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Posterior reversible encephalopathy syndrome (PRES) in patients with systemic lupus erythematosus (SLE) has been recognized increasingly. This study aimed to determine the prevalence, clinical features, brain imaging findings, outcomes, and associated factors of PRES in Thai SLE patients. SLE patients with PRES were identified from the lupus cohort of Chiang Mai University. Controls were SLE patients with a hospital number close to and actually had SLE diagnosis within 5 years of the case (case:control ratio = 1:4). Of 1,332 SLE patients, 30 episodes of PRES were identified in 24 female SLE patients (prevalence 1.80%). The mean ± SD age at SLE diagnosis and at onset of PRES was 25.02 ± 13.78 and 28.31 ± 12.61 years, respectively. Seizure was the most common presenting symptom, as seen in 28 episodes, followed by acute severe headache in 17, alteration of consciousness in 17, nausea and vomiting in 10, blurred vision in 11, and hemiparesis in 3. Abrupt increase in blood pressure and active nephritis were seen in 29 and 26 of the episodes, respectively. Urine protein/creatinine ratio > 1.00 (OR 15.72, 95% CI 3.12–79.12, p = 0.001) and hemoglobin

Objective.To evaluate the efficacy, safety, pharmacokinetics, and immunogenicity of CNTO6785, a fully human monoclonal antibody that binds to human interleukin 17A, in patients with active rheumatoid arthritis (RA) with inadequate response to methotrexate (MTX) therapy.Methods.This randomized, double-blind, placebo-controlled, dose-ranging study enrolled patients aged 18 to 80 years (inclusive) with active RA (≥ 6/66 swollen and ≥ 6/68 tender joints) who were refractory to MTX treatment (7.5–25 mg weekly, inclusive). The study duration was 38 weeks, containing a 10-week safety followup. Patients were randomized 1:1:1:1:1 to receive CNTO6785 15, 50, 100, or 200 mg every 4 weeks + MTX or placebo + MTX. The primary endpoint was American College of Rheumatology 20 (ACR20) response at Week 16.Results.There were no significant differences from placebo in the proportion of patients treated with CNTO6785 in the primary endpoint of ACR20 response at Week 16. There were no significant findings in any additional efficacy variables through Week 32. No dose-response relationships or specific patterns were observed in adverse event profiles among CNTO6785 treatment groups. Infections occurred with similar frequency across all groups, and injection site reactions were mild or moderate and did not demonstrate a dose-response relationship. Median serum CNTO6785 concentration increases through Week 38 were about dose-proportional; the incidence of neutralizing antidrug antibodies was 19.4% and was not associated with study drug dose level.Conclusion.CNTO6785 was well tolerated, but did not demonstrate clinical efficacy in patients with active RA with inadequate response to MTX.

Background:In the absence of evidence-based treatment guidelines, medication use in SLE is highly variable. Low rates of remission and lupus low disease activity state (LLDAS) suggest that suboptimal responses to standard medications, which include glucocorticoids (GC), anti-malarial (AM) drugs and immunosuppressive (IS) agents, are common. Understanding the utility of current medications will facilitate the selection of patients for advanced therapies as they emerge.Objectives:To examine medication use patterns in a large multicentre SLE cohort.Methods:We used 2013-18 data from the Asia Pacific Lupus Collaboration (APLC) cohort in which disease activity (SLEDAI-2K) and medication details were captured at every visit. LLDAS was defined as in Golderet al., 2019 (1). We examined the use of medication (med) categories (GC &/or AM &/or IS) by SLE disease activity and LLDAS at the visit level. Additionally, we performed Cox regression analyses to determine the time-to-discontinuation of meds stratified by SLE disease activity, ranked by time-adjusted mean SLEDAI-2K, and by percent-time spent in LLDAS.Results:We analysed data from 19,804 visits of 2,860 patients. We observed 8 med categories: no meds; GC, AM or IS only; GC+AM; GC+IS; AM+IS and GC+AM+IS (triple therapy). Triple therapy was the most frequent med pattern (32%); single agents were used in 21% of visits and biologicals in only 3%. Among visits where SLEDAI-2K was ≥10, triple therapy was used in 46%, with median [IQR] GC dose 10 [6, 24] mg/day; in contrast, among visits with SLEDAI-2K≤4 triple therapy was used in 28% (pMed persistence (survival analysis) varied widely, with lowest survivals for IS. Patients with time-adjusted mean SLEDAI-2K ≥10 had lower discontinuation of GC and higher discontinuation of IS including azathioprine, leflunomide and cyclosporine (Table 1). In contrast, increased time in LLDAS was associated with reduced discontinuation of AM and azathioprine.GCAMISMPhMPhAAZAMTXCyALEFOverall med survival, days to 25% discontinuation (95%CI)1048(938, 1197)1267(1113, 1428)175(175, 182)387(252, 756)409(350, 476)525(219, 686)268(182, 350)329(190, 524)Univariable associations,HR (95% CI) p-valueDisease activity≤41.001.001.001.001.001.001.001.00>4 & 0.69 (0.56,0.84)p1.15 (0.92,1.44)0.20.92 (0.80,1.05)0.21.37 (0.78,2.42)0.31.16 (0.97,1.39)0.111.11 (0.72,1.71)0.61.26 (0.90,1.77) 0.181.88 (1.07,3.30) 0.03≥100.65 (0.35,1.21) 0.181.56 (0.94,2.59) 0.080.84 (0.45,1.57)0.61.92 (0.80,4.63)0.142.69 (1.86,3.91) p1.85 (0.92,3.71) 0.082.66 (1.36,5.21) 0.0041.62 (1.13,2.32)0.009LLDAS1.001.001.001.001.001.001.001.00≥50%1.30 (1.09, 1.55)0.0030.67 (0.54, 0.84)1.22 (1.08, 1.40)0.0020.83 (0.44,1.57)0.60.83 (0.69, 1.00)0.0540.70 (0.46, 1.07)0.101.29 (0.92, 1.83)0.140.43 (1.5, 1.25)0.12Conclusion:In a large multicentre SLE cohort, most patients were receiving combination treatment. AM treatment survival was high and associated with low disease activity, GC survival was high and associated with high disease activity, while IS survival was low. Patients with high disease activity received more medication combinations but had reduced IS survival. These data suggest ongoing unmet need for improved medications for treatment of SLE.Reference:Golder, V., et al Lancet Rheum. 2019 1(2):e95-102Disclosure of Interests:Rangi Kandane-Rathnayake Grant/research support from: The APLC has received financial (non-restricted educational) grants from AstraZeneca, Bristol Myers Squibb, GlaxoSmithKline, Janssen, EMD Serono, Eli Lilly and UCB for the LLDAS Validation Study., Worawit Louthrenoo: None declared, Shue Fen Luo: None declared, Yeong-Jian Wu Consultant of: Pfizer, Lilly, Novartis, Abbvie, Roche, Speakers bureau: Lilly, Novartis, Yi-Hsing Chen Grant/research support from: Taiwan Ministry of Science and Technology, Taiwan Department of Health, Taichung Veterans General Hospital, National Yang-Ming University, GSK, Pfizer, BMS., Consultant of: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra& Zeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead., Paid instructor for: Pfizer, Novartis, Johnson & Johnson, Roche, Lilly, Astra& Zeneca, Sanofi, Astellas, Agnitio Science Technology, United Biopharma., Speakers bureau: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra& Zeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead., Vera Golder: None declared, Aisha Lateef: None declared, Jiacai Cho: None declared, Sandra Navarra Speakers bureau: Astellas, Novartis, Pfizer, Johnson & Johnson, Abbvie, Leonid Zamora: None declared, Laniyati Hamijoyo Speakers bureau: Pfizer, Novartis, Tanabe, Abbot, Dexa Medica, Roche, Sargunan Sockalingam: None declared, Yuan An: None declared, Zhanguo Li: None declared, Yasuhiro Katsumata: None declared, masayoshi harigai Grant/research support from: AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., and Teijin Pharma Ltd. MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Oxford Immuotec, Pfizer Japan Inc., and Teijin Pharma Ltd. MH is a consultant for AbbVie, Boehringer-ingelheim, Kissei Pharmaceutical Co., Ltd. and Teijin Pharma., Yanjie Hao: None declared, Zhuoli Zhang: None declared, Madelynn Chan: None declared, Jun Kikuchi: None declared, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd., Fiona Goldblatt: None declared, Sean O’Neill: None declared, Chetan Karyekar Shareholder of: Johnson & Johnson, Consultant of: Janssen, Employee of: Janssen Global Services, LLC. Previously, Novartis, Bristol-Myers Squibb, and Abbott Labs., Jennifer H. Lofland Employee of: Janssen, Sang-Cheol Bae: None declared, Chak Sing Lau: None declared, Alberta Hoi: None declared, Mandana Nikpour: None declared, Eric F. Morand Grant/research support from: AstraZeneca, Consultant of: AstraZeneca, Speakers bureau: AstraZeneca

Additional file 4: Figure S4. Radar charts showing mean SF36 scores with 95%confidence interval according to organ specific disease activity. SLEDAI = systemic lupus erythematosus disease activity index-2K, CNS = central nervous system, VAS = vasculitis, MSK = musculoskeletal, CUT = cutaneous, SEROL = serological.

