Prevalence and characteristics of diffuse idiopathic skeletal hyperostosis (DISH) in Italy

Purpose

Diffuse idiopathic skeletal hyperostosis (DISH) is a benign condition characterized by ossification of the spine and prominent enthesopathies. Highly heterogeneous epidemiological figures have been reported in the literature, while in Italy the largest study has been conducted in 1992. The aim of our research is to contribute updated information about prevalence of DISH in Italy and to describe the clinical and radiographic characteristics associated with the disorder.

Material and methods

A retrospective review of lumbosacral spine, thoracic spine and pelvis radiographs was performed. Consecutive patients visiting the emergency department of our Institution over 3 years were enrolled. Presence of DISH was evaluated applying the Resnick and Niwayama criteria. Clinical and radiological features were also assessed.

Results

We included 1012 individuals (60.6% women), and DISH was present in 130 cases. The overall prevalence of DISH was 12.8% (95% CI 10.8–15.1), with higher figures in the male sample (16.8%) than in females (10.3%). In binary logistic regression adjusted for age, BMI (OR 1.50, p < 0.001) diabetes (OR 1.85, p = 0.003), hypertension (OR 2.04, p = 0.007) ischiopubic enthesopathy (OR 7.08, p < 0.001), iliac crest enthesopathy (OR 4.63, p < 0.001) and greater trochanter enthesopathy (OR 3.51, p < 0.001), were significantly associated with the condition.

Conclusion

The prevalence of DISH observed in our study is consistent with previous literature, and we confirm that the disorder is more frequently retrieved in men and that it is associated with the presence of metabolic disorders and pelvic enthesopathy. Knowledge about the epidemiology and characteristics of DISH is needed to properly identify the condition.

Absent or suboptimal response to booster dose of COVID-19 vaccine in patients with autoimmune systemic diseases

Autoimmune systemic diseases (ASD) show impaired immunogenicity to COVID-19 vaccines. Our prospective observational multicenter study aimed at evaluating the seroconversion elicited by COVID-19 vaccine over the entire vaccination cycle including the booster dose.

Among 478 unselected ASD patients originally evaluated at the end of the first vaccination cycle (time 1), 344 individuals were re-evaluated after a 6-month period (time 2), and 244 after the booster vaccine dose (time 3). The immunogenicity of mRNA COVID-19 vaccines (BNT162b2 and mRNA-1273) was assessed by measuring serum IgG-neutralizing antibody (NAb) on samples obtained at the three time points in both patients and 502 age-matched controls.

In the 244 ASD group that received booster vaccine and monitored over the entire follow-up, the mean serum NAb levels (time 1, 2, and 3: 696.8 ± 52.68, 370.8 ± 41.92, and 1527 ± 74.16SD BAU/mL, respectively; p < 0.0001) were constantly lower compared to controls (p < 0.0001), but they significantly increased after the booster dose compared to the first two measurements (p < 0.0001). The percentage of patients with absent/suboptimal response to vaccine significantly decreased after the booster dose compared to the first and second evaluations (time 1, 2, and 3: from 28.2% to 46.3%, and to 7.8%, respectively; p < 0.0001). Of note, the percentage of patients with absent/suboptimal response after the booster dose was significantly higher compared to controls (19/244, 7.8% vs 1/502, 0.2%; p < 0.0001). Similarly, treatment with immune-modifiers increased the percentage of patients exhibiting absent/suboptimal response (16/122, 13.1% vs 3/122, 2.46%; p = 0.0031). Overall, the above findings indicate the usefulness of booster vaccine administration in ASD patients. Moreover, the persistence of a significantly higher percentage of individuals without effective seroconversion (7.8%), even after the booster dose, warrants for careful monitoring of NAb levels in all ASD patients to identify those with increased risk of infection. In this particularly frail patients’ setting, tailored vaccination and/or therapeutic strategy are highly advisable.

Location-Dependent Human Osteoarthritis Cartilage Response to Realistic Cyclic Loading: Ex-Vivo Analysis on Different Knee Compartments

Objective: Osteoarthritis (OA) is a multifactorial musculoskeletal disorder affecting mostly weight-bearing joints. Chondrocyte response to load is modulated by inflammatory mediators and factors involved in extracellular cartilage matrix (ECM) maintenance, but regulatory mechanisms are not fully clarified yet. By using a recently proposed experimental model combining biomechanical data with cartilage molecular information, basally and following ex-vivo load application, we aimed at improving the understanding of human cartilage response to cyclic mechanical compressive stimuli by including cartilage original anatomical position and OA degree as independent factors.

Methods: 19 mono-compartmental Knee OA patients undergoing total knee replacement were recruited. Cartilage explants from four different femoral condyles zones and with different degeneration levels were collected. The response of cartilage samples, pooled according to OA score and anatomical position was tested ex-vivo in a bioreactor. Mechanical stimulation was obtained via a 3-MPa 1-Hz sinusoidal compressive load for 45-min to replicate average knee loading during normal walking. Samples were analysed for chondrocyte gene expression and ECM factor release.

Results: Non parametric univariate and multivariate (generalized linear mixed model) analysis was performed to evaluate the effect of compression and IL-1β stimulation in relationship to the anatomical position, local disease severity and clinical parameters with a level of significance set at 0.05. We observed an anti-inflammatory effect of compression inducing a significant downmodulation of IL-6 and IL-8 levels correlated to the anatomical regions, but not to OA score. Moreover, ADAMTS5, PIICP, COMP and CS were upregulated by compression, whereas COL-2CAV was downmodulated, all in relationship to the anatomical position and to the OA degree.

Conclusion: While unconfined compression testing may not be fully representative of the in-vivo biomechanical situation, this study demonstrates the importance to consider the original cartilage anatomical position for a reliable biomolecular analysis of knee OA metabolism following mechanical stimulation.

Prevalence and death rate of COVID-19 in systemic autoimmune diseases in the first three pandemic waves. Relationship to disease subgroups and ongoing therapies

OBJECTIVE

Autoimmune systemic diseases (ASD) represent a predisposing condition to COVID-19. Our prospective, observational multicenter telephone survey study aimed to investigate the prevalence, prognostic factors, and outcomes of COVID-19 in Italian ASD patients.

