POS0629 PREVALENCE AND FACTORS ASSOCIATED WITH SARCOPENIA IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Sarcopenia is a progressive and generalized skeletal muscle loss associated with falls, fractures, physical disability, and mortality, described as age-related or secondary. Systemic inflammatory diseases, such as rheumatoid arthritis (RA), are well-known causes of secondary sarcopenia. However, the exact prevalence of sarcopenia in patients with RA is still unknown, partly due to the heterogeneous definitions of sarcopenia adopted in different studies.

Objectives

To assess the prevalence of sarcopenia in a cohort of patients affected by RA, and to evaluate the influence of age, sex, comorbidity, disease duration and activity, antibody status and therapies on sarcopenia.

Methods

We conducted a retrospective observational study on adult patients affected by RA undergoing evaluation at our outpatient clinic from January 2009 and July 2021. All patients underwent dual-energy X-ray absorptiometry (DXA) for assessment of body composition; diagnosis of sarcopenia was defined using Skeletal Muscle Mass Index (SMI), as proposed by consensus EWGSOP2 (1). We collected relevant demographic, clinical, therapeutic, and laboratory data at the time of DXA. We excluded patients affected by neoplastic disorders and/or malnutrition. Binary logistic regression analysis was employed to define predictors and protective factors of developing sarcopenia.

Results

A total of 266 patients (82.7% women) with a median age of 58.4 (IQR 14.4) years were included in the study. The prevalence of sarcopenia was 27.44%. From the binary logistic regression analysis, we found that the use of oral glucocorticoids (GCs) at a daily dose > 3.25 mg of prednisone-equivalent was significantly associated with sarcopenia (β 0.68, p = 0.047, aOR 1.98, 95% CI 1.009 – 3.881) (Figure 1). We found a significant inverse correlation between conventional disease-modifying antirheumatic drug (c-DMARDs) and sarcopenia (β -0.71, p = 0.027) as well. Age, sex, disease duration, mean disease activity - expressed as disease activity score based on 28 joints (DAS-28), erosive and seropositive disease - and biologic disease-modifying antirheumatic drug (b-DMARDs) therapy were not predictors of sarcopenia, albeit seropositive status showed a correlation trend with increased prevalence of sarcopenia (p = 0.092).

Figure 1.

Conclusion

Our study showed that sarcopenia is a common complication in RA. Glucocorticoid therapy was associated with an increased prevalence of sarcopenia, while c-DMARDs acted as protective factors, possibly decreasing chronic inflammation. No correlation was found with b-DMARDs, possibly due to association with longer and more aggressive rheumatic disease.

References

[1]Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48:16–31

Disclosure of Interests

None declared

POS0386 A NOVEL ECHOCARDIOGRAPHY METHOD FOR THE DETECTION OF SUBCLINICAL MYOCARDIAL FIBROSIS IN PATIENTS WITH SYSTEMIC SCLEROSIS: A CROSS-SECTIONAL STUDY

Background

Scar imaging echocardiography with ultrasound multi-pulse scheme (eSCAR) is a novel technique allowing detection of myocardial scars. eSCAR has never been explored in patients with systemic sclerosis (SSc).

Objectives

The aim of our study was to examine whether eSCAR may detect subclinical myocardial fibrosis in SSc.

Methods

In this cross-sectional study conducted between 11/2020 and 02/2021, consecutive SSc patients from the University of Verona underwent cardiovascular disease (CVD) screening procedures including standard transthoracic echocardiography (TTE) and myocardial scars detection through the eSCAR technique. We excluded patients with prior history of structural heart disease and pulmonary hypertension. To validate eSCAR findings, we assessed myocardial function through global longitudinal strain (GLS) analysis by speckle tracking echocardiography (STE). We also conducted a case-control study comparing eSCAR findings in randomly selected SSc patients and non-SSc controls matched 1:1 for age, sex and number of CVD risk factors. The primary outcome was the proportion of patients with myocardial scars. Principal component analysis (PCA) was used to determine main eSCAR patterns. Multivariable linear regression analysis was used to minimise confounding.

Results

Scar imaging echocardiography revealed that 42/92 (44%) SSc patients had myocardial scars involving a median [25th-75th percentile] of 4 [1-7] segments. PCA identified that myocardial scars localised mostly at the inferior and septal segments (inferoseptal pattern; Figure 1). STE validation confirmed that GLS was significantly reduced in SSc patients with inferoseptal scars (Table 1). Otherwise, all standard echocardiography measures were normal in both groups. In multivariable regression analysis, prior digital ulcerations (B=0.41, 95% CI 0.008 to 0.809, p=0.045) and body mass index (B=-0.06, 95% CI -0.113 to -0.015, p=0.012) were both significantly and independently associated with inferoseptal myocardial scars. Myocardial scars were found in 38% of SSc patients and no matched controls (p<0.0001).

Table 1.

Comparison of speckle tracking echocardiography (longitudinal myocardial strain) in eSCAR-positive (inferoseptal pattern) and eSCAR-negative (no inferoseptal pattern) patients.

Speckle tracking echocardiographyeSCAR-positive (n= 8)eSCAR-negative (n=31)P-valueGLS global (%)- 20.24 (2.39)- 20.42 (3.65)0.895GLS 4-chambers (%)- 20.66 (1.91)- 20.09 (4.12)0.720GLS 2-chambers (%)- 23.02 (5.23)- 21.97 (3.89)0.924GLS 3-chambers (%)- 17.11 (2.60)- 19.31 (5.26)0.015GLS apical- anterior- 19.60 (6.12)- 17.72 (4.42)0.857- inferior- 26.89 (7.79)- 23.65 (5.46)0.581- lateral- 18.91 (2.04)- 18.13 (5.12)0.508- septal- 22.68 (7.14)- 21.76 (7.04)0.844GLS basal- anterior- 23.35 (3.82)- 22.75 (8.36)0.752- anteroseptal- 14.09 (4.74)- 18.66 (7.46)0.109- inferior- 22.69 (8.49)- 22.78 (6.94)0.818- lateral- 19.99 (7.68)- 22.55 (7.01)0.218- septal- 14.26 (4.63)- 18.07 (8.79)0.081GLS mid- inferior- 23.09 (6.12)- 22.58 (5.07)0.917- septal- 14.80 (5.69)- 17.50 (7.53)0.056- anterior- 20.54 (3.28)- 19.73 (6.520.026- anteroseptal- 14.70 (4.96)- 18.13 (5.20)0.010- lateral- 18.64 (5.79)- 20.09 (5.73)0.270

Data are reported as mean (S.D.). GLS, global longitudinal strain.

Figure 1.

Conclusion

This simple ultrasound technique allows detection of myocardial dysfunction associated with scars in SSc patients, or its absence in matched controls. Patients with prior digital ulcerations and low body weight have the strongest association with inferoseptal myocardial scars. eSCAR may help detect subclinical myocardial fibrosis in SSc.

Disclosure of Interests

None declared

AB0692 Predictors of iloprost infusion tolerance in patients with systemic sclerosis

Background

Systemic Sclerosis (SSc) is an autoimmune disease characterized by vasospasm and microvascular involvement. Iloprost (ILO), a prostaglandin analogous, is used for the treatment of SSc-related Raynaud’s Phenomenon and digital ulcers. The indicated dosage is 0-5-2 ng/kg/min for 6-8 hours and the maximum dose is decided upon the patient’s tolerance.

Objectives

Our study aims to analyse ILO infusion tolerance and possible predictive factors in patients with SSc.

Methods

We evaluated patients with SSc beginning ILO iv treatment between 2004 and 2021. We assessed the maximum tolerated ILO iv infusion rate, the incidence of adverse events (AEs) and the need for symptomatic therapy during the dose-finding sessions. We collected relevant demographic and medical data at the beginning of ILO iv treatment. Statistical analysis were performed to assess possible predictors of maximum tolerated ILO infusion rate and AEs.

