POSITIONING ANALYSIS OF RHEUMATIC DISEASES AMONG RHEUMATIC PATIENTS AND THEIR RELATIVES

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

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Bone mineral density assessment by DXA in rheumatic patients with end-stage osteoarthritis undergoing total joint arthroplasty

BMC Musculoskeletal Disorders ◽

10.1186/s12891-021-04039-5 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Moritz Mühlenfeld ◽

André Strahl ◽

Ulrich Bechler ◽

Nico Maximilian Jandl ◽

Jan Hubert ◽

...

Keyword(s):

Bone Mineral Density ◽

Bone Mineral ◽

Rheumatic Diseases ◽

Total Joint Arthroplasty ◽

Joint Destruction ◽

Joint Arthroplasty ◽

Mineral Density ◽

T Score ◽

End Stage ◽

Rheumatic Patients

Abstract Background Patients with rheumatic diseases have a high risk for joint destruction and secondary osteoarthritis (OA) as well as low bone mineral density (BMD, i.e., osteoporosis). While several factors may lead to low BMD in these patients, the value of BMD measurements in rheumatic patients with end-stage OA scheduled for total joint arthroplasty is unknown. Methods In this retrospective cross-sectional study of 50 adults with secondary OA due to rheumatic diseases, we evaluated dual energy X-ray absorptiometry (DXA) measurements of both hips and the spine performed within 3 months prior to arthroplasty (n = 25 total hip arthroplasty, THA; n = 25 total knee arthroplasty, TKA). We analyzed various demographic and disease-specific characteristics and their effect on DXA results by using group comparisons and multivariate linear regression models. Results Although patients undergoing TKA were younger (63.2 ± 14.2 vs. 71.0 ± 10.8 yr., p = 0.035), osteoporosis was observed more frequently in patients scheduled for TKA than THA (32% vs. 12%). Osteopenia was detected in 13/25 patients (52%) in both the THA and TKA cohort. In the THA cohort, female sex, lower BMI and prednisolone use were associated with lower T-score in the hip. In TKA patients, higher OA grade determined by Kellgren-Lawrence score was associated with lower T-score in the hip of the affected side. Conclusions Osteoporosis is present in a considerable frequency of rheumatic patients with end-stage OA, and THA and TKA patients show distinct frequencies and risk factors of low BMD. Our findings point to a potential value of DXA regarding preoperative evaluation of bone status.

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Clinical characteristics of Chilean patients with rheumatic diseases and COVID-19: data from the Covid-19 Global Rheumatology Alliance physician-reported registry

10.1101/2021.12.07.21267429 ◽

2021 ◽

Author(s):

Oriela Martínez ◽

Francisca Valenzuela ◽

Sebastián Ibáñez

Keyword(s):

Rheumatoid Arthritis ◽

Mechanical Ventilation ◽

Mortality Rate ◽

Rheumatic Disease ◽

Rheumatic Diseases ◽

Clinical Characteristics ◽

Invasive Mechanical Ventilation ◽

List Type ◽

Non Invasive ◽

Rheumatic Patients

AbstractObjectiveThe coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), has registered more than 234 million confirmed cases and more than 4.7 million deaths throughout the world until October 2, 2021. During the last few months, a significant number of reports of COVID-19 in patients with rheumatic diseases have been published. In this study the objective is to report the clinical characteristics of Chilean patients with rheumatic diseases and COVID-19 reported in the “Global Rheumatology Alliance” (GRA) physician registration platform.MethodsChilean patients with rheumatic diseases and COVID-19 were included in the Covid-19 GRA physician-reported registry.Results54 patients were included. The most common primary rheumatic disease was rheumatoid arthritis (RA) with 28 cases (51.9%). 30 patients (55.6%) used corticosteroids, of which 20 (66.7%) used a dose of 10 mg or less. 33 patients (61.1%) only used conventional DMARDs, 4 (7.4%) only biological, and 6 (11.1%) the combination. A total of 35 patients (64.8%) had to be hospitalized. 2 patients (3.7%) died. 26 patients of the 35 hospitalized (74.2%) required some type of ventilatory support, of which 5 (19.2%) required non-invasive and 8 (30.8%) invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO).DiscussionMost of included Chilean rheumatic patients were hospitalized, with a low mortality rate but with a high percentage of patients requiring at least non-invasive mechanical ventilation.Key Points-The most common primary rheumatic disease was rheumatoid arthritis (RA) followed by lupus (LES)-Most of the included Chilean rheumatic patients were hospitalized, with a high percentage of patients requiring at least non-invasive mechanical ventilation, but with a low mortality rate.-Worsening of arthralgias or activation of the rheumatic disease was not reported.