METHOD

The study included 3,918 ASD pts (815 M, 3103 F; mean age 59±12SD years) consecutively recruited between March 2020 and May 2021 at the 36 referral centers of COVID-19 & ASD Italian Study Group. The possible development of COVID-19 was recorded by means of a telephone survey using a standardized symptom assessment questionnaire.

RESULTS

ASD patients showed a significantly higher prevalence of COVID-19 (8.37% vs 6.49%; p<0.0001) but a death rate statistically comparable to the Italian general population (3.65% vs 2.95%). Among the 328 ASD patients developing COVID-19, 17% needed hospitalization, while mild-moderate manifestations were observed in 83% of cases. Moreover, 12/57 hospitalized patients died due to severe interstitial pneumonia and/or cardiovascular events; systemic sclerosis (SSc) patients showed a significantly higher COVID-19-related death rate compared to the general population (6.29% vs 2.95%; p=0.018). Major adverse prognostic factors to develop COVID-19 were: older age, male gender, SSc, pre-existing ASD-related interstitial lung involvement, and long-term steroid treatment. Of note, patients treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) showed a significantly lower prevalence of COVID-19 compared to those without (3.58% vs 46.99%; p=0.000), as well as the SSc patients treated with low dose aspirin (with 5.57% vs without 27.84%; p=0.000).

CONCLUSION

During the first three pandemic waves, ASD patients showed a death rate comparable to the general population despite the significantly higher prevalence of COVID-19. A significantly increased COVID-19-related mortality was recorded in only SSc patients' subgroup, possibly favored by preexisting lung fibrosis. Moreover, ongoing long-term treatment with csDMARDs in ASD might usefully contribute to the generally positive outcomes of this frail patients' population.

AB1182 SPECIALIZED PRO-RESOLVING MEDIATORS (SPMS) AND INFLAMMATORY NETWORKS IN PATIENTS AFFECTED BY ADULT ONSET STILL’S DISEASE (AOSD) AND COVID-19

Background

Uncontrolled systemic inflammation characterizes COVID-19 and autoinflammatory diseases such as adult-onset Still’s disease (AOSD). Biosynthesis of pro-resolving mediators (SPMs), i.e. lipoxins (LX), resolvins (Rv), protectins (PD), and maresins (MaR), ensures inflammation shutdown and tissue repair, limiting neutrophils recruitment and stimulating macrophages to remove apoptotic cells. Among protectins, reduction of PD1 was found in the lungs of mice infected with the H5N1 influenza virus and experimental treatment with PD1 resulted in increased animals’ survival (Morita M et al 2013).

Objectives

We investigated the effects of SPMs in pathogenesis and clinical evolution of AOSD and compared these data with mild and severe COVID-19. Finally, we analyzed the potential role of PD1 in modulating the inflammatory response of macrophages obtained from AOSD patients, COVID-19 patients and healthy donors (HDs).

Methods

21 patients hospitalized for COVID-19 (10 ICU and 11 hospitalized in medical clinical unit) and 13 patients with AOSD were enrolled. Plasma PD1 levels from patients and controls were analyzed by ELISA, and monocytes-derived macrophages were polarized into M1 and M2 phenotype. We analyzed the effect of PD-1 on macrophages differentiation. At 10 days, macrophages were analyzed for surface expression of subtypes markers by flow cytometry. Cytokines production was measured in supernatants by Bio-Plex Assays. Peripheral blood mononuclear cells (PBMCS) from 3 AOSD patients, 2 COVID-19 patients and 3 HDs were obtained. Next-generation deep sequencing was then performed to identify the differences in PBMCs transcripts profiles.

Results

AOSD patients with systemic scored (SS) ≥1 showed an increase of PD1 levels compared to AOSD patients with lower systemic score (p=0.04) (Figure 1A). Similarly, plasma levels of PD1 were increased in COVID-19 patients independently from their clinical subsets, compared to HDs (p=0.02). In vitro treatment with PD1 of monocytes-derived macrophages from AOSD and COVID-19 patients induced a significant increase of M2 polarization vs control (p<0.05) (Figure 1B). Furthermore, a significant release of IL-10 and CCL4 from M2 macrophages was observed when compared to control (p<0.05) (Figure 1C). In the transcriptomes from 3 AOSD patients (2 mild and 1 severe), 2 COVID-19 patients (1 mild and 1 ICU) and 2 HDs, we observed that genes involved in inflammation, lipid catabolism and monocytes activation were specifically dysregulated in AOSD and COVID-19 patients when compared to HDs. Among them pla2g15, pla2g12a, pla2g2d, involved in mobilization of SPMs precursors, were significant upregulated in patients compared to HDs (p<.01, |log2FoldChange|>1.2) (Figure 1D). The largest part of the genes involved in inflammation, lipid catabolism, and monocytes activation are less expressed in AOSD patients when compared to COVID19 patients, as reported in Table 1.

Table 1.Gene symbolLog2 fold changepAdjusted pCounts COVID19Counts AOSDInflammation-related genesALOX50.980.0240.2116861.618562.92IL13RA11.280.0020.0537154.782938.95RTN30.720.0020.00699948.376045.92SSH21.056,78 E-70.0001618343.868848.67Lipid catabolism genesPLBD11.680.000110.008228051.888671.3CYP4F32.850.000340.0171996.63277.13STS1.530.0100.0361798.5623.9HADHA0.740.000140.009712766.447625.38Monocytes-related genesALDH21.462.48E-101.85E-079186.553340.87CD1632.379,99E-060.001466499.4512870.59MGST11.130.00260.0631385.54631.67RNASE42.480.00010.009286.6615.42Figure 1.

Conclusion

The counterbalance by SPMs during inflammation is still a largely unexplored pathway. Our study suggests that an imbalance of SPMs in autoinflammatory diseases as well as COVID-19. The modulation of SPMs as observed in our experiments, might represent a new possible therapeutic strategy during AOSD and COVID-19.

References

[1]Morita M et al. The lipid mediator protectin D1 inhibits influenza virus replication and improves severe influenza. Cell. 2013;153:112-25.

