Immunomodulatory therapies for SARS-CoV-2 infection: a systematic literature review to inform EULAR points to consider

OBJECTIVE

To summarise the available information on efficacy and safety of immunomodulatory agents in SARS-CoV-2 infection.

METHODS

As part of a European League Against Rheumatism (EULAR) taskforce, a systematic literature search was conducted from January 2019 to 11 December 2020. Two reviewers independently identified eligible studies according to the Population, Intervention, Comparator and Outcome framework and extracted data on efficacy and safety of immunomodulatory agents used therapeutically in SARS-CoV-2 infection at any stage. The risk of bias was assessed with validated tools.

RESULTS

Of the 60 372 records, 401 articles were eligible for inclusion. Studies were at variable risk of bias. Randomised controlled trials (RCTs) were available for the following drugs: hydroxychloroquine (n=12), glucocorticoids (n=6), tocilizumab (n=4), convalescent plasma (n=4), interferon beta (n=2), intravenous immunoglobulins (IVIg) (n=2) and n=1 each for anakinra, baricitinib, colchicine, leflunomide, ruxolitinib, interferon kappa and vilobelimab. Glucocorticoids were able to reduce mortality in specific subsets of patients, while conflicting data were available about tocilizumab. Hydroxychloroquine was not beneficial at any disease stage, one RCT with anakinra was negative, one RCT with baricitinib+remdesivir was positive, and individual trials on some other compounds provided interesting, although preliminary, results.

CONCLUSION

Although there is emerging evidence about immunomodulatory therapies for the management of COVID-19, conclusive data are scarce with some conflicting data. Since glucocorticoids seem to improve survival in some subsets of patients, RCTs comparing glucocorticoids alone versus glucocorticoids plus anticytokine/immunomodulatory treatment are warranted. This systematic literature review informed the initiative to formulate EULAR 'points to consider' on COVID-19 pathophysiology and immunomodulatory treatment from the rheumatology perspective.

OP0077 THE EMERGING EULAR NETWORK (EMEUNET): AN INTERNATIONAL SURVEY REFLECTING ON A TEN-YEAR JOURNEY

Background:

The Emerging EULAR NETwork (EMEUNET), founded in 2009, aims to promote education, foster research collaborations and facilitate the integration of young researchers and rheumatologists within EULAR.

Objectives:

After 10 years, we aimed to interview our members to assess how EMEUNET is fulfilling its goals, understand if there are unmet needs and explore new ideas.

Methods:

In July 2019 a survey was circulated for 3 months among EMEUNET members via its social media channels. The survey contained 18 closed and 2 open items, in addition to general questions on age, job and country of origin and work.

Results:

Out of 124 total respondents, most completed all items (120/124) and only a minority had some missing items (4/124). A little over half of the respondents were female (n=69, 54.8%) and median age was 33y (range 25y-42y). Most respondents were born (n=109, 88.6%) and/or worked in Europe (n=114, 92.7%) (fig. 1), although there was also a representation from extra-European countries, which is in line with the general EMEUNET membership (https://emeunet.eular.org/map.cfm).

Figure 1.

Country of origin and where respondents work at the time of completing the EMEUNET VISE questionnaire.

11 (9.1%) had been EMEUNET members for less than 2 years, 81 (66.9%) for 2-5years and 29 (24.0%) for more than 5 years.

Figure 2 shows a clear link between the respondents’ perception of EMEUNET aim(s) and the actual aims of EMEUNET set out in our mission statement (https://emeunet.eular.org/mission_statement.cfm).

Figure 2.

The links between what participants would like to see as EMEUNET aims and the aims of EMEUNET as they are now

Most of the respondents got to know about EMEUNET through a friend/colleague in Rheumatology (n=67, 54.0%), at EULAR/ACR annual conferences (n=32, 25.8%), via social media (n=9, 7.3%), other international meeting (n=6, 4.8%), national Rheumatology meeting (n=6, 4.8%) or via the EMEUNETs country liaisons (n=4, 3.2%).

29 respondents (24%) were part of the EMEUNET working group (WG), 43% (n=53) applied before to be part of the WG, 24% (n=29) never applied and 15% (n=19) did not know what the WG was. Most of the respondents who never applied to the WG thought it to be too time consuming. Only 21 (16.9%) felt there was a subgroup in the WG missing and most of those (n=8, 38.1%) found this should fully focus on research collaborations, which is actually part of the general aims of EMEUNET and a focus of all Working Groups.

Only a relatively small portion of EMEUNET of respondents (<5%) stated to have approached EMEUNET with their ideas. Although 90.2% (n=110) felt that the opportunity to submit new ideas is a good initiative, only 52.5% (n=..) knew that such possibilities exists. This suggests that EMEUNET could do more to make members aware of this possibility. Additionally, while the main reasons for not contacting EMEUNET with an idea were ‘not having one’ (41.9%) or having ‘no time’ (34.9%), 20.9% feels their ideas would not be received well, which is another aspect offering room for improvement.

