Yoo; E. Lee; J. Jeong
Chonbuk National University Hospital
Introduction: The purpose of the present study was to investigate
whether ER stress inhibition suppresses organ inflammation includ-
ing liver and kidney in lupus murine model and the activation of mi-
togen activated protein kinases (MAPK) and NF-­kB.
Methods: A murine lupus model was induced through a 4-­week
treatment with Resiquimod, a toll-­like receptor agonist 7. From the
8th week, the mice were treated with phosphate buffered saline,
4-­
phenylbutyric acid (4-­
PBA), and dexamethasone for 4 weeks.
The increment of body weight, liver weight, inflammation mediator
level, and the pathology of hepatitis and nephritis were analyzed at
12 weeks of age. The level of phosphorylated MAPK expression and
activation of NF-­kb were also evaluated.
Results: 4-­PBA-­treated group showed lower level of body weight
increment with liver to body weight ratio compared with vehicle-­
treated group. 4-­PBA group showed decreased inflammatory cell
infiltration and fibrosis in the histologic finding of liver and kidney
and lower level of inflammatory mediators, including TNF-­α and IL-­6,
compared to vehicle-­group. GRP78 and CHOP expression was de-
creased in the spleen of 4-­PBA treated mice compared to vehicle-­
treated mice and 4-­PBA group showed the lower expression level of
phosphorylated JNK, ERK, p38 and NF-­kB of the spleen.
Conclusion: Our results suggest that 4-­PBA attenuates the inflam-
mation on liver and kidney of experimental lupus model through sup-
pression of MAPK and NF-­kB activation. Thus, inhibition of ER stress
could be function as anti-­inflammatory therapeutics for SLE.
|
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1-­075 | Combination effect of exercise
instruction and biologics on rheumatoid arthritis
patients – a randomized controlled trial
K. Yoshida1,2; F. Oda1; T. Shoujinaga1; M. Kawasaki1; Y.
Yoshida1; A. Okada3; T. Suzuki3; A. Kawakami4; T. Origuchi2,4
1
Department of Rehabilitation, the Japanese Red Cross Nagasaki Genbaku
Hospital; 2Department of Rehabilitation Sciences, Nagasaki University Graduate
School of Biomedical Sciences; 3Department of Rheumatology, the Japanese
Red Cross Nagasaki Genbaku Hospital; 4Department of Immunology and
Rheumatology, Nagasaki University Graduate School of Biomedical Sciences
Background: Biological agents are well known to improve the ADL
and QOL of rheumatoid arthritis (RA). But there are few studies in-
vestigating the combined effect of biologics and physical therapy.
Objectives: This study is aimed to elucidate the combined effects of
biologics and exercise instruction.
Methods: Thirty-­nine patients were admitted to our hospital for the
initiation of biological agents from October 2017 to June 2018. We
randomly assigned these patients to control group and exercise in-
struction group. We conducted guidance on living behavior in the
control group, and instructed walking and standing sitting exercise in
addition to living action instruction to the exercise instruction group.
We conducted exercise intensity of modified Borg Scale 2 to 3 at a
frequency of twice to 4 times/wk and continued to instruct these
exercise for 3 months. We examined the disease activities, ADL and
psychological assessment before and 3 months after the initiation of
biologics treatment.
Results: Fifteen patients in the control group and 13 patients in the
exercise instruction group were completed this study program. In
both groups, tender joint number, swollen joint number, erythrocyte
sediment rate, DAS28-­CRP and mHAQ were likely to be improved.
In addition, in the exercise instruction group, daily role (mental) and
mental health in SF-­36 was significantly improved after the exercise
instruction compared to before the instruction.
Conclusion: We suggested that exercise instruction could add the
psychological effects on the effectiveness of biologics without
worsening the disease activities.
3-­086 | Study of 31 pregnancies during
rheumatoid arthritis treatment: treatment course,
condition of newborns, and problems
T. Yoshida1,2; Y. Akiyama1,2; N. Katsuyama1,2
1
Setagaya Rheumatology Clinic; 2Toshin Yoshida Internal Medicine
Rheumatology
Aim: To analyse the pregnancy of 31 women during RA treatment in
our hospital (treatment before, during and after pregnancy, health
condition of newborn), contributing to the underdeveloped opus
of studies on pregnancy in women with Rheumatoid Arthritis (RA)
Method: Analysis of RA patients in our clinic becoming pregnant be-
tween April 2013 and August 2018, including disease activity before,
 |
222      
during and after pregnancy, treatment method, and condition of new-
born. Survey of rubella and measles vaccination status during pregnancy.  quantitative real time PCR assay. Overexpression of LOC645166
Result: 31 cases of pregnancy, at average age of 34.8 years, with
average RA condition of 8.52 years.
Treatment before pregnancy with biological formulation in 24 cases
(14 cases of ETN, 4 cases of CZP, 2 cases of GLM, 1 case each of IFX,
ADA, TCZ, ABT), 3 cases of biological formulation with PSL (2 with
ETN, 1 with CZP), 2 cases of SASP with PSL, 1 case of PSL alone, and
1 case of no previous treatment.
Median DAS28 of 1.74 before pregnancy, median DAS28 of 2.45 at
birth, with lower disease activity in all cases.
After birth, 10 cases of no further treatment, 3 cases of PSL treat-
ment, 2 cases of SASP with PSL treatment, 12 cases of biological for-
mulation with PSL, and 4 cases where further treatment is unknown.
No case of malformation of newborns, and no cases of irregularities
detected 1 month after birth in mother and child.
19 cases where rubella antibody titer were confirmed (11 cases of
positive antibody titer, 8 cases of negative antibody titer after ru-
bella vaccination).
Conclusion: Safe delivery was achieved due to controlling disease
activity during pregnancy in the future, it is necessary to analyse the
further health condition of the babies, and to establish a vaccination
method to prevent congenital rubella syndrome.
1-­122 | Characterization of the role of
IncRNAs in regulation of ankylosing spondylitis
pathogenesis
H. Yu1; H.-B. Huang2; M.-C. Lu1; K-.Y. Huang1; N.-S. Lai1
1
Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation; 2National Chung
Cheng University
Background: Ankylosing spondylitis (AS) is a chronic systemic in-
flammatory disease. AS is highly associated with the expression of
HLA-­B27. Up to 95% AS patients are HLA-­B27-­positive. However,
only 1–2% of all people who are HLA-­B27-­positive suffer from AS,
suggesting that other genetic and environmental factors may de-
termine the development of AS. Long non-­coding RNAs (lncRNAs)
can serve as the cis-­acting or trans-­acting factors and modulate the
immune-­related gene expression and thereby control innate immune
response as well as T-­cell activation, development, and differentia-
tion. in this study, I characterize whether lncRNAs have a potential
role in regulation of the developmental progress for AS.
Methods: The levels of lncRNAs of AS patients were analyzed by
using microarrays and quantitative real-­time PCR. Jurkat cells were
used to determine whether overexpression of lncRNAs affects the
mRNA expressions of inflammation cytokines. Western blotting was
used to analyze the signaling pathway induced by overexpression of
lncRNAs in Jurkat cells. Finally, RNA pull-­down assay combined with
mass spectrometry was used to identify the lncRNA-­binding proteins
Results: The levels of nine lncRNAs in AS patients were sig-
nificantly reduced in microarray assay. Four, LOC100506014,
LOC645166, lncEXD2-­1 and LINC00282, of them were reduced in
in Jurkat cells can down-­regulate the mRNA expression of IL-­23
and suppress the Jak/Stat signaling in response to treatment
of phorbol 12-­
myristate 13-­
a cetate (PMA). Overexpression of
LOC100506014 in Jurkat cells suppresses the mRNA expression of
interferon □ (INF-□). in RNA pull-­d own assay, I identified that five
proteins, spectrin alpha chain, non-­e rythrocytic 1, heterogeneous
nuclear ribonucleoprotein H3, U1 small nuclear ribonucleoprotein
70 kDa, PC4 or SFRS1-­interacting protein and polyubiquitin-­C ,
can associate with LOC645166.
Conclusion: Both LOC645166 and LOC100506014 may involve in
pathogenesis of AS.
3-­063 | Cerebrovascular infarction in an
adolescent with systemic lupus erythematosus
and positive antiphospholipid antibody: a case
report
A. Yumul; M. F. C. Jocson; C. Tee; L. Dans
Philippine General Hospital
Background: The presence of antiphospholipid antibodies has been
associated with an increased risk of thromboembolic events in lupus
patients. While this phenomenon has been well described in adults,
reports on the incidence of these events in pediatric SLE patients
are limited.
Objective: To report a case of a Filipino adolescent female who was
recently diagnosed with systemic lupus erythematosus and posi-
tive antiphospholipid antibodies presenting with sudden-­onset right
sided upper extremity weakness.
Description: A 16-­year-­old Filipino female presented with a 2-­day
history of sudden-­onset weakness of her right upper extremity grad-
ually involving her right lower extremity one month after she was
diagnosed with Systemic Lupus Erythematosus with positive lupus
anticoagulant. Physical examination revealed flattening of the right
nasolabial fold with tongue protrusion deviated to the right. There
was also 3/5 motor power on both right upper and lower extremities
with intact sensation. Plain cranial CT scan showed the presence of
an acute infarct on the left parietal and frontal lobes with no evi-
dence of acute intracranial hemorrhage.
Discussion: Thromboembolism is an occasional but important occur-
rence in pediatric systemic lupus erythematosus with a prevalence
of 16–36%. It has been noted that the incidence of thrombosis in-
creased on the first year of diagnosis. Aside from high disease activ-
ity and circulating immune complexes, an associated increased risk
for early thrombosis has been attributed to the presence of circulat-
ing antiphospholipid antibodies among pediatric SLE patient where
up to 44% of them have positive antiphospholipid antibodies and 9%
of patients develop a thrombus.