Disclosure of Interests

luca navarini Speakers bureau: AbbVie, Pfizer, MSD, UCB, GSK, BMS, Roche, Sanofi Aventis, Novartis, Janssen, Galapagos, Eli Lilly, Paid instructor for: AbbVie, Eli Lilly, Consultant of: Philogen, Grant/research support from: AbbVie, Marta Vomero: None declared, Onorina Berardiucrti: None declared, Damiano Currado: None declared, Annalisa Marino: None declared, Alice Biaggi: None declared, Stefano Di Donato: None declared, Francesco Ursini: None declared, Piero Ruscitti: None declared, Riccardo Meliconi: None declared, Paola Cipriani: None declared, Annamaria Iagnocco Speakers bureau: AbbVie, Pfizer, MSD, UCB, GSK, BMS, Roche, Sanofi Aventis, Novartis, Janssen, Galapagos, Eli Lilly, Antonella Afeltra Speakers bureau: AbbVie, Pfizer, MSD, UCB, GSK, BMS, Roche, Sanofi Aventis, Novartis, Janssen, Galapagos, Eli Lilly, Roberto Giacomelli Speakers bureau: AbbVie, Pfizer, MSD, UCB, GSK, BMS, Roche, Sanofi Aventis, Novartis, Janssen, Galapagos, Eli Lilly, SOBI, Consultant of: Philogen, Grant/research support from: AbbVie, SOBI

AB0725 Scleroderma study group Emilia Romagna (Sclero-RER): real life use of prostacyclin analog. Preliminary data from a multicentric survey

Background

Systemic Sclerosis (SSc) is a complex autoimmune disease characterized by vascular damage, immune activation and fibrosis of skin and internal organs 1. Raynaud phenomenon (RP) is frequently the first symptom of the disease and growing evidences are supporting the hypothesis the SSc may be a vascular disease, with a pivotal role of endothelial cells, particularly in the very early phase2,3. Robust data support the use of vascular active drug to treat RP and to prevent vascular complication4–7.

Objectives

The use of prostacyclin analog (PA) is evertything but standardized, with different regimen used all around the Country. We report data on the use of PA in a multicentric regional reality to understand which regimen are prevalent (and why) and if there is the opportunity to standardized them.

Methods

We collected data from an online survey exploring different items related to the use of PA.

Results

Survey was fullfilled by 12 sites: 5 university hospital and 7 local hospitals, 7 driven by Rheumatologist and 5 from internal medicine specialists with/without concomitant rheumatologists. PA are ubiquitarly used for SSc-related digital ulcers (SSc-DU) and secondary RP but only a half of sites use it for primary RP. Seventy-five percent of sites (9/12) dispense PA at least once a month, but some other (1 each one respectively) on weekly basis, every other month or every 7 weeks. Drug administration may last from 2 to 5 consecutive days (mean 1.91+/- 1.5SD) with drug dose ranging from 0.5 to 2 ng/Kg/min with a minimum variability from site to site. Our regional hospitals may count on overall 68 spots, some available as beds (outpatient or inpatient), some as reclining chair or chair (outpatients only). University centers have usually more assigned personnel than local hospital (on average: 2 versus 1.5 physicians, 2 versus 1.2 nurse). Sites are able to offer meals (except one) and are able to accomodate from 1 to 12 patients at the same time (mean 3.45, +/- 3.2SD).

Conclusion

PA has known benefit in vascular involvement in SSc patients. Despite a multicenter palcebo-control study8 defining time and dose of this drugs and subsequent data based on the same regimen9, there is no homogeneity in treatment administration. The unequal treatment, based on our data, seems due to limited resources and personnel. High variability has been found in regimen duration and administration frequency.

References

[1]Ferri, C. et al. Systemic sclerosis evolution of disease pathomorphosis and survival. Our experience on Italian patients’ population and review of the literature. Autoimmunity Reviews vol. 13 1026–1034 (2014).

[2]Mulligan-Kehoe, M. J. et al. Antiangiogenic plasma activity in patients with systemic sclerosis. Arthritis Rheum.56, 3448–58 (2007).

[3]Wigley, F. M. Vascular disease in scleroderma. Clin. Rev. Allergy Immunol.36, 150–75 (2009).

[4]Brueckner, C. S. et al. Effect of sildenafil on digital ulcers in systemic sclerosis: Analysis from a single centre pilot study. Ann. Rheum. Dis.69, 1475–1478 (2010).

[5]Kowal-Bielecka, O. et al. EULAR recommendations for the treatment of systemic sclerosis: A report from the EULAR Scleroderma Trials and Research group (EUSTAR). Ann. Rheum. Dis.68, 620–628 (2009).

[6]Matucci-Cerinic, M. et al. Bosentan treatment of digital ulcers related to systemic sclerosis: Results from the RAPIDS-2 randomised, double-blind, placebo-controlled trial. Ann. Rheum. Dis.70, 32–38 (2011).

[7]Herrick, A. L. & Wigley, F. M. Raynaud’s phenomenon. Best Practice and Research: Clinical Rheumatology (2020) doi:10.1016/j.berh.2019.101474.

[8]Wigley, F. M. et al. Intravenous iloprost infusion in patients with Raynaud phenomenon secondary to systemic sclerosis: A multicenter, placebo-controlled, double- blind study. Ann. Intern. Med.120, 199–206 (1994).

[9]Cappelli, L. & Wigley, F. M. Management of Raynaud Phenomenon and Digital Ulcers in Scleroderma. Rheumatic Disease Clinics of North America vol. 41 419–438 (2015).

Disclosure of Interests

None declared

POS1267 LONG-TERM SURVEY STUDY OF THE IMPACT OF COVID-19 ON SYSTEMIC AUTOIMMUNE DISEASES. LOW DEATH RATE DESPITE THE INCREASED PREVALENCE OF SYMPTOMATIC INFECTION. ROLE OF PRE-EXISTING INTERSTITIAL LUNG DISEASE AND ONGOING TREATMENTS

Background

Patients with autoimmune systemic diseases (ASDs) can be counted among frail populations as regards the predisposition to COVID-19 due to the frequent visceral organ involvement and comorbidities, as well as the ongoing immunomodulating treatments.

Objectives

Our long-term multicenter telephone survey prospectively investigated the prevalence, prognostic factors, and outcomes of COVID-19 in Italian ASD patients during the first 3 pandemic waves.