Twice a year, EMEUNET organises networking events (NE) for their members to discuss their work in an informal setting. We found that 56/120 (46.7%) of the respondents prefer a low-budget (<€20) event, including an activity and the possibility to network, accompanied by drinks and bites. This is much in line with EMEUNETs past NE. In addition, past NEs were often mentioned as an example of ideal events.

Conclusion:

Awareness on EMEUNET often comes from colleagues and international conferences in rheumatology, which coincides with one of the focuses of EMEUNET to increase visibility in the last 10 years. Expectations about NE are in line with the previously organised NE.

Areas for improvement are dissemination of information on the EMEUNET WG, the possibility to submit ideas -which is open to all members- and the increased focus on research collaboration, an aspect on which we are actively working as EMEUNET is fully engaged with the newly launched EULAR Virtual Research Centre.

Disclosure of Interests:

None declared

EULAR portfolio for Rheumatology training: a EULAR School of Rheumatology initiative

OBJECTIVE

About half of the rheumatology trainees do not use a portfolio. This project was established to reach consensus about the content of a EULAR portfolio for Rheumatology training and subsequently develop portfolio assessment forms.

METHODS

After establishing a portfolio working group (WG), including nine rheumatologists and one educationalist, a systematic literature review (SLR) on the content and structure of portfolios for postgraduate learning was conducted (November 2018). This was followed by a survey among WG members and members of the EMerging EUlar NETwork, inquiring about the content and structure of existing national portfolios. The portfolio WG selected the key components of the portfolio, taking previous experience and feasibility into account. Assessment forms (eg, case-based discussion) were developed and pilot-tested.

RESULTS

13/2034 articles were included in the SLR (12 high/1 moderate risk of bias). Information on procedural skills, personal reflections, learning goals and multisource feedback was most often included a portfolio. Twenty-five respondents completed the survey (response≈50%). Feedback from assessors, reflective writing and formulation of learning goals were considered important dimensions to be covered in a portfolio. Six key components of the portfolio were established: curriculum vitae, personal development plan, clinical work, professional behaviours, education and research activities. Suggested minimal content for each component was formulated. Four assessment forms were successfully pilot-tested by 11 rheumatologists and their trainees.

CONCLUSION

A EULAR portfolio for Rheumatology training and assessment forms were developed. Portfolio implementation, particularly in countries without an existing portfolio, may promote a higher standard of rheumatology training across Europe.

POS0755 PREVALENCE AND RELEVANCE OF ANTIBODIES AGAINST CITRULLINATED ALPHA ENOLASE (ANTI-CEP1) IN CONNECTIVE TISSUE DISEASES

Background:

Anti-citrullinated alpha enolase antibodies have been investigated in rheumatoid arthritis and associated with bone erosion and interstitial lung disease but little is known about their prevalence and role in connective tissue diseases (CTDs).

Objectives:

The aim of this study was to investigate the prevalence and relevance of anti-CEP1 antibodies in CTDs.

Methods:

Serum samples from five independent patient cohorts were assessed: 1) established (est) primary Sjogren’s syndrome (pSS) N=78, 2) est-systemic lupus erythematosus (SLE) N=52, 3) est-systemic sclerosis (SSc) N=71, 4) pSS at disease onset N=30, 5) SLE at disease onset N=46 (cohorts 4 and 5 had at least 3 years of follow-up). Samples from ninety sex and age matched healthy donors (HD) and 200 patients with est-RA (disease controls) were also tested. Anti-CEP1 IgG antibodies were measured with a commercially available ELISA kit (Euroimmun, Luebeck, Germany).

Results:

Anti-CEP1 titer was significantly higher in est-pSS, est-SLE and est-SSc compared to HD, significantly lower in est-pSS and est-SSc compared to est-RA and comparable in est-SLE versus est-RA. We divided patients in every CTD group based on whether their anti-CEP1 titer was below or above the 25th, 50th and 75th percentile. In est-SLE anti-CEP1 values over the 25th percentile were associated with articular involvement (odds ratio, OR (95% confidence interval, CI)=11.5; 1.9-70.6, p=0.008). In est-pSS, no relationship between anti-CEP1>25th percentile and articular involvement was found but rather an association with rheumatoid factor positivity (OR (95% CI)=4.8, 1.6-14.1, p=0.004) and salivary gland swelling (OR (95% CI)=6.2, 1.3-29.1, p=0.021). In est-SSc no difference could be detected across the 3 groups. Anti-CEP-1 titers in pSS and SLE at onset did not differ from each other, were comparable also to those of HD and significantly lower than those of est-pSS, est-SLE and est-RA patients (all p<0.0001).). Of interest, we could retrieve a serum sample collected at the time of diagnosis for 5 patients from the cohort of established pSS and we observed that anti-CEP1 titers were significantly lower at pSS onset than during follow up (at least 12 months after the diagnosis, p=0.0024). No difference was observed in the clinical presentation at disease onset according to different anti-CEP1 titer and they did not predict the development of new clinical manifestations during follow-up.

