Validation of the Italian version of the ANCA-associated vasculitis patient-reported outcome (AAV-PRO) questionnaire

Objectives

The primary objective of this study was the translation and validation of the ANCA-associated vasculitis patient-reported outcome (AAV-PRO) questionnaire into Italian, denoted as AAV-PRO_ita. The secondary objective was to evaluate the impact of ANCA-associated vasculitis (AAV) on quality of life (QoL) and work impairment in a large cohort of Italian patients.

Methods

The study design took a prospective cohort study approach. First, the AAV-PRO was translated into Italian following the step guidelines for translations. The new AAV-PRO_ita questionnaire covered three disease domains: organ-specific and systemic symptoms and signs; physical function; and social and emotional impact. Second, Italian-speaking AAV patients were recruited from 17 Italian centres belonging to the Italian Vasculitis Study Group. Participants completed the AAV-PRO_ita questionnaire at three time points. Participants were also requested to complete the work productivity and activity impairment: general health questionnaire.

Results

A total of 276 AAV patients (56.5% women) completed the questionnaires. The AAV-PRO_ita questionnaire demonstrated a good internal consistency and test-retest reliability. Female AAV patients scored higher (i.e. worse) in all thee domains, especially in the social and emotional impact domain (P < 0.001). Patients on glucocorticoid therapy (n = 199) had higher scores in all domains, especially in the physical function domain (P < 0.001), compared with patients not on glucocorticoid therapy (n = 77). Furthermore, patients who had at least one relapse of disease (n = 114) had higher scores compared with those who had never had one (n = 161) in any domain (P < 0.05). Finally, nearly 30% of the patients reported work impairment.

Conclusion

The AAV-PRO_ita questionnaire is a new 29-item, disease-specific patient-reported outcome measuring tool that can be used in AAV research in the Italian language. Sex, glucocorticoids and relapsing disease showed the greatest impact on QoL.

Clinical and histological features of patients with primary Sjögren's syndrome and autoimmune thyroiditis: a national multicentre cross-sectional study

OBJECTIVES

Primary Sjögren's syndrome (pSS) is frequently associated with autoimmune thyroiditis (AT). The aim of this study was to evaluate the prevalence of AT in a national cohort of pSS and to describe the clinical and histological phenotype of patients with pSS and associated AT.

METHODS

In this multicentre cross-sectional study, data from 2546 pSS were collected and the presence of AT was reported. In a subgroup, the histology of minor salivary glands was evaluated. Differences between pSS with and without AT were evaluated.

RESULTS

A concomitant pSS and AT was detected in 19.6% of cases. Patients with pSS and AT displayed a lower prevalence of lymphoma, male sex and disease-modifying anti-rheumatic drugs (DMARDs) use and a higher prevalence of fibromyalgia, coeliac disease and hypergammaglobulinaemia. Multivariable analysis confirmed a higher prevalence of fibromyalgia and coeliac disease and lower use of DMARDs. In a subgroup of patients (n=232), a significantly higher focus score and number of foci was detected in pSS without AT (n=169) as compared to pSS with AT (n=54).

CONCLUSIONS

This is the largest study evaluating the coexistence of pSS and AT. We confirm a high association between pSS and AT and describe the presence of a different phenotype characterized by a higher rate of celiac disease and fibromyalgia. Although not significant, the lower prevalence of both lymphoma and intake of DMARDs, along with a significantly lower focus score and number of foci, possibly suggest a more favourable outcome in concomitant pSS and AT which further deserve future investigations.

Mortality risk factors in primary Sjögren syndrome: a real-world, retrospective, cohort study

Background

What baseline predictors would be involved in mortality in people with primary Sjögren syndrome (SjS) remains uncertain. This study aimed to investigate the baseline characteristics collected at the time of diagnosis of SjS associated with mortality and to identify mortality risk factors for all-cause death and deaths related to systemic SjS activity measured by the ESSDAI score.