Background Studies have shown that a low serum uric acid (SUA) level associates with Parkinson’s disease (PD), but many of them did not exclude patients with impaired renal function. Studies on the association between serum bilirubin level and PD also are limited. This study determined the association between SUA level, SUA/serum creatinine (SCr) ratio and serum bilirubin levels in PD patients with normal renal and liver functions. Methods The PD patients from a neurological clinic, and the controls from the club for the elderly, were recruited into this study. The PD stage and motor and non-motor function were determined by the Hoehn-Yahr (H&Y) scale and unified Parkinson’s disease rating scale (UPDRS), respectively. Results Sixty-one PD patients and 135 controls participated. The SUA/SCr ratio, but not SUA, was significantly lower in the PD patients than in the controls (4.12 ± 0.90 vs. 4.59 ± 1.04, P = 0.003). Serum total bilirubin (TB) and indirect bilirubin (IDB) were significantly higher in the PD patients (7.92 ± 3.67 µmol/L vs. 6.59 ± 2.78 µmol/L, P = 0.003 and 4.52 ± 2.48 µmol/L vs. 3.26 ± 1.82 µmol/L, P < 0.001), respectively. Serum TB and IDB, but not SUA or SUA/SCr ratio, were associated negatively with PD stages (P = 0.010 and P = 0.014, respectively). There was no association between TB, IDB, SUA or SUA/SCr ratio and PD disease duration or motor subtypes. No significant correlation was found between SUA or SUA/SCr ratio, serum TB and IDB. Conclusion The SUA/SCr ratio is more sensitive than SUA in determining their association with PD. The high serum TB and IDB levels in PD patients compared with the controls suggest that serum bilirubin might play a role in the pathogenesis of PD. However, the lack of association between SUA or the SUA/SCr ratio and serum TB or IDB suggests that these two biomarkers play a different role in the etiopathogenesis of PD.

Background The utility of generic health-related quality of life (HRQoL) questionnaires in patients with systemic lupus erythematosus (SLE) is uncertain. We compared the performance of generic (SF36) and specific (SLEQOL) HRQoL surveys by examining their associations with the Global Rating of Change (GRC) and SLE clinical indicators. Methods The study included SLE patients who attended a single-center rheumatology clinic between 2013 and 2017. Patients completed both specific (SLEQOL) and generic (SF36) surveys and rated their GRC compared to the previous visit using a 7-point Likert scale on the same day of routine visits. Based on GRC scores, patients’ change in HRQoL was categorized as “no change,” “deterioration,” or “improvement.” Disease activity (SLEDAI-2K), flare, and lupus low disease activity state (LLDAS) were assessed at each visit, and organ damage (SDI) was determined annually. Pairwise correlations between SLEQOL and SF36 components were examined, and associations between GRC status and SLE disease indicators were compared using generalized estimating equations (GEE). Results Three hundred thirty-seven patients with 2062 visits were included in the analysis. SLEQOL correlated significantly with SF36. Patients reported improvements in HRQoL in 58%, deterioration in 15%, and “no change” in 27% of all visits. Compared to the “no change” group, mean SF36 and SLEQOL scores were significantly lower in the deterioration group and higher in the improvement group. The magnitude of changes observed with SLEQOL and SF36 in the deterioration and improvement groups was similar. Patients in LLDAS had significantly higher mean scores in both SLEQOL and SF36. In contrast, patients with active disease, especially those with cutaneous, renal, central nervous system, and musculoskeletal activity, had significantly lower SLEQOL and SF36. Flare and organ damage were also associated with lower SLEQOL and SF36-PCS (physical component) but not with SF36-MCS (mental component). Conclusion SLEQOL and SF36 similarly describe HRQoL in SLE. Both instruments demonstrated strong associations with GRC-based deterioration or improvement as well as SLE disease status. LLDAS was associated with improved HRQoL.

Background The Definitions of Remission in SLE (DORIS) group has proposed multiple definitions of remission, but these are infrequently attained and have not been prospectively evaluated in relation to protection from damage accrual. In contrast, the Lupus Low Disease Activity State (LLDAS) is more attainable, and has been shown to be associated with improved patient outcomes. Objectives To compare the attainability, and association with outcomes, of LLDAS and remission in a prospective multicentre study. Methods A prospective multinational cohort study was undertaken 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 12,717 visits. LLDAS was achieved in 47.2% of observed visits. In contrast, remission was achieved in 1.1%-15.4% of visits depending on the stringency of remission definition. LLDAS attainment at any visit was associated with significantly reduced subsequent flare (HR 0.65, 95%CI 0.56-0.75, p Conclusion LLDAS was more attainable than any remission definition, whilst still conferring significant reduction in flares and damage accrual. Only the least stringent remission definitions could be shown to be associated with significantly lower damage accrual, likely reflecting a low frequency of remission attainment overall. LLDAS is a valid treatment target for SLE and is more achievable than remission. Disclosure of Interests Vera Golder: None declared, Eric F. Morand Grant/research support from: AstraZeneca, Bristol Myers Squibb, Janssen, Merck Serono, and UCB, Consultant for: AstraZeneca, Eli Lilly, Janssen, and Merck Serono, Speakers bureau: AstraZeneca, Rangi Kandane-Rathnayake: None declared, Molla Huq: None declared, Worawit Louthrenoo: None declared, Shue Fen Luo: None declared, Yeong-Jian Wu: None declared, Aisha Lateef : None declared, Sargunan Sockalingam: None declared, Sandra Navarra: None declared, Leonid Zamora: None declared, Laniyati Hamijoyo: None declared, Yasuhiro Katsumata: None declared, masayoshi harigai Grant/research support from: Tokyo Women’s Medical University (TWMU) has received unrestricted research grants for Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases from Ayumi Pharmaceutical Co. Ltd., Bristol Meyers Squib, Chugai Pharmaceutical Co. Ltd., Nippon Kayaku Co. Ltd., Taisho Toyama Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Corp., and with which TWMU paid the salary of MH. MH has also received research grants from AbbVie Japan GK, Eisai Co. Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Madelynn Chan: None declared, Sean O’Neill: None declared, Fiona Goldblatt: None declared, Chak Sing Lau: None declared, Zhanguo Li: None declared, Alberta Hoi Grant/research support from: GSK, AstraZeneca, UCB and Merck Serono, Consultant for: Janssen Steering Committee, Speakers bureau: Novartis, Mandana Nikpour: None declared

Background The recently validated Lupus Low Disease Activity State (LLDAS) definition has been shown to have utility as a treat to target endpoint in SLE, whereby LLDAS attainment is associated with reduction in permanent damage accrual. Robust evaluation is required to ensure this protective association is not simply reflective of milder disease phenotypes being over-represented among LLDAS attainers. Objectives To assess the effect of attainment of LLDAS on damage accrual in patients with active disease at baseline. SLEDAI-2K≥6 was chosen as this reflects clinical trial entry criteria. 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 score (SLICC-ACR damage index (SDI)) collected annually. Subgroup analyses were performed to assess the effect of LLDAS on damage accrual in patients who had active disease at baseline (SLEDAI-2K≥6). Time-dependent hazards regression models were used to assess the association of attainment of LLDAS at any time point, and proportion of time in LLDAS at the 50% observed time cut-off, with accrual of irreversible end-organ damage. Results 1,735 patients were followed for (mean ± SD) 2.2 ± 0.9 years, totalling 12,717 visits. LLDAS attainment was less frequent in patients with active disease at baseline (901 of 3835 visits in LLDAS, 23.5%), compared to patients with SLEDAI2-K Conclusion Despite lower attainment of LLDAS in patients with higher disease activity at baseline, the magnitude of association of LLDAS attainment with lower damage accrual was greater in this subgroup of patients compared to those less active baseline disease. This supports the validity of LLDAS as an outcome measure, in a population similar to that typically selected into clinical trials, and further highlights the potential impact of achieving a target outcome in SLE patients with active disease. Disclosure of Interests Vera Golder: None declared, Eric F. Morand Grant/research support from: AstraZeneca, Bristol Myers Squibb, Janssen, Merck Serono, and UCB, Consultant for: AstraZeneca, Eli Lilly, Janssen, and Merck Serono, Speakers bureau: AstraZeneca, Rangi Kandane-Rathnayake: None declared, Molla Huq: None declared, Hieu Nim: None declared, Worawit Louthrenoo: None declared, Shue Fen Luo: None declared, Yeong-Jian Wu: None declared, Aisha Lateef : None declared, Sargunan Sockalingam: None declared, Sandra Navarra: None declared, Leonid Zamora: None declared, Laniyati Hamijoyo: None declared, Yasuhiro Katsumata: None declared, masayoshi harigai Grant/research support from: Tokyo Women’s Medical University (TWMU) has received unrestricted research grants for Division of Epidemiology and Pharmacoepidemiology of Rheumatic Diseases from Ayumi Pharmaceutical Co. Ltd., Bristol Meyers Squib, Chugai Pharmaceutical Co. Ltd., Nippon Kayaku Co. Ltd., Taisho Toyama Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Corp., and with which TWMU paid the salary of MH. MH has also received research grants from AbbVie Japan GK, Eisai Co. Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Madelynn Chan: None declared, Sean O’Neill: None declared, Fiona Goldblatt: None declared, Chak Sing Lau: None declared, Zhanguo Li: None declared, Alberta Hoi Grant/research support from: GSK, AstraZeneca, UCB and Merck Serono, Consultant for: Janssen Steering Committee, Speakers bureau: Novartis, Mandana Nikpour: None declared

Background The Definitions of Remission in SLE (DORIS) group has proposed multiple definitions of remission, but these are infrequently attained and have not previously been evaluated in relation to protection from damage accrual. In contrast, the Lupus Low Disease Activity State (LLDAS) is more attainable, and has been shown to be associated with improved patient outcomes. The objective of this study was to compare the attainability and effect of LLDAS and remission on outcomes in a prospective multicenter study. Methods A prospective multinational cohort study was undertaken 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. 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 Conclusions LLDAS was markedly more attainable than any remission definition, whilst still conferring significant protection against flares and damage accrual. Only the least stringent remission definitions could be shown to be associated with significant reduction in damage accrual, likely reflecting a low frequency of remission attainment overall; and normal serology was required for protection from flare. LLDAS is a valid treatment target for SLE and is more achievable than remission. Funding Source(s): The Asia Pacific Lupus Collaboration receives project support grants from UCB, GlaxoSmithKline, Janssen, Bristo-Myers Squibb, and AstraZeneca.

