Clinical results in patients affected by moderate-severe knee osteoarthritis and treated with micro-fragmented adipose tissue: the therapeutic effects on symptomatology

Osteoarthrosis is a degenerative musculoskeletal disease that presents a major public health problem, due to the increasing average age of the active population, as well as the increasing percentage of obesity or overweight of the general population. New therapeutic approaches have been developed, such as regenerative medicine that uses mesenchymal stromal cells taken from adipose tissue. This study analyzed the clinical potential benefits of using autologous adipose tissue to treat patients with moderate-severe knee osteoarthritis.In 2021, a total of 50 knees, affected by moderate-severe knee osteoarthritis, were treated with an intra-articular injection of micro-fragmented subcutaneous adipose tissue. Patients were submitted to the KOOS questionnaire before the operation and one year after the operation and VAS pain score at time 0, 3, 6, 12 months.Of the 50 patients treated, 2 patients were excluded from the study. Of the remaining 48 patients, improvements have been achieved in all subclasses of KOOS. In particular, VAS score proves that improvements are more considerable starting from the 3rd month after surgery.The results obtained in this study show the safety and potential benefit of the use of autologous micro-fragmented adipose on people who are affected by moderate-severe knee osteoarthritis.

Closing the gap: Enhancing quality pediatric dermatologic care through project Extension for Community Healthcare Outcomes (ECHO)

This study focused on evaluating Extension for Community Healthcare Outcomes (ECHO) participating primary care clinician's (PCC's) diagnostic and treatment accuracy of pediatric dermatologic conditions. To evaluate this, pediatric cases presented to Dermatology ECHO by PCCs with questions regarding diagnosis, treatment regimen, or both were analyzed. After PCC case presentation, the hub team of dermatologists facilitated case-based discussion and provided the presenter with mentorship and guidance regarding diagnosis and treatment of their patient.

Development of SkinTracker, an integrated dermatology mobile app and web portal enabling remote clinical research studies

Introduction

In-person dermatology clinical research studies often face recruitment and participation challenges due to travel-, time-, and cost-associated barriers. Studies incorporating virtual/asynchronous formats can potentially enhance research subject participation and satisfaction, but few mobile health tools are available to enable remote study conduct. We developed SkinTracker, a patient-facing mobile app and researcher-facing web platform, that enables longitudinal collection of skin photos, patient reported outcomes, and biometric health and environmental data.

Methods

Eight design thinking sessions including dermatologists, clinical research staff, software engineers, and graphic designers were held to create the components of SkinTracker. Following iterative prototyping, SkinTracker was piloted across six adult and four pediatric subjects with atopic dermatitis (AD) of varying severity levels to test and provide feedback on SkinTracker for six months.

Results

The SkinTracker app enables collection of informed consent for study participation, baseline medical history, standardized skin photographs, patient-reported outcomes (e.g., Patient Oriented Eczema Measure (POEM), Pruritus Numerical Rating Scale (NRS), Dermatology Life Quality Index (DLQI)), medication use, adverse events, voice diary to document qualitative experiences, chat function for communication with research team, environmental and biometric data such as exercise and sleep metrics through integration with an Apple Watch. The researcher web portal allows for management and visualization of subject enrollment, skin photographs for examination and severity scoring, survey completion, and other patient modules. The pilot study requested that subjects complete surveys and photographs on a weekly to monthly basis via the SkinTracker app. Afterwards, participants rated their experience in a 7-item user experience survey covering app function, design, and desire for participation in future studies using SkinTracker. Almost all subjects agreed or strongly agreed that SkinTracker enabled more convenient participation in skin research studies compared to an in-person format.

Discussion

To our knowledge, SkinTracker is one of the first integrated app- and web-based platforms allowing collection and management of data commonly obtained in clinical research studies. SkinTracker enables detailed, frequent capture of data that may better reflect the fluctuating course of conditions such as AD, and can be modularly customized for different skin conditions to improve dermatologic research participation and patient access.

IVIg therapy in the management of BK virus infections in pediatric kidney transplant patients

BK virus-associated nephropathy (BKPyVAN) induces kidney allograft dysfunction. Although decreasing immunosuppression is the standard for managing BK virus (BKPyV) infection, this strategy is not always effective. The use of polyvalent immunoglobulins (IVIg) may be of interest in this setting. We performed a retrospective single-center evaluation of the management of BKPyV infection in pediatric kidney transplant patients. Among the 171 patients who underwent transplantation between January 2010 and December 2019, 54 patients were excluded (combined transplant n = 15, follow-up in another center n = 35, early postoperative graft loss n= 4). Thus, 117 patients (120 transplants) were included. Overall, 34 (28%) and 15 (13%) transplant recipients displayed positive BKPyV viruria and viremia, respectively. Three had biopsy-confirmed BKPyVAN. The pre-transplant prevalence of CAKUT and HLA antibodies was higher among BKPyV-positive patients compared to non-infected patients. After the detection of BKPyV replication and/or BKPyVAN, the immunosuppressive regimen was modified in 13 (87%) patients: either by decreasing or changing the calcineurin inhibitors (n = 13) and/or switching from mycophenolate mofetil to mTor inhibitors (n = 10). Starting IVIg therapy was based on graft dysfunction or an increase in the viral load despite reduced immunosuppressive regimen. Seven of 15(46%) patients received IVIg. These patients had a higher viral load (5.4 [5.0-6.8]log vs. 3.5 [3.3-3.8]log). In total, 13 of 15 (86%) achieved viral load reduction, five of seven after IVIg therapy. As long as specific antivirals are not available for the management of BKPyV infections in pediatric kidney transplant patients, polyvalent IVIg may be discussed for the management of severe BKPyV viremia, in combination with decreased immunosuppression.

Exploring disease perception in Behçet's syndrome: combining a quantitative and a qualitative study based on a narrative medicine approach

BACKGROUND

Behçet Syndrome (BS) has a significant psychological and social impact on patients, caregivers and families. The present study aims at exploring disease perception in BS patients, using both a co-designed survey and the narrative medicine (NM) approach.

METHODS

An ad-hoc questionnaire was co-designed by clinicians expert in BS, BS patients and caregivers and BS adult patients were invited to answer the online questionnaires. Cluster analysis was used to analyse data from the survey and to identify groups of patients with diverse disease perception. To further explore real-life perspectives, the stories of illness of a smaller group of adult BS patients were anonymously collected online and analysed by means of text, sentiment and qualitative analysis.

RESULTS

Two hundred and seven patients answered the survey and forty-three stories were collected. The cluster analysis highlighted that accepting or not the disease has a strong impact on the daily life, on how BS patients perceive themselves and in terms of hope for the future. The stories revealed that patients often address common issues, such as the long and complex journey faced from the disease onset until the BS diagnosis, which was strongly connected to the concept of time and perceived as an exhausting period of their lives.

CONCLUSION

To our knowledge, this is the first study that addressed disease perception also applying the NM principles in BS. The current perception that BS patients have of their disease should encourage the BS scientific and patient community in joining forces in order to improve the journey of BS patients.

Orthopaedic and plastic surgery collaboration in resolution of plantar heloma and metatarsalgia using lipofilling: a retrospective evaluation

BACKGROUND

Plantar heloma is a keratotic disorder that can be described as a circumscribed area of thickening with a central core that may penetrate the dermis. Although often considered a minor complaint, longstanding lesions can be debilitating and severely impact on person's quality of life. We present the first retrospective case series at long-term follow-up about the use of plantar lipofilling as a treatment for metatarsalgia caused by plantar heloma.

MATERIALS AND METHODS

Six patients affected by plantar heloma associated to external metatarsalgia underwent plantar lipofilling. The surgical session was performed as an outpatient procedure. Clinical evaluation was performed using the AOFAS lesser metatarsophalangeal-interphalangeal (MTP-IP) score.

RESULTS

Mean AOFAS lesser MTP-IP score improved from a preoperative score of 66.6 ± 3.2 points (range 47-77 points) to a post-operative score of 92.8 ± 2.7 points (range 86-95 points); all patients were satisfied with the outcome at the final follow-up. Post-operative clinical examination at final follow-up showed an increase in thickness of the subcutaneous layer and a decrease of dermal layer thanks to the supporting and trophic action of fat cells.

CONCLUSIONS

Plastic regenerative procedures applicated to a typical foot and ankle surgery field, such as metatarsal overloading, metatarsalgia and forefoot problems, should be encouraged to allow new treatment horizons.

Sleep quality in Behçet's disease: a systematic literature review

Behçet's Disease (BD) can be correlated with sleep impairment and fatigue, resulting in low quality of life (QoL); however, a comprehensive evaluation of this issue is still missing. We performed a systematic literature review (SLR) of existing evidence in literature regarding sleep quality in BD. Fifteen papers were included in the SLR. Two domains were mainly considered: global sleep characteristics (i) and the identification of specific sleep disorders (ii) in BD patients. From our analysis, it was found that patients affected by BD scored significantly higher Pittsburgh Sleep Quality Index (PSQI) compared to controls. Four papers out of 15 (27%) studied the relationship between sleep disturbance in BD and disease activity and with regards to disease activity measures, BD-Current Activity Form was adopted in all papers, followed by Behçet's Disease Severity (BDS) score, genital ulcer severity score and oral ulcer severity score. Poor sleep quality showed a positive correlation with active disease in 3 out of 4 studies. Six papers reported significant differences between BD patients with and without sleep disturbances regarding specific disease manifestations. Notably, arthritis and genital ulcers were found to be more severe when the PSQI score increased. Our work demonstrated lower quality of sleep in BD patients when compared to the general population, both as altered sleep parameters and higher incidence of specific sleep disorders. A global clinical patient evaluation should thereby include sleep assessment through the creation and adoption of disease-specific and accessible tests.

Kinetics of response to iloprost evaluated by laser speckle contrast analysis in systemic sclerosis

OBJECTIVE

Iloprost (ILO) is recommended for the treatment of systemic sclerosis (SSc) microangiopathy, but there is no common consensus on its optimal dosage. The aim of this study is to evaluate the kinetics of response to ILO administered in a daily outpatient scheme in SSc subjects using laser speckle contrast analysis (LASCA).

METHOD

Adult SSc patients in stable therapy with ILO administered for 6 h for 2 consecutive days every 4 weeks were enrolled. Peripheral finger perfusion was assessed by LASCA. Each patient underwent five LASCA evaluations: before and after each day of ILO (D1pre, D1post, D2pre, and D2post) and after 4 weeks (D30).

RESULTS

Twenty-seven SSc patients (77.8% female, mean age 61.5 years) were enrolled. LASCA showed an increase in perfusion at the end of each ILO course, but on the second day (both D1pre vs D2pre and D2pre vs D2post) the increase was no longer significant in half of the fingers. Moreover, compared to D1post, at the beginning of the second ILO day most of the fingers had already shown a significant reduction in perfusion. After 1 month, there were no statistically significant differences between the perfusion values of D1pre and D30.

CONCLUSION

This LASCA study highlights the transience of the vasoactive effect of ILO, with a perfusion benefit that is completely lost after 1 month. The brevity of the perfusion effect of ILO and the use of LASCA are elements to consider in the design of future SSc trials to determine the optimal ILO dosage.

Demographic and Clinical Factors Associated with Patient-Reported Remission in Psoriatic Arthritis

Introduction

Achievement of remission in psoriatic arthritis is a key goal for patients and clinicians, yet definitions of remission may vary. Previous efforts have utilized multidomain measures such as minimal disease activity that assess the status of joints, skin, and function to determine current level of psoriatic arthritis (PsA) disease activity. The goal of this study is to identify factors associated with patient-reported psoriatic arthritis remission.

Methods

The National Psoriasis Foundation conducted a cross-sectional study using an online survey of a random stratified sample of 1570 individuals with psoriatic disease in the USA. Participants were asked about a provider diagnosis of psoriasis and/or psoriatic arthritis, comorbid conditions, and psoriatic arthritis impact and disease activity, and demographic questions. All participants reporting a physician-given diagnosis of psoriatic arthritis were asked if they felt their psoriatic arthritis was in remission (“Do you feel your psoriatic arthritis is in remission?” Yes/No/Unsure) and, if so, length of remission. Individuals with psoriasis and psoriatic arthritis reporting a body surface area impacted by psoriasis 3% or less were asked if they felt their psoriasis was in remission. Psoriatic arthritis disease activity and impact was assessed using the nine-question Psoriatic Arthritis Impact of Disease (PsAID-9) instrument and a global PsA-related quality of life question. PsAID-9 scores ≤ 4 were used to indicate acceptable disease state. Multivariate logistic regression was used to identify factors associated with patient-perceived PsA remission.

Results

Of 834 participants with PsA, including 76 (4.8%) with PsA without skin involvement ever, 144 (17.3%) felt their psoriatic arthritis was in remission, with an average remission duration of 43 months. Of those in remission, 116 (78.4%) reported currently using a treatment for their PsA, with most (75.7%) reporting using a biologic therapy for their PsA in the past 12 months. Multivariate logistic regression revealed that patient-perceived psoriatic arthritis remission was independently associated with experiencing acceptable disease state (PsAID-9 ≤ 4), perception of psoriasis remission, lower impact of PsA on global quality of life, and non-white race. Age, sex, body mass index, or biologic use in the last 12 months were not associated with patient-reported PsA remission.

Conclusion

Overall, patient perception of PsA remission was most strongly associated with patient-reported psoriasis remission.

POS0753 PROSPECTIVE EVALUATION OF HEALTH-RELATED QUALITY OF LIFE (HRQoL) IN A MONOCENTRIC COHORT OF PATIENTS WITH LONGSTANDING SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background

The optimization of HRQoL in SLE patients is defined as one of the treatment goals in the 2019 EULAR recommendations1 for the management of SLE. Most studies have examined HRQoL at one point in time, while the few longitudinal studies do not report a clear variation in Patient Reported Outcomes (PROs) with respect to changes in disease activity. It would be important to understand if, even in a real-life setting, the improvement of patients’ HRQoL may represent an achievable target.

Objectives

the aim of this study was to analyze HRQoL over time in a monocentric cohort of patients with SLE and investigate which disease-related factors determine short-term variation of HRQoL in a real-life setting.

Methods

this is a longitudinal, prospective monocentric study which included consecutive adult outpatients with SLE (1997 ACR classification criteria), regularly followed at the Rheumatology Unit of Pisa. Patients were enrolled over a period of 2 years, before the pandemic outbreak, and had at least 2 assessments per year. For each patient, demographics, comorbidities, treatment, clinical and laboratory data were collected. Disease activity was evaluated with the SELENA-SLEDAI and organ damage with the SLICC/DI. We defined as a significant variation of disease activity, a difference of clinical SELENA-SLEDAI ≥ 4 points between 2 subsequent evaluations. At each visit, patients completed the following PROs: SF-36, FACIT-Fatigue and LIT.

Results

we enrolled 210 consecutive SLE patients, mainly female (93.8%) and of Caucasian ethnicity (97.1%), with a mean age at enrollment of 45.1±12.7 years and a median disease duration of 13 years (IQR 5-21). At baseline, the median SLEDAI of the cohort was 2 (IQR 0-4). The most frequent active disease manifestations were: articular (17.1%) and hematological (15.2%); 6.7% of patients had active renal disease. 47.14% had a SLICC-DI > 0 with a median SLICC-DI among them of 2 (IQR 1-3). 11.43% of patients had a concomitant fibromyalgia. Most patients were on Hydroxychloroquine (78.1%) and low dose glucocorticoid (55.2%), with a median daily dose of 2 mg (IQR 0-4) of prednisone equivalent; 41.4% were on conventional immunosuppressants and 11.9% on biologics, mainly belimumab. The median scores of PROs at enrollment are reported in Table 1. At baseline, fibromyalgia confirmed to have a significant negative impact on all PROs after adjustment for confounding factors (p<0.05). Each patient underwent two consecutive evaluations, with a median interval between them of 11.4 months. We observed a significant variation of disease activity in 36/210 patients (17.14%). Then, we compared the subgroup of patients with unchanged disease activity with that of patients who showed a significant variation of disease activity. We found that FACIT and LIT scores didn’t change over time in both subgroups, whereas PCS (p<0.001) and MCS (p<0.01) scores of the SF-36 showed a significant variation in both groups, between the first and the second clinical assessment. However, in the subgroup of patients with a significant change of disease activity, the variation of PCS and MCS was not correlated with the variation of disease activity or ongoing treatment. In particular, patients with a significant improvement of HRQoL over time didn’t have a corresponding significant reduction of the SLEDAI score or of the daily glucocorticoid dose.

Table 1.

PROs scores at baseline.