Conclusion:

Anti-CEP-1 antibodies can be detected in CTDs at different title during the disease course and may increase overtime, at least in pSS. Although anti-CEP1 antibodies are associated with specific clinical manifestation in est-CTDs, such as articular involvement in est-SLE, they seem to lack a predictive value for future manifestations when measured at disease onset.

References:

[1]Alunno A, Bistoni O, Pratesi F et al Rheumatology (Oxford) 2018.

[2]Manca ML, Alunno A, D’Amato C et al. Joint Bone Spine 2018.

Disclosure of Interests:

None declared

POS0052 PATHOPHYSIOLOGY OF ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 INFECTION: A SYSTEMATIC LITERATURE REVIEW TO INFORM EULAR POINTS TO CONSIDER

Background:

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a global health problem. Beside the specific pathogenic effect of SARS-CoV-2, incompletely understood deleterious and aberrant host immune responses play critical roles in severe disease. Rheumatologists have the best experience of studying and treating these complicated hyperinflammatory processes.

Objectives:

To summarize the available information on pathophysiology of COVID-19.

Methods:

As part of a EULAR taskforce, two systematic literature reviews were performed one on pathophysiology and one on immunomodulatory therapies. Two reviewers independently identified eligible studies according to the following PICO framework: P (population): patients with SARS-CoV-2 infection; I (intervention): any intervention/no intervention; C (comparator): any comparator; O (outcome) any clinical or serological outcome including but not limited to immune cell phenotype and function and serum cytokine concentration. The results pertaining to pathophysiology of COVID-19 are presented here.

Results:

Of the 55496 records yielded, 85 articles were eligible for inclusion. Included studies were at variable risk of bias and exploring various aspects of disease pathogenesis from immune to non-immune cells (Table 1). Pro-inflammatory cytokines’ expression including IL-6, was increased, especially in severe COVID-19, although not as high as other states with severe systemic inflammation. Innate and adaptative immune cell compartments were differentially affected by SARS-CoV-2 infection: neutrophils displayed an immature differentiation state and also increased neutrophil extracellular traps (NETs) formation. Dendritic cell number was reduced and classical monocytes was increased although displaying a reduced expression of HLA-DR. The lymphoid compartment was also affected: lymphopenia was present with a reduced number of CD4+ and CD8+ T lymphocytes and more frequent PD1+CD8+ T cells corresponding to an exhausted phenotype. Antibody response to SARS-CoV-2 infection showed a high variability across individuals and disease spectrum. Multiparametric algorithms showed variable diagnostic performances in predicting survival, hospitalization, disease progression or severity, and mortality. Differences in SARS-CoV-2 manifestations in adults and children were highlighted.

Conclusion:

Overall, SARS-CoV-2 infection affects both innate and adaptative immune responses in a variable way, according to both disease severity and individual parameters. This SLR informs the EULAR points to consider on pathophysiology and use of immunomodulatory therapies in COVID-19.

Table 1.

Studies on SARS-CoV-2 infection pathogenesis

Research questionNCytokines profile7Immune profile18Algorithm17Children3Comorbidities1Endothelial dysfunction and platelets8Gut and microbiota3Genetics and variants8Histology7Antibodies profiles8Viral load and immune response4Interferon3Immunosenecsnce3Total90*

*Some manuscripts were including in several research questions. Total number of studies included n=85.

Disclosure of Interests:

Aurelie Najm Speakers bureau: BMS, Consultant of: BMS, Alessia Alunno: None declared, Xavier Mariette Speakers bureau: BMS, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Novartis, Pfizer, Servier and UCB, Consultant of: BMS, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Novartis, Pfizer, Servier and UCB, Benjamin Terrier Speakers bureau: Roche, Chugai, Vifor Pharma, GSK, AstraZeneca, Terumo BCT, LFB and Grifols, Consultant of: Roche, Chugai, Vifor Pharma, GSK, AstraZeneca, Terumo BCT, LFB and Grifols, Gabriele De Marco: None declared, Laura Mason: None declared, Jenny Emmel: None declared, Dennis McGonagle Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Pedro M Machado Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB.

