Speciality training in rheumatology: Promotion, repetition and dropout rates in the city of Buenos Aires

OBJECTIVES

To evaluate the trajectory of students enrolled in the specialty training in rheumatology.

METHODS

Retrospective analysis (2009-2016). Promotion, repetition, and dropout rates were determined. Analysis was performed to define variables associated with academic success.

RESULTS

Out of 119 students, the actual promotion rate was 66.4%, 11.8% failed an exam (at least) and completed the course after the stipulated time, and the dropout rate was 7.6%. Among residents, the promotion rate was 82.5% vs. 48.2% among the rest (p < 0.001), the lagging students' repetition rate was 3.2% vs. 21.4% among the rest (p 0.005), and the dropout rate was 3.2% vs. 12.5% among the rest (p = 0.06). A higher average score in medical school increased the chances of success in the postgraduate programme (OR 3.41 CI 95% 2.0-6.4; p < 0.001).

CONCLUSIONS

The residency was associated with higher rates of academic success in postgraduate studies. The average score in medical school can help identify students at risk of failure.

Primary Sjögren syndrome and development of another autoimmune rheumatic disease during the follow-up

Background

Primary Sjögren syndrome (pSS) is a chronic autoimmune disease with its main target being exocrine glands, and is the connective tissue disease more frequently associated with other autoimmune diseases. The aim of this study was to assess the frequency of another autoimmune rheumatic disease (ARD) developed in primary Sjögren syndrome (pSS) patients and to describe it’s clinical, serological and histologic characteristics.

Materials and methods

This is a retrospective cohort study. Data of patients with pSS diagnosis (American-European criteria 2002), included in the GESSAR database (Grupo de Estudio Síndrome de Sjögren, Sociedad Argentina de Reumatología) were analyzed. The development of a second ARD was registered during the follow up.

Results

681 patients were included, 94.8% female. The mean age was 54 (SD 14) years and mean age at diagnosis of 50 (SD 13) years. The mean follow-up was 4.7 (SD 4.9) years; 30 patients (4.41%, CI 95%: 3.1–5.7) developed a second ARD during the follow up, incidence rate was 9.1/1000 patients-year (IR 95%: 5.8–12.4/1000 patients-year), the most frequent being rheumatoid arthritis (RA). 96% out of these 30 patients had xerophthalmia, 86.2% xerostomia, 92% positive Schirmer test, 88.24% positive Rosa Bengala test, lisamine green or Ocular Staining Score, 81.2% positive unstimulated salivary flow, 82.1% Ro(+) and 33.33% La(+). Minor salivary gland biopsy had been performed in 14 of the 30 patients, 12 with positive results. There were no statistically significant differences respect baseline characteristics when comparing the patients who developed another ARD to the ones that did not.

Conclusions

Of all the patients analyzed, 4.4% presented another ARD during their follow-up. It is important to be aware of this, to make an early and proper diagnosis and treatment of our patients.

POS0508 PREDICTORS OF PERSISTENT DISEASE IN EARLY ARTHRITIS: 12 MONTHS RESULTS

Background

Early arthritis is an inflammatory disease with the potential to progress to persistent arthritis, such as established Rheumatoid Arthritis (RA) or other articular disease, to resolve spontaneously or remain undifferentiated for indefinite periods of time.

Objectives

To identify predictors of persistent RA after 12 months follow up in the Argentinean early arthritis clinic (CONAART).

Methods

We conducted an observational, prospective longitudinal study, including patients with early arthritis (at least 1 swollen joint with <2 years of evolution) who had at least one year of follow-up.

Sociodemographic and clinical data and characteristics of the disease were recorded at baseline, at 3, 6 and 12 months. After 1 year of follow-up, each patient was classified according to diagnosis: self-limited arthritis, persistent non-erosive arthritis, or persistent erosive arthritis.

The association between the different predictors of diagnosis at 12 months was evaluated using multiple logistic regression, adjusted by potential confounders. Rheumatoid Factor (RF) and Anti Citrullinated Peptide Antibodies (ACPA) were included in separate models in order to avoid multicollinearity. A value of p<0.05 was considered significant.

Results

We included 839 patients, 83% females, mean age of 57±14 years and mean disease duration of 8.2±6.2 months; 67.5% were rheumatoid factor positive and 59% ACPA positive. Disease characteristics at baseline were DAS28 5.1±1.4, swollen joints 6±5, erythrocyte sedimentation rate (ESR) 34±25 mm/h, C Reactive Protein (CRP) 4±6 and Health Assessment Questionnaire-Argentinean (HAQ-A) 1.2±0.8.