PROsMedian scores at baselineSF-36 PCS58 (IQR 49.09- 68)SF-36 MCS57 (IQR 46.42-67)FACIT42 (IQR 32-46)LIT20 (IQR 7.5-40)

Conclusion

our findings seem to suggest that HRQoL over time in outpatients with longstanding SLE tends to be stable (maybe because patients are able to adapt to their illness) or varies unpredictably, maybe influenced by not disease-related factors. Further studies are needed to better understand which factors influence HRQoL over time and which questionnaires are more sensitive to catch its variation.

References

[1]PMID: 30926722

Disclosure of Interests

None declared

AB0555 SYMPTOMATIC NON-SEROSITIC LUNG INVOLVEMENT IN A MONOCENTRIC COHORT OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): A REAL-LIFE EXPERIENCE

Background

A growing interest has been addressed to the study of lung involvement in systemic autoimmune diseases. Non-serositic pulmonary manifestations have also been described in SLE. However, little is known about their exact prevalence, clinical features and outcomes.

Objectives

To describe the prevalence, clinical and immunological characteristics of symptomatic non-serositic lung involvement in a monocentric cohort of SLE patients.

Methods

This observational, retrospective study included patients with SLE, regularly followed at the Rheumatology Unit of Pisa, that presented a clinically relevant non-serositic pulmonary involvement during their disease history. Patients with lung manifestations related to other causes (e.g. infections, emphysema, Chronic Obstructive Lung Disease, bronchial asthma etc.) were excluded. The following data were collected from clinical charts: demographics, smoke exposure, comorbidities, respiratory symptoms, disease duration and disease activity (SELENA-SLEDAI) at the onset of lung involvement, immunological profile, treatment, CT and spirometry parameters.

Results

Over 450 SLE patients in regular follow-up, we found 11 female patients with a history of clinically relevant non-serositic lung involvement: 7 interstitial lung disease (ILD), 2 acute lupic pneumonitis (ALP), 1 diffuse alveolar hemorrhage (DAH) and 1 shrinking lung syndrome. 45.4% of patients had a history of smoke exposure and had stopped smoking on average 9 years before the onset of lung manifestations. For the 2 patients with ALP, this was the first manifestation of SLE. Among the other 9 patients, lung involvement was diagnosed after a mean disease duration of 14 ± 15 years. At the diagnosis of pulmonary involvement, 10/11 patients presented respiratory symptoms and an overall active disease, with a median SLEDAI of 9 (IQR 6-13). Clinical characteristics are summarized in Table 1. All patients were hospitalized and 2 of them (1 ALP and 1 DAH) were admitted in intensive care unit.

Table 1.

Clinical characteristics at the diagnosis of lung involvement

SystemicActive skin manifestations36%Arthritis36%Fever36%Leukopenia36%Hypocomplementemia91%Anti-dsDNA positivity36%RespiratoryDyspnea54%Exertional dyspnea18%Cough45%Acute respiratory failure27%

As for the immunologic profile, SSA/Ro60 were positive in 72% of patients and SSA/Ro52, SSB, U1-RNP in 36%; 36% had Sjogren Syndrome (SS) in overlap.

Spirometry was available for 6/11 patients: a restrictive pattern and a moderate/severe reduction of diffusing capacity of the lung for carbon monoxide was found in 5 patients.

In the ILD subgroup, the most prevalent CT pattern was the Non-specific interstitial pneumonia (NSIP) (5/7). 2 patients presented a Bronchiolitis obliterans/organizing pneumonia (BOOP) pattern.

Lung involvement was the driving manifestation in the treatment choice for 6/11 patients: 1 DAH, 2 ALP, 1 Shrinking lung and 2 ILD. All received pulse steroids and in 3 cases (2 ILD and 1 DAH) cyclophosphamide was added for the induction treatment; the patient with Shrinking lung had an overlap SS and was treated with Rituximab.

At last visit (mean follow-up of 8 ± 8.7 years since lung disease onset), 7/11 patients presented no respiratory symptoms and a complete resolution of CT alterations. 3/11 presented a residual exertional dyspnea and mild spirometry alterations. No patients developed respiratory insufficiency; only 1 patient died for cardiovascular complications.

Conclusion

In our large cohort of SLE patients, non-serositic lung involvement seems to be overall rare; the most frequent type of lung manifestation is ILD which appears to be associated with anti-SSA/SSB and anti-U1RNP positivity. The low prevalence of lung involvement (2.4%) in our cohort could be due to the presence of patients with a subclinical involvement. Further studies are needed to assess the real prevalence of subclinical lung manifestations in SLE and to identify the clinical phenotype of patients more prone to develop pulmonary disease.

Disclosure of Interests

Davide Schilirò: None declared, Elena Elefante: None declared, Chiara Stagnaro: None declared, Viola Signorini: None declared, Dina Zucchi: None declared, Francesca Trentin: None declared, Gaetano La Rocca: None declared, Linda Carli: None declared, Francesco Ferro: None declared, Chiara Tani: None declared, Marta Mosca Speakers bureau: advisor LILLY, ASTRA ZENECA, GSK, Consultant of: advisor LILLY, ASTRA ZENECA, GSK

AB0731 Thyroid disorders assessment: an unmet need in patients with idiopathic inflammatory myopathies?

Background

Thyroid diseases (TD) might compromise health status of patients, in particular owing to their possible impact on cardiovascular risk, bone mineral density (BMD) and muscle function. The prevalences of Hashimoto thyroiditis (HT), multinodular goiter (MNG) and Graves’ disease (GD) in general population correspond respectively to about 12%, 10% and 1.3%; it is well known HT represents a risk factor for the development of thyroid papillary cancer (TPC). Idiopathic inflammatory myopathies (IIMs) are rare systemic autoimmune disorders, with a pleiotropic clinical picture. TD are a known comorbidity of patients with connective tissue diseases; in particular, they might increase the risk of osteoporosis (OP) and fragility fractures (FF) in patients with SLE1. A recent study described the association between IIMs and both hyper- and hypo-thyroidism2.

Objectives

To evaluate the prevalence of TD in a monocentric cohort of patients with IIMs, exploring possible correlations with serology, organ involvement and comorbidities.

Methods

We retrospectively analyzed medical records of consecutive patients diagnosed with IIM according the EULAR/ACR 2017 criteria and regularly followed at our specialistic outpatient Myositis Clinic from January 2018 to December 2021. We collected data about demography, subset and duration of disease, organ involvement, serology, thyroid dysfunction and other comorbidities. As TD, we took into account the occurrence of HT, MNG and GD. Intergroups comparisons were assessed by using Chi-square, t-test and ANOVA. P values <0.05 were considered significant.

Results

The clinical charts of 151 patients were examined: 101 (66,9%) were female, the mean age was 65,1±14,0 years and the mean disease duration was 8,5±6,5 years. Clinical diagnosis were the following: 69 (45.7%) polymyositis, 59 (39.1%) dermatomyositis, 11 (7.3%) clinically amyopathic dermatomyositis, 10 (6.6%) inclusion body myositis, 2 (1.3%) juvenile dermatomyositis. Seventy-five patients (49.7%) had a TD; in particular, 39/151 (25.8%) had MNG, 34/151 (22.6%) had HT and 2/151 (1.3%) GD. The presence of a TD was significantly related with esophagus’ involvement (p=0.037), Raynaud’s phenomenon (RP) (p=0.045), sicca syndrome (SiS) (p<0,001), OP (p<0,001) and cataract (p=0,017). In particular, HT and MNG occurrence was respectively associated with a higher risk of OP (p<0,001) and of sicca syndrome (p<0,001). Interestingly, TD were significantly less frequent in patients with anti-Mi2beta autoantibodies (p=0,003) and anti-Jo1 autoantibodies (p=0,026). No further significant correlations emerged.

Conclusion

Our study showed nearly half of our IIMs patients had a TD, with a prevalence of both MNG and HT significantly higher than in general population; besides, owing to the retrospective nature of our study, these data could be underestimated. In addition to correlating with RP and SiS, TD showed a significant association with esophagus involvement; this result should be confirmed and clarified with future analyses. Moreover, in our cohort, TD were confirmed as a risk factor for a compromised BMD; in particular, HT was significantly associated with the occurrence of OP. Further studies are needed to corroborated our data in other cohorts of IIM patients and to explore if TD represent a risk factor for FF also in IIM; finally, since HT is a risk factor for TPC, an evaluation of its occurrence in our cohort should be designed. However, our data seem sufficient to underline the need to regularly screen IIM patients for thyroid function, aiming at optimizing their quality of care, both for activity and damage domains of their autoimmune disease.

References

[1]Carli L, et al. Risk factors for osteoporosis and fragility fractures in patients with systemic lupus erythematosus. Lupus Sci Med. 2016 Jan 19;3(1):e000098.

[2]Watad A, et al. Dysthyroidism in dermato/polymyositis patients: A case-control study. Eur J Clin Invest. 2021;51:e13460.

Disclosure of Interests

None declared

POS0364 UNMET NEEDS IN THE TREATMENT OF EXTRA-RENAL FLARES IN SLE PATIENTS: REAL LIFE EXPERIENCE VS ARTIFICIAL APPROACH

Background

Systemic lupus erythematosus (SLE) is a heterogeneous disease which can affect various organs and is characterized by different clinical phenotypes. While the treatment of renal involvement is quite standardized, the therapeutic approach to extra-renal manifestations is subjected to a degree of variability.

Objectives

1. To describe extra-renal disease flares in terms of clinical phenotype and outcomes in SLE patients 2. To compare data from a real-life setting with a machine learning (ML) approach.

Methods

This study is a retrospective analysis of data from a monocentric cohort of SLE patients who experienced a disease flare between 2015 and 2020. Each flare was followed for one year and was classified according to the organ involvement and categorized according to the BILAG definition of flare. At baseline and at 3,6,12 months the following variables were collected: disease activity (SELENA-SLEDAI score), ongoing therapy and disease state (DORIA definition of remission). Demographic data and previous organ involvement were retrieved from clinical charts. Flares’ features at baseline and during follow up were analyzed in terms of explained variance across the dataset’s Principal Components and clustered with a hierarchical unsupervised learning approach. A ML model based on neural networks was built to early detect flares’ therapeutic difficulty: it was validated after data augmentation to satisfy statistical requirements during the training phase.

Results

66 extra-renal flares were investigated (Table 1); 5 flares (7.5%) were treated with glucocorticoid (GC) pulses and 61 (92.5%) with oral GC therapy, while an immunosuppressive (IS) treatment was prescribed in 44 flares (66.7%). The remission rate at 12 months for the whole group was 50%, with musculo-skeletal (MS) flares, mucocutaneous (MC) flares and others (neuropsychiatric, cardiopulmonary, constitutional, haematologic) that was respectively 63.6%, 31.3% and 41.2%, showing lower rate of remission for MC flares. In 12 months, 17 flares (25.8%) did not respond to treatment (non-responders), requiring an increase in the dose of GC or the introduction of a new IS therapy. Using a machine learning approach, we were able to identify 4 flare clusters, grouping flares in relation to phenotypic characteristics (Figure 1), and recognized statistically relevant features for patients’ stratification (cluster 1“flare in systemic disease with high activity”, cluster 2 “outcast flares”, cluster 3 “flare in polymorphic disease with mild activity” and cluster 4 “recurrent skin flares”). Interestingly, cluster 4 (recurrent skin flares) was associated with the lowest rate of remission at 12 months with respect to clusters 1, 2, and 3 (33% vs 40%, 76.5% and 56% respectively). Moreover the neural network model correctly predicts difficult to treat flares in up to 80% of the cases

Table 1.WHOLE GROUPMUSKELMUCOCUTCONSTITUTIONALCARDIOPULMHAEMATOLNEUROpNUMBER (%)6633 (50)16 (24.2)7 (10.6)4 (6.1)5 (7.6)1 (1.5)SLEDAI at baseline median (IQR)7 (4-29)8 (6-10)5.5 (4-10)5 (4-9)9 (4.5-12)5 (5-6)29 (29-29)SLEDAI 12 mos median (IQR)2 (0-20)0.5 (0-4)3 (0-4)3 (2 – 4)0 (0-0)2 (0-3)14 (14 – 14)REMISSION 12 mos number (%)33 (50)21 (63.6)5 (31.3)4 (57.1)2 (40)2 (40%)1 (100)0.217NON RESPONSE 12 mos number (%)17 (25.8)8 (25)5 (31.3)2 (28.6)1 (20)1 (20%)1 (100)0.467Figure 1.

Flare clusters.

Conclusion

These data suggest that, in a real-life setting, the clinical response rate to therapy of patients with an extra-renal flare is not satisfactory, thus identifying an unmet need in the treatment of SLE and highlighting the absence of a standard treatment. Both the real-life data and the machine learning approach identify flares with MC manifestations as the most difficult to treat with the lower rate of remission after one year. Further prospective studies are necessary to improve the neural network model; ML techniques could help in the early identification of difficult to treat flares to be candidates for new and more aggressive therapeutic strategies for extra-renal manifestations.

Disclosure of Interests

None declared

AB1152 COVID-19 mRNA VACCINE BOOSTER IN PATIENTS WITH SYSTEMIC AUTOIMMUNE DISEASES

Background

Patients with systemic autoimmune diseases (SADs) are often treated with drugs that interfere with the immune system and previous data showed a reduced seroconversion rate after anti-SARS-CoV2 vaccine in these subjects compared to healthy controls1. Administration of a booster dose of the vaccine could be particularly important in these patients, but data available to date are still scarce.

Objectives

To evaluate the antibody response to the booster dose of mRNA SARS-CoV2 vaccine in patients with SADs and to compare it to the response after completion of the first vaccination course. Secondly, to find possible correlations between a low antibody titre and patients’ clinical features, with special regard to ongoing immunosuppressive therapies.

Methods

Consecutive patients with an established diagnosis of SADs undergoing SARS-CoV2 vaccine were prospectively enrolled from January 2021; among them, we selected the patients who received the third vaccination dose between September and December 2021. Demographic and clinical data were collected at enrolment (sex, age, diagnosis, disease duration, ongoing therapies, previous SARS-CoV2 infection, presence of hypogammaglobulinemia); the last three elements were reassessed at each follow-up visit. Blood samples were collected 4 weeks both after the second (W4a) and the third (W4b) dose of the vaccine; a minority of patients was also tested 12 weeks after the second dose (W12). IgG antibodies to SARS-CoV2 receptor-binding domain (RBD) and neutralizing antibodies inhibiting the interaction between RBD and angiotensin converting enzyme 2 were evaluated. IgG anti-RBD were detected by solid phase assay on plates coated with recombinant RBD, while neutralising antibodies by using the kit SPIA (Spike Protein Inhibition Assay). Cut-off values were defined as the 97.5th percentile of a pre-vaccine healthy population. Statistical analysis was performed using IBM SPSS Statistics 20 and GraphPad Prism statistical packages. P values <0.05 were considered significant.

Results

Forty-five patients (95.6% female; mean age ±SD 55.6±14.1 years; mean disease duration 12.9±10.6 years) were enrolled. Diagnosis was in most cases connective tissue disease (31/45, 68.9%), followed by inflammatory arthritis (11/45, 24.4%) and systemic vasculitis (3/45, 6.7%). Two patients (4.4%) had a previous SARS-CoV2 infection and three had hypogammaglobulinemia (6.7%). At the time of the second dose, 18/45 patients were treated with glucocorticoids (GCs) [mean daily 6-methylprednisolone (6MP) dose 3.9 mg (min. 2, max. 14)], 17/45 with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and 12/45 with biologic DMARDs (bDMARDs). At the third dose administration, 19/45 patients were treated with GCs [mean daily 6MP dose 4.1 mg (min. 1.5, max. 10)], 18/45 with csDMARDs and 13/45 with bDMARDs. Anti-RBD IgG were positive in 42/45 patients (93.3%) at W4a, in 16/18 (88.9%) at W12 and in 42/45 (93.3%) at W4b. Neutralizing antibodies were present in 38/45 patients (84.4%) at W4a, in 14/18 (77.8%) at W12 and in 42/45 (93.3%) at W4b. Both anti-RBD IgG titers and neutralizing antibody titers significantly increased after the third dose if compared to W4a (p<0.0001 both) (Figure 1). Interestingly, of the 7 patients who had not developed an adequate neutralizing antibody response after the first vaccination course, 5 mounted an adequate titer after the booster. Two non-responder patients were both on combination therapy (one with low dose of GCs plus mycophenolate mofetil, the other with methotrexate and infliximab).

Conclusion

Our data suggest that in patients with SADs there is a decline in the antibody titers developed after COVID-19 vaccination, however the booster dose is effective in restoring an adequate antibody titre. These data consolidate the importance of a booster dose of COVID-19 vaccination in patients with SADs to aid in the generation of an immune response.

References

[1]Jena A et al. Response to SARS-CoV-2 vaccination in immune mediated inflammatory diseases: systematic review and meta-analysis. Autoimmun Rev. 2022

Acknowledgements

The authors would like to thank all the patients who participated in the study and the nurses Sabrina Gori, Rosanna Lo Coco, Lucia Pedrocco, Carla Puccini, Pasqualina Semeraro, Manuela Terachi, Maria Tristano, Valentina Venturini and Catiuscia Zoina who took care of the patients.