EULAR points to consider on pathophysiology and use of immunomodulatory therapies in COVID-19

OBJECTIVES

Severe systemic inflammation associated with some stages of COVID-19 and in fatal cases led therapeutic agents developed or used frequently in Rheumatology being at the vanguard of experimental therapeutics strategies. The aim of this project was to elaborate EULAR Points to consider (PtCs) on COVID-19 pathophysiology and immunomodulatory therapies.

METHODS

PtCs were developed in accordance with EULAR standard operating procedures for endorsed recommendations, led by an international multidisciplinary Task Force, including rheumatologists, translational immunologists, haematologists, paediatricians, patients and health professionals, based on a systemic literature review up to 15 December 2020. Overarching principles (OPs) and PtCs were formulated and consolidated by formal voting.

RESULTS

Two OPs and fourteen PtCs were developed. OPs highlight the heterogeneous clinical spectrum of SARS-CoV-2 infection and the need of a multifaceted approach to target the different pathophysiological mechanisms. PtCs 1-6 encompass the pathophysiology of SARS-CoV-2 including immune response, endothelial dysfunction and biomarkers. PtCs 7-14 focus on the management of SARS-CoV-2 infection with immunomodulators. There was evidence supporting the use of glucocorticoids, especially dexamethasone, in COVID-19 cases requiring oxygen therapy. No other immunomodulator demonstrated efficacy on mortality to date, with however inconsistent results for tocilizumab. Immunomodulatory therapy was not associated with higher infection rates.

CONCLUSIONS

Multifactorial pathophysiological mechanisms, including immune abnormalities, play a key role in COVID-19. The efficacy of glucocorticoids in cases requiring oxygen therapy suggests that immunomodulatory treatment might be effective in COVID-19 subsets. Involvement of rheumatologists, as systemic inflammatory diseases experts, should continue in ongoing clinical trials delineating optimal immunomodulatory therapy utilisation in COVID-19.

Short-Term Outcomes and Predictors of Effectiveness of Tocilizumab in Systemic Juvenile Idiopathic Arthritis: A Prospective Cohort Study

Background: Systemic Juvenile Idiopathic Arthritis (sJIA) is a unique category of juvenile arthritis in which interleukin 6 plays a major pathogenic role. This study aimed to describe the therapeutic short-term outcomes among patients with sJIA starting tocilizumab (TCZ) therapy and to identify possible predictors of treatment response. Methods: We conducted a prospective observational study including 65 patients with sJIA meeting ILAR classification criteria with active disease despite conventional therapy that were treated by TCZ between August 2019 and October 2020 as the first-line biological therapy. Clinical and serological parameters were recorded at baseline and after 1 year of TCZ therapy. Results: After 1 year, 25% of the patients achieved minimal disease activity and 35% achieved clinically inactive disease. A significant reduction of the 10-joint juvenile arthritis disease activity score and acute phase reactants was also observed. Patients with younger age (≤7 years), shorter disease duration (≤3 years), lower disease activity, and higher serum ferritin and systemic manifestations showed more favorable results. Conclusion: Patients with sJIA showed favorable disease outcomes with TCZ treatment for 1 year, especially if the drugs were administered earlier in the disease course and in younger patients with a more pronounced inflammatory status. Our results may help to define the profile of patients with sJIA who are more likely to benefit from IL-6 blockade.

Efficacy of intra-articular corticosteroid injections in knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Knee osteoarthritis (OA) is a frequent degenerative disease representing an important health and economic burden. Symptomatic medical treatments available include intra-articular (IA) injections of corticosteroids (GC) but their efficacy and safety profile are debated.

METHODS

We performed a systematic literature review (SLR) and a meta-analysis (MA) of randomized controlled trials (RCTs) assessing the effect of IA GC injections for knee OA. The effect of the interventions on pain and function was extracted from the single studies and pooled. Standardized mean differences (SMD) are reported.

RESULTS

Of 520 studies screened, 23 were included in the SLR and 15 subsequently included in the MA. IA GC showed a trend towards a superior effect compared to control on both pain (SMD -0.61 (95% CI: -1.25, 0.03)) and function (SMD -1.02 (95% CI: -2.14, 0.10)) in short term follow-up (≤6 weeks), while long term follow-up (≥24 weeks) analysis showed a trend towards superiority of controls (IA HA, IA NSAID, physiotherapy) for pain (SMD 0.68 (95% CI: -0.11, 1.47)) and function (SMD 0.88 (95% CI: -0.36, 2.12). There were no differences between interventions in medium term (>6 weeks &<24 weeks).

CONCLUSION

In this work, IA GC injections reduced pain and improved function early after administration (≤6 weeks) compared to placebo; while this result was no longer statistically significant with other comparators (IA hyaluronic acid or physiotherapy). Other interventions seem to be more efficient in the long term (≥24 weeks) but this effect was largely driven by single studies with large effect sizes.