After 12 months follow up, 11% of the patients were diagnosed as self-limited disease, whereas 89% were diagnosed as persistent disease. For the persistent disease, 34% presented radiograph erosions and therefore were catalogued as persistent erosive disease.

The seropositivity for both, RF and ACPA, together with baseline DAS28, were the variables independently associated with the development of persistent disease at 12 months. [Model 1a: RF OR 2.33 (95% CI 1.44, 3.78) and DAS28 1.27 (1.06, 1.52); Model 2a: ACPA 2.61 (1.38, 4.93) and DAS28 1.59 (1.24, 2.04)]. (Table 1).

Table 1.

Predictors of Persistent Rheumatoid Arthritis at 12 months

OutcomesPersistent RAPersistent RAPersistent RAPersistent RAOR (95 IC)OR (95 IC)OR (95 IC)OR (95 IC)Model 1aModel 1bModel 2aModel 2bn708708507507Age (years)0.99 (0.98, 1.01)0.99 (0.98, 1.01)0.99 (0.97, 1.01)0.99 (0.97, 1.01)Female gender1.06 (0.57, 2.00)1.06 (0.56, 1.99)0.72 (0.30, 1.71)0.72 (0.30, 1.70)RF positive2.33 (1.44, 3.78)***2.45 (1.52, 3.98)***--ACPA positive--2.61 (1.38, 4.93)**2.63 (1.39, 4.98)**DAS28 at baseline1.27 (1.06, 1.52)**1.59 (1.24, 2.04)***Categorical DAS28  MDA (vs LDA)-1.81 (0.85, 3.86)^-2.86 (1.68, 6.99)*  HDA (vs LDA)-2.83 (1.30, 6.15)^-6.39 (2.42, 16.82)***

^ p<0.1, * p<0.05, ** p<0.01, *** p<0.001

RF, Rheumatoid Factor; ACPA, Anti Citrullinates Protein Antigen; DAS28, Disease activity Score-28; LDA, low disease activity; MDA, moderate disease activity; HDA, high disease activity.

In the patient prediction model, it can be observed that a patient with female gender, ACPA negative, and a low activity at baseline (DAS28 <3.1) presents a 62.3% of likelihood of developing persistent arthritis after 12 months, while a male patient, ACPA positive, with a high baseline activity level, the probability of having persistent disease rises to 97.5%. (Figure 1)

Figure 1.

Matrix prediction model. Probability of diagnosis of Persistent Rheumatoid Arthritis after 12 months of follow-up. Colors represents predictive probability of achieving the outcome as follow: grey: 0-69.9%; blue: 70.0-89.9%; purple: 90.0-100%.

DAS28, Disease Activity Score 28; LDA, low disease activity; MDA, Moderate Disease Activity; HDA, High Disease Activity.

Conclusion

Predictors of persistent arthritis after 12 months of follow up since AT diagnosis were RF and ACPA seropositivity and higher baseline disease activity level.

Disclosure of Interests

None declared.

POS0655 SURVIVAL AND SAFETY OF BIOLOGICAL AND TARGETED SYNTHETIC THERAPIES AS REGARDS TO AGE GROUPS. BIOBADASAR 3.0 REGISTRY

Background

Advances in rheumatology and new therapeutic options have certainly impacted patient survival, changing the age range, from youth to seniors. The differences between the age groups could influence the evolution of the disease and the adverse events (AEs) related to the treatments. There are few real-world data on the safety and efficacy of treatments in different age groups.

Objectives

To evaluate the frequency of AEs and the survival of treatments according to the age in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) or ankylosing spondylitis (AS).

Methods

Retrospective, observational, multicenter study of real-life data of patients included in the BIOBADASAR 3.0 registry; exposed and not exposed to original biological treatments (b-DMARDs), biosimilars, targeted synthetic drugs (ts-DMARDs). The unexposed group received treatment with conventional disease-modifying drugs (cDMARDs). A Kaplan-Meier and Log Rank Test analysis was performed to study AEs-free survival and treatment in different age groups (young people <25; young adults 25-34; mature adults 34-65; old adults >65). Factors related to treatment survival were evaluated using Cox regression models.

Results

5,297 patients were included, 80.3% female, mean age 43.7 years (SD 15.6) and median disease progression 14.3 [IQR 11.5]. RA 4658 (87.9%); APs 490 (9.25%) and EA 149 (2.8%). The main reason for treatment discontinuation was ineffectiveness, in 624 patients in the exposed group and in 53 (2.5%) patients in control group, followed by the presence of AEs in 352 (11.2%) and 83 (3.9%), respectively (p=0.001).

