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Background:Early referral of patients with suspicion of progression to rheumatoid arthritis (RA) is of paramount importance in disease prognosis. We had previously described a time delay of 28 months between symptom onset and evaluation by a rheumatologist, and a mean wait time of 9.5 weeks for referral to a secondary-level public hospital (1). The availability of specialized interdisciplinary evaluation of patients in a third-level of care raises the possibility of shortening this time gap, as well as describing patient and physician decisions amidst the referral to a Rheumatology center.Objectives:Describe the diagnosis profile of patients with hand arthralgia and time of referral to Rheumatology in a Family Medicine clinic.Methods:A cohort study was conducted in 110 patients from October 2018 to December 2020 in a Family Medicine clinic within the tertiary-care University Hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico. Patients with hand arthralgia as their chief complaint were recruited. An observational, descriptive compilation of patient history was retrieved prospectively through medical records. Variables included time of inclusion, number of medical visits until referral and definitive diagnosis. Descriptive statistics, Kaplan-Meier curves and log-rank tests were used to test the association between time of diagnosis and clinical variables of interest.Results:Assessed variables are shown in Table 1. Out of 110 patients with hand arthralgia, a quarter received a final diagnosis within 3 medical visits. Less than half of patients were referred, and only a third attended the referral indication. It takes 39.3 days from the first medical visit to be referred, and 69 days and 2.89 consultations to receive a definitive diagnosis. Around half of patients will have a definitive diagnosis, osteoarthritis being the most common. The log-rank test for categoric variables including a positive squeeze test or ≥4 criteria of clinically suspect arthralgia did not show a significant association for time of referral and definitive diagnosis (data not shown).Table 1.Diagnostic and referral characteristics of patients with hand arthralgia attending a Family medicine clinicPatients recruited in a Family Medicine clinicn = 110Female, n (%)90 (81.8)Age in years, mean ± SD49.69 ± 14.90RF, ACPA, or hand radiography request, n (%)100 (90.9)Diagnosis in Family MedicineDiagnosed patients after 1 medical visit, cumulative n (%)5 (4.6)Diagnosed patients after 2 medical visits, cumulative n (%)22 (20.0)Diagnosed patients after 3 medical visits, cumulative n (%)26 (23.6)Referral to Rheumatology for diagnostic doubt or clinical follow-upPatients referred to a Rheumatology clinic, n (%)49 (44.5)Patients attending Rheumatology referral, n (%)34 (30.9)Time for referral, days ± SD39.37 ± 38.64Global definitive diagnosisPatients with a definitive diagnosis, n (%)51 (46.4)Osteoarthritis diagnosis, n (%)23 (20.9)Rheumatoid arthritis diagnosis, n (%)13 (11.8)Overlap syndrome diagnosis, n (%)5 (4.5)Time for definitive diagnosis, days ± SD68.96 ± 106.57Number of consultations for definitive diagnosis, mean ± SD2.86 ± 1.05RF, rheumatoid factor; ACPA, anticitrullinated protein antibodies; SD, standard deviation.Conclusion:Patients with hand arthralgia evaluated in a tertiary-care Rheumatology center receive a timely referral in one month and a definitive diagnosis after 3 medical visits in around two months.References:[1]Vega-Morales, D., Covarrubias-Castañeda, Y., Arana-Guajardo, A. C., & Esquivel-Valerio, J. A. (2016). Time Delay to Rheumatology Consultation: Rheumatoid Arthritis Diagnostic Concordance Between Primary Care Physician and Rheumatologist. American journal of medical quality: the official journal of the American College of Medical Quality, 31(6), 603.Graphs:Disclosure of Interests:None declared