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 damage 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 associated with reduction in subsequent flare (HR 0.65, 95% CI 0.56–0.76, p 6) or pre-existing damage (SDI>0). Conclusions LLDAS attainment provides significant protection against disease flare and damage accrual thereby supporting its use as a treatment target in SLE, and as an outcome measure for clinical trials and treat-to-target strategies. Funding Source(s): The Asia Pacific Lupus Collaboration receives project support grants from UCB, GlaxoSmithKline, Janssen, Bristo-Myers Squibb, and AstraZeneca.

To evaluate the sensitivity and specificity of the 2015 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) gout classification criteria in Thai patients presenting with acute arthritis in a real-life setting. Data were analyzed on consecutive patients presenting with arthritis of less than 2 weeks duration. Sensitivity and specificity were calculated by using the presence of monosodium urate (MSU) crystals in the synovial fluid or tissue aspirate as gold standard for gout diagnosis. Subgroup analysis was performed in patients with early disease (≤2 years), established disease (>2 years), and those without tophus. Additional analysis also was performed in non-tophaceous gout patients, and patients with acute calcium pyrophosphate dihydrate crystal arthritis were used as controls. One hundred and nine gout and 74 non-gout patients participated in this study. Full ACR/EULAR classification criteria had sensitivity and specificity of 90.2 and 90.0%, respectively; and 90.2 and 85.0%, respectively, when synovial fluid microscopy was excluded. Clinical-only criteria yielded sensitivity and specificity of 79.8 and 87.8%, respectively. The criteria performed well among patients with early and non-tophaceous disease, but had lower specificity in patients with established disease. The variation of serum uric acid level was a major limitation of the classification criteria. The ACR/EULAR classification criteria had high sensitivity and specificity in Thai patients presenting with acute arthritis, even when clinical criteria alone were used.

Objective: To examine the performance of ultrasound (US) for the diagnosis of gout using the presence of monosodium urate monohydrate (MSU) crystals as the gold standard. Methods: We analyzed data from the Study for Updated Gout Classification Criteria (SUGAR), a large, multicenter observational cross-sectional study of consecutive subjects with at least 1 swollen joint who conceivably may have gout. All subjects underwent arthrocentesis; cases were subjects with confirmed MSU crystals. Rheumatologists or radiologists who were blinded with regard to the results of the MSU crystal analysis performed US on 1 or more clinically affected joints. US findings of interest were double contour sign, tophus, and snowstorm appearance. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Multivariable logistic regression models were used to examine factors associated with positive US results among subjects with gout. Results: US was performed in 824 subjects (416 cases and 408 controls). The sensitivity, specificity, PPV, and NPV for the presence of any 1 of the features were 76.9%, 84.3%, 83.3%, and 78.2%, respectively. Sensitivity was higher among subjects with a disease duration of ≥2 years and among subjects with subcutaneous nodules on examination (suspected tophus). Associations with a positive US finding included suspected clinical tophus (odds ratio [OR] 4.77 [95% confidence interval (95% CI) 2.23–10.21]), any abnormality on plain radiography (OR 4.68 [95% CI 2.68–8.17]), and serum urate level (OR 1.31 [95% CI 1.06–1.62]). Conclusion: US features of MSU crystal deposition had high specificity and high PPV but more limited sensitivity for early gout. The specificity remained high in subjects with early disease and without clinical signs of tophi. (Less)

Objectives: To compare the muscle pathology findings among subgroups of idiopathic inflammatory myopathies (IIM) patients, and to determine the correlations of muscle biopsy scores with muscle power and creatine kinase (CK). Methods: The medical records of IIM patients consisting of the demographic data, clinical parameters and laboratory conducted were retrospectively reviewed. Their initial muscle biopsies were reviewed, and four domains were scored: inflammation, vascular, muscle, and connective tissue. Results: Ninety-five IIM patients (28 patients with idiopathic polymyositis (PM) 9 idiopathic dermatomyositis (DM), 5 DM associated with malignancy, and 53 PM/DM associated with connective tissue disease) with median (IQR: Q1, Q3) disease duration of 1.2 (0.5, 3.1) months were included. No significant differences in initial muscle pathology findings and muscle pathology score among the subgroups were found. Muscle degeneration and endomysial fibrosis scores were negatively correlated with muscle power (r=-0.23 and-0.24, respectively, p Conclusion: In this study, muscle biopsy cannot be used to differentiate among subgroups of IIM patients. In addition, we found only modest correlation of muscle biopsy scores with muscle power and CK. Further study is necessary to confirm our findings.

Objective To identify the best-performing survey definition of gout from items commonly available in epidemiologic studies. Methods Survey definitions of gout were identified from 34 epidemiologic studies contributing to the Global Urate Genetics Consortium (GUGC) genome-wide association study. Data from the Study for Updated Gout Classification Criteria (SUGAR) were randomly divided into development and test data sets. A data-driven case definition was formed using logistic regression in the development data set. This definition, along with definitions used in GUGC studies and the 2015 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) gout classification criteria were applied to the test data set, using monosodium urate crystal identification as the gold standard. Results For all tested GUGC definitions, the simple definition of “self-report of gout or urate-lowering therapy use” had the best test performance characteristics (sensitivity 82%, specificity 72%). The simple definition had similar performance to a SUGAR data-driven case definition with 5 weighted items: self-report, self-report of doctor diagnosis, colchicine use, urate-lowering therapy use, and hyperuricemia (sensitivity 87%, specificity 70%). Both of these definitions performed better than the 1977 American Rheumatism Association survey criteria (sensitivity 82%, specificity 67%). Of all tested definitions, the 2015 ACR/EULAR criteria had the best performance (sensitivity 92%, specificity 89%). Conclusion A simple definition of “self-report of gout or urate-lowering therapy use” has the best test performance characteristics of existing definitions that use routinely available data. A more complex combination of features is more sensitive, but still lacks good specificity. If a more accurate case definition is required for a particular study, the 2015 ACR/EULAR gout classification criteria should be considered.

Author(s): de Lautour, Hugh; Taylor, William J; Adebajo, Ade; Alten, Rieke; Burgos-Vargas, Ruben; Chapman, Peter; Cimmino, Marco A; da Rocha Castelar Pinheiro, Geraldo; Day, Ric; Harrold, Leslie R; Helliwell, Philip; Janssen, Matthijs; Kerr, Gail; Kavanaugh, Arthur; Khanna, Dinesh; Khanna, Puja P; Lin, Chingtsai; Louthrenoo, Worawit; McCarthy, Geraldine; Vazquez-Mellado, Janitzia; Mikuls, Ted R; Neogi, Tuhina; Ogdie, Alexis; Perez-Ruiz, Fernando; Schlesinger, Naomi; Ralph Schumacher, H; Scire, Carlo A; Singh, Jasvinder A; Sivera, Francisca; Slot, Ole; Stamp, Lisa K; Tausche, Anne-Kathrin; Terkeltaub, Robert; Uhlig, Till; van de Laar, Mart; White, Douglas; Yamanaka, Hisashi; Zeng, Xuejun; Dalbeth, Nicola | Abstract: To establish consensus for potential remission criteria to use in clinical trials of gout.Experts (n = 88) in gout from multiple countries were invited to participate in a web-based questionnaire study. Three rounds of Delphi consensus exercises were conducted using SurveyMonkey, followed by a discrete-choice experiment using 1000Minds software. The exercises focused on identifying domains, definitions for each domain, and the timeframe over which remission should be defined.There were 49 respondents (56% response) to the initial survey, with subsequent response rates ranging from 57% to 90%. Consensus was reached for the inclusion of serum urate (98% agreement), flares (96%), tophi (92%), pain (83%), and patient global assessment of disease activity (93%) as measurement domains in remission criteria. Consensus was also reached for domain definitions, including serum urate (l0.36 mm), pain (l2 on a 10-point scale), and patient global assessment (l2 on a 10-point scale), all of which should be measured at least twice over a set time interval. Consensus was not achieved in the Delphi exercise for the timeframe for remission, with equal responses for 6 months (51%) and 1 year (49%). In the discrete-choice experiment, there was a preference towards 12 months as a timeframe for remission.These consensus exercises have identified domains and provisional definitions for gout remission criteria. Based on the results of these exercises, preliminary remission criteria are proposed with domains of serum urate, acute flares, tophus, pain, and patient global assessment. These preliminary criteria now require testing in clinical data sets.

Acute bone infarction is a well-described complication in sickle cell hemoglobinopathy but it is rarely reported in patients with thalassemia. This report describes an 18-year-old man with homozygous β-thalassemia presenting with a fever and severe acute bilateral ankle pain. The acute onset of severe pain and fever were clinical mimics of infectious arthritis and osteomyelitis. Magnetic resonance imaging revealed acute bone infarction in the meta-diaphysis of bilateral tibias presenting as central unenhanced devitalized bone with T1-high signal intensity fluid in the subperiosteum and soft tissue. Characteristic imaging features are discussed, emphasizing the benefit of fat suppression pre-and post-intravenous gadolinium T1-weighted images. The etiologies of bone infarction in thalassemia are reviewed.