A mean Charlson Score of 0.268 (SD 0.6) in the exposed group and 0.306 (SD 0.7) in the control group (p=0.095). Median EAs-free survival in the exposed group was 12.5 years [IQR 16.6] while in controls was 28 years [IQR 11], p<0.0001. Median AEs-free survival was 12 years (IQR 11) in young people, 11.5 years [IQR: 4.9] in young adults, 10 years [IQR: 3.25] in mature adults and 7.6 years [IQR: 6] in old adults with a difference statistically significant (p>0.017). The exposed group presented a median treatment survival in years of 11.25 years [IQR: 10] in young people; 12.5 years [IQR: 4.7] in young adults, 7.5 years [IQR: 12.1] in mature adults and 4.5 years [IQR: 1.14] in old adults (p>0.0001). Considering only the first line of treatment, a median survival of 11.5 years [IQR: 10] was evidenced in the age group <25; 12 years [IQR: 2.6] between 25-34 years old, 10 years [IQR: 12] in the group between 34-65 years old and 5.5 years [IQR: 1.14] in the group > 65 years old (p>0.004). (Figure 1). Considering the second line of treatment, the differences between the groups were not statistically significant (p=0.57). In the multivariate regression model for patients with RA, the factors with the greatest impact on treatment survival were female sex (HR 1.3, 95% CI 1.2-1.4), old age (HR 1.01, 95% CI 1.008-1.01), treatment with steroids (HR 1.19, 95% CI1.1-1.2) and longer disease duration (HR 1.01, 95% CI1.01 – 1.02).

Conclusion

In the present study we were able to demonstrate a greater occurrence of AEs in old adults and mature adults compared to young people and young adults. Conversely, survival for b-DMARDs and ts-DMARDs were greater in youth and young adults. In patients with RA, female sex, corticosteroid therapy, old aged and longer disease duration were associated with treatment discontinuation.

References

[1]Souto A, et al. Rate of discontinuation and drug survival of biologic therapies in rheumatoid arthritis: a systematic review and meta-analysis of drug registries and health care databases. Rheumatology (Oxford). 2016;55(3):523–34.

[2]Ray D, et al. Immune senescence, epigenetics and autoimmunity. Clin Immunol. 2018 Nov;196:59-63. doi: 10.1016/j.clim.2018.04.002. Epub 2018 Apr 11.

[3]Vela P, et al. Influence of age on the occurrence of adverse events in rheumatic patients at the onset of biological treatment: data from the BIOBADASER III register. Arthritis Res Ther. 2020 Jun 15;22(1):143. doi: 10.1186/s13075-020-02231-x.

Disclosure of Interests

None declared

A novel mutation in GCK gene: Beware of SGA child with diabetic mother

MODY is a monogenic, autosomal dominant form of diabetes mellitus. MODY can be caused by mutations in several genes; glucokinase (GCK) accounts for 30-50% of the cases. The diagnosis can be suspected in early-onset diabetes with atypical features for type 1/type 2. Treatment is usually not recommended. A 5-year-old girl came to our attention for occasional episodes of hyperglycaemia. She was born at term, her birth weight was small for gestational age. At the beginning of her pregnancy, her mother was already on insulin therapy for impaired fasting glucose levels, detected before conception and confirmed in the first weeks of gestation. She was treated with insulin until the childbirth without further investigations. The patient was asymptomatic and in good clinical condition. Basal blood tests have shown a fasting plasma glucose of 125 mg/dl, an HbA1c of 6.5%. Antibodies against islet cells, anti-GAD and anti-ZNT8 antibodies were all negative. A 2-h oral glucose tolerance test was performed and underlined an impaired glucose tolerance. HLA haplotypes were screened, excluding susceptibility. GCK Sanger Sequencing identified a novel heterozygous variant. It is not described as a classical mutations. The analysis has been extended to the parents, finding out the same variant in her mother. To our knowledge this mutation has not been described previously; we believe that this variant is responsible for MODY2 due to FBG and Hb1Ac of all the affected members of family. We suggest high suspicion of an underlying GCK variant in SGA children with hyperglycaemia born to a diabetic mother.

Parotid gland swelling in primary Sjögren's syndrome: activity and other sialadenosis causes

OBJECTIVE

To assess the prevalence of parotid gland swelling (PGS), and its association with features of Sjögren's syndrome (SS) and other causes of sialadenosis in a Latin-American cohort of primary SS.

