Morphologic, dynamic and high-resolution microscopy MRI in early-onset spondyloarthritis finger dactylitis

OBJECTIVE

Up to now, the pathophysiology of SpA dactylitis has not been entirely clarified. It is not clear which are the involved tissues and which is the primary lesion of the "sausage-like" digit. The aim of our study was to examine the finger structures in early-onset finger dactylitis using high-resolution microscopy MRI together with morphologic and dynamic MRI.

SUBJECTS AND METHODS

In a 6-month period, 13 SpA patients (7 females and 6 males), mean age 54.07 years (range 37-73 years) and mean disease duration 7.07 years (range 1-44 years) with early-onset finger dactylitis (less than 3 months) were recruited. Nine patients had PsA, 3 HLA-B27-positive uSpA and 1 HLA-B27-negative uSpA. One patient had 2 dactylitis fingers. Ten healthy volunteers matched for age and sex with no personal and family history of SpA were enrolled. All dactylitis fingers and randomly selected fingers of the normal control subjects were imaged by morphologic, dynamic and high-resolution microscopy MRI.

RESULTS

We have found flexor tenosynovitis in all the 14 dactylitis fingers, joint synovitis in 5 and oedema in the finger soft tissue in 10. In 2 dactylitis fingers, there was oedema at the insertion of the joint capsule suggesting enthesitis. In 5 dactylitis fingers, there was only mild enhancement at the enthesis organ (collateral ligament, flexor and extensor tendons).

CONCLUSIONS

Our MRI study on early-onset dactylitis demonstrates that flexor tenosynovitis, joint synovitis and oedema of the digit soft tissue are the predominant alterations visible in the early phase of evolution of dactylitis and that, therefore, enthesitis may not be considered the primary lesion of dactylitis.

Predictors of in-hospital mortality of COVID-19 patients and the role of telemetry in an internal medicine ward during the third phase of the pandemic

OBJECTIVE

The first pandemic phase of COVID-19 in Italy was characterized by high in-hospital mortality ranging from 23% to 38%. During the third pandemic phase there has been an improvement in the management and treatment of COVID-19, so mortality and predictors may have changed. A prospective study was planned to identify predictors of mortality during the third pandemic phase.

PATIENTS AND METHODS

From 15 December 2020 to 15 May 2021, 208 patients were hospitalized (median age: 64 years; males: 58.6%); 83% had a median of 2 (IQR,1-4) comorbidities; pneumonia was present in 89.8%. Patients were monitored remotely for respiratory function and ECG trace for 24 hours/day. Management and treatment were done following the timing and dosage recommended by international guidelines.

RESULTS

79.2% of patients necessitated O2-therapy. ARDS was present in 46.1% of patients and 45.4% received non-invasive ventilation and 11.1% required ICU treatment. 38% developed arrhythmias which were identified early by telemetry and promptly treated. The in-hospital mortality rate was 10%. At multivariate analysis independent predictors of mortality were: older age (R-R for≥70 years: 5.44), number of comorbidities ≥3 (R-R 2.72), eGFR ≤60 ml/min (RR 2.91), high d-Dimer (R-R for≥1,000 ng/ml:7.53), and low PaO2/FiO2 (R-R for <200: 3.21).

CONCLUSIONS

Management and treatment adherence to recommendations, use of telemetry, and no overcrowding appear to reduce mortality. Advanced age, number of comorbidities, severe renal failure, high d-Dimer and low P/F remain predictors of poor outcome. The data help to identify current high-risk COVID-19 patients in whom management has yet to be optimized, who require the greatest therapeutic effort, and subjects in whom vaccination is mandatory.

Empowering Patients in the Therapeutic Decision-Making Process: A Glance Into Behçet's Syndrome

Behçet's syndrome (BS) represents a challenging condition, characterized by a variable spectrum of disease profile and associated with a significant limitation of the daily activities as well as a potential negative impact on relationships and psychological status. Considering also the complexity of the therapeutic management of BS, that often includes biological off-label treatments, the participation in the therapeutic decision-making process of the BS patients is essential to ensure the integration of the care process into the life of the patient. For this reason, the empowerment of BS patients represents a crucial need and the present work is aimed at fully exploring all the potential variables implicated in the BS patient empowerment, also highlighting major points to consider and concrete actions to be planned in the immediate future in order to implement a pragmatic facilitation of the patients' empowerment.

Large-Scale Postmarketing Surveillance of Biological Drugs for Immune-Mediated Inflammatory Diseases Through an Italian Distributed Multi-Database Healthcare Network: The VALORE Project

BACKGROUND

Biological drugs have improved the management of immune-mediated inflammatory diseases (IMIDs) despite being associated with important safety issues such as immunogenicity, infections, and malignancies in real-world settings.

OBJECTIVE

The aim of this study was to explore the potential of a large Italian multi-database distributed network for use in the postmarketing surveillance of biological drugs, including biosimilars, in patients with IMID.