Disclosure of Interests

None declared

POS0922 RECOMBINANT HUMAN HYALURONIDASE-FACILITATED SUBCUTANEOUS IMMUNOGLOBULIN FOR IDIOPATHIC INFLAMMATORY MYOSITIS: A MULTICENTER OBSERVATIONAL STUDY

Background

The spectrum of idiopathic inflammatory myositis (IIM) includes a heterogeneous group of diseases characterized by chronic inflammation of skeletal muscle, often associated with skin, joints, lungs, esophageal, gastrointestinal and cardiac involvement. Conventional treatment for IIM is based on glucocorticoids and immunosuppressants. Moreover, intravenous immunoglobulin (IVIg) has emerged as a promising steroid- and DMARD-sparing treatment for myositis [1]. However, the long-term use of IVIg is complicated by the fact that the intravenous route requires in-hospital drug administration, which not only influences patients’ quality of life, but is also associated with an increased risk of systemic adverse effects, difficulties in venous access over time, and high costs [2]. On these bases, administration of subcutaneous Ig (SCIg) by a programmable pump has been considered as a possible alternative to IVIg.

Recombinant human hyaluronidase-facilitated (hf)-SCIg is currently approved for the use in patients with primary immunodeficiency disorders, while its efficacy and safety in myositis disorders is limited [3].

Objectives

This multicenter retrospective observational study is sought to evaluate the effectiveness and safety of recombinant human hf-SCIg in patients with IIM treated at different referral centers.

Methods

A multicenter, retrospective, cohort study was conducted on adult patients diagnosed with IIM according to the EULAR/ACR classification criteria [4] treated with recombinant human hf-SCIg according to routine clinical practice. The effectiveness of this treatment was assessed in terms of variations in the Medical Research Council (MRC) score, creatine kinase values, inflammatory parameters, and daily prednisolone dosage. Safety data were also collected.

Results

Twenty-three patients with IIM treated with hf-SCIg were included (16/23 females, 70%; median age at diagnosis of 61 years (IQR 43-65)).

In most patients (22/23, 96%), IIM had been initially treated with high-dose corticosteroids (+/- synthetic or biologic DMARDs), and 20/23 patients (87%) had received previous IVIg treatment (in 12 for remission induction and in 8 for maintenance).

Hf-SCIg were introduced after a median time of 2 years (1-4) from the diagnosis of IIM, mostly for remission maintenance (18/23). Hf-SCIg was started in combination with oral corticosteroids in 19/23 [83%, at a median dose of 5 mg/day (4-12.5)] and/or with traditional or biologic DMARDs (18/23, 78%).

At time of hf-SCIg introduction, the median MRC score was 4 (3-4) and the median creatine kinase level was of 134 U/L (44-243). After 6 months of treatment, the median MRC score was 4 (3-5); no patient discontinued hf-SCIg, and only one experience a mild adverse event.

Conclusion

Hf-SCIg seems effective to maintain remission in a high proportion of IIM patients, while showing a good safety profile in the first 6 months of treatment.

References

[1]Oddis. Treatment in myositis. Nat Rev Rheumatol 2018

[2]Danieli. Subcutaneous IgG in the Myositis Spectrum Disorders. Curr Rheumatol Rev. 2018.

[3]Wasserman. Recombinant human hyaluronidase-facilitated subcutaneous infusion of human immunoglobulins for primary immunodeficiency. JACI.2012.

[4]Lundberg. 2017 European League Against Rheumatism/American College of Rheumatology classification criteria for adult and juvenile idiopathic inflammatory myopathies and their major subgroups. ARD. 2017

Table 1.

Effectiveness and safety of hf-ScIG treatment in a cohort of patients with IIM

hf-ScIg beginning3 months6 monthsN patients with available follow-up data2320 *19*MRC score §4 (3-4)4 (4-5)4 (3-5)Creatine kinase, U/L §134 (44-243)118 (77-308)130 (84-222)ESR, mm/h §21 (15-28)30 (25-43)31 (23-39)CRP, mg/dl §0.2 (0.1-0.5)0.3 (0.1-0.5)0.3 (0.1-0.3)Prednisolone dosage, mg/day §5 (4-12.5)7.5 (5-10)5 (5-7.5)Adverse events-NA1 **

*none discontinued

**One infusion site reaction

§ median value (IQR)

CRP=C reactive protein; ESR=erythrocyte sedimentation rate

Disclosure of Interests

None declared

AB0441 PREDICTORS OF CLASI RESPONSE OVER TIME IN A MULTICENTRIC REAL LIFE COHORT OF SLE PATIENTS TREATED WITH BELIMUMAB

Background

Over 80% of patients affected with SLE experience skin involvement. The anti-BLyS drug belimumab was shown effective in ameliorating mucocutaneous SLE manifestations in clinical trials and real-life studies. Cutaneous response is quantified through the CLASI (cutaneous lupus erythematosus area and severity index). Clinically relevant improvements are defined as decreases of ≥50% (CLASI50) or 70% (CLASI70) from baseline values.

Objectives

To assess rates and predictors of CLASI50 and CLASI70 in the Berliss multicentric SLE cohort1 of patients treated with belimumab.

Methods

Baseline and ongoing features of patients with baseline active skin involvement (CLASI>0) were assessed in relationship to the chosen outcomes CLASI50 and CLASI70 at 24 and 52 weeks. A subanalysis on patients with CLASI≥5 was as well conducted. Logistic regression was employed to identify predictors of response.

Results

172 patients displayed skin involvement at baseline (CLASI>0). Of those, 124 displayed at least a 12-month-follow-up and were included in the analysis. Seventy-seven (62.1%) patients reached CLASI50 at 24 weeks and 91 (77.8%) at 52 weeks; 87 (70.2%) reached CLASI70 at 24 and 99 (79.8%) at 52 weeks. Baseline predictors of CLASI50 at 24 weeks were CLASI-damage (CLASI-d) (OR [95%CI], p; 0.79 [0.65-0.98] 0.03) and disease duration (0.93[0.86-0.99], 0.011). No baseline predictors of CLASI70 at 24 weeks emerged, however having achieved a CLASI50 response at 24 weeks portended CLASI50 and 70 response through week 52 (p<0.01, Table 1). In the subgroup of patients with CLASI≥5, longer disease and increased CLASI-d at baseline confirmed as negative predictors of CLASI50 at 24 weeks. In this subset, use of antimalarials and active smoking at baseline predicted CLASI70 at 24 weeks (Table 1).

Table 1.

Predictors of CLASI-A Response at Week 24 and 52 by Baseline CLASI-A at 50% and 70% Response Thresholds

TimepointOutcomeVariableOR[95%CI] pCLASI>024 weeksCLASI50CLASI-d0.79 [0.65-0.98] 0.030Disease duration0.93[0.86-0.99], 0.011CLASI70CLASI-d0.93 [0.74-1.16], 0.51Disease duration0.97 [0.97-1.02], 0.1852 weeksCLASI50CLASI50 at 24 weeks14.3[4.88-44.42], <0.001CLASI70CLASI50 at 24 weeks6.22 [2.00-19.34], 0.002CLASI≥524 weeksCLASI50CLASI-d0.72 [0.53-0.98], 0.037Disease duration0.93 [0.66-1.00], 0.071CLASI70Antimalarials6.61 [1.20-36.29] 0.032Smoking0.15 [0.03-0.83], 0.03452 weeksCLASI50CLASI50 at 24 weeks22.0 [2.47-196.05], 0.006CLASI70CLASI50 at 24 weeks1.24 [0.06-25.08], 0.88

CLASI, cutaneous lupus erythematosus area and severity index; CLASI-d, CLASI damage; CLASI50 and CLASI70: decrease ≥50% or ≥70% in CLASI from baseline. OR and 95%CIs are estimated using a logistic regression model with stratification factors as covariates (SLEDAI-2K at baseline, baseline prednisone dosage).

Conclusion

Earlier use of belimumab favors achievement of skin response among SLE patients and attainment of a prompt response predicts further response. Use of antimalarials reinforces while smoking hampers a more profound CLASI improvement over time.

References:

[1]Gatto M, et al. Arthritis Rheumatol. 2020 Aug;72(8):1314-1324

Disclosure of Interests

Mariele Gatto Speakers bureau: GSK, Grant/research support from: GSK, Roberto Depascale: None declared, Angela Tincani: None declared, Giacomo Emmi: None declared, Salvatore Scarpato: None declared, Fabrizio Conti: None declared, Marcello Govoni: None declared, Marta Mosca: None declared, Maria Gerosa: None declared, Enrica Bozzolo: None declared, Valentina Canti: None declared, Armando Gabrielli: None declared, Elisa Gremese: None declared, Salvatore De Vita: None declared, francesco ciccia: None declared, Carlo Salvarani: None declared, Maurizio Rossini: None declared, Paola Faggioli: None declared, Antonella Laria: None declared, Amato De Paulis: None declared, Roberto Gerli: None declared, Enrico Brunetta: None declared, Alessandro Mathieu: None declared, Carlo Selmi: None declared, Rossella De Angelis: None declared, Simone Negrini: None declared, Margherita Zen: None declared, Andrea Doria Speakers bureau: GSK, Eli Lilly, Roche, Grant/research support from: GSK, Luca Iaccarino Speakers bureau: GSK, Grant/research support from: GSK

POS0910 PSYCHIATRIC COMORBIDITIES ASSESSMENT: AN UNMET NEED IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOPATHIES?

Background

Idiopathic Inflammatory Myopathies (IIMs) are rare and complex chronic diseases, with a strong impact on patients’ Quality of Life (QoL) in terms of both physical and emotional functioning. Despite its key role in daily life, patients’ emotional status could be difficult to be investigated by physicians. As known, patients with chronic conditions are at higher risk of anxiety and depression, but data about their prevalence in IIMs are still limited. The Hospital Anxiety and Depression Scale (HADS) is a validated questionnaire to evaluate the presence and severity of both anxiety (HADS-A) and depression (HADS-D) in patients.

Objectives

To determine the prevalence of anxiety and depression in a monocentric cohort of IIMs patients and to evaluate possible correlations with clinical features, disease activity and parameters of QoL.

Methods

Consecutive adult patients with a diagnosis of IIM (2017 EULAR/ACR criteria) were recruited during a scheduled follow-up visit. Demographic and clinical features were recorded (sex, age, disease subset and duration, organ involvement, comorbidities). IIM disease activity was evaluated following International Myositis Assessment & Clinical Studies Group Disease Activity Core Set Measures. To detect anxiety and depression status, HADS was administered to patients, who were also asked to fill in Short-Form 36 Items Health Survey (SF-36). For both HADS-A and -D subscales, patients were classified as at risk for scores ≥8 (borderline for scores 8-10, high risk if ≥11). Results were reported as mean±SD for continuous variables and as percentage for categorical variables. Intergroup comparisons were assessed by using Chi-square, t-test and ANOVA. Pearson coefficient was used to analyse the correlations between variables. P values <0.05 were considered significant.

Results

Fifty-three patients (72% female; mean age 64.8±12.0 years; mean disease duration 7.4±6.2 years) were enrolled. Twenty (37.7%) showed increased anxiety scores (mean 11.35, min. 8 – max. 17): 10 (50%) borderline and 10 (50%) high risk. Twenty (37.7%) had an increased depression score (mean 11.75, min. 8 – max. 19): 6 (30%) borderline and 14 (70%) high risk. If abnormal scores of both HADS-A and -D were found in 15 patients (28.3%), 17 patients (32.1%) were at high risk of at least one of the conditions. Sex, age, disease subset and duration did not seem to influence patients’ emotional status. Apart from an association between Raynaud’s Phenomenon occurrence and higher HADS-A scores (p=0.045), no significant correlations with organ involvements emerged. A strong association was found between fibromyalgia and higher HADS-A and -D scores (p=0.006 both). Patients with elevated anxiety levels presented significantly higher scores of Patient Global Assessment (PGA, p=0.002) and Health Assessment Questionnaire (HAQ, p=0.007) and significantly lower scores of Manual Muscle Testing (MMT8, p=0.004). HADS-D scores were similarly associated with PGA (p=0.001), HAQ (p<0.0001) and MMT8 (p=0.001). The presence of anxiety and depression was associated with lower scores in all SF-36 domains (all p≤0.016 for HADS-A and all p≤0.006 for HADS-D). Moreover, a correlation was found among SF-36 scores and PGA (all r <-0.516, p<0.01), HAQ (all r <-0.541, p<0.01) and MMT8 values (all r >0.299, p<0.05).

Conclusion

These results show nearly 40% of our cohort was at risk of anxiety or depression; almost 30% were at risk of developing both conditions together and quite one third was at high risk to develop at least one of them. As expected, these conditions were favoured from a concomitant fibromyalgia. Moreover, a compromised QoL and a functional limitation, as evaluated by PGA, HAQ and MMT8, in agreement with SF-36 domains, were significant risk factors for their occurrence. Therefore, our data, although preliminary, underline the need of a more comprehensive evaluation of IIMs patients, who should be screened for psychiatric comorbidities and, in case of high risk, referred to a specialist evaluation, in the perspective of improving their quality of care.

Disclosure of Interests

None declared

POS1242 BARICITINIB AND PULSE STEROIDS COMBINED TREATMENT IN SEVERE COVID-19 PNEUMONIA: PRELIMINARY DATA FROM A RHEUMATOLOGIC EXPERIENCE IN INTENSIVE CARE UNIT

Background

Growing evidence from in vitro and clinical studies have highlighted important similarities between severe COVID-19 and rapidly progressive interstitial lung diseases (ILD) occurring in systemic autoimmune disorders. These data supported the use of anti-rheumatic drugs, baricitinib and glucocorticoids, for the treatment of COVID-19 pneumonia.

Objectives

To compare mortality rate and inflammatory response in critically ill COVID-19 patients treated with either a “rheumatologic approach” based on baricitinib plus pulse steroids (BPS) or with a “conventional approach” (Standard of Care, SoC).

Methods

In this retrospective study, we enrolled patients admitted to the Intensive Care Unit (ICU) with CT-proven SARS-CoV2 pneumonia, from September 2020 to April 2021. Demographic, laboratory, and clinical data were collected at the admission to ICU and after one week of treatment. SoC included dexamethasone 6 to 8 mg daily plus remdesivir (+/- antibiotics and hydroxychloroquine); BPS approach was based on baricitinib 4 mg daily for 10-14 days plus 6-methylprednisolone pulses (250-500 mg) for three consecutive days followed by rapid tapering. The primary endpoint was the intra-ICU mortality rate; the secondary endpoint was the change in inflammatory biomarkers at week 1 after treatment.

Results

We enrolled a total of 210 consecutive patients with SARS-CoV2 pneumonia (male 61.4%, mean age 66.6 ± 10.9 years); 137/210 (male 59.8%, mean age 66.3 ± 11.9 years) were treated with SoC and 73/210 (male 64.3%, mean age 67.3 ± 8.8 years) with BPS.

At admission in ICU, all patients presented lag time from the first symptom of SARS-CoV2 infection ≤ 10 days, laboratory biomarkers’ alterations suggestive of hyper-inflammatory response (CRP 10.8 ± 11.9 mg/dL, ferritin 1238 ± 1005 µg/L, fibrinogen 575 ± 173 mg/dL, LDH 385 ± 152 U/L) and severe respiratory failure, requiring non-invasive or invasive ventilatory support. Lung-CT pattern showed multiple and diffuse areas of ground glass opacities, septal thickening, and/or consolidation.

No statistically significant differences were found between SoC and BPS groups in terms of demographic, laboratory, and clinical features at enrolment.

59/210 (28.1%) patients died during ICU hospitalization (mean ICU length of stay 14.6 ± 9.6 days). Mortality rate in the BPS group (13/73, 17.8%) resulted significantly lower compared to that in the SoC group (46/137, 33.6%) (p= 0.016). Furthermore, patients in the BPS group had significantly lower levels of CRP (BPS=1.9 ± 2.8 vs SoC 6.1 ± 7.3, p<0.001) and fibrinogen (BPS=335 ± 108 vs SoC 453 ± 172, p<0.001) at one week after the start of treatment.

Conclusion

Our real-life experience, in an ICU setting, showed that baricitinib and pulse steroids combination was associated with a lower mortality rate paralleled by a prompt reduction of inflammatory biomarkers. These results shed new light on the possible usefulness of baricitinib for the treatment of rapidly progressive ILD in patients with systemic autoimmunity and hyper-inflammation.