METHODS

We included 668 patients from Argentina, Brazil, Mexico, and Paraguay. We retrospectively registered demographics, disease duration, oral/ocular symptoms, serology and scored the basal ESSDAI. We defined PGS as a recurrent or persistent increase of volume of any parotid glands during adulthood (self-reported and/or physical examination). We registered the presence of diabetes mellitus, dyslipidaemia, body mass index, and alcohol consumption. We used logistic regression analysis reporting OR and 95% CI.

RESULTS

PGS was present in 242 patients (36.2%): 78 previous to SS diagnosis, 86 concomitantly, 73 during follow-up, and five unknown. At the multivariate analysis, PGS was associated with RF (OR 2.47, 95% CI 1.1-6.5, p= 0.0001), basal articular ESSDAI domain (OR 1.63, 95% CI 1.01-2.6, p= 0.04), and alcohol consumption (OR 2.42, 95% CI 1.41-4-15). Patients with PGS during the follow-up had a higher prevalence of alcohol consumption (45.3%) compared with the remaining PGS cases (26.8%; OR 2.41 95% CI 1.2-4.7), or patients without parotid gland swelling (15.6%; OR 3.8 95% CI 1.7-8.2) in all the adjusted models.

CONCLUSION

PGS generally precedes or presents concomitantly with SS diagnosis, and is related to RF and articular activity. Alcohol consumption is an additional factor in PGS, especially during follow-up. The meaning of this last finding as well as its prognostic implications remains to be elucidated and deserves further evaluation in prospective studies.

Lung involvement prevalence in patients with early rheumatoid arthritis without known pulmonary disease: a multicentric cross sectional study

BACKGROUND

Clinically evident interstitial lung disease (ILD) affects between 10 and 42% of the patients with rheumatoid arthritis (RA). Airway involvement seems to be even more common. Most of the available evidence comes from studies performed in established RA patients. The aim of our study was to know the prevalence of non-diagnosed lung disease (airway and interstitial involvement) in patients with early RA and look for associated factors.

METHODS

We designed an observational, multicenter, cross-sectional study, and included patients with RA of less than two years since diagnosis. We performed a structured questionnaire, HRCT and lung functional tests looking for lung disease, together with joint disease evaluation. We analyzed which variables were associated with the presence of lung disease on HRCT.

RESULTS

We included 83 patients, 83% females. The median (IQR) of time since RA diagnosis was 3 (1-6) months. In the HRCT, 57 patients had airway compromisea (72%), and 6 had interstitial abnormalities (7.5%). The most common altertion found in lung functional tests was a reduced DLCO (14%). The presence of at least one abnormality in the physical exam was associated with lung involvement on HRCT [13 (21.6%) vs 0 (0%); p = 0.026]. Also, patients with lung involvement presented significantly lower values of FVC% and DLCO%, and higher values of RV/TLC. No variable related to joint involvement was found associated with alterations in HRCT.

CONCLUSION

Our study shows that a large proportion of early RA patients has abnormal findings in HRCT. Further studies are required to confirm these findings.

Epidemiología, uso de recursos y costos de la artritis reumatoidea en Argentina

La presente revisión tiene como objetivo identificar información sobre parámetros epidemiológicos y estimar el costo de la artritis reumatoidea (AR) moderada a severa. Se llevó a cabo una búsqueda de la literatura en las principales bases de datos. Se recurrió a un consenso de expertos locales en reumatología para encontrar los parámetros más realistas, utilizando un método Delphi modificado. Se estimaron los costos médicos directos, utilizando información recopilada en la base de datos de costos unitarios del Instituto de Efectividad Clínica y Sanitaria de Argentina. Los costos indirectos se estimaron a través del enfoque del capital humano. Los costos se expresaron en dólares estadounidenses (USD) a noviembre de 2017. La prevalencia reportada de AR en Argentina fue 0,94% (IC95%: 0,86 a 1,02), con una tasa de incidencia anual de 19 cada 100 000 personas (IC95%: 17 a 20). El costo anual de las drogas modificadoras de la enfermedad fue de USD 33 936,10 por paciente. El costo atribuido a las infecciones serias fue de USD 2474,6. El costo del reemplazo bilateral de rodillas por paciente fue de USD 5276,8, y el del reemplazo total de cadera, de USD 9196,4. El costo por paciente por año de días de hospitalización y los costos indirectos de la AR se acrecentaron al aumentar el puntaje de discapacidad. La revisión reporta información útil acerca de parámetros epidemiológicos y de costos de la AR moderada a severa en la era de los agentes biológicos, con el fin de resultar de utilidad para la conducción de evaluaciones económicas de salud en Argentina.