Strategies for the assessment of competences during rheumatology training across Europe: results of a qualitative study

OBJECTIVES

To gain insight into current methods and practices for the assessment of competences during rheumatology training, and to explore the underlying priorities and rationales for competence assessment.

METHODS

We used a qualitative approach through online focus groups (FGs) of rheumatology trainers and trainees, separately. The study included five countries-Denmark, the Netherlands, Slovenia, Spain and the United Kingdom. A summary of current practices of assessment of competences was developed, modified and validated by the FGs based on an independent response to a questionnaire. A prioritising method (9 Diamond technique) was then used to identify and justify key assessment priorities.

RESULTS

Overall, 26 participants (12 trainers, 14 trainees) participated in nine online FGs (2 per country, Slovenia 1 joint), totalling 12 hours of online discussion. Strong nationally (the Netherlands, UK) or institutionally (Spain, Slovenia, Denmark) standardised approaches were described. Most groups identified providing frequent formative feedback to trainees for developmental purposes as the highest priority. Most discussions identified a need for improvement, particularly in developing streamlined approaches to portfolios that remain close to clinical practice, protecting time for quality observation and feedback, and adopting systematic approaches to incorporating teamwork and professionalism into assessment systems.

CONCLUSION

This paper presents a clearer picture of the current practice on the assessment of competences in rheumatology in five European countries and the underlying rationale of trainers' and trainees' priorities. This work will inform EULAR Points-to-Consider for the assessment of competences in rheumatology training across Europe.

Duplex Ultrasound as a reliable alternative to CT angiography for treatment planning of Peripheral Artery Disease

BACKGROUND

The aim of this work is to compare the diagnostic accuracy of Duplex ultrasound (DUS) and CT angiography (CTA) in the study of arterial vessels, in patients with chronic peripheral arterial disease (PAD) of the lower limbs to undergo endovascular revascularization with the use of intraprocedural digital angiography (DSA).

METHODS

94 patients with obstructive pathology of the arterial axes of the lower limbs were enrolled in the study. In all patients, endovascular revascularization treatment was considered the most suitable therapeutic choice. For this reason, ultrasound and CTA was performed preoperatively in all and based on the data obtained it was decided to classify the arterial tree into five segments: iliac, common femoral, superficial femoral, popliteal and infra-geniculate. According to the degree of stenosis or occlusion, the arteries were scored in no stenotic, stenotic and occluded. The comparison of the data provided by the DUS and the CTA was carried out with reference to the parameters obtained by the DSA.

RESULTS

The results of our experience have shown that in the iliac arterial district DUS proved to be less accurate than CT angiography when compared to DSA (Cohen's Kappa agreement of 0.91 and 1.0, respectively). Good diagnostic concordance were found in the femoro-popliteal district (Cohen's Kappa agreement 33 between 0.96 and 0.93). On the contrary, when the data of the infra-geniculate area were compared, CT angiography showed a net deficiency compared to DSA and DUS (Cohen's k: 0.75).

CONCLUSIONS

Due to its accuracy, high-quality DUS performed by well-trained operators may therefore represent a good alternative to CTA in patients undergoing endovascular revascularization, in order to reduce the use of contrast-enhanced radiological imaging especially when a condition of intolerance to the contrast medium and/or renal insufficiency coexists.

Influence of COVID-19 pandemic on decisions for the management of people with inflammatory rheumatic and musculoskeletal diseases: a survey among EULAR countries

OBJECTIVES

To investigate how the first wave of COVID-19 pandemic influenced decisions of rheumatologists and health professionals in rheumatology regarding the management of patients with inflammatory rheumatic and musculoskeletal diseases (RMDs).

METHODS

An English-language questionnaire was developed by a EULAR working group and distributed via national rheumatology societies of EULAR countries, EMEUNET and individual working group members. Responses were collected using an online survey tool. Descriptive statistics were calculated.

RESULTS

We analysed 1286 responses from 35/45 EULAR countries. Due to containment measures, 82% of respondents indicated cancellation/postponement of face-to-face visits of new patients (84% of them offering remote consultation) and 91% of follow-up visits (96% with remote consultation). The majority of respondents (58%) perceived that the interval between symptom onset and first rheumatological consultations was longer during containment restrictions than before. Treatment decisions were frequently postponed (34%), and the majority (74%) of respondents stated that it was less likely to start a biological disease modifying anti-rheumatic drug (DMARD)/targeted synthetic DMARD during the pandemic, mainly because of patients' fear, limited availability of screening procedures and decreased availability of rheumatological services. Use of (hydroxy)chloroquine (HCQ) and tocilizumab (TCZ) for the COVID-19 indication was reported by 47% and 42% of respondents, respectively, leading to a shortage of these drugs for RMDs indications according to 49% and 14% of respondents, respectively.