Conclusion: Patients recently diagnosed with systemic lupus ery-
thematosus and with positive antiphospholipid antibodies should
be closely monitored for possible thromboembolic events that may
occur as early as their first year from diagnosis.
2-­062 | Tuberculosis infection in chinese
patients with giant cell arteritis
Y. Zhang1; D. Wang2; Y. Yin1; Y. Wang1; H. Fan1; W. Zhang1;
X. Zeng1
1
Peking Union Medical College Hospital (PUMCH); 2Nan fang Hospital of
Southern Medical University
Introduction: Giant cell arteritis (GCA) is a medium-­and large-­vessel
vasculitis with an onset age after 50 years. The association between
tuberculosis (TB) and Takayasu arteritis (TA) which is also a large-­
vessel vasculitis with an onset age younger than 40 years was sug-
gested. However, the association between GCA and TB was rarely
reported.
Methods: Clinical data between November 1998 and October 2017
at Peking Union Medical College Hospital, Beijing, China, were retro-
spectively reviewed. Ninety-­one patients diagnosed with GCA were
included in the study. Precise clinical data were collected and ana-
lyzed. This study has been approved by the Ethics Board of Peking
Union Medical College Hospital and the ethics approval number is
S-­K437.
      223|
Results: A total of 20 patients (22.0%) had a history of active tu-
berculosis and received anti-­
tuberculosis therapy. On comparing
the clinical features of patients with GCA and concomitant TB and
those without TB, obvious weight loss (P = 0.011), lower percentage
of dyslipidemia (P = 0.042), higher percentage of anti-­phospholipid
antibodies (P = 0.010), and lower white blood cells (P = 0.006) were
noted in the TB group.
Conclusion: This study demonstrated that the percentage of TB
history in patients with GCA was higher than that in the Chinese
general population. The definite association between TB and GCA
remains unknown. Hence, further studies are required to eluci-
date the mechanisms underlying TB in the pathogenesis of GCA.
Clinicians should recognize the possibility of comorbid TB in pa-
tients with obvious weight loss and relatively lower white blood
cell count.
3-­029 | Preparation and biological effects of
iguratimod nanoscale sustained release system
Z. Ma1; C. Tao2; L. Sun1; J. Zhang2; J. Zhao1
1
Department of Rheumatology and Immunology; Peking University Third
Hospital; 2College of Chemical Engineering, Beijing University of Chemical
Technology
Background: Iguratimod is a novel disease-­
modifying antirheu-
matic drug with remarkable efficacy in treating RA. In order to
improve the bioavailability and alleviate the side effect of gastro-
intestinal reaction, we changed the dosage form of Iguratimod to
NanoIguratimod-­loaded Hydrogel Composite. The biological prop-
erties and therapeutic effect of NanoIguratimod@Hydrogel were
compared with the raw Iguratimod in vitro and in vivo.
Methods: We used the high-­
gravity anti-­
solvent precipitation
(HGAP) technique to prepare NanoIguratimod and tested its proper-
ties. The NanoIguratimod-­loaded Hydrogel Composite was prepared
and the delivery of the payload was demonstrated. In vitro, the bio-
logical effects of NanoIguratimod@Hydrogel on fibroblast-­like syn-
oviocytes (RA-­FLS) were evaluated. In vivo, the pharmacokinetics of
oral Raw Iguratimod or subcutaneous injection of NanoIguratimod@
Hydrogel was carried out in the healthy rats. Further, we evaluated
the efficacy of NanoIguratimod@Hydrogel in treating collagen-­
induced arthritis (CIA) rats.
Results: By the HGAP technique, we acquired the amorphous form
NanoIguratimod with an average sizes of 295 nm, which had higher
dissolution rates and high stability. The release of Iguratimod from
hydrogel composite in PBS was gradual and sustained for up to
48 hour compared with NanoIguratimod. Different concentrations
of NanoIguratimod@Hydrogel inhibited the proliferation, migration
and invasion of RA-­FLS. The pharmacokinetic parameters showed
better bioavailability and longer half-­life time with NanoIguratimod@
Hydrogel by subcutaneous administration than oral raw Iguratimod.
Animal experiments confirmed that subcutaneous injection of
NanoIguratimod@Hydrogel (10 mg/kg every three days) and oral
 |
224      

Raw Iguratimod (10 mg/kg daily) showed similar efficacy in decreas- Table 1. Demographic characteristics of PE, and non-­PE groups of
ing arthritis index score, pathological score, and expression of cy- patients with systemic lupus erythematosus
tokines (IL-­6, TNF-­a and IL-­1β). non-­PE
Conclusions: Overall, our data suggested NanoIguratimod@ Variable PE (n = 77) (n = 231) P value
Hydrogel provided new administration routes and extended the ad- Female, n, (%) 63 (81.8%) 193 (83.5%) 0.726
ministration interval, it may serve as a promising drug delivery ap-
Age at study entry 38.03 ± 3.78 38.08 ± 3.64 0.977
proach for the treatment of RA. (mean ± SE, range in (10–66) (13–68)
years)
Age at SLE diagnosis 35.10 ± 3.71 31.87 ± 3.65 0.068
(mean ± SE, range in (10–64) (7–64)
3-­123 | Clinical features and risk factors of years)
pulmonary embolism in patients with systemic SLEDAI (mean ± SE) 10.17 ± 2.70 7.05 ± 2.65 0.001
lupus erythematosus Values in bold are statistically significant at P < 0.05.
H. You; J. Zhao; Q. Wang; X. Zeng; M. Li SE: standard error; SLEDAI: Systemic Lupus Erythematosus Disease
Department of Rheumatology, Peking Union Medical College Hospital, Chinese Activity Index.
Academy of Medical Sciences & Peking Union Medical College Table 2. Complications and prognosis in SLE-­PE group

Short-­term symptoms/complications n (%)

Purpose: To explore the clinical features and risk factors of pulmo-
Shock 2 (2.6%)
nary embolism (PE) in patients with systemic lupus erythematosus
Hemoptysis 7 (9.1%)
(SLE).
Stethalgia 18 (23.4%)
Methods: A case-­control study was conducted in patients complicated
Fever 18 (23.4%)
with PE among SLE patients admitted to Peking Union Medical College
Hospital from 2012 to 2017. Clinical and laboratory data of case group Death 7 (9.1%)

(SLE-­PE) and age-­, sex-­, and entry-­time-­matched control group (SLE-­ Long-­term complications
non-­PE) were analyzed by the single factor analysis and multivariate Chronic thromboembolic pulmonary hypertension 23 (29.9%)
analysis to explore the risk factors of PE among SLE patients. A P value
of 0.05 or less was considered to be statistically significant.
Results: 77 patients were eligible for enrollment into the case
group and 231 contemporaneous SLE patients without PE as the
control group. Among the SLE-­PE group, the majority were female
(63/77; 81.8%), with a mean SLE course of 29.04 ± 6.61 months
before PE events and a high mortality rate of 9.1% after PE (Table 1
& 2). Multivariate analysis revealed that duration of SLE<1.5 years
(odds ratio (OR) 5.129, P < 0.001), lupus nephritis (OR 3.225,
P = 0.001), thrombocytopenia (OR 3.121, P = 0.005), high hyper-
sensitive c-­reactive protein (hsCRP) (OR 6.937, P < 0.001), anti-­
SSA positive (OR 2.989, P = 0.003) and aPL positive (OR 9.15,
P < 0.001) were independent significant risk factors of PE in SLE
patients (Figure 1).
Conclusion: PE is a serious complication among SLE patients with 3-­124 | The risk factors and prognosis
a high mortality rate. The risk is higher during the first year im-
of primary Sjögren's syndrome-­associated
mediately after the diagnosis of SLE. Shorter SLE course less than
interstitial lung disease: a multi-­centered cohort
1.5 years, positive antiphospholipid antibodies, lupus nephritis and
elevated inflammatory markers are independent risk factors of PE study
among SLE patients. J. Zhao; Z. Liu; Q. Wang; D. Xu; M. Li; X. Zeng
Peking Union Medical College Hospital

Purpose: This study aimed to investigate the risk factors and prog-
nosis of primary Sjögren's syndrome-­associated interstitial lung dis-
ease (pSS-­ILD) a multi-­centered cohort.
Method: Data were retrospectively collected from Peking Union
Medical College Hospital and 27 CTD-­ILD centers in China. Chest
high resolution CT and pulmonary function test were performed
 |
      225

to confirm and evaluate ILD. Patients with pSS but without lung
involvement (pSS-­non-­ILD) were enrolled as controls. The primary
end point was all-­cause death, and the secondary end point was ILD
deterioration.
Result: A total of 258 patients with pSS-­ILD were enrolled, and
89.1% were female. The age at baseline were 58.0 ± 10.6 years.
3-­017 | Vitamin D protects podocytes from
autoantibodies induced injury in lupus nephritis
by reducing aberrant autophagy
Q. Yu; Z. Zheng; Z. Liu
The First Affiliated Hospital of Zhengzhou University

In 44.2% of the patients, ILD was the initial manifestation of pSS.