Studies on predicting factors for adverse pregnancy outcomes (APOs) in Thai patients with systemic lupus erythematosus (SLE) are limited. This retrospective observation study determined APOs and their predictors in Thai patients with SLE. Medical records of pregnant SLE patients in a lupus cohort, seen from January 1993 to June 2017, were reviewed. Ninety pregnancies (1 twin pregnancy) from 77 patients were identified. The mean age at conception was 26.94 ± 4.80 years. At conception, 33 patients (36.67%) had active disease, 23 (25.56%) hypertension, 20 (22.22%) renal involvement, and 6 of 43 (13.95%) positive anti-cardiolipin antibodies or lupus anti-coagulants, and 37 (41.11%) received hydroxychloroquine. Nineteen patients (21.11%) had pregnancy loss. Of 71 successful pregnancies, 28 (31.11%) infants were full-term, 42 (46.67%) pre-term and 1 (11.11%) post-term; 19 (26.39%) were small for gestational age (SGA), and 38 (52.58%) had low birth weight (LBW). Maternal complications occurred in 21 (23.33%) pregnancies [10 (11.11%) premature rupture of membrane (PROM), 8 (8.89%) pregnancy induced hypertension (PIH), 4 (4.44%) oligohydramnios, 2 (2.22%) post-partum hemorrhage, and 1 (1.11%) eclampsia]. Patients aged ≥ 25 years at pregnancy and those ever having renal involvement had predicted pregnancy loss with adjusted odds ratio (AOR) [95% CI] of 4.15 [1.10–15.72], P = .036 and 9.21 [1.03–82.51], P = .047, respectively. Renal involvement predicted prematurity (6.02 [1.77–20.52, P = .004), SGA (4.46 [1.44–13.78], P = .009), and LBW in infants (10.01 [3.07–32.62], P 10 mg/day) and immunosuppressive drugs used at conception protected against prematurity (0.11 [0.02–0.85], P = .034). Flares and hematologic involvement predicted PROM (8.45 [1.58–45.30], P = .013) and PIH (9.24 [1.70–50.24], P = .010), respectively. Cutaneous vasculitis (33.87 [1.05–1,094.65], P = .047), and renal (31.89 [6.66–152.69], P 10 mg/day) and immunosuppressive drug use at conception reduced that risk (0.08 [0.01–0.68, P = .021). APOs remain a problem in Thai pregnant SLE patients. Renal involvement and SLE flares were associated with the risk of APOs.

To evaluate the efficacy and safety of diacerein in patients with rheumatoid arthritis (RA) who are methotrexate inadequate responders (MTX-IR).In this pilot, multicenter, double-blind, placebo-controlled trial, MTX-IR RA patients were randomized to either diacerein or matching placebo as add-on treatment to MTX for 24 weeks. Efficacy and safety were evaluated every 4 weeks until week 28. Primary and secondary efficacy endpoints were the percentage of patients achieving the ACR20 criteria and a moderate EULAR response at week 24, respectively.Forty patients were equally randomized to both study treatments; 16 and 19 participants completed the study in the diacerein and the placebo arms, respectively. Baseline characteristics were similar in both groups, except that tender joint count, DAS28-ESR score, and non-steroidal anti-inflammatory drug consumption were higher in the placebo arm. The ACR20 response at week 24 was similar in the diacerein and placebo groups (65% vs 45%, P = .20). However, treatment response according to the EULAR criteria was better in patients taking diacerein (75% vs 25% of moderate response, P = .002). In the 35 patients with assessments through week 28, diacerein was superior to placebo in ACR20 at weeks 24 and 28 (both 81% vs 47%, P = .04). Incidence of adverse events was comparable in both arms, with only chromaturia being more common with diacerein than placebo (40% vs 10%, P = .03).These preliminary results show the potential benefits of diacerein on pain, joint function, and disease activity in MTX-IR RA patients.ClinicalTrials.gov Identifier: NCT01264211 Key Points • Diacerein has shown positive effects on rheumatoid arthritis symptoms. • A good safety profile of diacerein has been observed when it was administered as add-on therapy to methotrexate in patients with rheumatoid arthritis.

OBJECTIVE: The language currently used to describe gout lacks standardisation. The aim of this project was to develop a consensus statement on the labels and definitions used to describe the basic disease elements of gout. METHODS: Experts in gout (n=130) were invited to participate in a Delphi exercise and face-to-face consensus meeting to reach consensus on the labelling and definitions for the basic disease elements of gout. Disease elements and labels in current use were derived from a content analysis of the contemporary medical literature, and the results of this analysis were used for item selection in the Delphi exercise and face-to-face consensus meeting. RESULTS: There were 51 respondents to the Delphi exercise and 30 attendees at the face-to-face meeting. Consensus agreement (≥80%) was achieved for the labels of eight disease elements through the Delphi exercise; the remaining three labels reached consensus agreement through the face-to-face consensus meeting. The agreed labels were: monosodium urate crystals, urate, hyperuric(a)emia, tophus, subcutaneous tophus, gout flare, intercritical gout, chronic gouty arthritis, imaging evidence of monosodium urate crystal deposition, gouty bone erosion and podagra. The face-to-face meeting achieved consensus agreement for the definitions of all 11 elements and a recommendation that the label 'chronic gout' should not be used. CONCLUSION: Consensus agreement was achieved for the labels and definitions of 11 elements representing the fundamental components of gout aetiology, pathophysiology and clinical presentation. The Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) recommends the use of these labels when describing the basic disease elements of gout. This article is protected by copyright. All rights reserved.

ObjectiveThere is a lack of standardisation in the terminology used to describe gout. The aim of this project was to develop a consensus statement describing the recommended nomenclature for disease states of gout.MethodsA content analysis of gout-related articles from rheumatology and general internal medicine journals published over a 5-year period identified potential disease states and the labels commonly assigned to them. Based on these findings, experts in gout were invited to participate in a Delphi exercise and face-to-face consensus meeting to reach agreement on disease state labels and definitions.ResultsThe content analysis identified 13 unique disease states and a total of 63 unique labels. The Delphi exercise (n=76 respondents) and face-to-face meeting (n=35 attendees) established consensus agreement for eight disease state labels and definitions. The agreed labels were as follows: ‘asymptomatic hyperuricaemia’, ‘asymptomatic monosodium urate crystal deposition’, ‘asymptomatic hyperuricaemia with monosodium urate crystal deposition’, ‘gout’, ‘tophaceous gout’, ‘erosive gout’, ‘first gout flare’ and ‘recurrent gout flares’. There was consensus agreement that the label ‘gout’ should be restricted to current or prior clinically evident disease caused by monosodium urate crystal deposition (gout flare, chronic gouty arthritis or subcutaneous tophus).ConclusionConsensus agreement has been established for the labels and definitions of eight gout disease states, including ‘gout’ itself. The Gout, Hyperuricaemia and Crystal-Associated Disease Network recommends the use of these labels when describing disease states of gout in research and clinical practice.

Thalassemia patients have a high cell turnover rate due to chronic hemolysis and ineffective erythropoiesis; therefore, hyperuricemia is anticipated. This study aimed to identify the prevalence of hyperuricemia, gout and nephrolithiasis, conditions associated with serum uric acid (SUA), and urine uric acid excretion (UUA) in thalassemia patients. This was a cross-sectional study in patients aged 15 years or older at Chiang Mai University Hospital. All patients had blood and 24-h urine collection test. We enrolled 112 thalassemia patients in which 67.0% were female, 64.3% had beta thalassemia/Hb E, 76.8% were transfusion dependent, and 59.8% were post splenectomy. The median age was 29 (16-58) years. Mean SUA was 6.7 ± 2.0 mg/dl and hyperuricemia (SUA 6.8 mg/dl) was found in 47 cases (45.2%). Intact spleen (ORs 4.3, 95%CI 1.55-12.50, p = 0.01) and lower FEuric (ORs 2.08, 95%CI 1.35-3.33, p 0.01) were associated with hyperuricemia significantly. Seven (6.3%) had gouty arthritis and nine (8%) had microscopic hematuria, one case being confirmed nephrolithiasis. The mean UUA excretion was 981.3 ± 335.0 mg/day and UUA hyperexcretion ( 700 mg/24 h) was found in 83.3%. UUA hyperexcretion patients had renal hyperfiltration 46%, glomerular dysfunction 84%, and tubular dysfunction 7.7%. From our study, hyperuricemia was found in approximately 40% of thalassemia patients but gouty arthritis occurred only in few patients (6%). This may be explained by urinary uric hyperexcretion which is found in over 80%. The significant risk factors for hyperuricemia were intact spleen and lower fraction excretion of uric acid.