Results

We retrospectively analysed 113 patients. The median ILO infusion rate at the end of the dose-finding process was 0.88 ng/kg/min (IQR 0.37). We found a significant inverse correlation between ILO infusion rate and body mass index (BMI) at the beginning of treatment. BMI was negatively associated with ILO infusion rate (β -0.29, p = 0.001) after correction for relevant confounding factors. Subjects in the upper BMI tertile (BMI above 25) had a lower tolerance to ILO compared with subjects in the lower BMI tertile BMI below 22 (p=0.002). Disease pattern, disease duration, age at the onset of disease, mean blood pressure, gender, smoking habits, combination therapy with calcium channel blocker or endothelin inhibitors were not predictors of ILO tolerance. AEs during ILO titration occurred in 47.8% of patients, of whom 22.2% presented concomitant hypotension. The most common AEs were headache, nausea, vomiting, diarrhoea, oedema, hypotension, and symptomatic therapy was needed in half of the patients at least once. Overweight patients (BMI >26) presented a 13-fold increased risk of developing AEs during ILO titration (adjusted odd ratio 13.979 95% CI 2.359-82.845).

Conclusion

Our study showed that only a higher BMI was associated with lower ILO infusion rate tolerance and higher AEs rate, underlying a possible BMI-dependent endothelial dysfunction possibly mediated by endothelin receptor expression. Individual ILO regimens still need to be tailored to the patient.

Disclosure of Interests

None declared

Association between exposure to fine particulate matter and osteoporosis: a population-based cohort study

Long-term environmental air pollution exposure was associated with osteoporosis' risk in a cohort of women at high risk of fracture. Cortical sites seemed to be more susceptible to the exposure's effect.

INTRODUCTION

Environmental air pollution has been associated with disruption of bone health at a molecular level. Particulate matter (PM) exposure can simultaneously stimulate bone resorption and halt bone formation. The primary aim of the present study is to describe the association between long-term exposure to PM and osteoporosis in a large cohort of women at high risk of fracture.

METHODS

Clinical, demographic, and densitometric data were extracted from the DeFRAcalc79 dataset, which gathers data on women at risk for osteoporosis. Data on the monitoring of PM10 and PM2.5 concentrations were retrieved from the Italian institute of environment protection and research (Istituto Superiore per la Protezione e la Ricerca Ambientale, ISPRA). Generalized linear models with robust estimators were employed to determine the relationship between BMD and PM long-term exposure.

RESULTS

A total 59,950 women from 110 Italian provinces were included in the study. PM 2.5 exposure was negatively associated with T-score levels at the femoral neck (β -0.005, 95 CI -0.007 to -0.003) and lumbar spine (β -0.003, 95% CI -0.006 to -0.001). Chronic exposure to PM2.5 above 25 μg/m3 was associated with a 16% higher risk of having osteoporotic T-score at any site (aOR 1.161, 95% CI 1.105 to 1.220), and exposure to PM10 above 30 μg/m3 was associated with a 15% higher risk of having osteoporotic T-score at any site (aOR 1.148, 95% CI 1.098 to 1.200).

CONCLUSION

Long-term exposure to air pollution was associated with higher risk of osteoporosis. Femoral neck site seemed to be more susceptible to the detrimental effect of PM exposure than lumbar spine site.

KEY MESSAGE

Exposure to air pollution is associated with osteoporosis, mainly at femoral site.

OP0178 ASSOCIATION BETWEEN ENVIRONMENTAL AIR POLLUTION AND RHEUMATOID ARTHRITIS FLARES

Background:

Environmental air pollution has been linked to the pathogenesis of Rheumatoid Arthritis (RA). Nevertheless, evidence linking higher concentrations of air pollutants with the risk of RA reactivations is missing.

Objectives:

The objective of the present study was to determine the association between RA flares and air pollution.

Methods:

We collected longitudinal data of patients affected by RA and of the daily concentration of air pollutants in the Verona area. We designed a case-crossover study. In case-crossover studies, instead of obtaining information from two groups (cases and controls), the exposure information is obtained comparing two different periods of time in the same group of patients followed longitudinally. We compared the exposure to pollutants in the 30-day and 60-day periods preceding an arthritic flare referent to the 30-day and 60-day preceding a low-disease activity visit. Flare was defined as an increase in DAS28-CRP of >1.2 points with current DAS28-CRP ≥3.2 (OMERACT definition).

Results:

888 patients with RA with 3,396 follow-up visits were included in the study. 13,636 daily air pollution records were retrieved. We found an exposure-response relationship between the concentration of air pollutants and the risk of having abnormal CRP levels (Figure 1). Patients exposed to greater concentrations of air pollutants were at higher risk of having CRP levels ≥5 mg/L. Patients exposed to PM10 concentrations ≥50 μg/m3 had a 70% higher risk of having CRP levels ≥5 mg/L (OR 1.696 95% CI, 1.245-2.311). Among RA patients, 440 patients (49.5%) had at least 2 follow-up visits with a difference in DAS28-CRP of more than 1.2 points (with current DAS28-CRP ≥3.2), serving as our sample for the case-crossover study. Concentrations of CO, NO, NO2, NOx, PM10, PM2.5 and O3 were higher in the 60-day period preceding a flare (Table 1). Sensitivity analyses considering geometric mean and cumulative concentrations yielded similar results (data not shown). Remarkably, we found that the cumulative exposure to NO2 in the 60 days preceding a flare was approximately 500 µg/m3 higher than the low disease activity visit, an exposure that equates to approximately to 200 passively smoked cigarettes (3.5 cigarettes per day on a 60-day period).

Table 1.

Case-crossover study. Mean concentrations (mean and Area Under the Curve) of air pollutants in the 60 days before low-disease activity visit and flare visit (DAS28-CRP difference >1.2)

PollutantControl period (low disease activity, n=440)Hazard period (flare, n=440)p valueCO μg/m3Mean0.380.420.001AUC22.0024.530.001NO μg/m3Mean19.2324.110.002AUC1,120.531,403.880.002NO2μg/m3Mean30.9132.440.042AUC1,800.961,892.050.040NOxμg/m3Mean60.3469.350.004AUC3,515.774,041.060.004PM10 μg/m3Mean31.2133.650.011AUC1,789.221,942.520.005O3μg/m3Mean31.0833.790.002AUC1,776.371,934.350.001PM2.5 μg/m3Mean23.0824.740.018AUC1,272.611,403.60<0.001Figure 1.

Odds of having abnormal CRP serum levels (≥5 mg/L) at different exposures of PM10 and PM2.5 (mean concentration in the 60 days before assessment)

Conclusion:

We found a striking association between air pollution and RA disease severity and reactivations in a cohort of patients followed over a 5-year period. The exposure to high levels of air pollutants was associated with increased CRP levels and a higher risk of experiencing a flare of arthritis. This excessive risk was evident at very low levels of exposure, even below the proposed threshold for the protection of human health. Our study has important and direct consequences. In order to reduce the burden of RA, public and environmental health policy makers should aim to diminish gaseous and PM emissions to a larger extent as currently recommended.

Disclosure of Interests:

None declared

POS0218 TUMOR-NECROSIS FACTOR INHIBITORS IMPROVE AORTIC STIFFNESS IN PATIENTS WITH LONGSTANDING RHEUMATOID ARTHRITIS

Background:

Major cardiovascular disease (CVD) benefits of disease-modifying anti-rheumatic drugs (DMARDs) therapy occur in early RA patients with treat-to-target strategy. However, it is unknown whether long-term DMARDs treatment in established RA could be useful to improve CVD risk profile.

Objectives:

The aim of this study was to comparatively describe aortic stiffness progression in patients with longstanding and established RA treated with tumor necrosis factor inhibitors (TNFi) or conventional synthetic DMARDs (csDMARDs).

