AB0517 USE OF POSITRON EMISSION TOMOGRAPHY IN RHEUMATOLOGY PRACTICE

Background:

Positron emission tomography (PET), which is widely used in oncology, has recently been used as a guide in the diagnosis of vasculitis and activity monitoring.

Objectives:

In this study, we aimed to present the desired PET results for the preliminary diagnosis of vasculitis and follow-up.

Methods:

PET results requested from the rheumatology outpatient clinic between 2012–2019, clinical findings of patients and other imaging methods were reviewed and evaluated retrospectively.

Results:

PET results were achieved of 36 patients (47% male, 53% female). Constitutional symptoms were present in 67% of the patients with a mean age of 51 ± 18 years. The mean erythrocyte sedimentation rate (ESR) was 49 ± 33 mm/h, CRP was 46 ± 33 mg / L, and leukocyte value was 8.8 ± 3 K / mm3at the onset of the disease. While 60% of 25 patients with large vessel vasculitis had a murmur in at least one affected area, 48% had no pulse. While 78% of all patients had a finding in favor of vasculitis in non-PET imaging, this rate was 39% in PET(Table-1). Although the most commonly used imaging method is conventional angiography, recently CT and MR angiography have been requested more frequently. Only 32% of patients who are signs of vasculitis in other images had vasculitis in PET.

PET was requested with preliminary diagnosis of vasculitis in 24 patients and vasculitis was detected in 46% of the cases. In twelve of the patients with vasculitis had 25% activity involvement in the desired PET for the presence of activation.

In 5 of 8 patients with a pre-diagnosis of vasculitis who had no evidence of vasculitis in any other imaging modalities, the involvement of vasculitis was detected in the PET, and the diagnosis was confirmed

Before PET, 44% of the patients had not received steroid treatment. In this group, 63% of patients who did not take steroids, had vasculitis findings in PET. In steroid receiving group, the rate of PET involvement was 20%. Presence of vasculitis in PET was significantly higher in patients who did not receive steroid prior to PET (p = 0.009)(Table-2). The mean duration of steroid intake before PET was 28 ± 69 months.

Conclusion:

PET is an increasingly used imaging technique in rheumatology practice. The main advantage of PET is that it recognizes other pathologies such as infection and tumor in patients with systemic symptoms. Disadvantage is an expensive test, high radiation rate and misinterpretation of atherosclerosis. Vasculitis is a group of diseases that require rapid diagnosis and treatment. Because of the indisputable contribution of imaging methods at the diagnosis stage, PET was emphasized in this study

References:

[1]Dejaco C, et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice Ann Rheum Dis 2018;77:636–643.

Table-1:

Clinical and Demographic Data of Vasculitis Patients

N(%)GenderFemale19(53)Male17(47)DiagnosisTakayasu Arteritis19(53)Polymyalgia Rheumatica3(8)Polymyalgia Rheumatica + Giant Cell Arteritis2(6)Temporal Arteritis4(11)Polyarteritis Nodosa1(3)Granulomatous Polianjitis1(3)Behcet Disease4(11)Non-classification vasculitis2(6)Constitutional Symptoms24(67)Vasculitis evidence in non-PET imaging28(78)Imaging methodMR Angio10(28)CT Angio10(28)Arteriography16(43)Computed Tomography12(34)Ultrasonography3(8)Vasculitis evidence in PET14(39)Steroid use prior to PET20(56)High CRP at diagnosis> 5 mg / L28(78)High ESR at diagnosis> 30 mm / h23(64)Table-2

The effect of findings on PET positivity

Vasculitis PatientsN(%)PET (±)14PET (-)22pOR%95CIVasculit in Non-PET Imaging9(64)19(86)0,2170,280,05-1,4Constitutional Symptoms11(79)13(59)0,2922,530,54-11,7Murmur6(43)11(50)0,6760,750,19-2,88Pulselessness3(21)9(41)0,2920,390,08-1,8High CRP11(79)15(68)0,7061,70,35-8,1High ESR11(79)12(54)0,1433,050,66-14Steroid use prior to PET4(29)16(73)0,0090,150,03-0,66Preliminary diagnosis of vasculitis11(46)13(54)0,2922,530,54-11,7

Disclosure of Interests:

None declared

AB0438 MALIGNANCIES IN PATIENTS WITH PRIMARY SJOGREN’S SYNDROME

Background:

Sjogren’s syndrome (SS) is a chronic, systemic, autoimmune disease. The risk of developing lymphoproliferative malignancies is high in primary Sjogren’s syndrome(pSS).

Objectives:

In this study, we planned to present malignancy data in patients who were followed up in our outpatient clinic with a diagnosis of pSS.

Methods:

Data of 151 patients diagnosed with pSS between 2004-2019 were retrospectively reviewed and clinical, demographic characteristics of 15 patients diagnosed with malignancy were examined.

Results:

All 15 patients with malignancy were female, their mean age was 59 ± 13 years, and the disease duration was 9 ± 1 years.

In this group, 7% of the patients had fever, 13% had weight loss and 7% had night sweats. Dry eye was present in 87%, dry mouth in 93%, LAP in 53% (Table 1). None of the patients had myositis, neuropathy and vasculitis. In 87% of the patients, schirmer was below 5 mm and in 67% of the salivary gland scintigraphy, decreased involvement in the parotid and submandibular gland was detected. Salivary gland biopsy was compatible with pSS diagnosis in 53% of patients. Rheumatoid factor, ANA, SS-A and SS-B were positive in %60, %93, %67 and %53 of patients, respectively.

Table 1.