METHODS

A retrospective cohort study was conducted using 13 Italian regional claims databases during 2010-2019. A tailor-made R-based tool developed for distributed analysis of claims data using a study-specific common data model was customized for this study. We measured the yearly prevalence of biological drug users and the frequency of switches between originator and biosimilars for infliximab, etanercept, and adalimumab separately and stratified them by calendar year and region. We then calculated the cumulative number of users and person-years (PYs) of exposure to individual biological drugs approved for IMIDs. For a number of safety outcomes (e.g., severe acute respiratory syndrome coronavirus 2 [SARS-COV-2] infection), we conducted a sample power calculation to estimate the PYs of exposure required to investigate their association with individual biological drugs approved for IMIDs, considering different strengths of association.

RESULTS

From a total underlying population of almost 50 million inhabitants from 13 Italian regions, we identified 143,602 (0.3%) biological drug users, with a cumulative exposure of 507,745 PYs during the entire follow-up. The mean age ± standard deviation of biological drug users was 49.3 ± 16.3, with a female-to-male ratio of 1.2. The age-adjusted yearly prevalence of biological drug users increased threefold from 0.7 per 1000 in 2010 to 2.1 per 1000 in 2019. Overall, we identified 40,996 users of biosimilars of tumor necrosis factor (TNF)-α inhibitors (i.e., etanercept, adalimumab, and infliximab) in the years 2015-2019. Of these, 46% (N = 18,845) switched at any time between originator and biosimilars or vice versa. To investigate a moderate association (incidence rate ratio 2) between biological drugs approved for IMIDs and safety events of interest, such as optic neuritis (lowest background incidence rate 10.4/100,000 PYs) or severe infection (highest background incidence rate 4312/100,000 PYs), a total of 43,311 PYs and 104 PYs of exposure to individual biological drugs, respectively, would be required. As such, using this network, of 15 individual biological drugs approved for IMIDs, the association with those adverse events could be investigated for four (27%) and 14 (93%), respectively.

CONCLUSION

The VALORE project multi-database network has access to data on more than 140,000 biological drug users (and > 0.5 million PYs) from 13 Italian regions during the years 2010-2019, which will be further expanded with the inclusion of data from other regions and more recent calendar years. Overall, the cumulated amount of person-time of exposure to biological drugs approved for IMIDs provides enough statistical power to investigate weak/moderate associations of almost all individual compounds and the most relevant safety outcomes. Moreover, this network may offer the opportunity to investigate the interchangeability of originator and biosimilars of several TNFα inhibitors in different therapeutic areas in real-world settings.

Clinical application of lung ultrasound score on COVID-19 setting: a regional experience in Southern Italy

OBJECTIVE

We aimed to assess the correlation between LUS Soldati proposed score and clinical presentation, course of disease and the possible need of ventilation support/intensive care.

PATIENTS AND METHODS

All consecutive patients with laboratory confirmed SARS-CoV-2 infection and hospitalized in two COVID Centers were enrolled. All patients performed blood gas analysis and lung ultrasound (LUS) at admission. The LUS acquisition was based on standard sequence of 14 peculiar anatomic landmarks with a score between 0-3 based on impairment of LUS picture. Total score was computed with their sum with a total score ranging 0 to 42, according to Soldati LUS score. We evaluated the course of hospitalization until either discharge or death, the ventilatory support and the transition in intensive care if needed.

RESULTS

One hundred and fifty-six patients were included in the final analysis. Most of patients presented moderate-to-severe respiratory failure (FiO2 <20%, PaO2 <60 mmHg) and consequent recommendation to invasive mechanic ventilation (CPAP/NIV/OTI). The median ultrasound thoracic score was 28 (IQR 18-36) and most of patients could be ascertained either in a score 2 (40%) or score 3 pictures (24.4%). The bivariate correlation analysis displayed statistically significant and high positive correlations between the LUS score and the following parameters: ventilation (rho=0.481, p<0.001), lactates (rho=0.464, p<0.001), dyspnea (rho=0.398, p=0.001) mortality (rho=0.410, p=0.001). Conversely, P/F (rho= -0.663, p<0.001), pH (rho = -0.363, p=0.003) and pO2 (rho = -0.400 p=0.001) displayed significant negative correlations.

CONCLUSIONS

LUS score improve the workflow and provide an optimal management both in early diagnosis and prognosis of COVID-19 related lung pathology.

AB0617 OPTICAL COHERENCE TOMOGRAPHY IN THE ASSESSMENT OF SKIN FIBROSIS IN SYSTEMIC SCLEROSIS: A CROSS-SECTIONAL STUDY

Background:

Previous studies have shown that Optical Coherence Tomography (OCT) is a reliable biomarker of skin fibrosis and significantly correlates with the severity of the skin involvement in Systemic Sclerosis (SSc)1,2.