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Incidence of Tuberculosis in Inflammatory Rheumatic Diseases: Results from a Lithuanian Retrospective Cohort Study

Medicina ◽

10.3390/medicina56080392 ◽

2020 ◽

Vol 56 (8) ◽

pp. 392

Author(s):

Dalia Miltinienė ◽

Giedrė Deresevičienė ◽

Birutė Nakčerienė ◽

Valerija Edita Davidavičienė ◽

Edvardas Danila ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Cohort Study ◽

Incidence Rate ◽

Rheumatic Diseases ◽

Retrospective Cohort ◽

Significant Risk ◽

Inflammatory Rheumatic Diseases ◽

The Mean ◽

Rheumatic Patients

Background and objective: With an increase in survival rates among rheumatic patients, comorbidities and infections, in particular, have gained more importance, especially after the introduction of biologicals to the treatment algorithms. Tuberculosis (TB) infection has always been given a special attention in patients with rheumatic diseases (RD). Although Lithuanian population has one of the highest TB incidence rates among European countries, the incidence of TB in the rheumatic patients’ population is still unknown. The aim of this study was to assess the incidence rate of TB in an inflammatory RD retrospective cohort and to compare that rate with a rate in a general population. Material and Methods: Patients with the first-time diagnosis of inflammatory RD during the period between 1 January 2012 and 31 December 2017 were identified from the Lithuanian Compulsory Health Insurance Information System database SVEIDRA. All cases were cross-checked with Health Information center at the Institute of Hygiene, for the vital status of these patients and date of death if the fact of death was documented, and with Tuberculosis Register operated by Vilnius University Hospital Santaros Klinikos, for the confirmation of TB cases. Sex and age standardized incidence ratios (SIR) were calculated by dividing the observed numbers of TB among rheumatic patients by the expected number of cases, calculated using national rates from Lithuanian Department of Statistics Official Statistics website. Results: Overall, 8779 patients with newly diagnosed RD were identified during the 2013–2017 period, these included 458 patients who used biological disease modifying drugs (bDMARDs). The mean duration of the follow-up period was 2.71 years. The cohort consisted mainly of women (70%) and a half of the cohort were rheumatoid arthritis (RA) patients (53%). Mean age of patients at the time of RD diagnosis was 56 years (range = 18–97 years). There were 9 TB cases identified during 23,800 person years of follow-up: 2 cases among them were treated with bDMARDs. The mean calculated annual TB incidence in RD cohort was 37.81 per 100,000 person years, which is consistent with the incidence rate predicted by national estimates, with a resultant SIR of 0.90 (0.41–1.70). The unadjusted hazard ratio for bDMARD use versus no bDMARD use was 4.54 (0.94; 21.87) in a total cohort and very similar in rheumatoid arthritis cohort; in both cohorts, it was not a statistically significant risk. Conclusions: Here, we present the first nationwide cohort study to assess the incidence of TB in a broad spectrum of inflammatory RD. Although limited by short follow-up period, this study shows that TB incidence in RD cohort does not exceed TB incidence in the general Lithuanian population.

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Aspects of xerostomia prevalence and treatment among rheumatic inpatients

Medicina ◽

10.3390/medicina44120120 ◽

2008 ◽

Vol 44 (12) ◽

pp. 960 ◽

Cited By ~ 8

Author(s):

Žygimantas Guobis ◽

Nomeda Basevičienė ◽

Pajauta Paipalienė ◽

Irena Niedzelskienė ◽

Giedrė Januševičiūtė

Keyword(s):