Background Lupus nephritis (LN) is a common feature of systemic lupus erythematosus (SLE). While LN is considered a contributor to irreversible organ damage in SLE, the magnitude of impact of active renal disease relative to other contributors to damage accrual is unknown. Objectives To determine the time-dependent association of active lupus nephritis (LN) with organ damage accrual in SLE. Methods This study was performed on patients from the Asia Pacific Lupus Collaboration (APLC) cohort. SLE Disease Activity Index-2000 (SLEDAI-2k) is collected per-visit and SLICC-ACR Damage Index (SDI) annually. Analysis was restricted to patients with ≥2 SDI scores. Active LN was defined if patients had urinary casts, proteinuria, haematuria or pyuria as indicated in the SLEDAI-2k descriptor. Organ damage accrual was defined as a change of SDI (ΔSDI>0) between baseline and final visit. Glucocorticoid (GC) categories were defined according to cumulative GC exposure at each visit as either no GC (cum.GC=0); low GC (cum.GC ≤median) or high GC (cum.GC >median). Cox regression analyses were performed. Results 1735 patients and 5593 visits were included in the analysis. 93% of patients was female with a median ([inter-quartile range (IQR), (range)] age of 40 years.31, 51 18, 77 Median study observation period was 853 days [621, 1094].98, 1443 36% were Chinese; 20% Thai and 10% Caucasian ethnicity. 82% of patients were exposed to glucocorticoids. 40% had active renal disease at least once during the study period, and active renal disease was observed in 22% of visits (n=1238 visits). 41% of patients had organ damage at baseline and 14% accrued organ damage (272 damage accrual episodes in 250 patients). Active renal disease was significantly associated with damage accrual; after adjusting for confounders, patients with active renal disease were 66% more likely to accrue organ damage compared to those without active renal disease (adjusted hazard ratio=1.66 (95% CI: 1.26, 2.19), p-value Conclusions Active LN is an independent risk factor for damage accrual in SLE. The concomitant independent association of GC exposure with damage accrual suggests non-GC treatments to reduce active LN are needed to reduce damage burden in SLE. Disclosure of Interest None declared

Aim The aim of this manuscript is to describe the development of the Asia Pacific Lupus Collaboration (APLC) cohort. Method The APLC cohort is an ongoing, prospective longitudinal cohort. Adult patients who meet either the American College of Rheumatology (ACR) Modified Classification Criteria for systemic lupus erythematosus (SLE), or the Systemic Lupus International Collaborating Clinics (SLICC) Classification Criteria, and provide informed consent are recruited into the cohort. Patients are routinely followed up at 3- to 6-monthly intervals. Information on demographics, clinical manifestations, treatment, pathology results, outcomes, and patient-reported quality of life (Short-form 36 version 2) are collected using a standardized case report form. Each site is responsible for obtaining local ethics and governance approval, patient recruitment, data collection, and data transfer into a centralized APLC database. Results The latest APLC cohort comprises 2160 patients with >12 000 visits from Australia, China, Hong Kong, Indonesia, Japan, Malaysia, Philippines, Singapore, Taiwan and Thailand. The APLC has proposed the Lupus Low Disease Activity State (LLDAS) as a treat-to-target (T2T) endpoint, and reported several retrospective and cross-sectional analyses consistent with the validity of LLDAS. Longitudinal validation of LLDAS as a T2T endpoint is currently underway. Conclusion The APLC cohort is one of the largest contemporary SLE patient cohorts in the world. It is the only cohort with substantial representation of Asian patients. This cohort represents a unique resource for future clinical research including evaluation of other endpoints and quality of care.

Objective.To determine the frequency of adverse events of diagnostic arthrocentesis in patients with possible gout.Methods.Consecutive patients underwent arthrocentesis and were evaluated at 6 weeks to determine adverse events. The 95% CI were obtained by bootstrapping.Results.Arthrocentesis was performed in 910 patients, and 887 (97.5%) were evaluated for adverse events. Any adverse event was observed in 12 participants (1.4%, 95% CI 0.6–2.1). There was 1 case (0.1%, 95% CI 0–0.34) of septic arthritis.Conclusions.Diagnostic arthrocentesis is associated with a low frequency of adverse events. Septic arthritis rarely occurs.

Objective The aim of this study was to determine the prevalence, spectrum, and clinical, radiological, and serologic findings as well as hand functions among Thai systemic lupus erythematosus (SLE) patients with deforming arthropathy. Methods All SLE patients attending the rheumatology clinic between January and December 2012 were interviewed, with their complete history and a physical examination being taken. Those with hand deformities were invited to join the study. Results Forty (8.7%) of 458 SLE patients had deforming arthropathy, with 13 (2.8%) of them having erosive arthritis (EA group) and 27 nonerosive arthropathy (NEA group) (8 [1.8%] with Jaccoud arthropathy [JA subgroup] and 19 [4.1%] with mild deforming arthropathy [MDA subgroup]). Three of 13 EA patients (0.7% of all SLE patients) had high titer of rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies that might represent true overlapping between rheumatoid arthritis and SLE. There were no statistically significant differences in autoantibodies, RF, or anti-CCP between the EA and NEA groups or the JA and MDA subgroups, except for discoid rash that was seen more commonly in the MDA subgroup. Rheumatoid factor and anti-CCP were not present in the JA subgroup. Hand joint destruction and deformities were seen more commonly in the EA group and JA subgroup. The hand grip and palmar pinch strength decreased moderately, with hand functions quite well preserved in all groups. Conclusions Deforming arthropathy was not uncommon in Thai SLE patients, but true overlapping between rheumatoid arthritis and SLE was rare. Despite significant hand joint deformities and moderately decreased hand grip and palmar pinch strength, preservation of hand functions was generally apparent.

To determine and compare the prevalence of interstitial lung disease (ILD), the severity of high-resolution computed tomography (HRCT) score and incidence rate (IR) of ILD between the two subsets of early-SSc (systemic sclerosis) patients. We also determined the factors associated with ILD.We used an inception cohort of early-SSc patients seen between January 2010 and June 2014. All patients underwent HRCT at study entry and annually thereafter.One hundred and thirteen patients (66 females and 89 diffuse cutaneous SSc [dcSSc]) with a mean ± SD age of 53.4 ± 8.4 years and mean disease duration of 12.9 ± 10.3 months at cohort entry were enrolled. At enrollment, patients with dcSSc had a higher prevalence of ILD (78.7% vs. 45.8%, p = 0.002), and a higher total HRCT score (10.3 ± 9.5 vs. 4.4 ± 5.6, p = 0.001) compared with limited cutaneous SSc (lcSSc). DcSSc patients had a higher IR of ILD than lcSSc patients (58.8 vs.17.3 per 100 person-years, p 0.001). Univariable analysis revealed that male gender, presence of anti-Scl 70 and absent anti-centromere antibody was significant predictors of ILD. In Cox-regression analysis, a positive anti-centromere [hazard ratio (HR) 0.09 95% confidence interval (95% CI 0.01-0.73)] was a protective factor.DcSSc patients had more severe HRCT scores and higher IR of ILD compared with lcSSc patients. Male gender, presence of anti-Scl 70, and absent anti-centromere antibody predicted the future development of ILD in early-SSc patients.

This study aimed to evaluate the long-term effectiveness and safety of the first anti-tumor necrosis factor α therapy (TNFi) and to identify the associated factors of drug discontinuation in patients with spondyloarthritis.This was a medical records review study. Patients with spondyloarthritis who were prescribed the first TNFi between December 2009 and October 2014 in the Rheumatic Disease Prior Authorization registry were enrolled. Baseline clinical data were retrieved. The Cox proportional hazards model was used to identify factors associated with discontinuation of drugs.Among 138 patients, 97 had ankylosing spondylitis (AS), and 41 had psoriatic arthritis (PsA). The effectiveness of TNFi in AS and PsA was 55% to 59% at 4 months and 75% to 96% at 3 years, as measured by a 50% decrease in the Bath Ankylosing Spondylitis Disease Activity Index from baseline. For PsA with peripheral arthritis, improvement of the joint count by 50% was observed in 61.8% of patients at 4 months and 100% at 3 years. Survival from TNFi was 63% for AS and 56% for PsA at 3 years. For AS, the factors associated with good response leading to discontinuation of TNFi were baseline patient global assessment 3 to 6/10 (hazard ratio [HR], 6.3) and the use of leflunomide (HR, 6.0) and infliximab (HR, 4.8). A good response (38.5%) was the most common cause of discontinuation of the first TNFi, followed by toxicity (28.2%), nonadherence (20.5%), and lack of effectiveness (12.8%).Ankylosing spondylitis and PsA responded well to TNFi during the 3-year follow-up. The retention rate was approximately 60% for AS and PsA. A good response to the first TNFi was the most common reason for discontinuation.

Objective To study the response of lupus nephritis (LN) patients with persistent proteinuria (≥ 1 g/day after ≥ 6 months corticosteroid and single immunosuppressant treatment, or ≥ 3 g/day after ≥ 3 months of corticosteroid and single immunosuppressant treatment) to corticosteroid combined with two immunosuppressants, and to evaluate associated factors of response within 1 year. Method A retrospective study of proteinuria and renal function observed in LN patients with persistent proteinuria after adding a second immunosuppressant at 3, 6, 9 and 12 months. Result Twenty-one LN patients (100.0% female) with persistent proteinuria were treated with corticosteroid and two immunosuppressants (mycophenolate mofetil [MMF] plus cyclosporine A [CSA]). Their mean age and duration from first immunosuppressant to initiating a combination therapy were 33.2 ± 10.2 years and 17.5 ± 15.7 months, respectively. Twelve (57.1%) patients had proteinuria levels ≥ 3 g/day. The renal pathology from 18 patients were Classes III or IV in 11 (61.1%). Fifteen patients (71.4%) responded to treatment (complete remission [CR], proteinuria ≤ 0.5 g/day, in seven patients and partial remission [PR], proteinuria reduced > 50%, in eight patients). Changing from a single immunosuppressant to combined immunosuppressants was associated with CR within 1 year (hazards ratio = 0.88; 95% CI = 0.78–0.99). Adverse events consisted of one patient with severe infection, two herpes zoster and one with transient increased serum creatinine level. Conclusion Approximately 70% of LN patients with persistent proteinuria responded to MMF plus CSA. However, infection should be a concern with these patients.