The most common radiologic pattern was nonspecific interstitial
pneumonia (NSIP). In case control study, 1243 patient with pSS but
without ILD were enrolled. Male gender (OR 2.494, 95%CI 1.166–
5.333, P = 0.018), age of pSS onset (OR 1.066, 95%CI 1.047–1.085,
P < 0.001), anti-­
Ro52 antibody (OR 2.797, 95%CI 1.585–4.936,
P < 0.001), and C-­reaction protein (OR 1.015, 95%CI 1.003–1.027,
P = 0.017) were identified as independent risk factors for develop-
ing ILD in pSS. Eighteen patients died. The 1-­, 3-­, and 5-­year survival
rates were 98.1%, 93.6%, and 87.6%, respectively. Male gender (HR
4.810, 95%CI 1.271–18.205, P = 0.021), older age (HR 1.079, 95%CI
1.008–1.156, P = 0.033), and DLCO/pred% <50% (HR 5.762, 95%CI
1.149–28.891, P = 0.028) were identified as independent prognostic
factors. A total of 42 patients entered the ILD deterioration analy-
sis, and 14 patients deteriorated. Organizing pneumonia (OR 5.258
95%CI 1.014–27.262, P = 0.048) was identified as predictive factors
for ILD deterioration.
Conclusion: This study presents a large cohort of Chinese patients
with pSS-­ILD, providing evidence for early diagnosis as well as prog-
nosis predicting.
Subject: The aim of this study was to investigate whether vitamin D
plays a protective role in podocyte injury induced by autoantibodies
purified from lupus nephritis (LN) patients serum via autophagic way.
Methods: Autophagic activities of LN patients renal tissues were
evaluated under transmission electronic microscope (TEM). IgG from
patients with LN were purified to induce human podocyte injury and
the role of vitamin D in injury was observed. Podocytes were ob-
served under TEM and autophagic activity was evaluated by west-
ern blot analysis and qRT-­PCR, mRFP-­GFP-­LC3B adenovirus were
infected into HPC in vitro.
Results: Significantly higher autophagic levels were observed in LN
patients (P < 0.05) and apparently greater autophagic levels in podo-
cytes were shown (P < 0.05). Among different classifications of LN,
Class V(n = 5), III+V(n = 5) and IV+V (n = 5) gained higher autophagic
levels than Class III(n = 5) and IV(n = 5). Induced autophagy, which
was evident by increased LC3B-­II and Beclin 1 level, caused con-
sumption of p62, more autophagosomes observed under TEM, and
more LC3B dots observed under confocal microscope in IgG group,
along with decreased Nephrin expression, which suggests podocyte
injury. Reduction of autophagy as well as alleviated podocytes injury
was observed in the IgG+ VD group.

Table 1. Clinical features of pSS-­ILD and pSS control population

Characteristics pSS-­ILD (n = 258) pSS-­non-­ILD (n = 1243) P value

Female gender, No. (%) 230 (89.1) 1182 (95.1) <0.001*

Age at pSS onset, mean ± SD 52.6 ± 12.6 45.0 ± 18.6 <0.001*
Saprodontia 225 of 258 (87.2) 1098 of 1243 (88.3) 0.611
Parotid enlargement 26 of 258 (10.1) 181 of 1243 (14.6) 0.057
Non-­erosive arthritis 14 of 258 (5.4) 89 of 1243 (7.2) 0.316
Purpura 5 of 258 (1.9) 46 of 1243 (3.7) 0.155
Biliary cirrhosis 5 of 258 (1.9) 29 of 1243 (2.3) 0.698
Hematologic involvement 21 of 258 (8.1) 176 of 1243 (14.2) 0.009*
Hyperglobulinemia 99 of 248 (39.9) 517 of 1083 (47.7%) 0.026*
CRP 11.5 ± 23.5 (n = 171) 6.5 ± 14.0 (n = 450) 0.011*
IgG 17.7 ± 9.4 (n = 247) 17.7 ± 8.3 (n = 1087) 0.191
C3 0.97 ± 0.25 (n = 174) 0.96 ± 0.27 (n = 439) 0.444
C4 0.20 ± 0.17 (n = 168) 0.20 ± 0.10 (n = 249) 0.992
SSDAI 10.0 ± 6.4 (n = 250) 4.1 ± 5.6 (n = 1106) <0.001*
SSDDI 2.8 ± 1.3 (n = 252) 1.4 ± 1.1 (n = 1107) <0.001*
ANA 220 of 249 (88.4) 1032 of 1114 (92.6) 0.025*
Anti-­SSA 202 of 251 (80.5) 969 of 1123 (86.3) 0.019*
Anti-­SSB 89 of 249 (35.7) 562 of 1110 (50.6) <0.001*
Anti-­Ro52 186 of 237 (78.5) 705 of 1063 (66.3) <0.001*
 |
226      
Conclusion: This study demonstrates that vitamin D plays a protec-
tive role in podocytes injury induced by autoantibodies from LN pa-
tients and that appears to be a novel therapy target in LN.
3-­104 | Real-­world utilization and outcomes
of rheumatoid arthritis patients managed with
biologic-­DMARDs in an Australian tertiary
hospital rheumatology outpatient clinic
M. Zia1; H. Benham1,2
1 2
Princess Alexandra Hospital; Faculty of Medicine, the University of Queensland
Objectives: To evaluate the use and outcomes of RA patients com-
menced on biologic disease modifying drugs (bDMARDs) including
persistence, switching and discontinuation in a real world Australian
RA cohort.
Methods: A retrospective review of all RA patients commenced
on a bDMARD at the rheumatology bDMARD clinic at Princess
Alexandra Hospital, Brisbane, between 2006 and 2016 was con-
ducted. Patient characteristics including demographics, disease
activity, co-­
morbidities and concomitant conventional DMARDs
(cDMARDs) was collected. Data regarding bDMARD persistence,
discontinuation and switching (including inadequate response, ad-
verse events, patient preference and co-­morbidity) for all RA pa-
tients was analysed.
Results: 171 RA patients were commenced on a bDMARD be-
tween 2006 and 2016. 63% (n = 108) were female, mean age of
60 (18–84 years), 55% ACPA positive and 23% were ever smok-
ers. Concomitant cDMARD use was recorded with 81% (n = 140)
on methotrexate in combination with a bDMARD. Anti-­TNFs were
the most commonly prescribed bDMARD (71%, n = 274) and usage
altered with switching with Etanercept and Adalimumab the most
commonly used first and second line bDMARDs and Rituximab and
Tociluzimab third and fourth. 48% remained on their first or second
bDMARD with 19% ceasing completely due most commonly to in-
fection (n = 10) or death (n = 8). With progressive switches the me-
dian length of bDMARD persistence decreased (1st to 2nd bDMARD
12.6 (95% CI 9.3–17.3) and 4th to 5th 6.4 (95% CI 4.0–11.0) months).
Most often switching of a bDMARD was for primary (20%) or sec-
ondary failure (36%) with a smaller number due to partial response
(14%) or rash (10%).
Conclusions: bDMARDs have revolutionized the management of RA
however there is a paucity of data regarding their real-­world use.
Understanding outcomes related to bDMARD persistence, switching
and discontinuation allows for improved RA patient care in Australia.
Keywords: rheumatoid arthritis
biologic disease modifying drugs (bDMARDs)
AUTHOR INDEX

A Antony B.S.E. O-039 Batool S. 2-146

Aonuma H. 3-089 Bauer L. 1-114, 1-117
Abbot S. 1-101
Apiwattanakul N. 3-137 Beaton D. 1-110, 3-025
Abdolahi N. 1-008, 1-009, 1-102
Apostolopoulos D. 1-123 Behera M. O-001
Abe Y. 2-110
Appuhamy H.S.D. 2-040 Behera S. 3-030
Abeysinghe D. 1-002
Appuhamy S. 3-045 Behrens F. 2-077
Acar M. 2-033
Aquino-Villamin M. 3-144 Benham H. O-021, 2-038, 3-104
Achuthan A. 1-017
Ara R. 1-103, 1-124 Bennell K. O-037
Adam K. 1-041, 2-113, 2-076, 3-087
Arai T. 2-096 Bereza-Malcolm L. 2-038
Adams R. 3-021
Arain S. 2-054, 2-108 Bernal C. 1-065
Adhami P. O-055
Arain S.R. 1-080, 2-031 Berry G. 3-010
Adib N. 2-038
Aramaki T. 1-027 Bhasin S. 1-020, 2-118, 3-099, 3-105
Agematsu K. 1-036
Ariful I. 2-082 Black R. 1-090, 2-038
Aggarwal A. 1-010
Arii K. 1-026 Black R.J. O-053
Aghaei M. 1-009, 1-102
Arima K. 1-027 Blanco R. 1-096
Agosto H.G. 3-055
Arinuma Y. 1-125, 2-017 Boado C.A. 1-126
Ahmad A. 1-023
Asai S. 2-095 Boland E. 1-007
Ahmed M. 3-108
Asavatanabodee P. 2-063, 3-083 Borja-Dimal J. 1-088
Ahmed N.M. 2-146
Ashizawa K. 1-082 Boros C. 2-038
Ahmed S. 1-103, 1-124, 2-028, 2-027,
Assawasaksakul T. 3-035 Bosch F.V.D. O-055
2-082
Aung K. 3-114 Bossingham D. 1-101
Ahmedullah A.K. 2-034
Author S. O-005 Bowling A. 3-064
Aitken D. O-039
Awan S. 2-090 Bradbury L. O-027, 3-012
Akai Y. 2-049, 3-094, 3-097
Ayob S.N.A.M. 2-127 Brady S. 3-046
Akashi K. 3-094
Azad A.K. 2-082 Breban M. O-028
Akira S. 2-084
Azimi H.-R. 1-102 Briffa K. 1-007
Akiyama Y. 1-076, 3-086
Aziz H. 3-039 Briggs A. O-024
Akkoc N. O-028
Azman A.N. 2-127 Briggs F. 2-078
Alam H. 3-117, 3-118
Brooks A. 3-064
Alam M. 2-082
B Brown M. O-027, 1-037, 1-015, 2-038,
Alam M.Z. 1-103, 1-124
3-012
Ali H. 1-069 Babu D. 3-002
Brown M.A. O-028
Allcroft P. 2-010 Badsha H. 1-069
Brown Z. 3-090
Aloia A. 3-103 Baek H.J. 2-064
Bruce A. 2-030
Amano E. 2-045 Baek W.-K. 2-015
Bryant K. 1-140
Amano K. 2-086 Bagga H. 3-064
Buchanan R. 2-009, 3-147
Amin M.Z. 2-028 Baharuddin H. 2-123
Buchanan R.R.C. 2-048, 3-140
Aminian P. 2-009 Bajic N. 2-043
Buchbinder R. O-022, O-042, O-053, 1-090,
Amital H. 2-101 Baker D. O-015 1-110, 2-038, 2-041, 3-025, 3-047
Amuro H. 3-094 Baker D.G. O-017 Bull C. 3-107
Anam A.M. 3-143 Balsa A. 1-097 Bupparenoo P. 2-063
Anari N. 2-052 Bao C. 1-100 Burmester G. O-055, 2-099, 2-100,
Andayani S. 2-139 Baraliakos X. 1-117 2-101, 2-077
Ando M. 2-095 Barclay M. O-036 Burmester G.R. 1-097
Anggoro S. 2-103, 3-106 Barrett C. 1-090, 2-038, 3-074 Butcher B. O-060
Angkodjojo S. 2-039, 2-029 Barton A. O-057 Byun J.W. 2-051

Editorial material and organiza on © 2019 Asia Pacific League of Associa ons for Rheumatology and John Wiley & Sons Australia, Ltd. Copyright of individual
abstracts remains with the authors.

