AB0594 ULTRASOUND INTIMA MEDIA THICKNESS CUT-OFF VALUES FOR CRANIAL AND EXTRACRANIAL ARTERIES IN PATIENTS WITH GIANT CELL ARTERITIS

Background

Ultrasound (US) is a valid imaging tool to detect signs of giant cell arteritis (GCA). Although the halo sign has always been considered the most useful finding for GCA diagnosis, modern high frequency transducers are able to precisely measure the intima-media thickness (IMT) of cranial and extracranial arteries. However, data on optimal cut-off values for IMT to differentiate patients and controls in clinical practice are limited.

Objectives

To determine the optimal cut-off value for IMT of cranial and extracranial arteries in patients with suspected GCA.

Methods

This is a retrospective observational study of patients referred to our US fast-track clinic with suspected GCA. All patients underwent bilateral US examination of the cranial and extracranial (carotid, subclavian and axillary) arteries within 24 hours per protocol. The exam was performed using an EsaoteMyLab8 with a 12-18 MHz frequency transducer for cranial arteries and an 8-14 frequency transducer for extracranial arteries. The IMT was measured in gray scale mode and the presence of a non-compressible halo sign was checked in all arteries. The gold standard for GCA diagnosis was clinical confirmation by the referring rheumatologist after 6 months follow-up. Mean IMT values of each artery were compared between patients with and without GCA by independent samples T-test. Receiver operating characteristics analysis was performed and the Youden index was used to determine the optimal cut-off value for IMT of each artery.

Results

Of the 157 patients with suspected GCA (67.5% female, mean age 73.7 years) referred to the fast-track clinic, 47 (29.9%) had GCA clinical confirmation after 6 months. 41 (87.2%) patients with GCA had positive US findings (61.7% had cranial involvement, 44.7% extracranial involvement and 19.1% a mixed pattern of cranial and extracranial arteries). The following IMT cut-off values showed the highest diagnostic accuracy: 0.44mm for the common superficial temporal artery; 0.34 mm for the frontal branch; 0.36 mm for the parietal branch; 1.1 mm for the carotid artery: 1 mm for the subclavian and axillary arteries. The area under the ROC curve of the IMT for a clinical diagnosis of GCA was 0.984 (95% CI 0.959 - 1) for common superficial temporal artery, 0.989 (95% CI 0.976 -1) for frontal branch, 0.991 (95% CI 0.980 - 1) for parietal branch, 0.977 (95% CI 0.961 – 0.993) for carotid, 0.99 (95% CI 0.979 - 1) for subclavian and 0.996 (95% CI 0.991 -1) for axillary arteries (Table 1).

Table 1.

Optimal IMT cut-off values for cranial and extracranial arteries

ArterySidePatients without GCAPatients with GCACut-off (mm)AUC (CI 95%)Sensitivity (%)Specificity (%)Common superficialtemporal artery mm, mean (SD)Right0.33 (0.06)0.68 (0.28)0.430.997 (0.988 -1)10097.1Left0.35 (0.11)0.57 (0.21)0.450.966 (0.905 -1)10092.3Both0.34 (0.08)0.63 (0.25)0.440.984 (0.959 -1)94.795.1Frontal branch mm, mean (SD)Right0.26 (0.05)0.4 (0.18)0.340.994 (0.983 -1)10097.1Left0.27 (0.05)0.4 (0.18)0.340.985 (0.962 -1)10096.1Both0.26 (0.05)0.4 (0.18)0.340.989 (0.976 -1)10096.6Parietal branch mm, mean (SD)Right0.27 (0.05)0.43 (0.18)0.360.994 (0.981 -1)10098.9Left0.27 (0.05)0.41 (0.16)0.360.987 (0.967 -1)10097.6Both0.27 (0.05)0.42 (0.17)0.360.991 (0.980 -1)10098.3Carotid mm, mean (SD)Right0.8 (0.17)0.88 (0.29)10.974 (0.949 – 0.999)10092.6Left0.82 (0.15)1 (0.42)1.20.982 (0.961 - 1)90.996.2Both0.81 (0.16)0.96 (0.36)1.10.977 (0.961 – 0.993)9094Subclavian mm, mean (SD)Right0.74 (0.18)0.99 (0.44)10.987 (0.97 - 1)10093.4Left0.67 (0.17)0.9 (0.35)1.10.991 (0.975 - 1)10098.3Both0.7 (0.18)0.94 (0.4)10.99 (0.979 - 1)10096Axillary mm, mean (SD)Right0.69 (0.16)0.99 (0.5)10.992 (0.982 - 1)10096Left0.67 (0.17)0.99(0.49)10.998 (0.995 -1)10098.3Both0.68 (0.17)0.99 (0.49)10.996 (0.991 -1)10097.1

Conclusion

Different IMT cut-off values for each artery are necessary to establish a correct US diagnosis of GCA. These proposed IMT cut-off values may help to improve the diagnostic accuracy of US in clinical practice.

Disclosure of Interests

None declared

AB1021 FACTORS ASSOCIATED WITH FRAGILITY FRACTURE IN PATIENTS WITH SYSTEMIC MASTOCYTOSIS: DATA FROM AN INCEPTION COHORT IN A SINGLE CENTRE

Background

Systemic Mastocytosis (SM) is a very rare disease. Most common manifestations are skin related or anaphylaxis, however almost one third of patients may present with concomitant osteoporosis (OP) resulting in fragility fracture (FF) in around 5 -37% of patients affecting lumbar spine (LS) in young men. Alcohol consumption, high serum tryptase level, and low femoral T score have been described as risk factors but there are some discrepancies between studies. 1-2

Objectives

Our primary objective was to identify factors associated with FF in patients with SM.

Methods

We analysed all consecutive patients attending a multidisciplinary clinic up to April 2021 with SM diagnosis according to the 2001 WHO criteria. We collected demographic data, general risk factors for OP, cutaneous, bone involvement and laboratory data as serum tryptase level. Bone involvement is defined as densitometric OP (T score ≤ - 2.5) or FF. Normally distributed variables are described as means (SD) and dichotomous variables as number and frequencies. Comparison between patients with and without FF is performed using t-test and Chi2 when needed.

Results

Seventeen patients with SM are included in this preliminary analysis. Four patients (24%) presented a FF, all of them vertebral fractures identified by plain radiographies.Two men and two women presented FF, they were older versus patients without FF (Table 1), and without general risk factors for OP. All of them have a high basal serum tryptase and most of them presented other MS symptoms (cutaneous, anaphylaxia). FRAX tool was useful in only one patient to predict FF risk. The two men with FF diagnosis do not met criteria for densitometric OP, specific characteristics for these patients are presented in Table 2.

Table 1Population (N = 17)Without fragility fracture (N = 13)With fragility fracture (N=4)PMale, n (%)9 (53%)7 (54%)2 (50%)0.89Age at first symptoms, years, mean (SD)37.6 (21.1)33.0 (20.2)58.1 (10.1)0.05Age at diagnosis, years, mean (SD)47.7 (21.1)38.8 (20.9)59.7 (13.1)0.08Ever smoker, n (%)6 (35%)4 (30.8%)2 (50%)0.48Alcohol, n (%)2 (11.76%)1 (7.69%)1 (25%)0.34BMI, mean (SD)26.5 (4.3)25.3 (4.0)30.6 (2.0)0.02BMI<19kg/m2, n (%)1 (6%)1 (7%)0 (0%)0.56Cutaneous mastocytosis, n (%)8 (47%)5 (38.5%)3 (75%)0.20Anaphylaxia, n (%)8 (47%)6 (46.1%)2 (50%)0.89Digestive symptoms, n (%)8 (47%)7 (53.5%)1 (25%)0.31Basal serum tryptase >11,412 (70.6%)8 (61.5%)4 (100%)0.14Basal serum tryptase, mean (SD)20.20 (18.33)10.68 (20.75)22.85 (7.64)0.75General risk factors for OP present, n (%)5 (29%)5 (38.5%)0 (100%)0.14Femoral T score, mean (SD)-1.03 (1.22)-3.82 (1.36)-1.86 (1.23)0.12Lumbar T score, mean (SD)-1.06 (1.57)-5.27 (1.36)-1.95 (2.08)0.20Femoral Z score, mean (SD)-0.34 (1.05)-1.79 (1.44)-0.75 (0.65)0.39Lumbar Z score, mean (SD)-0.30 (1.88)-5,38 (1.57)-0.67 (2.96)0.66FRAX global fracture, mean (SD)2.27 (2.52)2.34 (1.57)6.83 (7.82)0.11FRAX hip fracture, mean (SD)0.23 (1.01)0.48 (0.27)2.1 (1.92)0.18Table 2.

Characteristics of Fragility Fracture in four patients with Systemic Mastocytosis.

PatientAgeGenderLocalization of FFSeverity of FractureTime to fracture diagnosisPatient 165MaleD6,D8,D10,D11, L13 Mild2 Moderate2 years prior SM diagnosisPatient 281FemaleD4,D8,D12, L11 Mild3 Severe2 years after SM diagnosisPatient 365FemaleD4,D11Unknown2 years prior SM diagnosisPatient 442MaleD7,D8,D9,D11,D12, L1,L2,L3,L53 Mild3 Moderate3 SevereAt time of SM diagnosis

Conclusion

Twenty five percent of patients present FF (multiple, located in dorsal spine, and without densitometric diagnosis of OP). SM should always be considered in differential diagnosis in the presence of FF, especially in men with no OP or another risk factor associated.

References

[1]van Doormaal JJ. J Allergy Clin Immunol. 2013;131(5):1429-31 e1

[2]van der Veer E. J Allergy Clin Immunol. 2014;134(6):1413-21.

Disclosure of Interests

None declared

POS1318 JUVENILE IDIOPATHIC ARTHRITIS DISEASE ACTIVITY IN TRANSITIONAL CARE

Background

Juvenile Idiopathic Arthritis (JIA) is a group of heterogeneous arthritis with onset earlier than 16 years old. According to previous studies, these patients experience an improvement of their disease activity, functionality and even remission probability as they become young adults.[1] Transitional care units aim to coordinate an uninterrupted follow-up in patients with chronic diseases in order to accomplished the objective of improving the ability of manage their own disease.[2] Our transitional care unit attend patients from 18 to 25 years old who have been previously diagnosed with any pediatric rheumatic disease

Objectives

Our primary objective was to describe the disease activity of JIA patients at the transference to our unit and the remission maintenance during follow-up.

Methods

We conducted an observational retrospective longitudinal study from a cohort of patients with JIA who have been transferred to our transitional care unit. We selected patients with at least one clinical visit and active follow-up. We collected demographic data, JIA classification, previous treatments and the treatment at time of transfer, articular and ocular flares, remission defined by Wallace criteria3 and changes in treatment during follow-up.

We calculated the percentage of patients who had active disease activity at the transference to the Unit and the proportion of patients who had an inflammatory flare (ocular or articular) during the follow-up.

Results

From December 2016 to December 2021 we received 184 patients in our Transitional Care Unit, from them 127 had a JIA and 1 had asymptomatic chronic uveitis. Demographics of JIA patients is shown in Table 1. From 127 JIA patients, 34 (26,8%) were active at the transference and 53 (41,8%) had at least one flare during the follow-up.

Table 1.

Demographic data from JIA included in the study, divided according to disease activity at the transference to our transitional care unit.