Quality Of Life ◽

Rheumatic Diseases ◽

Medical Literature ◽

Statistical Significance ◽

Older Age ◽

Adequate Treatment ◽

Significant Evidence ◽

Sicca Symptoms ◽

Rheumatic Patients

Objectives. The aim of the study was to evaluate the prevalence of xerostomia among inpatients with rheumatic disorders at the Hospital of Kaunas University of Medicine (HKUM) and its association with age, sex, and xerophthalmia. Determining adequate treatment for xerostomia was also important, because untreated xerostomia may become aggravated and thus significantly impair patient’s quality of life. Material and methods. The authors designed a special questionnaire for conducting all studyrelated enquiries. Patients for this study were selected according to their case records ranging from 1998 to 2004. In total, there were 483 cases chosen based on prevalent rheumatic diseases, which were most conducive to xerostomia. Results. The results showed no significant evidence that the prevalence of xerostomia increased with age. Also, women were more susceptible to rheumatic diseases than men (W:M = 10:1) and are more likely to be affected by xerostomia and xerophthalmia (W:M = 2.5:1). A significant correlation was found between xerostomia and xerophthalmia. Only 17.7% of xerostomia-positive patients were treated for xerostomia, in comparison with xerophthalmia-positive patients who were treated for xerophthalmia in 84.8% of cases. It was shown that the modalities of treatment administered for xerostomia were neither sufficient nor up-to-date according to current recommendations found in medical literature. Conclusions. Xerostomia is closely correlated with xerophthalmia in rheumatic diseases. Xerostomia is more prevalent in older segments of population, especially in women, but we failed to prove statistical significance of older age in prevalence of sicca symptoms. Treatment administered to rheumatic patients for xerostomia in the HKUM is neither sufficient nor adequate.

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Patients with Rheumatic Diseases Overlooked during COVID-19 Pandemic: How are They Doing and how do They Behave?

Current Rheumatology Reviews ◽

10.2174/1573397116666201228144318 ◽

2020 ◽

Vol 16 ◽

Author(s):

Anass Adnine ◽

Ilias Soussan ◽

Khawla Nadiri ◽

Siriman Coulibaly ◽

Khadija Berrada ◽

...

Keyword(s):

Rheumatic Disease ◽

Rheumatic Diseases ◽

Preventive Measures ◽

Medication Compliance ◽

Level Of Education ◽

Disease Characteristics ◽

Level Of Knowledge ◽

Knowledge And Attitude ◽

Rheumatic Patients

Background: People with rheumatic disease may be at higher risk for more severe course with COVID- 19, and the adverse effects of drugs used to treat rheumatic diseases is a major concern. Objective: We conducted this survey to learn about the real impact of COVID-19 pandemic on patients with rheumatic diseases. Methods: Participants were asked to complete a questionnaire using a telephonic interview conducted by two rheumatologists. Rheumatic disease characteristics, knowledge and attitude toward COVID-19, and impacts of pandemic on rheumatology care and patient’s compliance were assessed. Results: We included 307 patients in the survey, and rheumatoid arthris was the main rheumatic disease. Patients had mostly moderate level of knowledge about COVID-19, and patients with higher level of education were more likely to have better knowledge. Participants respected mainly recommended preventive measures. The pandemic and sanitary containment impacted strongly the rheumatology care. Over quarter of patients noted worsening of their rheumatic disease, two-thirds reported postponed or canceled medical apointments and more than three quarters postponed their laboratory tests. Patients with higher disease activity were more likely to have lack of follow-up. Medication change was noted in more than third of cases. It was mostly stopped, and DMARDs were mainly affected. Patients living in rural area and who had canceled, or postponed their appointments were more likely to change their treatment. Conclusions: Our data are useful to better manage rheumatic patients. Physicians are encouraged to renew contact with their patients to insure medication compliance.

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The role of architectural design for rheumatic patients’ wellbeing: the point of view of Environmental Psychology

Reumatismo ◽

10.4081/reumatismo.2020.1251 ◽

2020 ◽

Vol 72 (1) ◽

pp. 60-66

Author(s):

L. Punzi ◽

M. Chia ◽

S. Cipolletta ◽

C. Dolcetti ◽

P. Galozzi ◽

...

Keyword(s):