The data of pSS patients with malignancy

N(%)Gender (Female)15(100)Dry mouth14(93)Dry Eye13(87)Arthritis3(20)Parotitits4(27)Raynaud Phenomenon2(13)Lymphadenopathy8(53)Interstitial Lung Disease4(27)Smoking7(47)Hypocomplementemia4(27)MalignancyLung Cancer2(13)Breast Cancer4(27)Thyroid Papillary Cancer3(20)Cervical Cancer2(13)Vulva Cancer1(7)Mycosis Fungoides1(7)MALT lymphoma1(7)Diffuse Large B Cell Lymphoma1(7)

Low C3 level was detected in 27% of patients and C4 level was normal in all patients. Hypergammaglobulinemia was detected in%27 patents but data of five patients could not be reached. Malignancy was detected in 10% of the patients who were followed up with the diagnosis of PSS. Two patients had cervical cancer (CA), four had breast CA, three had thyroid papillary CA, one had diffuse large b cell lymphoma, one had MALT (mucous-associated lymphoid tissue) lymphoma, one had mycosis fungoides, one had vulva epithelial carcinoma and two had lung CA. Patients with malignancy and those without were compared in terms of clinical and laboratory findings. There was a significant relationship between presence LAP and smoking with development of malignancy. Subgroup analysis was performed according to titers of C-Reactive protein (CRP) and erythrocyte sedimentation rates (ESH), but there was no significant relationship between laboratory findings and the development of malignancy. (Table 2)

Conclusion:

According to 2015 data of Turkey unified database for all age groups, the rate of cancer in woman is 25% for breast cancer, 12% for thyroid CA, 5.1% for lung CA, 2.5% for cervical CA, 2.8% for non-hodgkin lymphoma. Patients with pSS have a 6 to 19-fold increased risk for the development of non-Hodgkin B-cell lymphoma. For these reasons, detailed questioning and physical examination gain importance in the follow-up of patients

References:

[1]E Theander, G Henriksson, O Ljungberg.Lymphoma and other malignancies in primary Sjögren’s syndrome: a cohort study on cancer incidence and lymphoma predictors. Ann Rheum Dis. 65 (6):796-803 2006

Table-2.

Relationship between presence of malignancy and clinical and laboratory findings

N(%)Malignancy(±)15Malignancy(-)136POR%95 CIHypocomplementemia4(27)11/96(12)0,1192,810,76-10,3Fever1(7)7(5)0,5761,310,15-11,4Night Sweats1(7)0***Weight Loss2(13)10(7)0,3391,930,38-9,81Smoking7(47)24(20)0,0433,61,19-10,9LAP8(53)36(27)0,0393,171,07-9,38Hypergammaglobulinemia4/10(40)26/86(30)***ESH>50 mm/h2(13)8(6)0,2602,460,47-12,8CRP>3XNormal2(13)14(10)0,6621,340,27-6,56

*No analysis was done because the data was not enough

Disclosure of Interests:

None declared

AB0439 LUNG FINDINGS IN PATIENTS WITH PRIMARY SJOGREN’S SYNDROME

Background:

Sjogren’s syndrome (SS) is a systemic, autoimmune disease and can affect many organs and systems.

Objectives:

In this study, we planned to present the lung findings of primary SS (pSS) patients who are being followed in our outpatient clinic.

Methods:

Chest radiographs and thorax CTs of 151 patients who were admitted to the rheumatology outpatient clinic between 2004 and 2017 and diagnosed as pSS according to the classification criteria of the American-European consensus group Sjogren’s syndrome were retrospectively scanned.

Results:

In our study, 97% of pSS patients were female and 3% were male and the mean age was 56 ± 12 years, disease duration was 10.5 ± 5 years.

It was observed dry eye in 86% of patients, dry mouth in 88%, parotitis in 17%, arthritis in 29%, vasculitis in 4%, neuropathy in 6%, myositis in 1%, lymphadenopathy in 29% (LAP), and 20% of patients had Raynaud phenomenon. In 50% of the patients, chest radiography was normal, and there were no respiratory complaints. Thorax CT was requested due to suspicious appearance on 50% chest x-ray.

According to CT findings, 23% had nodules in the lung, nodule sizes were less than 1 cm, and patients were followed up for an increase in size. Hiler and subcarinal lymph nodes were present in 6% of patients and their sizes was ranged from 5 mm to 15 mm. Bronchoscopy was performed for two patients due to mediastinal LAP. Biopsy results were evaluated as reactive changes.

Interstitial lung disease (ILD) findings were present in 16 patients. (69% NSIP, 25% LIP, 6% UIP). All patients with ILD received steroid therapy. Two patients received 6 cycles of cyclophosphamide treatment for active alveolitis and azathioprine (AZA) was used in maintenance therapy. Due to ILD, one patient was receiving rituksimab, one patient was receiving mycophenolate mofetil, while nine patients were using AZA.

It was found bronchiectasis in 3% of patients, emphysema in 5%, sequelae fibrotic changes in 13%, and 1% patients had thickening of the pleura. One patient was diagnosed with hypersensitivity pneumonia and two patients had lung cancer (Table-1).

There was a smoking history in 21% of the patients. There was a significant relationship between smoking and development of emphysema and malignancy. The relationship between smoking and lung cancer development could not be assessed due to the absence of lung cancer in the non-smoking group (Table-2).

Conclusion:

Lung findings are detected in 9-12% of patients in pSS, which can increase to 75% with the use of tomography, pulmonary function tests and bronchoscopy.

Since pSS has a wide spectrum from airway disease or interstitial lung disease to BALT lymphoma lung involvement of the disease has been emphasized.

References:

[1]Hatron PY, Tillie-Leblond I, Launay D, et al.: Pulmonary manifestations of Sjogren’s syndrome. Presse Med. 40:e49-e64 2011

Table 1.

Lung Findings of Primary Sjogren’s Syndrome Patients

%(N)Nodule23(34)Mediastinal LAP9(6)Interstitial Lung Disease11(16)NSIP69(11)LIP25(4)UIP6(1)Bronchiectasis3(4)Atelectasis5(7)Emphysema5(7)Sequelae Fibrotic Change13(19)Tuberculosis Sequelae1(2)Airway disease1(1)Pleural effusion1(2)Lung cancer1(2)Table 2.