Total (n: 127)Actives (n:34)Not actives (n:93)Sex (female) n (%)84 (66.1)24 (70.6)60 (64.5)Age median (IR)8.64 (3-13)9.1 (3-13)8.4 (3-12.9)Previous joint injections n(%)43 (33.9)16 (47.1)27 (29)sDMARD prior transference n (%)98 (76.6)26 (76.5)72 (77.4)bDMARD prior transference n (%)79 (61.7)20 (58.8)59 (63.4)Uveitis n (%)23 (18.1)8 (23.5)15 (16.1)JIA subcategory n (%)oligo persist43 (33.9)12 (35.3)31 (33.3)oligo extend16 (12.6)3 (8.8)13 (14)poly RF -25 (19.7)6 (17.6)19 (20.4)poly RF +3 (2.4)1 (2.9)2 (2.2)ERA24 (18.9)8 (23.5)16 (17.2)systemic9 (7.1)2 (5.9)7 (7.5)psoriatic7 (5.5)2 (5.9)5 (5.4)

We calculated the percentage of patients who had active disease at the transference to the Unit and the percentage of patients who had an inflammatory flare during the follow-up. Figures 1 and 2 showed the proportion of flares depending on the inflammatory status at transference to the Transitional care unit and the use of biological therapy before transition.

Conclusion

JIA patients remain active in one quarter of the cases at the transference to the Transitional care unit and flares are twice frequent when they were active at the transference.

References

[1]S. Sabbagh, T. Ronis, PH White. Pediatric rheumatology: addressing the transition to adult-orientated health care. Research and Reviews 2018:10 83–95

[2]H. Relas, R. Luosujärvi, S. Kosola. Outcome of transition phase patients with juvenile idiopathic arthritis, Modern Rheumatology 2018 Sep;28(5):32-837

[3]Wallace CA, Ruperto N, Giannini EH, Childhood Arthritis and Rheumatology Research Alliance, Pediatric Rheumatology International Trials Organization, Pediatric Rheumatology Collaborative Study Group. Preliminary criteria for clinical remission for select categories of juvenile idiopathic arthritis. J Rheumatol2004;31:2290–4

Disclosure of Interests

None declared

OP0288 IMPACT OF CARDIOVASCULAR RISK ON THE DIAGNOSTIC ACCURACY OF THE ULTRASOUND HALO SCORE FOR GIANT CELL ARTERITIS

Background

The ultrasonographic (US) Halo Score provide a quantitative measure of the extent of vascular inflammation in patients with giant cell arteritis (GCA). High Halo Scores correlate with systemic markers of inflammation, rate of ocular ischaemia and may help to firmly diagnose GCA with high specificity. However, an increase in the intima media thickness (IMT) in patients with elevated cardiovascular risk (CVR) may lead to false-positive US findings.

Objectives

Our aim is to evaluate the impact of CVR on the diagnostic accuracy of the US Halo Score in patients with suspected GCA.

Methods

This is a retrospective observational study of patients suspected of having GCA and referred to our US fast track clinic. All patients underwent US exam within 24 hours per protocol. The IMT was measured in gray scale mode in cranial and extra-cranial (carotid, subclavian and axillary) arteries and the Halo Score was also determined to assess the extent of vascular inflammation. GCA diagnosis was confirmed after 6-month follow-up by the referring clinician. The European Society of Cardiology (ESC) Guidelines on CV Disease Prevention in clinical practice were used to define different categories of CVR. Patients were classified as very high, high, moderate or low CVR according to the Systemic Coronary Risk Evaluation (SCORE) obtained using the ESC CVD Risk Calculator app for mobile devices. Comparison between groups was performed and the diagnostic accuracy of the Halo Score in patients according to CVR was evaluated using ROC curves.

Results

Of the 157 patients referred to our US fast track clinic (67.5% female, mean age 73.7 years), 47(29.9%) had GCA confirmed after 6-month follow-up. There were no differences in CVR between patients with and without GCA (mean SCORE 20.6[21.6] vs 18.7[21];p=0.601). Among patients without GCA, extra-cranial artery IMT was significantly higher in patients with high/very high CVR than in those with low/moderate CVR (Table 1). The Halo Score was significantly higher in patients with high/very high CVR in non-GCA patients (9.38 (5.93) vs 6.16 (5.22);p=0.007). The area under the ROC curve of the Halo Score to identify GCA was 0.835 (CI95% 0.756-0.914), slightly greater in patients with low/moderate CVR (0.965 [CI95% 0.911-1]) versus patients with high/very high CVR (0.798[CI95% 0.702-0.895]) (Figure 1). A statistically weak positive correlation was found between the Halo Score and the SCORE (r 0.245;p=0.002).

Table 1.

Measurements of IMT in cranial and extracranial arteries and Halo Score values according to CVR

Artery IMT mm, mean (SD)Patients with GCA n=47Patients without GCA n=110Patients with high/very high CVR n=37(78.7%)Patients with low/moderate CVR n=10(21.3%)pPatients with high/very high CVR n=79(71.8%)Patients with low/moderate CVR n=31(28.2%)pSuperficial temporal artery (both)0.66(0.25)0.45(0.11)0.0250.35(0.09)0.32(0.07)0.354Frontal branch (both)0.42(0.18)0.31(0.15)0.0560.26(0.05)0.26(0.06)0.577Parietal branch (both)0.43(0.17)0.35(0.12)0.1020.27(0.04)0.28(0.08)0.173Carotid artery (both)0.88(0.21)1.2(0.6)<0.0010.83(0.16)0.74(0.13)<0.001Subclavian artery (both)0.86(0.31)1.2(0.5)0.0010.74(0.18)0.6(0.13)<0.001Axillary artery (both)0.92(0.38)1.22(0.73)0.0210.72(0.16)0.59(0.15)<0.001Halo Score, mean (SD)18.5(8.8)17.2(10.6)0.699.38(5.93)6.16(5.22)0.007Figure 1.

Diagnostic accuracy of the Halo Score for a clinical diagnosis of GCA after 6-month follow-up in (A) all GCA suspected patients, (B) patients with high/very high CVR and (C) patients with low/moderate CVR

Conclusion

High CVR may influence the diagnostic accuracy of the US Halo Score leading to false-positive findings in these patients. Higher IMT values may be found in extracranial arteries of subjects with high/very high CVR without GCA. Thus, CVR should be taken into consideration in the US vascular assessment of patients with suspected GCA. These results need to be confirmed in larger cohorts to develop a modified US Halo Score applicable to patients with high CVR.

Disclosure of Interests

None declared

AB0422 DIAGNOSTIC PERFORMANCE OF THE ACR/EULAR 2013 CLASSIFICATION CRITERIA FOR SYSTEMIC SCLEROSIS IN A ROUTINE CARE SETTING

Background:

An ACR/EULAR task force released new criteria in 2013 to classify patients with systemic sclerosis (SSc).

Objectives:

This study evaluates the diagnostic performance of these criteria in a multidisciplinary care setting.

Methods:

Patients with an active follow-up in a Systemic Autoimmune Diseases Unit with a clinical diagnosis of SSc were matched by age and gender with consecutive patients referred to a capillaroscopy clinic. The classification criteria were tested on discrimination and diagnostic accuracy between both groups of patients defined as cases-SSc and controls. Receiver operating characteristic (ROC) curve and the area under the curve (AUC) was calculated for the global score to define the best cut off to classify the patients as having SSc.

Results:

A total of 130 patients with SSc and 130 matched-controls were included in this analysis, 90% women, with a mean age of 61.5. Main diagnosis for the control groups were primary Raynaud´s phenomenon (34.6%), undiferentiated connective tissue disease (13.1%), and mixed connective tissue disease (9.2%). The 92% and 8% of patients in the SSc-cases and control groups met the 2013 ACR/ EULAR SSc classification criteria respectively. Sensitivity and specificity of the criteria were 81.5% and 93.7%, respectively. The best cut offs for the total score were 8 and 9, and the AUC (95%CI) was 0.962 (0.939-0.985). The individual items with a better discriminatory capacity were abnormal capillaroscopy, telangiectasia and anticentromere antibody positivity.

Table 1.

Demographic data and ACR/ EULAR SSc classificacion criteria of SSC patients and controls.

Cases-SSc, n= 130Controls, n= 130pAge, mean (SD)62.4 (16.0)61.3 (14.8)0.58Female, %90.590.80.92Disease duration from onset of symptoms, mean (SD)7.5 (6.4)7.8 (6.7)0.73% Patients with individual ACR/EULAR 2013 Criteria ItemsSkin thickening15.80.7<0.001Sclerodactily45.56.1<0.001Puffy fingers27.71.5<0.001Digital tip ulcers30.25.3<0.001Fingertip pitting scars18.84.60.001Telangiectasia51.56.1<0.001Abnormal nailfold capillaries79.40.8<0.001Pulmonary Arterial Hypertension16.33.80.001Pulmonary fibrosis18.86.20.002Raynaud´s phenomenon90.766.9<0.001Anticentromere antibody60.718.9<0.001Scl7012.00<0.001Total Score12.5 (4.8)3.4 (2.9)<0.0001Figure 1.

ROC curve for global score of the ACR/EULAR2013 SSc classification criteria.

Conclusion:

The ACR/EULAR 2013 criteria showed good diagnostic properties in this cohort reflecting daily practice. Individual items showing the highest discriminatory capacity were abnormal capillaroscopy, telangiectasia and anticentromere antibody positivity.

References:

[1]van den Hoogen F, Khanna D, Fransen J, et al. 2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative. Annals of the Rheumatic Diseases 2013;72:1747-1755.

Disclosure of Interests:

None declared

POS0579 LOCAL ADAPTATION OF RECOMMENDATION-BASED MATERIALS FOR SHARED DECISION-MAKING AND MANAGEMENT OF COMORBIDITY IN RHEUMATOID ARTHRITIS

Background:

Evolving the management of rheumatoid arthritis (eRA) is a European-wide educational initiative aiming to support improved patient care through practical and educational tools addressing specific unmet needs. The aims of the eRA program were: (1) To identify priority unmet needs with the greatest impact on disease outcomes; (2) To develop practical, educational and guidance tools in line with EULAR recommendations to address identified unmet needs; and (3) To improve RA management and patient care.

Objectives:

To describe the process by which local adaptations were made of materials derived from evidence-based recommendations in a training programme in rheumatoid arthritis (RA).

Methods:

A multidisciplinary Steering Committee (17 members, 12 countries) identified unmet needs within the management of RA and prioritised those with the greatest impact on patient outcomes. Practical educational tools addressing priority needs were then developed for dissemination and implementation by the rheumatology community across Europe, including shared decision making practises and a checklist for managing comorbidity in RA, among others. These materials were evaluated in detailed and discussed in small regional groups by practicing rheumatologists. Voting, open discussions and recommendations were extracted from the meetings.

Results:

Thirty-five Spanish rheumatologists from diverse geographic regions discussed a comorbidity checklist and a shared decision making tool. The results of the local meetings were synthesised as (1) a judicious commitment to check agreed comorbidities, and (2) a list of barriers and facilitators for the implementation of shared decision making at the local settings. With regards to ways to implement the agreed list and periodicity, two issues standed-out: (1) patient education and (2) the need of easy access to information and the use of local organisational systems in place. With respect to shared decision-making, issues raised included messages for self-awareness, challenges, and practical facilitators.

Conclusion:

Discussion, adaptation, and planning are needed before implementing any evidence-based recommendation and materials if we want to achieve a successful implementation. Further studies should demonstrate whether this initiative was successful in achieving the goals of improved patient care. Our experience could be used as a guidance or example for implementation elsewhere.

Disclosure of Interests:

None declared

POS0812 SUBCLAVIAN ARTERIES INVOLVEMENT IN PATIENTS WITH GIANT CELL ARTERITIS: DO WE NEED A MODIFIED HALO SCORE?

Background:

EULAR recommendations propose temporal and axillary arteries ultrasound (US) as first-line investigation when predominantly cranial giant cell arteritis (GCA) is suspected. Recently, two novel US scoring systems, the halo count and the Southend Halo Score, have been developed to quantify the extent of inflammation by US in GCA.

Objectives:

To assess whether adding the subclavian arteries examination into the ultrasound (US) Southend Halo Score, as proposed in the modified Halo Score, improves the diagnostic accuracy of GCA and its relationship with systemic inflammation.