Methods:

Ultrasound aortic stiffness index (AoSI) has to be considered a proxy outcome measure in established RA patients. We measured AoSI in a group of RA patients on long-term treatment with TNFi or csDMARDs. Eligible participants were assessed at baseline and after 12 months; changes in serum lipids, glucose and arterial blood pressure were assessed. All patients were on stable medications during the entire follow-up.

Results:

We included 107 (64 TNFi and 43 csDMARDs) RA patients. Most patients (74%) were in remission or low disease activity and had some CVD risk factors (45.8% hypertension, 59.8% dyslipidemia, 45.3% smoking; table 1). The two groups did not differ significantly for baseline AoSI (5.95±3.73% vs 6.08±4.20%, p=0.867). Follow-up AoSI was significantly increased from baseline in the csDMARDs group (+1.00%; p<0.0001) but not in the TNFi group (+0.15%, p=0.477). Patients on TNFi had significantly lower follow-up AoSI from baseline than the csDMARDs group (-1.02%, p<0.001; ANCOVA corrected for baseline AoSI, age and systolic blood pressure). Furthermore, follow-up AoSI was significantly lower in TNFi users with 1-2 or >2 CVD risk factors than in those without (figure 1).

Conclusion:

Long-term treatment with TNFi was associated with reduced aortic stiffness in patients with established RA and several CVD risk factors.

Baseline characteristics of the study population.csDMARDs(n=43)TNFi(n=64)P valueAge, median years (IQR)58.6 (53.0, 66.0)58.1 (49.3, 67.0)0.839Female sex33 (76.7)54 (84.4)0.321Obesity5 (11.6)7 (10.9)0.999Hypertension19 (44.2)30 (46.9)0.784Anti-hypertensive drug17 (39.5)28 (43.8)0.784Smoking status, ever18 (42.9)30 (46.9)0.684Dyslipidemia30 (40.2)34 (59.8)0.085Current statin use13 (34.2)10 (15.9)0.033Diabetes mellitus3 (7.0)3 (4.7)0.676Anti-diabetic medication1 (2.3)1 (1.5)0.999CVD risk factors, median (IQR)2 (1, 3)2 (1, 3)0.199RF and/or ACPA positive28 (65.1)33 (51.6)0.165Disease duration, median years (IQR)14.1 (11.5)15.4 (10.5)0.538Methotrexate38 (88.4)52 (81.3)0.192Leflunomide5 (17.9)12 (19.0)0.999Hydroxychloroquine9 (31.0)5 (7.8)0.009Prednisone > 5 mg daily7 (7.7)5 (5.5)0.823NSAIDs6 (20.7)22 (34.4)0.227

ACPA, anti-citrullinated peptides antibodies; csDMARDs, conventional synthetic disease-modifying anti-rheumatic drugs; IQR, interquartile range; NSAIDs, non-steroidal anti-inflammatory drugs; RF, rheumatoid factor; TNFi, tumor necrosis factor inhibitors. All data reported as absolute numbers (percentage) otherwise specified. P-value refers to Chi-squared or Fisher test for categorical variables or ANOVA for continuous variables.

Disclosure of Interests:

None declared

POS0693 EFFICACY AND SAFETY OF BELIMUMAB IN PATIENTS WITH LUPUS NEPHRITIS IN REAL-LIFE SETTING: RESULTS FROM A LARGE, NATIONWIDE, MULTICENTRIC, PROSPECTIVE COHORT

Background:

LN is still a severe manifestation of Systemic lupus erythematosus (SLE) and multitarget therapy is needed to control the disease especially in refractory cases.

Objectives:

To evaluate renal response in SLE patients with glomerulonephritis (GN) treated with Belimumab in real-life setting.

Methods:

Patients with proteinuria >0.5 g/24 h and/or active sediment at baseline enrolled in a multicentre Italian cohort of SLE patients (BeRLiSS study), treated with monthly iv Belimumab 10 mg/kg plus standard of care were considered in this study. Complete renal response (CRR) was defined as proteinuria <0.5 g/24 h, estimated glomerular filtration rate (eGFR)≥90ml/min/1.73m2 and no rescue therapy. Primary efficacy renal response (PERR) was defined as proteinuria ≤0.7 g/24 h, eGFR ≥60ml/min/1.73m2 and no rescue therapy. Prevalence and predictive factors of CRR and PERR at 12 and 24 months after Belimumab initiation were analyzed by multivariate logistic regression analysis.

Results:

A total of 91 patients were considered in this study, 79 female, mean age 40.51±9.03 years, mean disease duration 12.18±8.15 years, median follow-up time after Belimumab initiation 22 months. Twenty patients had baseline proteinuria ≥0.5 <1 g/day, 17 ≥1 <2 g/day, 13 ≥2 g/day. Belimumab was started at GN onset in 20 (22%) patients and at the time of a renal flare in all other cases. Seventy-five patients underwent a renal biopsy: 1 class I, 4 class II, 14 class III, 47 class IV and 9 class V. Baseline serum creatinine was 82.44±29.26 umol/L; 15 patients showed eGFR<60ml/min/1.73m2 at baseline. Immunosuppresants were taken by 70 (76.9%) patients: 47 micofenolate, 15 azathioprine and 5 ciclosporine. Sixty patients (65.9%) were on antimalarials. During follow-up 34 (37.4%) patients achieved CRR. Among them 5 (14.7%) patients relapsed and 29 (85.3%) patients maintained remission. Mean time to achieved CRR was 9.71±5.91 months.

High levels of baseline proteinuria were a negative independent predictor of CRR and PERR at 6 months (OR 0.044 CI95% 0.006-0.320 p=0.002 and OR 0.232 CI95% 0.091-0.596 p=0.002) and 12 months (OR 0.029 CI95% 0.002-0.556 p=0.019 and OR 0.056 CI95% 0.009-0.327 p=0.001). High levels of baseline creatinine were a negative independent predictor of renal response. Renal response at 6 months was a strong predictive factor of renal response at 12 and 24 months.

Conclusion:

Belimumab is an effective add-on therapy in the treatment of GN in real-life practice setting.

Disclosure of Interests:

None declared

Vitamin D and disease severity in coronavirus disease 19 (COVID-19)

The role of 25-OH-vitamin D in the assessment of coronavirus disease 19 (COVID-19) has not been investigated. We sought to investigate the prevalence of 25-OH-vitamin D deficiency among COVID-19 patients, and to determine the associations between 25-OH-vitamin D status and the severity of the disease. We have conducted a retrospective observational study of COVID-19 patients admitted to the University of Verona Hospital Trust. Demographic, clinical and biochemical parameters were collected at hospital admission, and serum 25-OH-vitamin D levels were measured. The following outcomes were assessed: arterial partial oxygen pressure (PaO2); C-reactive protein (CRP); length of hospitalization; requirement of oxygen therapy; non-invasive ventilation (NIV); mechanical ventilation; and death. Among 61 patients enrolled, 72.1% was 25-OH-vitamin D deficient (<20 ng/mL) and 57.4% had 25-OHvitamin D <15 ng/mL. Patients with arterial PaO2 <60 mmHg had significantly lower mean 25-OH-vitamin D levels compared to patients with PaO2 ≥60 mmHg (13.3 ng/mL vs 20.4 ng/mL respectively, p=0.03). Vitamin D deficiency was associated with 3-fold higher risk of having arterial pO2 <60 mmHg. 25-OH-vitamin D deficiency was associated with increased CRP and dyspnea. 25-OH-vitamin D deficiency was associated with more severe systemic inflammatory response and respiratory failure in COVID-19 patients.

Risk of fragility fractures in obesity and diabetes: a retrospective analysis on a nation-wide cohort

This study aims to investigate the role of obesity and diabetes on bone health in a nation-wide cohort of women with high risk of fracture.