Effects of smoking on lung findings

N(%)Smoker31(21)Non-Smoker107(71)pOR%95 CIEmphysema6(19)1(1)0,001252,9-220Interstitial Lung Disease2(7)14(13)0,5240,4580,09-2,13Raynaud6(19)22(21)0,8830,9260,33-2,53LAP10(32)32(30)0,8021,110,47-2,63Nodule9(29)23(22)0,3811,490,60-3,68Malignancy7(23)8(8)0,0433,61,19-10,9Lung Cancer2(7)0---Atelectasis2(7)3(3)0,3132,390,38-14,9Bronchiectasis04(4)---

Disclosure of Interests: :

None declared

SAT0544 USE OF BIOLOGICAL DMARDS IN PATIENTS WITH ADULT-ONSET STILL’S DISEASE: RESULTS FROM TURKBIO REGISTRY

Background:

Adult-onset Still’s disease (AOSD) is a rare multisystemic inflammatory disorder, and is diagnosed by exclusion. AOSD is generally treated with nonsteroidal antiinflammatory drugs, corticosteroids, and conventional disease modifiying antirheumatic drugs (cDMARDs). Biological disease modifiying antirheumatic drug (bDMARD) therapy are recommended in AOSD patients who are refractory to tradional therapy, and bDMARDs is becoming increasingly important in AOSD treatment.

Objectives:

To evaluate the use of bDMARDs and drug survival in AOSD patients.

Methods:

TURKBIO registry is the Turkish version of Danish DANBIO rheumatological database which has been established in 2011. All patients with AOSD who received biological agents registered in TURKBIO registry between dates of October 2011 and October 2019 were included in this study. The demographic data, response of therapy, frequency of using and switching biological agents were collected.

Results:

As of October, 21 AOSD patients were recruited. Mean age of patients was 34.6±7.3 (min-max: 24-49) years, mean disease duration was 9.3±7.4 (min-max: 1-22) years, and 57.1% of patients was female. Mean duration from onset to start of bDMARDs was 7±6.1 (min-max: 0.5-21) years. It was observed that 13 patients (61.9%) received tocilizumab (TCZ), 6 patients (28.6%) received IL-1 inhibitors (5 anakinra and one canakinumab), 2 patients (9.5%) received certolizumab and one patient (4.8%) received etanercept as a first-line bDMARDs. The most frequently used biological agents in current treatment were as follows: 52.4% of patients received TCZ and 33.3% received IL-1 inhibitors (4 anakinra, 3 canakinumab), and the most frequently used concomitant drugs were methotrexate (47.6%) and hydroxychloroquine (14.3%). The switching rate was 33.3%, and in half of them the reason of switching was adverse events. The median drug survival for bDMARDs was 28.6 months (Table).

Table.

Demographic, laboratory features and management of AOSD

(median;25-75)n=21Age (year)34.7 (28.3-40.6)Gender (Female) n(%)12 (57.1)Disease duration (year)8 (2-17)Duration from onset to start of bDMARs (year)6 (1.5-10)ESR (on onset)44 (21-66)CRP (on onset)65 (3.1-108)Current bDMARDs n(%) Tocilizumab11(52.4) IL-1 inhibitors7 (33.3) Etanercept1 (4.8) Certolizumab2 (9.5)Concomitant cDMARD n(%) Methotrexate10 (47.6) Leflunomide4 (19) Sulfasalazine1 (4.8) Hydroxychloroquine3 (14.3)bDMARDs Survival (months)28.6 (5.5-75)Switching Rate n(%)7 (33.3)Adverse Event n(%)3 (14.3)

Conclusion:

This is the first evaluation of AOSD patients who used biological agents from TURKBIO registry. According our data, TCZ and anti-IL1 agents were the most frequent biological choices. The limitation of this study was the low number of the patients with AOSD who used biological agents.

References:

[1].Zhou S, Qiao J, Bai J, Wu Y, Fang H. Biological therapy of traditional therapy-resistant adult-onset Still’s disease: an evidence-based review. Ther Clin Risk Manag 2018;14:167-71.

Acknowledgments:

None

Disclosure of Interests:

None declared

AB0562 SLEEP HYGIENE: COULD IT BE A CONFOUNDING FACTOR FOR SLEEP QUALITY IN SYSTEMIC SCLEROSIS?

Background:

Sleep disturbances have been described in Systemic Sclerosis (SSc). Confounding factors related to sleep quality are also investigated. Although sleep hygiene plays an important role in sleep quality, as far as we know, there are not enough data to show the effect of sleep hygiene on sleep quality of SSc.

Objectives:

To investigate sleep hygiene, its impact on sleep quality, and its association with demographic-clinical factors in patients with SSc, rheumatoid arthritis (RA), and healthy controls.

Methods:

The study was designed as cross-sectional. Forty-nine patients with SSc who fulfilled the 2013 ACR/EULAR classification criteria for SSc, 66 patients with RA who fulfilled 1987 revised classification criteria, and 30 healthy controls were included in the study. All participants were female. Demographic and clinical variables were documented. Disease activity index of both SSc and RA was calculated. SSc patients were assessed by questionnaires including Short Form 36 (SF-36), The Health Assessment Questionnaire Disability Index (HAQ-DI), Beck Anxiety and Beck Depression Inventory, Pittsburg Sleep Quality Index (PSQI), Sleep Hygiene Index (SHI). Additionally, RA patients and healthy controls were estimated by HAQ-DI, Beck Anxiety and Beck Depression Inventory, PSQI, and SHI. Logistic regression analysis was used to determine the predictors of sleep quality.