Methods

A large series of 3,918 ASD patients (815 M, 3103 F; mean age 59±12SD years) was consecutively recruited at the 36 referral centers of COVID-19 & ASD Italian Study Group. In particular, ASD series encompassed the following conditions: rheumatoid arthritis (n: 981), psoriatic arthritis (n: 471), ankylosing spondylitis (n: 159), systemic sclerosis (n: 1,738), systemic lupus (172), systemic vasculitis (n: 219), and a miscellany of other ASDs (n: 178). The development of COVID-19 was recorded by means of telephone survey using standardized symptom-assessment questionnaire (1).

Results

A significantly increased prevalence of COVID-19 (8.37% vs 6.49%; p<0.0001) was observed in our ASD patients, while the cumulative death rate revealed statistically comparable to the Italian general population (3.65% vs 2.95%; p: ns). In particular, among the 328 ASD patients complicated by COVID-19, 57 (17%) needed hospitalization, while mild-moderate manifestations were observed in the large majority of individuals (83%). In addition, 12/57 hospitalized patients died due to severe interstitial pneumonia and/or cardiovascular manifestations.

Interestingly, a significantly higher COVID-19-related death rate was observed in systemic sclerosis patients compared to the Italian general population (6.29% vs 2.95%; p=0.018). Other adverse prognostic factors to develop COVID-19 were the patients’ older age, male gender, pre-existing ASD-related interstitial lung involvement, and chronic steroid treatment. Conversely, patients treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) showed a significantly lower prevalence of COVID-19 compared to those without (3.58% vs 46.99%; p=0.000), as well as the chronic administration of low dose aspirin in a subgroup of SSc patients (with 5.57% vs without 27.84%; p=0.000).

Conclusion

The cumulative impact of COVID-19 on ASD patients after the first 3 pandemic waves revealed less severe than that observed during the first phase of pandemic (1), especially with regards to the death rate that was comparable to the Italian general population in spite of the increased prevalence of complicating COVID-19 in the same ASD series.

Ongoing long-term treatments, mainly csDMARDs, might usefully contribute to generally positive outcomes of in this frail patients’ population.

Of note, a significantly increased COVID-19-related mortality was recorded in only SSc patients’ subgroup, possibly favored by pre-existing lung fibrosis. Among different ASD, SSc deserves special attention, since it shares the main pathological alterations with COVID-19, namely the interstitial lung involvement and the endothelial injury responsible for diffuse microangiopathy.

Besides SSc, the patients’ subgroups characterized by older age, chronic steroid treatment, pre-existing interstitial lung disease, and/or impaired COVID-19 vaccine response (1-3), may deserve well-designed prevention and management strategies.

References

[1]Ferri C, et al. Ann Rheum Dis. 2020 Oct 14 doi: 10.1136/annrheumdis-2020-219113.

[2]Ferri C et al. J Autoimmun. 2021 Dec;125:102744. doi: 10.1016/j.jaut.2021.102744.

[3]Visentini M et al. Ann Rheum Dis. 2021 Nov 24. doi: 10.1136/annrheumdis-2021-221248

Disclosure of Interests

None declared

AB0261 CARDIOMETABOLIC COMORBIDITIES MAY IDENTIFY A MORE SEVERE SUBSET OF RHEUMATOID ARTHRITIS, RESULTS FROM A “REAL-LIFE” STUDY

Background

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease associated with a significant increased rate of cardiometabolic comorbidities contributing to an increased risk of morbidity and mortality of these patients [1,2]. RA patients with cardiometabolic comorbidities might differ from those without in their clinical presentation and prognosis.

Objectives

This “real-life” cross-sectional study was designed to describe disease features of RA consecutive participants affected by cardiometabolic comorbidities than those without, among those attending recruiting centres from January 1, 2021 to December 31, 2021. Our purpose was also the identification of possible associations between these diseases and clinical characteristics of patients (i.e. fulfilment of ACR1987 criteria, ACPA positivity, presence of extra-articular manifestations, remission, and bDMARD failure).

Methods

Consecutive RA patients were assessed, all fulfilling 2010 ACR/EULAR criteria for RA. We have defined the participant as having such comorbidities if affected by 2 or 3 among high blood pressure (HBP), type 2 diabetes (T2D), and/or dyslipidaemia. The presence of cardiometabolic comorbidities for each participant was verified by reviewing the clinical charts, interview, and extensive medical examinations. Patients with and without cardiometabolic comorbidities were grouped and compared. After that, regression models were built to assess the influence of the presence of cardiometabolic comorbidities on RA features of disease severity.

Results

757 consecutive RA participants were evaluated [(female 56.6%, age 64.7 ± 12.3 years, median disease duration 6 years (IQR 12)]. Among assessed participants, 13.5% showed cardiometabolic comorbidities. These were older (63.9 ± 13.1 vs 70.4 ± 9.0 years, p<0.001) and characterised by a longer disease duration with 64.7% between 5 and 10 years (p=0.003). They were more often affected by extra-articular manifestations (8.2% vs 17.7%, p=0.029) and frequently displayed smoking habit (36.6% vs 50.0%, p=0.003). A lower percentage of participants with these comorbidities was in remission (15.7% vs 8.5%, p=0.048) and they showed a higher prevalence of history of bDMARD failure (40.4% vs 78.4%, p<0.001).

Finally, regression models showed that cardiometabolic comorbidities were significantly correlated with RA features of disease severity. Participants with cardiometabolic comorbidities more frequently fulfilled ACR1987 criteria in both univariate (OR: 1.47, 95%CI: 1.15-1.89, p=0.002) and multivariate analyses (OR: 1.48, 95%CI: 1.15-1.91, p=0.002). These participants had a higher probability of ACPA positivity in both univariate (OR: 1.52, 95%CI: 1.10-2.09, p=0.009) and multivariate analyses (OR: 1.47, 95%CI: 1.06-2.04, p=0.020). Cardiometabolic comorbidities also predicted the presence of extra-articular manifestations in both univariate (OR: 3.26, 95%CI: 1.77-5.89, p<0.001) and multivariate analyses (OR: 2.41, 95%CI: 1.30-4.87, p=0.005). Participants with cardiometabolic comorbidities had a higher probability of previous bDMARD failure in both univariate (OR: 1.73, 95%CI: 1.24-2.43, p<0.001) and multivariate analyses (OR: 7.17, 95%CI: 3.61-14.2, p<0.001). Cardiometabolic comorbidities resulted to be a negative predictor of being in remission in both univariate (OR: 0.53, 95%CI: 0.39-0.97, p=0.041) and multivariate analyses (OR: 0.61, 95%CI: 0.41-0.96, p=0.035).