FRI0056 LUNG COMPROMISE SCREENING IN PATIENTS WITH EARLY RA. A MULTICENTRIC CROSS SECTIONAL STUDY

Background:

Rheumatoid arthritis (RA) affects 0.4-1.3% of general population (1). It can affect lungs in different ways, with interstitial lung disease (ILD) as the most severe. Clinically evident ILD has been reported in 10-42% of patients, with a great impact in prognosis (2).

Objectives:

Toidentify the prevalence of lung involvement in early rheumatoid arthritis patients (ERA) without previous known lung disease and describe the association between high resolution computed tomography (HRCT), lung functional tests (LFT) and clinical findings.

Methods:

Cross sectional multicentric study. We included ERA patients (1 year or less since diagnose) consecutively. Patients with previous RA related lung disease or biologic/targeted synthetic Dmard treatment were excluded. HRCT, immunological tests (rheumatoid factor, anti-CCP, ANA), LFT and clinical evaluation were performed.

Results:

We included 74 patients, 63 (85,1%) woman, mean (SD) of 47 (17,7) years. Thirty-seven patients (50%) were current or former smokers. Abnormal findings in HRCT were found in 62 patients (88,6%): ILD in 6 (8,6%), airway involvement in 40 (70%) and emphysema in 7 (10%). Ten patients (13,5%) had abnormal auscultation (2 sibilances, 2 roncus, and 6 crackles). Six patients (8,1%) had digital clubbing. Regarding immunological tests, 54/61 (88,5%) patients were positive for Anti CCP, and 53/61 (86,9%) were positive for FR. We compared features of patients with findings related to RA in HRCT (interstitial and/or airway) with those without them. We found no differences in the mean (SD) of DAS-28 [4,74 (1,38) vs 4,32 (1,39); p= 0,27]. The prevalence of anti- CCP was not higher in patients with abnormal HRCT [38/44 (86,3%) vs 16/17 (94,1%); p=0,39]. Patients with abnormal HRCT were older [median (IQR) 50,5 years (44,5-59,5) vs 43 years (32-51); p=0,008) and showed higher VSG values [mean (SD) 39,09 (24,03) vs 27,38 (17,6); p= 0,043]. Abnormal physical examination or dyspnea (class 2 mMRC or higher) was significantly associated with HRCT abnormalities [26 (50%) vs 3 (13,6%); p=0.003) and the presence of ILD on HRCT was significantly associated with crackles on the auscultation [4/68(6,25%) vs 2/6 (33,33%); p 0,023].

Conclusion:

This study shows a high prevalence of lung involvement in ERA patients of less 1 year from diagnosis. Also, we showed a significant association between HRCT and physical examination findings. This data highlights the importance of the clinical examination in Rheumatoid Arthritis patients. More studies with bigger samples and longitudinal follow up are needed to confirm and complete our results.

References:

[1]Rooney BK, Silman AJ. Epidemiology of the rheumatic diseases. Curr Opin Rheumatol [Internet]. 1999 Mar [cited 2016 Jul 19];11(2):91–7. Available from:http://www.ncbi.nlm.nih.gov/pubmed/10319210.

[2]Antin-Ozerkis D, Evans J, Rubinowitz A, Homer RJ, Matthay RA. Pulmonary Manifestations of Rheumatoid Arthritis. Clin Chest Med [Internet]. 2010;31(3):451–78. Available from:http://dx.doi.org/10.1016/j.ccm.2010.04.003.

Disclosure of Interests:

None declared

Transcultural adaptation of the EULAR activity index for primary Sjogren's syndrome in Argentine

OBJECTIVE

To adapt the EULAR Activity Index for primary Sjögren's syndrome (ESSDAI) to the Argentine population.

METHODS

observational, cross-sectional study that included patients in a period of ten months. Three Argentine rheumatologists adapted and translated to Spanish the original version in English and the final version was translated back into English by a research associate whose mother language was English. In order to estimate the constructive validity of the index, the visual analogous scale (VAS) of disease activity was used by experts. A subgroup of patients attended a second visit in order to evaluate test-retest reliability.

RESULTS

51 patients were included, 49 (96.1%) were female, the median age was 58 ((interquartile range (IQR): 49-69)). The median global VAS was 10 (IQR: 4-22.25) and the median total ESSDAI score was 5 (IQR: 3-9). The correlation between the global VAS and the total ESSDAI score of the scale was 0.79. The intraclass correlation coefficient was 0.67 (95% CI: 0.32-0.92) for the total score and 0.98 (95% CI: 0.92-0.995) for the global VAS. The results of the correlation coefficient between the VAS and the scale for each domain were: constitutional symptoms: 0.46; lymphadenopathy: 0.76; glandular: 0.78; joint: 0.61; skin: 1; respiratory: 0.83; renal: 1; muscular:- (no patient had myositis); peripheral nervous system: 0.72; central nervous system: 0.67; hematological: 0.96; biomarkers: 0.86.