Results:

Preliminary results of the study were given. The baseline demographics were similar among groups. When comparing groups according to HAQ-DI, Beck Anxiety and Beck Depression Inventory, PSQI, and SHI, we found higher scores in SSc and RA rather than healthy controls (p<0.001, p=0.001, p=0.001, p<0.001, p=0.003; respectively). While depression and sleep hygiene were determined as the risk factors of sleep quality in SSc in univariate analysis, depression (OR=1.380, 95%CI: 1.065−1.784, p=0.015) and sleep hygiene (OR=1.201, 95%CI: 1.003−1.439, p=0.046) were also found in multivariate logistic model. In RA patients, while health status, depression, and anxiety were found as risk factors according to the univariate analysis, depression (OR=1.120, 95%CI: 1.006−1.245, p=0.038) was the only factor according to multivariate logistic model (Table).

Conclusion:

Although depression is a well-known clinical variable impacting on sleep quality, sleep hygiene should also be kept in mind as a confounding factor.

References:

[1]Milette K, Hudson M, Körner A, et al. Sleep disturbances in systemic sclerosis: evidence for the role of gastrointestinal symptoms, pain and pruritus. Rheumatology (Oxford). 2013 Sep;52(9):1715-20.

[2]Sariyildiz MA, Batmaz I, Budulgan M, et al. Sleep quality in patients with systemic sclerosis: relationship between the clinical variables, depressive symptoms, functional status, and the quality of life. Rheumatol Int. 2013 Aug;33(8):1973-9.

Table

Univariate logistic regression analysis of clinical variables to assess predictors of sleep quality

Systemic sclerosisRheumatoid arthritisOR (95% CI)pOR (95% CI)pHAQ-DI1.019 (0.882−1.177)0.8011.089 (1.011−1.173)0.025BDI score1.293 (1.082−1.547)0.0051.129 (1.036−1.230)0.006BAI score1.080 (0.997−1.169)0.0591.122 (1.038−1.214)0.004SHI1.200 (1.060−1.357)0.0041.048 (0.965−1.137)0.264Disease activitya0.707 (0.439−1.138)0.1531.446 (0.839−2.492)0.185

aDisease activity was calculated by Valentini disease activity index for SSc and DAS28-CRP for RA.

Disclosure of Interests:

None declared

SAT0243 SUBPHENOTYPES IN POLYARTERITIS NODOSA (PAN): TARGET ORGAN ASSOCIATIONS OF A WORLDWIDE COLLABORATION STUDY

Background:

There is a paucity of information on the current phenotypes, ethnic and geographic differences of PAN. A global PAN study group has been working for clinical subphenotype and GWAS studies.

Objectives:

This study is aimed to look for target organ associations in PAN.

Methods:

PAN patients fulfilling the EMA vasculitis classification algorithm were recruited. In addition to baseline characteristics, treatment and outcome data, occurrence of any of the clinical manifestations related to PAN during disease course was recorded.

Factor analysis was used to analyse target organ associations of 306 patients. Five factors were identified by factor analysis of variables sex, paediatric-onset, HBV, monogenic disease relationship, cutaneous features, musculoskeletal symptoms, constitutional symptoms and involved areas (abdominal, renal, neurologic, ENT, cardiac, pulmonary).

Results:

PAN cohort from 7 countries were used (Italy: n=59, Japan: n=39, Mexico: n=29, Slovenia: n=14, Sweden:11, TUR: n=106, UK: n=48). 306 (M/F: 171/135 and Caucasian 77.1%, Asian 13.4%, and Hispanic 9.5%) patients were included. 8 were HBV-related, and 22 of TUR patients had a monogenic form of disease (FMF n=15, DADA2 n=7). 21.8% of patients were cutaneous-only PAN patients. 48.4% of patients had radiologic, 64% had biopsy-proven PAN. Median age at disease onset was 40 (IQR 27.0-57.5) years. During a median 57 (16-120) months follow-up, 39 (13%) patients died.

Factor analysis revealed 5 factors that explained 54.1% of the original information on the matrix as follows:Factor 1,represented the association between gastrointestinal and renal involvement, male gender and negatively associated with cutaneous features;Factor 2,the association between monogenic relationship with paediatric onset disease;Factor 3,any of musculoskeletal findings with positive constitutional symptoms;Factor 4any neurologic involvement was associated with ENT and pulmonary findings;Factor 5cardiac involvement in non-HBV patients (Table).

The eigenvalues of the 5 factors were 2.034, 1.470, 1.427, 1.079 and 1.030, in decreasing order, i.e., the highest contribution to the overall variance in the matrix came from the togetherness of the 4 clinical and demographic characteristics that made up Factor 1.

Conclusion:

Target organ associations could support distinctive subphenotypes in PAN. Factor 1 seems the most severe form. Patients with FMF or DADA2 have distinct target organ associations. The jury is out to decide whether these patients should be classified as ‘vasculitis associated with probable etiology’ just as HBV-related-PAN. Factor 4 might define a different subphenotype (ANCA- medium vessel vasculitis?).