227  | 
wileyonlinelibrary.com/journal/apl Int J Rheum Dis. 2019;22(Suppl. 3):227–237.
 |
228      

C Chiowchanwisawakit P. 1-067 D
Ch’ng S. 3-139
Cader R.A. 3-113 Dabare C. 1-043
Cho J.H. 3-033
Cai G.Q. 3-053 Dahani A. 1-080, 2-031, 2-054, 2-108
Cho M.-L. 1-094, 3-077
Camp H.S. 1-091, 1-099 Dai X. 1-011, 1-012, 2-065, 3-036
Cho O. 3-023
Candrianita S. 1-137, 1-035 Dalbeth N. O-035, O-036
Choe J.-Y. 2-070, 2-121
Cann M. 1-057, 1-058 Dandeniya C. 1-081
Choi C. 2-069
Cappelleri J.C. 2-075 Dans L. 1-063, 3-055, 3-058, 3-059,
Choi H. 2-064
Cardoso A. 1-093 3-063
Choi I.A. 2-084
Carmel Jocson M.F. 1-063 Das B.K. O-001, 2-020, 2-018
Choi J.H. 2-069
Carroll G. 1-090, 2-038 Davies B. 1-061
Choi J.-W. 1-094
Cash K. 1-104 Davis C. 3-021
Choi S.J. 1-038
Chae J.-N. 2-015 Day J. 1-104, 2-043
Choi S.T. O-033, 2-064, 3-101
Chaiamnuay C.S. 3-083 Day R. O-032
Choi Y. 3-014
De La Torre I. 1-097
Chaiamnuay S. 2-063
Choi Y.-S. 1-112
De Silva T. 2-142, 3-048
Chaitow J. 2-038
Chong YY E. 2-143
Dehdashtian A. 3-050
Chakera A. 2-132
Chong H.C. 1-030, 2-042, 3-028
d’Emden H. 2-032
Chan Chan C. 1-003
Chopra A. 1-041, 1-045, 2-076, 2-113,
Demerre E. 1-126
Chan C.P. 3-120 3-087, 3-038
Demoruelle M.K. O-058
Chan J. 2-073 Chou C.-T. O-028
Densupsoontorn N. 1-059
Chan K. 2-129 Choudhury M.R. 2-028, 2-082, 3-143
Deodhar A. 1-114
Chan M. 1-123, 1-061, 1-135 Choy C.-O. 3-127
Deshapriya K. 1-089
Chanapai W. 3-096 Chu C.S. 2-129
Dewi S. 1-105, 1-106
Chand V. 2-038 Chu S.-J. 1-046
Dhanasekaran P. 1-079, 3-095
Chang D.-M. 3-127 Chu X. 2-141, 3-148
Dickson C. O-055, 1-097
Chang M. O-076 Chua S.H. 2-071, 2-072, 2-008
Diekman L. O-028
Chang M.M. 1-066 Chularojanamontri L. 1-067
Ding H. 2-125
Chang S.-H. 2-006 Chung H.Y. 1-111, 2-114
Ding H.J. 2-066
Chang S.H. 2-106, 3-091 Chung M.K. 2-036
Distler J. 3-013
Chang T.-H. 3-146 Chung S.W. 2-119
Doi K. 2-046, 3-092
Charuvanij S. 1-059, 1-061 Chunlertrith K. 1-109
Dolcetti R. O-002
Chatfield S. 2-038 Cicuttini F. O-039, 3-022, 3-046
Donovan P. O-035
Cheah C.K. 1-056, 2-008, 2-072 Cleland L. 3-090
Dore R. 1-091
Chen A. 1-078 Clout M. 3-012
Dougados M. 1-117
Chen D.-Y. 3-136 Co E.V. 1-128, 3-128
Downie A. 2-041
Chen H. O-007, 3-006 Cobb J. 2-038
Du X. 3-006
Chen H.-C. 1-046 Cohen S. 1-099
Dudler J. O-055
Chen K. 1-091 Coiera E. 2-038
Durez P. 1-093
Chen P. 3-076 Combe B. 1-097
Chen S. O-007, 1-096 Conaghan P. 3-025
E
Chen W.-S. 3-127 Connor C. 1-007
Chen Y.-H. 3-076 Corias C. 2-032 Ebina K. 3-094
Chen Y.-M. 1-097 Coronel I.J. 1-129 Edelman J. 1-007
Cheng T.H. 1-066 Cortez K.J. 3-128 Edwards D. 3-020
Cheon Y. 3-023 de Costa C. 1-101 Eguchi K. 1-036
Cheon Y.-H. 2-014 Croker A. 3-024 Eguchi M. 1-082
Chessman D. 2-038, 2-078 Croker J. 3-024 Eilertsen G. 2-137
Cheung M.B. 2-093 Cross M. 2-038 Ekbote G.G. 3-141
Cheung P. 1-079, 3-095 Crossley K. O-038 Elderton S. 3-076
Cheung T.T. 2-093, 2-114 Crouch B. 3-032 El-Haddad C. 1-072
Chhetri R. 1-016 Crusius J.B.A. O-028 Emery P. 1-099
Chia K. 3-064 CT Q. 3-028 En Hong L. 1-016
Chino K. 2-086 Cummins L. 2-032, 3-067 Endo Y. 1-082, 1-036, 2-004
 |
229      

Endoh T. 2-046 Fujita Y. 2-096 Gupta R. 3-141

Enejosa J. 1-091 Fukuda K. 1-014, 3-007 Guzman E. O-027
Eng-Frost J. 3-134 Fukui S. 1-036
English C. 1-061 Funahashi K. 3-007 H
Englund M. 3-049 Furtner D. 3-068
Ha E.-H. 2-036
Eow L.H. 2-044 Furukawa K. 2-088
Ha Y.-J. 2-064
Erfani-Moghadam V. 1-008 Furuta S. O-003
Haas R. 1-110
Erum U. 3-117, 3-118 Furuya H. O-003
Habib P. 2-104
Espiritu D.N. 3-128
Hagino O. 2-099
Esposo E. 1-126 G
Hagiwara T. 3-093
Estrella A.M. 1-005
Gafor A.H.A. 2-140 Hall S. O-055, 1-091, 1-114
Euathrongchit J. 3-111
Gagnier J. 1-110, 3-025 Halloran J. 2-032
Gaich C. 1-100 Hamid M. 2-032
F
Galea R. 2-016 Hamijoyo L. O-076, 1-105, 1-135, 1-137,
F Griffith J. 2-080 Gan S.P. 2-066, 2-055 1-035, 1-123, 2-139, 2-138, 3-009

Fallahi S. 3-050 Gearry R. 3-071 Hamilton J. 1-017

Fallon L. 2-075 Geelhoed E. O-024 Han J. 3-127

Fan H. 2-062 Genovese M. 2-099, 2-100, 2-101 Han J.-X. 3-047

Fang R. 1-140, 2-134 Genovese M.C. O-055, 1-097 Han S.T. 2-003

Fang X. 1-011, 1-012, 2-065, 3-036 Gensler L.S. O-028, 1-117, 1-114 Han W.H. 2-066

Farman S. 1-060 Gentili S. 2-043 Hanabayashi M. 2-095

Favorito W. 3-076 Gervitz L. 2-101 Hancock M. 2-041

Fei K. 3-133 Ghang B. 1-083 Handa R. O-050

Fei-Hung H. 3-136 Ghorpade R. 1-041, 3-087 Hannan R. 2-038

Fenech M. 3-107 Giacomini J. 3-010 Hanson A. 1-015

Ferdous N. 1-113, 2-035, 2-002, 3-003 Gibson K. 1-140, 2-134 Haq S.A. O-023, O-005, 1-124, 2-028,
2-082, 3-143
Ferriani V. 1-061 Gibson K.A. 3-076
Hara R. 2-049, 3-094, 3-097
Fifer S. 2-033 Gill T. 3-021, 3-025
Hardhani A.S. 2-067
Filarca C. 2-005 Ginting A. 2-103
Harifi G. 1-069
Firth J. O-047 Gladman D.D. 3-133
Harigai M. O-076, 1-135, 1-097, 1-123
Fitzcharles M.-A. O-009, O-026 Glaezter K. 2-010
Haroon N. 1-114
Fleischmann R. 1-098, 2-099 Gluzman I. 2-125
Harris I. 2-041
Fletcher A. 1-090, 2-038, 3-047 Goergen S. 2-041
Harrison D. 3-010
Foeldvari I. O-045, O-046 Goldblatt F. O-076, 1-135, 1-123
Hasan M.M. 2-034
Foley C. 1-061 Golder V. O-076, O-077, 1-123, 1-135
Hasegawa Y. 3-068
Foley P. 1-068 Gordon R. 3-133
Hashimoto M. 1-085, 2-046, 3-092,
Fong B. O-052 Goronzy J. 3-010 3-094
Fong W. 2-120 Gossec L. 2-077 Hashimura T. 1-047
Foocharoen C. 1-108, 1-109, 2-105 Gowdie P. 2-038 Hassett G. 2-038, 2-078
Forsblad-D’elia H. O-028 Graf S. 2-010 Hay P. 1-072
Foster H. O-047, 1-061 Graves S. O-039 Hayashi M. 2-095
Foster N. 3-025 Gregan Y.I. 3-133 Hayashi S. 1-014, 3-007
Frampton C. 3-071 Gruta N.L. O-015 Hayball J. 1-104
Frauman A. 2-009 Gul H. 2-007, 3-081, 3-100, 3-108 He D. 1-100
Freeman D. 3-064 Guleria A. 1-010, 3-141 van der Heijde D. 1-114, 1-117, 2-100
Frentiu F.D. O-030 Gun S.C. 1-056, 2-072, 2-008, 2-071 Hellmi R.Y. 2-067
Friedman A. 1-096, 1-099 Gunathilaka M.L. 1-002 Hilhorst M. 3-010
Fu Y.-P. O-079 Gunawardana R. 1-049 Hill C. 1-090, 2-038, 2-010, 3-021, 3-025
Fujimoto T. 2-049, 3-094, 3-097 Gunawardena M. 1-089 Hill C.L. O-053
Fujimura T. 3-094 Guo C. O-049, 3-026 Hirai T. 2-021
Fujio K. 1-013 Gupta A. 1-136 Hirani S. 2-090
Fujita S. 1-047 Gupta L. 1-010, 3-141 Hirano T. 3-094
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230      