CONCLUSION

The results of this study showed that the ESSDAI is a reliable and valid index for this pSS argentinian population.

Do antimalarials protect against damage accrual in primary Sjögren's syndrome? Results from a Latin-American retrospective cohort

OBJECTIVES

To assess the use of antimalarials and to evaluate their association with damage accrual in a Latino-American cohort of patients with primary Sjögren's syndrome (pSS).

METHODS

We included 377 patients attending three tertiary referral centers from: Argentina (n=110), Brazil (n=49) and Mexico (n=218). We retrospectively registered demographics, disease duration and use of prednisone (PDN), immunosupressors and antimalarials. We scored the cumulative ESSDAI and the SSDDI at last follow-up.

RESULTS

Most patients were females, median disease duration 6 years, mean SSDDI score 2.7±1.8, mean cumulative ESSDAI score 9.3±8.3, 39% used PDN and 37.4% immunosupressors. A total of 191 patients (50.6%) had ever used antimalarials, mean use 43.5±40 months, being the main indication arthritis. These patients had a longer disease duration, used more PDN and immunosupressors and had lower SSDDI scores. The pleuro-pulmonary domain was significant different among groups (6.7% antimalarials users vs.14.9% not users, p=0.01). At the logistic regression, the pleuro-pulmonary domain (OR 0.37, 95% CI 0.17-0.78, p=0.01), the age (OR 0.97, 95% CI 0.96-0.99, p=0.01) and the disease duration (OR 1.07, 95% CI 1.03-1.1, p=0.0001) were associated with antimalarials use. When we compared patients with a SSDDI ≥3 vs. SSDDI<3, in the multivariate analysis the use of antimalarial was protective (OR 0.58, 0.36-0.93 CI 95%, p=0.02) and the cumulative ESSDAI a risk factor for damage accrual (OR 1.1, 1.07-1.15 CI 95%, p<0.001).

CONCLUSIONS

Antimalarials were frequently used in pSS and seemed to protect against damage accrual, specifically at the pleuro-pulmonary domain. This finding should be confirmed in prospective studies.

Metabolic control and complications in Italian people with diabetes treated with continuous subcutaneous insulin infusion

BACKGROUND AND AIM

The objective of this cross-sectional study was to evaluate the degree of glycaemic control and the frequency of diabetic complications in Italian people with diabetes who were treated with continuous subcutaneous insulin infusion (CSII).

METHODS AND RESULTS

Questionnaires investigating the organisation of diabetes care centres, individuals' clinical and metabolic features and pump technology and its management were sent to adult and paediatric diabetes centres that use CSII for treatment in Italy. Information on standard clinical variables, demographic data and acute and chronic diabetic complications was derived from local clinical management systems. The sample consisted of 6623 people with diabetes, which was obtained from 93 centres. Of them, 98.8% had type 1 diabetes mellitus, 57.2% were female, 64% used a conventional insulin pump and 36% used a sensor-augmented insulin pump. The median glycated haemoglobin (HbA_1c) level was 60 mmol/mol (7.6%). The HbA_1c target (i.e. <58 mmol/mol for age <18 years and <53 mmol/mol for age >18 years) was achieved in 43.4% of paediatric and 23% of adult participants. Factors such as advanced pump functions, higher rate of sensor use, pregnancy in the year before the study and longer duration of diabetes were associated with lower HbA_1c levels. The most common chronic complications occurring in diabetes were retinopathy, microalbuminuria and hypertension. In the year before the study, 5% of participants reported ≥1 episode of severe hypoglycaemic (SH) episodes (SH) and 2.6% reported ≥1 episode of ketoacidosis.

CONCLUSIONS

Advanced personal skills and use of sensor-based pump are associated with better metabolic control outcomes in Italian people with diabetes who were treated with CSII. The reduction in SH episodes confirms the positive effect of CSII on hypoglycaemia.

CLINICAL TRIAL REGISTRATION NUMBER

NCT 02620917 (ClinicalTrials.gov).