CONCLUSION

Measures related to containment of COVID-19 pandemic led to a perceived delay between symptom onset and a first rheumatological visit, postponement of treatment decisions, and shortage of HCQ and TCZ, thereby negatively impacting early treatment and treat-to-target strategies.

The role of self-expanding vascular stent in superior vena cava syndrome for advanced tumours

INTRODUCTION

Superior vena cava (SVC) syndrome (SVCS) is a life-threatening occurrence that necessitates prompt treatment. At present, endovascular stenting is proposed as a first-line treatment to relieve symptoms. We assessed the effectiveness, safety and outcome of SVC stent positioning in patients affected with advanced cancer.

METHODS

Forty-two patients undergoing stent positioning in the SVC for neoplasms from January 2002 to December 2018 form the basis of this retrospective study. Demographic data, risk factors, associated diseases, symptoms at presentation according to the score proposed by Kishi and the type of SVCS according to Sanford and Doty were collected. Minor and major complications were recorded. Suspected stent occlusion was confirmed by means of recurrence of symptoms followed by a confirmatory computed tomography (CT).

RESULTS

Thirty-four (81%) patients had a nonresectable lung tumour invading or compressing the SVC. Five (12%) patients had a non-Hodgkin's lymphoma, and three (7%) had metastatic lymphadenopathies. Nitinol stents (Memotherm^®) were employed in 19 (45%) patients, and steel stents (Wallstent™) in the remaining 23 (55%) patients. Thirty-five (85%) patients died during follow up for disease progression and the overall survival rate at 24 months was 11% (standard error (SE)=0.058). Thirteen patients (32%) had a recurrence of SVCS because of stent thrombosis in three (23%) and extrinsic compression from uncontrolled cancer progression in ten (77%). The overall symptom-free interval at 24 months was 57% (SE=0.095).

CONCLUSIONS

We recommend the use of the endovascular procedure as a first-line treatment in locally advanced or metastatic tumour in the presence of SVCS.

Ferritin is associated with the severity of lung involvement but not with worse prognosis in patients with COVID-19: data from two Italian COVID-19 units

The coronavirus 2019 disease (COVID-19) is characterised by a heterogeneous clinical presentation, a complex pathophysiology and a wide range of imaging findings, depending on disease severity and time course. We conducted a retrospective evaluation of hospitalized patients with proven SARS-CoV-2 infection, clinical signs of COVID-19 and computed tomography (CT) scan-proven pulmonary involvement, in order to identify relationships between clinical, serological, imaging data and disease outcomes in patients with COVID-19. Clinical and serological records of patients admitted to two COVID-19 Units of the Abruzzo region in Italy with proven SARS-CoV-2 pulmonary involvement investigated with CT scan, assessed at the time of admission to the hospital, were retrospectively evaluated. Sixty-one patients (22 females and 39 males) of median age 65 years were enrolled. Fifty-six patients were discharged while death occurred in 5 patients. None of the lung abnormalities detected by CT was different between discharged and deceased patients. No differences were observed in the features and extent of pulmonary involvement according to age and gender. Logistic regression analysis with age and gender as covariates demonstrated that ferritin levels over the 25th percentile were associated with the involvement of all 5 pulmonary lobes (OR = 14.5, 95% CI 2.3–90.9, p = 0.004), the presence of septal thickening (OR = 8.2, 95% CI 1.6–40.9, p = 0.011) and the presence of mediastinal lymph node enlargement (OR = 12.0, 95% CI 1.1–127.5, p = 0.039) independently of age and gender. We demonstrated that ferritin levels over the 25th percentile are associated with a more severe pulmonary involvement, independently of age and gender and not associated with disease outcomes. The identification of reliable biomarkers in patients with COVID-19 may help guiding clinical decision, tailoring therapeutic approaches and ultimately improving the care and prognosis of patients with this disease.

Pathophysiology of acute respiratory syndrome coronavirus 2 infection: a systematic literature review to inform EULAR points to consider

BACKGROUND

The SARS-CoV-2 pandemic is a global health problem. Beside the specific pathogenic effect of SARS-CoV-2, incompletely understood deleterious and aberrant host immune responses play critical roles in severe disease. Our objective was to summarise the available information on the pathophysiology of COVID-19.

METHODS

Two reviewers independently identified eligible studies according to the following PICO framework: P (population): patients with SARS-CoV-2 infection; I (intervention): any intervention/no intervention; C (comparator): any comparator; O (outcome) any clinical or serological outcome including but not limited to immune cell phenotype and function and serum cytokine concentration.