Hirano Y. 3-074 Inderjeeth A. O-006, 1-051, 1-084 Jin M.S.S.-H. 2-116

Hirata M. 3-145 Inderjeeth C. O-024, O-006, 1-018, Jin Z.-B. O-027
Hirata S. 3-076 1-051, 1-007, 1-044, 1-084, 1-050, Jinzaki M. 2-046
2-060, 2-059
Hirohata S. 1-125, 2-017 Jirapattananon N. 3-137
Inns S. 3-071
Hirose K. O-003, 3-145 Jiunn-Horng C. 3-136
Inotani S. O-072, 1-026, 2-045
Hirose T. 1-098 Jocson M.F.C. 3-063
Inouye M. 2-038
Hiwase D. 1-016 Jones C. O-015
intapiboon P. 2-145
Hng M. 2-144 Jones G. O-039, 3-053
Intarasattakul N. 2-105
H’ng M.K. 3-040 Joo Y.B. 3-054
Isaacs J. O-025, O-051
Ho K.-A. 2-033 Joshi V. 1-142, 1-086
Isbagio H. 1-105
Ho L.Y. 2-129 Joshua F. 2-030
Ishiguro N. 2-095
Hoepken B. 1-114, 1-117 Joules E. 2-009
Ishii T. O-055
Hoi A. O-076, O-077, 1-123, 1-135 Ju J.H. 3-033, 3-077
Islam M.N. 2-028, 2-034, 2-035, 2-082,
Hong S. 1-138, 1-139, 3-129, 3-023 Jun J. 3-052
2-002, 3-143
Hong S.-J. 1-039, 2-064, 2-119 Jung J.H. 1-038
Islam N. 1-113, 3-003
Hong S.J.H. 1-053 Jung J.-Y. 2-064
Ismail A.M. 2-144, 3-040
van Hoogstraten H. 2-099, 2-100, 2-101 Jung K.-H. 2-122, 3-054
Ismail H. 2-127
Hor C. 1-017, 2-142 Junsuwan N. 1-067
Issa M. O-055
Horita T. 1-024
Ito H. 1-085, 3-092
van de Horst-Bruinsma. I.E. O-028
Iwai Y. 2-046
K
Hsiao E. O-084
Iwamoto N. 1-082, 1-036, 1-027, 2-004 K Gill T. 2-010
Hsieh C.-J. 3-146
Iwanaga N. 1-027 Kakade G. 3-109
Hsieh T.-Y. 1-097
Iwasaki Y. 1-013 Kam J. 3-116
Hsu B. 2-091
Izuka S. 1-021 Kamada K. 3-093
Hu J. 1-100
Izumi K. 2-046 Kamalaraj N. 1-072
Huang C.-M. 3-136
Kamaruzaman S.N. 2-127
Huang F. 1-140, 2-134
J Kambayana G. 1-052, 1-006
Huang H. 1-110, 3-025
Kamenaga T. 3-007
Huang H.-B. 1-122 Jackson C. 2-038
Kamruzzaman A.K.M. 2-082
Huang J.-L. 1-062, 3-062 Jahan S. 2-035
Kandane-Rathnayake R. O-076, 1-135,
Huang K.-Y. 1-119, 2-091 Jahrom M.M. 1-022
1-123
Huang K-.Y. 1-122 Jain A. 2-076, 3-141
Kaneko Y. 3-076
Huang W.-N. 1-097 Jain N. 1-141, 2-115, 3-025
Kang A. 2-132
Huang X. O-027 James M. 3-090
Kang H.J. 3-073
Hunter D. O-040 Jamshidi A. O-028
Kang J.-H. 2-116
Huq M. O-076, 1-135 Jandial S. O-047, 1-061
Kang M.I. 2-106, 3-091
Hur J. 3-052 Jansen D. 3-011
Kang Y.M. 2-087
Hussain S.M. 3-046 Janssen B. O-084
Karashima T. O-072
Hutas G. 2-033 Jasmine Y. 3-028
Karunadasa K.P. 1-002
Huyen T.T. 3-084 Javed S. 3-081
Kashiwagura T. 3-089, 3-072
Hwang D.W. 2-051 Jazaeri S.Z. 3-050
Kataoka H. 2-083
Jenkins H. 2-041
Katayama M. 3-094
Jeong H.-J. 2-015
I Katayama N. 2-074
Jeong J. 3-014
Katchamart W. 3-096
Iagnocco A. O-029 Jeong W.S. 1-083, 2-069
Katigbak G. 1-088, 1-005
Ichinose K. 1-082, 1-036, 1-027, 2-004 Jeong Y. 1-094, 3-077
Katikireddi S. 1-032
Igawa T. 1-082, 2-004 Jhun J.-Y. 1-094
Katsumata Y. O-076, 1-135, 1-123
Iikuni N. 1-098 Jhun J.Y. 3-077
Katsuyama N. 1-076, 3-086
Ikai H. 2-096 Ji F. 1-100
Kawakami A. 1-082, 1-036, 1-027, 1-075,
Ikari K. 3-070 Ji G.E. 1-094, 3-077 2-004
Ikeda K. O-003, 3-074 Jiang H. 2-141 Kawasaki M. 1-075
Ikuro N. 3-034 Jiang M. 3-053 Kawashiri S. 1-082, 1-036, 1-027, 2-004
Illangasinghe C. 2-094 Jin L. 1-011, 1-012 Kay J. 1-114
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231      

Kay T. O-012 Kivitz A. 2-100 Lau I.S. 2-055, 3-139

Keen H. 1-044, 2-085, 2-038, 2-059, Knight J. 1-037 Lau N.S. 1-030
2-060, 2-112, 2-050, 2-104 Ko S. 2-046 Laurent R. O-084
Kelly A. 2-038 Koay B.S. 3-056 Law A. O-077
Kenna T. O-061, 1-015, 2-038, 3-012 Kobayashi M. 3-089, 3-072 Law S.-C. 3-011
Kertia N. 1-105 Kobayashi S. O-072 Lawrence M. 3-024
Keystone E. 1-093 Koelmeyer R. O-077 Le Cao K.-A. 1-015
Khadra Y. 2-107 Koes B. 3-025 Lee A.P.W. 1-066
Khan F. 1-080, 2-031, 2-054, 2-108 Koga T. 1-082, 1-036, 1-027, 2-004 Lee C.H. 2-124
Khan H. 1-092, 2-146 Kojima T. 2-095 Lee C.-K. 1-083, 1-138, 1-139, 3-129
Khan M.M. O-005 Kokuryo W. 2-096 Lee C.L. 1-053
Khanna S. O-004 Koltsova E. 1-073, 2-097, 3-066 Lee D.G. 1-112
Khatun Y. 1-113 Kon T. 2-110 Lee E. 3-073, 3-014
Khawaja K. 1-061 Kondo M. 2-083 Lee E.B. 2-084
Khoo K. 2-038 Kondo T. 2-086 Lee E.E. 3-082
Khubchandani R. 1-061 Koo B.S. 1-116 Lee E.Y. 2-084, 2-051
Khune A. 3-109 Kook M.S.H. 2-116 Lee G.Y. 3-101
Kido A. 2-049, 3-094, 3-097 Kopkow C. 3-025 Lee H.J. 3-067, 3-078
Kim B.Y. 1-039 Koyama M. 2-110 Lee J. O-053, 1-083, 1-066, 2-036,
Kim D.-W. 3-102 Kubler P. 2-038, 3-121 2-133, 2-064, 3-077, 3-033
Kim G.-T. 2-014 Kuga T. 2-110 Lee J.H. 2-051
Kim H. 1-055, 2-147, 2-147, 3-023 Kulkarni N. 3-038 Lee J.-H. 3-054
Kim H.-A. 2-064, 3-082, 3-073 Kumar D. 1-010, 3-141 Lee J.-K. 3-102
Kim H.A. O-041 Kumar S. 3-132 Lee J.M. 1-112
Kim H.-O. 2-064 Kumar U. 3-141 Lee J.S. 3-129
Kim I.J. 2-064 Kumke T. 1-114 Lee K.H. 2-071, 2-072, 2-008
Kim J. 1-083 Kuo S.-Y. 1-046 Lee K.-H. 3-101
Kim J. 2-069 Kurasawa T. 2-086 Lee M.S. 1-053
Kim J.H. 2-084 Kurniari P.K. 1-052, 1-006 Lee S. 3-052, 3-077, 3-023
Kim J.-M. 2-015 Kuroda R. 1-014, 3-007 Lee S.G. 2-064
Kim J.-S. 2-015 Kurzawa M. 2-077 Lee S.-H. 1-039, 2-014, 2-119
Kim J.-W. 3-077 Kuwana M. O-062 Lee S.-I. 2-014
Kim J.-Y. 1-053 Kuwatsuka Y. 2-095 Lee S.-J. 1-057, 1-058, 2-116
Kim J.Y. 2-051 Kwan Y.H. 2-120 Lee S.J. 2-087
Kim K.N. 1-064 Kwiatek R. O-010, 3-032 Lee S.K. 3-073
Kim M. 2-014 Kwok S.-K. 2-133, 3-077 Lee S.-K. 3-082
Kim M.G. 3-023 Kwon B. 1-094 Lee S.-S. 2-116
Kim M.J. 1-112 Kwon O.C. 1-138, 1-139 Lee S.W. 2-106, 3-091
Kim M.U. 3-091 Kwon S.-R. 2-122 Lee S.-Y. 1-094
Kim M.Y. 2-133, 3-077 Kwon S.R. 3-054 Lee S.Y. 2-122
Kim S. 2-070, 2-121, 3-101 Lee Y.-A. 2-064, 2-119
Kim S.-H. 2-015 Lee Y.N. 3-073
L
Kim S.-S. 1-039 Lee Y.-S. 2-051
Kim T.-H. O-028, 1-116, 2-015, 3-102 La Gruta N. 3-011 Lei Q. 2-117
Kim T.-J. 2-116 Lahiri M. 1-079, 3-095 Lenza M. 3-025
Kim W.-J. O-033 Lai N.-S. 1-025, 1-122, 2-091 Leo P. O-027, 1-037
Kim Y. 1-083 Lan J.-L. 3-136 Leo P.J. O-028
Kim Y.-G. 1-138, 1-139, 3-129 Landewé R. 1-114, 1-117 Lerkvaleekul B. 3-137
Kinsey K. O-047 Larkins N. 1-057, 1-058 Lester S. O-053, 1-090, 2-038, 3-103
Kira T. 2-049, 3-094, 3-097 Lassere M. O-053, 1-090, 2-038 Leung A. 1-043, 2-142, 3-048
Kirupananther R. 2-085 Lateef A. O-076, 1-135, 1-123 Leung J. 3-147
Kishimoto M. 1-115, 3-076 Lau C.-S. 2-093, 3-076 Leung J.L. 3-140
Kitamura F. 2-096 Lau C.S. O-076, 1-135, 2-114 Leung M.A. 2-073
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232      