Conclusion

We described disease features of RA participants with cardiometabolic comorbidities, identifying a disease subset characterised by clinical features of disease severity and to be considered as “difficult-to-treat”. Thus, cardiometabolic comorbidities may represent a considerable burden for RA patients requiring an appropriate management which should focus, in addition to cardiovascular risk prediction, on targeting these metabolic components.

References

[1]England BR, et al. BMJ. 2018;361:k1036.

[2]Ferguson LD, et al. Nat Rev Rheumatol. 2019;15:461-474.

Disclosure of Interests

None declared

OP0044 CYTOKINE PROFILE, HYPERFERRITINEMIA, AND MULTI-VISCERAL INVOLVEMENT CHARACTERISE MACROPHAGE ACTIVATION SYNDROME COMPLICATING ADULT ONSET STILL’S DISEASE. RESULTS FROM A MULTIDIMENSIONAL EVALUATION

Background

Adult-onset Still’s disease (AOSD) is a rare multigenic autoinflammatory disease of unknown aetiology burdened by life-threatening, such as macrophage activation syndrome (MAS) [1]. Considering the poor outcome of MAS patients, previous works tried to assess predictive factors of its occurrence during AOSD [2-4]. However, an integrated evaluation of clinical features with biomolecules, more reflecting the pathogenic mechanisms of the disease and its complications, is still missing.

Objectives

To multidimensionally characterise MAS complicating AOSD considering cytokine profile, inflammatory markers, and multi-visceral involvement of the disease. To perform a high-dimensional phenotypic analysis of circulating immune cells in AOSD patients with and without MAS. To assess interferon (IFN)-related pathways in AOSD synovial tissues by a bulky RNA sequencing.

Methods

The present evaluation was designed to multidimensionally compare AOSD patients with or without MAS, considering cytokine profile, inflammatory markers, and multi-visceral involvement of the disease. Clinical and biologic data were collected and compared in AOSD patients with and without MAS. Sera biomolecules were analysed by Luminex multiplexing technology. Mass cytometry (CyTOF) was used to characterise circulating immune cells. A bulky RNA sequencing was performed in AOSD synovial tissues.

Results

In this study, 40 consecutive AOSD patients (47.7±15.0 years, 50.0% male gender) were assessed at the time of diagnosis before the administration of any immunosuppressive therapy. Out of those, 14 (35%) patients were complicated by MAS. Paralleling with increases of systemic score and ferritin, MAS patients were characterised by an increased concentration of IL-1α, IL-1β, IL-1Ra, IL-2Ra, IL-6, IL-10, IL-17A, IFN-γ, G-CSF, MCP-1, MIP-1α, SCF. Among these biomolecules, IL-1Ra, IFN-γ, MCP-1, and SCF were correlated with MAS.

Combining the discriminatory ability of these data in identifying MAS, the best model was composed by systemic score, ferritin, IFN-γ, and IL-10. This model was characterised by AUC=0.99 (Standard error: 0.008; 95%CI: 0.976–1.000), sensitivity=100%, specificity=95.45%. By CyTOF analysis, AOSD patients, who were complicated or not with MAS were characterised by a significant increase of circulating “classical monocytes” (CD14+CD38+). MAS patients were characterised by a significant reduction of NK cells (CD45RA+CD56dim) than AOSD patients. Finally, the transcriptomic profile, by RNA-sequencing analysis, showed that 3477 among type I, II, and III IFN-related genes (IRGs) were significantly different in AOSD synovial tissues.

Conclusion

A multidimensional characterisation of AOSD patients was provided suggesting that IFN-γ, IL-10, ferritin, and systemic score discriminated MAS, thus identifying the occurrence of the cytokine storm syndrome. The inflammatory milieu of AOSD and MAS may be associated with a signature of circulating immune cells. Finally, our results about IRGs reinforced the role of IFN-γ in these patients.

References

[1]Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still’s disease. J Autoimmun. 2018;93:24-36.

[2]Ruscitti P, et al. Macrophage Activation Syndrome in Patients Affected by Adult-onset Still Disease: Analysis of Survival Rates and Predictive Factors in the Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale Cohort. J Rheumatol. 2018;45:864-872.

[3]Di Benedetto P, et al. Ferritin and C-reactive protein are predictive biomarkers of mortality and macrophage activation syndrome in adult onset Still’s disease. Analysis of the multicentre Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale (GIRRCS) cohort. PLoS One. 2020;15:e0235326.

[4]Wan L, et al. Total metabolic lesion volume of lymph nodes measured by 18F-FDG PET/CT: a new predictor of macrophage activation syndrome in adult-onset Still’s disease. Arthritis Res Ther. 2021;23:97.

Disclosure of Interests

None declared.

Expanding the spectrum of the hyperferritinemic syndrome, from pathogenic mechanisms to clinical observations, and therapeutic implications