RESULTS

Of the 55 496 records yielded, 84 articles were eligible for inclusion according to question-specific research criteria. Proinflammatory cytokine expression, including interleukin-6 (IL-6), was increased, especially in severe COVID-19, although not as high as other states with severe systemic inflammation. The myeloid and lymphoid compartments were differentially affected by SARS-CoV-2 infection depending on disease phenotype. Failure to maintain high interferon (IFN) levels was characteristic of severe forms of COVID-19 and could be related to loss-of-function mutations in the IFN pathway and/or the presence of anti-IFN antibodies. Antibody response to SARS-CoV-2 infection showed a high variability across individuals and disease spectrum. Multiparametric algorithms showed variable diagnostic performances in predicting survival, hospitalisation, disease progression or severity, and mortality.

CONCLUSIONS

SARS-CoV-2 infection affects both humoral and cellular immunity depending on both disease severity and individual parameters. This systematic literature review informed the EULAR 'points to consider' on COVID-19 pathophysiology and immunomodulatory therapies.

The Impact of SARS-CoV-2 Outbreak on Primary Sjögren's Syndrome: An Italian Experience

Objective: Since no data is available about the personal experience of people with primary Sjögren's syndrome (pSS) with regard to disease burden and management during the novel Severe Acute Respiratory Syndrome coronavirus (SARS-CoV)-2 outbreak, we aimed to explore these aspects with the ultimate goal to identify unmet needs and priorities. Methods: A telephone consultation was scheduled with patients with pSS and information regarding the disease status, ongoing treatment and symptoms/diagnosis of coronavirus disease 2019 (COVID-19) were collected. Clinical records were retrospectively evaluated to gather pre-COVID-19 information. Results: One hundred and two patients with pSS were contacted. Most rheumatology consultations and other pSS-related tests were canceled during the SARS-CoV-2 outbreak. Less than 30% of patients contacted the rheumatologist via telemedicine despite experiencing disease flares or therapy shortage. Disease activity and patient reported symptoms significantly worsened during the closure period. All patients practiced social distancing, most of those employed switched to smart working and different work settings impacted on the type of symptom worsening. Conclusion: This is the first study addressing the personal experience of pSS patients resulting from the impact of the SARS-CoV2 outbreak and it identifies unmet needs and priorities requiring to be addressed. Our findings may help designing individualized strategies.

Novel insights on lymphoma and lymphomagenesis in primary Sjögren's Syndrome

Primary Sjögren's Syndrome (pSS) is a systemic autoimmune disease characterized by a chronic inflammatory process mainly affecting the exocrine glands but also burdened by a wide range of extraglandular manifestations. Non-Hodgkin lymphoma (NHL) is the most severe pSS complication worsening disease prognosis. We summarized original articles published between April 2018 and May 2020 on this topic aiming to highlight novelties on lymphoma and lymphomagenesis. Results have been grouped by epidemiology, etiopathogenesis and predictors of lymphoma. NHL is the most severe complication of pSS and occurs in around 5-10% of patients. Over the last two years, several clinical, serological, and histopathological features have been proposed as predictive for lymphoma in pSS patients, allowing early diagnosis and consequently, better management and prognosis. Individual monitoring for disease activity and possible lymphoma development is a central clue in the evaluation of pSS patients.

Nellix endovascular aneurysm-sealing system: a single-center experience and review of current evidence

Aims: We report the 6-year results of our use of the Nellix^® endovascular aneurysm sealing system. Materials & methods: This is a retrospective review of patients we treated from 2013 to 2019. The outcomes described include technical success rate, mortality, all procedure-related complications, reinterventions, open surgical conversion and secondary sac rupture. Results & conclusions: A total of 68 patients were treated. Mortality was 2.9%. Secondary interventions were carried out for distal embolization (3), stent occlusion (1), pseudoaneurysm (1) and endoleak (5). Open surgical conversion was required in 6.4% of cases. Medium- and long-term complications of EVAS occurred more frequently than expected. Because the durability of endovascular aneurysm sealing is questionable, strict postoperative surveillance of Nellix is crucial to identify features of failure.

Duplex ultrasound versus CT angiography for the treatment planning of lower-limb arterial disease

PURPOSE

This study aimed to assess the diagnostic accuracy of duplex sonography (DUS) compared with that of computed tomography angiography (CTA) in detecting occlusion and stenosis in peripheral arterial disease (PAD) in candidate patients for endovascular revascularization with intraprocedural digital subtraction angiography (DSA).

METHODS

The study involved 94 patients suffering from PAD who were candidates for endovascular procedures requiring DSA. They were all submitted preoperatively to DUS and CTA. Based on image analysis, five segments of the arterial tree were assessed: iliac, common femoral, superficial femoral, popliteal, and infrageniculate. According to the stenosis or occlusion degree, the arteries were rated as nonstenotic, stenotic, and occluded.