Leung Y.Y. O-071, 2-120 Lynch T. 2-038 Matsuda S. 1-085, 3-092

Lew K.M. 2-072 Lytkina K. 1-073, 2-097, 3-066 Matsueda Y. 1-125, 2-017
Li C. 2-117 Mcquade J. 1-007
Li E.K. 1-066 M Mei-Chin Y. 3-136
Li L. O-008 Ma Z. 3-029 Mejia M.G. 1-065
Li M. 3-123, 3-124 McDermott B. 2-032 Melaku Y. 3-021
Li S. 1-018 Machacon-Wong M.S. 2-061 Melicor A. 3-055
Li X. 1-011, 1-011, 1-012, 1-012, 1-100, McMaster C. 2-009, 2-048 Menzies A. 2-030
1-100, 2-065, 2-065, 3-036, 3-036 Mercer V. O-047
McNaught J. O-047
Li Z. 1-135 Merriman T. O-036
Maeda J. 1-013
Li Z. O-076, O-027, O-028, 1-037, 1-100, Metcalf R. 3-090
1-100, 3-076 Maeda T. 1-014
Maeda-Aoyama N. 1-026 Mian M. 2-048
Liao H.-T. 3-127
Maeshima E. 2-088 Midwinter W. 1-037
Liao R. 1-097
Maeshima S. 2-088 Migita K. 1-036
Lichauco J.J. 1-126
Magalhães C.S. 1-061 Min H.K. 3-077
Liew D. 2-009
Magallanes J. 1-129 Min K. 1-112
Liew D.F. 3-140
Mahakkanukrauh A. 1-108, 1-109, 2-105 Minn Soe Y. 3-110
Light H. O-047
Mahashur A. 3-109 Mishima H. 1-036
Lim B. 1-129
Maher C. 2-041 Mishra P. 1-054, 1-001, 2-089, 3-018
Lim H. 2-124
Mahmood T. 2-082 Misra R. O-069, 3-141
Lim I. 2-075, 2-038
Mahmoudi M. O-028 Miura Y. 1-014
Lim J.J. O-015
Mahmud F. 1-113 Miyachi K. O-003
Lim K. 1-017, 1-043, 3-048
Maillet I. 3-013 Miyakoshi N. 3-089, 3-072
Lim M.J. 2-122
Mairiang P. 1-109 Miyashita T. 1-027
Lim S.C. 3-056, 3-057
Majedah S. 3-039 Moghimy N. 1-022, 3-019
Limaye V. 1-104, 2-043
Major T. O-034 Mohamed M.F. 1-096
Lin H. 2-078
Majumder M.S.M. O-005 Mohammadi M. 1-102
Lin K. 3-114
Maksymowych W.P. 1-114 Mohammed S. 1-120, 1-095
Lin Y. 2-100
Malakorn H. 1-059 Mohan A. 2-076, 3-038, 3-087
Lipsky P. 2-125
Maldonado-Cocco J.A. 2-100 Mohapatra S. 2-018
Little C.A. 1-097
Malek A. 1-124 Mohapatro N. O-074
Littlejohn G. O-060
Malek M. 1-110 Mohd Nor N. 1-056
Litwin M. 3-134
Malliaras P. 3-025 Mohd Zain M. 1-023
Liu B. 2-009
Manchanda B. 1-041, 3-038 Mohd R. 2-140, 3-113
Liu C.-W. 3-127
Mandrup-Poulsen T. 2-099 Mohibullah A.K.M. 1-103
Liu F.-C. 1-046
Mangan E. 2-099 Mok C.C. O-052, O-079, 2-129
Liu X. 2-016
Manickam V. 3-121 Mon S.Y. 3-121
Liu Z. 3-124, 3-017
Manivannan A. 1-118 Moon K.W. 2-064, 2-001
Liu-Leage S. 2-077
Manlulu E. 2-037 Morand E. O-076, O-077, O-078, 1-135,
Loh K.L. O-017 1-123
Mannering S. O-012, 3-011
Loh T.J. O-015 Morishima Y. 1-098
March L. O-053, 1-090, 2-078, 2-079,
Loh Z.W. 3-116 Morley P. 2-011
2-038
Long G. 2-030 Mosch T. 3-068
Marine F. 2-038
Lorenzo J.P. 3-001 Mountain D. O-024
Marshall D.A. O-013
Lorimer M. O-039 Mu R. 3-076
Marshall K.L. 2-142, 3-048
Louis S. O-060 Mudiyanselage U.D. 2-094
Martel-Pelletier J. O-039
Louthrenoo W. O-076, 1-135, 1-123, Muennuch S. 2-111
Marzo-Ortega H. O-028
3-037
Masakon O. 3-039 Mughal N. 1-051
Lu C.-C. 1-046
Masduul H. 2-082 Mukai M. 2-083
Lu M.-C. 1-122, 2-091
Mason R.S. O-014 Mumtaz S. 2-108
Lukina G. 1-073, 2-097, 3-066
Masumoto J. 1-036 Mun C.H. 2-019
Lundberg I. O-063
Mate E. 1-068 Munidasa S.M.P.D. 2-040, 3-045
Luo S.F. O-076, 1-135, 1-123
Matsubara T. 3-007 Munirajan S. 3-119
 |
233      

Munro J. 1-061, 2-038 Ng K.J. 1-025, 1-119, 2-091 Ong S.G. 2-066

Munugoda I. O-039 Ng K.L. 3-040 Ong W.J. 2-120
Murai Y. 2-096 Ng R. 2-073 Onishi A. 3-094
Murakami K. 1-085 Ng S.K. 3-056, 3-057 Onishi E. 1-047
Murata K. 1-085, 3-094, 3-092 Ngamjanyaporn P. 2-111 Origuchi T. 1-036, 1-027, 1-075, 2-004
Murray K. 1-057, 1-058, 2-038 Nguyen K. O-084 O’Shea F. O-028
Murray-Brown W. 3-103 Nguyen M. 1-140, 2-134 Osio-Salido E. 2-005
Murugan M. 1-118 Niari J. 2-020 Osiri M. 3-035
Musa W.R.W. 2-140 Nikpour M. O-076, 1-135, 1-123 Ostli-Eilertsen G. 2-136
Mushtaq M. 3-081, 3-100 Nim H. O-076, 1-135 Ota M. 1-013
Mushtaq S. 2-007 Ninan J. 2-038 Ota S. 1-047
Mustafar R. 2-127, 3-113 Nirmal B. 3-069 Otahal P. O-039
Mustapha M.H. 1-023 Nishikawa H. O-072, 1-026, 2-045 Othman A.A. 1-099
Nishimura H. 2-049, 3-097 Otsuka M. 2-004
N Nishio Y. 2-074 Otto S. 1-104
Nishioka K. 3-034 Owen C. 3-147
Nadiah M.N. 2-072
Nishitani K. 1-085, 3-092 Owen C.E. 3-140
Nagafuchi Y. 1-013
Noh J. 2-003 Ozaki Y. 2-049, 3-097
Nagai K. 3-094
Nonaka F. 1-036
Nagai T. 2-017
Noor N.M. 2-008 P
Nahar N. 2-076
Norager R. 3-076
Naik P. 1-045 Padhan P. 3-098
Nordin A.A. 2-127
Nakahara H. 3-076 Paeng J.C. 2-051
Norton R. O-031
Nakajima H. O-003 Page C. 1-043
Nossent J. O-073, 1-044, 2-132, 2-136,
Nakajima K. 1-026 2-059, 2-137, 2-060 Page M. 1-110, 3-025
Nakamura H. 1-082, 1-036, 1-024, Nozawa K. 2-021 Paizis K. 3-074
1-027, 2-004 Pajes N.N. 1-129
Nye A. O-047
Nakamura K. O-003 Pak H. 2-124
Nakamura S. 2-074 Pakchotanon R. 2-063
O
Nakamura Y. 2-096 Pakr W. 3-054
Nakavachara P. 1-059 Oakley S. 2-038 Palupi W. 1-106
Nakayama S. 2-045 O’Brien E. 2-011 Panda A.K. 2-018
Nallasivam S. 1-118 O’Connor D. 1-110, 3-047 Panda B. O-074
Nallasivan S. 3-069, 3-132 Oda F. 1-075 Pandey S. 1-020, 2-118, 3-099, 3-105
Namura N. 3-093 Ogasawara M. O-072, 1-026 Pandya S. 1-141, 2-115
Namvijit S. 1-109 Ognjenovic M. O-073, 2-132 Pangan A.L. 1-096, 1-099
Nanagara R. 1-108, 1-109, 2-105 Oh J.S. 1-138, 1-139, 3-129 Paramalingam S. 2-050
Narongroeknawin P. 2-063, 3-096, 3-083 Oh K. 3-070 Parida J.R. 1-120
Nasadurai R. 2-123 Oh M. 2-133, 3-033 Parida M.K. O-001, 2-020, 2-018
Nash P. O-048, 1-093, 2-077 Oh Y. 3-121 Park D.-J. 2-116
Nasim A. 2-007, 3-081, 3-100 Ohura H. 2-074 Park E.K. 2-064
Nasir N. 2-130, 2-090 Okada A. 1-075 Park J.S. 2-124, 2-051
Navarra S. O-076, 1-135, 1-123 Okada Y. 2-086 Park J.-S. 2-147
Nazir L. 3-117, 3-118 Okamoto M. 1-082, 2-004 Park K.-S. 3-054
Nazrul F.B. 1-113, 2-035, 2-002, 3-003 Okamura T. 1-013 Park M.S.P.-R. 2-116
Needham M. 2-050 Okano M.S. 3-121 Park S.-H. 1-094, 2-133, 3-033, 3-077
Needs C. O-011 Okazaki K. 3-070 Park S.J. 1-094
Negi V.S. 3-115 Oliffe M. 2-078 Park W. 2-122
Nel H. 2-016, 3-011 Olsson-White D. 2-112 Park Y.-B. 2-019, 3-073
New-Tolley J. O-053 O’Neill S. O-076, 1-135, 1-140, 1-123, Park Y.-W. 2-116
Ng C.M. 3-078 2-078, 2-134
Parlindungan F. 3-106
Ng H. 2-075 Ong E. 3-022
Patel S. 2-043
Ng J. 1-055, 2-038 Ong P.A. 2-138
Patro R. 2-018
 |
234      