From the introduction of hyperferritinemic syndrome concept, a growing body of evidence has suggested the role of ferritin as a pathogenic mediator and a relevant clinical feature in the management of patients with inflammatory diseases. From a pathogenic point of view, ferritin may directly stimulate the aberrant immune response by triggering the production of pro-inflammatory mediators in inducing a vicious pathogenic loop and contributing to the occurrence of cytokine storm syndrome. The latter has been recently defined as a clinical picture characterised by elevated circulating cytokine levels, acute systemic inflammatory symptoms, and secondary organ dysfunction beyond that which could be attributed to a normal response to a pathogen It is noteworthy that the occurrence of hyperferritinemia may be correlated with the development of the cytokine storm syndrome in the context of an inflammatory disease. In addition to adult onset Still's disease, macrophage activation syndrome, catastrophic anti-phospholipids syndrome, and septic shock, recent evidence has suggested this association between ferritin and life-threatening evolution in patients with systemic lupus erythematosus, with anti-MDA5 antibodies in the context of poly-dermatomyositis, with severe COVID-19, and with multisystem inflammatory syndrome. The possible underlying common inflammatory mechanisms, associated with hyperferritinemia, may led to the similar clinical picture observed in these patients. Furthermore, similar therapeutic strategies could be suggested inhibiting pro-inflammatory cytokines and improving long-term outcomes in these disorders. Thus, it could be possible to expand the spectrum of the hyperferritinemic syndrome to those diseases burdened by a dreadful clinical picture correlated with hyperferritinemia and the occurrence of the cytokine storm syndrome. In addition, the assessment of ferritin may provide useful information to the physicians in clinical practice to manage these patients. Therefore, ferritin may be considered a relevant clinical feature to be used as biomarker in dissecting the unmet needs in the management of these disorders. Novel evidence may thus support an expansion of the spectrum of the hyperferritinemic syndrome to these diseases burdened by a life-threatening clinical picture correlated with hyperferritinemia and the occurrence of the cytokine storm syndrome.

Mesenchymal stromal cells from a progressive pseudorheumatoid dysplasia patient show altered osteogenic differentiation

Background

Progressive pseudorheumatoid dysplasia (PPRD) is a rare autosomal recessive non-inflammatory skeletal disease with childhood onset and is characterized by a progressive chondropathy in multiple joints, and skeletal abnormalities. To date, the etiopathological relationship between biological modification occurring in PPRD and genetic mutation remains an open issue, partially due to the limited availability of biological samples obtained from PPRD patients for experimental studies.

Case presentation

We describe the clinical features of a PPRD patient and experimental results obtained from the biological characterization of PPRD mesenchymal stromal cells (MSCs) and osteoblasts (OBs) compared to normal cell populations. Phenotypic profile modifications were found in PPRD compared to normal subjects, essentially ascribed to decreased expression of CD146, osteocalcin (OC) and bone sialoprotein in PPRD MSCs and enhanced CD146, OC and collagen type I expression in PPRD OBs. Gene expression of Dickkopf-1, a master inhibitor of WNT signaling, was remarkably increased in PPRD MSCs compared to normal expression range, whereas PPRD OBs essentially exhibited higher OC gene expression levels. PPRD MSCs failed to efficiently differentiate into mature OBs, so showing a greatly impaired osteogenic potential.

Conclusions

Since all regenerative processes require stem cell reservoirs, compromised functionality of MSCs may lead to an imbalance in bone homeostasis, suggesting a potential role of MSCs in the pathological mechanisms of PPRD caused by WNT1-inducible signaling pathway protein-3 (WISP3) mutations. In consideration of the lack of compounds with proven efficacy in such a rare disease, these data might contribute to better identify new specific and effective therapeutic approaches.

Prevalence of Type 2 and Type 1 Diabetes in Psoriatic Arthritis: An Italian Study

OBJECTIVE

Psoriatic arthritis (PsA) is burdened by an increased susceptibility to cardiovascular diseases. Comorbid diabetes may represent one of the key factors contributing to this risk. The aim of our medical records review study was to investigate the prevalence of type 2 diabetes (T2D) and type 1 diabetes (T1D) in an Italian PsA cohort.

METHODS

The clinical records of all patients consecutively seen at our clinic with a diagnosis of PsA during a 12-month period were reviewed to identify comorbid T2D or T1D. For comparison, a 1:1 age- and sex-matched group of individuals with noninflammatory diseases was recruited.

RESULTS

The final study cohort comprised 408 patients. The prevalence of T2D was 7.8% (95% confidence interval, 5.6-10.8) in PsA and 4.4% in controls (95% confidence interval, 2.8-6.9; p = 0.04). Two cases (0.49%) of T1D were identified in the PsA cohort, whereas no cases were observed in controls. In a multivariate logistic regression model including age, disease duration, and body mass index (BMI) as covariates, increasing age (odds ratio [OR], 1.079; p = 0.006) and BMI (OR, 1.188; p = 0.011) but not PsA duration predicted being classified as having T2D. In a similar model accounting for age and BMI, average disease activity score including 28 joints and C-reactive protein showed a trend toward significance (OR, 1.639; p = 0.066).

CONCLUSIONS

In conclusion, our data provide further support to the emerging evidence of an increased risk of T2D in PsA patients. Cardiometabolic comorbidity represents a significant aspect of integrated arthritis management to improve long-term cardiovascular outcomes and to provide a comprehensive treatment.

The Effect of Ketogenic Diet on Inflammatory Arthritis and Cardiovascular Health in Rheumatic Conditions: A Mini Review

The principle of ketogenic diet (KD) is restriction of carbohydrates to a maximum of 5-10% of the total daily caloric intake, aiming at shifting body metabolism toward ketone bodies. Different studies suggested promising results of KD to help patients to lose weight, to reduce insulin requirements in diabetes, to supplement cancer protocols, to treat neurological conditions and to optimize control of metabolic and cardiovascular diseases. However, literature about the anti-inflammatory properties of KD in rheumatic diseases is still limited. The beneficial effects of weight loss in patients with inflammatory arthritis can be explained by biomechanical and biochemical factors. Obesity is associated with macrophage activation and production of pro-inflammatory cytokines including TNF-α, IL-1b, and IL-6. The clinical effect of KD may be primarily attributed to improvement of insulin sensitivity. Insulin resistance is associated with an increase of TNF-α, IL-1α, IL-1β, IL-6, and leptin. Moreover, reduction of body's adipose tissue and weight loss account for part of the anti-inflammatory effects and for the impact of KD on cardiovascular health. In rheumatoid arthritis, fasting was shown to be effective in reducing disease symptoms, possibly through the production of β-hydroxybutyrate (BHB), the main ketone body. BHB may exert inhibitory effects also on IL-17 and intermittent fasting improved the clinical manifestations of psoriatic arthritis. In ankylosing spondylitis, current literature doesn't allow to draw conclusion about the effects of KD. Future prospective studies will be needed to elucidate the potential beneficial effects of KD on specific domains and clinical outcomes in patients with inflammatory arthritis.