Rheumatic Diseases ◽

Social Life ◽

Architectural Design ◽

Environmental Psychology ◽

Point Of View ◽

Non Profit ◽

The Public ◽

Regular Work ◽

Rheumatic Patients

Rheumatic diseases (RD) are among the most frequent disorders in the population and the major causes of chronic pain and disability. The resulting consequences are catastrophic, leading to a significant socio-economic burden, which includes significant reductions in quality of life (QoL) and limitations in regular work and daily activities of patients. In spite of this, rheumatic diseases are often misunderstood or diagnosed late, probably due to their characteristics of silent diseases, sometimes unrecognizable to unaffected or unskilled people. Actually, it is surprising that, despite their consequences on QoL and on individual impact, rheumatic diseases are underestimated by the public opinion, which is probably more attracted by other major diseases causing death. This silent perception can even be seen in some among the most recent psycho-social approaches to population needs in the fields of Health Psychology and Environmental Psychology. The latter, also known as Architectural Psychology, is a branch of Psychology that analyses the effects of the built environment on humans, including those affected by diseases. Paradoxically, in many cases, some components of the environments created to protect individuals and/or the population may represent barriers and subsequently causes of disability and suffering in patients with rheumatic diseases. In order to increase awareness about this particular aspect of social life, HEMOVE Onlus, a non-profit association, has promoted the creation of a multidisciplinary Task Group, which included mainly rheumatologists, psychologists and architects, with the aim of applying also for the benefit of rheumatic patients the most modern technical skills available in the context of Environmental Psychology, including in particular design and information technology.

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US assessment of hip joint synovitis in rheumatic diseases: A comparison with MR imaging

Acta Radiologica ◽

10.1258/rsmacta.44.1.72 ◽

2003 ◽

Vol 44 (1) ◽

pp. 72-78

Author(s):

I. Soini ◽

A. Kotaniemi ◽

H. Kautiainen ◽

M. Kauppi

Keyword(s):

Mr Imaging ◽

Rheumatic Disease ◽

Rheumatic Diseases ◽

Hip Joint ◽

False Positive ◽

Gold Standard ◽

Intraclass Correlation ◽

Hip Joints ◽

Mri Evaluation ◽

Rheumatic Patients

Purpose: To assess the significance of ultrasonography (US) in detecting hip joint synovitis in patients with rheumatic diseases. Material and Methods: Forty patients with rheumatic disease and suspected hip joint synovitis underwent MRI and US of the hip joint. In addition to the throughout MRI evaluation, the anterior collum-capsule distance (CCD) was determined by both MRI and US. Thirteen healthy volunteers were examined with MRI to establish the criteria for normal findings in MRI when classifying hip joints to those with synovitis and those without. MRI was used as a gold standard. Results: Synovitis was found using MRI in 31 hips of 22 patients (9 patients had bilateral synovitis). The intraclass correlation was 0.61 between MRI and US in measuring CCD. In classifying hip joint synovitis with US, the sensitivity of the method was 87% and specificity 42%, when the CCD criterion for synovitis was determined to be ≥7 mm. If the cut-off point was raised to 9 mm, the sensitivity decreased to 61% while specificity increased to 94%. A difference in CCD of ≥1 mm between the hips as an additional criterion for synovitis increased the number of false-positive findings. Conclusion: Measurement of CCD with US proved to be a rather inaccurate method to point out synovitis in rheumatic patients when using MRI as a reference. The main reason for this result was the thickened capsule, which US could not differentiate from a thickened synovium.

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Antibodies to infliximab in Remicade-treated rheumatic patients show identical reactivity towards biosimilars

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2015-208684 ◽

2016 ◽

Vol 75 (9) ◽

pp. 1693-1696 ◽

Cited By ~ 48

Author(s):

M Begoña Ruiz-Argüello ◽

Ainara Maguregui ◽

Ainhoa Ruiz del Agua ◽

Dora Pascual-Salcedo ◽

Ana Martínez-Feito ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Immune Response ◽

Therapeutic Drug Monitoring ◽

Rheumatic Diseases ◽

Drug Monitoring ◽

Correlation Coefficients ◽

Therapeutic Drug ◽

Switching Strategy ◽

Loss Of Response ◽

Rheumatic Patients

ObjectivesThe aim of this study was to determine whether antibodies to infliximab (IFX) in Remicade-treated patients cross-react with the biosimilar CT-P13.Methods250 consecutive patients with rheumatic diseases under Remicade and 77 controls were retrospectively selected for the study. Anti-IFX antibodies at drug through levels were measured in parallel with three different bridging ELISA assays: Promonitor-ANTI-IFX kit, which uses Remicade to detect antibodies, and two more assays that use either Inflectra or Remsima with the same format. Correlation and association between each assay was studied.Results50.4% of patients were tested positive with Promonitor-ANTI-IFX. All were antibodies to IFX (ATI)-positive when either Inflectra or Remsima assays were used. In all comparisons positive and negative percentage agreements were 100%, and correlation coefficients were ≥0.995. No differences between rheumatoid arthritis and spondyloarthritis, or between concomitant immunosuppressives, were observed.ConclusionsAnti-IFX antibodies of Remicade-treated patients cross-react with either Inflectra or Remsima. Although additional epitopes may be present in the biosimilar, results suggest that epitopes influencing the immune response to IFX are also present in the biosimilar. Antibody-positive patients treated with Remicade should not be switched to the biosimilar, since antibodies will interact with the new drug and potentially lead to loss of response. This finding supports the utility for therapeutic drug monitoring before a switching strategy is considered.