Methods:

Retrospective observational study of patients referred to a GCA fast track pathway (FTP) over a 1-year period. Patients underwent US exam of temporal and large vessel (LV) (carotid, subclavian and axillary) arteries. The extent of inflammation was measured by the halo count, the Southend Halo Score and the modified Halo Score (Image 1). The gold standard for GCA diagnosis was clinical confirmation after 6 months follow-up.

Results:

64 patients were evaluated in the FTP, 17(26.5%) had GCA. Subclavian arteries involvement was present only in patients with GCA (29.4% versus 0%,p<0.001) (Table 1). Overall, the three scores showed excellent diagnostic accuracy for GCA (ROC AUC 0.906, 0.930 and 0.928, respectively) and moderate correlations with acute phase reactants (0.35-0.51, p<0.01). However, in the subgroup of patients presenting LV involvement, moderate correlations were found between the modified Halo Score and ESR (rho 0.712, p<0.05), haemoglobin (rho 0.703, p<0.05) and platelets (rho 0.734, p<0.05), but not with the other two US scores.

Figure 1.

Proposed scores to quantify the extent of vascular inflammation by ultrasound in giant cell arteritis. A. Halo count, B. Halo Score, C: Modified Halo Score

Table 1.

Clinical, laboratory and ultrasound findings of patients included in the fast track pathway with or without GCA clinical confirmation.

Totaln=64Patients with GCAn=17Patients without GCAn=47pAge, median (IQR)78 (69.3-83)78 (72.5-83)78 (66-83)0.5Female, n (%)42 (65.6%)10 (58.8%)32 (68.1%)0.491Temporal artery biopsy positive n=13, no. of patients5 (38.5%)5 (50%)0 (0%)0.23118F-FDG-PET/CT positive n=14, no. of patients7 (50%)5 (62.5%)2 (33.3%)0.592Fulfilling 1990 GCA criteria, no. of patients16 (25%)8 (47.1%)8 (17%)0.022PMR diagnosis before US examination, no. of patients21 (32.8%)4 (23,5%)17 (36,2%)0.386Headache, no. of patients31 (48.4%)12 (70.6%)19 (40.4%)0.033Jaw claudication, no. of patients12 (18.8%)9 (52.9%)3 (6.4%)<0.001Ocular ischaemia, no. of patients4 (6.3%)2 (11.8%)2 (4.3%)0.285Abnormal TA clinical examination, no. of patients5 (7.8%)3 (17.6%)2 (4.3%)0.112CRP (mg/dL), median (IQR)1.7(0-6.5)7 (2.1-14)1.1 (0-5.1)0.001ESR (mm/h), mean (SD)52.8 (34.6)68.3 (33.3)46.8 (33.3)0.044Haemoglobin (g/dL), mean (SD)12.5 (1.7)11.8 (1.6)12.7 (1.7)0.059Platelets 109/L, mean (SD)276.1 (105.8)323.4 (116.3)258.7 (97.3)0.52Positive US findings, no. of patients17 (26.6%)15 (88.2%)2 (4.3%)<0.001Temporal artery positive US findings, no. of patients13 (20.3%)12 (70.6%)1 (2.1%)<0.001Axillary positive US findings, no. of patients9 (14.1%)8 (47.1%)1 (2.1%)<0.001Subclavian positive US findings, no. of patients5 (7.8%)5 (29.4%)0 (0%)<0.001Temporal artery + axillary or subclavian positive US findings, no. of patients5 (7.9%)5 (29.4%)0 (0%)0.003Halo Count, median (IQR)0 (0-0.75)2 (1-4.5)0 (0-0)<0.001Halo Score, median (IQR)0 (0-4.5)18 (7-22.5))0 (0-0)<0.001Modified Halo Score, median (IQR)0 (0-2.75)8 (3-13.5)0 (0-0)<0.001

Conclusion:

The inclusion of subclavian arteries examination in the modified Halo Score does not improve the diagnostic accuracy of GCA. Nevertheless, it correlates better with markers of systemic inflammation in LV-GCA

Disclosure of Interests:

None declared

POS0055 SARS-COV-2 OUTBREAK IN AUTOIMMUNE DISEASES: THE EURO-COVIMID STUDY

Background:

Coronavirus disease 2019 (COVID-19), has raised several questions in patients with immune-mediated inflammatory diseases (IMID). Whether the seroprevalence and factors associated with symptomatic COVID-19 are similar in IMID patients and in the general population is still unknown.

Objectives:

To assess the serological and clinical prevalence of COVID-19 in European IMID patients, along with the factors associated with its risk and the impacts the pandemic had on the IMID management.

Methods:

Prospective multicentre cross-sectional study among patients with five IMID (i.e. systemic lupus erythematous, Sjögren’s syndrome, rheumatoid arthritis, axial spondylarthritis or giant cell arteritis) from six tertiary-referral centers from France, Germany, Italy, Portugal, Spain and United Kingdom. Demographics, comorbidities, IMID, treatments, flares and COVID-19 details were collected. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serological tests were systematically performed.

Results:

Between June 7 and December 8, 2020, 3028 patients were included (median age 58 years, 73.9% females). SARS-CoV-2 antibodies were detected in 166 (5.5%) patients. Symptomatic COVID-19 was seen in 122 patients (prevalence: 4.0%, 95% CI 3.4-4.8%); 23 (24.2%) of them were hospitalized and four (3.2%) died. In multivariate logistic regression analysis, symptomatic COVID-19 was more likely to be observed in patients with higher levels of C-reactive protein (OR: 1.18; 95% CI 1.05-1.33; p = 0.006), and increased with the number of IMID flares (OR: 1.27; 95% CI 1.02-1.58; p = 0.03). Conversely, it was less likely to occur in patients treated with biological therapy (OR: 0.51; 95% CI 0.32-0.82; p = 0.006). During the pandemic, at least one self-reported disease flare was seen in 654 (21.6%) patients. Also, 519 (20.6%) patients experienced changes in their treatment, with 125 of these (24.1%) being due to COVID-19.

Conclusion:

The SARS-CoV-2 prevalence in IMID patients over the study period seems to be similar to that of the general population1. The IMID inflammatory status seems to be independently associated with the development of COVID-19.

References:

[1]Pollán M, Pérez-Gómez B, Pastor-Barriuso R, Oteo J, Hernán MA, Pérez-Olmeda M, et al. Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study. Lancet Lond Engl. 2020 Aug 22;396(10250):535–44.

Disclosure of Interests:

None declared.

AB0185 ULTRASOUND IN INFLAMMATORY ARTHRALGIA: SHOULD WE ALWAYS SCAN?

Background:

Patients with inflammatory arthralgia (IA) are considered to be at increased risk for progression to RA. Ultrasound (US) has shown high sensitivity to detect synovitis compared with physical examination. Thus, US is recommended to identify subclinical synovitis in patients without clinical signs of inflammation.

Objectives:

To determine the frequency and pattern of US detected active inflammation in patients with IA and investigate factors contributing to predict this outcome.

Methods:

An US clinic is scheduled in an academic center running twice every week. A retrospective analysis of our US unit cohort during a period of 12 months was undertaken. Patients with IA and no previous diagnosis of inflammatory arthropathies were included for analysis. Inclusion criteria of IA definition included: severe symptoms presenting in the morning, duration of morning stiffness ≥60 min, symptoms predominantly located in MCP joints and absence of clinically detected synovitis by the referral rheumatologist. The following routinely collected variables were included in the analysis: demographics, clinical features and laboratory tests. Patients underwent bilateral US examination of hands and/or feet according to the European League Against Rheumatism (EULAR) guidelines. The presence of synovitis and tenosynovitis was assessed on a semi quantitative scale (0–3) for Grey Scale(GS)/Power Doppler(PD). Active inflammation was defined as PD synovitis and/or tenosynovitis >1 at any location. First, differences between groups were tested using chi-squared/Fisher and Student-t tests in the univariate analysis. Second, multivariate logistic regression models were employed to investigate the association between possible predictive factors of US active inflammation.

Results:

A total of 110 patients were included in the analysis. Mean age was 53.6±15.6 years, 80 (72.7%) were females, and mean symptoms duration was 11.7±9.9 months (Table1). A total of 76 (69.1%) patients presented with a polyarticular arthralgia pattern. US active inflammation were present in 38 (34.5%) patients (28.2% showed PD synovitis and 19.1% PD tenosynovitis). Hands were most commonly involved with PD synovitis at wrists in 18.2% and at MCP in 14.5% of patients. For PD tenosynovitis, the flexor MCP 2-5 (4.5%) and 6th extensor tenosynovitis (5.5 %) were the most frequent affected locations. Only 9 (8.2%) patients had erosions in hands and/or feet at baseline examination. In the univariate analysis, the higher ESR values, the shorter time from symptoms onset and the presence of ACPA were significantly associated with the presence of US active inflammation (p<0.001, p=0.035 and p=0.01, respectively). In the multivariate analysis, only ACPA and ESR values (OR=1,0003; 95%CI 1,000-1,006 and OR=1.054; 95%CI 1.016-1.094), remained significantly associated with the detection of US active inflammation.

Conclusion:

US features of active inflammation are found in 1 over 3 patients with IA being PD synovitis the most common finding, specially at the wrists and MCP joints. Higher ESR and ACPA values are significantly associated with the presence of US active inflammation. Thus, we strongly recommend the use of PD US to detect subclinical inflammation in at-risk patients with IA with no sign of inflammation on clinical examination, especially those with high ESR and ACPA values.

Table 1.

Baseline characteristics of patients with IA

Totaln= 110US inflammatoryfindingsn= 38 (34.5%)Non-US inflammatoryfindingsn=72 (65.5%)pAge53.6 ± 15.657.2±16.251.6±13.40.071SexFemale80 (72.7%)26 (68.4%)54 (75%)0.461Smokingn= 87Non smoker45 (51.7%)12 (44.4%)33 (55%)0.412Smoker34 (39.1%)11 (40.7%)23 (38.3%)Former smoker8 (9.2%)4 (14.8%)4 (6.7%)ExtensionMonoarticular12 (10.9%)6 (15.8%)6 (8.3%)0.176Oligoarticular 22 (20%)10 (26.3%)12 (16.7%)Polyarticular76 (69.1%)22 (57.9%) 54 (75%)Time (months)from symptoms onset11.7 ± 9.99.1±8.113±10.50.035ESR (mm/h) n=4524.7 ± 18.233.1±21.820.3 ±14.4<0.001RF (IU/mL) n=5339.1 ± 230.528.5±5645.1±286.10.647ACPA (IU/mL) n=5698.1 ± 331.2209.4±488.426±125.20.01

Disclosure of Interests:

None declared

THU0579 “EVOLVING THE MANAGEMENT OF RA” PROGRAMME: EDUCATIONAL TOOLS TO SUPPORT DAILY PRACTICE

Background:

The eRA (evolving the management of RA) programme was initiated in Europe to provide practical educational tools that address unmet needs in the management of rheumatoid arthritis (RA). Several eRA tools – covering early access to care, management of comorbidities, treat-to-target strategies, and patient empowerment – are available to the rheumatology community. Through ongoing activities, the eRA Steering Committee (SC) identified a need for tools on non-pharmacological management of RA.

Objectives:

To improve accessibility to eRA tools for rheumatology professionals; to review the evidence base of non-pharmacological interventions to create new eRA resources that may support management decisions.

Methods:

A web platform providing information on eRA programme and tools was developed in 2019. The platform collects survey-based metrics to quantify perception of eRA and use of eRA tools in clinical practice. Platform and tools are translated to further support access and use across Europe.

To address unmet needs in non-pharmacological patient management, the eRA SC reviewed the core literature on agreed priority interventions, including physical activity, diet, patient education and self-management, psychosocial interventions, occupational therapy and orthotics, hand exercises, and hydrotherapy/balneotherapy. Available evidence for each intervention was assessed and graded according to the Oxford Centre for Evidence-based Medicine Levels of Evidence.

Results:

The eRA web platform is now live in 3 countries (www.evolvingthemanagementofRA.com), hosting translated copies of the eRA tools, with additional countries launching throughout 2020.