Aim In June 2015, the Thai Rheumatism Association (TRA) approved an update of its recommendation for the use of biologic disease-modifying anti-rheumatic drugs (bDMARDs) and targeted synthetic (tsDMARD) in the treatment of rheumatoid arthritis (RA) to cover those currently available in Thailand (etanercept, infliximab, golimumab, rituximab, tocilizumab, abatacept and tofacitinib). Method A search of the literature was performed between January 2000 and June 2015. Existing RA recommendations, in relation to the use of bDMARDs and tsDMARD, were identified and evaluated by the AGREE II instrument prior to their use as a 'guide' for developing this TRA recommendation. An additional literature search was performed in order to answer specific clinical questions that could not be found in existing guidelines. Result Thirteen recommendations were developed. They covered the use of RA classification criteria, the aim of RA treatment, when to initiate bDMARDs/tsDMARD or taper or switch them to other medications, as well as monitoring these drugs during their use. In addition, specific issues including their use and vaccination, malignancies, pregnancy and lactation, and perioperative period also were addressed. Public hearings were performed at the annual meeting of the TRA and of the Royal College of Physicians of Thailand. The recommendations were distributed to other professional associations related to RA management, as well as government sectors associated with the reimbursement policy, prior to development of the final version. Conclusion These recommendations will help Thai rheumatologists prescribe bDMARDs and tsDMARD more appropriately when treating RA patients.

OBJECTIVE: To perform external validation of a provisional definition of disease flare in patients with gout. METHODS: Five hundred nine patients with gout were enrolled in a cross-sectional study during a routine clinical care visit at 17 international sites. Data were collected to classify patients as experiencing or not experiencing a gout flare, according to a provisional definition. A local expert rheumatologist performed the final independent adjudication of gout flare status. Sensitivity, specificity, predictive values, and receiver operating characteristic (ROC) curves were used to determine the diagnostic performance of gout flare definitions. RESULTS: The mean ± SD age of the patients was 57.5 ± 13.9 years, and 89% were male. The definition requiring fulfillment of at least 3 of 4 criteria (patient-defined gout flare, pain at rest score of >3 on a 0-10-point numerical rating scale, presence of at least 1 swollen joint, and presence of at least 1 warm joint) was 85% sensitive and 95% specific in confirming the presence of a gout flare, with an accuracy of 92%. The ROC area under the curve was 0.97. The definition based on a classification and regression tree algorithm (entry point, pain at rest score >3, followed by patient-defined flare "yes") was 73% sensitive and 96% specific. CONCLUSION: The definition of gout flare that requires fulfillment of at least 3 of 4 patient-reported criteria is now validated to be sensitive, specific, and accurate for gout flares, as demonstrated using an independent large international patient sample. The availability of a validated gout flare definition will improve the ascertainment of an important clinical outcome in studies of gout.

Background Treatment recommendations for patients with spondyloarthritis (SpA) who inadequately respond to non-steroidal anti-inflammatory drugs (NSAIDs) and/or traditional disease-modifying antirheumatic drugs (DMARDs) are anti-tumour necrosis factor-alpha therapy (TNFi). There has been no data on the long-term efficacy and safety of TNFi in Thai patients with SpA. Objectives To evaluate the long-term efficacy and safety of the first TNFi in real-life practice and to identify the risk factors related to drug discontinuation in Thai patients with SpA from the RDPA registry. Methods Patients who fulfilled the 1984 Modified New York criteria for ankylosing spondylitis (AS), CASPAR criteria or Moll and Wright criteria for psoriatic arthritis (PsA) and the European Spondyloarthropathy Study Group Criteria or Modified Amor criteria for undifferentiated SpA (uSpA), and were prescribed the first TNFi between December 2009 and October 2014 in the RDPA registry were enrolled. Baseline demographic and clinical data were retrieved. A Cox proportional hazard model was used to identify the factors associated with discontinuation. The P-value of Results Of the 142 patients included, 97 had AS, 41 had PsA, and 4 had uSpA. Most AS patients were male (54.6%) with mean (SD) age of 44.6 (10.6) years, median (P25–P75) baseline BASDAI was 6.5 (5.6, 8.2) [from a 10-cm visual analog scale (VAS)], and median baseline patient global assessment (bPGA) was 7.2 (P25–P75 6.0, 8.0) (from a 10-cm VAS). For PsA patients, most were female (68.3%) with mean age of 52.6 (SD 12.2) years, median baseline BASDAI was 6.6 (P25–P75 4.9, 7.4) in patients with active axial involvement and median baseline number of joint involvement was 13.5 (P25–P75 6, 18.3) joints per patient with active peripheral joint involvement. The Efficacy of the TNFi treatment was good and it was increased over time in AS and PsA patients (figure 1). During the 5-year follow-up, AS, PsA, and uSpA patients had comparable discontinuation rate of their first TNFi treatment [25 (26%) in AS, 14 (34%) in PsA, and 1 (25%) in uSpA; p=0.82]. In univariate analysis, leflunomide use, and bPGA 6 (from a 10-cm VAS) were associated with the discontinuation of TNFi in AS patients with hazard ratio (HR) (95% CI) of 2.56 (1.13, 5.81) and 8.59 (1.82, 40.65), respectively. For the patients with PsA, only infliximab use was associated with TNFi discontinuation with HR of 4.79 (95% CI 1.33, 17.20) in univariate analysis. The reasons for TNFi discontinuation were good response (38%), serious adverse effects (SAE) (30%), non-adherence (20%), and lack of efficacy (13%). Among SAE, 58% was infectious causes (57% tuberculosis and 43% non-mycobacterium infections). The others were non-infectious causes. Conclusions During the 5-year follow-up period, patients with SpA responded well to TNFi and the response rate increased over time. Tuberculosis was the most common SAE in this registry therefore surveillance of TB should be done. Disclosure of Interest P. Chiowchanwisawakit Grant/research support from: The Thai Rheumatism Association, W. Katchamart: None declared, P. Chevaisrakul: None declared, P. Narongroeknawin: None declared, W. Louthrenoo: None declared, M. Osiri: None declared

Objectives The aims of this study were to evaluate the incidence of clinical quiescence in early-diagnosed SLE patients and to determine factors associated with a prolonged clinically quiescent phase. Methods We used an inception cohort of SLE patients seen between May 2007 and June 2012. All patients were assessed for clinical quiescence [modified SLEDAI 2000 (mSLEDAI-2K) score = 0, no new features of lupus activity o increase in treatment] then evaluated for the occurrence of flare (mSLEDAI-2K increase ≥4 and increased disease activity in one or more organ systems or an increase in treatment). Results Ninety-five patients (88 females) with a mean age of 33.22 years (s.d. 13.24) and mean disease duration 2.79 months (s.d. 3.19) at cohort entry were enrolled during a mean observation period of 3.04 years (s.d. 1.38). Sixty-six patients (69.5%) reached clinical quiescence within 11.31 months (s.d. 1.10) of enrolment. Thirty-six patients (54.5%) had a disease flare during the observation period. The clinically quiescent phase was 28.2 months (s.d. 3.4). Cox regression analysis revealed that age ≥25 years at diagnosis [hazard ratio (HR) 2.57 (95% CI 1.23, 5.40)] and continued antimalarial drug treatment [HR 2.80 (95% CI 1.40, 5.58)] were associated with a longer clinically quiescent phase. Conclusion Most early-diagnosed SLE patients could have a good prognosis. Age at diagnosis ≥25 years or continued treatment with antimalarial drugs after reaching clinical quiescence may result in a longer clinically quiescent phase. More studies are needed to elucidate the mechanism of action for these protective effects.

Rheumatic diseases are a common health-care problem in Thailand. Patient care is influenced not only by differences in the prevalence, clinical traits and genetic variants of these diseases in Thailand compared with other countries, but by the country's health-care systems, availability of medicine and physicians, and rheumatology training, education and research. The author provides his expert view of the current challenges and barriers, recent successes and future prospects of rheumatology in Thailand.

OBJECTIVE The objective of this study was to investigate the hypouricemic effects of green tea extract (GTE) in healthy individuals. METHODS This study comprised 1-week control, 2-week interventional, and 1-week follow-up periods. Participants were assigned randomly at the interventional period to consume GTE at 2 (GTE2), 4 (GTE4), or 6 (GTE6) g/d. Levels of serum uric acid (SUA), uric acid clearance, and serum antioxidant power (using trolox equivalent antioxidant capacity assay) were measured at both ends of each study period. RESULTS Of 30 participants, 11, 11, and 8 received GTE2, GTE4, and GTE6, respectively. After 2 weeks of consumption, the mean SUA level tended to decrease in all groups, with no statistical significance. Serum uric acid reduction was greatest in GTE2 (from 4.81 ± 0.81 mg/dL to 4.64 ± 0.92 mg/dL, 3.53%). Uric acid clearance decreased significantly in GTE2 (from 11.37 ± 6.41 mL/min per 1.73 m to 7.44 ± 2.74 mL/min per 1.73 m, 34.56%, P < 0.05) and GTE4 (from 8.36 ± 3.41 mL/min per 1.73 m to 5.78 ± 2.33 mL/min per 1.73 m, 30.86%, P < 0.05). Serum antioxidant capacity (TEAC) increased significantly in GTE6 (from 32.77 ± 3.39 mg/mL to 35.41 ± 3.17 mg/mL, 8.06%, P < 0.05). There was no significant change in creatinine clearance. Gastrointestinal adverse events were common, but usually mild, with no medical treatment required. CONCLUSIONS Green tea extract may modestly lower SUA level and decreases uric acid clearance. Green tea extract also significantly elevated serum antioxidant capacity with a positive dosage effect. The effect of GTE on SUA in healthy individuals was short term. The effects of GTE on urate handling in patients with hyperuricemia or gout need to be determined.