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AB0296 PASSIVE TRANSFER OF ANTI-SSA, ANTI-Ro52, AND ANTI-MITOCHONDRIAL M2 FROM INTRAVENOUS IMMUNOGLOBULIN PRODUCTS TO PATIENTS WITH RHEUMATIC DISEASES

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2021-eular.3544 ◽

2021 ◽

Vol 80 (Suppl 1) ◽

pp. 1174.2-1174

Author(s):

L. J. Yang ◽

H. G. Li ◽

A. Q. Zeng ◽

Z. M. Ouyang ◽

X. N. Wei ◽

...

Keyword(s):

Intravenous Immunoglobulin ◽

Rheumatic Diseases ◽

Ivig Therapy ◽

Passive Transfer ◽

Enzyme Linked Immunosorbent Assay ◽

Serum Samples ◽

Chemiluminescence Immunoassay ◽

Indirect Immunofluorescent Assay ◽

Necrotizing Myositis ◽

Rheumatic Patients

Background:Passive transfer of ANA and anti-SSA has been reported in patients with common variable immunodeficiency disorder who received intravenous immunoglobulin (IVIG). IVIG is also recommended to treat some special or life-threatening rheumatic diseases.Objectives:This study was aimed to explore whether any extractable nuclear antibodies (ENAs) were transferred to these rheumatic patients who received IVIG therapy.Methods:IVIG products of three batches were tested for ANA by using indirect immunofluorescent assay, and for ENAs by using line immunoassay (LIA) and chemiluminescence immunoassay (CLIA). These IVIG products were administrated to rheumatic patients at a dose of 20g/d×3 days (day1 to day3). Serum samples of these patients before IVIG (day0) and after IVIG (day4, day8, day10, day12, and more than one month) were tested by using LIA and CLIA. Anti-SSA was also detected using ELISA.Results:In these IVIG products, ANA was positive at a titer of 1:640 (cytoplasmic speckled) and 1:80 (speckled). Among 14 types of ENAs that could be tested using LIA, anti-SSA, anti-Ro52, anti-mitochondrial M2, and anti-centromere B antibodies were clearly detectable in IVIG products (Table 1). Likewise, another assay CLIA also detected the same positive autoantibodies in these products. LIA showed the highest concentration in anti-mitochondrial M2, while CLIA showed the highest concentration in anti-mitochondrial M2 and anti-Ro52. One 31-year-old male patient who was diagnosed as SLE (Figure 1) and one 72-year-old male patients who was diagnosed as necrotizing myositis received these IVIG products. Anti-SSA, anti-Ro52, anti-mitochondrial M2, but not anti-centromere B, were positive in the day4 serum samples, although all of these antibodies were negative at baseline (day0). The concentration of these antibodies decreased gradually as days passed and became undetectable around one month after IVIG.Table 1.The concentration of autoantibodies in intravenous immunoglobulin productsanti-SSAanti-Ro-52anti-mitochondrial M2anti-centromere BCut-offLIA(grey value)20±328±369±1019±4≥11CLIA (U/ml)333±107444±86434±66390±89>20ELISA (U/ml)90±13NANANA>20LIA, line immunoassay; CLIA, chemiluminescence immunoassay; ELISA, enzyme linked immunosorbent assayConclusion:This study preliminarily reported transient positivity of anti-SSA, anti-Ro52, and anti-mitochondrial M2 in rheumatic patients maybe because the passive transfer of these antibodies from IVIG products to the patients, although the potential influence of this transfer on the rheumatic diseases remained unknown.Figure 1.The concentration of autoantibodies in a 31-year-old male SLE patient receiving intravenous immunoglobulin at a dose of 20g/d×3 days (day1 to day3). Serum samples of these patients before IVIG (day0) and after IVIG (day4, day8, day10, day12, and day51) were tested by using line immunoassay (LIA) and chemiluminescence immunoassay (CLIA). Anti-SSA was also detected using ELISA. The horizontal red lines were the corresponding cut-off values of each assay.Disclosure of Interests:None declared

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