New research and recommendations were presented at EULAR 2019, the European League Against Rheumatism annual meeting, from June 12 to 15 in Madrid. The features below highlight key presentations from the conference.


Pollutants as Risk Factors for Osteoarthritis

Data indicating a doubling of knee osteoarthritis (OA) prevalence since the mid-20th century cannot be explained solely by longer life expectancy and the obesity epidemic, suggesting, according to researchers, that environmental factors know to have increased during this period may play a role. As such, they performed a systematic literature review to summarize the existing knowledge about associations between OA and pollutants. Among a total of 21 full-text articles that were analyzed, four underlined the link between polychlorinated biphenyls (PCBs) and OA, among which three reported an association with past PCB exposure; of these, the most robust showed that risk of OA was significantly increased, at least in men. The fourth study found the highest serum concentration of PCB to be associated with a higher risk of arthritis, but no significant associated was seen with OA. Adjusted odds ratios (aOR) for OA were 1.42 and 1.77 for the highest serum levels of perfluorooctanoate and perfluorooctane sulfonate. Two articles showed an association between serum lead levels and knee OA in the general population. Another study that compared with electricity, the risk of OA was increased with the use of liquids (kerosene/paraffin: aOR, 1.73) or solids (coal, wood: aOR, 1.73), (agriculture/crop: aOR, 2.0. Four studies showed highest concentrations of lead and zinc accumulation in cartilage versus bone, with another finding lead serum levels to be associated with biomarkers of joint tissue metabolism. Two studies with X-ray fluorescence on cadavers found a high accumulation of lead and zinc in the articular cartilage tidemark. Four studies found the viability of chondrocytes to be reduced in the presence of PCB, gold, silver, fluvic acid, and bisphenol A. The researchers suggest a critical need for novel epidemiological, clinical and basic research studies in order to identify other potential environmental factors in OA.



The Gut Microbiome’s Role in Rheumatoid Arthritis

With data lacking on the intestinal microbiome profiles of patients with rheumatoid arthritis (RA) and the mechanism through which it intervenes in the pathogenesis of RA, investigators evaluated disease activity and examined fecal samples .among patients with RA and healthy controls. Participants with RA had an average disease activity score (DAS28) of 3.6. Data showed that patients with RA tended to differ from healthy controls according to their microbiota. Those with RA exhibited decreased diversity in the gut microbiome than controls, but the difference was not statistically significant. When compared with controls, participants with RA had increased levels of the Collinsella aerofaciens species and enterococcus genera. “Likewise, an increase of arginine deaminase activity was observed, which belonged, in approximately 90%, to the RA genes of the genus Collinsela,” write the study authors. Decreases in other bacterial lineages were also observed. Patients with RA showed an altered metabolic capacity for transporting zinc and copper. The study authors suggest that these alterations may significantly influence the perpetuations of the autoimmunity of RA.


Heart Failure Risk in Patients With SLE

Although prior research indicates that patients with systemic lupus erythematosus (SLE) have a similar risk of myocardial infarction as those with diabetes mellitus (DM), whether those with SLE have a similarly elevated risk for heart failure (HF) as do those with DM remains unclear. Using Medicaid data from 2007-2010, researchers calculated incidence rates (IRs), incidence rate ratios (RRs), and adjusted hazard ratios (HRs) of a first HF-related hospitalization among patients with SLE (n=37,902) or DM (n=76,657) and a matched cohort from the general Medicaid population (n=158,695). IRs for HF-related hospitalization were 6.9 per 1,000 person-years for patients with SLE, 6.6 for those with DM, and 1.6 for the general Medicaid patients. The highest IRR, when compared with the general Medicaid population, was 14.7, observed among those aged 18-39 with SLE. Multivariable-adjusted HRs for HF compared with the general Medicaid population were similar for SLE (2.7) and DM (3.0).



Acute Gouty Arthritis-Related ED Visits

Data suggest that many US veterans are at risk for gout flare, leading to healthcare resource use, including emergency department (ED) and outpatient office visits. To identify risk factors for ED visits among this patient population, researchers performed retrospective chart reviews of veterans diagnosed with gout in the ED between January 2011 and December 2016. Baseline demographics, medical comorbidities, serum uric acid level, medication history, and whether they patients were followed by rheumatologist or primary care physician (PCP) were extracted from electronic health records. Among patients, 26% had a history of alcohol use, 89% had hypertension, 88% had chronic kidney disease (CKD), 86% were followed by PCPs, 5% were followed by rheumatologists, and 9% were non-compliant with follow-up care. Only 30% were receiving urate-lowering therapy (ULT), and 23% were on gout prophylactic therapy. Nearly one-quarter (21%) of patients had two or more ED visits, with a mean uric acid level of 9.04 mg/dl, compared with 8.5 mg/dl for those with a single ED visit. CKD, higher uric acid level, and lack of ULT were associated with increased ED visit frequency, whereas ULT (regardless of the prescriber, PCP vs rheumatologist) was associated with reduced ED visit frequency. “Improving ULT dispensing by the physician and patient compliance with ULT can decrease healthcare utilization,” concluded the study authors.



Benefits Seen With Nurse-Performed RA Assessment

In rural areas where there are few rheumatologists to treat a growing population of patients with rheumatoid arthritis (RA), innovative solutions are needed. Joint count evaluations performed by a nurse assistant between rheumatologist visits is one such solution. To validate the accuracy of the assessment of RA and psoriatic arthritis disease activity by a nurse in comparison to assessments conducted by rheumatologists for Clinical Disease Activity Index (CDAI) and Disease Activity Score (DAS28), researchers performed a trial in a private clinic. Patients were examined by a physician and then by a nurse who had undergone a 14-hour joint count training course. Patients were also provided with brief training on self-evaluation. Overall correlation between patient and physician DAS28 was good, and it was very good between nurse and physician DAS28 and CDAI. Correlations between the various parts of the DAS28 followed the same pattern. “This study is another argument to work with a nurse assistant and to use DAS28 or CDAI in order to save time, as we can be confident that the results of the nurse examination [are] accurate and valuable,” write the study authors. “Treat to Target is possible even in remote areas lacking of resources.”