Sleep disturbance is a common problem in systemic lupus erythematosus (SLE) patients. This study was performed to determine the prevalence of sleep disturbance in SLE, the factors that might be associated with sleep disturbance, and the correlation between changes in clinical parameters and sleep quality over time. Fifty-six female SLE patients from a total of 497 SLE patients (11.3%) agreed to join the study. The demographic data were recorded at baseline and the clinical data, the Pittsburgh Sleep Quality Index (PSQI) and other standardized assessment tools, disease activity index, quality of life (QoL), damage index, depression, anxiety and fatigue score, were assessed three times: the first visit was at baseline, the second time was one month later, and the third time was three months after the baseline. Thirty-one of these 56 patients (55.36%) were found to have sleep disturbances. All were females with their mean ± SD age of 37.5 ± 12.3 years, and disease duration at study entry of 8.6 ± 7.3 years. There was no association between sleep disturbances and demographic data, disease activity, clinical symptoms, the presence of autoantibodies and current steroid use. In multiple logistic regression analyses, only moderate to severe depression was the independent determinant of sleep disturbances, p = 0.036. During the three-month observation, with the treatment, the changing of total PSQI score showed a significantly positive correlation with depression, anxiety, pain and QoL. Sleep disturbances in Thai SLE patients were not uncommon but a correctable condition. Depression was strongly associated with sleep disturbances. Awareness of underlying depression as well as sleep disturbances in SLE patients and treating them properly improve QoL in SLE.

Background Lupus nephritis (LN) is relapsing remitting disease. The standard regimen for LN treatment comprises of induction and maintenance phases. Aims To study the incidence of LN flare in patients who had renal complete remission (CR) after receiving standard regimens for LN, time from renal remission to flare and to identify factors associated with renal flare after CR in clinical practice. Methods We observed the clinical outcomes of patients who had 1 st LN episode and achieved CR (24 hour urine protein Results Among 548 patients who were currently follow-up, 171 patients had 1 st LN episode. Of these, 87 patients (96.6% female with mean age 29.5±10.8 years) met the inclusion criteria. During 6.1±3.4 years of observation, the incident of LN flare was 48.3%. The mean time from CR to flare was 3.14 years (min 0.5, max 9.5). Logistic regression analysis revealed remaining dose of prednisololne ≥7.5 mg/day after remission reduced incidence of renal flare (Odd ratio 0.26 (95%CI 0.08–0.85), p=0.025), while demographic characteristics, clinical variables, and other treatments variables were not associated with incidence of LN flare. Conclusions Although achieving CR with standard treatment, almost half of patients had LN flare within a few years. This study emphasise that maintenance phase in LN is crucial.

Background and aims PRES in SLE is increasingly recognised. This study aimed at determining the prevalence, clinical features, brain imaging findings, risk factors, and outcomes of PRES in Thai SLE patients. Methods SLE patients with PRES seen between 1 January 1986 and 31 August 2013 were identified. Controls were matched with hospital number and disease duration to cases (ratio, 1:4). Clinical features, brain imaging patterns, risk factors, treatment and outcome of PRES were determined. Results Of 1141 SLE patients, 26 PRES episodes occurred 20 in females (prevalence 1.8%). Mean±SD age at diagnosis and disease duration was 29.3±13.1 and 2.8±3.4 years, respectively. Among the 26 episodes, 24 (92.3%) had seizure, 14 (53.8%) headache, 9 (34.6%) fever and vomiting and 8 (30.8%) visual disturbance. All of them had acutely elevated blood pressure. 20 and 23 patients had active lupus nephritis (LN) within 3 months prior to and at PRES onset, respectively. Dominant parietal-occipital pattern was the most common brain imaging abnormality. 22 episodes improved with blood pressure control. Immunosuppressive therapy was given for active disease in 8 episodes. Anti-convulsive therapy could be discontinued in 21 of 22 episodes (median duration 3 months). Auto-immune hemolytic anaemia (AIHA) and LN were PRES risk factors (OR 6.55, 95% CI 1.09–39.39, p=0.04 and OR 3.06, 95% CI 1.12–8.39, p=0.03, respectively). 6 patients (23.1%) died during PRES episodes. The mortality rate in SLE patients with PRES was significantly higher than those without (30% vs. 10%, p Conclusions The mortality rate was high in Thai SLE with PRES. AIHA and LN were risk factors for PRES.

Infections in the Asia Pacific Region Infections in patients with systemic lupus erythematosus (SLE) are not uncommon, and are major causes of morbidity and mortality. The prevalence of infections is high among developing countries, and those with low socioeconomic status, particularly in Asia. Dysregulation of the immune system by the disease itself and the use of corticosteroids and immunosuppressive drugs increase susceptibility to infection, which can cause by both usual and opportunistic pathogens. Infections caused by viruses, bacteria, mycobacterium, fungi, and parasites have been described. Varicella zoster, Salmonella spp., both Mycobacterium tuberculosis and non-tuberculosis, Nocardia spp., Aspergillus spp., Pneumocystis jiroveci, etc. are common opportunistic pathogens. Diagnosing infections in SLE is sometimes difficult. Acute infections can cause protean manifestations that sometimes simulate disease flare. Atypical presentations are not uncommon. Fever and leukocytosis might not be present due to the use of corticosteroids and immunosuppressive drugs. Occult infections can be overlooked if not searched for carefully. Furthermore, infections themselves can trigger disease flare. A high level of hsCRP correlates well with infection. Procalcitonin can be used as a marker for bacterial infection. Treatment of infections in SLE also is problematic. Use of high dose corticosteroids and immunosuppressive drugs to control SLE activity can reactivate latent infections, or exacerbate current infections, making them more difficulty to control. Infections should be suspicious in SLE patients with fever or clinical presentations that do not respond to appropriate SLE treatment. Appropriate evaluation is needed and treatment should be started immediately to cover pathogens most likely possible, and prevent morbidity and mortality.

Background and aims To compare specific health-related quality of life (HR-QoL) questionnaire (SLE-QoL) with a generic HRQoL questionnaire (SF-36) and to examine their sensitivity to changes defined by the global rating for change (GRC). Methods Patients attending a single-centre lupus clinic in Thailand completed both validated SLE-QoL and SF-36 questionnaires, and rated their global change in QoL compared to previous visit using a 7-point Likert scale (GRC). Patients were grouped into either ‘no change’ (control group), ‘deterioration’ or ‘improvement’ categories (GRC status). Physician global assessment (PGA, 0–3) scores were collected for clinician-assessed disease activity. Associations between GRC status and SLE-QoL/SF-36 scores were examined using generalised estimating equations. Cohen’s d effect sizes were estimated to compare mean changes in SLE-QoL and SF-36 scores. Results The analysis included 248 patients with 1265 visits. Patients reported improvement in ˜59%, deterioration in ˜16% and no change in QoL in ˜25% of visits. PGA demonstrated statistically significant (p Conclusions Both SLE-QoL and SF-36 demonstrated similar, strong associations with GRC-based deterioration or improvement.

Background and Aims Systemic lupus erythematosus (SLE) is associated with significant impairment of health-related quality of life (HR-QoL). The Lupus Low Disease Activity State (LLDAS) definition has not been previously evaluated for association with patient reported outcomes. The objective of this study was to determine whether LLDAS was associated with better HR-QoL, and examine predictors of HR-QoL, in a large multiethnic, multinational cohort of SLE patients. Methods HR-QoL was measured using the Medical Outcomes Study 36-item Short Form Health Survey (SF-36v2) in a prospective study of 1422 patients. Disease status was measured using SLE disease activity index (SLEDAI-2K), physician global assessment (PGA) and LLDAS. Results Significant differences in SF-36 domain scores were found between patients stratified by ethnic group, education level, damage score, and with the presence of active musculoskeletal or cutaneous manifestations. In multiple linear regression analysis, Asian ethnicity (p Conclusions Ethnicity, education, disease damage, and specific organ involvement impacts on HR-QoL in SLE. Attainment of LLDAS is associated with better HR-QoL.

Background Systemic lupus erythematosus (SLE) is associated with significant impairment of health-related quality of life (HR-QoL). Recently, meeting a definition of a lupus low disease activity state (LLDAS), analogous to low disease activity in rheumatoid arthritis, was preliminarily validated as associated with protection from damage accrual. The LLDAS definition has not been previously evaluated for association with patient-reported outcomes. The objective of this study was to determine whether LLDAS is associated with better HR-QoL, and examine predictors of HR-QoL, in a large multiethnic, multinational cohort of patients with SLE. Methods HR-QoL was measured using the Medical Outcomes Study 36-item short form health survey (SF-36v2) in a prospective study of 1422 patients. Disease status was measured using the SLE disease activity index (SLEDAI-2 K), physician global assessment (PGA) and LLDAS. Results Significant differences in SF-36 domain scores were found between patients stratified by ethnic group, education level and damage score, and with the presence of active musculoskeletal or cutaneous manifestations. In multiple linear regression analysis, Asian ethnicity (p

Disease manifestations ever present. Table S2. Comparison of SF-36 domain scores by patient and disease characteristics (DOCX 19 kb)

Objective.To identify a comprehensive list of features that might discriminate between gout and other rheumatic musculoskeletal conditions, to be used subsequently for a case-control study to develop and test new classification criteria for gout.Methods.Two Delphi exercises were conducted using Web-based questionnaires: one with physicians from several countries who had an interest in gout and one with patients from New Zealand who had gout. Physicians rated a list of potentially discriminating features that were identified by literature review and expert opinion, and patients rated a list of features that they generated themselves. Agreement was defined by the RAND/UCLA disagreement index.Results.Forty-four experienced physicians and 9 patients responded to all iterations. For physicians, 71 items were identified by literature review and 15 more were suggested by physicians. The physician survey showed agreement for 26 discriminatory features and 15 as not discriminatory. The patients identified 46 features of gout, for which there was agreement on 25 items as being discriminatory and 7 items as not discriminatory.Conclusion.Patients and physicians agreed upon several key features of gout. Physicians emphasized objective findings, imaging, and patterns of symptoms, whereas patients emphasized severity, functional results, and idiographic perception of symptoms.