Background:Rheumatoid Arthritis (RA) has been associated with depression by up to 46% (1)Within the universe of manifestations of depression is learned helplessness (LH)LH is defined as an inadequate perception of the disease, generating feelings of defenselessness, loss of self-esteem, pessimism, and negativity. This leads to passivity, surrendering to fate, and thoughts that nothing within their power can change their situation, this condition produces a rapid deterioration which prevents responding adaptively to a traumatic situation, increasing the frequency of anxiety and depression. (2)Objectives:To assess the relationship between depression, LH, disability and disease activity among patients with RAMethods:Descriptive observational study included RA patients diagnosed according to ACR / EULAR 2010 randomly recruited between June and September 2019 at University Hospital “Dr. José Eleuterio González” in Monterrey, México.Beck Depression Inventory (BDI) and Rheumatology Attitude Index (RAI) were applied for measure depression and LH, to measure disability Health Assessment Questionnaire (HAQ-DI) was applied. CDAI and DAS28-PCR scales were used for measure disease activity.Descriptive analysis was carried out with measures of central tendency and dispersion. Spearman correlation were used for comparisons, according to the distribution of the variables. A p <0.05 was considered statistically significant.Results:A total of 177 patients were included, demographic and clinic features are presented in table 1. Prevalence of LH was 94.5% (167/177); 60% (100/167) mild levels (9-15) and 33% (67/167) high levels (>15). A significant correlation was found between higher levels of dysfunctionality and BDI and higher levels of LH (rho = 0.338; p = 0.001). There was a positive association when measuring CDAI (rho = 0.235; p = 0.002) BDI (rho=0.278 P=<0.001) and DAS28-PCR (rho=0.166; p=0.027) with higher levels of LH. There was no association found between other variables as gender, years of diagnosis of RA, years of study or presence of comorbidities like fibromyalgia or osteoarthritis.Table 1.Demographic and clinical characteristics of the patients. HAQ-DI Health Assessment Questionnaire RAI Rheumatology attitude index, DAS28-PCR Disease Activity Score CDAI Clinical disease activity index BDI Beck Depression InventoryDemographicsn = 177Gender Female n, %165 (93.3%). Male n, %12 (6.8%)Age (mean), SD.52.16 (12.8)Years of study (average), SD.8.3 (3.6)Years with RA (mean), SD.8.2 (8.0)RAI (mean), SD13.83 (3.9)HAQ-DI (mean), SD0.67 (0.77)CDAI (mean), SD12.0 (11.4)DAS28-PCR (mean), SD2.4 (0.6)BDI (mean), DE9.30 (9.7)LH, n (%)168/177 (94.5%)High levels 108/177 (61%)Low levels 60/177 (33%)Conclusion:In this study the prevalence of LH was high >90%, mainly in mild levels. Dysfunctionality seems to be the factor most associated with the presence of depression and LH.Rheumatologist should consider the high levels of LH, to assess patients in order to obtain a better outcome.Table 2.Correlation between learned helplessness and clinical variables LH Learned Helplessness HAQ-DI Health Assessment Questionnaire RAI Rheumatology Attitude Index DAS28-PCR Disease Activity Score CDAI Clinical Disease Activity Index BDI Beck Depression InventoryrhopLH –HAQ-DI0.338<0.001LH-CDAI0.2350.002LH-DAS28PCR0.1660.027LH-BDI0.278<0.001[1]Margaretten M, Julian L, Katz P, Yelin E. Depression in patients with rheumatoid arthritis: description, causes and mechanisms. Int J Clin Rheumtol. 2011;6(6):617-23.[2]Moyano S, Scolnik M, Vergara F, Garcia MV, Sabelli MR, Rosa JE, et al. Evaluation of Learned Helplessness, Perceived Self-efficacy, and Functional Capacity in Patients With Fibromyalgia and Rheumatoid Arthritis. J Clin Rheumatol. 2019;25(2):65-8.Disclosure of Interests:None declared

Background:Primary care physicians (PCP) are usually the first contact of people with inflammatory rheumatic diseases, and find the early symptoms of Rheumatoid Arthritis (RA) difficult to distinguish from those of other rheumatic diseases. A time-delay in the reference to Rheumatology is a health issue in several countries. The clinical aspects that general practitioner took into account in hand arthralgia patients are important to make the reference. In particular the Squeeze Test (ST) - which is simple to perform and rapidly done, ST is useful for identifying progression to RA in patients with undifferentiated arthritis. The ST has been described as not reliable because is clinician-dependent.Objectives:To identify the required force that needs to be applied in order to obtain a positive Automatized Squeeze Test (AST) in a cohort of patients with hand arthralgia.Methods:Ninety-seven patients were recruited in Family Medicine Consultation and in Rheumatology Consultation of the Hospital Universitario “Dr. José Eleuterio González” in Monterrey, Nuevo León, México. Eligible patients were adults (aged≥18 years) with hand arthralgia (that wasn’t caused by trauma) as their chief complaint. After obtaining informed consent and after a questionnaire application, patients were