Objectives:

Aim of this cross-sectional study was to evaluate the performance of skin OCT to discriminate between SSc and healthy controls (HC) and to compare results with the current gold standard, the modified Rodnan skin score (mRss), in a different SSc study cohort.

Methods:

Dorsal forearm skin of consecutive diffuse cutaneous SSc (dcSSc) patients and matched-HC was scanned by an investigator blinded to the clinical data using Vivosight scanner (Michelson Diagnostics, Kent, UK). Minimum Optical Density (MinOD), Maximum OD (MaxOD) and OD at 300 micron-depth (OD300) were measured. Clinical involvement was assessed by a blinded operator using the mRss and results were compared with imaging data. Statistical analysis was performed using GraphPad Prism software V.7.0.

Results:

A total of 88 OCT images were obtained from 22 dcSSc patients [20 Female, mean age 49 (±11) years, 12 with < 5 years disease duration) and 22 HC (20 Female, mean age 50.7 (±6.7) years]. All OCT measures (MinOD, MaxOD and OD300) were significantly lower in SSc patients than in HC (p=0.011, p<0.0001, p<0.0001 respectively). MaxOD and OD300 were significantly different between the four groups (0-3) of patients based on the mRss at the site of analysis (p=0.035, p=0.001 respectively). Skin OCT showed a good performance in discriminating SSc skin vs HC (overall AUC 0.72, 0.8 and 0.89 for MinOD, MaxOD and OD300 respectively).

Conclusion:

These results confirm in a cohort different from those of the previous studies that skin OCT is able to reflect the severity of skin involvement in SSc. Longitudinal studies are needed to validate its potential as surrogate outcome measure of skin fibrosis in SSc patients.

References:

[1]Abignano G et al. Ann Rheum Dis 2013; 2. Pires NSM et al. Ann Rheum Dis 2018.

Disclosure of Interests:

None declared

FRI0569 SERUM AMYLOID A: ASSESSMENT OF REFERENCE VALUE AND COMPARISON OF SERUM CONCENTRATION IN HEALTHY SUBJECTS AND PATIENTS WITH BEHÇET SYNDROME

Background:

Serum amyloid A (SAA) is a family of acute-phase reactants. The rise of SAA concentration in blood circulation is a clinical marker of active inflammation in several auto-inflammatory diseases, including Behçet syndrome (BS). Despite its practical and analytical advantages, SAA measurement by ELISA has been mainly used as a research tool rather than for the routine laboratory testing due to the lack of a robust reference data in the literature.

Objectives:

Using the recommended procedures of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC), we aimed to develop the SAA reference interval for a well-defined Italian healthy population (HC). Secondly, we compared the SAA serum concentration between HC and patients with BS.

Methods:

Sera specimens were collected from adult healthy blood donors after rule out the exclusion criteria (inflammatory disorders, ongoing infections, pregnancy and breastfeeding, obesity, using oral contraceptives, use of any medication, or consumed of alcohol), and from unselected BS patients fulfilling the International Study Group (ISG) classification criteria. Serum SAA concentrations were detected and quantified with a commercial solid phase sandwich enzyme-linked immunosorbent assay (Human SAA ELISA kit, IBL International GmbH, Hamburg, Germany) used on automated analyzer (Immunomat, SERION Diagnostic, Alifax, Polverara (PD), Italy) according to the manufacturer’s protocol. Statistical analysis and data normalization of HC SAA values were carried out to determine the reference cut off. In the second step of the study, HC and BS patients were stratified in two groups according to the cut-off value.

Results:

We recruited 141 HC (84 M and 57 F; mean age, 44.5±13.2 years) and 63 BS patients (39 M and 24 F mean age, 45.3±13.2 years) assayed for SAA. The reference cut-off was calculated as 225 ng/ml. No statistically significant differences were found between males and females when SAA means were compared, suggesting that not gender-partitioned reference range is recommended for this analyte. After the stratification according to the cut-off value (group 1: < 225 ng/ml and group 2: > 225 ng/ml), we found 53/63 (84.1%) BS patients and 133/141 (94.3%) HC with concentration less than cut-off value, respectively. We identified 10/63 (15.9%) BS patients and 8/141 (5.7%) HC within the second group. The difference was statistically significant (p=0.0177; OR: 3.14, 95% CI: 1.17-3.38).

Conclusion:

This study allowed to define a widely accepted reference cut-off for the SAA detected by ELISA, responding to an unmet need of laboratory medicine. We found a statistically significant higher frequency of BS patients compared with HC when SAA values is higher than cut-off (225 ng/ml). This preliminary data could add significant information for better clarify the role of SAA as biomarker of inflammation and in guidance of clinical practice. Further studies will be required to stratify SAA values in relation to disease activity of BS.