Disclosure of Interests

None declared

POS1232 LONG-TERM OUTCOMES OF COVID-19 VACCINATION IN PATIENTS WITH RARE AND COMPLEX CONNECTIVE TISSUE DISEASES: AN AD-INTERIM ANALYSIS OF ERN-ReCONNET VACCINATE STUDY

Background

Since the COVID-19 vaccination campaign was launched all over Europe, there has been general agreement on how benefits of SARS-CoV2 vaccines outweigh the risks in patients with rare connective tissue diseases (rCTDs). Yet, there is still limited evidence regarding safety and efficacy of such vaccines in these patients, especially in the long-term. For this reason, in the framework of ERN-ReCONNET, an observational long-term study (VACCINATE) was designed in order to explore the long-term outcome of COVID-19 vaccination in rCTDs patients. The consent form was developed thanks to the involvement of the ERN ReCONNET ePAG Advocates (European Patients Advocacy Group).

Objectives

To evaluate the safety profile of COVID-19 vaccination in rCTDs patients and the potential impact on disease activity. Primary endpoints were the prevalence of adverse events (AEs) and of disease exacerbations post-vaccination. Secondary endpoints were the proportion of serious adverse events (SAEs) and adverse events of special interest for COVID-19 (adapted from https://brightoncollaboration.us/wp-content/uploads/2021/01/SO2_D2.1.2_V1.2_COVID-19_AESI-update-23Dec2020-review_final.pdf)

Methods

The first ad-interim analysis of the VACCINATE study involved 9 ERN-ReCONNET Network centres. Patients over 18 years of age with a known rCTD and who received vaccine against COVID-19 were eligible for recruitment. Demographic data and diagnoses were collected at the time of enrolment, while the appearance of AEs and potential disease exacerbations were monitored after one week from each vaccination dose, and then after 4, 12 and 24 weeks from the second dose. A disease exacerbation was defined as at least one of the following: new manifestations attributable to disease activity, hospitalization, increase in PGA from previous evaluation, addition of corticosteroids or immunosuppressants.

Results

A cohort of 300 patients (261 females, mean age 52, range 18-85) was recruited. Systemic lupus erythematosus (44%) and systemic sclerosis (16%) were the most frequent diagnoses, followed by Sjogren’s syndrome (SS,12%), idiopathic inflammatory myositis (IMM,10%), undifferentiated connective tissue disease (UCTD,8%), mixed connective tissue disease (MCTD,4%), Ehlers-Danlos’s syndrome (EDS,4%), antiphospholipid syndrome (APS,2%). AEs appearing 7 days after the first and second doses were reported in 93 (31%) and 96 (32%) patients respectively, mainly represented by fatigue, injection site reaction, headache, fever and myalgia. Otitis, urticaria, Herpes Simplex-related rash, stomatitis, migraine with aura, vertigo, tinnitus and sleepiness were reported with very low frequency. Less than 2% of patients experienced AEs within 24 weeks from the second dose. No SAEs or AEs of special interest were observed in the study period. There were 25 disease exacerbations (8%), 7 of which severe. The highest number of exacerbations was observed after 4 weeks from the second dose (12 within week 4, 6 within week 12 and 7 within week 24). Disease exacerbation was most frequent in patients with EDS (33%) and MCTD (25%).

Conclusion

This preliminary analysis shows that COVID-19 vaccination is safe in rCTDs patients. AEs appear most often early after vaccination and are usually mild. Disease exacerbations are not frequent, but can be potentially severe and tend to occur most frequently within the first month after vaccination. Exacerbations can also occur 3-6 months after vaccination, although a causal relationship with the vaccination remains to be established. Our present data underline the importance of long-term observational studies.

Table 1.

AEs and disease exacerbations per disease

DiagnosisPatients enrolled (%) (n=300)EAs after 1st and 2nd dose (%)Exacerbations (%)APS25714EDS45033IIM10527MCTD44225SS12598SLE44698SSC16492UCTD850-

Acknowledgements

VACCINATE is a study promoted by the European Reference Network on rare and complex connective tissue diseases, ERN ReCONNET. This publication was funded by the European Union’s Health Programme (2014-2020)

Disclosure of Interests

None declared

POS0909 THE ROLE OF IMACS CORE SET MEASURES TO ROUTINELY EVALUATE THE QUALITY OF LIFE OF IDIOPATHIC INFLAMMATORY MYOPATHIES PATIENTS IN CLINICAL PRACTICE

Background

Idiopathic Inflammatory Myopathies (IIMs) are rare, multisystemic and complex diseases, often impacting on patients’ quality of life (QoL). Patient Reported Outcomes (PROs) assess the overall health status of patients, particularly for emotional and functional domains. In clinical practice the administration of PROs might have some limitations, because they tend to be time-consuming and sometimes difficult to be filled in by patients. The International Myositis Assessment & Clinical Studies Group Disease Activity Core Set Measures (IMACS-CSM) are a tool created to specifically assess disease activity and QoL in IIMs.

Objectives

To evaluate the ability of IMACS-CSM in assessing IIMs patients’ QoL in comparison with both generic and IIMs specific PROs.

Methods

Consecutive adult patients with an established diagnosis of IIM (2017 EULAR/ACR criteria) followed at our Myositis Clinic were enrolled and evaluated during scheduled follow-up visits. Demographic and clinical data (age, sex, disease subset and duration, organ involvement) were collected. IMACS-CSM [Physician Global Activity (PhGA), Patient Global Activity (PGA), 8-items Manual Muscle Testing (MMT8), Health Assessment Questionnaire (HAQ), CPK values, Myositis Disease Activity Assessment Tool (MDAAT)] were used to evaluate both disease activity and QoL. Patients’ perspective was evaluated also by administration of PROs not included in the IMACS-CSM: Short-Form 36 Items Health Survey (SF-36), Functional Assessment of Chronic Illness Therapy Fatigue Subscale (FACIT-F), Myositis Activity Profile (MAP), MD Anderson Dysphagia Inventory (MDADI). Results were expressed as mean±SD for continuous variables and as percentage for categorical variables. Intergroup comparisons were assessed by using Chi-square, t-test and ANOVA. Pearson coefficient was used to analyse the correlations between IMACS-CSM variables and the other PROs. P values <0.05 were considered significant.

Results

Sixty patients (65% female, mean age 59.9±13.5 years, mean disease duration 7.7±6.1 years), 37 (61.7%) with polymyositis, 20 (33.3%) with dermatomyositis and 3 (5%) with inclusion body myositis, were enrolled. Among IMACS-CSM, the mean HAQ and PGA scores were significantly worse in case of muscle (p=0.017) and oesophageal involvement (p=0.017), respectively; as expected, MMT8 score was associated with muscle involvement (p=0.017); MDAAT score was instead associated with oesophageal dysfunction (p<0.001). No associations were found between IMACS-CSM and others clinical and demographic parameters. FACIT-F correlated positively with MMT8 (r 0.432, p=0.001) and negatively with PhGA, PGA, HAQ and MDAAT (all r <-0.404 and p≤0.002 except for PhGA with r=-0.338 and p=0.016). SF-36 domains correlated positively with MMT8 (all r >0.259, p≤0.05) and negatively with PGA (all r <-0.393, p≤0.001), HAQ (all r <-0.422, p≤0.001) and MDAAT (all r <-0.276, p≤0.05). Opposite correlations were found for MAP domains: MMT8 all r <-0.297, p≤0.05; PGA all r >0.326, p≤0.05; HAQ all r >0.483, p≤0.001; MDAAT all r >0.268, p≤0.05. Similarly, MDADI scores correlated negatively with MMT8 (r <-0.363, p=0.005) and positively with PGA, HAQ and MDAAT (all r >0.318, p≤0.015). Notably, no correlations emerged between these PROs and CPK values.

Conclusion

Even if IMACS-CSM offer a partial evaluation of patients’ perspective, our data show how not only HAQ and PGA, but also PhGA, MMT8 and MDAAT (expressing rheumatologist’s point of view) seem to adequately reflect overall health status of IIMs patients, thus giving to clinicians a reliable assessment of their QoL. Therefore, the core set should be routinely used in clinical practice during every outpatient visit, while more accurate and complex PROs might be administered at larger time intervals or during disease flares, to optimize IMACS-CSM’s analysis.

Disclosure of Interests

None declared

POS0123 MAJOR SALIVARY GLAND ULTRASONOGRAPHY AND MRI WITH DIFFUSION WEIGHTED IMAGING (DWI) AS COMPLEMENTARY TOOLS TO IDENTIFY FEATURES OF MALT IN PRIMARY SJÖGREN’S SYNDROME (pSS): A SINGLE CENTER CROSS SECTIONAL STUDY

Background

Salivary MALT lymphoma represents the major complication of primary Sjögren’s Syndrome (pSS). However, the early recognition of MALT lymphoma may be challenging due to its indolent, slow clinical course.

Objectives

1. to identify salivary gland ultrasonographic (SGUS) features and magnetic resonance (MRI) abnormal findings with Diffusion Weighted Imaging (DWI) and Apparent Diffusion Coefficient (ADC) of MALT in pSS patients 2. To evaluate the correlation between salivary gland ultrasonography (SGUS) and MRI in pSS patients with suspected lymphoma.

Methods

consecutive patients with pSS (2016 ACR/EULAR criteria) and suspected MALT lymphoma undergoing histological examination were included in this cross sectional study from September 2017 to November 2021. The US echostructure of each gland on B-mode images was graded using the latest 2019 OMERACT semiquantitative SGUS scoring systems (0-3). Sonographic features of focal lesions were described. Conventional MRI techniques (i.e T1WI, T2WI, and STIR images) combined with MR sialography was performed in all the cases. DWI was acquired at b-value 0, 500 and 1000. ADC values were calculated. Patients’ clinical and histological data were collected. Data were presented as mean±SD, or percent frequency as appropriate. Intergroup comparisons were made using the t-test/Mann–Whitney test for continuous variables and Fisher’s exact test for categorical variables.

Results

45 pSS (mean age, S.D=55±15 yrs) were included. MALT lymphoma was histologically confirmed in 14/45 pSS patients and, specifically in 18/180 major salivary glands (17 parotids and 1 submandibular glands). At SGUS examination, MALT salivary glands presented an OMERACT grade 3 in 16/18 and a grade 2 in 2/18, significantly higher than the OMERACT scoring observed in no-MALT pSS glands (p=0.0001). The sonographic features more commonly detected in MALT were: hypoecoich macroareas with posterior enhancement, presence of septa or hyperechogenic strands and anarchic intralesional vascularization. At MRI, 15/18 (83.3%) MALT lymphoma appeared as intraglandular solid lesions: 9/15 (60%) were solid-cystic lesions and 6/15 (40%) were solid lesions without cystic changes. The frequency of solid lesions in pSS patients without lymphoma was 3/124 (2.4%), significanlty lower than in MALT-pSS. Furthermore 15/18 (83.3%) MALT lymphoma showed glandular fatty substitution. The presence of fatty substitution did not differ in MALT lymphoma and in no-MALT pSS glands. The mean (SD) ADC value of MALT lesions was significantly lower than the ADC of the parotid glands in pSS without lymphoma (0.63±0.07 x 10^-3 mm2/s vs 1.13± 0.19 x 10^-3 mm2/s, p =0.001). A negative correlation between SGUS OMERACT score and mean glandular ADC values (r = – 0.776, p < 0.001) was found; patients with OMERACT score 3 presented the lowest mean salivary gland ADC when compared to the other OMERACT scores (0-2) (p=0.001).

Conclusion

OMERACT semiquantitative SGUS scoring systems and MRI with DWI represent promising complementary tools in the differential diagnosis of pSS MALT lymphoma, particularly useful to guide parotid biopsy. Patients with an OMERACT score 3 in their SGUS deserve a careful screening for lymphoma.

Disclosure of Interests

None declared

POS0721 ASSOCIATION BETWEEN PRECONCEPTION COMPLEMENT LEVELS AND USE OF HYDROXYCHLOROQUINE WITH PREGNANCY OUTCOME IN PATIENTS WITH PRIMARY ANTIPHOSPHOLIPID SYNDROME AND CARRIERS OF ANTIPHOSPHOLIPID ANTIBODIES: AN INTERNATIONAL MULTICENTER STUDY

Background

Antiphospholipid Syndrome (APS) is a rare autoimmune disease characterized by thrombotic events and/or pregnancy morbidities in the presence of confirmed positivity for antiphospholipid antibodies (aPL). Complement was demonstrated to be involved in aPL-related pregnancy loss in animal models and several groups investigated the significance of complement levels in human disease. C3 and C4 serum levels were assessed in several cohorts of pregnant patients with APS and/or aPL positivity in order to relate complement consumption with adverse pregnancy outcome (APO).

According to some authors, hydroxychloroquine (HCQ) can control the activation of the complement system, improve pregnancy outcome and reduce aPL title.

Objectives

This study was designed to verify the effect of HCQ in addition to low dose aspirin (LDA) + low molecular weight heparin (LMWH) treatment in a multicenter cohort of primary APS (PAPS) and aPL carriers pregnant women and the possible correlation with preconception serum C3/C4 levels.

Methods

Medical records of pregnant women with confirmed positivity for aPL antibodies attending twelve referral centers from January 2010 to December 2020 were retrospectively evaluated. We considered as aPL-related APO: spontaneous abortions (<10 weeks of gestation), fetal loss (≥10 weeks of gestation), neonatal death (death of a formed fetus alive at birth in the first 28 days of life), preterm delivery before 37 weeks of gestation, preeclampsia, eclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet).

Results

We have analyzed 164 singleton PAPS/aPL carrier pregnancies (22 aPL carriers - 13%) in 128 patients: all were treated with combination therapy (LDA+LMWH), and in 30 HCQ was added. 58 pregnancies (43%) had low levels of preconception C3/C4. A triple aPL positivity was observed in 54 pregnancies, 14 of them were treated with combination therapy + HCQ. When considering the whole cohort, the addition of HCQ had not significantly improved the gestational outcome. Further stratification was performed on the basis of complement consumption. In the group of patients with preconception low C3/C4 levels the addition of HCQ had not significantly improved pregnancy outcome. We have lastly evaluated 40 pregnancies with a high-risk profile (triple aPL positivity and complement consumption), in which we have found that HCQ significantly improved gestational outcome (p=0.018, Table 1).

Table 1.

Relationship between APO, therapy during pregnancy and risk profile.

All pregnancies (n=164)Reduced C3/C4 (n=58)Triple aPL+ and reduced C3/C4 (n=40)LDA+LMWH (n, %)LDA+LMWH+HCQ (n, %)pLDA+LMWH (n, %)LDA+LMWH+HCQpLDA+LMWHLDA+LMWH+HCQp(n, %)(n, %)(n, %)APO62 (46%)16 (53%)ns32 (68%)4 (36%)ns23 (77%)3 (30%)0.018No APO72 (54%)14 (47%)15 (32%)7 (64%)7 (23%)7 (70%)Total1343047113010

This observation could not be confirmed in patients with single or double aPL positivity.

Conclusion

The study shows that administering HCQ in addition to combination therapy can improve gestational outcome in aPL/PAPS high-risk patients. This observation confirms that HCQ exerts a beneficial effect on aPL pregnancies by complement inhibition as it was shown in animal models. In addition, our results provide the clinicians a useful tool to implement conventional treatment in patients at high risk of pregnancy complication or loss.

References

[1]De Carolis S, et al. Is there any role for the hydroxychloroquine (HCQ) in refractory obstetrical antiphospholipid syndrome (APS) treatment? Autoimmun Rev 2015;14:760-2.

[2]Mekinian A, et al. The efficacy of hydroxychloroquine for obstetrical outcome in antiphospholipid syndrome: data from a European multicenter retrospective study. Autoimmun Rev 2015;40:498-502.

[3]Mekinian A et al. Obstetrical APS: is there a place for hydroxychloroquine to improve the pregnancy outcome? Autoimmun Rev 2015;14:23-9.

Disclosure of Interests

None declared

POS0714 POOLED SAFETY ANALYSIS OF BARICITINIB IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS FROM THREE RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, CLINICAL TRIALS

Background

Baricitinib (BARI), an oral selective inhibitor of Janus kinase 1 and 2 approved for the treatment of rheumatoid arthritis and atopic dermatitis, has been evaluated in clinical studies in patients with systemic lupus erythematosus (SLE).

Objectives

To assess the safety profile of BARI in patients with SLE.

Methods

Patients with SLE receiving stable background therapy were randomised 1:1:1 to BARI 2-mg, 4-mg, or placebo (PBO) once daily in one 24-week, phase 2 (NCT02708095) and two 52-week, phase 3, PBO controlled studies (NCT03616912 and NCT03616964).

Results

A total of 1,849 patients were included in this pooled analysis, representing 1,463.5 patient years of exposure (PYE). The incidence rates per 100 PYR at risk (IR/100 PYR) for serious adverse events (SAEs) were 9.5, 14.7, and 14.1 respectively for PBO, BARI 2-mg, and BARI 4-mg. There were no clinically meaningful differences between treatment groups for discontinuations due to AEs or death (Table 1).