INTRODUCTION

The role of obesity and diabetes on fracture risk is yet poorly understood. Body mass index (BMI) and bone mineral density (BMD) are strongly correlated; however, patients with elevated BMI are not protected against fractures, configuring the obesity paradox. A similar controversial association has been also found in diabetic patients. Herein, we present a retrospective analysis on 59,950 women.

METHODS

Using a new web-based fracture risk-assessment tool, we have collected demographic (including BMI), densitometric, and clinical data (including history of vertebral or hip and non-vertebral, non-hip fractures, presence of comorbidities). We performed a propensity score generation with 1:1 matching for patients in the obese (BMI ≥ 30) and non-obese (BMI < 30) groups, in the diabetics and non-diabetics. Propensity score estimates were estimated using a logistic regression model derived from the clinical variables: age, lumbar spine T-score, and femoral neck T-score.

RESULTS

We found an association between diabetes and fractures of any kind (OR 1.3, 95% CI 1.1-1.4 and 1.3, 95% CI 1.2-1.5 for vertebral or hip fractures and non-vertebral, non-hip fractures, respectively). Obesity, on the other hand, was significantly associated only with non-vertebral, non-hip fractures (OR 1.3, 95% CI 1.1-1.6). To estimate the individual effect of obesity and diabetes on bone health, we ran sensitivity analyses which included obese non-diabetic patients and non-obese diabetic patients, respectively.

CONCLUSIONS

Non-obese diabetics had the highest risk of vertebral or hip fracture, whereas obese non-diabetics predominantly had non-vertebral, non-hip fracture's risk. These results should raise awareness in clinical practice when evaluating diabetic and/or obese patients.

Different fracture risk profile in patients treated with anti-osteoporotic drugs in real-life

In this retrospective study, we intended to investigate the baseline fracture risk profile in patients who started treatment with different anti-osteoporotic medications. We analyzed retrospectively the fracture risk calculated with DeFRA, a validated FRAX derived tool, in women who started an anti-osteoporotic treatment from 2010 to 2017. We analyzed baseline data of 12,024 post-menopausal women aged over 50 years. Teriparatide initiators had a baseline 10-year risk of major osteoporotic fracture of 82.1% with a Standard Deviation (SD) of 66.5%. Denosumab initiators and zoledronic acid initiators had a greater 10-year baseline risk of fracture (54.3%, SD 46.5% and 47.0%, SD 42.0 respectively) than patients initiated on alendronate (24.9%, SD 34.6%) and patients initiated on risedronate (23.9%, SD 24.1%). Using DeFRA, a FRAX™ derived tool, we showed significantly different fracture risk profiles in women who were started on various therapeutic agents for the treatment of osteoporosis in routine clinical practice.

AB1094 SCAR IMAGING ECHOCARDIOGRAPHY WITH ULTRASOUND MULTI-PULSE SCHEME [eSCAR] FOR THE DETECTION OF MYOCARDIAL FIBROSIS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: PRELIMINARY RESULTS

Background:

Myocardial fibrosis is a severe complication of immune-mediated diseases, occurring in up to 30% of systemic lupus erythematosus (SLE) patients. Cardiovascular magnetic resonance imaging allows myocardial scar detection in SLE patients, but it is costly, time consuming, and unfit for patients with renal disease. Scar imaging echocardiography with ultrasound multi-pulse scheme (eSCAR) is a novel and promising technique that proved to be effective in detecting ischemic myocardial scars in patients with coronary artery disease (CAD).

Objectives:

To evaluate if the eSCAR technique is feasible and to better characterize SLE patients with cardiac involvement by eSCAR.

Methods:

We recruited consecutive patients with SLE classified according to the 2019 EULAR/ACR recommendations. Patients with diabetes mellitus, obesity, prior cardiovascular (CV) disease or anti-phospholipid (aPL) syndrome were excluded. Eligible participants underwent a thorough clinical assessment and a full echocardiography examination, including the eSCAR technique. Data on clinical variables were collected; disease activity was estimated by the SLE Disease Activity Index (SLEDAI) score. Lupus flare was defined as new/worse clinical signs and symptoms and/or lab measurements and a change/increase in treatment. Patients were compared according to the presence or absence of eSCAR. In this preliminary report, only descriptive analyses are provided. Continuous data are reported as median [25th; 75thpercentile].

Results:

We enrolled fifteen patients diagnosed with SLE (age 45 years [36; 47], disease duration 14 years [12; 20]), 13 (87%) were females. Median SLEDAI was 5 [2; 8]. The most frequent disease involvement included arthritis (73%), skin and mucous membranes (60%), lupus nephritis (47%) and cytopenias (47%). Patients had received treatment for lupus with 5 drugs [5; 8]. Cumulative prednisone dosage was 25 g [20; 44], whilst the current daily dosage of prednisone was 4 mg [0.0; 5.0]. Hypertension was present in 4 (27%) and hypercholesterolemia in 2 (13%) subjects; 4 patients (27%) were current or past smokers. The eSCAR technique was feasible in all participants with no adverse effects. Myocardial scars were detected in 2 patients (eSCAR-positive 13%; figure and table); eSCAR positive patients were females and had no history of cardiovascular involvement (including pericarditis); they had at least one relapse within the prior 12 months before enrollment; at least one cardiovascular risk factor was found in both patients (one was a smoker and the other one had hypertension); none received prior treatment with cyclophosphamide or rituximab; they had no renal involvement; arthritis and cytopenia were the prominent features of disease; anti-dsDNA titer was higher than eSCAR-negative patients.

Conclusion:

Echocardiography allowed detection of myocardial scars in patients with SLE. Our preliminary data show that eSCAR is feasible and well tolerated in a SLE population. Further data from this ongoing study will help investigate whether eSCAR might improve risk stratification, by identifying myocardial involvement in SLE patients with a more active disease.

eSCAR positivePatient 1eSCAR positivePatient 2eSCAR negativeSLE patients (n=13)Age, years324545SexFemaleFemale11 F / 2 MESR mm/h29715CRP mg/L30.62Anti-dsDNA (IF)PositivePositivePositive 7 (47)Anti-dsDNA (CLIA)10514934 [7; 66]C3 (mg/L)618085 [70; 94]C4 (mg/L)41310 [9; 16]P-Cr (mg/dL)0.60.80.7 [0.6; 0.7]aPLPositiveNegative7 (47)Disease duration, years152814 [12; 15]SLEDAI1205 [2; 8]Lupus flare in the past 12 monthsyesyes5 (33)Cumulative prednisone dosage (g)606124 [19, 32]Previous use of cyclophosphamideNoNo3 (20)Previous use of rituximabNoNo1 (1)

Acknowledgments:

This study was granted by Gruppo LES Italia Onlus

Disclosure of Interests:

Alessandro Giollo: None declared, Giulia Vinco: None declared, Giovanni Orsolini: None declared, Giovanni Cioffi: None declared, Giovanni Adami: None declared, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Luca Idolazzi: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Flavio Luciano Ribichini: None declared, Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB, Ombretta Viapiana: None declared

SAT0452 DIFFERENT PROFILE OF RISK OF FRACTURE IN PATIENTS TREATED WITH ANTI-OSTEOPOROTIC DRUGS IN ITALY USING A NEW ALGORITHM

Background:

A new algorithm for management of patients at low, high and very high risk of osteoporotic fractures has been recently proposed, has been also recommended treating those patients at very high risk of fracture with bone anabolics (1). A similar treatment algorithm has been applied in Italy since 2015, when the “Nota 79”, that regulates the reimbursability for osteoporosis medications, has been developed by the Italian Agency for Drugs (AIFA) (2).

Objectives:

In the present study, using a new mathematical and computerized algorithm, we seek to investigate the profile of risk of fracture of patients starting treatment with different anti-osteoporotic medications in Italy.