Disclosure of Interests:

Teresa Carbone: None declared, Maria Carmela Padula: None declared, Vito Pafundi: None declared, Carlo Schievano: None declared, Nancy Lascaro: None declared, Angela Padula: None declared, Pietro Leccese: None declared, Salvatore D’Angelo Consultant of: AbbVie, Biogen, BMS, Celgene, Eli Lilly, MSD, Novartis, and UCB, Speakers bureau: AbbVie, BMS, Celgene, Eli Lilly, Novartis, Pfizer, and Sanofi

FRI0226 OPTICAL COHERENCE TOMOGRAPHY OF THE SKIN DETECTS SCLERODERMA CHANGES IN CLINICALLY UNAFFECTED SKIN: AN OPPORTUNITY FOR EARLY DETECTION OF SYSTEMIC SCLEROSIS

Background:

The Very Early Diagnosis Of Systemic Sclerosis (VEDOSS) study has shown that 82% of patients with Raynaud’s Phenomenon, specific ANA positivity and scleroderma pattern at nail fold videocapillaroscopy will fulfil classification criteria within 5 years. This is suggesting that there is a subclinical window of opportunity to diagnose systemic sclerosis (SSc) before clinical manifestations occur. In this scenario, a non-invasive tool to diagnose SSc in clinically unaffected skin might improve the early detection of disease in at risk-patients. Optical coherence tomography (OCT) of the skin has been shown to be a sensitive and accurate biomarker of skin fibrosis in SSc.

Objectives:

Here we aimed to assess the ability of skin OCT to “detect” SSc in clinically unaffected skin from a multicentre cohort.

Methods:

Dorsal forearm skin of SSc patients and matched-healthy controls (HC) was evaluated using VivoSight scanner (Michelson Diagnostics). Mean A-scans (mean OCT signal plotted against depth-in-tissue) were derived as previously described. Minimum Optical Density (MinOD), Maximum OD (MaxOD) and OD at 300 micron-depth (OD300) were calculated. Clinical involvement was assessed by an operator blinded to OCT findings using the mRSS. Receiver-operating characteristic (ROC) curve analysis was carried out for MinOD, MaxOD, and OD300 to evaluate their ability to discriminate between SSc and HC. Statistical analysis was performed using GraphPad Prism software V.7.0.

Results:

One hundred seventy four OCT images were collected from 87 subjects [43 SSc (39 Female, mean age 49.7±9.1 years) and 44 gender/age-matched healthy controls (HC) (36 Female, mean age 50.2±8.3 years)] in two different SSc centres. All patients fulfilled classification criteria for SSc. OCT measures demonstrated discriminative ability in SSc skin detection with any clinical skin involvement (0-3 at site of analysis) with an AUC of 0.73 (MinOD, 95%CI 0.64-0.81), 0.77 (MaxOD, 95%CI 0.7-0.85) and 0.82 (OD300, 95%CI 0.76-0.89); p<0.0001 for all as previously indicated. Most importantly, all three measures showed comparable performance in detecting scleroderma also in clinically unaffected skin (mRss=0 at site of analysis), with an AUC of 0.7 (95%CI 0.6-0.81, p=0.001), 0.72 (95%CI 0.61-0.83, p=0.0003) and 0.72 (95%CI 0.61-0.83, p=0.0003) for MinOD, MaxOD and OD300 respectively.

Conclusion:

Virtual biopsy by OCT recognises clinically unaffected skin of SSc patients from the HC skin. This is consistent with gene array data showing that scleroderma specific signatures are consistent in affected and clinically unaffected skin. These results inform future studies on at risk patients with clinically unaffected skin which may define a role for OCT in detecting subclinical SSc.

Disclosure of Interests:

Giuseppina Abignano: None declared, Duygu Temiz Karadağ: None declared, Ozcan Gundogdu: None declared, Giovanni Lettieri: None declared, Maria Carmela Padula: None declared, Angela Padula: None declared, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Salvatore D’Angelo: None declared, Francesco Del Galdo: None declared

AB0018 TNFΑ RS1800629 POLYMORPHISM: WHAT ABOUT ITS ASSOCIATION WITH CLINICAL MANIFESTATIONS AND ANTI-TNFΑ THERAPY? DATA FROM A SERIES OF ITALIAN PATIENTS WITH BEHÇET SYNDROME

Background:

Tumor Necrosis Factor-alpha (TNF-α) is a pleiotropic cytokine with a critical role in the pathogenesis of Behçet syndrome (BS). Anti-TNF-α therapy is useful for patients with refractory, severe BS, in particular for ocular, central nervous system, and gastrointestinal manifestations. However, although biological treatment with anti-TNF-α agents are effective in BS, not all patients are definite responders. Non-responders patterns could be due to: alternative non-TNFα related pathway of inflammation; anti-drug antibodies presence or development; polymorphic alleles ofTNFαgene.TNFαrs1800629 (-308G>A) is a drug-response single nucleotide polymorphism (SNP) located within the gene promoter. Poor and conflicting data are currently available about the association of this polymorphism and clinical manifestations of BS, as well as about the responsivness to the TNFα blockers in BS patients [1-3].