Patterson K. 3-107 Ramaraj P. 2-048 Ruediger C. 3-021

Pelletier J.-P. O-039 Ramarathinam S. O-017 Rukhsar Q. 3-100
Peng H.-Y. 3-136 Ramiro S. 1-110, 3-025 Russo R. 1-061
Penserga E. 1-029 Ramiro V. 1-129 Ryffel B. 3-013
Penserga G. 1-129, 1-028, 1-029, 2-005 Ramlan A.H. 1-030 Ryu J.-G. 1-094
Perera C. 2-038 Randika Wimalasiri-Yapa B.M.C. O-030 Ryu J.-Y. 1-094
Perry N. 3-024 Ranganathan D. 3-121
Petersen J. O-017 Rapacon J. 3-058 S
Pettit A. O-043 Rapley T. O-047, 1-061
Saadoun C. 3-074
de Peyrecave N. 1-114 Rath P. 1-020
Saepudin A. 2-138
Pham C. 1-043, 3-048 Rath P.D. 2-118, 3-099, 3-105
Sagar V. 3-132
Phan P. 1-079, 3-095 Rath S.K. 2-020
Sagawa A. 2-074
Phang J.K. 2-120 Ravindran Y.V. 3-132
Sage A. 1-057, 1-058
Phipps J. 3-012 Rawat A. 1-010
Sahiratmadja E. 1-137, 1-035
Phiriyakrit P. 3-111 Raymond W. O-024, O-006, O-073,
1-050, 1-007, 1-044, 2-136, 2-104, Said M.S.M. 2-127, 3-039, 3-113
Pile K. 1-072, 3-076
2-137, 2-059, 2-060, 2-132 Saifan C. O-055
Plucena L.P. 3-055
Redente E. 3-013 Sakagami T. O-003
Pok L.S.L. 1-095, 3-078
Reid H. O-015, 3-011 Sakuraba T. 3-072
Pongchaiyakul C. 2-105
Reid H.H. O-017 Salido E. 1-128, 1-028, 1-029
Pontifex E. 2-038
Reino J.J.G. 2-100 Salim B. 2-007, 3-081, 3-100, 3-108
Pope J. 1-093
Remmers E.F. O-019 Salleh A.F.M. 2-143
Poppelwell D. 3-071
Rengaswamy P. 3-002 Salman M. 3-108
Poulsen K. 1-032
Reveille J.D. O-028 Salonga A. 1-055, 3-067
Prasertwittayakit N. 3-111
Reyes H.B. 3-128 Saluja M. 1-041, 1-045, 3-038
Preen D. 1-044, 2-060, 2-059
Riaz M. 2-090 Samant R. 3-109
Prieto-Alhambra D. 3-049
Richards B. 1-090, 2-038, 3-025 Sameshima A. 3-074
Priyantini D. 1-106
Richards P. 1-110, 3-025 Sammel A. O-084
Proudman S. O-064, 1-104, 1-016,
1-101, 2-038, 3-103, 3-090 Riches D. 3-013 Samreen S. 2-007, 3-081, 3-100, 3-108
Puig A. 2-033 Rigby W. 1-099 Sangeetha A. 3-069
Purcell A. O-015 Riley J. 3-020 Sapin C. 2-077
Purcell A.W. O-017 Rini I.A. 1-137, 1-035 Saputra R. 2-139
Purwaningsih E.H. 1-105 Rischin A. 2-142, 3-048 Sarmukaddam S. 1-045
Putra T.R. 1-052 Rischmueller M. O-081, 1-096, 2-038 Sato A. 1-074
Rivera M.F. 3-059 Sato S. 1-036
Roberts L. O-068 Sazzad N. 2-082
Q
Roberts-Thomson P. 2-107, 3-107 Scally S.W. O-017
Qing S. 1-066 Robinson P. O-035 Schembri G. O-084
Quake C.T. 2-042 Roccatello D. O-083, O-065 Scherer H.U. O-059
Roddy J. 2-104, 2-112 Schlenker-Herceg R. 3-013
R Roe Y. 3-025 Schmidt E. 1-073
Romas E. 1-097 Scholte-Voshaa M. 1-110
Rademaker M. 3-071
Rooney T. O-055, 1-100 Scholte-Voshaar M. 3-025
Rahbar M.H. O-028
Rosa C.T. 1-002 Schrieber L. O-084
Rahmadi A.R. 1-105
Rosales C. 1-126 Sciascia S. O-083, O-065
Rahman M.A. 1-113, 3-003
Rose S. 3-133 Scott A. 3-147
Rahman R.A. 3-113
Rosman A. 2-123, 3-139 Scott C. 1-061
Rahman S. 3-041
Rossi D. O-083, O-065 Sekaran C. 3-132
Raj A.D. 2-038
Rossjohn J. O-015, O-017, 3-011 Sekigawa I. 2-021
Raj R. 3-141
Roy J.S. 1-124 Senaratne V. 1-081
Raja J. 3-078
Rubasinghe J. 1-081 Seo M.R. 2-064
Raja S.F. 2-146
Rubbert-Roth A. 2-101 Seri Y. 1-031
Rajagopala L. 1-002
Rudwaleit M. 1-114 Sethupathy M. 3-119
Rajendran R. 3-069
 |
235      

Setiabudi R. 1-105 So M. O-012 Suri A. O-017

Setiati S. 1-105 Sockalingam S. O-076, 1-135, 1-123, Surin A.K. O-074
Setyohadi B. 2-103, 3-106 3-078 Sutedja E. 1-137, 1-035
Sewell J. 3-022 Soden M. O-031, 2-013, 2-012, 3-121 Sutu B. 2-011
Shaharir S.S. 2-140, 3-039, 3-113 Soe C. 3-114 Suwannaroj S. 1-108, 1-109, 2-105
Shaheen Ahmed A.K.M. 1-103 Soe Y.M. 3-114 Suyin S.C. 2-123
Shahin A. 2-082, 3-143 Sollano H.M. 3-001 Suzuki A. 1-031
Shahril N.S. 2-044, 2-140 Soltani A. 1-008, 1-009 Suzuki K. O-003, 2-074, 2-046
Shaikh S. 1-080, 2-054, 2-108 Son C. 2-015 Suzuki T. 1-031, 1-075
Shamdasani P. 3-140 Son Y. 3-094 Sweeney A. 1-032
Shamim R. 1-060 Song G.G. 1-038 Sy-Alvarado F.M. 3-128
Shan S. 2-048 Song J. 2-064
Shanahan E.M. 2-010 Song J.-S. O-033, 3-101 T
Shanmugakumar S. 2-136 Song R. 2-119
Song S. 3-012 Tada K. 2-110
Shaw T. 1-091
Song Y.W. 2-084 Taibanguay N. 3-083
Shea B. 1-110, 3-025
Songsomboon C. 3-037 Takahashi N. 2-095
Sheikh S. 2-031
Soo L.I. 2-123 Takahiro O. 3-034
Shekarchi B. 2-052
Soontornpun A. 3-037 Takashima Y. 3-007
Shen B. O-007, 3-006
Sorek R. 2-125 Takasugi K. 2-096
Shen M. 2-141, 3-148
Soroush M. 2-052 Takatani A. 1-082, 2-004
Shen N. 2-125
Spargo L. 1-101, 3-090 Takei H. 2-086
Sherwood V. 3-032
Srisala S. 3-137 Takeshima Y. 1-013
Shi X. 2-117
Srivastava P. 1-141, 2-115 Takeuchi T. O-055, 1-097, 1-098, 1-096,
Shibata A. 2-086
2-046
Shih Y. 2-006 Srivastava V. 2-012
Takizawa N. 2-096
Shimada Y. 3-089, 3-072 St John G. 2-100, 2-101
Talekar M. 2-016
Shimizu T. 1-082, 2-004 Stamp L. O-036
Tam L. 1-066
Shimmyo N. 2-049, 3-094, 3-097 Steinberg K. 2-075
Tam L.H.P. 1-066
Shin J.H. 2-051 Stidolph B. O-047
Tam L.-S. O-075, O-049, 2-080, 3-026,
Shin J.-Y. 2-036 Stone N. 2-016 3-076
Shin K. 3-082, 3-073 Stowasser S. 3-013 Tamachi T. O-003
Shin Y.D. 2-019 Stoykov I. 1-093 Tamai M. 1-082, 1-036, 1-027, 2-004
Shmidt E. 2-097, 3-066 Strand V. 1-096 Tamilarasu K. 3-002
Shoujinaga T. 1-075 Su E. 2-009 Tamura N. 2-110, 2-021
Shruthi S. 3-115 Suaco J. 2-061 Tan D. 1-079
Shukla D. 1-141, 2-115 Suahilai D.M. 1-023 Tan H.L. 2-008
Shumpei Y. 3-034 Suboticki J.L. 1-091 Tanagon M.B. 3-144
Shumy F. 3-143 Sueyoshi T. 1-047 Tanaka M. 1-085, 3-092
Silpa-archa N. 1-067 Sugimura Y. 3-089, 3-072 Tanaka S. 2-017
Silva M.E. 2-037 Sugiyama N. 1-098 Tanaka Y. O-082, 1-098, 1-099, 1-093,
Singhal D. 1-016 Suh C.-H. 2-064 2-049, 3-074, 3-097, 3-094
Singh-Grewal D. 2-038 Suh Y.S. 3-023 Tang R.C.P. 1-111
Sinnathurai P. O-053, 2-078, 2-079, Sukumaran S. 3-061 Tang S.P. 3-056
2-038 Sulaiman H.S. 2-071 Tang S.-P. 3-057
Siripaitoon B. 2-145 Sullivan T. 3-090 Tangnararatchakit K. 3-137
Skillecorn M. 3-076 Sultan I. 2-082 Taniguchi Y. O-072, 2-045
Smith G. 3-134 Sumiyoshi R. 1-082, 1-036, 2-004 Taniguchi Y.Y. 1-026
Smith M. 3-103 Sumpton D. 2-078, 2-079 Tanprawate S. 3-037
Smith N. O-047, 1-061 Sun L. 3-029 Tao C. 3-029
Smith T. O-060, 3-025 Sung I. 1-116, 3-102 Tao J. 1-011, 1-012, 2-065, 3-036
Smolen J. 1-093, 2-077 Sung Y.-K. O-044 Taylor P. O-055
Smolen J.S. O-055, 1-099, 1-097 Suntoko B. 2-067 Taylor P.C. 1-093
Snowden N. O-047 Suppiah R. 3-071 Tee C. 1-063, 3-058, 3-063
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236      