Methods:

We retrospectively analyzed the 10-year risk of major osteoporotic fracture calculated with the DeFRAcalc79 tool in postmenopausal women aged over 50 years that were initiating an anti-osteoporotic treatment (fully reimbursed according to the Nota 79). DeFRAcalc79 is a new web-based fracture risk-assessment tool (https://defra-osteoporosi.it) that arithmetically adjusts the risk based on the integration of multiple risk factors contemplated by the AIFA’s Nota 79, including: demographic and anthropometric data, femoral and/or lumbar spine BMD T-score, family history of femoral or vertebral fractures, number and site of previous osteoporotic fracture (including vertebral, femoral, and nonvertebral nonfemoral fractures), glucocorticoid treatment (> 3 or > 12 months, ≥5 mg prednisone or equivalent), adjuvant hormone therapy for breast or prostate cancer, and comorbidities that increase the risk (rheumatoid arthritis and other connective tissue diseases, chronic obstructive pulmonary disease, inflammatory bowel diseases, Parkinson’s disease, multiple sclerosis, HIV infection, diabetes, or severe physical handicap).

Results:

We retrieved data for 10,235 women prescribed with an anti-osteoporotic treatment.Figure 1shows the mean 10-year fracture risk estimated with DeFRAcalc79 tool at the time of the treatment initiation. Teriparatide users had the highest 10-year risk of fracture (67.4% Standard Deviation [SD] 21.5%). We found that in 2,231 patients starting denosumab, the 10-year baseline risk of fracture was 38.5%, SD 22.8%. In 5,759 patients initiating alendronate was 25.7%, SD 15.3% and in patients initiating risedronate was 27.9%, SD 26.9%. Patients prescribed with zoledronic acid had a mean 10-year risk of fracture of 35.6%, SD 21.6. P values between means were all <0.01.

Figure 1.

Mean 10-year risk of fracture estimated with DeFRAcalc79 tool at the time of treatment initiation, p< 0.01 between all means.

Conclusion:

The risk of fracture of Italian post-menopausal women initiating different anti-osteoporotic medications varies significantly. Teriparatide is prescribed to patients with greater risk of fracture. The Nota 79 correctly individuates patients at very high risk of fracture that merit treatment with a bone anabolic. Denosumab and zoledronic acid are prescribed to patients with a greater risk of fracture compared to oral bisphosphonates.

DeFRAcalc79 is a useful and practical tool for the integrated evaluation of the profile of risk of fracture.

References:

[1]Kanis JA et al. Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures. Osteoporos Int 2019 31:1–12.https://doi.org/10.1007/s00198-019-05176-3

[2]Adami G et al. Comments on Kanis et al.: Algorithm for the management of patients at low, high, and very high risk of osteoporotic fractures. Osteoporos Int. 2020. doi: 10.1007/s00198-020-05302-6. [Epub ahead of print]

Disclosure of Interests:

Giovanni Adami: None declared, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Alessandro Giollo: None declared, Giovanni Orsolini: None declared, Ombretta Viapiana: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB

SAT0456 REAL-LIFE RISK OF FRACTURE AND TREATMENT PREVALENCE IN DRUG-INDUCED OSTEOPOROSIS IN ITALY USING A NEW ALGORITHM

Background:

Glucocorticoid-induced osteoporosis and osteoporosis induced by adjuvant hormone therapy for breast cancer are the most common forms of secondary osteoporosis.

Objectives:

The exact real-life prevalence of treatment with anti-osteoporotic drugs in women with drug-induced osteoporosis is not known. In the present study, using a new mathematical and computerized algorithm, we investigate the profile of risk of fracture of women with drug-induced osteoporosis and the prevalence of treatment with anti-osteoporotic drugs.

Methods:

We have retrospectively analyzed the 10-year risk of major osteoporotic fracture calculated with the DeFRAcalc79 tool in postmenopausal women aged over 50 years that were initiating an anti-osteoporotic treatment (fully reimbursed according to the Nota 79). DeFRAcalc79 is a new web-based fracture risk-assessment tool (https://defra-osteoporosi.it) that arithmetically adjusts the risk based on multiple risk factors contemplated by the Nota 79, which regulates the reimbursability for osteoporosis medications in Italy (Italian Agency for Drugs, AIFA), including demographic and anthropometric data, femoral and/or lumbar spine BMD T-score, family history of femoral or vertebral fractures, number and site of previous osteoporotic fracture (including vertebral, femoral, and non-vertebral non-femoral fractures), glucocorticoid treatment (> 3 or > 12 months, ≥5 mg prednisone or equivalent), adjuvant hormone therapy for breast cancer, and comorbidities that induce an increased risk of fracture (rheumatoid arthritis and other connective tissue diseases, chronic obstructive pulmonary disease, inflammatory bowel diseases, Parkinson’s disease, multiple sclerosis, human immunodeficiency virus infection, diabetes, or severe physical handicap). This is a sub-analysis of the cross-sectional observational study to validate and further develop the DeFRA algorithm for the estimation of the risk of osteoporotic fractures, promoted by Verona hospital with the unconditional support of Amgen Srl.

Results:

Among 208 women, 116 (55.8%) were treated with adjuvant hormone therapy for breast cancer and 92 (44.2%) were on glucocorticoid ≥5 mg/day. Women on glucocorticoids had a greater mean 10-year risk of fracture compared to women on adjuvant hormone therapy for breast cancer (67.0% vs 39.1% p<0.01). 50.7% of women on adjuvant hormone therapy for breast cancer used denosumab, 28.0% zoledronic acid and 17.3% alendronate. In glucocorticoid-induced osteoporosis, 17.6% of the women used teriparatide, 37.3% alendronate, 29.4% zoledronic acid and 13.7% denosumab.

Conclusion:

In our cohort of patients, treatment with adjuvant hormone therapy for breast cancer was slightly more common than glucocorticoids. Women with glucocorticoid-induced osteoporosis had a greater risk of fracture compared to patients treated with adjuvant hormone therapy for breast cancer. Half of the patients on adjuvant hormone therapy for breast cancer were prescribed with denosumab. One-fifth of the patients with glucocorticoid-induced osteoporosis was treated with teriparatide. DeFRAcalc79 is a useful and practical tool for the integrated evaluation of fracture risk in drug-induced osteoporosis.

Disclosure of Interests:

Giovanni Adami: None declared, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Alessandro Giollo: None declared, Giovanni Orsolini: None declared, Ombretta Viapiana: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB

AB0893 THE EFFECTS OF THREE DIFFERENT VITAMIN D3 SUPPLEMENTATION REGIMENS IN DEFICIENT SUBJECTS - A RANDOMIZED OPEN-LABEL PARALLEL GROUP STUDY

Background:

Currently, most experts agree that levels of serum 25OH-Vitamin D (25OHD) lower than 20 ng/mL represent an acceptable threshold for deficiency (1). However, recommendations for vitamin D supplementation vary between scientific societies, and the best regimen to treat deficient patients is still not clear (1).

Objectives:

The aim of our study was to compare the pharmacokinetic profile of three different regimes of cholecalciferol supplementation in terms of 25OHD exposure and their safety profiles.

Methods:

We evaluated, in healthy subjects affected by vitamin D deficiency (defined as 25OHD<20 ng/mL), 18 to 60 years of age, the efficacy of three different oral supplementation regimens: daily 10,000Iu administered for 8 weeks, weekly 50,000Iu for 12 weeks and biweekly 100,000Iu for 12 weeks. Serum 25OHD was dosed at baseline, at week 2, 4, 8 in all three groups and also at week 12 in the 50,000 and 100,000Iu groups (the blood sample was taken before the drug administration if scheduled on the same day). Baseline characteristics and 25OHD changes from baseline to the various observation points were tested with ANOVA and t-test. 25OHD was measured by the IDS-ISYSMulti-Discipline automated analyser (Immunodiagnostic System, Boldon, UK) based on chemiluminescence technology. The CV intra-assay measured in our laboratory was 6% (inter-assay CV 9%). The study was authorized by the local ethical committee (protocol DIBA/11. Supported by Abiogen Pharma, Italy).