Methods

In this international, real-world, retrospective, cohort study, we retrospectively collected data from 27 countries on mortality and causes of death from the Big Data Sjögren Registry. Inclusion criteria consisted of fulfilling 2002/2016 SjS classification criteria, and exclusion criteria included chronic HCV/HIV infections and associated systemic autoimmune diseases. A statistical approach based on a directed acyclic graph was used, with all-cause and Sjögren-related mortality as primary endpoints. The key determinants that defined the disease phenotype at diagnosis (glandular, systemic, and immunological) were analysed as independent variables.

Findings

Between January 1st, 2014 and December 31, 2023, data from 11,372 patients with primary SjS (93.5% women, 78.4% classified as White, mean age at diagnosis of 51.1 years) included in the Registry were analysed. 876 (7.7%) deaths were recorded after a mean follow-up of 8.6 years (SD 7.12). Univariate analysis of prognostic factors for all-cause death identified eight Sjögren-related variables (ocular and oral tests, salivary biopsy, ESSDAI, ANA, anti-Ro, anti-La, and cryoglobulins). The multivariate CPH model adjusted for these variables and the epidemiological features showed that DAS-ESSDAI (high vs no high: HR = 1.68; 95% CI, 1.27-2.22) and cryoglobulins (positive vs negative: HR = 1.72; 95% CI, 1.22-2.42) were independent predictors of all-cause death. Of the 640 deaths with available information detailing the specific cause of death, 14% were due to systemic SjS. Univariate analysis of prognostic factors for Sjögren-cause death identified five Sjögren-related variables (oral tests, clinESSDAI, DAS-ESSDAI, ANA, and cryoglobulins). The multivariate competing risks CPH model adjusted for these variables and the epidemiological features showed that oral tests (abnormal vs normal results: HR = 1.38; 95% CI, 1.01-1.87), DAS-ESSDAI (high vs no high: HR = 1.55; 95% CI, 1.22-1.96) and cryoglobulins (positive vs negative: HR = 1.52; 95% CI, 1.16-2) were independent predictors of SjS-related death.

Interpretation

The key mortality risk factors at the time of SjS diagnosis were positive cryoglobulins and a high systemic activity scored using the ESSDAI, conferring a 2-times increased risk of all-cause and SjS-related death. ESSDAI measurement and cryoglobulin testing should be considered mandatory when an individual is diagnosed with SjS.

Funding

Novartis.

Multicentre case-control study evaluating the safety of anti-SARS-CoV-2 vaccines in a cohort of patients with systemic vasculitis

OBJECTIVES

Data on the safety of anti-SARS-CoV-2 vaccines in patients with rare rheumatic diseases, such as systemic vasculitis (SV), are limited. The aim of this study was to evaluate the occurrence of a disease flare and the appearance of adverse events (AEs) following administration of anti-SARS-CoV-2 vaccine in a multicentre cohort of patients with SV.

METHODS

Patients with SV and healthy controls (HC) from two different Italian rheumatology centres were asked to complete a questionnaire assessing disease flares occurrence, defined as new onset of clinical manifestations related to vasculitis needing an implementation of therapy, and local/systemic AEs appearance following anti SARS-CoV-2 vaccination.

RESULTS

107 patients with SV (57 ANCA-associated) and 107 HC were enrolled. A disease flare occurred in only one patient (0.93%) with microscopic polyangiitis after the first dose of an mRNA vaccine. After both the first and the second vaccine dose administration, no significant differences in AEs between patients with SV and HC were observed; no serious AEs were reported as well.

CONCLUSIONS

These data suggest a good risk profile for anti-SARS-CoV-2 vaccine in patients with systemic vasculitis.

POS1266 MULTICENTER RETROSPECTIVE STUDY EVALUATING THE SAFETY OF ANTI-SARS-CoV-2 VACCINE IN A COHORT OF PATIENTS WITH SYSTEMIC VASCULITIS

Background

Vaccinations against SARS-CoV-2 represent a fundamental tool in controlling the pandemic. To date, data on the safety of anti-SARS-CoV-2 vaccines in patients with rare rheumatic diseases, such as systemic vasculitis, are limited.