Objectives:

Aims of this study were to investigate in a cohort of Italian patients with BS the frequency of rs1800629 genotypes and its association with clinical features and anti-TNFα therapy response.

Methods:

Consecutive patients with BS were recruited. Patients demographic and clinical data were collected by medical records and analyzed. Home-made specific primer pairs were used for rs1800629 coverage. gDNA was isolated and amplified using PCR. Good-quality amplicons were sequenced (Sanger method).In silicoanalysis was downstream performed using specific software for query-subject similarity analysis.

Results:

130 BS patients (64M:66F; mean age: 45.8±12.3 years) were included in the study. Patients predominant lesions were oral aphtosis (100%), eye involvement (86.2%), skin lesions (72.3%) and genital ulcers (57.7%).TNFαrs1800629 wild-type GG genotype was found in 106/130 BS patients (81.5%); the heterozygous genotype (GA) was identified in 24/130 patients (18.5%). No statistically significant differences were found in genotypes frequencies when the patients were stratified for presence and absence of each clinical manifestation (p>0.05), while statistical significant differences were found when the patients were compared for therapy (anti-TNFα drugs) response. In detail, 73/130 patients (56.2%) were treated with anti-TNFα agents. We found 16/73 (21.9%) non-responders patients (NRP). In NRP group, we identified 9/16 patients (56.3%) with GG genotype and 7/16 (43.7%) with GA genotype, while 8/57 (14.0%) responder patients showed GA genotype and 49/57 responder patients (86.0%) showed GG genotype (p=0.0093; OR: 0.21, CI: 0.06-0.729).

Conclusion:

Here we described a low frequency ofTNFαrs1800629 SNP-containing allele and the lack of association between SNP and BS clinical hallmark, as previously reported in literature [1-4]. We also found higher percentage of GG genotype in case of therapy response than GA genotype. The SNP is a promoter polymorphism that could affect the auto-inflammatory response and the therapy responsivness, as suggested by our preliminary data of pharmacogenomics. Analyses of a larger cohort of patients are need to confirm the study findings and to explain the SNP role as outcome predictor.

References:

[1]Touma Z et al. (2010). Arch Med Res 41(2):142-6;

[2]Vallet H et al. (2015). J Autoimmun 62:67-74.

[3]Zhang M et al. (2013). Mol Vis 19:1913-24.

[4]Ateş A et al. (2006). Rheumatol Int 26(4):348-53.

Disclosure of Interests:

Maria Carmela Padula: None declared, Pietro Leccese: None declared, Nancy Lascaro: None declared, Giusi Gaia Sorrento: None declared, Rosa Paola Radice: None declared, Antonina Rita Limongi: None declared, Teresa Carbone: None declared, Angela Padula: None declared, Giuseppe Martelli: None declared, Salvatore D’Angelo Consultant of: AbbVie, Biogen, BMS, Celgene, Eli Lilly, MSD, Novartis, and UCB, Speakers bureau: AbbVie, BMS, Celgene, Eli Lilly, Novartis, Pfizer, and Sanofi

SAT0305 PERFORMANCE OF HIGH FREQUENCY ULTRASOUND IN THE ASSESSMENT OF SKIN INVOLVEMENT IN SYSTEMIC SCLEROSIS

Background:

The modified Rodnan skin score (mRSS) is the current gold standard for skin assessment in systemic sclerosis (SSc) both in clinical trials and practice. High frequency ultrasound (HFUS) has been suggested to offer a quantitative assessment of skin thickness in SSc by several studies, however results are inhomogeneous with regards to the machine used, number of imaged sites, as well as the various stages of skin involvement.

Objectives:

Aim of this cross-sectional study was to compare performance of HFUS in the assessment of skin involvement in diffuse cutaneous SSc (dcSSc) patients, at different disease stages, as compared with healthy controls (HC).

Methods:

Dorsal finger, hand, forearm and upper arm skin of consecutive dcSSc patients, at different disease stages, and of matched-HC were scanned bilaterally using HFUS. Two investigators, expert in MSK ultrasound, blinded to the clinical details, measured skin thickness using Esaote MyLab70 equipped with a 22 MHZ probe. Clinical involvement was assessed by a blinded operator using the mRSS and results were compared with imaging data. Statistical analysis was performed using GraphPad Prism software V.7.0.