Table 1.

Overview of safety measures of baricitinib in patients with SLE

Safety measurePBOBARI 2-mgBARI 4-mgPooled-BARIN=614N=621N=614N=1235PYE=488.1PYE=494.0PYE=481.4PYE=975.4n(%)n(%)n(%)n(%)PYRPYRPYRPYR[IR; 95%CI][IR; 95%CI][IR; 95%CI][IR; 95%CI]SAEs45 (7.3)70 (11.3)*65 (10.6)*135 (10.9)*473.2476.6461.9938.5[9.5; 6.9, 12.7][14.7; 11.5, 18.6][14.1; 10.9, 17.9][14.4; 12.1, 17.0]Discontinuation of study drug due to AE48 (7.8)58 (9.3)57 (9.3)115 (9.3)485.3492.3480.6973.0[9.9; 7.3, 13.1][11.8; 8.9, 15.2][11.9; 9.0, 15.4][11.8; 9.8, 14.2]Death4 (0.7)1 (0.2)4 (0.7)5 (0.4)488.2494.0481.5975.5[0.8; 0.2, 2.1][0.2; 0.0, 1.1][0.8; 0.2, 2.1][0.5; 0.2, 1.2]Serious infections12 (2.0)22 (3.5)28 (4.6)*50 (4.0)*484.3487.2472.5959.7[2.5; 1.3, 4.3][4.5; 2.8, 6.8][5.9; 3.9, 8.6][5.2; 3.9, 6.9]Herpes Zoster18 (2.9)17 (2.7)29 (4.7)46 (3.7)481.1486.5468.6955.1[3.7; 2.2, 5.9][3.5; 2.0, 5.6][6.2; 4.1, 8.9][4.8; 3.5, 6.4]VTEs#6 (1.2)3 (0.6)1 (0.2)4 (0.4)444.0450.2438.1888.3[1.4; 0.5, 2.9][0.7; 0.1, 1.9][0.2; 0.0, 1.3][0.5; 0.1, 1.2]MACE#01 (0.2)3 (0.6)4 (0.4)443.9450.1438.1888.3[0.0; NA, 0.8][0.2; 0.0, 1.2][0.7; 0.1, 2.0][0.5; 0.1, 1.2]Malignancy excluding NMSC2 (0.3)3 (0.5)2 (0.3)5 (0.4)488.0494.1481.4975.5[0.4; 0.0, 1.5][0.6; 0.1, 1.8][0.4; 0.1, 1.5][0.5; 0.2, 1.2]NMSC2 (0.3)000*486.7494.0481.4975.4[0.4; 0.0, 1.5][0.0; NA, 0.7][0.0; NA, 0.8][0.0; NA, 0.4]

Data are n (%) patients PYR [IR; 95% CI]. #Phase 2 study data not included. AE=adverse event; CI=confidence interval; MACE=major adverse cardiac event; NMSC=non-melanoma skin cancers; VTE=venous thrombotic event (includes deep vein thrombosis and pulmonary embolism); IR=incidence rate (100 times the number of patients reporting an adverse event divided by the event-specific exposure to treatment); N=number of patients in the analysis population; n=number of patients in the specified category; PYE=patient-year of exposure; PYR=patient years at risk; SAE=serious adverse event. *p≤0.05 vs placebo.

The IR/100 PYR for serious infections were 2.5, 4.5, and 5.9 respectively for PBO, BARI 2-mg, and BARI 4-mg. The risk of Herpes Zoster was higher in BARI 4-mg (4.7%) vs PBO (2.9%) (Table 1).

The IR/100 PYR for positively adjudicated venous thrombotic events (VTEs) were 1.4, 0.7, and 0.2 respectively for PBO, BARI 2-mg, and BARI 4-mg. The IR/100 PYR for positively adjudicated major adverse cardiac event (MACE) was numerically higher in BARI 2-mg (0.2) and BARI 4-mg (0.7) vs PBO (0.0), however the pooled-BARI IR/PYR (0.5) was within the range of background disease (1). No increased risk for malignancies was observed.

Conclusion

The safety profile of BARI in SLE patients was consistent with the known BARI safety profile. There was no increased risk of VTE in BARI treatment groups.

References

[1]Barbhaiya M, Feldman CH, et al. Arthritis Rheumatol. 2017;69(9):1823-31.

Disclosure of Interests

Thomas Dörner Speakers bureau: Eli Lilly and Company and Roche, Consultant of: AbbVie, Celgene, Eli Lilly and Company, Janssen, Novartis, Roche, Samsung and UCB, Grant/research support from: Chugai, Janssen, Novartis and Sanofi, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Marta Mosca Speakers bureau: Eli Lilly, GSK, Astra Zeneca, Consultant of: Eli Lilly, GSK, Astra Zeneca, Ian N. Bruce Speakers bureau: GSK, Astra Zeneca, UCB, Consultant of: Eli Lilly, GSK, UCB, BMS, Merck Serono, Astra Zeneca, IL-TOO, Aurinia, Grant/research support from: GSK, Janssen, Mario Cardiel Speakers bureau: Eli Lilly, Pfizer, Abbvie, Consultant of: Eli Lilly, Pfizer, Grant/research support from: Pfizer, Gilead, Roche, Janssen, Eric F. Morand Speakers bureau: AstraZeneca, Eli Lilly, Novartis, Consultant of: Amgen, AstraZeneca, Asahi Kasei, Biogen, BristolMyersSquibb, Capella, Eli Lilly, EMD Serono, Genentech, GlaxoSmithKline, Janssen, Neovacs, Sanofi, Servier, UCB, Wolf, Grant/research support from: Janssen, AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, GlaxoSmithKline, Michelle A Petri Consultant of: Eli Lilly, Grant/research support from: Eli Lilly, Maria Silk Shareholder of: Eli Lilly, Employee of: Eli Lilly, christina dickson Shareholder of: Eli Lilly, Employee of: Eli Lilly, Gabriella Meszaros Shareholder of: Eli Lilly, Employee of: Eli Lilly, Maher Issa Shareholder of: Eli Lilly, Employee of: Eli Lilly, Lu Zhang Shareholder of: Eli Lilly, Employee of: Eli Lilly, Daniel J. Wallace Consultant of: Amgen, Eli Lilly and Company, EMD Merck Serono and Pfizer

POS0190 EFFICACY AND SAFETY OF BARICITINIB IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS FROM TWO RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, PARALLEL-GROUP, PHASE 3 STUDIES

Background

In a 24-week, phase 2 clinical study (NCT02708095) in patients with systemic lupus erythematosus (SLE), baricitinib (BARI), an oral selective inhibitor of Janus kinase 1 and 2 approved for the treatment of rheumatoid arthritis and atopic dermatitis, inhibited the type l interferon gene signature, multiple other cytokine pathways, and improved disease activity (1) (2).

Objectives

To further evaluate the efficacy and safety of BARI in patients with SLE.

Methods

Patients with active SLE receiving stable background therapy were randomised 1:1:1 to BARI 2-mg, 4-mg, or placebo (PBO) once daily in two identically designed, 52-week, phase 3 randomised, PBO-controlled studies. In SLE-BRAVE-I (NCT03616912) and -II (NCT03616964), 760 and 775 patients, respectively were enrolled in a balanced manner across regions, although different countries per region participated in each study. The primary endpoint for both studies was the proportion of patients achieving an SLE Responder Index-4 (SRI-4) response at week 52. Glucocorticoid tapering was encouraged but not required per protocol.

Results

The mean Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) at baseline was 10.1 for both SLE-BRAVE-I and -II participants; musculoskeletal and mucocutaneous domains were the most common domains involved at baseline. In SLE-BRAVE-I, the proportion of SRI-4 responders at week 52 among patients treated with BARI 4-mg (56.7%), but not BARI 2-mg (49.8%), was significantly greater than in patients treated with PBO (45.9%, p = 0.016) (Table 1). No difference was seen in SLE-BRAVE-II (47.1%, 46.3%, and 45.6%, BARI 4-mg, 2-mg, and PBO, respectively). None of the key secondary endpoints, including glucocorticoid tapering or time to first severe flare (SFI), were met in either study. The proportions of patients with serious adverse events (SAEs) were 7.1% and 8.6% for PBO, 9.4% and 13.4% for BARI 2-mg and 10.3% and 11.2% for BARI 4-mg in SLE-BRAVE-I and II, respectively.

Table 1.

Efficacy and safety of baricitinib in patients with SLE-BRAVE-I and -II

SLE-BRAVE-ISLE-BRAVE-IIEfficacy measurePBO (N=253)BARI 2-mg (N=255)BARI 4-mg (N=252)PBO (N=256)BARI 2-mg (N=261)BARI 4-mg (N=258)SRI-4 (W52)116 (45.9)126 (49.8)142 (56.7)*116 (45.6)120 (46.3)121 (47.1)SRI-4 (W24)99 (39.1)114 (44.8)117 (46.5)98 (38.6)104 (40.0)108 (42.1)Severe Flares (n, events)38 (15.0)34 (13.3)26 (10.3)26 (10.2)29 (11.1)29 (11.2)HR for time to first severe flare (SFI) HR [CI]NA0.8 [0.52, 1.32]0.65 [0.40, 1.08]NA1.1 [0.65, 1.89]1.1 [0.67, 1.94]Glucocorticoid sparing36 (30.8)31 (29.2)36 (34.0)33 (31.7)34 (29.8)36 (34.3)LLDAS (W52)66 (26.2)65 (25.7)74 (29.7)59 (23.2)62 (24.0)65 (25.4)Safety measureTEAE210 (83.0)210 (82.4)208 (82.5)198 (77.3)199 (76.2)200 (77.5)SAE18 (7.1)24 (9.4)26 (10.3)22 (8.6)35 (13.4)29 (11.2)

Data are n (%) patients, unless otherwise indicated. BARI=baricitinib; CI=confidence interval; HR=hazard ratio compared with PBO; LLDAS=lupus low disease activity state; N=number of patients in the analysis population; n=number of patients in the specified category; PBO=placebo; TEAE=treatment-emergent adverse event; SAE=serious adverse event; W=week. *p≤0.05 vs PBO.

Conclusion

Although phase 2 data suggested BARI as a potential treatment for patients with SLE (2), the SLE-BRAVE-I and -II phase 3 study results were discordant for the primary outcome measure, with only SLE-BRAVE-I positive, making it difficult to elucidate benefit. Additional analyses are being performed to understand this discordance. No new safety signals were observed.

References

[1]Dörner T, Tanaka Y, et al. Lupus Sci Med. 2020;7(1).

[2]Wallace DJ, Furie RA, et al. Lancet. 2018;392(10143):222-31.

Disclosure of Interests

Eric F. Morand Speakers bureau: Astra Zeneca, Eli Lilly, Novartis, Sanofi, Consultant of: Amgen, AstraZeneca, Asahi Kasei, Biogen, BristolMyersSquibb, Capella, Eli Lilly, EMD Serono, Genentech, Glaxosmithkline, Janssen, Neovacs, Sanofi, Servier, UCB, Wolf, Grant/research support from: Janssen, AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, GlaxoSmithKline, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Richard Furie Consultant of: Eli Lilly, Edward Vital Consultant of: Eli Lilly (consultant and honoraria), Ronald van Vollenhoven Consultant of: Abbvie, Biotest, BMS, Celgene, Crescendo, Eli Lilly and Company, GSK, Janssen, Merck, Novartis, Pfizer, Roche, UCB, Vertex, Grant/research support from: Abbvie, Amgen, BMS, GSK, Pfizer, Roche, UCB, Kenneth Kalunian Consultant of: Eli Lilly, Marta Mosca Consultant of: Eli Lilly, GSK, Astra Zeneca, Thomas Dörner Speakers bureau: AbbVie, Eli Lilly, BMS, Novartis, BMS/Celgene, Janssen, Consultant of: AbbVie, Eli Lilly, BMS, Novartis, BMS/Celgene, Janssen, Daniel J. Wallace Consultant of: Amgen, Eli Lilly and Company, EMD Merck Serono, and Pfizer, Maria Silk Shareholder of: Eli Lilly, Employee of: Eli Lilly, christina dickson Shareholder of: Eli Lilly, Employee of: Eli Lilly, Inmaculada De La Torre Shareholder of: Eli Lilly, Employee of: Eli Lilly, Gabriella Meszaros Shareholder of: Eli Lilly, Employee of: Eli Lilly, Bochao Jia Shareholder of: Eli Lilly, Employee of: Eli Lilly, Brenda Crowe Shareholder of: Eli Lilly, Employee of: Eli Lilly, Michelle A Petri Consultant of: Eli Lilly

AB0423 STRATEGIES FOR GLUCOCORTICOID TREATMENT IN SYSTEMIC LUPUS ERYTHEMATOSUS FLARES: A REAL-LIFE EXPERIENCE

Background

Glucocorticoids (GC) are a cornerstone for the treatment of Systemic Lupus Erythematosus (SLE) manifestations but there is still open debate concerning their optimal therapeutic employment.

Objectives

To describe and compare the GC therapeutic strategies used in a real-life setting for the initial treatment of SLE flares.

Methods

This study is a retrospective analysis of data from a monocentric cohort of SLE patients who registered a disease flare between 2015 and 2020. Flares were first categorized in “pulse-treated” (PT) and “non pulse-treated” (NPT). PT flares were then divided into “low-dose regimen” (250 mg iv 6MP for 3 consecutive days or less) and “high-dose regimen” (more than 250 mg iv 6MP for 3 days). GC daily and cumulative 6MP doses, rate of remission and relapse were evaluated at 3, 6 and 12 months.

Results

101 flares were analyzed (30 PT and 71 NPT). PT flares were more severe in terms of median SLEDAI (PT 16(12-22) vs NPT 8(5-10) p=0,00) and BILAG score index (BILAG A PT 71% vs NPT 30% p=0,001). PT patients received significantly higher GC doses at 1 month (PT median cumulative dose 1372 IQR 1028 – 3076 mg of 6MP vs NPT median 160 IQR 120-288 mg of 6MP, p=0,000), 6 months (PT median cumulative dose 2964 IQR 2294 – 4305 mg of 6MP vs NPT 880 IQR 720 – 1284 mg of 6MP, p=0,000) and 12 months (PT median cumulative dose 3510 IQR 3014-5025 vs NPT median cumulative dose 1571 IQR 1098 – 2122 mg of 6MP, p=0,000). Characteristics of flares that were treated with low-dose (N=19) or high-dose (N=11) pulse regimen are summarized in Table 1. As expected, the “low-dose regimen” subgroup received lower cumulative GC dosage over time. However, no statistically significant differences were found neither in term of disease severity at baseline nor in term of disease activity, remission rates or new flares over time.

Table 1.

Comparison between low-dose pulse regimen and high-dose pulse regimen in terms of cumulative GC dose and outcome in the first year after a SLE flare

Median GC doses (6MP)Low-dose regimenN=19 (63,33%)High-dose regimenN=11 (36,67%)P value Median SLEDAI16 (12 -20)18 (8-24)0,6186BILAG score (A, B, C)A=14, B=4, C=1A=10, B=1, C=00,488Cum. dose 1 mo1350 (1028 – 1534)1752 (960 – 2356)0,126Cum. dose 3 mos1858 (1604 – 2463)2784 (2184 – 3240)0,040Cum. dose 6 mos2450 (2218 – 3586)3456 (2906 – 4380)0,029Cumulative doses 12 mos3150 (2851 - 4448)4246 (3591 – 5772)0,011Remission 3 mos no – (%)2 (10%)0 (0%)0,265Remission 6 mos no – (%)8 (42%)1 (9%)0,057Remission 12 mos no – (%)12 (63%)5 (45%)0,346Median SLEDAI 3 mos4 (2 – 9)9 (4 – 12)0,138Median SLEDAI 6 mos3 (0 - 4)4 (0 – 9)0,154Median SLEDAI 12 mos2 (0 – 5)2 (0 – 12)0,363New flares 6 mos no – (%)2 (10%)1 (9%)0,900New flares 12 mos no – (%)2 (10%)2 (18%)0,552

GC=glucocorticoids, 6MP=6-methylprednisolone, no=number, Cum.=cumulative, mos=months

Conclusion

These data suggest that in a real-life setting, pulse GC therapy is preferred over oral administration for severe SLE flares and entails administration of high cumulative doses of GC. However, the experience outlined suggests that the low-dose pulse regimen is as effective in remission induction of severe flares as the high-dose regimen, allowing significant GC sparing. Since the cumulative GC dose is a known strong predictor of organ damage, strategies aimed to minimize the GC dosage should be encouraged.