Primary Sjögren's syndrome: Extraglandular manifestations and hydroxychloroquine therapy

The use of hydroxychloroquine (HCQ) in Primary Sjögren's Syndrome (pSS) has been assessed in different studies over the last years, with conflicting results regarding its efficacy in sicca syndrome and extraglandular manifestations (EGM). The goal of this study was to compare the incidence rate of EGM in pSS patients with and without HCQ therapy.We performed a multicenter retrospective study, including patients with pSS (European classification criteria) with at least 1 year of follow-up. Subjects with concomitant fibromyalgia, autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis were excluded. Demographics and pSS characteristics were recorded. The EGM were defined by EULAR-SS disease activity index (ESSDAI). Patients were divided into two groups according to their use or not of HCQ therapy. We evaluated the use of HCQ and its relationship to EGM. HCQ therapy was defined as the continuous use of the drug for at least 3 months. A descriptive analysis of demographics and pSS characteristics was performed. We compared the incidence of EGM between groups defined by HCQ therapy using chi² test or Fisher's exact test. A total of 221 patients were included (97.3% women), mean age, 55.7 years (SD 14). Mean age at diagnosis, 48.8 years (SD 15); median disease duration, 60 months (IQR 35-84). One hundred and seventy patients (77%) received HCQ. About half of the patients had at least one EGM during the course of the disease, 20% of them developed an EGM before the onset of the sicca syndrome and 26% simultaneously with dryness symptom. Overall, EGM were less frequent in those on HCQ therapy (36.5% vs 63.5%, p < 0.001). Considering each EGM individually, the following manifestations were more frequent in the non-treated group: arthritis (p < 0.001), fatigue (p < 0.001), purpura (p = 0.01), Raynaud phenomenon (p = 0.003), and hypergammaglobulinemia (p = 0.006). Immunosuppressive treatment was indicated on 28 patients (12.7%), 13 of which were receiving also HCQ. The first reason for those treatments was the presence of arthritis in 12/28 patients (42.8%), and the drug used in all the cases was methotrexate. Only three patients required immunosuppressive therapy with cyclophosphamide, due to the presence of glomerulonephritis, vasculitis, and interstitial lung disease. None of the patients received biologic therapy. The lower incidence of EGM was observed in patients on HCQ therapy supports its efficacy in pSS. However, further large scale prospective studies are needed to confirm these findings.

A tracking system for laboratory mice to support medical researchers in behavioral analysis

The behavioral analysis of laboratory mice plays a key role in several medical and scientific research areas, such as biology, toxicology, pharmacology, and so on. Important information on mice behavior and their reaction to a particular stimulus is deduced from a careful analysis of their movements. Moreover, behavioral analysis of genetically modified mice allows obtaining important information about particular genes, phenotypes or drug effects. The techniques commonly adopted to support such analysis have many limitations, which make the related systems particularly ineffective. Currently, the engineering community is working to explore innovative identification and sensing technologies to develop new tracking systems able to guarantee benefits to animals' behavior analysis. This work presents a tracking solution based on passive Radio Frequency Identification Technology (RFID) in Ultra High Frequency (UHF) band. Much emphasis is given to the software component of the system, based on a Web-oriented solution, able to process the raw tracking data coming from a hardware system, and offer 2D and 3D tracking information as well as reports and dashboards about mice behavior. The system has been widely tested using laboratory mice and compared with an automated video-tracking software (i.e., EthoVision). The obtained results have demonstrated the effectiveness and reliability of the proposed solution, which is able to correctly detect the events occurring in the animals' cage, and to offer a complete and user-friendly tool to support researchers in behavioral analysis of laboratory mice.

General characteristics of an early arthritis cohort in Argentina

OBJECTIVE

The aim of the present study is to describe the general characteristics of a cohort of patients with early arthritis in Argentina.

METHODS

CONAART (Consorcio Argentino de Artritis Temprana--Argentine Consortium for Early Arthritis) is an initiative of seven rheumatology centres across Argentina. Patients were included if they had at least one or more swollen joints and <2 years of disease duration. Social, demographic, familiar, hereditary, clinical and laboratory data were recollected. At first visit and every year, X-rays of hands and feet were performed and working characteristics and pharmaco-economic data were re-collected.

RESULTS

A total of 413 patients were included. Of them, 327 (79.2%) were women with a median age of 49 years and a median disease duration of 6 months. Of the total, 183 (44.3%) had RA (ACR 1987) and 167 (40.4%) undifferentiated arthritis (UA). Other diagnoses included: 12 crystalics, 11 PsA, 6 uSpA, 6 other CTD, 1 AS and 27 other diagnosis. As 85% of our population had RA and UA, we only compared these two groups of patients. Patients with RA had significantly worse activity parameters of the disease (DAS of 28 joints), functional capacity (HAQ) and quality of life (Rheumatoid Arthritis Quality of Life) than patients with UA. The frequency of RF and anti-CCP, and symmetrical distribution were also significantly higher in patients with RA compared with UA patients. All patients with RA initiated early specific treatment, in a period no longer than 6 months from the beginning of the disease.