Disclosure of Interests:

Omer Karadag: None declared, Ertugrul Cagri Bolek: None declared, Shunsuke Furuta: None declared, Giacomo Emmi: None declared, ALOJZIJA HOCEVAR: None declared, Andrea Hinojosa-Azaola: None declared, Aladdin J Mohammad Speakers bureau: lecture fees from Roche and Elli Lilly Sweden, PI (GiACTA study), Serdal Ugurlu: None declared, Fatma Alibaz-Oner: None declared, Ayten Yazici: None declared, Luca Quartuccio: None declared, Enrica Bozzolo: None declared, Lorenzo Dagna Grant/research support from: Abbvie, BMS, Celgene, Janssen, MSD, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, SG, SOBI, Consultant of: Abbvie, Amgen, Biogen, BMS, Celltrion, Novartis, Pfizer, Roche, SG, and SOBI, Giuseppe Alvise Ramirez: None declared, Luca Cantarini: None declared, Gina Gregorini: None declared, Jeannin Guido: None declared, Sara Monti: None declared, Eduardo Martin-Nares: None declared, Franco Schiavon: None declared, Roberto Padoan: None declared, Hajime Kono: None declared, Augusto Vaglio: None declared, Saadettin Kiliçkap: None declared, Ali İhsan Ertenli: None declared, Haner Direskeneli: None declared, Seza Özen Consultant of: Novartis, Pfizer, Speakers bureau: SOBI, Novartis, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim

AB0618 COMPREHENSIVE ANALYSIS OF AUTOANTIBODY PROFILE IN A TURKISH SYSTEMIC SCLEROSIS COHORT

Background:

Serum autoantibodies closely reflect patterns of organ involvement and disease progression in systemic sclerosis (SSc). The entire autoantibody profile is less well defined in many cohorts and the data regarding their clinical associations and frequencies is limited.

Objectives:

To determine the autoantibody profile of patients with SSc, as well as their clinical associations, in well-characterized inception- cohort with disease duration less than 3 years.

Methods:

Serum samples of 100 patients out of 105 enrolled in the study were analyzed for ANA patterns with indirect immunofluorescence (IIF) assay using HEp-20-10/primate liver mosaic IIFT kit. Sera of 96 patients were subjected to commercial line immunoassay to quantify autoantibodies against 13 different autoantigens.

Results:

92 (92%) out of 100 patients were positive for ANA by IIF (Table 1). The speckled staining was the most pattern followed by nucleolar in 10 patients, centromere in 4, reticular in 1, nuclear in 2 and homogenous in 1. All patients (n= 96) patients were positive for at least 1 autoantibody by immunoblotting (Table 2). Twenty-two (49%) of patients with antiTopo I, 12 (44%) of the patients with antiCENP and 4 (22%) of the patients with antiRNAPIII were single positive. There was no difference in terms of the clinical findings when the patients with single and coexpression of these antibodies were compared. The distributions of the most frequent autoantibodies are shown in Figure 1. Interstitial lung disease was more frequent in the patients positive for anti-Topo I (78.8%) and anti-RNAPIII (27.3%). One of the two patients with breast cancer was anti-RNAPIII positive and none of the patients have diagnosed scleroderma renal crisis. Anti-Topo I was more common in patients with dcSSc (75%) and anti-CENP in lcSSc (46.4%).

Table 1.

Demographic, clinical and laboratory characteristics of the SSc patients.

Sex Female N, %91 (86.7%) Male N, %14 (13.3) Female-to-male ratioAge, mean±SD years48.6±12.7Disease duration, mean±SD years2±1.4Disease classification N, % Diffuse39 (36.5%) Limited65 (62.5%) Sine scleroderma1 (1%)Interstitial lung disease37 (34.3%)Pulmonary arterial hypertension3 (2.8%)Scleroderma renal crisis0Digital ulcer14 (13.3%)Raynaud phenomenon105(100%)Telengiectasia31 (28.8%)Calcinosis1 (1%)Malignancy3 (2.9%)Antinuclear antibody profile N*, % Positive92 (92%)Staining pattern Speckled65 (65%) Nucleolar13 (13%) Centromere29 (29%) Homogeneous3 (3%) Reticular3 (3%)Table 2.

Numbers and combinations of autoantibodies identified in the 96 SSc patients.

Topo-ICENPRNAP IIIFibrillarinNOR90Th/ToPm/SclKuPDGFRRo52Topo-I22170159507CENP12202222011RNAPIII40121307Fibrillarin0000000NOR90011002Th/To04202Pm/Scl4306Ku102PDGFR00Ro522Single positive221240004102Total452718058179024Figure 1.

Diagram of disease-related antibodies against the four main autoantibodies [anti-centromere (antiCENP) anti-Topoisomerase I (antiTopo I), anti-RNA polymerase III (antiRNAP III) and anti-Ro52).

Conclusion:

We presented the clinical and serologic features of the Turkish SSc patients from a new inception cohort. Clinical features of the SSc patients with single or multiple antibody positivity were not different.

References:

None

Disclosure of Interests:

None declared

Damage assessment in adult IgA vasculitis. Cross-sectional results of a multicentre cohort

OBJECTIVES

Immunoglobulin (Ig) A vasculitis affects children more commonly than adults and previous literature lacks any formal damage assessment. Our aim in this study is to investigate the disease course, relapse rates and prognostic factors in adult patients with IgA vasculitis and to evaluate the disease-related damage.

METHODS

We assembled a retrospective cohort of adult IgA vasculitis from six tertiary Rheumatology Centres in Turkey. The demographics, clinical characteristics, treatment and outcomes of patients were abstracted from medical records.

RESULTS

The study included 130 (male/female: 85/45) patients and the mean age was 42.2±17 years. Cutaneous manifestations and arthritis/arthralgia were the most common clinical manifestations. One hundred thirteen patients (86.9%) were treated with oral glucocorticoids (GC). As additional immunosuppressive (IS) agents, azathioprine was given to 44 (34.9%) and pulse cyclophosphamide to 18 (12.6%) patients. Seventy-nine patients (60%) had follow-up of median 15 (IQR 7-40) months. Twelve (15%) patients relapsed during follow-up. The mean VDI score was 0.4 in the last visit. Nineteen (24.7%) patients had at least one damage item at the end of follow-up. Most frequent damage items were renal 11 (42%), ocular 4 (15%) and cardiovascular 4 (15%).

CONCLUSIONS

In this cohort the most frequent damage item was renal and was related to the disease itself. Damage score was higher in patients with more severe disease and treated more aggressively. Our results suggest that more effective treatment options are needed in a subgroup of patients with IgA vasculitis to prevent the damage related with the vasculitis, especially with more severe disease.