Results:

A total of 704 HFUS images were obtained from 22 dcSSc patients [20 Female, mean age 49 (±11) years, 12 with ≤ 5 years disease duration] and 22 HC [20 Female, mean age 50.7 (±6.7) years]. Skin thickness was significantly higher in SSc patients than in HC at fingers (p<0.0001) and hands (p<0.0001), while no significant difference was found at the forearms and upper arms (p>0.05). HFUS showed a good discriminative ability between SSc and HC skin at fingers and hands (AUC 0.91, 0.81, 0.6 and 0.65 for fingers, hands, forearms and upper arms respectively). When analysing the subgroup of SSc patients with ≤5 years disease duration, HFUS showed a slightly lower performance in discriminating between SSc without clinical skin involvement (site mRSS=0) and HC (AUC 0.68, 0.57, 0.68 for hands, forearms and upper arms respectively). Mean HFUS skin thickness significantly correlated with mRSS at site of analysis (hand: r=0.78, p=<0.0001; forearm: r=0.47, p=0.0013; upper arm: r=0.52, p=0.0003) and total mRSS (hand: r=0.53, p=0.0002; forearm: r=0.63, p<0.0001; upper arm: r=0.63, p<0.0001). No significant correlation was found between finger skin thickness and mRSS (both local and total, p>0.05). Interobserver reliability for skin thickness was good to excellent at all sites with intraclass correlation coefficient ranging between 0.79 and 0.94.

Conclusion:

HFUS of the skin is a reliable measure of skin involvement in SSc. Studies with higher number of patients with different clinical features are needed to explore the potential of HFUS to discriminate between healthy and SSc skin, including sites at a preclinical stage of involvement.

Disclosure of Interests:

None declared

Alveolar haemorrhage in ANCA-associated vasculitis: Long-term outcome and mortality predictors

INTRODUCTION

Alveolar haemorrhage (AH) is considered an important cause of morbidity and early mortality in anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV).

OBJECTIVES

The aim of this study was to identify predictors of outcome in patients with AH-AAV and to evaluate outcome and causes of death in this subset.

MATERIALS AND METHODS

A multicenter retrospective study was conducted in 29 Italian Centers. Clinicians were asked to recruit all patients diagnosed with AAV-associated AH during the last 10 years, from 2007 to 2016. Univariate and multivariable analysis were performed.

RESULTS

One-hundred and six patients were included (median age at onset of 55 years [IQR 42-67]). The majority were ANCA-positive (PR3 57.1%, MPO 33.7%) and 72.6% had also renal involvement. At presentation, anaemia was shown in 97 (92.4%) patients, hemoptysis in 54 (51.9%), respiratory failure in 68 (66.7%), of whom 48 (70.6%), requiring respiratory support. At the end of the 37 months [IQR 13-77] follow-up, 19/106 (17.9%) patients were dead. The main causes of death were active disease and infections. By stepwise regression analysis, age >65 years (HR 3.66 [95% CI 1.4-9.51], p = 0.008) and the need for respiratory support (HR 4.58 [95% CI 1.51-13.87], p = 0.007) at AH onset were confirmed to be predictive of mortality.

CONCLUSIONS

Predictors of outcome in AAV-AH were determined. Factors related to the patient's performance status and the severity of the lung involvement strongly influenced the outcome. Balancing harms and benefits for the individual patient in induction and maintenance treatment strategies is crucial.

Relationship of Psoriatic Arthritis to Other Spondyloarthritides

In the early 1970s, Moll and co-workers formulated the unified concept of spondyloarthritides, a group of conditions sharing similar clinical features. Subsequently, criteria for their classification have been proposed by Amor and coworkers, the European Spondylarthropathy Study Group, and the Assessment in SpondyloArthritis international Society. Opinion, however, is divided between those who believe that the different entities of the complex represent the variable expression of the same disease ("lumpers") and those who think that these should be considered separately but under the same umbrella ("splitters"). Several sets of criteria have been proposed for psoriatic arthritis (PsA), the most recent being the ClASsification for Psoriatic Arthritis (CASPAR) criteria. According to some authors, there are persuasive arguments to support the view of PsA as a distinct entity.

High prevalence of Behçet's disease in southern Italy

OBJECTIVES

This paper aims to estimate the prevalence of Behçet's disease (BD) in the city of Potenza, the regional capital of Basilicata (or Lucania) Region, in southern Italy.

METHODS

Patients with BD living in Potenza for at least 12 months prior to diagnosis were identified through the following sources: general practitioners, community-based specialists, San Carlo Hospital specialists, the Basilicata centralised index and the Basilicata database for rare diseases. All identified patients were contacted by phone and were recalled to our outpatient clinic for re-evaluation. Patients were classified as having complete BD if they met the International Study Group (ISG) criteria for BD.

RESULTS

By surveying a population of 69.060 subjects, 13 patients with a diagnosis of BD were identified. All were white and Italian by descendent. Eleven out of these satisfied the ISG criteria and allowed us to obtain a prevalence rate of 15.9 per 100.000 (95%CI 8.9-28.5), which is the highest ever found value in Europe.

CONCLUSIONS

This cross-sectional population-based study suggests that BD is more frequent in the southern part than in the northern part of Italy and confirms that the prevalence of the disease increases in a north-to-south manner within the European continent.