CONCLUSION

Early arthritis clinics are a useful tool to identify and treat patients with different forms of joint involvement.

Quantitative ultrasound detects bone changes following bone marrow transplantation in pediatric subjects with hematological diseases: a longitudinal study

BACKGROUND

Bone marrow transplantation (BMT) is associated with bone morbidity. We investigated bone status with quantitative ultrasound (QUS) in pediatric patients with hematological diseases prior to and up to 3 yr following BMT.

METHODS

Phalangeal QUS measures for amplitude- dependent speed of sound (Ad-SoS) and bone transmission time (BTT) were obtained in 40 hematological patients (25 with malignant, 15 with non-malignant disease; 9.7+/-4.9 yr) before BMT and 6, 12, 24, and 36 months after BMT. Bone parameters were expressed as Z-scores based on age-sex-matched normal controls.

RESULTS

Mean Ad-SoS and BTT Z-scores were normal before BMT and reduced at 36 months (analysis of variance: p=0.0542 and p=0.0233). Ad-SoS and BTT Z-scores remained relatively stable in the first 6 months after BMT and then progressively decreased reaching a plateau at 12-36 months. In non-malignant patients, BTT Z-score decreased at 6-12 months (p=0.029) and subsequently increased, while in malignant patients BTT Z-score showed a decrease at 12-24 months. Pre-pubertal subjects displayed a drop of BTT Z-Score values at both 12 (p=0.023) and 36 months after BMT (p=0.049), while BTT Z-score remained relatively unchanged in pubertal subjects. Early impairment of BTT Z-score was found in patients who suffered acute graft versus host disease (GVHD) compared to patients without this clinical condition; BTT Z-score was lower at 36 months (p=0.045).

CONCLUSIONS

Longitudinal assessment by QUS of pediatric BMT survivors evidenced that bone status is mildly affected up to 36 months after BMT, mainly in malignant patients, in pre-pubertal subjects at BMT and in patients who suffered acute GVHD.

Evaluation of adrenal function in patients with growth hormone deficiency and hypothalamic-pituitary disorders: comparison between insulin-induced hypoglycemia, low-dose ACTH, standard ACTH and CRH stimulation tests

OBJECTIVES

Patients with organic growth hormone deficiency (GHD) or with structural hypothalamic-pituitary abnormalities may have additional anterior pituitary hormone deficits, and are at risk of developing complete or partial corticotropin (ACTH) deficiency. Evaluation of the integrity of the hypothalamic-pituitary-adrenal axis (HPA) is essential in these patients because, although clinically asymptomatic, their HPA cannot appropriately react to stressful stimuli with potentially life-threatening consequences.

DESIGN AND METHODS

In this study we evaluated the integrity of the HPA in 24 patients (age 4.2-31 years at the time of the study) with an established diagnosis of GHD and compared the reliability of the insulin tolerance test (ITT), short synacthen test (SST), low-dose SST (LDSST), and corticotropin releasing hormone (CRH) test in the diagnosis of adrenal insufficiency.

RESULTS

At a cortisol cut-off for a normal response of 550 nmol/l (20 microg/dl), the response to ITT was subnormal in 11 subjects, 6 with congenital and 5 with acquired GHD. Four patients had overt adrenal insufficiency, with morning cortisol concentrations ranging between 66.2-135.2 nmol/l (2.4-4.9 microg/dl) and typical clinical symptoms and laboratory findings. In all these patients, a subnormal cortisol response to ITT was confirmed by LDSST and by CRH tests. SST failed to identify one of the patients as adrenal insufficient. In the seven asymptomatic patients with a subnormal cortisol response to ITT, the diagnosis of adrenal insufficiency was confirmed in one by LDSST, in none by SST, and in five by CRH tests. The five patients with a normal cortisol response to ITT exhibited a normal response also after LDSST and SST. Only two of them had a normal response after a CRH test. In the seven patients with asymptomatic adrenal insufficiency mean morning cortisol concentration was significantly higher than in the patients with overt adrenal insufficiency. ITT was contraindicated in eight patients, and none of them had clinical symptoms of overt adrenal insufficiency. One of these patients had a subnormal cortisol response to LDSST, SST, and CRH, and three exhibited a subnormal response to CRH but normal responses to LDSST and to SST.

CONCLUSION

We conclude that none of these tests can be considered completely reliable for establishing or excluding the presence of secondary or tertiary adrenal insufficiency. Consequently, clinical judgment remains one of the most important issues for deciding which patients need assessment or re-assessment of adrenal function.