Disclosure of Interests

None declared

POS0860 ULTRA-HIGH FREQUENCY ULTRASOUND FOR DIGITAL ARTERIES: COMPLETING THE CHARACTERIZATION OF VASCULOPATHY IN SYSTEMIC SCLEROSIS

Background

Despite microangiopathy is the hallmark of systemic sclerosis (SSc), macrovascular involvement is arousing interest. In particular, proper palmar digital arteries (PPDA) play an important role in Raynaud’s phenomenon and can contribute to the exacerbation of vascular damage. However, PPDA full characterization is still an unmet need.

Objectives

To assess the state of PPDA in a cohort of patients with SSc using ultra-high frequency ultrasound (UHFUS), comparing the results with those obtained in healthy controls (HC) and looking for any association with SSc-specific characteristics. Correlations between UHFUS features of PPDA and microvascular bed were also investigated.

Methods

Consecutive SSc patients without active digital ulcers and HC were enrolled. Epidemiological and SSc-specific data were collected. Each subject underwent UHFUS (70 MHz) evaluation of PPDA (2 per finger, from II to V finger bilaterally), searching for occluded or not viewable vessels and measuring the thickness of the three arterial layers, as well as the systo-diastolic excursion range. Finally, microvascular bed was investigated by capillaroscopy and laser speckle contrast analysis (LASCA).

Results

Forty-six SSc patients (87% female, mean age 55.5 years, mean disease duration 8.2 years) and 15 HC matched for age and sex were enrolled. UHFUS in SSc revealed 123 (16.7%) PPDA occluded or not viewable, whereas in HC they were all patent. Considering the finger with at least one of the two PPDA occluded or not viewable as ultrasonographically pathological, 30 (65.2%) patients presented at least one pathological finger (Figure 1). All three arterial layers were significantly thicker in SSc than in HC (p<0.001 for all), as well as systo-diastolic excursion range was significantly reduced in SSc (p<0.001). On 63 fingers previously affected by digital ulcers, 73% were ultrasonographically pathological. A direct correlation emerged between disease duration and the thickness of all three arterial layers (intima p<0.001; ρ=0.527; intima-media p<0.001; ρ=0.502; intima-media-adventitia p=0.001; ρ=0.491). No significant correlations emerged between capillaroscopy or LASCA findings and UHFUS features.

Figure 1.

Representation of the number of ultrasonographically pathological fingers per patient.

Conclusion

SSc presents a vasculopathic involvement of PPDA well characterized by UHFUS, a useful diagnostic tool able to show also subclinical vascular impairment. The lack of correlations between UHFUS and capillaroscopy or LASCA reflects the existence of vasculopathic processes that are not exactly the same. Thus, UHFUS evaluation of PPDA emerges as complementary to microcirculation assessment, in order to obtain a more accurate and complete characterization of the vasculopathy in SSc.

Disclosure of Interests

None declared

POS1502-HPR A PHYSICAL EXERCISE PROGRAM FOR THE MANAGEMENT OF FATIGUE IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) AT THE TIME OF PANDEMIC: A PILOT STUDY

Background

Fatigue in SLE has a multifactorial origin and disease activity seems to contribute only minimally to its genesis. Therefore, non-pharmacological therapeutic strategies should also be considered in the management of fatigue. There is some evidence on the effectiveness of aerobic exercise programs in improving fatigue, without a negative impact on disease manifestations.

Objectives

the aim of this study was to analyze fatigue and Health Related Quality of Life (HRQoL) in a monocentric cohort of patients with SLE, in a condition of stable remission or low disease activity, before and after a program of physical exercise, through the administration of validated Patient Reported Outcomes (PROs).

Methods

this is a cross-sectional interventional study which included patients with SLE, aged between 18 and 55 years, in a condition of stable (≥12 months) remission (DORIS)1 or low disease activity (LLDAS)2. Patients enrolled had a FACIT score ≤40 in the previous 6 months. Patients with other possible causes of fatigue (e.g.: anemia, hypothyroidism, severe vitamin D deficiency), active arthritis or physical disabilities were excluded. For each patient, demographics, comorbidities, treatment, clinical and laboratory data were collected. Disease activity was evaluated with the SELENA-SLEDAI and organ damage with the SLICC/DI. Each patient completed the following PROs before and after the interventional program: SF-36, FACIT-Fatigue, LIT, HADS. Due to the limitations related to the COVID-19 pandemic, the physical exercise sessions were carried out using the Google Meet digital platform. Patients were asked to participate to at least 70% of the lessons. The physical exercise program included moderate intensity aerobic exercises (muscle strengthening, joint mobility, breathing, static and dynamic stretching, balance and neuro-dynamics); workouts were performed 3 times a week, consisting of 60 minutes each. The program lasted for 12 weeks.

Results

we enrolled 12 female patients, regularly followed at the Rheumatology Unit of Pisa; only 9 of them completed the study (mean age 38.56 ± 9.1 years; median disease duration 7 years (IQR 5,25-9,75)). 8/9 were in stable remission, while 1/9 was in LLDAS for the presence of leukopenia.

2/9 patients presented organ damage, one for cataract and one for renal insufficiency, while none presented damage in the musculoskeletal system. 33.3% of patients had fibromyalgia. 88.8% was on treatment with Hydroxychloroquine, 55.5% was on low dose steroids (2±1.9 mg/daily), 33.3% was on Mycophenolate Mofetil; only 1 patient was on Belimumab. All PROs showed a trend to improvement at the end of the 12-week program of physical activity (Table 1). We demonstrated a statistically significant improvement of: FACIT, LIT, depression score of the HADS and MCS of the SF-36. The items of role physical (RP), vitality (VT) and mental health (MH) of the SF-36 also showed a significant improvement.

Table 1.

Scores of PROs before and after the physical exercise program.

PROsMean scores at baselineMean scores after the 12-week exercise programpFACIT30.2 ± 4.939.3 ± 7.20.01PF73.18 ± 10.978.9 ± 10.50.18RP50 ± 13.267.4 ± 18.60.03BP52 ± 12.154.1 ± 11.10.73GH41.7 ± 11.148.4 ± 11.10.07VT34.7 ± 12.559.0 ± 14.20.002SF58.3 ± 15.666.7 ± 16.70.3RE55.5 ± 21.569.4 ± 18.00.13MH58.3 ± 15.867.2 ± 16.20.03PCS43.8 ± 4.046.1 ± 4.80.19MCS38.6 ± 8.845.6 ± 8.70.03LIT36.9 ± 14.227.5 ± 14.10.05HADS (A)9 ± 4.47.7 ± 3.20.4HADS (D)7.9 ± 4.45.1 ± 2.960.05

Conclusion

In a small cohort of SLE patients in remission but with severe fatigue, in the difficult context of COVID-19 pandemic, we demonstrated that an online program of physical exercise may determine a significant improvement of fatigue, perception of disease burden and mental health. In the context of a multidisciplinary management, finding effective intervention programs to improve fatigue and HRQoL in SLE patients appears of utmost importance, with the final aim of improving patients’ health status.

References

[1]PMID 27884822; 2PMID 26458737

Disclosure of Interests

None declared

AB1410 IMPACT OF COVID-19 PANDEMIC ON HEALTHCARE RESOURCE USE AND CLINICAL OUTCOMES IN A COHORT OF PATIENTS WITH SYSTEMIC AUTOIMMUNE DISEASES- AN INTERIM ANALYSIS FROM THE PER-MAS PROJECT

Background

Management of the health emergency caused by COVID-19 pandemic majorly disrupted the delivery of healthcare services to patients with chronic conditions like Systemic Autoimmune Diseases (SAD), both because resources were mainly channeled towards the care of infected patients, but also because patients tended to avoid seeking medical care for fear of becoming infected. PER-MAS is a 2-year project aimed at assessing the clinical, psychopathological, and socio-economic impact of COVID-19 in a cohort of patients with SAD.

Objectives

To assess the impact of COVID-19 pandemic on drug withdrawal, disease flares and hospitalizations for disease exacerbation in a cohort of patients with SAD through an interim analysis of data from the PER-MAS project.

Methods

A sample of 214 consecutive patients was recruited in a reference center for rare and complex autoimmune diseases from April 2021 to January 2022. Inclusion criteria were definite diagnosis of SAD (Connective Tissue Disease (CTD), Inflammatory Arthritis (IA) or Vasculitis), regular follow-up and at least 2 years of disease. Patients were asked to fill out an extensive self-administered questionnaire on disease activity and healthcare resource use during the pandemic (March 2020-moment of assessment). Pre-pandemic (March 2019-February 2020) and early pandemic (March 2020-February 2021) clinical data were recorded through retrospective chart review and patient interview.

Results

At enrolment, 119 patients were affected by CTDs (55.6%), 71 by IA (33.18%), 24 by vasculitis (11.21%), with mean age 50.44± 12.97, and mean disease duration 11.17 ± 8.94. 30.37% took steroids, 39.7% hydroxychloroquine, 61.68% DMARDs, and 9.3% vasoactive drugs.

Overall, disease course was similar in pre-pandemic and early pandemic phase: in the first period, rheumatologic condition was stable in 57.35% of patients, persistently active in 27.3% and 35.61% had ≥ 1 episode of disease exacerbation (mean 0.665±1.15, range 0-6); in the second period, 60.56% of patients was stable, 24.88% persistently active, and 39.44% had ≥1 exacerbation (mean 0.49 ±0.77, range 0-4). Mean number of visits (2.56±2.57 and 2.61±2.79), hospitalizations (0.168±0.698 and 0.14±0.473, p=0.6), number of patients with outpatient visits=0 (7.47 vs 7%), and number of patients with ≥ 1 hospital admission (10.28 vs 11.6%) were also similar, while the number of patients with hospital admissions for disease exacerbation was significantly higher in the second period (6.1 vs 11.21%, p=0.001).

170 patients completed the survey: from March 2020 to enrolment, 18.2% suspended ≥1 anti-rheumatic drug (6.25% of them for fear of contracting COVID-19 disease, 15.6% for difficulty in obtaining medications), 20% self-managed ≥ 1 disease exacerbation, and 40% had ≥ 1 telemedicine consult. From March to July 2020, 41.76% had their visit rescheduled (35.23% for hospital access restrictions, 5.3% for travel restrictions, 1.17% for fear). Conversely, only 14.7% of patients had their visit rescheduled (8.23% for hospital access restrictions, 4.7% for other reasons) from July 2020 to enrolment.

Conclusion

In the early pandemic phase, overall disease course was similar to the pre-pandemic phase, but we observed an increase in the number of patients with ≥ 1 hospitalization for disease. Moreover, despite our efforts, patients reported a non-negligible rate of drug discontinuation for non-medical indication and difficulty to get access to rheumatologic consultation, highlighting the need of alternative organizational models in case of future pandemics.

Acknowledgements

Giulia Sacco for helping in patient recruitment and data management.

Disclosure of Interests

Francesca Trentin: None declared, Giovanni Fulvio: None declared, Gianni Andreozzi: None declared, Cosimo Cigolini: None declared, Mattia Da Rio: None declared, Valerio Dell’Oste: None declared, Elena Elefante: None declared, Federico Fattorini: None declared, Silvia Fonzetti: None declared, Valentina Lorenzoni: None declared, Michele Maffi: None declared, Inmaculada Concepción Navarro García: None declared, Ilaria Palla: None declared, Virginia Pedrinelli: None declared, Laura Scagnellato: None declared, Davide Schilirò: None declared, Anastasiya Valevich: None declared, Andrea Gaglioti: None declared, Claudia Carmassi: None declared, Chiara Tani: None declared, Liliana Dell’Osso: None declared, Giuseppe Turchetti: None declared, Marta Mosca Speakers bureau: Lilly, Astra Zeneca, GSK, Consultant of: Lilly, Astra Zeneca, GSK

POS0771 ULTRA HIGH-FREQUENCY ULTRASOUND (UHFUS) OF MINOR LABIAL SALIVARY GLANDS (MLSGS): DIAGNOSTIC ACCURACY IN ANTI-Ro/SSA POSITIVE AND ANTI-Ro/SSA NEGATIVE PATIENTS WITH PRIMARY SJÖGREN’S SYNDROME (pSS)

Background

Last-generation Ultra High-frequency ultrasound (UHFUS) transducers are highly sensitive tools for the study of tiny superficial structures such as minor labial salivary glands (MLSGs). Compared to conventional ultrasound, UHFUS operates with higher frequencies allowing for outstanding image resolution, up to 30 µm.

Objectives

To determine the diagnostic accuracy of MLSG UHFUS in primary Sjogren’s syndrome (pSS) and to assess its contribution in anti-Ro/SSA positive and anti-Ro/SSA negative patients

Methods

Consecutive patients undergoing a MLSG biopsy for clinically suspected pSS were included in this cross-sectional study from January 2018 to October 2021. MLSG UHFUS was performed by using a 70 MHz probe, evaluating parenchymal inhomogeneity (score 0-3, similar to major salivary glands four-grade OMERACT scoring system). Patients’ clinical, biological, and histological features were collected. Anti-Ro/SSA antibody specificity was determined by immunoblotting. Receiver operating characteristic (ROC) curves, optimal cut-off point, AUC (area under curve), sensitivity (SE), specificity (SP), positive (PPV) and negative predictive values (NPV) were identified.

Results

A total of 194 patients were enrolled. Out of them, 88 patients fulfilled the ACR/EULAR 2016 criteria for pSS and 74 were anti-Ro/SSA+ (69 pSS and 5 no-SS). The distribution of UHFUS grades was significantly different in patients with pSS than in no-SS subjects: grade 0: 0/88 (0) vs 17/106 (16%); grade 1: 28/88 (31.8%) vs 55/106 (51.9%); grade 2: 46/88 (52.3%) vs 31/106 (29.2%); grade 3: 14 (15.9%) vs 3(2.8%); p<0.0001. ROC curve analysis indicated that at the optimal cut-off value of 2, UHFUS identified pSS and no-SS patients with a SE=68.2%, a SP=67.9%, a PPV= 63.8%, and a NPV= 72% (AUC=0.722, 95%CI: 0.651-0.793) and can predict a FS≥1 at the MLSG biopsy with a SE =73%, a SP=63.4%, a PPV= 48.9% and a NPV = 83% (AUC= 0.732, 95% CI: 0.657-0.806). Subgroup analyses highlighted significant differences in UHFUS diagnostic accuracy between anti-Ro/SSA+ and anti-Ro/SSA- patients. Particularly, in the latter group UHFUS showed a higher diagnostic accuracy (AUC= 0.754, 95% CI: 0.641-0.867) with a NPV increased up to 93.3%; similarly, UHFUS showed a higher accuracy (AUC= 0.755, 95% CI: 0.650-0.860) in predicting a MLSG FS≥1 with a NPV raised up to 90.7%.

Conclusion

MLSG UHFUS score system presents a good SE and SP in distinguishing pSS from no-SS subjects. The diagnostic accuracy of MLSG UHFUS may be significantly enhanced when combined with anti-Ro/SSA antibodies status. If anti-SSA antibodies are negative and UHFUS grade is 0 or 1, the diagnosis of pSS is very improbable and MLSG biopsy could be avoided. Further studies are in progress to define the added value of UHFUS with respect to major salivary gland ultrasonography.

Table 1.

UHFUS diagnostic accuracy in pSS (A) and for predicting a MLSG FS≥1 in all the cases and in anti-Ro/SSA negative patients. OCP, optimal cut-off value.

SESPPPVNPVAUC (95%CI)OCPpSS diagnosis (all pts)60/88 (68.2%)72/106 (67.9%)60/94 (63.8%)72/100 (72%)0.722 (0.651-0.793)2FS≥1 prediction (all pts)46/63 (73%)83/131 (63.4%)46/94 (48.9%)83/100 (83%)0.732 (0.657-0.806)2pSS diagnosis (SSA- pts)14/19 (73.7%)70/101 (63.9%)14/45 (31.1%)70/75 (93.3%)0.754 (0.641-0.867)2FS≥1 prediction (SSA- pts)17/24 (70.8%)68/96 (70.8%)17/45 (37.9%)68/75 (90.7%)0.755 (0.650-0.860)2Figure 1.

ROC curves showing UHFUS diagnostic accuracy in pSS (A) and for predicting a MLSG FS≥1

Disclosure of Interests

None declared

OP0128 ADHERENCE TO MEDICATIONS DURING PREGNANCY IN SYSTEMIC AUTOIMMUNE DISEASE

Background

Low medication adherence is a well known issue in the management of patients with systemic autoimmune diseases (SAD), little however is known on adherence to medication during pregnancy, especially in these patients with high risk pregnancies.

Objectives

This study is aimed at evaluating the level of adherence to medication in pregnant patients with SAD in comparison with non-pregnant patients with SAD, and at identifying determinants of low adherence.