submitted to AST maneuver, using an automated compressor with different forces already predetermined in the interface of the software used for compression.Results:In this cohort of 98 patients, 79 (80.6%) were women. The mean age was 51.14 years (SD 14.66). Ninety-six (97.9%) patients were right handed. The diagnoses were Osteoarthritis (OA) (16.3%), RA (5.1%), Undifferentiated arthritis (1.2%), Psoriatic arthritis (1.2%) and Fibromyalgia (2%). Force measures according to diagnoses are reported in Table 1.Table 1.Diagnoses and mean forcesDiagnosisn (%)Right hand force mean (kg/s2) (SD)Left hand force mean (kg/s2) (SD)OA16 (16.3)3.53 (2.74)3.18(2.73)RA5 (5.1)3.60 (2.53)3.16(1.36)UA1 (1.2)7.60(0)8.70(0)PsA1 (1.2)7.60(0)7.80(0)FM2 (2.0)4.11(4.40)1.75(1.06)OA, Osteoarthritis;RA, Rheumatoid Arthritis;UA, Undifferentiated Arthritis;PsA, Psoriatic Arthritis;FM, Fibromyalgia;SD, Standard DeviationConclusion:In the cases of RA and OA, the means of force to obtain a positive AST was lower than in the rest of the diagnoses.References:[1]Stack R, Nightingale P, Jinks C, Shaw K, Herron-Marx S, Horne R et al. Delays between the onset of symptoms and first rheumatology consultation in patients with rheumatoid arthritis in the UK: an observational study. BMJ Open. 2019;9(3):e024361.Disclosure of Interests:None declared

Background:Patients with rheumatic diseases (RD) are at increased risk of infections, attributed to the underlying RD, comorbidities and immunosuppressive therapy, including glucocorticoids, disease-modifying antirheumatic drugs, etc. (1). While many infectious diseases can generally be prevented by vaccines, immunization rates in this specific patient population remain suboptimal (2). Despite being recognized as one of the most successful public health measures, vaccination is perceived as unsafe and unnecessary by a growing number of individuals. Lack of confidence in vaccines is now considered a threat to the success of vaccination programs (3).Objectives:To describe the main causes of non-vaccination in patients with RD.Methods:A self-questionnaire was applied to a sample of patients with RD in the rheumatology clinic of the university hospital “Dr. Jose Eleuterio Gonzalez” in Monterrey, Mexico between September and December 2019. The questionnaire evaluated demographic characteristics (age, gender, diagnosis) and the vaccination status for Influenza (last year), pneumococcal (last 5 years), Herpes zoster (ever), Human papillomavirus (any dose) and Hepatitis B (any dose). It also includes a question asking: If you didn’t receive any of the previous vaccines, what was the reason? (multiple-choice are shown in Table 2). Results are shown in frequencies and percentages.Table 2.Vaccination barriersN=82If you didn’t receive any of the previous vaccines,what was the reason? n (%)1)Did not was recommended22 (26.8)2) Lack of availability21 (25.6)3) Vaccines don’t work13 (15.8)4) Fear of adverse events8 (9.7)5) Previous adverse event3 (3.6)6) Other reason- Own decision8 (9.7)- Disinformation7 (8.5)Results:102 patients were evaluated: Mean age was 51.27 (SD 14.68) years; 84 (82.4%) were females; 71 (69.6%) had rheumatoid arthritis, 13 (12.7%) had systemic lupus erythematosus, 6 (5.8%) had other autoimmune diseases and 12 (11.8%) had osteoarthritis. The rate of vaccination for Influenza was 49 (48%), for pneumococcal 25 (24.5%), for Herpes zoster 5 (4.9%), for Human papillomavirus 9 (8.8%), for Hepatitis B 14 (13.7%) (Table 1). 82 (80.3%) patients reported some barriers in vaccination, from these: 22 (26.8%) did not get the recommendation from the rheumatologist, 21 (25.6%) did not found available the vaccine, 13 (15.8%) believes that vaccines don’t work, 8 (9.7%) had fear of adverse events, 3 (3.6%) reported previous adverse events, and 15 (18.2%) reported other reasons, that we classified as own decision 8 (9.7%) and disinformation 7 (8.5%) (Table 2).Table 1.Demographic characteristicsN= 102Age, years, mean (SD)51.27 (14.68)Female, n (%)84 (82.4)Diagnosis, n (%)-RA71 (69.6)-SLE13 (12.7)-OA12 (11.8)-Other AID6 (5.8)Conclusion:The main barriers in vaccination of rheumatic patients reported were the lack of availability of the indicated vaccines and the medical and patient disinformation. This problem must be combated to ensure the complete vaccination of rheumatic patients.References:[1]Ann Rheum Dis. 2020;79:39-52.[2]J Rheumatol. 2019;46(7):751-754[3]Hum Vaccin Immunother. 2013;9(8):1763-73.Disclosure of Interests:None declared