Results:

A total of 75 subjects were randomized to receive one supplementation regimen. The descriptive of the sample at baseline and relative 25OHD levels at the various observation points are reported in table 1. 25OHD increased significantly already at week 2 in all three groups (p=0.000). At week 2, 100% of the subject of the daily regimen group presented 25OHD levels >20ng/mL, 96% in the weekly and 88% in the biweekly ones.

Table 1.

mean values ± SD at the different observation points.

ParameterDaily 10.000 Ui(N = 25)Weekly 50.000 Ui(n = 25)Biweekly 100.000 Ui(N = 25)p-valueM:F12:137:1812:13Age (years)30.2 ± 9.936.7 ± 8.735.4 ± 11.0*0.059Body Weight (kg)65.8 ± 13.267.8 ± 10.866.6 ± 13.7*NSHeight (m)1.7 ± 0.11.68 ± 0.11.7 ± 0.1*NSBMI22.55 ± 2.723.8 ± 2.222.8 ± 2.7*NSBaseline 25OHD (ng/mL)14.6 ± 3.912.8 ± 313.5 ± 4.1*NS25OHD week 232.3 ± 526.5 ± 3.425.6 ± 5a0.007b0.00025OHD week 455 ± 10.139.9 ± 4.236.9 ± 7.2a0.000b0.00025OHD week 879.1 ± 16.253.5 ± 7.246.4 ± 8.2a0.000b0.000c0.00125OHD week 12NA58.5 ± 7.850.6 ± 9.6b0.000c0.001

*ANOVA test.

aDaily 10.000 Ui vs weekly 50.000 Ui.

bDaily 10.000 Ui vs Biweekly 100.000 Ui.

cWeekly 50.000 Ui vs biweekly 100.000 Ui.

In addition, the 25OH levels of the daily regimen group at week 8 were higher than both the ones of the weekly and the biweekly regimen groups both at week 8 and week 12 (p<0.000 vs both groups).

No serious adverse event occurred.

Conclusion:

All the three different regimens proved to be effective in correcting vitamin D deficiency already after 1 months (2 weeks for the daily regimen). A more refracted approach seems to more effective than the bolus-based regimens. The safety profile was excellent in all groups.

References:

[1]R. Bouillon, Comparative analysis of nutritional guidelines for vitamin D, Nat. Rev. Endocrinol. 13 (2017) 466–479.https://doi.org/10.1038/nrendo.2017.31.

Disclosure of Interests:

Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Giovanni Adami: None declared, Ombretta Viapiana: None declared, Giovanni Orsolini: None declared, Alessandro Giollo: None declared, Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work.

Changes in Dkk-1, sclerostin, and RANKL serum levels following discontinuation of long-term denosumab treatment in postmenopausal women

PURPOSE

The positive effects of denosumab (DMAb) on bone mineral density (BMD) are quickly reversible after its discontinuation. We investigated whether this rebound was associated with dysregulation of the Wnt canonical pathway and/or by the increase in the receptor-activator of nuclear factor-kappa B ligand (RANKL) serum levels.

METHODS

The study included patients (n = 15) with postmenopausal osteoporosis to whom DMAb was administered for 78 months and then discontinued. We collected BMD data at baseline/month 0 (M0), M60, M84 (6 months after last DMAb administration, coinciding when the next DMAb dose would typically be due), and after 3 and 12 months of follow-up (FU-M3 and FU-M12, respectively). Serum C-terminal telopeptide of type 1 collagen (CTX-I), Dickkopf-1 (Dkk-1), and sclerostin were measured at M0, M60, M84, FU-M3, and FU-M12. Serum N-terminal propeptide of type 1 procollagen (PINP) and RANKL were dosed at M60, M84, FU-M3, and FU-12.

RESULTS

We found a significant decrease in the T-score at all sites at FU-M12, when compared to M84 (-0.51 ± 0.91 at the lumbar spine; -0.72 ± 0.33 at the total hip; and -0.42 ± 0.27 at the femoral neck, p < 0.05). After DMAb discontinuation (M84 vs FU M12) CTX-I, PINP increased already at FU-M3 (+0.921 ± 0.482 ng/mL, +126.60 ± 30.36 ng/mL, respectively, p < 0.01), RANKL increased at FU-M12 (+0.041 ± 0.062 ng/mL, p < 0.05), while Dkk-1 and sclerostin decreased at FU-M12 (-10.90 ± 11.80 and - 13.00 ± 10.52 pmol/L, respectively, p < 0.01). No changes in BMD or any of the markers were found between M60 and M84.

CONCLUSIONS

RANKL serum levels progressively increased after discontinuation of long-term DMAb while Dkk-1 and sclerostin serum levels decreased. The increase in RANKL serum levels supports the hypothesis of a sudden loss of inhibition of the resting osteoclast line after DMAb clearance, with a hyperactivation of these cells. Our results suggest that the changes in serum Wnt inhibitors after DMAb suspension might represent a mere feedback response to the increased bone turnover.

Inhibition of tumor necrosis factor-alpha (TNF-alpha) in patients with early rheumatoid arthritis results in acute changes of bone modulators

OBJECTIVE

Dicckopf-1 (Dkk-1) is a potent inhibitor of the Wnt canonical pathway. In rheumatoid arthritis (RA), Dkk-1 is upregulated by tumor necrosis factor-α (TNF). Certolizumab pegol (CMZ) is a biologic TNF-inhibitor (TNFi) effective in RA and slows radiographic progression. Data on the immediate effects (≤1-8 weeks) of TNFi on Wnt modulators are lacking. This study investigated the acute influence of TNFi treatment on Wnt modulators (Dkk-1 and sclerostin) and bone turnover markers (BTM), including intact N-terminal propeptide of collagen type I (PINP) and C-terminal telopeptide of type I collagen (CTX-I).

METHODS

This longitudinal, uncontrolled study involved female RA patients with inadequate response to conventional methotrexate who underwent treatment with CMZ. ESR, Dkk-1, sclerostin, BTM, parathyroid hormone (PTH), and 25OH-vitamin D levels were evaluated at baseline, week 1, week 4, and week 8. Radiographs of the hands and feet were obtained at baseline and the total and erosion scores were assessed using the Simple Erosion Narrowing Score method (SENS).

RESULTS

Seventeen patients were enrolled. Dkk-1 and CTX-I significantly decreased after one week of treatment with CMZ (-49.1 ± 17.1% and -25.0 ± 20.6%, respectively, p < 0.01), whereas PINP increased (+43.2 ± 31.5%, p < 0.01). These changes persisted at week 4 and 8.

CONCLUSIONS

Our study showed that TNF-alpha inhibition with CMZ promptly results in a rapid decline of serum Dkk-1 levels, alongside decreased bone resorption and increased bone formation.

Long-term Effects of Neridronate in Adults with Osteogenesis Imperfecta: An Observational Three-Year Italian Study

The aim of this study was to assess the long-term efficacy and safety of i.v. neridronate in the treatment of osteogenesis imperfecta (OI). One hundred and fourteen patients affected by OI were included in the study. Neridronate was administered by i.v. infusion at the dosage of 2 mg/kg, up to a maximum of 100 mg at three-month intervals for 3 years. Dual X-ray absorptiometry of the lumbar spine, hip, and ultradistal and proximal radius were evaluated every 6 months. Blood calcium, phosphate, albumin, fasting urinary calcium/creatinine ratio, total serum alkaline phosphatase, and bone alkaline phosphatase were obtained at baseline and every 3 months. The mean lumbar spine and total hip BMD significantly increased from baseline to any time point (p < 0.001). The mean ultradistal radius BMD significantly increased from baseline only at month 18 (p = 0.026), 30 (p = 0.046), and 36 (p = 0.013), respectively. The mean proximal radius BMD did not change during the whole observation. The levels of bone turnover markers significantly decreased from baseline to any post-baseline observation time. The study was not able to find any statistically significant effect on fracture risk (p = 0.185). The percentage of patients with fractures was unaltered during treatment as compared to the 3-year period before treatment. The most common AEs were fragility fractures, back pain, arthralgia, fever, and joint sprain. An acute phase reaction was reported in 26 (22.8%) patients. None of the reported SAEs were considered as treatment-related. Long-term treatment with i.v. neridronate has positive effects on BMD and bone turnover markers with a good safety profile, although no significant effect on the risk of fracture was observed.