Efficacy of TNFα inhibitors for refractory vascular Behçet's disease: A multicenter observational study of 27 patients and a review of the literature

OBJECTIVES

Vascular involvement is one of the major causes of morbidity and mortality in Behçet's disease (BD) patients. Immunosuppressive (IS) agents are the mainstay of vascular BD (VBD) treatment; however, up to one-third of patients relapse under conventional ISs. In this case series, we present the results of tumor necrosis factor-alpha (TNFα) inhibitor use for the treatment of VBD patients who were refractory to conventional ISs and corticosteroids.

METHODS

This retrospective multicenter study included 27 refractory VBD patients treated with TNFα inhibitor agents. All data were acquired from patient charts.

RESULTS

Complete clinical remission was achieved in 22 (80%) patients within 3 months of the initiation of TNFα inhibitors. Infliximab was the first choice of TNFα inhibitor in 24 and adalimumab in three patients. The median daily dose of corticosteroids significantly decreased at 3 months. A trend toward a higher rate of complete remission was observed with concomitant IS use compared to monotherapy of TNFα inhibitors (93% vs 67%, P = .09). Serious side effects were observed in two patients (one pneumonia and one tuberculosis).

CONCLUSION

Tumor necrosis factor-alpha inhibitors seem a highly effective option for remission-induction of refractory VBD with an acceptable safety data. Concomitant IS use may achieve higher complete remission rates as compared to TNFα inhibitor monotherapy. Comparative efficacy and safety of biological agents for VBD require further prospective, randomized controlled studies with a longer duration of follow-up.

The correlation of computed tomography in the evaluation of septoplasty patients

Background

Septoplasty is one of the frequently applied nasal surgical procedures. There is still no gold standart objective method to evaluate the patients whom suffers from nasal blockage. To evaluate the septoplasty candidate with a Paranasal Computerised Tomography (PNCT) is one of the most discussed topic in the otorhinolaryngology surgical philosophy.

Objectives

In this study, we aim to interpret the value of nasal valve areas measured by PNCT for both septoplasty candidates and the control population. We believe that this information could be useful for the evaluation of patients before undergoing a septoplasty procedure.

Material and Methods

600 coronal and axial tomography sections performed between May 2014 and February 2018 at the University Of Gaziantep Radiology Dept. were assessed. These tomography sections were divided into two groups called the septoplasty and the control. The septoplasty group was made up of three hundred paranasal sinus tomography images scanned before patients' septoplasty operations. The control group was created by screening 300 maxillofacial tomography's which were taken due to the suspicion of trauma at the University Of Gaziantep Emergency Clinic between May 2014 and January 2018.

Results

There were 192 (64%) patients with left nasal septal deviation and 108 (36%) patients with right nasal septal deviation. The Independent Sample T-Test revealed that the mean internal nasal valve angle in the left septoplasty group was significantly lower than that of the control group (P < 0.005). A comparison of the right side nasal values revealed a significant statistical change according to the Independent Sample T-Test between the value of the right septoplasty and the control groups (P < 0.005).

Conclusion

The sectional areas of nasal tomography images may show different values. However, it is still difficult to say that the clinical application of tomography images could be used as one of the indication criteria for the septoplasty procedure.

Simultaneous Biofortification of Wheat with Zinc, Iodine, Selenium, and Iron through Foliar Treatment of a Micronutrient Cocktail in Six Countries

Field experiments were conducted on wheat to study the effects of foliar-applied iodine(I) alone, Zn (zinc) alone, and a micronutrient cocktail solution containing I, Zn, Se (selenium), and Fe (iron) on grain yield and grain concentrations of micronutrients. Plants were grown over 2 years in China, India, Mexico, Pakistan, South Africa, and Turkey. Grain-Zn was increased from 28.6 mg kg^-1 to 46.0 mg^-1 kg with Zn-spray and 47.1 mg^-1 kg with micronutrient cocktail spray. Foliar-applied I and micronutrient cocktail increased grain I from 24 μg kg^-1 to 361 μg kg^-1 and 249 μg kg^-1, respectively. Micronutrient cocktail also increased grain-Se from 90 μg kg^-1 to 338 μg kg^-1 in all countries. Average increase in grain-Fe by micronutrient cocktail solution was about 12%. The results obtained demonstrated that foliar application of a cocktail micronutrient solution represents an effective strategy to biofortify wheat simultaneously with Zn, I, Se and partly with Fe without yield trade-off in wheat.

Epicardial adipose tissue thickness in systemic sclerosis patients without overt cardiac disease

Systemic sclerosis is associated with an increased prevalence/incidence of coronary artery disease. The aim of this study was to investigate epicardial adipose tissue (EAT) thickness which may contribute to cardio-metabolic risk in systemic sclerosis (SSc) patients without overt cardiac disease. EAT thickness was measured by transthoracic conventional Doppler echocardiography and compared in SSc patients (n = 47) and age- and sex-matched healthy controls (n = 36). The relationships between EAT thickness and markers of cardio-metabolic risk in SSc were examined. EAT thickness was significantly greater in patients with SSc compared to healthy controls (6 [7-5] vs 5 [6.75-3.25], p = 0.041). Compared to controls, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), leukocyte, neutrophil, B-type natriuretic protein (BNP), fasting plasma insulin and HOMA-IR were elevated (18 [31-10] vs 8.5 [18-4], p < 0.001; 0.4 [0.67-0.18] vs 0.21 [0.48-0.09], p = 0.012; 7510 [8731-5990] vs 6435 [7360-5195], p = 0.002; 4350 [5440-3570] vs 3390 [4168-2903], p < 0.001; 111 [185-74] vs 70 [127-70], p = 0.010; 6.7 [10.5-4.7] vs 4.7 [6.8-4.1], p = 0.008; 1.7 [2.6-1] vs 1.1 [1.7-0.9], p = 0.015, respectively). The total and low-density lipoprotein (LDL)-cholesterol were decreased in SSc patients (197 ± 45 vs 284 ± 36, p = 0.005; 118 [148-84] vs 140 [180-115], p = 0.003, respectively). In patients with SSc, the EAT thickness correlated positively with age, ESR, CRP, insulin, hemoglobin A1c and total and LDL-cholesterol (r = 0.574, p < 0.001; r = 0.352, p = 0.015; r = 0.334, p = 0.022; r = 0.290, p = 0.048; r = 0.317, p = 0.030; r = 0.396, p = 0.006 and r = 0.349, p = 0.016, respectively). Our study confirms that EAT thickness is greater in SSc patients compared to healthy controls using echocardiographic measurements. The results of our study suggest that EAT thickness is a candidate for atherosclerotic risk assessment in SSc.