From a review of core literature on non-pharmacological interventions, the eRA SC determined that strong evidence exists to support use of physical activity, patient education and self-management, psychosocial interventions, and occupational therapy and orthotics. Evidence was lacking or conflicting for diet and nutrition, hand exercises, and balneotherapy/hydrotherapy. A set of educational slides was produced by the eRA SC to summarise the evidence (Fig. 1) and provide top-line guidance on use of interventions in practice that should engage relevant members of the multi-disciplinary team. These slides are available through eRA dissemination activities.

Conclusion:

The eRA programme content is now freely available to health care professionals in several countries on a web platform, supported by translations of the eRA tools. An additional slide set on non-pharmacological management serves to further increase the practical guidance of this programme’s educational offering.

Acknowledgments:

The eRA programme is funded by Sanofi Genzyme. Programme direction and content creation are driven by an independent Steering Committee

Disclosure of Interests:

Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Neil Betteridge Consultant of: Amgen, Eli Lilly and Company, Grunenthal, GSK, Sanofi Genzyme, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Patrick Durez Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Pfizer, Sanofi, Ricardo J. O. Ferreira Grant/research support from: Abbvie, Consultant of: Sanofi Genzyme, Amgen, MSD, Paid instructor for: UCB, Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi, Carlomaurizio Montecucco: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Andrea Rubbert-Roth Consultant of: Abbvie, BMS, Chugai, Pfizer, Roche, Janssen, Lilly, Sanofi, Amgen, Novartis, Tanja Stamm Grant/research support from: AbbVie, Roche, Consultant of: AbbVie, Sanofi Genzyme, Speakers bureau: AbbVie, Roche, Sanofi, Zoltán Szekanecz Grant/research support from: Pfizer, UCB, Consultant of: Sanofi, MSD, Abbvie, Pfizer, Roche, Novertis, Lilly, Gedeon Richter, Amgen, Peter C. Taylor Grant/research support from: Celgene, Eli Lilly and Company, Galapagos, and Gilead, Consultant of: AbbVie, Biogen, Eli Lilly and Company, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Roche, and UCB, Mart van de Laar Consultant of: Sanofi Genzyme, Speakers bureau: Sanofi Genzyme

THU0445 PREVALENCE AND INFLUENCE OF DISEASE DURATION IN THE AMOUNT OF ARTICULAR AND PERIARTICULAR DEPOSITS OF MONOSODIUM URATE (MSU) CRYSTALS IN NON-TREATED GOUTY ARTHRITIS PATIENTS

Background:

Monosodium urate crystals deposition arthritis (Gout) is the most prevalent inflammatory arthropathy in our society. The use of muskuloskeletal ultrasound (MSUS) is emerging as a diagnostic method of patients with gout, mainly in the past few years.

Objectives:

Our objective is to establish the prevalence of articular and periarticular ultrasound lesions in patients with known or recent gout diagnosis without urate-lowering therapy (ULT) as well as to analyze the influence of disease duration on these findings.

Methods:

Observational, cross-sectional and descriptive study, including patients with diagnosis of Gout (fulfilling the ACR / EULAR Classification Criteria 2015) between September and November 2019 in our Rheumatology service of a tertiary center. Demographic and clinical records were collected (table 1) and MSUS was performed on each patient systematically by two rheumatologists, exploring a total of 20 structures (8 tendons and 12 joints). Suggestive images of MSU crystals deposition were defined following the OMERACT 2015 ultrasound elementary lesions definitions. Deposits included lesions as tophus, hyperechoic aggregates (HA) and double contour (DC).

Table 1.

Demographic and laboratory data

FeaturesPatients (n=38)%SexMen 34 Women 489,5 10,5Age (years)Mean ±SD 60±14,43ComorbiditiesArterial hypertension18 Mellitus diabetes 4 Dyslipidemia 13 Smoking 7 Alcohol 1447,4 10,5 34,2 18,4 36,8BMI (Kg/m2)Mean±SD 27,3±4,23Blood urate levels (mg/dL)Mean±SD 8,2±1,74Blood creatinine levels (mg/dL)Mean±SD 1,09±0,75

Results:

A total of 38 patients were included, 34 men (89.5%) and 4 women (10.5). Twenty seven (71.1%) presented MSU crystals in synovial fluid samples, while rest of them (28.9%) met 2015 ACR / EULAR Clasiffication Criteria for Gout. Disease duration (since onset of symptoms) was less than 6 months in 20 patients (52.6%) and longer than 6 months in 18 (47.36%). Thirty seven patients (97.36%) presented some type of MSU deposits on the explored areas. One hundred and thirty (17,10%), out of 760 explored locations, had MSU deposits. Patients with disease duration less than 6 months had 56 locations with deposits (43.07%), while those with a symptomathology longer than 6 months had 74 locations with deposits (56.92%). Left knee was the most frequent location of UMS deposits (78.95%). Out of the 145 MSUS images with elementary lesions due to MSU crystal deposits, 28 were tophi (19.31%), 33 HA (22.75) and 84 DC (57.93%). Out of the total images with deposits (DC, HA and tophi), DC in the left knee was the most frequent (21.38%), followed by DC in right knee (17.24%) and DC in 1st MTP (10.24%).

Conclusion:

Almost 100% of patients with recently diagnosed gout without ULT, presented on at least one of the scanned locations MSUS images suggestive by MSU crystals deposition. Most of MSU crystals deposits were on knees and 1st MTP. Patients with non-treated longer than 6 months of disease duration gout had a greater number of MSU crystals deposit locations detected by MSUS. The presence of tophi and HA was statistically higher in patients with disease duration longer than 6 months (table 2).

Table 2.

MSU crystals median locations and MSUS images in both groups

<6months (n,%)>6months (n,%)p valueDeposits locations56 (43,07)74 (56,92)0,0751MSUS images with deposits -Tophi Median, IR () - HA Median, IR () - DC Median, IR ()8 (28,57) 0 (0-0) 7 (21,21) 0 (0-0) 39 (46,43) 0,5 (0-1)20 (71,43) 0 (0-1) 26 (78,79) 0 (0-1) 45 (53,57) 0 (0-2)0,01810,02310,8531

1Mann-Whitney U test comparing medians between both groups IR: interquartile range

References:

[1]Norkuviene E, Petraitis M, Apanaviciene I, Virviciute D and Baranauskaite A. An optimal ultrasonographic diagnostic test for early gout: A prospective controlled study. J Int Med Res. 2017 Aug.

[2]Neogi T, Jansen TLA A, Dalbeth N, Fransen J, Schumacher HR, Berendsen D et al. 2015 Gout Classification Criteria. An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative. Arthritis & Rheumatology. Vol. 67, No. 10, October 2015.

Disclosure of Interests: :

Luis A Torrens Cid: None declared, Juan Molina Collada: None declared, Christian Y Soleto: None declared, Liz R. Caballero Motta: None declared, Ana Melissa Anzola Alfaro: None declared, Alfonso Ariza: None declared, Isabel Castrejón Fernández: None declared, Javier Rivera: None declared, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Juan Carlos Nieto Speakers bureau: Pfizer, Abbvie, MSD, Novartis, Janssen, Lilly, Nordic Pharma, BMS, Gebro, FAES Farma, Roche, Sanofi

AB1116 DOPPLER EVALUATION OF ENTHESITIS SEEMS TO BE A RELEVANT OUTCOME IN THE ASSESSMENT OF ACTIVITY IN SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS

Background:

The assessment of activity in spondyloarthritis (SpA) and psoriatic arthritis (PsA) involves several domains, including enthesitis. Clinical enthesitis evaluation has shown low sensitivity, specificity and reliability. Ultrasound (US) examination of enthesitis can be an accurate and objective way to evaluate this domain, supporting its inclusion in the assessment of the global state of the disease

Objectives:

The main objective of this study is to analyze de prevalence of Doppler enthesitis in active SpA and PsA patients and to evaluate its association with the disease activity at patient level prior to start a biological therapy

Methods:

A prospective multicenter cross-sectional study in patients with SpA and PsA with active disease (defined as patients who were going to start or switch biological therapy according to physician criteria and in agreement with clinical guidelines) was undertaken. Basal assessment included clinical features, physical examination and laboratory tests. Patients underwent bilateral US examination of peripheral entheses according to the MAdrid Sonographic Enthesitis Index (MASEI). MASEI and Outcome Measures in Rheumatology (OMERACT) enthesitis Power Doppler (PD) definitions were checked. Each enthesis was scanned in two planes: longitudinal and transverse, and 5 second videos were recorded for reliability. An inter-reader analysis by three readers was performed at each included center. For statistical analysis Mann-WhitneyU and Kruskal-Wallis tests were used. Intraclass correlation coefficient (ICC) and kappa test were used for reliability

Results:

64 consecutive patients were included, of whom 19(29.7%) were ankylosing spondylitis (AS), 7(10.9%), non-radiographic axial spondyloarthritis (nr-axSpA) and 38(59.4%) PsA patients. Mean age was 52.4±12.5 years and 36(56.3%) were males. Mean DAS28 (3.6±1.3) for peripheral involvement, mean BASDAI (5.6±2.2) for axial involvement, and CRP values (10±10.9) reflect moderate-high disease activity at baseline. Demographic, clinical and MASEI baseline characteristics are shown in Table 1. Mean global MASEI score was 29.4 (±11.4) and 55 patients (86%) scored ≥18 (proposed cut-off point to diagnose SpA). At the patient level, abnormal US findings consistent with at least one enthesis showing PD signal were observed in 52(81.3%) of patients using MASEI PD and 48(75%) using OMERACT PD definition without significant variation among the different SpA subtypes (p=0.8 and p=0.6, respectively). The inter-reader reliability among the two cohorts from each center performed by three readers was high (ICC cohort 1:0.92; cohort 2:0.85) and inter three readers kappa was good (0.92 and 0.86 for Doppler MASEI and Doppler OMERACT respectively).

Table 1.

Baseline characteristics of SpA and PsA patients

Totaln= 64ASn=19 (29.7%)PsAn=38 (59.4%)nr-axSpAn=7 (10.9%)pAge52.4±12.550.3±14.554.6±11.646.3±9.90.2Sex (Male)36 (56.3%)10 (52.6%)23 (60.5%)3 (42.9%)0.6CRP (mg/L)10±10.913.7±11.49±10.96.8±9.10.3VSG (mm/h)17.3±1512.6±7.520.6±1811.9±40.4DAS28 n= 403.6±1.33.1±1.13.9±1.33.2±1.40.2BASDAI n=235.6±2.25.3±2.55.4±0.86.9±0.90.2MASES n=261.1±1.51.1±1.6-1.1±1.30.9MASEI29.4±11.429.1±930±12.826.7±10.40.9MASEI score ≥1855 (85.9%)18 (94.7%)32(84.2%)5(71.4%)0.3Mean number of enthesis with PD OMERACT1.6±1.41.7±1.31.5±1.51.6±1.70.6Mean number enthesis with PD MASEI2.1±1.71.9±1.42.2±1.81.7±1.70.8PD OMERACT ≥148 (75%)15(78.9%)28(73.7%)5(71.4%)0.9PD MASEI ≥152 (81.3%)15(78.9%)32(84.2%)5(71.4%)0.7

Conclusion:

PD enthesitis is found in the vast majority of patients with active SpA and PsA, independent of SpA subtype. MASEI PD might have some advantages versus OMERACT PD definition to detect active enthesitis. These findings support the usefulness of PD US in the assessment of activity in SpA and PsA at patient level.