Methods

Pregnant and non-pregnant patients with an established diagnosis of SAD were consecutively enrolled. Pregnant patients were included in a tight monitoring protocol for high risk pregnancies, and treatments were checked every month. The following data were collected at enrolment: epidemiological and demographic characteristics, disease duration and type of medications. Each patient completed the following anonymous questionnaires: the 8-item Morisky Medication Adherence Scale (MMAS-8) and Hospital Anxiety and Depression Scale (HADS) to assess the presence of anxiety and depression. With regard to MMAS-8, we assessed adherence to hydroxychloroquine (HCQ) and to other disease modifying antirheumatic drugs (DMARDs) separately. We considered a score ≥ 6 as indicator of good adherence. Vitamins and dietary supplements were not considered.

Results

A total of 80 pregnant women and 72 non-pregnant women were enrolled. Clinical data and results of the questionnaires are summarized in Table 1.

Table 1.

Characteristics of the cohort

Pregnant patients N=80Non-pregnant patients N=72P valueAge at study entry (years, mean ±SD)35.8±4.340.1±12.20.001Disease duration (years, mean ±SD)8.5±6.68.6±9.1n.sNumber of tablets/day (mean ±SD)4.3±1.64.1±1.8n.sNumber of assumption/day (mean ±SD)1.4±0.61.6±0.8n.sScore MMAS for HCQ (mean ±SD)6.99±0.26.38±0.20.039Score MMAS for other DMARDs (mean ±SD)6.99±0.36.39±0.20.018Patients with good adherence to HCQ (%)38/50 (76.0%)34/59 (57.6%)0.044Patients with good adherence to medications (%)53/71 (74.6%)37/60 (61.7%)n.sPatients with low adherence to HCQ (%)12/50 (24%)25/59 (42.4%)0.044Patients with low adherence to medications (%)18/71 (25.4%)23/60 (38.3%)n.sAnxiety (%)20 (25%)30 (41.7%)0.029Depression (%)11 (13.7%)19 (26.4%)0.051

MMAS-8 score was significantly higher in pregnant women both for HCQ (p=0.039) and other DMARDs (p=0.018), as well as the rate of patients with good medication adherence for HCQ (76.0% vs 57.6%, p=0.044). The rate of patients with good medication adherence for other DMARDs was higher in pregnant patients (74.6% vs 61.7%) but this different was not statistically different.

Demographic and clinical characteristics and the number of therapies received didn’t seem to influence treatment adherence. Fifty patients (32.8%) suffered from anxiety, and this disorder was a significant determinant of low medication adherence in all groups. Conversely, depression didn’t seem to have an impact on adherence on neither group.

Conclusion

Overall, pregnant patients with SAD had a good adherence to prescribed medication; nevertheless, 25% of patients didn’t take therapies adequately despite being closely monitored in a dedicated clinic for high risk pregnancies and an adequate pregnancy counselling; anxiety seems to be one determinant of low medications adherence both in pregnant and non-pregnant women.

Disclosure of Interests

None declared

AB0588 GIANT CELL ARTERITIS: DO DIFFERENT PHENOTYPES OF PRESENTATION MEAN DIFFERENT CLINICAL ENTITIES?

Background

Giant cell arteritis (GCA) represents the most common primary vasculitis of the elderly, affecting large and medium-sized arterial vessels. GCA often also involves the aorta and its major branches and may lead to aortic aneurysm/dissection as well as large artery stenoses; it seems that unrecognized extra-cranial involvement may be even more common.

Objectives

The primary aim of this study was to explore the different clinical entities in a large cohort of patients with GCA; a secondary aim was to evaluate long-term outcome of GCA patients with at least 5 years of follow-up.

Methods

A cohort of 278 GCA patients (54 males and 224 females, mean ± SD age 75 ± 6 years) were retrospectively studied. Clinical symptoms at disease onset and during the follow-up, time delay until diagnosis, as well as laboratory findings at the time of diagnosis and therapeutic approach were retrospective evaluated. In order to characterize the different clinical phenotypes, overall clinical symptoms were grouped for macro-area (cranial versus systemic). Moreover, long-term outcomes in patients with a minimum follow-up of 3 years were evaluated. A disease flare was defined as the presence of any further clinical manifestation compatible with the clinical spectrum of GCA and an increase of ESR ≥ 30 mm/hour, not otherwise justifiable, that required higher doses or new introduction of glucocorticoids (GC) therapy and/or the introduction of steroid sparing treatments (e.g. tocilizumab, methotrexate).

Results

The most frequent clinical manifestations presented at the onset included: constitutional symptoms 69%, new onset headache and/or scalp pain 64%, jaw claudicatio 32%, vision loss 30%, abnormal temporal artery on examination 19%, neuropsychiatric symptoms 17%, cough not otherwise justifiable 7%, cerebrovascular accidents 6% and hearing loss 3%. Irreversible (mono- or bilateral) blindness was reported in 7% of patients, mainly due to a latency period between onset and treatment of ≥ 3 months. Temporal artery biopsy was performed in 171 patients, resulting positive in 72%. Globally, about 38% of subjects (was characterized by a clinical profile compatible with extra-cranial GCA. In all cases, extra-cranial involvement was confirmed by (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET). Moreover, patients who presented symptoms compatible with large-vessel involvement were characterized by a more relapsing course compared with patients with cranial involvement GCA profile (both in terms of dose of corticosteroids and use of steroid-sparing agents).

Conclusion

According to the literature data, different phenotypes of GCA exist and they may probably represent different clinical entities, also in terms of prognosis and therapeutic approach. This is particularly crucial in order to plan a tailored therapy and prevent disease damage in the short and long-term follow-up.

Disclosure of Interests

None declared

POS0767 GLANDULAR INVOLVEMENT IN PRIMARY SJÖGREN SYNDROME PATIENTS WITH INTERSTITIAL LUNG DISEASE (ILD) ONSET: A SINGLE CENTER CROSS-SECTIONAL STUDY

Background

Primary Sjögren Syndrome (pSS) is an autoimmune exocrinopathy classically presenting with sicca symptoms. Nonetheless, disease onset with extraglandular manifestations, particularly interstitial lung disease (ILD), is increasingly reported and probably underestimated. However, studies investigating pSS patients presenting with ILD (pSS-ILD) are limited.

Objectives

Aim of this study was to better characterize the phenotype of pSS patients presenting with ILD in comparison to pSS patients with classical sicca-onset. We especially investigated whether the two groups differed in glandular involvement comparing functional, imaging and histologic findings, as well as patient reported outcome (PRO).

Methods

Consecutive newly diagnosed pSS patients, all fulfilling the ACR/EULAR 2016 criteria, were included in this cross-sectional study from September 2016 to October 2021. Clinical, serological and histological initial features where compared in pSS-ILD patients and in pSS patients without ILD involvement, diagnosed during the same time period. Presence of ILD at pSS diagnosis was defined based on clinical findings, imaging assessment and pulmonary function tests. In addition to functional tests, a minor salivary gland biopsy was performed in all cases, recording number of foci and GC-like structures and focus score (FS). Salivary glands ultrasonography (SGUS) was graded using the OMERACT semiquantitative scoring system (0-3) based on parenchyma inhomogeneity. PRO including ESSPRI, OHIP and OSSDI were collected. Extraglandular clinical features and biological abnormalities included in the ESSDAI were recorded. Data were presented as mean±SD, or percent frequency as appropriate. Intergroup comparisons were made using the t-test/Mann–Whitney test for continuous variables and Fisher’s exact test for categorical variables.

Results

We included 178 newly diagnosed pSS patients (F:M=158:20). ILD was the first pSS manifestation in 11 (6%) cases, 8 F and 3 M, with a median time from ILD onset to pSS diagnosis of 2 ± 2 years. At HRCT, the following patterns were observed: NSIP (4/11), UIP (4/11), NSIP+OP (2/11) and LIP (1/11). Dyspnea on exertion or chronic cough were reported by 7/11 (63.6%) patients.

In comparison to sicca-onset patients, pSS-ILD patients presented an older age at diagnosis (55±13 vs 70±7, p= 0.001) and a higher ESSDAI (3.9±4.7 vs 12.3±4.3, p=0.001) driven by the pulmonary domain. Regarding glandular involvement, pSS-ILD patients reported milder xeropthalmia (VAS 5.8±3.1 vs 2.8±3.5, p=0.002), and significative lower scores in OSDI (35.6±24.9 vs 15.3±22.9, p=0.04) and OHIP (4.8±4.4 vs 1.4±3.8, p=0.04), despite no significant differences observed between the two groups in ocular tests and unstimulated salivary flow rate. With respect to histology, no significant differences were found in number of foci and GC-like structures, and FS. Notably, there was a trend towards a different distribution of the SGUS OMERACT score in the two groups. Particularly, none of pSS-ILD patients presented OMERACT score 3 in parotid and submandibular glands, in contrast to 26/167 (15.5%) and 18/167 (10.8%) of classic sicca-onset pSS patients respectively. Finally, no significant differences were observed between the two groups with respect to non-pulmonary extraglandular manifestations, serologic features and other biological parameters.

Conclusion

ILD-onset pSS patients represent an atypical phenotypic subset, with less pronounced sialadenitis sonographic changes in salivary glands, and with sicca symptoms probably overshadowed by the respiratory disease.

Disclosure of Interests

None declared

OP0197 POST-TRAUMATIC STRESS DISORDER AND SYMPTOMS IN PATIENTS WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES DURING THE COVID-19 PANDEMIC: PRELIMINARY RESULTS FROM THE PERMAS STUDY

Background

The COVID-19 pandemic, with its uncertainties, fears of contagion, mass lockdowns and containment measures, has dramatically impacted on people’s everyday lives leading to an increased risk of mental disorders, particularly Post-Traumatic Stress Disorder (PTSD). Despite evidence in general population and healthcare workers1,2, scant data emerged on vulnerable populations, such as of patients with chronic illness, particularly rheumatic and musculoskeletal diseases (RMDs)3,4, who also underwent difficulties in the management and treatment of their disorders.

Objectives

To assess PTSD and post-traumatic stress symptoms in a sample of patients with RMDs, during the COVID-19 pandemic in Italy.

Methods

PERMAS is a monocentric prospective observational study led by the Rheumatology Unit, the Psychiatric Clinic and the Institute of Management of the School of Advanced Studies. Patients with a RMD diagnosis, were consecutively enrolled from May 2021 to January 2022. During the visit, sociodemographic characteristics and psychopathological data were collected through online survey, whereas clinical data were collected by physician. The survey included the Trauma and Loss Spectrum- Self Report (TALS-SR) and the Impact of Event Scale- Revised (IES-R), aimed to assess symptomatological PTSD and post-traumatic stress symptoms related to the impact of the COVID-19 pandemic.

Results

A total of 194 eligible patients, with a mean age of 50.3±12.17 years, was included: 142 (73.19%) were females; 112 (57.74%) patients reported connective tissue diseases (CTD), 63 (32.47%) arthritis and 19 (9.8%) vasculitis. A total of 33 (17%) subjects reported a symptomatological PTSD by means of the TALS-SR. The prevalence of Partial PTSD (defined by at least 2 out of the 4 criteria for DSM-5 diagnosis of the disorder) was 56.7%, with significant higher rates among females (90, 81.8%) with respect to males (20, 18.2%) (p=.013). Accordingly, a IES-R mean total score of 21.90 ±15.98 was found in the total sample and a gender difference emerged, with higher mean scores among females rather than males (23.42 ±16.26 vs 21.90 ±15.98, p=.031).

Conclusion

The present findings point out high prevalence rates of symptomatological PTSD among patients suffering from RMDs, highlighting the potentially traumatic burden of the COVID-19 pandemic in this particular population, especially among females, suggesting the need of further investigations to address tailored prevention and intervention strategies.

References

[1]Fiorillo A, Sampogna G, Giallonardo V, Del Vecchio V, Luciano M, Albert U, Carmassi C, Carrà G, Cirulli F, Dell’Osso B, Nanni MG, Pompili M, Sani G, Tortorella A, Volpe U. Effects of the lockdown on the mental health of the general population during the COVID-19 pandemic in Italy: Results from the COMET collaborative network. Eur Psychiatry 2020; 63(1), e87.

[2]Carmassi C, Dell’Oste V, Bui E, Foghi C, Bertelloni CA, Atti AR, Buselli R, Di Paolo M, Goracci A, Malacarne P, Nanni MG, Gesi C, Cerveri G, Dell’Osso L. The interplay between acute post-traumatic stress, depressive and anxiety symptoms on healthcare workers functioning during the COVID-19emergency: A multicenter study comparing regions with increasing pandemic incidence. J Affect Disord 2022; 298(Pt A), 209-216.

[3]Garrido-Cumbrera M, Marzo-Ortega H, Christen L, Plazuelo-Ramos P, Webb D, Jacklin C, Irwin S, Grange L, Makri S, Frazão Mateus E, Mingolla S, Antonopoulou K, Sanz-Gómez S, Correa-Fernández J, Carmona L, Navarro-Compán V. Assessment of impact of the COVID-19 pandemic from the perspective of patients with rheumatic and musculoskeletal diseases in Europe: results from the REUMAVID study (phase 1). RMD 2021; 7(1), e001546. doi: 10.1136/rmdopen-2020-001546

[4]Wang XA, Duculan R, Mancuso CA. Coping Mechanisms Mitigate Psychological Stress in Patients With Rheumatologic Diseases During the COVID-19 Pandemic. J Clin Rheumatol 2021. doi: 10.1097/RHU.0000000000001757

Disclosure of Interests

Giovanni Fulvio: None declared, Virginia Pedrinelli: None declared, Gianni Andreozzi: None declared, Francesca Trentin: None declared, Sara Fantasia: None declared, Silvia Fonzetti: None declared, Chiara Fustini: None declared, Mattia Da Rio: None declared, Gabriele Cappellato: None declared, Cosimo Cigolini: None declared, Davide Schilirò: None declared, Michele Maffi: None declared, Laura Scagnellato: None declared, Anastasiya Valevich: None declared, Federico Fattorini: None declared, Inmaculada Concepción Navarro García: None declared, Ilaria Palla: None declared, Valentina Lorenzoni: None declared, Andrea Gaglioti: None declared, Claudia Carmassi: None declared, Chiara Tani: None declared, Giuseppe Turchetti: None declared, Liliana Dell’Osso: None declared, Marta Mosca Speakers bureau: Lillly, Astra Zeneca, GSK, Consultant of: Lillly, Astra Zeneca, GSK

AB0259 THE IMPACT OF LOCKDOWN IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

The COVID-19 pandemic has impacted on face to face assessments of patients with rheumatic diseases, including rheumatoid arthritis (RA) and telemedicine has offered a valid opportunity to follow these patients. DEDICARE is a Patient Support Program (PSP) which has been active at our center since 2016, which allows the telemonitoring of PROs (Patient Reported Outcomes) for patients being treated with abatacept. Since 2016, 98 RA patients followed at out Unit entered the DEDICARE program. During COVID19 pandemic these patients continued their monitoring using this PSP.

Objectives

To evaluate the impact of the first COVID wave on PROs and CROs (Clinical Reported Outcomes) in patients with RA included in the DEDICARE programme

Methods

Data collected in the dedicated platform three months before (from December 2019 to February 2020, pre-lockdown), during (from March 2020 to May 2020, lockdown) and after (from June 2020 to August 2020, post-lockdown) the first lockdown period in Italy were compared. In detail DAS28 (CRP, ESR), CDAI and SDAI were evaluated before and after the lockdown period; while VAS-pain, Global Health (GH); Patient Global Assessment of Disease Activity (PGA); Health Assessment Questionnaire (HAQ); Functional Assessment Chronic Illness Therapy (FACIT) were evaluated pre, during e post lockdown with the DEDICARE platform.

Results

36 RA patients, all females, were included in the study; mean age was 62.4 (32-85) years; mean disease duration 15.5 (5-38) years; 18 were ACPA and RF+. All patients were treated with abatacept, 13 as monotherapy and 23 in association with csDMARDs. No patients had COVID19 disease during the evaluated period.

A significant worsening of global health and patient global assessment of disease activity was observed; while no differences were observed regarding the CROs and other PROs (Figure 1)

Figure 1.

Conclusion

In the present study we were able to compare PROs in patients with RA before and after the first COVID wave in Italy. While no significant changes in disease activity were observed, patients experienced an increased perception of disease activity and a decline in their overall health status which began during the lockdown and continued over the following 3 months.

This may highlight a discordance between the patient and the physician perception of the disease, which may partly due to the psychological impact of pandemic on the general perception of health particular in patients with chronic diseases.

Since this discrepancy may have consequences on disease management, and particularly on treatment adherence, there is a need to promote studies to better understand the reasons for these discrepancies and to improve the patient perception of their disease particularly in difficult situations such as COVID 19 pandemic.

References

[1]Lockwood MM, et al Telemedicine in Adult Rheumatology: In Practice and In Training. Arthritis Care Res (Hoboken). 2021 Feb 8. doi: 10.1002/acr.24569.