Pharmacoeconomic issues in psoriatic arthritis

Therapies for psoriatic arthritis were inadequate until a short time ago. Nonsteroidal antiinflammatory drugs are helpful in relieving symptoms but do not prevent joint damage. Traditional disease-modifying antirheumatic drugs are used to control symptoms, but there is no evidence that they prevent or significantly slow the progression of structural damage in peripheral joints. The introduction of tumor necrosis factor-α (TNF-α) blocking agents has opened new horizons. These drugs lessen signs and symptoms of inflammation, enhance functional capacity and quality of life, and inhibit structural joint damage. On the other hand, TNF-α blockers are very costly and not easily available to all patients, whether they rely on a national health system or on private insurance. Pharmacoeconomic studies on these drugs so far have shown that they are cost-effective on both the musculoskeletal and skin manifestations of psoriatic disease, offering good value for money.

Can we reduce the dosage of biologics in spondyloarthritis?

TNF blockers have revolutionized the management of spondyloarthritis (SpA). To date, four anti-TNFα agents (etanercept, infliximab, adalimumab, golimumab) have been approved for the management of ankylosing spondylitis (AS) and psoriatic arthritis (PsA). The first objective in the management of AS and PsA with TNF inhibitors is to reduce disease activity to clinical remission or low disease activity. After remission has been achieved, this state should be maintained as long as possible. However, the financial burden associated with the cost of anti-TNF agents as well as concerns about their long-term safety suggest reducing the dosage of the drug or discontinuing the therapy in the hopes of drug-free remission. The aim of this review is to examine what has, till now, been published on this topic in axial SpA, which includes AS and non-radiographic axial SpA (nr-axSpA), peripheral SpA and PsA. Discontinuation of therapy in axial SpA is not possible in the majority of patients, while on the contrary, reducing the dosage often is. In some patients with peripheral SpA and PsA it is also possible to discontinue therapy and to achieve drug-free remission.

Low frequency of axial involvement in southern Italian Caucasian children with HLA-B27 positive juvenile onset undifferentiated spondyloarthritis

OBJECTIVES

To establish how many children with HLA B27-positive juvenile undifferentiated spondyloarthritis (JuSpA) living in southern Italy develop axial disease after 5 years of disease.

METHODS

All children with B27-positive enthesitis-related arthritis (ERA) consecutively seen in a 7-year period were entered in a special register and were followed prospectively. Each patient was examined at 6-month intervals, even if asymptomatic. In patients with inflammatory spinal pain and/or buttock pain, MRI of the sacroiliac joints and spine was performed. Five years after inclusion, sacroiliac joint plain radiographs were obtained and read blindly after being mixed with those of control subjects.

RESULTS

Thirteen children, 9 boys and 4 girls, with B27-positive ERA and one girl with B27-positive isolated SpA dactylitis were seen in the study period. Their median age at disease onset and at our first examination were 10 (range 2-16) and 12 years (range 3-16), respectively. During follow-up, only one patient had axial symptoms, i.e. alternate buttock pain. MRI revealed moderate bone oedema at both sacroiliac joints. After five years of disease, no patient showed reduced spinal movement. No sign of sacroiliitis was seen in any patient and control on plain films. A new MRI of the sacroiliac joints of the patient who showed bone oedema in the first years of disease was normal.

CONCLUSIONS

This study confirms that the onset of axial involvement in Italian Caucasian HLA-B27 positive children with ERA is rare in the first five years of disease.

IMAGING OF PSORIATIC ARTHRITIS

Imaging of psoriatic arthritis (PsA) is important for two reasons: the differential diagnosis from other arthritides and the assessment of structural damage that can be inhibited by the new drugs such as the anti-TNFalpha agents. Plain film radiographic findings of peripheral arthritis have been important in elaborating the concept of PsA as a separate disease entity. Characteristic aspects of psoriatic peripheral arthritis help the differentiation from rheumatoid arthritis. High-resolution ultrasonography (US), US combined with power Doppler (PDUS) and magnetic resonance imaging (MRI) can be used to image joint synovitis of PsA. Radiologic features of spondylitis associated with psoriasis are similar to spondylitis associated with reactive arthritis and differ from those of primary ankylosing spondylitis (AS) and the spondylitis associated with inflammatory bowel disease. MRI is very sensitive for the early diagnosis of sacroiliitis. There have been no MRI studies on the spine of patients with PsA. In primary AS bone oedema in the vertebral bodies is an indicator of active disease and can ameliorate during anti-TNFalpha therapy. Historically, plain film radiography have played a pivotal role in defining enthesitis lesions of SpA. However, entheseal bone changes appear late. US and MRI have proved to be a highly sensitive and non invasive tools. Recent US and MRI studies on both finger and toe dactylitis have established that dactylitis is due to flexor tenosynovitis and marked adjacent soft tissue swelling with a variable degree of small joint synovitis. There is no evidence of enthesitis of the insertion of the flexor digitorum tendons and of the attachment of the capsule of the digit joints.