Disclosure of Interests:

Juan Molina Collada: None declared, Cristina Macía-Villa: None declared, Chamaida Plasencia: None declared, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Eugenio de Miguel Grant/research support from: Yes (Abbvie, Novartis, Pfizer), Consultant of: Yes (Abbvie, Novartis, Pfizer), Paid instructor for: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Speakers bureau: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi)

AB0357 USE OF TOFACITINIB AND REASONS FOR DISCONTINUATION IN CLINICAL PRACTICE

Background:

Tofacitinib is an oral JAK 1 and 3 inhibitor for the treatment of moderate to severe active rheumatoid arthritis (RA) or psoriatic arthritis (PsA) in adults with inadequate response or intolerant to one or more conventional disease-modifying antirheumatic drugs (cDMARDs). Since its approval by the European Medicines Agency (EMA), there is limited data about its use in daily practice in Europe.

Objectives:

To describe rates and reasons for discontinuation of Tofacitinib in patients with RA and other inflammatory conditions

Methods:

We identified patients with a prescription for tofacitinib at our academic center from January 2017 to January 2020. Patients were treated according to their rheumatologist evaluation following standards of care. The following variables were retrospectively collected from the electronic medical chart: age, gender, diagnosis, date of treatment initiation, date and reasons for treatment discontinuation, the use of concomitant or previous cDMARDs and of biologics. A comparison between patients continuing and stopping tofacitinib was performed through chi2or t-test for qualitative and quantitative variables, respectively. Survival analysis was done by Kaplan-Meier method

Results:

Ninety patients receiving tofacitinib were identified, 81 with RA, 6 with PsA, 1 with Dermatomyositis, 1 with Sjögren´s and 1 with juvenile idiopathic arthritis. Table 1 shows the baseline characteristics. 84% percent patients were women and the mean (SD) age was 58.5 (14.2) years. 51% patients started tofacitinib in monotherapy. When used, methotrexate was the most frequent cDMARD (61.3%); 10% patients used tofacitinib as first line after cDMARD and the majority used it after 1 or 2 previous biologics (46.7%).

Table 2.

Clinical coutcome of patients who developed HZ at initiation of baricitinib

All patients(n=90, 100%)Continue Tofacitinib(n=58; 64%)Not continue Tofacitinib(n=32; 35.5%)p-valueFemale (%)76 (84.4)48 (82.7)28 (87.5)0.55Age (year) – mean (SD)58.5 (14.2)58 (12.9)59.5 (16.5)0.63Diagnosis0.66Rheumatoid arthritis81 (90)52 (89.6)29 (90.6)Psoriatic arthritis6 (6.7)4 (6.8)2 (6.2)Other3 (3.3)2 (3.4)1 (3.1)Treatment duration (months) – mean (SD)10.6 (6.9)11.9 (7.3)8.2 (5.5)0.02Prednisone (mg) – mean (SD)1.75 (3.2)1.20 (2.5)2.73 (4.1)0.03Monotherapy (%)46 (51.1)28 (48.2)18 (56.2)0.244Concomitant csDMARDs (%)44 (48.8)30 (51.7)14 (43.7)0.62Methotrexate (%)27 (30)17 (29.3)10 (31.2)Leflunomide (%)10 (11.1)8 (13.7)2 (6.2)Other (%)7 (7.7)5 (8.6)2 (6.2)Prior biologic treatment0.13None (%)9 (10)6 (10.3)3 (9.3)1-2 (%)42 (46.6)28 (48.2)14 (43.7)≥3 (%)39 (43.3)24 (41.3)15 (46.8)

Survival rates when used as first or second line were 85% at 6 months and 70% at 12 months; when used as third line or further, 76% and 70%, respectively (graphic 1).

Factors associated to tofacitinib discontinuation were treatment duration and baseline prednisone dose. In contrast concomitant csDMARD and number of previous biologics were not. Reasons for tofacitinib discontinuation were: lack/loss of efficacy 46.9%, adverse events 50% (including intolerance -22%- herpes zoster -16%-, other infections 12%) and others.

Conclusion:

Tofacitinib in our experience is mostly used in RA patients after biologic failure. Overall survival rate at 12 months was good regardless line of therapy. Adverse event rates were similar to other biologic treatments. Herpes zoster was the most common infectious AE.

Graphic 1:

References:

[1]Wollenhaupt J, Lee EB, Curtis JR, et al. Safety and efficacy of tofacitinib for up to 9.5 years in the treatment of rheumatoid arthritis: final results of a global, open-label, long-term extension study. Arthritis Res Ther. 2019;21(1):89.

Disclosure of Interests:

Christian Y Soleto: None declared, Belén Serrano Benavente: None declared, Luis A Torrens Cid: None declared, Julia Martínez-Barrio Consultant of: UCB Pharma, Juan Molina Collada: None declared, Javier Rivera: None declared, Teresa González: None declared, Indalecio Monteagudo: None declared, Carlos Gonzalez Consultant of: Gilead, Janssen, Novartis,, Speakers bureau: Abbvie, Celgene, Gilead, Janssen, Novartis, Pfizer, Roche, Isabel Castrejon: None declared, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB

AB0205 PREDICTORS OF ULTRASOUND DETECTED INFLAMMATORY FINDINGS IN PATIENTS WITH INFLAMMATORY ARTHRALGIA

Background:

Patients with inflammatory arthralgia (IA) are considered to be at increased risk for progression to RA. US has shown high sensitivity to detect synovitis compared with physical examination. Thus, US is recommended to identify subclinical synovitis in patients without clinical signs of inflammation.

Objectives:

The objective of our study is to determine the frequency and pattern of US detected inflammatory findings in patients with IA and investigate factors contributing to predict these findings.

Methods:

An US clinic is scheduled in an academic center running three days every week. A retrospective analysis of our US unit cohort during a period of 6 months was undertaken. Patients with IA and no previous diagnosis of inflammatory arthropathies were included for analysis. Inclusion criteria of IA definition included: severe symptoms presenting in the morning, duration of morning stiffness ≥60 min, symptoms predominantly located in MCP joints and abscense of clinically detected synovitis by the referral rheumatologist. The following routinely collected variables were included in the analysis: demographics, clinical features and laboratory tests. Patients underwent bilateral US examination in GS and PD mode of hands and/or feet according to the European League Against Rheumatism (EULAR) guidelines. The presence of synovitis, tenosynovitis and enthesitis was assessed on a semi quantitative scale (0–3) for Grey Scale(GS)/Power Doppler(PD) or using enthesitis OMERACT definition, respectively. Patients were stratified in two groups based on the presence of US inflammatory findings (synovitis, tenosynovitis or enthesitis with PD signal). First, differences between groups were tested using chi-squared and Student-t tests in the univariate analysis. Second, multivariate logistic regression models were employed to investigate the association between possible predictive factors of US detected inflammatory findings.

Results:

A total of 57 patients were included in the analysis. Mean age was 55.8±15.2 years, 41 (71.9%) were females, and mean symptoms duration was 11.4±10.4 months (Table 1). A total of 42 (73.7%) patients presented with a polyarticular arthralgia pattern. US inflammatory findings were present in 20 (35.1%) patients (26.3% PD synovitis, 21.1% PD tenosynovitis and 3.5% PD enthesitis). Hands were most commonly involved with PD synovitis at wrists in 19.3% and at MCP in 12.3% of patients (Table 2). For PD tenosynovitis, the flexor MCP 2-5 (5.3%) and compartment IV tenosynovitis (1.8 %) were the most frequent affected locations. Only two patients had PD enthesitis at feet and 6 (10.5%) had erosions in hands or feet at baseline examination. In the univariate analysis, the higher ESR values and the shorter time from symptoms onset were significantly associated with US detected inflammatory findings (p=0.044 and 0.049, respectively). In the multivariate analysis, only ESR values (OR=1,04; 95%CI 1,002-1,078), remained significantly associated with the presence of US inflammatory findings (Table 3).

Table 3.

Independent predictors of US detected inflammatory findings

pOdds ratio95% C.I.LowerUpperESR (mm/h)0.0391.041.0021.078Time (months) from symptoms onset0.10.9240.8411.015

Conclusion:

PD US inflammatory findings are found in 1 over 3 patients with IA being PD synovitis the most common finding, specially at the wrists and MCP joints. Higher ESR values were significantly associated with the presence of US inflammatory findings. Our data highlights how the use of PD US may be useful to detect subclinical synovitis in patients with IA.

Disclosure of Interests:

Katerine López Gloria: None declared, Isabel Castrejon: None declared, Laura Trives Folguera Speakers bureau: ROCHE, Juan Carlos Nieto Speakers bureau: Pfizer, Abbvie, MSD, Novartis, Janssen, Lilly, Nordic Pharma, BMS, Gebro, FAES Farma, Roche, Sanofi, Belén Serrano Benavente: None declared, Julia Martínez-Barrio Consultant of: UCB Pharma, Javier Rivera: None declared, Carlos Gonzalez Consultant of: Gilead, Janssen, Novartis,, Speakers bureau: Abbvie, Celgene, Gilead, Janssen, Novartis, Pfizer, Roche, Indalecio Monteagudo: None declared, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Juan Molina Collada: None declared

SAT0607-HPR MULTIDISCIPLINARY CARE CLINIC FOR PATIENTS WITH IMMUNITY MEDIATED INFLAMMATORY DISEASES. FIRST YEAR OF COORDINATED MANAGEMENT

Background:

Patients with immunity mediated inflammatory diseases (IMID) often have clinical manifestations and comorbidity in the field of various medical specialties. A center has been created in our hospital for the comprehensive care of patients with IMID who are being treated with biological therapies (BT) or targeted synthetic molecules (TSM). It is an innovative healthcare model, that incorporate patients into its governance. Physicians, pharmacists and advanced practice nurses (APN), collaborates in consultation or in the day hospital (DH).

Objectives:

To analyze the activity developed during the first year of operation of the center, with special attention to effectiveness, efficiency, interdisciplinary relationships and patient satisfaction.

Methods:

Observational analysis with indicators of management and monitoring of patients, care activity, effectiveness, adverse effects, resource consumption and patient satisfaction using the hospital’s own information systems.

Results:

Center staff during 2019: two admission assistants, one nursing assistant, six nurses, seven part-time doctors and three pharmacists. 1,490 patients were included: 694 (46.6%) Rheumatology (Rheu), 585 (39.3%) Digestive (Dig) and 211 (14.1%) Dermatology (Der) generated 11,363 medical consultations, 14,850 APN consultations and 3,920 treatment sessions in the DH. IV treatment 529/1490 (35.5%) patients (45.0% Reu, 53.9% Dig, 1.1% Der). Patients with rheumatic diseases: rheumatoid arthritis: 339/694, 48.8%; Spondyloarthritis: 226/694, 32.6%; psoriatic arthritis: 117/694, 16.9%; and juvenile idiopathic arthritis: 12/694, 1.7%. 217/1490 (14.6%) patients needed multidisciplinary consultations.

Table 1. shows the most relevant indicators and table 2 shows the patient satisfaction survey for 2019.

Table 1.

relevant indicators

RHEUDIGDEROn demand consultations 2019 %21.0%34.2%14.3%Teleconsultations 2019 %17.8%41.9%0.0%BT, TSM tapering. %201931.9%0.2%45,5%201818.9%0.2%13.4%BT, TSM intensification. %20195.8%35.2%0.5%20182.6%36.5%0.5%Biosimilars %201943.1%48.5%15.9%201830.4%4.0%12.1%Adherence>90% 2019 %89.4%91.7%86.4%Remission 2019 %47.8%67.3%78.5%hospital admission, any cause pat-years20191.41.70.120181.51.50.04emergency admission, any cause pat-years20192.12.11.620182.12.01.5Table 2.

patient satisfaction survey

CategoríaMean and (DS) 1-5General aspects of the center4.3 (0.9)Physicians4.5 (1.1)DH and APN4.5 (1.2)Pharmacy4.6 (0.9)Health proffesional coordinaton4.4 (0.9)Hospital global satisfaction4.3 (0.8)

Conclusion:

From previous situation there is an increase in interdisciplinary consultations and HD activity maintenance without an increase in human resources. Efficiency (tapering, biosimilars) and patient and staff satisfaction have improved. However, no improvement in adverse effects has been observed, which is an area of improvement. Effectiveness is good, waiting to compare with the previous year. Nutrition and preventive medicine consultations has not been evaluated because have been recently established. Other indicators are being analyzed at the end of the submission deadline.