Objectives The English version of the Systemic Lupus Erythematosus Quality of Life Questionnaire (SLEQOL) is a validated disease-specific quality of life instrument. The aim of this study was to evaluate the psychometric properties of the Thai version of the SLEQOL (SLEQOL-TH). Methods Two independent translators translated the SLEQOL into Thai. The back translation of this version was performed by two other independent translators. The final version, SLEQOL-TH, was completed after resolving the discrepancies revealed by the back translation. One hundred and nine patients with SLE were enrolled to test the reliability, construct validity, floor and ceiling effects, and sensitivity to the changes of the SLEQOL-TH at six months. The differential item functioning (DIF) between the Thai and English versions was analyzed using the partial gamma. Results The internal consistency of the SLEQOL-TH was satisfactory with the overall Cronbach’s alpha of 0.86. The test-retest reliability of the SLEQOL-TH was acceptable with the intra-class correlation coefficient of 0.86. Low correlations between the SLEQOL-TH and SLEDAI were observed. The total score of the SLEQOL-TH was moderately responsive to changes in quality of life, with a standardized response mean of 0.50. When comparing the SLEQOL-TH from Thai SLE patients with the original SLEQOL version obtained from Singapore SLE patients, 11 out of 40 items showed a moderate to large DIF. Conclusions The SLEQOL-TH has acceptable psychometric properties and shows construct validity. In comparison with the English version of SLEQOL, there are some items that showed DIF. The applicability of the SLEQOL-TH in real-life clinical practice and clinical trials needs to be determined.

This article elucidates the prevalence and pathogenic roles of the MHC and microbial infections and clinical features and treatment of SpA across different populations from the arctic and subarctic regions to Central America, Asia, and Africa. Preliminary evidence suggests significant genetic and environmental influences on the onset and presentation of SpA, particularly AS, in these populations, which are different than those reported in white Caucasians; however, community surveys and longitudinal and case control studies are difficult to undertake in many of the developing countries. Thus, most of the currently available data have been devised from short-term and retrospective studies and should be treated with caution. Differences in referral and follow-up practices and the availability of rheumatology expertise and relevant resources may explain some of the differences observed in the populations discussed in this article. Furthermore, widely accepted criteria for the classification of SpA may not be applicable to non-Caucasians and need to be evaluated in these subjects. With gradual improvement in the economic status in many of the developing countries in Asia and Africa, it is hoped that with improvement in medical services, more physicians and specialty clinics in rheumatology, and changing referral patterns, better documentation of the various aspects of different SpA can be achieved. Future research should focus on the evaluation of specific risk or protective factors in population groups to better delineate the relative importance of genetic and environmental effects in the pathogenesis of SpA.

Data regarding the clinical and radiographic hand involvement in Asian patients with systemic sclerosis (SSc) are limited. Thus, we determined the prevalence of clinical and radiographic hand involvement in Thai SSc patients, comparing diffuse cutaneous SSc (dcSSc) and limited cutaneous SSc (lcSSc). We also determined the factors associated with arthritis, contracture of fingers and digital ulcers.SSc patients seen at the Rheumatology Clinic, Chiang Mai University, Thailand, from December 2012 to June 2013 were consecutively invited to enroll in the study. After study entry, demographic data, clinical features and hand radiographs were evaluated.We studied 110 SSc patients (73 dcSSc) with mean ± SD age of 53.2 ± 9.2 years and disease duration from non-Raynaud's phenomenon of 4.9 ± 4.8 years. The prevalence of arthritis, finger contractures and digital ulcers were 10 (9.1%), 47 (42.7%), and 14 (12.7%), respectively. DcSSc patients had significantly more of the following hand complications than lcSSc patients: digital pitting scar (53.4% vs. 27.0%, P = 0.008), digital ulcer (17.8% vs. 2.7%, P = 0.032), traumatic ulcer (27.4% vs. 0%, P 0.001), acrolysis (45.2% vs. 18.9%, P = 0.007) and flexion contracture (60.3% vs. 8.1%, P 0.001). Radiographic finger contractures were more prevalent in the dcSSc subset. In multivariate logistic regression analysis, a positive rheumatoid factor was associated with arthritis; dcSSc, arthritis and modified Rodnan skin score (MRSS) 18 were associated with contracture of fingers. Furthermore, hand MRSS 4 was associated with digital ulcers.Our results confirm that dcSSc patients had more severe clinical hand complications than lcSSc. However, radiographic findings were similar among subgroups, except that more finger contractures were seen in dcSSc. Finally, the presence of rheumatoid factor is associated with arthritis, and high MRSS is associated with finger contractures and digital ulcers.

To evaluate the value of ultrasonographic features of crystal deposition for diagnosing gout in patients presenting with acute arthritis. Ultrasound scanning of the most inflamed joint was performed on 89 consecutively enrolled patients with acute arthritis. Two radiologists independently reviewed the ultrasound images, and a consensus was achieved with a third radiologist when the interpretations of four key ultrasound features of gout differed. Arthrocentesis and crystal analysis using compensated polarized light microscopy of aspirates are considered the gold standards for gout diagnosis. Fifty-three (60%) patients had gout, whereas the remaining 36 (40%) had non-gout arthritis. The mean serum uric acid level was 7.1 mg/dl in patients with gout and 4.7 mg/dl in patients with non-gout arthritis. Three US features differed significantly (p

Summary Human leucocyte antigen (HLA) study in patients with systemic lupus erythematosus (SLE) has been investigated in various countries, but the results are still inconclusive. This study was performed to investigate the association between HLA-DR and SLE in patients in northern Thailand. HLA-DR subtyping was performed in 70 patients with SLE and 99 normal healthy controls living in northern Thailand using the INNO-LiPA HLA-DR Decoder kit (Innogenetics) and MICRO SSP HLA DNA Typing kit (One Lambda) for reconfirmation. The allele frequency (AF) of DRB5*01:01 in SLE was significantly higher than in the controls [25.7% vs. 14.6%, P = 0.012, Pc = 0.048, OR = 2.02 (95%CI = 1.17–3.48)]. The AF of DRB1*15:01 and DRB1*16:02 showed a nonsignificant tendency to be higher in SLE (10.7% vs. 8.1%, and 17.9% vs. 11.1%). Interestingly, the DRB5*01:01 allele linked to DRB1*16:02 in 47.2% of SLE and 37.9% of controls, and the prevalence of the DRB1*16:02-DRB5*01:01 haplotype was higher in the patients with SLE [12.1% vs. 5.6%, P = 0.044, OR = 2.35 (95%CI = 1.06–5.19)]. The DRB1*16:02 linked to DRB5*02:02 and *02:03 in 18.2% and 31.8% of controls, respectively, and linked to DRB5*02:03 in 32.0% of SLE patients. The frequency of DRB1*03:01 and *15:02 alleles was not increased in Thai SLE. There was no significant association between DRB5*01:01 and any auto-antibodies or clinical manifestations of SLE. DRB5*01:01 is associated with Thai SLE, and the association is stronger than that of DRB1*15:01. The genetic contribution of DRB5*01:01 is due partially to the linkage disequilibrium between DRB1*16:02 and DRB5*01:01 in the northern Thai population.

This study aimed to compare the high-resolution computed tomographic (HRCT) findings between patients with diffuse cutaneous systemic sclerosis (DcSSc) and limited cutaneous systemic sclerosis (LcSSc) as well as to correlate the HRCT scores and the other variables.The medical records of all patients with SSc who presented at the Rheumatology Clinic, Chiang Mai University Hospital, from March 2005 to 2010 and underwent HRCT of the chest for the presence of interstitial lung disease were retrospectively reviewed. The extent of ground glass, lung fibrosis, and honeycombing was scored. All scores were aggregated to produce a total CT perfusion score. The widest coronal esophageal diameter (WED), the maximum diameter of the main pulmonary artery (MPAD), and ascending aortic diameter (AD) were measured. The ratio of MPAD to AD (MPAD/AD) was calculated.Of the 71 patients with SSc, mean (SD) age and disease duration were 54.8 (11.8) and 3.9 (4.2) years, respectively. Of them, 69.0% were female and 67.6% were classified as having DcSSc. There were no significant differences between patients with DcSSc and LcSSc with respect to age, disease duration, New York Heart Association Functional Classification, the calculated HRCT scores, WED, and MPAD. The lung fibrosis and total CT perfusion score correlated inversely with the SpO2 (r = -0.47, P0.01). The honeycombing correlated positively with the New York Heart Association Functional Classification and the WED (r = 0.29 and r = 0.32, respectively, P0.05).The HRCT scores of these patients were comparable in both subtypes of SSc. Careful evaluation of lungs and esophageal involvement should be performed irrespective of SSc subtypes. The calculated HRCT scores may be useful to assess the severity of the interstitial lung disease in SSc.