Impaired immunogenicity to COVID-19 vaccines in autoimmune systemic diseases. High prevalence of non-response in different patients' subgroups

Autoimmune systemic diseases (ASD) may show impaired immunogenicity to COVID-19 vaccines. Our prospective observational multicenter study aimed to evaluate the seroconversion after the vaccination cycle and at 6-12-month follow-up, as well the safety and efficacy of vaccines in preventing COVID-19.

The study included 478 unselected ASD patients (mean age 59 ± 15 years), namely 101 rheumatoid arthritis (RA), 38 systemic lupus erythematosus (SLE), 265 systemic sclerosis (SSc), 61 cryoglobulinemic vasculitis (CV), and a miscellanea of 13 systemic vasculitis. The control group included 502 individuals from the general population (mean age 59 ± 14SD years). The immunogenicity of mRNA COVID-19 vaccines (BNT162b2 and mRNA-1273) was evaluated by measuring serum IgG-neutralizing antibody (NAb) (SARS-CoV-2 IgG II Quant antibody test kit; Abbott Laboratories, Chicago, IL) on samples obtained within 3 weeks after vaccination cycle.

The short-term results of our prospective study revealed significantly lower NAb levels in ASD series compared to controls [286 (53–1203) vs 825 (451–1542) BAU/mL, p < 0.0001], as well as between single ASD subgroups and controls. More interestingly, higher percentage of non-responders to vaccine was recorded in ASD patients compared to controls [13.2% (63/478), vs 2.8% (14/502); p < 0.0001]. Increased prevalence of non-response to vaccine was also observed in different ASD subgroups, in patients with ASD-related interstitial lung disease (p = 0.009), and in those treated with glucocorticoids (p = 0.002), mycophenolate-mofetil (p < 0.0001), or rituximab (p < 0.0001). Comparable percentages of vaccine-related adverse effects were recorded among responder and non-responder ASD patients.

Patients with weak/absent seroconversion, believed to be immune to SARS-CoV-2 infection, are at high risk to develop COVID-19. Early determination of serum NAb after vaccination cycle may allow to identify three main groups of ASD patients: responders, subjects with suboptimal response, non-responders. Patients with suboptimal response should be prioritized for a booster-dose of vaccine, while a different type of vaccine could be administered to non-responder individuals.

Hyperuricemia in Psoriatic Arthritis: Epidemiology, Pathophysiology, and Clinical Implications

Psoriatic arthritis (PsA) represents the articular component of the systemic psoriatic disease and the extra-cutaneous disorder most frequently found in patients with psoriasis. Besides the articular involvement, PsA is associated with several metabolic abnormalities such as insulin resistance, hypertension, diabetes and hyperuricemia. Uric acid is the final product of purine metabolism and the etiological substrate of gout. Accumulating evidence highlights the emerging role of hyperuricemia as a major cardiovascular risk factor. Moreover, different studies evaluated the interplay between hyperuricemia and psoriatic disease, suggesting that individuals affected by psoriasis or PsA might present higher serum levels of uric acid and that hyperuricemia might affect severity of clinical manifestations and degree of inflammation in PsA patients. In this review, we focus on the bidirectional relationship between uric acid and PsA, analyzing how uric acid may be involved in the pathogenesis of psoriasis/PsA and how clinical manifestations of PsA and inflammatory mediators are affected by uric acid concentrations. Finally, the effects of anti-rheumatic drugs on uric acid levels and the potential benefit of urate-lowering therapies on psoriasis and PsA were summarized.

Osteitis condensans ilii: prevalence and characteristics of a neglected mimic of sacroiliitis

OBJECTIVES

Osteitis condensans ilii (OCI) is a benign condition characterised by triangular sclerosis of the iliac bone which may mimic radiographic sacroiliitis. Prevalence is estimated between 0.9 and 2.5%, with female predominance, but the most recent article reporting original epidemiological data in the general population was published in 1971. The aim of our study is to contribute updated figures about prevalence of OCI in Italy.

METHOD

A retrospective review of pelvic radiographs was conducted. Consecutive patients visiting the emergency department of our Institution between 1st January and 31st December 2020 were enrolled. Individuals with a past diagnosis of axial spondyloarthritis were excluded. Presence of OCI was evaluated by two musculoskeletal radiologists. Clinical and radiologic features such as osteoarthritis and insertional enthesopathy were also assessed.

RESULTS

We included 1047 individuals (61% female) with a median age of 74 years. OCI was present in 10 cases, accounting for a prevalence in the general population of 1.0% (95% CI 0.5-1.7). All patients with OCI were women and, in the female sample, prevalence was 1.6% (95% CI 0.7-2.8). Clinical characteristics and associated radiographic features were not different between patients with OCI and women without OCI.

CONCLUSIONS

The prevalence of OCI observed in our study is consistent with previous literature, and we confirm that it is more frequently retrieved in women. Longitudinal research is warranted to elucidate the evolution, while knowledge about the disorder is needed to raise the awareness of rheumatologists and radiologists and to properly identify and report the condition. Key Points • OCI may mimic sacroiliitis and is a major differential diagnosis of radiographic axial spondyloarthritis. • Prevalence of OCI in our sample is 1.0%, in line with previous literature. • OCI predominantly affects women, and our study suggests that the disorder can be incidentally identified even after childbearing age. • Increased awareness of the characteristics of OCI can facilitate identification and reporting of the disorder.

Covid-19 And Rheumatic Autoimmune Systemic Diseases: Role of Pre-Existing Lung Involvement and Ongoing Treatments

BACKGROUND

The Covid-19 pandemic may have a deleterious impact on patients with autoimmune systemic diseases (ASD) due to their deep immune-system alterations.

OBJECTIVE

To investigate the prevalence of symptomatic Covid-19 and its correlations with both organ involvement and ongoing treatments in a large series of Italian ASD patients during the first wave of pandemic.

METHOD

Our multicenter telephone 6-week survey included 3,029 unselected ASD patients enrolled at 36 tertiary referral centers of northern, central, and southern Italian macro-areas with different diffusion of pandemic. Symptomatic SARS-CoV-2 infection was classified as definite Covid-19 (presence of symptoms plus positive oral/nasopharyngeal swabs) or highly suspected Covid-19 (highly suggestive symptoms, in absence of a swab testing).