[2]D’Silva KM, Wallace ZS. COVID-19 and rheumatoid arthritis. Curr Opin Rheumatol. 2021 May 1;33(3):255-261. doi: 10.1097/BOR.0000000000000786. PMID: 33625043; PMCID: PMC8784188.

[3]Sloan M,et al. Telemedicine in rheumatology: A mixed methods study exploring acceptability, preferences and experiences among patients and clinicians. Rheumatology (Oxford). 2021 Oct 26:keab796. doi: 10.1093/rheumatology/keab796.

Disclosure of Interests

None declared

OP0125 THE MANAGEMENT OF PREGNANCY IN AUTOIMMUNE RHEUMATIC DISEASES: ANALYSIS OF 758 PREGNANCIES FROM THE PROSPECTIVE NATIONWIDE P-RHEUM.IT STUDY (THE ITALIAN REGISTRY OF PREGNANCY IN THE RHEUMATIC DISEASES)

Background

Pregnancy is a topic of fundamental importance for women living with autoimmune rheumatic diseases (ARD). Efforts at national and international levels have been put in the collection and harmonization of data in order to implement an evidence-based management of pregnant patients.

Objectives

The P-RHEUM.it study was designed as a nationwide, web-based longitudinal observational cohort study to collect data about pregnancy in ARD in 26 centers in Italy. The study started in May 2018 and has been supported by the Italian Society for Rheumatology.

Methods

Pregnant patients with a definite rheumatic disease according international criteria were enrolled up to gestational week (GW) 20. The course of maternal disease activity, the use of medications, fetal and maternal complications, and the quality of life (EuroQoL questionnaire) were collected for each trimester, as well as pregnancy outcome, mode of delivery, neonatal complications, and maternal and children’s follow-up to 6 months after delivery, including the screening for post-partum depression by means of EPDS (Edinburgh Postnatal Depression Scale).

Results

As of December 2021, 758 pregnancies had been enrolled, 205 (27%) ongoing and 553 (73%) with outcome. Pregnancy loss occurred in 54 (9.8%) cases (40 spontaneous miscarriages; 6 voluntary terminations). Live births were 495 (89.5%), perinatal death occurred in 4 (0.7%) cases. Table 1 reports on the group of 495 live births, along with subgroups of Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE), the two most represented diseases. Regarding treatments, 166 (30%) pregnancies were exposed to corticosteroids, 239 (43%) to hydroxychloroquine, 59 (10.7%) to csDMARDs, 84 (15.2%) to TNF inhibitors, 1 (0.2%) to non-TNFi bDMARDs, 299 (54%) to low dose acetylsalicylic acid, and 126 (22.8%) to heparin.

Table 1.PREGNANCIES WITH LIVE BIRTHS, EXCLUDING PERINATAL DEATHSTotal pregnancies (n=495)RA pregnancies (n=69)SLE pregnancies (n=93)Age at conception (years)34 (31 - 37)34.5 (32 - 38)34 (31 - 36)Disease duration (years)6.1 (2.2 - 11.1)7.1 (4.3 - 11.6)9.3 (5.9 - 15.9)Caucasian431 (87.8%)53 (79.1%)75 (80.6%)Never smokers358 (73.8%)53 (80.3%)66 (71.7%)Body Mass Index >3045 (9.5%)7 (10.3%)5 (5.6%)Arterial Hypertension6 (1.2%)0 (0%)2 (2.2%)Time to pregnancy (months)3 (1 - 6)3 (1 - 6)3 (0 - 10)Physician-reported flares in the 12 months prior to conception107 (23%)22 (34.4%)13 (14.8%)Physician global assessment at enrolment (VAS 0-100)5 (0 - 17)5 (0 - 20)4 (0 - 10)Patient global health at enrolment (VAS 0-100)18 (7 - 30)10 (5 - 29)10 (5 - 25)EuroQoL at enrolment (-1.6 – 1)1 (0.8 - 1)1 (0.8 - 1)1 (0.8 - 1)Flares during pregnancy35 (7.1%)6 (8.7%)7 (7.5%)Hypertensive disturbances*8 (1.7%)1 (1.6%)6 (6.6%)Delivery at term (≥37 GW)410 (85.1%)53 (77.9%)74 (80.4%)Spontaneous vaginal delivery173 (35.9%)23 (33.8%)23 (25.3%)Congenital malformations11 (2.4%)2 (3.1%)1 (1.1%)Small for gestational age (SGA) neonate24 (4.9%)1 (1.4%)9 (9.9%)Breastfeeding in the first 4 weeks after delivery341 (79.7%)45 (77.6%)59 (76.6%)EPDS score at risk for post-partum depression22 (14.1%)0 (0%)3 (10.3%)

Continuous variables are expressed as median (interquartile range); *gestational hypertension/preeclampsia/HELLP syndrome/eclampsia.

Conclusion

Multiple factors may have contributed to the high rate of live births, including good disease control before and during pregnancy thanks to the use of anti-rheumatic drugs and low frequency of general risk factors. SLE pregnancy was affected by a higher frequency of complications (hypertensive disturbances, SGA babies) as compared to RA pregnancy. Nearly 80% of patients breastfed in the first month after delivery. For the first time, data about the screening questionnaire for post-partum depression were collected, showing at least 1 out 10 patients can be at risk.

References

[1]Meissner Y et al. Arthritis Res Ther;21(1):241; Ann Rheum Dis. 2021;80(1):49-56.

Acknowledgements

P-RHEUM.it study is supported by the Italian Society for Rheumatology (SIR). All the Investigators are acknowledged for their contribution.

Disclosure of Interests

None declared

OP0146 ISOLATED ANTI-Ro52 ANTIBODIES IN SJÖGREN’S SYNDROME: A MILDER INFLAMMATORY PHENOTYPE AT HIGHER RISK FOR FIBROTIC ORGAN INVOLVEMENT

Background

Autoimmune response against the Ro antigen (Ro52 and/or Ro60 subunits) represents a distinctive serological hallmark in primary Sjögren Syndrome (pSS). The double positivity for anti-Ro60 and anti-Ro52 has been associated with a higher glandular inflammation and B-cell hyperactivity. By contrast, the clinical significance of isolated anti-Ro52 antibodies in pSS remains controversial.

Objectives

To investigate the association between isolated anti-Ro52 antibodies and glandular and extra-glandular pSS features in order to explore whether anti-Ro52 antibodies may help to identify a specific subset of pSS.

Methods

In this retrospective study we included unselected pSS patients prospectively followed at our Unit between 2012 to 2021. Of them, anti-Ro/SSA positive patients were identified and stratified by the presence of anti-Ro52 isolated, anti-Ro60 isolated and both anti-Ro60 and anti-Ro52. Demographics, clinical, biological and histological data were compared between the three groups. Data were presented as mean±SD, or percent frequency as appropriate. Intergroup comparisons were made using the t-test/Mann–Whitney test for continuous variables and Fisher’s exact test for categorical variables.

Results

Out of a study cohort of 432 pSS patients, we included 300 anti-Ro/SSA positive patients (21 M: 279 F, mean age 57±14 yrs) followed for a mean follow-up of 6.5±6.7 years. Of them, 59/300 (19.7%) presented isolated Ro52 antibodies, 214/300 (71.3 %) both anti-Ro60 and anti-Ro52 and 27/300 (9%) had isolated Ro60 antibodies. At diagnosis, patients with anti-Ro52 alone were older than those with double positivity (57.4±13.2 vs 48.8±13.8, p=0.0001) and presented a lower focus score (FS) in their minor salivary gland biopsies (MSGBs) (p=0.9±1.0 vs 1.6±0.9, p=0.02). No differences in demographic and glandular infiltrate were detected between anti-Ro52 alone and anti-Ro60 alone patients. Similarly, the three subgroups did not differ in oral and ocular function tests as well as in the patient reported outcomes (ESSPRI, OHIP and OSDI). Salivary gland ultrasonography showed a decreasing trend of the OMERACT scoring system with the highest grade detected more commonly in anti-Ro60 and anti-Ro52 patients and the lowest grade in anti-Ro60 alone. Regarding extraglandular manifestations significant differences were observed among the three subgroups as shown in the heat map (Figure 1). Patients with anti-Ro52 alone presented the highest frequency of interstitial lung disease (ILD) and primary biliary cirrhosis (PBC) and the lowest prevalence of lymphadenopathy, anti-La/SSB and hyper-IgG (p<0.05). By contrast, patients presenting anti-Ro52 in association with anti-Ro60 had a prominent B cell hyperactivity with higher levels of serum IgG, anti-La SSB antibodies and Rheumatoid factor positivity (p<0.05). Finally, patients with isolated anti-Ro60 presented a milder disease activity and an ESSDAI (3.4±4.5 vs 6.3±4.8 vs 5.2±5.1, p=0.009) significantly lower than the other two subgroups.

Conclusion

Patients with isolated anti-Ro52 seems to represent a specific subset of pSS with milder tissue focal inflammation but at higher risk for systemic fibrotic changes, particularly in the lungs. The identification of molecular pathogenetic processes, common to both isolated anti-Ro52 pSS and other anti-Ro52 positive connective tissue diseases may offer new insights into our understanding of disease etiology, and facilitate the development of targeted therapeutic approaches.

Disclosure of Interests

None declared

Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study

BACKGROUND

Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation.

AIM

We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project".

METHODS

We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale.

RESULTS

Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001).

CONCLUSION

This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

Empowering rare disease patients through patient education: the new BehçeTalk programme

BACKGROUND

Educating patients and caregivers on their disease can improve their knowledge and promote the active involvement in the therapeutic decision-making process. Naturally, patient education programmes are critically important in rare systemic autoimmune diseases, where relevant knowledge and expertise still remain scattered. Behçet's disease (BD) represents a challenging rare condition, characterized by a variable spectrum of disease profile and a relapsing course.

RESULTS

Recently, BehçeTalk, an educational programme tailored for BD patients, families and caregivers with, was launched. BehçeTalk, entirely co-designed with BD patients, is offering educational on-line webinars on different aspects of the disease, as well support groups for patients and caregivers coordinated by a psychologist with specific expertise in BD.

CONCLUSIONS

The therapeutical management of BD is often challenging and frequently includes off-label treatments. Considering the specificities of BD, providing a specific education on the disease to patients will lead to empower them in being part of the decision-making processes, in the self-management and in improving their quality of life.

The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017

Introduction

Delirium and sarcopenia are common, although underdiagnosed, geriatric syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium.

Methods

The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses.

Results

A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001].

Discussion and conclusion

Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01950-8.

Review of the diagnosis and management of pediatric psychodermatologic conditions: Part I

Pediatric psychodermatologic conditions encompass both primary dermatologic conditions with psychiatric comorbidities and primary psychiatric conditions with self-induced dermatologic manifestations. Detection, diagnosis, and management of primary psychiatric conditions with dermatologic manifestations are challenging due to patient-perceived stigma and lack of educational opportunities for dermatology providers. This two-part series highlights the most up-to-date evidence-based data and management techniques of some of the more common dermatoses of primary psychiatric conditions in children. Part I includes trichotillomania, skin-picking disorder, and onychophagia, and part II covers dermatitis artefacta, body dysmorphic disorder, and delusions of parasitosis by proxy, with special considerations for family dynamics.

A review of the diagnosis and management of pediatric psychodermatologic conditions: Part II

Pediatric psychodermatologic conditions encompass both primary dermatologic conditions with psychiatric comorbidities and primary psychiatric conditions with self-induced dermatologic manifestations. Detection, diagnosis, and management of primary psychiatric conditions with dermatologic manifestations are challenging due to patient-perceived stigma and lack of educational opportunities for dermatology providers. This two-part series highlights the most up-to-date evidence-based data and management techniques of some of the more common dermatoses of primary psychiatric conditions in children. Part I includes trichotillomania, skin picking disorder, and onychophagia, and part II covers dermatitis artefacta, body dysmorphic disorder, and delusions of parasitosis by proxy, with special considerations for family dynamics.

Hallux valgus associated to osteoarthritis: Clinical-radiological outcomes of modified SERI technique at mid- to long-term follow-up. A retrospective analysis

INTRODUCTION

Treatment of hallux valgus deformity associated with mild or moderate osteoarthritis (OA) is still a topic of debate. In the literature, there are few studies concerning the management of patients affected by this condition. This study aims to report the experience at mid- to long-term results of an original joint-preserving surgical technique.

MATERIALS AND METHODS

Patients affected by mild to moderate hallux valgus deformity and associated to grade 1-2 OA and treated with modified Simple-Effective-Rapid-Inexpensive (SERI) technique from 2008 to 2018 were selected. Inclusion criteria were mild or moderate hallux valgus angle (HVA) <40° and an intermetatarsal angle (IMA) <20° and associated grade 1-2 OA of the first metatarso-phalangeal joint (MTPJ).

RESULTS

128 feet in 120 consecutive patients, undergone modified SERI procedure, have been retrospectively reviewed at a mean follow-up of 5.1 ± 3.8 years (range 2-11). American Orthopaedics Foot Ankle Society (AOFAS) score that was significantly improved from 44.2 ± 13.2 to 88.2 ± 9.6. Pre-operative average HVA and IMA values decreased respectively from 31.6° ± 3.9° to 9.1° ± 4.4° and from 16.2° ± 3.8° to 7.2° ± 3.1°. The average distal metatarsal articular angle (DMAA) value improved from 28.2° ± 6.5° to 7.1° ± 6°. OA of the first MTPJ highlighted a grade 1 in 46 feet and a grade 2 in 82 feet pre-operatively and a grade 0 in 30 feet, grade 1 in 82 feet, and grade 2 in 16 feet at the final follow-up.

CONCLUSIONS

The modifications to the SERI technique could extend the indications to patients affected by hallux valgus with mild to moderate OA. The wider case series and the longer follow-up of this study make us believe this technique is very useful for improving the quality of life in these patients.

LEVEL OF EVIDENCE

IV.

The Role of IL-17 Cytokines in Psoriasis

Psoriasis is a chronic inflammatory skin condition associated with immune dysregulation. The immunologic cascade mediated by the interleukin (IL)-17 pathway plays a critically important role in the pathogenesis of psoriasis. The IL-17 effectors (IL-17A, IL-17C, IL-17E, and IL17F) act on keratinocytes, endothelial cells, and immune cells to stimulate epidermal hyperplasia and the pro-inflammatory feed-forward cycle seen within plaque psoriasis. The IL-17 pathway is also hypothesized to modulate the inflammatory responses linking comorbid systemic diseases with psoriasis. Furthermore, the robust clinical response seen with current and emerging therapies targeting IL-17 emphasizes the importance of the IL-17 cytokines in the pathogenesis of psoriasis.

A systematic literature review of existing tools used to assess medication adherence in connective tissue diseases: the state of the art for the future development of co-designed measurement tools

Lack of medication adherence is frequent in chronic connective tissue diseases and is associated with poorer health outcomes, low quality of life and economic loss. This research is based on a systematic literature search and aims to identify the surveys and tools used for the assessment of medication adherence in patients with connective tissue diseases (CTDs) and in particular the tools co-designed with patients. A systematic literature review was performed in PubMed and Embase databases searching for studies concerning the application of surveys or tools designed for medication adherence assessment. A specific analysis was also performed to identify which of these existing tools were developed in co-design with patients affected by CTDs. 1958 references were identified, and 31 studies were finally included. Systemic lupus erythematosus was the most investigated disease, followed by the Behçet's disease. The tools used to assess adherence in CTDs were, in most cases, valid and useful. However, the results showed a certain degree of heterogeneity among the studies and the medication adherence assessment and measurement tools adopted, which were mostly based on selfreported questionnaire. No co-designed tools with patients were found. Low- and non-adherence were explored in some CTDs with valid and useful tools, while other CTDs still need to be assessed. Therefore, more efforts should be made to better understand the specific reasons for the low- and non-adherence in CTDs patients.

Innovations in translational research in dermatology: minimally invasive methods for biosample acquisition

Translational research has improved patient care over the last decade. In dermatology, this research often requires human tissue for laboratory analysis. The skin biopsy remains the gold standard for tissue acquisition, but the procedure comes with a small risk of bleeding and infection. It also causes scarring and anxiety in certain populations. These risks and concerns may affect participation rates in translational studies, which can require multiple biopsies. Minimally invasive procedures may mitigate these risks and concerns. We queried the PubMed database for all minimally invasive technologies studied as of May 2021. Of the 53 articles reviewed, we identified 13 unique, minimally invasive methods for tissue biosample acquisition. Herein, we describe each sampling method, biosample type analyzed, disease target, molecular application, procedure, quantity of obtained biosample, purpose, and required equipment. We organize this information into a comprehensive chart. We then synthesize this information into another table that compares the pros and cons of each intervention. We found that tape stripping, suction blistering, hair plucking, microbiopsy, and microneedle patching provide a variety of useful biosample types for laboratory analysis. In translational research, these technologies have the potential to replace more invasive methods like the punch biopsy, likely improving participation in studies.