Traditional cardiovascular risk factors or inflammation: Which factors accelerate atherosclerosis in arthritis patients?

Patients with chronic inflammatory arthritis experience an increased incidence of cardiovascular (CV) events. In addition to visualizing atherosclerotic plaques, ultrasound examinations (USs) of the carotid arteries permit the measurement of subclinical markers of atherosclerosis, such as intima-media thickness (cIMT) and carotid segmental distensibility (cDC). The aims of the study were to identify the determinants of atherosclerosis acceleration (plaques, cIMT and cDC) in a sample of patients suffering from chronic arthritis and to compare these patients with a control group of people with ≤1 traditional risk factor (TRF) for CV disease.

METHODS

We recruited 137 patients with rheumatoid arthritis (RA), 43 patients with psoriatic arthritis (PsA), 28 patients with ankylosing spondylitis (AS) and 48 healthy volunteers without histories of previous CV events. These patients underwent carotid artery US examinations using dedicated hardware.

RESULTS

Regression and multivariate analyses demonstrated that only age (p<0.001) was consistently associated with cDC, cIMT and atherosclerotic plaques, both in the entire sample of patients with arthritis and in the subgroup of patients with RA. Among modifiable TRFs for cardiovascular disease, only hypertension, diabetes mellitus and smoking exhibited associations with some carotid phenotypes, with borderline significance. When patients with RA carrying ≤1 TRF were compared with control subjects carrying ≤1 TRF, only cDC was slightly lower in the RA group than in the control group.

CONCLUSIONS

Age is the major determinant of subclinical atherosclerosis in patients with different types of arthritis, as the contributions of other TRFs and disease activity and duration indices to the disease seem to be limited.

Prevalence, pathogenesis, and treatment options for mastocytosis-related osteoporosis

Mastocytosis is a rare condition characterized by abnormal mast cell proliferation and a broad spectrum of manifestations, including various organs and tissues. Osteoporosis is one of the most frequent manifestations of systemic mastocytosis, particularly in adults. Osteoporosis secondary to systemic mastocytosis is a cause of unexplained low bone mineral density that should be investigated when accompanied by suspicious clinical elements. Bone involvement is often complicated by a high recurrence of fragility fractures, mainly vertebral, leading to severe disability. The mechanism of bone loss is the result of different pathways, not yet fully discovered. The main actor is the osteoclast with a relative or absolute predominance of bone resorption. Among the stimuli that drive osteoclast activity, the most important one seems to be the RANK-RANKL signaling, but also histamine and other cytokines play a significant role in the process. The central role of osteoclasts made bisphosphonates, as anti-resorptive drugs, the most rational treatment for bone involvement in systemic mastocytosis. There are a few small studies supporting this approach, with large heterogeneity of drug and administration scheme. Currently, zoledronate has the best evidence in terms of gain in bone mineral density and bone turnover suppression, two surrogate markers of anti-fracture efficacy.

Why golimumab in the treatment of psoriatic arthritis, ankylosing spondylitis and rheumatoid arthritis?

Golimumab is an anti-TNF monoclonal antibody administred subcutaneously once a month and produced with an innovative technology that minimizes immunogenicity. This paper reviews and updates the main studies on the efficacy, safety and pharmacoeconomic aspects of treatment with golimumab of psoriatic arthritis, ankylosing spondylitis and rheumatoid arthritis.

Regional differences of vitamin D deficiency in rheumatoid arthritis patients in Italy

Vitamin D deficiency is very common in patients with rheumatoid arthritis (RA). Aim of this study was to evaluate the prevalence of vitamin D deficiency among the different Italian regions and whether these variations are associated with different severity of the disease. The study includes 581 consecutive RA patients (464 women), not taking vitamin D supplements, from 22 Italian rheumatology centres uniformly distributed across Italy. Together with parameters of disease activity (disease activity score 28), functional impairment (activities of daily living and health assessment questionnaire disability index) and mean sun exposure time, all patients had serum 25-hydroxyvitamin D (25OHD) measured in a centralized laboratory. Vitamin D deficiency (25OHD level &lt;20 ng/mL) was very frequent among RA patients; its prevalence was 60%, 52% and 38% in southern, central and northern Italy, respectively. Mean disease activity and disability scores were worse in southern regions of Italy. These scores were inversely related to 25OHD levels and this correlation remained statistically significant after adjusting for both body mass index (BMI) and sun exposure time. However, disease severity remained significantly higher in southern regions versus central-northern Italy after adjustment also for serum 25OHD levels, age and BMI. In RA Italian patients there are significant regional differences in the prevalence of vitamin D deficiency explained by different BMI, and sun exposure time, and inversely associated with disease activity and disability scores.

Effectiveness of antioxidants (propolis, blueberry, vitamin E) associated with verapamil in the medical management of Peyronie's disease: a study of 151 cases

A total of 151 patients (age: 24–74 years, mean: 55 ± 10.3) diagnosed with Peyronie's disease were enrolled in a non-surgical treatment. In addition to medical histories and physical examinations, all patients underwent the following tests: penile ultrasound, IIEF questionnaire and photographic documentation. The penile curvature was measured by taking a photograph during maximum erection. All 151 patients were treated at different times and with different combinations of drugs, and afterwards, they were clinically studied and divided into five different treatment groups: 1st = verapamil (injection + iontophoresis) + vitamin E + topical diclofenac + blueberries; 2nd = verapamil (injection + iontophoresis) + vitamin E + topical diclofenac + propolis; 3rd = verapamil (injection) + vitamin E + topical Diclofenac; 4th = verapamil (iontophoresis) + vitamin E + topical diclofenac; 5th = verapamil (injection + iontophoresis) + topical diclofenac + blueberries + propolis. All patients were treated for 6 months after which they underwent the same follow-up tests as performed prior to the treatment. The following was achieved: group 1 had the most reduction in plaque size (−66.4%; p = 0.000), group 2 obtained the highest rate where penile curvature disappeared (24.5%; p = 0.019); the best results with reference to decrease in curvature angle were reached by the 2nd group (−14°) and group 1 obtained −9.6° (p = 0.000).

Complete Intermittent Androgenic Deprivation in Prostate Cancer: Our Experience

Our study aimed at a retrospective evaluation of clinicAL/biochemical progression in prostate cancer patients treated with intermittent androgenic deprivation (IAD) after a period of continuous cut off (CAD).

Methods

From 1996 to 2003 40 patients have been screened. 8 (gr.A) with increased PSA after radical prostatectomy (pT2N0M0); 32 (gr.B) had no surgical treatment due to age or other pathologies (Gleason ≤ 8). Patients have been monitored dosing out PSA every 3 months. CAD has been applied for an average period of 40 ± 10 months (med. 36). IAD has been performed by an “off” stage of interruption, alternately with an “on” stage of treatment. The cut-off for the suspension/resumption of therapy has been 0.4 ng/mL of PSA for group A and 3 ng/mL for group B. All patients have been received at least 3 cycles of therapy, each including “on” and “off” stages.

Results

After an average follow-up of 48 ± 12 months (med. 42) since the beginning of IAD, the progression-free survival has been 100% for group A and 96.8% for group B. The intermediate time of stage “off” during IAD pointed out a progression increment from the first cycle (51.6% gr. A, 46.6% gr. B) to the third cycle (73.5% gr. A, 76% gr. B).