Efficacy of adalimumab in patients with Behçet's disease unsuccessfully treated with infliximab

OBJECTIVES

To evaluate the clinical response after switching from infliximab to adalimumab in patients with Behçet's disease (BD).

METHODS

In this ongoing, prospective, longitudinal and observational study, data were collected on efficacy and safety of every patient with BD beginning anti-TNF therapy in the last 8 years. The present analysis was restricted to patients who were switched to adalimumab after failing or not tolerating infliximab.

RESULTS

A total of 69 patients with BD have been treated with infliximab so far. Seventeen of these (25%) have been switched to adalimumab for lack or loss of efficacy or infusion reactions. In 10 out of these 17, the main manifestations requiring switching were the mucocutaneous lesions, in 4 retinal vasculitis and in 3 the neurological involvement. Of the 17 treated patients, 9 showed sustained remission of the disease and 3 a good response. No side effects were observed in any patient.

CONCLUSIONS

The results of our study suggest that patients with BD showing a scarce response or adverse events to infliximab may successfully be treated with adalimumab, regardless of the reason for switching.

Psoriatic arthritis sine psoriasis

In about 20% of patients with psoriatic arthritis (PsA) the rheumatological manifestations precede the onset of the cutaneous lesions. If there is a family history of psoriasis these patients are diagnosed as having psoriatic arthritis sine psoriasis. In the past, they were also classified among patients with undifferentiated spondyloarthritis. The clinical spectrum of PsA sine psoriasis is wide and identified by dactylitis and/or distal interphalangeal arthritis, HLA-Cw6, and a family history of psoriasis. The ClASiffication of Psoriatic ARthritis (CASPAR) criteria of PsA include PsA sine psoriasis.

Dactylitis, a term for different digit diseases

Dorland's Illustrated Medical Dictionary gives the following definition of dactylitis (deltaalphachitauupsilonlambdaomicronsigma = digit): 'inflammation of a finger or toe'. Although any inflammatory process involving the fingers or toes may be called dactylitis, the term has entered in current use only in some well-defined entities. These differ in the involved tissue of the digit and in the type of involvement. Tuberculous dactylitis is the variant of tuberculous osteomyelitis affecting the short tubular bone of the hands and feet. Radiographs typically show a central, lytic, cystic, and expansive lesion known as spina ventosa. Syphilitic dactylitis is a manifestation of congenital syphilis. Radiological findings mimic those of tuberculous dactylitis but the involvement is bilateral and symmetric. Sarcoid dactylitis is due to typical non-caseating granulomas invading the phalanges and the adjacent soft tissue. Blistering distal dactylitis is an infection of the anterior fat pad on the volar surface of the distal portion of a single finger or more rarely a toe, mostly caused by group A beta-haemolytic streptococci. Sickle cell dactylitis, also known as 'hand-foot syndrome', is due to localized bone marrow infarction of the carpal and tarsal bones and phalanges. Spondyloarthritis dactylitis, also called 'sausage-like' digit, is a diffuse painful swelling of the fingers and toes. Recent ultrasonography (US) and magnetic resonance imaging (MRI) studies on both finger and toe dactylitis have established that dactylitis is due to flexor tenosynovitis and that the enlargement of the joint capsule is not an indispensable condition for the 'sausage-like' feature. There is no evidence of enthesitis of flexor digitorum tendons and joint capsule.

Late-onset rheumatoid arthritis and late-onset spondyloarthritis

Both rheumatoid arthritis and spondyloarthritis may have a late onset. Elderly-onset rheumatoid arthritis is usually defined as rheumatoid arthritis with onset at age 60 or over. It appears to be a heterogeneous disease, with a seropositive subset resembling adult-onset rheumatoid arthritis, and a less severe seronegative subset which sometimes exhibits features overlapping with those of polymyalgia rheumatica. The spondyloarthritis complex includes definite entities as well as undifferentiated forms. Each of these may have a late-onset. Late-onset undifferentiated spondyloarthritis appears to be relatively more frequent than late-onset ankylosing spondylitis. Its clinical spectrum seems to be as broad as that observed in young and middle-aged adults with the exception of distal inflammatory swelling with pitting oedema. A special aspect of the differential diagnosis is the discrimination from other elderly-onset diseases showing the inflammatory swelling with pitting oedema over the dorsum of feet or hands. Psoriatic arthritis frequently begins in the elderly and shows some differences from the younger onset disease. Regarding the management, patients with late-onset rheumatoid arthritis and spondyloarthritis are treated similarly to younger patients taking into account age-related changes in the pharmacokinetics and pharmacodynamics of drugs and the presence of conditions able to reduce medication adherence.