Evaluation of left and right ventricle by two-dimensional speckle tracking echocardiography in systemic sclerosis patients without overt cardiac disease

BACKGROUND/OBJECTIVE

The aim was to evaluate the left and right ventricular functions concurrently by two-dimensional speckle tracking echocardiography (STE) in systemic sclerosis (SSc) patients without overt cardiac disease.

METHODS

A total of 47 patients with SSc and 36 age- and sex-matched controls were evaluated cross-sectionally. Two-dimensional STE was used to assess the longitudinal peak systolic strains (PSS) of both ventricles including apical long-axis (APLAX), apical four-chamber (4-CH), apical two-chamber (2-CH), and global longitudinal measurements. Any association of metabolic, cardiac, and inflammatory biomarkers with PSS was investigated.

RESULTS

The longitudinal PSS of the left ventricle [APLAX, 4-CH, 2-CH and global] were significantly lower in SSc patients than controls (- 18.2 ± 3.2 vs - 19.8 ± 2.7% p = 0.02; - 17.8 ± 3.5 vs. - 20.3 ± 3.3% p = 0.001; - 18.6 ± 3.1 vs. - 21.8 ± 3% p < 0.001; - 17.5 ± 5.7 vs. - 20.6 ± 2.7% p = 0.003, respectively). No difference was found between the groups for right ventricular strains. The longitudinal PSS-4CH correlated positively with CRP and ESR (r = 0.349, p = 0.016; r = 0.356, p = 0.014, respectively) and negatively with serum Galectin-3 (r = - 0.362, p = 0.012). Global longitudinal PSS-left ventricle (LV) correlated positively with CRP and homocysteine (r = 0.297, p = 0.043; r = 0.313, p = 0.041, respectively) and negatively with serum Galectin-3 (r = -0.314, p = 0.041). After multivariable adjustment, CRP remained the only predictor of longitudinal PSS-4CH (95% CI 0.35, 0.70, p = 0.028) and global longitudinal PSS of left ventricle (95% CI 0.004, 0.22, p = 0.043).

CONCLUSIONS

Biventricular evaluation of patients with SSc by two dimensional STE revealed reduced left ventricular longitudinal strains, despite preserved right ventricular strain, and no diastolic dysfunction. In SSc without overt cardiac disease, global cardiac assessment with 2DSTE is a promising method which seems to contribute to the detection of patients without clinical findings.

KEY POINTS

• Two dimensional STE revealed reduced left ventricular longitudinal strains, despite preserved right ventricular strain in SSc patients without overt cardiac disease. • CRP was the predictor of decreased longitudinal strains. • Cardiac assessment in SSc should be made globally.

Factors Affecting Intraocular Pressure Measured by Noncontact Tonometer

Purpose

To investigate the mean values of intraocular pressure (IOP) measured with non-contact tonometer (NCT) and evaluate the factors that may affect IOP.

Methods

A total of 850 subjects who were admitted to our clinic between March 2005 and February 2006 were recruited for the study. Subjects having blepharitis, conjunctivitis, corneal diseases, glaucoma suspicion, or glaucoma were not accepted to the study. All subjects were questioned about systemic diseases. IOP measurement with NCT and central corneal thickness (CCT) with ultrasound pachymetry were performed for each patient between 9 and 11 AM.

Results

The mean ages of 367 (43.2%) male subjects and 483 (56.8%) female subjects were 43.9±18.1 and 40.7±18.0 years ± SD, respectively. Since right and left eye IOP, CCT, and keratometric values were significantly correlated, right eye values were used for statistical purposes. Mean IOP values in males and females were 13.2±3.0 and 13.5±2.9 mmHg, respectively. Mean CCT values were 552.5±34.7 μm for males and 550.1±34.3 μm for females. In multiple regression analysis, IOP was found to be associated with gender, refractive error, CCT, and the presence of diabetes mellitus (DM).

Conclusions

Gender, CCT, the presence of DM, and refractive error may be significantly associated with IOP in this particular population.

Response rate of initial conventional treatments, disease course, and related factors of patients with adult-onset Still's disease: Data from a large multicenter cohort

BACKGROUND

Adult-onset Still's disease (AOSD) is a rare condition, and treatment choices are frequently dependent on expert opinions. The objectives of the present study were to assess treatment modalities, disease course, and the factors influencing the outcome of patients with AOSD.

METHODS

A multicenter study was used to reach sufficient patient numbers. The diagnosis of AOSD was based on the Yamaguchi criteria. The data collected included patient age, gender, age at the time of diagnosis, delay time for the diagnosis, typical AOSD rash, arthralgia, arthritis, myalgia, sore throat, lymphadenopathy, hepatomegaly, splenomegaly, pleuritis, pericarditis, and other rare findings. The laboratory findings of the patients were also recorded. The drugs initiated after the establishment of a diagnosis and the induction of remission with the first treatment was recorded. Disease patterns and related factors were also investigated. A multivariate analysis was performed to assess the factors related to remission.