Conclusions

The study pointed out that the actual average time of pharmacological treatment has been 47% for the period CAD+IAD and 31.5% for IAD only, keeping the PSA always near the nadir. Besides keeping the progression close to 0, we obtained an appreciable saving on the pharmacological costs and an improvement in the quality of life of patients due to the regression of the side-effects of therapy during stage “off”. Nevertheless it is still controversial in the Litterature on the pharmacological procedure to adopt, on the more suitable values of cut-off in PSA and on the timing of monitoring of patients.

[Interactions between drugs and food in pediatric age]

Interactions between food and drugs represent a very interesting chapter even in paediatric field, although this subject has not been very treated so far. We have tried to locate common points between pharmacology and elementary metabolism, in order to divide drug-food interactions into five great categories, according to the scheme suggested by Vannucci and Capriati. This scheme is based on the phases in which the interactions take place: 1) before gastroenteric absorption; 2) during gastroenteric absorption; 3) during distribution and storage in tissues; 4) during process of bio-transformation; 5) during excretion. If we want rationally to give a drug, we must exactly know its pharmacokinetic, particularly in paediatrics. In fact, we can avoid detrimental interactions drug-food merely adjusting the pharmacologic dosage to the particular diet of the considered child and vice versa.

[Catering services in schools for children (critique and operative proposals)]

Several protests by pupils' parents against bad-quality of food given in school-meal--widely and minutely reported by local press--advised Autors to give due emphasis on some deficiencies in school-meal administration, rightly denounced by relatives. To cut down health troubles, Authors suggest to commit school-meal's management to catering firms for their great experience in field of collective meal. In fact they have implements and competence to check properly: -education and skill of staff attached to school-meal and distribution; -places, structures, tools used to get meals; -victualling, carriage, storage and condition of food maintenance; -the fancy diets, appropriately diversified by age. Authors think that each school should have places, structures and tools to prepare and take meals and should engage a sole firm both for cooking and serving school-meal.

[Correlations of the response to the prick test and blood levels of specific IgE in children]

A good correlation between intensity of prick test result and haematic levels of specific IgE is a fundamental presupposition to affirm that both diagnostic methods are equivalent to demonstrate a condition of IgE-mediate hypersensitivity. Using a retrospective analysis of our data, we intended to examine the degree of this correlation for the most common food and inhalant allergens. The comparison between prick test results and specific IgE haematic levels for all considered allergens-shows a good concordance of F.A.S.T. for prick negative results and a sharp discordance of F.A.S.T. for prick positive results. Both food and inhalant allergens are equally involved in the discordance between the tests. Therefore, we cannot exclude the possibility of clashing results between prick test reaction and specific IgE haematic levels, even in further analysis would be necessary to obtain more reliable verifications.

[Sensitization to house dust mites and juvenile atopic dermatitis]

The etiopathogenetic bases of atopic dermatitis are still much discussed and controversial. Nevertheless most of the Authors agree upon the pathogenetic role of an IgE mediated hypersensitivity mechanisms with respect to many alimentary and/or environmental allergens. We have looked for the IgE mediated sensitization to the house dust mites by means of skin tests (prick) and/or haematic dosage of specific IgE (F.A.S.T.) in a group of 40 children aged less than 6 with atopic dermatitis. We have divided the examined children into three groups according to their age and found out a high percentage of dust mites sensitization in the children of the oldest age group. This datum could give credit to the hypothesis of a pathogenetic role developed by the allergy to dust mites in the keeping of eczematous lesions. From the anamnestic search emerge both the leading role developed by dust mites on the development of allergic breathing pathology in the subjects with atopic dermatitis and the finding out of a settled exordium of breathing manifestations due to dust mites at an older age in comparison with the age in which the cutaneous disease manifests itself. These observations lead us to recommend a very accurate environmental cleaning since the first manifestations of atopic dermatitis prescinding from the checking of a demonstrated IgE mediated house dust mites hypersensitivity.

[Food allergy in children. Diagnostic difficulties, doubts and digressions]

It is very difficult to diagnose an alimentary allergy especially because of: the difference among individuals in their physical, psychic and humoral reactions to the environment; weakness and variability of these reactions during the puberty; limited reliability in the results of certain kind of research (i.e. false positiveness and negativeness, discordance between laboratory results and the results of the challenge, neutralization of diagnostic antigenic extracts and/or the presence in these extracts of lectin, etc.); the bad compliance of some therapies and their restricted efficaciousness, particularly in the little children. Moreover: the superimposition of the clinical manifestations of alimentary allergy and pseudoallergy with those of allergy, the possibility of an association between the alimentary and the respiratory allergy, the acquisition on behalf of the allergic child of other kinds of allergy, false polyallergy, the allergy might change its seats and in consequence also its manifestations. The authors, apart a short account of the different diagnostic methods, lay stress on the challenge as the most reliable. They discuss upon the dose of a nourishment that can be given to the patient without risk, besides they suggest to take into account the type and the seriousness of the clinical manifestations in fixing this dose.

[IgA deficiency in pediatrics]

To evaluate the IgA deficiency we have considered 368 children, admitted to "Day hospital" for different pathologies: 64 of them had serum IgA levels lower than the normal values for their age according to Ellis and Robbin. The age of the children with this deficiency was included from 4 months up to 8 years: 39 were boys, 25 were girls. In 54 cases the IgA deficiency was "partial" that is: the IgA value found out was lower than the normal for the age, but higher than 5 mg%. In 10 cases the IgA deficiency was "severe" (the IgA value was lower than 5 mg%). Six cases, among the 29 ones with intestinal diseases, had a severe deficiency, whereas among the 22 cases with respiratory diseases 3 had a "severe" deficiency. The 2 patients with urinary disease had a partial deficiency; only one case of the remaining 11 with different pathologies had a "severe" deficiency. Among the carriers of serum IgA deficiency an high incidence of chronic pathology has been found out (83%). Nevertheless the percentage of IgA deficiency extrapolated from the all case histories doesn't differ very much (64 cases among 368 = 17.39%) considering only those patients with chronic relapsing pathology (53 cases among 275 = 18.2%). Therefore it seems that the IgA deficiency could be considered a chronicizing factor in the examinated pathology even if in few cases. Anyway the frequency of IgA deficiency has reached major values (29/54; 45.3%) in the patients with enteric diseases. The frequency of IgA deficiency is smaller but still important in those patients with respiratory diseases (22/64: 34.3%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Short near-fainting in children with or without loss of conscience]

Short near-faints with or without loss of consciousness have different etiologies and pathogenesis and, according to these, they recur with various frequency. This subject was reported on several publications and here is again examined with the contribute of personal experience and the description of distinct cases. The following causes were examined: vagal hypertonia, digestive troubles (gastroesophageal reflux), metabolic troubles (cyclic ketosis, hypoglycemia and hypocalcemia with peculiar clinic manifestations). Among the neurological causes were examined: epilepsy, benign paroxysmal vertigos and, particularly, the so called breath-holding spells and the migraine, about that were reported a few examples of "migraine accompagnée". Among the cardiovascular causes (ischaemic cerebral crisis), -particular attention was dedicated to orthostatic hypotension syncope. A short hint about hysteria ends the exposition of psychical causes of short near-faints.

Monitoring the radiation dose to a multiprogrammable pacemaker during radical radiation therapy: a case report

Multiprogrammable pacemakers, using complimentary metaloxide semiconductor (CMOS) circuitry, may fail during radiation therapy. We report about a patient who received 6,400 cGy for unresectable carcinoma of the left lung. In supine treatment position, arms raised above the head, the pacemaker was outside the treated area by a margin of at least 1 cm, shielded by cerrobend blocking mounted on a tray. From thermoluminescent dosimeter (TLD) measurements, we estimate that the pacemaker received 620 cGy in scatter doses. Its function was monitored before, during, and after completion of radiation therapy. The pacemaker was functioning normally until the patient's death 5 months after completion of treatment. The relevant electrocardiograms (ECGs) are presented.