The impact of this pioneering management model, with a holistic approach and incorporating patients into its governance, is difficult to measure until its implementation is completed. Uveitis and psychology consultations and patient school starting in 2020 will improve the quality of IMID patient care, as well as their satisfaction and that of their relatives.

Disclosure of Interests:

Carlos Gonzalez Consultant of: Gilead, Janssen, Novartis,, Speakers bureau: Abbvie, Celgene, Gilead, Janssen, Novartis, Pfizer, Roche, Luis Alberto Menchén Viso Grant/research support from: Abbvie, Janssen, MSD, Takeda, Consultant of: Abbvie, Janssen, Takeda, MSD, Medtronic, Tillotts, Pfizer, Dr. Falk Pharma, Speakers bureau: Abbvie, Janssen, Takeda, MSD, General Electric, Tillotts, Pfizer, Ferring, General Electric, Fresenius, Ofelia Baniandrés Rodríguez: None declared, Ignacio Marín-Jiménez Consultant of: AbbVie,Chiesi,FAES Farma,Falk-Pharma,Ferring,Gebro Pharma, Hospira,Janssen,MSD,Otsuka Pharmaceutical,Pfizer,Shire,Takeda,Tillots and UCB Pharma, Speakers bureau: AbbVie,Chiesi,FAES Farma,FalkPharma,Ferring,Gebro Pharma,Hospira,Janssen,MSD,Otsuka Pharmaceutical,Pfizer,Shire,Takeda,Tillots and UCB Pharma, Juan Carlos Nieto Speakers bureau: Pfizer, Abbvie, MSD, Novartis, Janssen, Lilly, Nordic Pharma, BMS, Gebro, FAES Farma, Roche, Sanofi, Indalecio Monteagudo: None declared, Arantza Ais Larisgoitia: None declared, Esther Chamorro de Vega: None declared, Elena Lobato Matilla: None declared, Rosa Romero Jiménez: None declared, Ana Herranz Alonso: None declared, Carmen Lobo Rodríguez: None declared, María Prado Simón Moreno: None declared, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Sonia García de San José: None declared

AB1117 CLINICAL IMPACT OF MUSCULOSKELETAL ULTRASOUND ON RHEUMATOID ARTHRITIS IN ROUTINE CLINICAL PRACTICE

Background:

Musculoskeletal ultrasound (MSUS) is a useful tool to assess disease activity in rheumatoid arthritis (RA) patients. However, it has not yet been established if its use would change treatment decisions within a treat to target strategy or whether it would lead to better outcomes in RA patients

Objectives:

Our aim was to determine the impact of MSUS in the clinical management of RA patients and investigate factors associated with subsequent clinical actions by the referring rheumatologist

Methods:

A prospective analysis of RA patients seen at an MSUS clinic over a 6-month period was undertaken. Pre- and post-US follow-up data (± 3 months) were analyzed. Baseline assessment included clinical features, physical examination and laboratory tests. All MSUS examinations were performed according to EULAR guidelines and using an Esaote MyLab 8 (Esaote, Genoa) with a high frequency (8-15 MHz) transducer. Patients were stratified in groups based on the clinical impact of the MSUS visit: 1) No clinical impact and 2) US findings leading to subsequent clinical action by the referring rheumatologist (including changes in dosages of current rheumatologic treatments, addition/substraction of medications or interventional procedures based on the MSUS results). First, differences between groups were tested using chi-squared and Student-t tests in the univariate analysis. Second, multivariate logistic regression models were employed to investigate factors associated to a change in clinical management

Results:

A total of 61 RA patients were included for analysis. Mean age was 61.9± 11.4 years and 51 (83.6%) were female. Disease activity assessment was the most frequent referral reason (43; 70.5%). Overall, MSUS led to a subsequent therapeutic action by the referring rheumatologist in 39 (63.9%) patients, and to a change in the underlying diagnosis and/or in the clinical impression of the chief complaint that generated the referral in 7 (11.5%) patients. Baseline characteristics between both groups are compared in Table 1. In the univariate analysis, the detection of Power Doppler (PD) synovitis/tenosynovitis and 28 swollen joint count were significantly associated with a subsequent clinical action. In the multivariate analysis only PD synovitis/tenosynovitis (OR=3.28; 95%CI 1.06-10.27) remained significantly associated with a change in clinical management (Table 2)

Table 1.

Baseline characteristics of RA patients

Total n= 61Change in clinical management n= 39 (63.9%)No change in clinical management n= 22 (36.1%)pAge61.9±11.461.5±12.562.6±9.20.7SexFemale51(83.6%)35(89.7%)16(72.7%)0.09SmokingNon smoker33(54.1%)17(43.6%)16(72.7%)0.08Smoker13(21.3%)11(28.2%)2(9.1%)Former smoker15(24.6%)11(28.2%)13(21.3%)Radiographic erosions29(48.3%)22(57.9%)7(31.8%)0.0528 Tender Joint Count2.3±3.42.7±3.91.6±2.40.228 Swollen Joint Count2±32.6±3.51.1±1.6<0.05ESR (mm/h)28.1±20.626.1±15.531.7±27.40.4CRP (g/L)1±1.51±1.40.9±1.70.7RF (IU/mL)175.8±452.8139.9±249.5243.9±697.40.4ACPA (IU/mL)775.6±998.6619.4±797.11079.9±1,275.90.2US PD synovitis/tenosynovitis37(60.7%)28(71.8%)9(40.9%)<0.05Table 2.

Independent factors associated with a change in clinical management based on logistic regression model

pOdds ratio95% C.I.LowerUpper28 Tender Joint Count0.131.240.941.64US PD synovitis/tenosynovitis0.043.281.0610.17

Conclusion:

The most common indication of MSUS examination in RA patients was disease activity assessment. MSUS findings led frequent changes in therapeutic management and even to a change in the diagnosis in some of cases. The presence of PD synovitis/tenosynovitis was significantly associated to a change in the therapeutic management. These data highlight the impact of MSUS inflammatory findings in RA patients in daily clinical practice

Disclosure of Interests:

Juan Molina Collada: None declared, María Pérez: None declared, Isabel Castrejon: None declared, Juan Carlos Nieto Speakers bureau: Pfizer, Abbvie, MSD, Novartis, Janssen, Lilly, Nordic Pharma, BMS, Gebro, FAES Farma, Roche, Sanofi, Teresa González: None declared, Javier Rivera: None declared, Carlos Gonzalez Consultant of: Gilead, Janssen, Novartis,, Speakers bureau: Abbvie, Celgene, Gilead, Janssen, Novartis, Pfizer, Roche, Indalecio Monteagudo: None declared, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB

SAT0566 ULTRASOUND DOPPLER MASEI SHOWS SENSITIVITY TO CHANGE AFTER BIOLOGICAL THERAPY IN SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS PATIENTS

Background:

The assessment of activity in spondyloarthritis (SpA) and psoriatic arthritis (PsA) involves several domains, including enthesitis. Clinical enthesitis has shown low sensitivity, specificity and reliability. The MAdrid Sonographic Enthesitis Index (MASEI) is a feasible and reliable ultrasound score, but its responsiveness to treatment has not yet been evaluated.

Objectives:

The main objective of this study was to investigate the sensitivity to change of MASEI in active SpA and PsA patients.

Methods:

Longitudinal study in patients with SpA and PsA with active disease (defined as patients who were going to start or switch biologic disease modifying antirheumatic drugs (bDMARD) therapy according to physician criteria and in agreement with clinical guidelines). MASEI evaluation was performed at baseline, 3- and 6-months visits. MASEI and Outcome Measures in Rheumatology (OMERACT) enthesitis Power Doppler (PD) definitions were checked. Each enthesis was scanned in both the longitudinal and transverse planes, and 5 second videos were recorded for reliability. An inter-reader analysis by three readers was performed. For statistical analysis t-Student test was used to determine changes between visits and kappa test was used for reliability.

Results:

A total of 72 US evaluations of 25 patients were included, of whom 13(52%) were ankylosing spondylitis (AS) patients, 9(36%) PsA, and 3(12%) non radiographic axial spondyloarthritis (nr-axSpA). Mean age was 51.2±14.1 years and 13(52%) were females. Mean DAS28 (3.5±1.2) for peripheral involvement, mean BASDAI (5.8±2) for axial involvement, and CRP values (13.1±13.6) reflect moderate-high disease activity at baseline. US parameters at baseline and at the 3- and 6-month follow-up visits are shown in Table 1. Global MASEI score was responsive at the 3- and 6-month follow-up visit (-4.9 and -5.7, respectively) (p<0.05) and both MASEI and OMERACT PDUS definitions of active enthesitis improved significantly at 3- (-0.6 and -1.1) and 6-month follow-up visits (-0.7 and -1.1) (p<0.05). Reliability of PD MASEI definition among the three readers was excellent (kappa = 0.918).

Table 1.

MASEI evaluation at baseline, 3- and 6-month follow-up visits

ParameterBaselinen=253 monthsn=25Pa6 monthsn=22PaMASEI score28±9.323.2±7.60.00224.7±8.10.01PD US MASEI score1.8 ±1.31.1±1.10.0461±0.90.004PD US OMERACT score1.6±1.20.9±0.90.0240.8±0.90.006

at-Student test for comparison to baseline

Conclusion:

MASEI score significantly improves at 3 and 6 months of follow up in patients under bDMARD treatment and both MASEI and OMERACT Doppler definitions of active enthesitis reflects treatment response. These findings support the usefulness of PD US in the assessment of bDMARD treatment response in SpA and PsA.

Disclosure of Interests:

Juan Molina Collada: None declared, Cristina Macía-Villa: None declared, Chamaida Plasencia: None declared, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Eugenio de Miguel Grant/research support from: Yes (Abbvie, Novartis, Pfizer), Consultant of: Yes (Abbvie, Novartis, Pfizer), Paid instructor for: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Speakers bureau: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi)

Aggressive transformation of a quiescent primary bone lymphoma simulating Paget's disease

Primary multifocal osseous lymphoma is a rare and poorly recognized entity. Here, we present an instructive case of a young man who, six years after a local contusion of the left ankle, developed a painful polylobulated large soft tissue mass. This mass turned out to have arisen from the transformation of a centro follicular non-Hodgkin's lymphoma into a diffuse large B-cell lymphoma involving the calcaneus, talus, cuboid and navicular bones. The diagnostic difficulties as well as the implications of this aggressive transformation are highlighted here.

Licofelone--clinical update on a novel LOX/COX inhibitor for the treatment of osteoarthritis

Licofelone, a competitive inhibitor of 5-lipoxygenase, cyclooxygenase (COX)-1 and COX-2, is currently in clinical development for the treatment of osteoarthritis (OA). Licofelone decreases the production of proinflammatory leukotrienes and prostaglandins-which are involved in the pathophysiology of OA and in gastrointestinal (GI) damage induced by NSAIDs-and has the potential to combine good analgesic and anti-inflammatory effects with excellent GI tolerability. Initial endoscopy data in healthy volunteers have demonstrated that licofelone is well tolerated and has a GI safety profile similar to placebo and significantly better than naproxen. These tolerability results were confirmed in patients with OA in two separate randomized studies. Furthermore, a long-term study (52 weeks) has shown that licofelone is at least as effective as naproxen in the treatment of OA. Licofelone also appears to be as effective as the selective COX-2 inhibitor celecoxib in the treatment of the signs and symptoms of OA. Licofelone has a GI safety profile similar to that of celecoxib, but may offer the advantage of fewer incidences or worsening of peripheral oedema. Preliminary data have also shown that licofelone coadministration with low-dose aspirin does not lead to increased GI toxicity. The emerging clinical data for licofelone indicate that it is an effective and well-tolerated therapy that could offer safety advantages over current treatment options, and that it could be suitable for the long-term treatment of a broad spectrum of patients with OA.