Tee Y.C. 1-095, 3-078 Tvedten O. 3-024 Wang Q. 3-123, 3-124

Teguh D. 1-018 Tymms K. O-060, 2-038 Wang S. 2-100
Teichtahl A. 3-046 Wang X. O-080
Teo Y.L. 3-056 U Wang X.J. O-031
Terada Y. O-072, 1-026, 2-045 Wang Y. O-027, 2-062, 3-046, 3-022
Terrill M. 1-049, 2-012, 2-013 Ueki Y. 1-036, 1-027
Wangkaew S. 3-111
Thabah M. 3-115, 3-002 Ueno A. 3-145
Wantaneeyawong C. 3-037
Thakur B. 3-098 Ukritchon S. 3-035
Wantha O. 1-109
Thammaroj P. 2-105 Umeda M. 1-036, 1-027
Ward M. O-028
Thangavelu K. 2-099, 2-101 Umer T.P. 3-117, 3-118
Watanabe R. 3-010
Thaweeratthakul P. 3-096 Underwood M. 2-041
Watanabe T. 1-024, 2-096
Thi Thanh B.P. 3-042 Urowitz M.B. 3-133
Wechalekar M. O-018, 1-016, 3-103
Thiyagarajan D. 1-118 Urquhart D. 3-046
Wechelakar M. 2-038
Thomas K. 1-117 Ur-Rehman Z. 1-101
Wee A. 1-016
Thomas R. O-016, O-017, 2-016, 2-038, Uz Zaman A. 3-003
Weedon H. 3-103
3-011 Wehr P. 3-011
Thong B. 3-116 V Wei J. O-070, 1-117, 1-114
Thorlund J.B. 3-049 Weinblatt M. O-055, 1-093
Van den Bosch F. 1-117
Tian Y.T. O-015 Weisman M. O-028
Van H.N. 3-042
Tickner J. 1-018 Weyand C. 3-010
Vecchio P. 1-049
Ting Y.T. O-017 Whitehead B. 2-032
Venkataraman K. 3-119
Ting-Yin X. 3-136 Whittle S. 1-110, 3-032, 3-025
Venning B. 2-013
To C.H. 2-129 Whyte J. 3-012
Venugopalan A. 1-041, 1-045, 2-076,
Tomizawa T. 1-085, 3-092 Wickrematilake G. 2-102
2-113, 3-087, 3-038
Tony H.-P. 1-097 Willers C. 2-038
Verhagen A. 1-110, 3-025
de la Torre I. 2-077 Williams K. 3-024
Vilaiyuk S. 3-137
Toshihiro N. 3-034 van der Windt D. 1-110, 3-025
Villarubin A. 1-088
Touma Z. 3-133 Winthrop K. O-055, 1-097
Villo J.G. 1-033
Toyoizumi S. 1-098 Wisbey H. O-067
Vitri R. 3-009
Tran H.T. 3-042 Witcombe D. 2-075
Vogrin S. 1-043, 3-048
Tranquilino F. 1-129 Withana M. 1-081
Vojinovic J. 1-061
Tresnadi W. 1-106 Wluka A. 3-046
van Vollenhoven R. 1-091, 1-096
Trina S.S. 2-034 Wollin L. 3-013
Tripathy R. O-001, 2-020, 2-018 Won J. 3-129
W
Tripathy S.R. O-001, 2-020, 2-018 Wong D. 2-132
Trivedi V. 1-001 Wachjudi R. 3-009 Wong K.T. 3-120
True B. 3-032 Wachjudi R.G. 1-105, 1-106 Wong P. O-054, O-049, 2-080, 3-026,
Tsai C.-Y. 3-127 Wahab A.A. 2-127 3-064
Tsai S.-F. 3-127 Wahking B. 3-076 Wong P.C.H. 1-066
Tsai T. 2-038 Walker J. 3-107 Wong P.S. 1-056
Tsay G. 3-136 Walker J.G. 2-107 Wong S.R. 1-079
Tse S.M. 2-129 Wall A. 3-032 Wongpraparut C. 1-067
Tseng M.-H. 3-062 Wallace S. 2-125 Wook S.Y. 2-051
Tsoi L.-K. O-079 Wallis B. 3-010 Wordsworth B.P. O-028
Tsoi M.-F. 2-093 Walls C. O-055 Wright D. O-036
Tsuji S. 1-082, 2-004 Walsh M. 1-068 Wu C.-H. 2-091
Tsukada T. 1-027 Walsh P. 2-038 Wu C.-S. 3-146
Tsushima H. 2-021 Walter W. 2-038 WU D. 3-026
Tsutsui S. 1-082 Wan R. O-052 Wu D. O-049, 2-080
Tung C.-H. 2-091 Wang C. 2-120 Wu H. 1-100
Tungteerabunditkul S. 3-111 Wang D. 2-141, 2-062, 3-148 Wu P.-C. 2-006
Turkiewicz A. 3-049 Wang G. 1-100 Wu W.-S. 1-097
 |
237      

Wu Y.-J. O-076, 1-135, 1-123 Yang V. 3-147 Yu Q. 3-017

Wyllie R. 1-061 Yang Y. 1-100 Yue J. 2-080
Yano K. 3-070 Yumul A. 3-063
X Yap A. 1-079 Yusof H.M. 3-139
Yap K.K. 2-071 Yusof N. 2-140
Xavier R.M. 1-096
Yasuda T. 1-047 Yusoof H. 2-123
Xia Y. 1-011, 1-012, 2-065, 3-036
Yates D. 3-121
Xiang N. 1-011, 1-012
Yeh K.-W. 3-062 Z
Xie L. 1-093
Yen K.W. 2-140
Xiong M. 2-120 Zachariah B. 3-115
Yeoh F.B.H. 2-072
Xu D. 3-124 Zain M.M. 2-123, 3-139
Yesmin S. 2-082
Xu H. O-027, O-028 Zainuddin N. 2-123
Yi S.W. 2-127
Xu J. 1-100 Zainudin N. 1-023, 2-055, 3-139
Yin Y. 2-141, 2-062, 3-148
Xu J. 1-018, 1-100 Zaman A.U. 1-113, 2-002
Yoo B. 1-139
Xue M. 2-038, 2-078 Zamora L. O-076, 1-135, 1-123
Yoo B. 1-083, 1-138, 3-129
Zeisbrich M. 3-010
Yoo D.H. O-020
Y Zeng X. 2-141, 2-062, 3-148, 3-123,
Yoo W.Y. 3-014 3-124
Yachie A. 1-036 Yoon B.Y. 3-054 Zhan L. 1-100
Yahya F. 1-095, 3-078 Yoshida H. 2-096 Zhang H. 3-010
Yamaji K. 2-110, 2-021 Yoshida K. 1-075 Zhang J. 3-029
Yamamoto K. 1-013 Yoshida T. 1-076, 3-086 Zhang W. O-085, 2-062
Yamamoto M. 2-096 Yoshida Y. 1-075 Zhang X. 1-100
Yamamoto W. 3-094 Yoshii N. 1-098 Zhang Y. 1-099, 2-141, 2-062, 3-148
Yamamura M. 3-145 Yoshinaga Y. O-072 Zhao J. 3-029, 3-123, 3-124
Yamamura Y. 3-145 Yoshiura K. 1-036 Zhao Q. 3-006
Yamanaka H. 1-098 Yoshiyuki K. 3-034 Zheng Z. 3-017
Yamaoka K. 1-125, 1-098, 2-017 You H. 3-123 Zhilyaev E. 1-073, 2-097, 3-066
Yamsuwan J. 3-137 You S. 2-125 Zhu B. 1-093
Yan J. 1-061 Young L. O-056 Zhuang Y. 3-006
Yang D.-H. 1-046 Youssef P. O-084, 2-038 Zia M. 3-104
Yang H.-I. 2-119 Yu H. 1-122 Zuo C. 1-055