RESULTS

The agreement between DUS and CTA findings using DSA as a reference modality was expressed as a Cohen's kappa (κ) statistic agreement. Our results show that DUS has been less accurate than CTA in evaluating iliac arterial diseases (Cohen's κ agreement of 0.91 and 1.0, respectively) when measured against DSA. We found good diagnostic concordance between DUS and DSA in detecting hemodynamic stenosis and occlusion of the femoro-popliteal axis (Cohen's κ agreement between 0.96 and 0.93). Below the knee, CTA showed even less concordance with DSA (Cohen's κ 0.75).

CONCLUSIONS

Because of its accuracy, high-quality DUS performed by well-trained operators may therefore represent a good alternative to CTA in patients undergoing endovascular revascularization to minimize the use of contrast-enhanced radiological imaging. Nevertheless, preoperative CTA imaging is required in cases of nondiagnostic DUS or when a more complete overview of the vascular tree is needed for complex invasive interventions.

Comparison of Rituximab Originator With CT-P10 Biosimilar in Patients With Primary Sjögren's Syndrome: A Retrospective Analysis in a Real-Life Setting

Introduction: Over the last two decades, rituximab (RTX) has been widely used, albeit off-label, in primary Sjögren's syndrome (pSS). Several studies reported that B lymphocyte depletion with RTX is effective to treat some aspects within the disease spectrum, by reducing disease activity and affecting the inflammation and lymphoid organization that occur in target tissues. Notwithstanding, randomized controlled trials failed to confirm such evidence. With the recent release of several RTX biosimilars on the market, their efficacy and safety compared to the originator must be ascertained across different indications. This study aimed at comparing efficacy and safety of RTX originator and CT-P10 RTX biosimilar in pSS patients in a real-life setting.

Methods: Clinical and laboratory records of pSS patients referring to a tertiary rheumatology clinic were retrospectively evaluated. Patients having received at least two courses of either RTX originator or CT-P10 with complete data at baseline and after 12, 24, 36, and 48 weeks of treatment were enrolled. Disease activity was assessed with the EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI) and its clinical version without the biological domain (clinESSDAI). Patient-reported symptoms were assessed with the EULAR Sjögren's Syndrome Patient-Reported Index (ESSPRI). Adverse events (AEs) occurring during the study period were also recorded.

Results: Nine patients who received RTX originator and eight patients who received CT-P10 were enrolled. Baseline clinical and serological features, including ESSDAI and ESSPRI, were similar in the two treatment groups. An efficient depletion of circulating CD19⁺ B lymphocytes was achieved in both treatment arms. Both RTX originator and CT-P10 significantly reduced ESSDAI and clinESSDAI by week 24, and no difference between the groups was observed at any timepoint. Conversely, changes of ESSPRI overtime did not differ between the two treatment arms and were not statistically significant compared to corresponding baseline values. With regard to safety, at 48 weeks of follow-up, only four mild AEs (two in the RTX originator and two in the CT-P10 group) were observed.

Conclusion: Our study provides the first evidence that, at 48 weeks of follow-up, RTX originator and CT-P10 display similar efficacy and safety profiles in pSS.

2019 EULAR points to consider for the assessment of competences in rheumatology specialty training

BACKGROUND AND AIM

Striving for harmonisation of specialty training and excellence of care in rheumatology, the European League Against Rheumatism (EULAR) established a task force to develop points to consider (PtCs) for the assessment of competences during rheumatology specialty training.

METHODS

A systematic literature review on the performance of methods for the assessment of competences in rheumatology specialty training was conducted. This was followed by focus groups in five selected countries to gather information on assessment practices and priorities. Combining the collected evidence with expert opinion, the PtCs were formulated by the multidisciplinary task force, including rheumatologists, medical educationalists, and people with rheumatic and musculoskeletal diseases. The level of agreement (LoA) for each PtC was anonymously voted online.

RESULTS

Four overarching principles and 10 PtCs were formulated. The overarching principles highlighted the importance of assessments being closely linked to the rheumatology training programme and protecting sufficient time and resources to ensure effective implementation. In the PtCs, two were related to overall assessment strategy (PtCs 1 and 5); three focused on formative assessment and portfolio (PtCs 2-4); three focused on the assessment of knowledge, skills or professionalism (PtCs 6-8); one focused on trainees at risk of failure (PtC 9); and one focused on training the trainers (PtC 10). The LoA (0-10) ranged from 8.75 to 9.9.

CONCLUSION

These EULAR PtCs provide European guidance on assessment methods throughout rheumatology training programmes. These can be used to benchmark current practices and to develop future strategies, thereby fostering continuous improvement in rheumatology learning and, ultimately, in patient care.