RESULTS

The initial data of 356 patients (210 females; 59%) from 19 centers were evaluated. The median age at onset was 32 (16-88) years, and the median follow-up time was 22 months (0-180). Fever (95.8%), arthralgia (94.9%), typical AOSD rash (66.9%), arthritis (64.6%), sore throat (63.5%), and myalgia (52.8%) were the most frequent clinical features. It was found that 254 of the 306 patients (83.0%) displayed remission with the initial treatment, including corticosteroids plus methotrexate with or without other disease-modifying antirheumatic drugs. The multivariate analysis revealed that the male sex, delayed diagnosis of more than 6 months, failure to achieve remission with initial treatment, and arthritis involving wrist/elbow joints were related to the chronic disease course.

CONCLUSION

Induction of remission with initial treatment was achieved in the majority of AOSD patients. Failure to achieve remission with initial treatment as well as a delayed diagnosis implicated a chronic disease course in AOSD.

Assessment of the New 2012 EULAR/ACR Clinical Classification Criteria for Polymyalgia Rheumatica: A Prospective Multicenter Study

Objective.

To assess the performance of the new 2012 provisional European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) polymyalgia rheumatica (PMR) clinical classification criteria in discriminating PMR from other mimicking conditions compared with the previous 5 diagnostic criteria in a multicenter prospective study.

Methods.

Patients older than 50 years, presenting with new-onset bilateral shoulder pain with elevated acute-phase reactants (APR), were assessed for the fulfillment of the new and old classification/diagnostic criteria sets for PMR. At the end of the 1-year followup, 133 patients were diagnosed with PMR (expert opinion) and 142 with non-PMR conditions [69 rheumatoid arthritis (RA)]. Discriminating capacity, sensitivity, and specificity of the criteria sets were estimated.

Results.

Discriminating capacity of the new clinical criteria for PMR from non-PMR conditions and RA as estimated by area under the curve (AUC) were good with AUC of 0.736 and 0.781, respectively. The new criteria had a sensitivity of 89.5% and a specificity of 57.7% when tested against all non-PMR cases. When tested against all RA, seropositive RA, seronegative RA, and non-RA control patients, specificity changed to 66.7%, 100%, 20.7%, and 49.3%, respectively. Except for the Bird criteria, the 4 previous criteria had lower sensitivity and higher specificity (ranging from 83%–93%) compared with the new clinical criteria in discriminating PMR from all other controls.

Conclusion.

The new 2012 EULAR/ACR clinical classification criteria for PMR is highly sensitive; however, its ability to discriminate PMR from other inflammatory/noninflammatory shoulder conditions, especially from seronegative RA, is not adequate. Imaging and other modifications such as cutoff values for APR might increase the specificity of the criteria.

Characteristics Predicting Tuberculosis Risk under Tumor Necrosis Factor-α Inhibitors: Report from a Large Multicenter Cohort with High Background Prevalence

Objective.

Screening strategies for latent tuberculosis (TB) before starting tumor necrosis factor (TNF)-α inhibitors have decreased the prevalence of TB among patients who are treated with these agents. However, despite vigilant screening, TB continues to be an important problem, especially in parts of the world with a high background TB prevalence. The aim of this study was to determine the factors related to TB among a large multicenter cohort of patients who were treated with anti-TNF.

Methods.

Fifteen rheumatology centers participated in this study. Among the 10,434 patients who were treated with anti-TNF between September 2002 and September 2012, 73 (0.69%) had developed TB. We described the demographic features and disease characteristics of these 73 patients and compared them to 7695 patients who were treated with anti-TNF, did not develop TB, and had complete data available.

Results.

Among the 73 patients diagnosed with TB (39 men, 34 women, mean age 43.6 ± 13 yrs), the most frequent diagnoses were ankylosing spondylitis (n = 38) and rheumatoid arthritis (n = 25). More than half of the patients had extrapulmonary TB (39/73, 53%). Six patients died (8.2%). In the logistic regression model, types of anti-TNF drugs [infliximab (IFX), OR 3.4, 95% CI 1.88–6.10, p = 0.001] and insufficient and irregular isoniazid use (< 9 mos; OR 3.15, 95% CI 1.43–6.9, p = 0.004) were independent predictors of TB development.

Conclusion.

Our results suggest that TB is an important complication of anti-TNF therapies in Turkey. TB chemoprophylaxis less than 9 months and the use of IFX therapy were independent risk factors for TB development.

Incidence of Cyclophosphamide-induced Urotoxicity and Protective Effect of Mesna in Rheumatic Diseases

Objective.

To assess bladder toxicity of cyclophosphamide (CYC) and uroprotective effect of mesna in rheumatic diseases.

Methods.

Data of 1018 patients (725 women/293 men) treated with CYC were evaluated in this retrospective study. All of the following information was obtained: the cumulative CYC dose, route of CYC administration, duration of therapy, concomitant mesna usage, and hemorrhagic cystitis. Cox proportional hazard model was used for statistics.

Results.

We identified 17 patients (1.67%) with hemorrhagic cystitis and 2 patients (0.19%) with bladder cancer in 4224 patient-years. The median time for diagnosis to hemorrhagic cystitis was 10 months (4–48) and bladder cancer was 8 years (6–10.9). There were 583 patients (57.2%) who received mesna with intravenous CYC therapy. We observed similar incidence rate for hemorrhagic cystitis in both patient groups concomitantly treated with or without mesna [9/583 (1.5%) vs 8/425 (1.8%) respectively, p = 0.08]. Cumulative CYC dose (HR for 10-g increments 1.24, p < 0.001) was associated with hemorrhagic cystitis.

Conclusion.

Cumulative dose was the only risk factor for hemorrhagic cystitis in patients treated with CYC. No proof was obtained for the uroprotective effect of mesna in our cohort.