Treatment of rheumatoid arthritis with recombinant human interleukin-1 receptor antagonist

OBJECTIVE

To evaluate the efficacy and safety of interleukin-1 receptor antagonist (IL-1Ra) in patients with rheumatoid arthritis (RA).

METHODS

Patients with active and severe RA (disease duration <8 years) were recruited into a 24-week, double-blind, randomized, placebo-controlled, multicenter study. Doses of nonsteroidal antiinflammatory drugs and/or oral corticosteroids (< or =10 mg prednisolone daily) remained constant throughout the study. Any disease-modifying antirheumatic drugs that were being administered were discontinued at least 6 weeks prior to enrollment. Patients were randomized to 1 of 4 treatment groups: placebo or a single, self-administered subcutaneous injection of IL-1Ra at a daily dose of 30 mg, 75 mg, or 150 mg.

RESULTS

A total of 472 patients were recruited. At enrollment, the mean age, sex ratio, disease duration, and percentage of patients with rheumatoid factor and erosions were similar in the 4 treatment groups. The clinical parameters of disease activity were similar in each treatment group and were consistent with active and severe RA. At 24 weeks, of the patients who received 150 mg/day IL-1Ra, 43% met the American College of Rheumatology criteria for response (the primary efficacy measure), 44% met the Paulus criteria, and statistically significant improvements were seen in the number of swollen joints, number of tender joints, investigator's assessment of disease activity, patient's assessment of disease activity, pain score on a visual analog scale, duration of morning stiffness, Health Assessment Questionnaire score, C-reactive protein level, and erythrocyte sedimentation rate. In addition, the rate of radiologic progression in the patients receiving IL-1Ra was significantly less than in the placebo group at 24 weeks, as evidenced by the Larsen score and the erosive joint count. IL-1Ra was well tolerated and no serious adverse events were observed. An injection-site reaction was the most frequently observed adverse event, and this resulted in a 5% rate of withdrawal from the study among those receiving IL-1Ra at 150 mg/day.

CONCLUSION

This study confirmed both the efficacy and the safety of IL-1Ra in a large cohort of patients with active and severe RA. IL-1Ra is the first biologic agent to demonstrate a beneficial effect on the rate of joint erosion.

Treatment of rheumatoid arthritis with recombinant human interleukin-1 receptor antagonist

OBJECTIVE

To evaluate the efficacy and safety of interleukin-1 receptor antagonist (IL-1Ra) in patients with rheumatoid arthritis (RA).

METHODS

Patients with active and severe RA (disease duration <8 years) were recruited into a 24-week, double-blind, randomized, placebo-controlled, multicenter study. Doses of nonsteroidal antiinflammatory drugs and/or oral corticosteroids (< or =10 mg prednisolone daily) remained constant throughout the study. Any disease-modifying antirheumatic drugs that were being administered were discontinued at least 6 weeks prior to enrollment. Patients were randomized to 1 of 4 treatment groups: placebo or a single, self-administered subcutaneous injection of IL-1Ra at a daily dose of 30 mg, 75 mg, or 150 mg.

RESULTS

A total of 472 patients were recruited. At enrollment, the mean age, sex ratio, disease duration, and percentage of patients with rheumatoid factor and erosions were similar in the 4 treatment groups. The clinical parameters of disease activity were similar in each treatment group and were consistent with active and severe RA. At 24 weeks, of the patients who received 150 mg/day IL-1Ra, 43% met the American College of Rheumatology criteria for response (the primary efficacy measure), 44% met the Paulus criteria, and statistically significant improvements were seen in the number of swollen joints, number of tender joints, investigator's assessment of disease activity, patient's assessment of disease activity, pain score on a visual analog scale, duration of morning stiffness, Health Assessment Questionnaire score, C-reactive protein level, and erythrocyte sedimentation rate. In addition, the rate of radiologic progression in the patients receiving IL-1Ra was significantly less than in the placebo group at 24 weeks, as evidenced by the Larsen score and the erosive joint count. IL-1Ra was well tolerated and no serious adverse events were observed. An injection-site reaction was the most frequently observed adverse event, and this resulted in a 5% rate of withdrawal from the study among those receiving IL-1Ra at 150 mg/day.

CONCLUSION

This study confirmed both the efficacy and the safety of IL-1Ra in a large cohort of patients with active and severe RA. IL-1Ra is the first biologic agent to demonstrate a beneficial effect on the rate of joint erosion.

Transient osteoporosis of the hip: successful response to deflazacort

Transient osteoporosis of the hip (TOH) is an uncommon condition with a poorly defined aetiology. Despite its benign prognosis, its long clinical course causes a prolonged period of functional disability in middle-aged patients. We describe two patients with TOH who showed a rapid response to deflazacort, a bone-sparing corticoid. Deflazacort may become a useful tool to shorten the otherwise lengthy recovery period of TOH.

Mutual antagonism between interferon-gamma and tumor necrosis factor-alpha on fibroblast-like synoviocytes: paradoxical induction of IFN-gamma and TNF-alpha receptor expression

We recently described mutual antagonism between IFN-gamma and TNF-alpha on human fibroblast-like synoviocytes (FLS). TNF-alpha inhibits IFN-gamma-induced HLA-DR expression and IFN-gamma blocks TNF-alpha-dependent synoviocyte proliferation, collagenase production, and GM-CSF secretion. To study the mechanism of antagonism we have analyzed the effect these factors on the expression of cytokine surface receptors. 125I-Labeled cytokine binding was measured on cultured FLS and the results were analyzed by Scatchard plots. Unstimulated synoviocytes expressed 9300 +/- 1560 IFN-gamma binding sites per cell. A single class of high-affinity receptor was observed (Kd = 4.5 +/- 2.5 x 10(-10) M). TNF-alpha did not competitively inhibit 125I-IFN-gamma binding. When FLS were incubated with TNF-alpha (100 ng/ml), there was a paradoxical 49.5 +/- 5.6% increase in the number of binding sites for IFN-gamma (P = 0.001), with no change in the Kd. Unstimulated FLS also expressed 2850 +/- 700 TNF-alpha receptors per cells, with a single Kd consistent with the lower-affinity TNF-alpha receptor (7.4 +/- 0.2 x 10(-10) M). IFN-gamma did not directly interfere with TNF-alpha binding. Preincubation of FLS with 100 U/ml of IFN-gamma resulted in a 28.9 +/- 9.0% increase in TNF-alpha receptor expression (P < 0.008), with no change in the Kd. Low levels of the soluble 55-kD TNF receptor were detected in FLS supernatants. IFN-gamma did not effect soluble TNF receptor production.(ABSTRACT TRUNCATED AT 250 WORDS)

Alpha 4/beta 1 integrin (VLA-4) ligands in arthritis. Vascular cell adhesion molecule-1 expression in synovium and on fibroblast-like synoviocytes

Expression of vascular cell adhesion molecule-1 (VCAM-1) in synovial tissue was determined using the immunoperoxidase technique. Normal, rheumatoid arthritis (RA), and osteoarthritis (OA) synovia bound VCAM-1 antibodies in the intimal lining as well as blood vessels. The amount of VCAM-1 was significantly greater in the synovial lining of RA and OA tissues compared with normal synovium (p less than 0.002). There was also a trend toward greater levels of VCAM-1 staining in blood vessels of arthritic tissue (RA greater than OA greater than normal). Because VCAM-1 staining was especially intense in the synovial lining, VCAM-1 expression and regulation was studied on cultured fibroblast-like synoviocytes (FLS) derived from this region. Both VCAM-1 and intercellular adhesion molecule 1 were constitutively expressed on FLS. VCAM-1 expression was further increased by exposure to IL-1 beta, TNF-alpha, IL-4, and IFN-gamma. These cytokines (except for IL-4) also induced intercellular adhesion molecule 1 expression on FLS. ELAM was not detected on resting or cytokine-stimulated FLS. The specificity of VCAM-1 for FLS was demonstrated by the fact that only trace amounts were detected on normal and RA dermal fibroblasts. Cytokines induced intercellular adhesion molecule 1 display on dermal fibroblasts but had minimal effect on VCAM-1 expression. Finally, in adherence assays, Jurkat cell binding to resting FLS monolayers was inhibited by antibody to alpha 4/beta 1 integrin (VLA-4), CS-1 peptide from alternatively spliced fibronectin (which is another VLA-4 ligand), and, to a lesser extent, anti-VCAM-1 antibody. After cytokine stimulation of FLS, Jurkat-binding significantly increased, and this increase was blocked by anti-VCAM-1 antibody. Therefore, both CS-1 and VCAM-1 participate in VLA-4-mediated adherence to resting FLS in vitro, and VCAM-1 is responsible for the increase in Jurkat binding mediated by cytokines.

Alpha 4/beta 1 integrin (VLA-4) ligands in arthritis. Vascular cell adhesion molecule-1 expression in synovium and on fibroblast-like synoviocytes

Expression of vascular cell adhesion molecule-1 (VCAM-1) in synovial tissue was determined using the immunoperoxidase technique. Normal, rheumatoid arthritis (RA), and osteoarthritis (OA) synovia bound VCAM-1 antibodies in the intimal lining as well as blood vessels. The amount of VCAM-1 was significantly greater in the synovial lining of RA and OA tissues compared with normal synovium (p less than 0.002). There was also a trend toward greater levels of VCAM-1 staining in blood vessels of arthritic tissue (RA greater than OA greater than normal). Because VCAM-1 staining was especially intense in the synovial lining, VCAM-1 expression and regulation was studied on cultured fibroblast-like synoviocytes (FLS) derived from this region. Both VCAM-1 and intercellular adhesion molecule 1 were constitutively expressed on FLS. VCAM-1 expression was further increased by exposure to IL-1 beta, TNF-alpha, IL-4, and IFN-gamma. These cytokines (except for IL-4) also induced intercellular adhesion molecule 1 expression on FLS. ELAM was not detected on resting or cytokine-stimulated FLS. The specificity of VCAM-1 for FLS was demonstrated by the fact that only trace amounts were detected on normal and RA dermal fibroblasts. Cytokines induced intercellular adhesion molecule 1 display on dermal fibroblasts but had minimal effect on VCAM-1 expression. Finally, in adherence assays, Jurkat cell binding to resting FLS monolayers was inhibited by antibody to alpha 4/beta 1 integrin (VLA-4), CS-1 peptide from alternatively spliced fibronectin (which is another VLA-4 ligand), and, to a lesser extent, anti-VCAM-1 antibody. After cytokine stimulation of FLS, Jurkat-binding significantly increased, and this increase was blocked by anti-VCAM-1 antibody. Therefore, both CS-1 and VCAM-1 participate in VLA-4-mediated adherence to resting FLS in vitro, and VCAM-1 is responsible for the increase in Jurkat binding mediated by cytokines.

Cytokines in chronic inflammatory arthritis. VI. Analysis of the synovial cells involved in granulocyte-macrophage colony-stimulating factor production and gene expression in rheumatoid arthritis and its regulation by IL-1 and tumor necrosis factor-alpha

Granulocyte-macrophage CSF (GM-CSF) is a potent stimulator of macrophages and neutrophils and is produced by rheumatoid arthritis (RA) synovium. We now report studies that identify some of the synovial cells and cytokines responsible for local GM-CSF production and gene expression in RA. GM-CSF was assayed by ELISA in supernatants from cultured RA fibroblast-like synoviocytes stimulated with various cytokines (IL-1 beta, TNF-alpha, macrophage-CSF, IFN-gamma, IL-6, and TGF-beta). Immunoreactive GM-CSF was detected in IL-1 beta and TNF-alpha-stimulated cultures, but not in cells cultured in medium or stimulated with any of the other cytokines. IL-1 and TNF-alpha had a synergistic effect on GM-CSF production. GM-CSF gene expression by fibroblast-like synoviocytes was analyzed by ribonuclease protection assay, Northern blot analysis, and in situ hybridization. Both IL-1 beta and TNF-alpha induced GM-CSF mRNA accumulation, with a maximum effect after 4 h of stimulation. We then studied GM-CSF production by macrophage-like synoviocytes (MLS) isolated from fresh synovial specimens by flow microfluorimetry. Fresh MLS spontaneously secreted the cytokine and exogenous IL-1 beta or TNF-alpha had no effect. After 1 wk in culture, additional stimulation with IL-1 beta or TNF-alpha was required for GM-CSF production. Finally, in situ hybridization performed on freshly isolated subpopulations of synovial cells, identified GM-CSF RNA transcripts in MLS.