RESULTS

A significantly higher prevalence of definite plus highly suspected Covid-19 compared to Italian general population was detected in the whole ASD series (p=.000), as well as in patients from the three macro-areas (p=.000 in all). Statistically higher prevalence of Covid-19 was also found in connective tissue diseases compared to chronic arthritis subgroup (p=.000) and in ASD patients with pre-existing interstitial lung involvement (p=.000). Patients treated with either conventional disease modifying anti-rheumatic drugs (DMARDs) and/or biological DMARDs showed a significantly lower prevalence of Covid-19 (p=.000 in both). Finally, scleroderma patients undergoing low-dose aspirin showed significantly lower rate of Covid-19 compared to those without (p=0.003).

CONCLUSION

The higher prevalence of Covid-19 in ASD patients along with the significant correlations with important clinical features and therapeutic regimens suggests the need to develop targeted prevention/management strategies during the current pandemic wave.

18F-FDOPA PET/CT SUV-Derived Indices and Volumetric Parameters Correlation in Patients with Primary Brain Tumors

Simple Summary

This paper aims to improve the knowledge regarding 18F-FDOPA PET/CT parameters that may influence both the interpretation of PET data and the management of primary brain tumors. The evaluation of volumetric parameters in 18F-FDOPA imaging is uncommon, and we aim to increase the scientific interest on the potential role of volumetric parameters in the clinical practice. The standardized uptake value (SUV)-derived indices as SUV max, SUV mean, SUV max ratio, and SUV mean ratio are widely used but the exact methodology to elaborate SUV ratio is not well established. Therefore, this study aims to assess the correlation between SUV-derived indices and volumetric uptake parameters.

Abstract

Novel parameters in PET imaging, such as volumetric parameters, are gaining interest in the scientific literature, but the role of dopaminergic tumor volume (DTV) and total lesion F-DOPA activity (TLDA) and the correlation between volumetric and SUV-derived parameters are not well defined yet. One hundred and thirty-three patients that underwent 18F-FDOPA imaging for primary brain tumors were included in this retrospective study. SUV-derived indices were calculated (the occipital region was chosen to generate ratios of tumor SUV) and compared with volumetric parameters. Regression models were applied in univariate analysis and lnSUVmax was positively associated with lnDTV (beta 0.42, p = 0.007), the lnSUVmax ratio was positively associated with lnDTV (beta 0.80, p = 0.011), lnSUVmax was positively associated with lnTLDA (beta 1.27, p < 0.0001), and the lnSUVmax ratio was positively associated with lnTLDA (beta 1.87, p < 0.0001). Our study demonstrates that volumetric uptake parameters in 18F-FDOPA PET/CT are easier to assess in primary brain tumors with higher SUV max and SUV max ratios, and supports the emerging role of volumetric parameters in the data interpretation.

Fibromyalgia: a new facet of the post-COVID-19 syndrome spectrum? Results from a web-based survey

Objective

Postacute COVID-19 syndrome (PACS) is an emerging entity characterised by a large array of manifestations, including musculoskeletal complaints, fatigue and cognitive or sleep disturbances. Since similar symptoms are present also in patients with fibromyalgia (FM), we decided to perform a web-based cross-sectional survey aimed at investigating the prevalence and predictors of FM in patients who recovered from COVID-19.

Methods

Data were anonymously collected between 5 and 18 April 2021. The collection form consisted of 28 questions gathering demographic information, features and duration of acute COVID-19, comorbid diseases, and other individual’s attributes such as height and weight. The American College of Rheumatology (ACR) Survey Criteria and the Italian version of the Fibromyalgia Impact Questionnaire completed the survey.

Results

A final sample of 616 individuals (77.4% women) filled the form 6±3 months after the COVID-19 diagnosis. Of these, 189 (30.7%) satisfied the ACR survey criteria for FM (56.6% women). A multivariate logistic regression model including demographic and clinical factors showed that male gender (OR: 9.95, 95% CI 6.02 to 16.43, p<0.0001) and obesity (OR: 41.20, 95% CI 18.00 to 98.88, p<0.0001) were the strongest predictors of being classified as having post-COVID-19 FM. Hospital admission rate was significantly higher in men (15.8% vs 9.2%, p=0.001) and obese (19.2 vs 10.8%, p=0.016) respondents.

Conclusion

Our data suggest that clinical features of FM are common in patients who recovered from COVID-19 and that obesity and male gender affect the risk of developing post-COVID-19 FM.

Fibromyalgia syndrome - a risk factor for poor outcomes following orthopaedic surgery: A systematic review

BACKGROUND

Fibromyalgia (FM) is a complex syndrome incorporating many features associated with poor outcome in orthopaedic surgery. Aim of the present review was to comprehensively characterize the available evidence on the consequences of pre-existent FM on the outcomes of orthopaedic surgery.

METHODS

We performed a systematic search in MedLine and Web of Science (WOS) to identify studies evaluating the effect of FM on patient-centred outcomes, opioids consumption and postoperative complications.

RESULTS

The search strategy identified 519 records in PubMed and 507 in WOS. A total of 27 articles were deemed eligible for inclusion in qualitative synthesis. Based on quality assessment, 10 studies were rated as good quality, 10 as fair quality and 7 as poor quality. Studies reporting the prevalence of FM in consecutive patients undergoing orthopaedic surgery (n = 19) were included in quantitative synthesis. The pooled prevalence of FM in patients undergoing orthopaedic surgery was 4.1% (95% CI: 2.4-6.8) in those receiving hip or knee surgery, 10.1% (95% CI: 5.7-17.2) in those receiving shoulder or elbow surgery and 21.0% (95% CI: 18.5-23.7) in those receiving spinal surgery. The results of our systematic review consistently report FM as a significant risk factor for less satisfaction, higher pain, worse functional outcome, increased risk for postoperative opioids prescription and higher rate of medical and surgical complications following orthopaedic surgery.

CONCLUSION

Identifying pre-existing FM in patients scheduled for elective orthopaedic surgery may help to better assess the benefit/risk ratio, improve patients' awareness and minimize any discrepancy between expectancy and results.