Cytokines in chronic inflammatory arthritis. VI. Analysis of the synovial cells involved in granulocyte-macrophage colony-stimulating factor production and gene expression in rheumatoid arthritis and its regulation by IL-1 and tumor necrosis factor-alpha

Granulocyte-macrophage CSF (GM-CSF) is a potent stimulator of macrophages and neutrophils and is produced by rheumatoid arthritis (RA) synovium. We now report studies that identify some of the synovial cells and cytokines responsible for local GM-CSF production and gene expression in RA. GM-CSF was assayed by ELISA in supernatants from cultured RA fibroblast-like synoviocytes stimulated with various cytokines (IL-1 beta, TNF-alpha, macrophage-CSF, IFN-gamma, IL-6, and TGF-beta). Immunoreactive GM-CSF was detected in IL-1 beta and TNF-alpha-stimulated cultures, but not in cells cultured in medium or stimulated with any of the other cytokines. IL-1 and TNF-alpha had a synergistic effect on GM-CSF production. GM-CSF gene expression by fibroblast-like synoviocytes was analyzed by ribonuclease protection assay, Northern blot analysis, and in situ hybridization. Both IL-1 beta and TNF-alpha induced GM-CSF mRNA accumulation, with a maximum effect after 4 h of stimulation. We then studied GM-CSF production by macrophage-like synoviocytes (MLS) isolated from fresh synovial specimens by flow microfluorimetry. Fresh MLS spontaneously secreted the cytokine and exogenous IL-1 beta or TNF-alpha had no effect. After 1 wk in culture, additional stimulation with IL-1 beta or TNF-alpha was required for GM-CSF production. Finally, in situ hybridization performed on freshly isolated subpopulations of synovial cells, identified GM-CSF RNA transcripts in MLS.

Cytokines in chronic inflammatory arthritis. V. Mutual antagonism between interferon-gamma and tumor necrosis factor-alpha on HLA-DR expression, proliferation, collagenase production, and granulocyte macrophage colony-stimulating factor production by rheumatoid arthritis synoviocytes

The effects of a broad array of cytokines, individually and in combination, were determined on separate functions (proliferation, collagenase production, and granulocyte macrophage colony-stimulating factor [GM-CSF] production) and phenotype (expression of class II MHC antigens) of cultured fibroblast-like RA synoviocytes. The following recombinant cytokines were used: IL-1 beta, IL-2, IL-3, IL-4, IFN-gamma, tumor necrosis factor (TNF)-alpha, GM-CSF, and macrophage colony-stimulating factor (M-CSF). Only IFN-gamma induced HLA-DR (but not HLA-DQ) expression. TNF-alpha inhibited IFN-gamma-mediated HLA-DR expression (46.7 +/- 4.1% inhibition) and HLA-DR mRNA accumulation. This inhibitory effect was also observed in osteoarthritis synoviocytes. Only TNF-alpha and IL-1 increased synoviocyte proliferation (stimulation index 3.60 +/- 1.03 and 2.31 +/- 0.46, respectively). IFN-gamma (but none of the other cytokines) inhibited TNF-alpha-induced proliferation (70 +/- 14% inhibition) without affecting the activity of IL-1. Only IL-1 beta and TNF-alpha induced collagenase production (from less than 0.10 U/ml to 1.10 +/- 0.15 and 0.72 +/- 0.24, respectively). IFN-gamma decreased TNF-alpha-mediated collagenase production (69 +/- 19% inhibition) and GM-CSF production but had no effect on the action of IL-1. These data demonstrate mutual antagonism between IFN-gamma and TNF-alpha on fibroblast-like synoviocytes and suggest a novel homeostatic control mechanism that might be defective in RA where very little IFN-gamma is produced.

Quantitative analysis of cytokine gene expression in rheumatoid arthritis

Previous studies of the cytokine profile of rheumatoid arthritis (RA) have been primarily limited to the assessment of the levels of these mediators in synovial fluid (SF) or synovial tissues (ST) by biologic or immunologic assays. We have studied cytokine gene expression in RA by in situ hybridization of SF cells, enzymatically dispersed ST cells, and frozen sections of ST. RA ST cells (n = 7) were studied and a high percentage of cells hybridized to the following anti-sense probes: IL-6 = 19 +/- 3.3%; IL-1 beta = 9.9 +/- 1.7%; TNF-alpha = 5.8 +/- 1.4%; granulocyte-macrophage-CSF = 2.2 +/- 0.8%; transforming growth factor-beta 1 = 1.3 +/- 0.2% (p less than 0.05 for each compared to sense probes). Similar results were found using osteoarthritis ST cells, although the percentage of cells expressing the IL-6 gene (7.1 +/- 2.5%) was significantly less in osteoarthritis compared to RA. RA ST cells did not significantly bind the IFN-gamma probe (0.2 +/- 0.1% positive), although they were capable of expressing the IFN-gamma gene if stimulated with PHA. The OKM1+ population of ST cells (i.e., macrophage lineage cells) was greatly enriched for IL-1 beta and TNF-alpha, whereas the OKM1- population (lymphocytes, fibroblasts, and type B synoviocytes) was enriched for IL-6. The vast majority of cells expressing the IL-6 gene were non-T cells. Furthermore, hybridization to RA ST frozen sections localized IL-6 mRNA to the synovial lining layer, which is comprised of type A and type B synoviocytes. In contrast to the high level of cytokine gene expression observed in ST, SF cells did not hybridize significantly to any of the cytokine probes. If stimulated with LPS or PHA, SF cells expressed IL-1 beta or IFN-gamma genes, respectively.

Quantitative analysis of cytokine gene expression in rheumatoid arthritis

Previous studies of the cytokine profile of rheumatoid arthritis (RA) have been primarily limited to the assessment of the levels of these mediators in synovial fluid (SF) or synovial tissues (ST) by biologic or immunologic assays. We have studied cytokine gene expression in RA by in situ hybridization of SF cells, enzymatically dispersed ST cells, and frozen sections of ST. RA ST cells (n = 7) were studied and a high percentage of cells hybridized to the following anti-sense probes: IL-6 = 19 +/- 3.3%; IL-1 beta = 9.9 +/- 1.7%; TNF-alpha = 5.8 +/- 1.4%; granulocyte-macrophage-CSF = 2.2 +/- 0.8%; transforming growth factor-beta 1 = 1.3 +/- 0.2% (p less than 0.05 for each compared to sense probes). Similar results were found using osteoarthritis ST cells, although the percentage of cells expressing the IL-6 gene (7.1 +/- 2.5%) was significantly less in osteoarthritis compared to RA. RA ST cells did not significantly bind the IFN-gamma probe (0.2 +/- 0.1% positive), although they were capable of expressing the IFN-gamma gene if stimulated with PHA. The OKM1+ population of ST cells (i.e., macrophage lineage cells) was greatly enriched for IL-1 beta and TNF-alpha, whereas the OKM1- population (lymphocytes, fibroblasts, and type B synoviocytes) was enriched for IL-6. The vast majority of cells expressing the IL-6 gene were non-T cells. Furthermore, hybridization to RA ST frozen sections localized IL-6 mRNA to the synovial lining layer, which is comprised of type A and type B synoviocytes. In contrast to the high level of cytokine gene expression observed in ST, SF cells did not hybridize significantly to any of the cytokine probes. If stimulated with LPS or PHA, SF cells expressed IL-1 beta or IFN-gamma genes, respectively.

A subset of antibodies from the sera of patients with systemic lupus erythematosus react with vimentin and DNA

Sera from patients with systemic lupus erythematosus were tested for the simultaneous presence of antibodies to intermediate filaments (vimentin) and to DNA, using radioimmunoassay and immunofluorescence techniques. Our results indicate that 3 of 17 sera tested contain an IgM population which recognizes an antigenic determinant common to vimentin and DNA by a solid phase immunoassay.

Systemic lupus erythematosus and tetrasomy-X

An 18-year-old woman with tetrasomy-X (48,XXXX karyotype) who developed systemic lupus erythematosus is described. This is, to our knowledge, the first recorded case of this association. The occurrence of autoimmune disorders in patients with chromosomal aberrations is discussed.

Cytokines in chronic inflammatory arthritis. IV. Granulocyte/macrophage colony-stimulating factor-mediated induction of class II MHC antigen on human monocytes: a possible role in rheumatoid arthritis

Granulocyte/macrophage CSF (GM-CSF) has recently been identified in rheumatoid arthritis (RA) synovial effusions. To study a potential role for GM-CSF and other cytokines on the induction of HLA-DR expression on monocytes and synovial macrophages, we analyzed the relative ability of recombinant human cytokines to induce the surface expression of class II MHC antigens on normal peripheral blood monocytes by FACS analysis. GM-CSF (800 U/ml) (mean fluorescence channel 2.54 +/- 0.33 times the control, p less than 0.001) and IFN-gamma (100 U/ml) (5.14 +/- 0.60, p less than 0.001) were the most potent inducers of HLA-DR. TNF-alpha and IL-4 also increased HLA-DR expression, although to a lesser degree [1.31 +/- 0.06 (p less than 0.02) and 1.20 +/- 0.03 (p less than 0.01), respectively]. IL-1 (40 U/ml), IL-2 (10 ng/ml), IL-3 (50 U/ml), IL-6 (100 U/ml), and CSF-1 (1,000 U/ml) did not affect surface HLA-DR density. GM-CSF also increased HLA-DR mRNA expression and surface HLA-DQ expression, but decreased CD14 (a monocyte/macrophage antigen) expression. The effect of GM-CSF on HLA-DR was not mediated by the generation of IFN-gamma in vitro because it was not blocked by anti-IFN-gamma mAb. GM-CSF was additive with IL-4 and low amounts (less than 3 U/ml) of IFN-gamma and synergistic with TNF-alpha. Because we have recently reported that supernatants of cultured RA synovial cells produce a non-IFN-gamma factor that induces HLA-DR on monocytes, we then attempted to neutralize this factor with specific anti-GM-CSF mAb. Four separate synovial tissue supernatants were studied, and the antibody neutralized the HLA-DR-inducing factor in each (p less than 0.01).

Proteins responsible for anticentromere activity found in the sera of patients with CREST-associated Raynaud's phenomenon

Anticentromere antibodies (ACA) present in a high percentage of patients with complete or incomplete CREST scleroderma, and which are presently used in the diagnosis of this disease, also appear in some primary Raynaud's phenomenon patients. Three principal centromeric antigens, CENP-A, CENP-B and CENP-C, have been described as reacting with the sera of these individuals. We attempt to determine whether or not a correlation between the presence of ACA and serum reactivity against one or more of these peptides could be established, and have observed that CENP-A, but not CENP-B or CENP-C, is specifically recognized by all patients sera tested. The fact that this reactivity is clearly detectable at very high serum dilutions, thus eliminating other non-specific interference, suggests that anti-CENP-A activity might be useful in the diagnosis of patients with CREST-associated Raynaud's phenomenon.

Antithymocyte globulin in the treatment of gold induced severe aplastic anemia

Severe aplastic anemia is the most serious complication of chrysotherapy. No treatment for this condition has been demonstrated effective. We report 3 patients with gold induced severe aplastic anemia treated with antithymocyte globulin. Complete marrow recovery was obtained in 1 case and a partial but satisfactory response in the other. All the patients remain alive without requiring blood transfusion after followup of longer than 16 months.