Objectives

In this study we aimed at evaluating the safety of anti-SARS-CoV-2 vaccines in a multicentric cohort of patients with systemic vasculitis.

Methods

Patients with systemic vasculitis from two Rheumatology centres who had received anti-SARS-CoV-2 vaccine were retrospectively examined. The primary outcome was to evaluate, in this multi-centric cohort, the occurence of a disease flare after the administration of the vaccine, defined as development of clinical manifestations related to vasculitis with a concomitant increase in serum inflammatory markers. As a secondary outcome we aimed at evaluating, in a monocentric cohort of patients with vasculitis, the occurrence of adverse events (AEs) following vaccine administration compared to healthy controls (HC).

Results

We examined 111 patients with systemic vasculitis (n=69 female, n=42 male), with a mean age of 64.3 (± 13) years. Sixty had ANCA-associated vasculitis (AAV), fourty-two had Giant-Cell Arterities (GCA), five had Periarteritis Nodosa, four had Takayasu’s arteritis. One-hundred and five patients received a mRNA vaccine and six a viral vector one. A disease flare occurred in only 2 patients (1.8%) after the first dose of a mRNA vaccine: both had AAV (microscopic poliangioitis) and developed a pulmunary disease flare (respiratory failure requiring hospitalization and treatment with high-dose glucocorticoids). Of note, one of these patients had multiple previous comorbidities, including a severe COPD. Multivaried analysis, adjusted for age and sex, performed in a single monocentric cohort of patients with systemic vasculitis [n=60 (39 AAV, 21 GCA), 37 female, 23 male, mean age 71 (± 12.5) years] demonstrated a statistically significant higher frequency of AEs in vasculitis patients compared to HC (p=0.015) after the first dose of vaccination. No significant differences in the frequency of AEs in vasculitis patients compared to HC after the second dose were detected. All the AEs were mild in both groups (malaise was the most frequently reported); no serious AEs were reported.

Conclusion

Our data show a very low incidence of disease flares after the administration of anti-SARS-CoV-2 vaccines in patients with systemic vasculitis. Patients with systemic vasculitis seem more prone to develop mild AEs after the first dose of the vaccine. Taken together, this data suggest a good risk profile for anti-SARS-CoV-2 vaccine in patients with systemic vasculitis.

Disclosure of Interests

None declared

OP0236 JAK-STAT INHIBITION RESTORES EPITHELIAL CELLS’ HOMEOSTASIS IN PRIMARY SJOGREN’S SYNDROME

Background

Although salivary gland epithelial cells (SGECs) are key players in the pathogenesis of autoimmune epithelitis that characterizes primary Sjӧgren’s Syndrome (pSS), the mechanisms sustaining SGECs activation in pSS remain largely undetermined. Therefore, therapeutic strategies to counteract SGECs activation in pSS are also lacking. In previous studies, we revealed that maladaptive autophagy sustains survival and pro-inflammatory activation of SGECs in pSS (1).

Objectives

To determine the therapeutic potential of JAK/STAT inhibition with baricitinib to restore homeostatic regulation of SGECs in pSS, by reducing autophagy, survival, and expression of adhesion molecules.

Methods

Primary SGECs were isolated from minor salivary glands (SG) of large cohort of patients with pSS or sicca syndrome and subjected to mechanistic and functional studies including flow-cytometry, immunoblotting, and immunofluorescence to assess autophagy (autophagic-flux, LC3IIB, p62, LC3B+/LAMP1+ staining), apoptosis (annexin V/PI, Caspase-3) and activation (ICAM, VCAM). Focus score and germinal centers were determined in homologous SG biopsies to assess correlations of findings with histological disease severity. Primary SGECs of patients with pSS were treated with Baricitinib (1 mM) for 24 prior to assessment of autophagy, apoptosis and activation.

Results

SGECs from pSS patients (n=29) exhibited increased autophagy (as determined by autophagic-flux p=0.001; LC3IIB p=0.02; p62 p=0.064; LC3IIB/LAMP1+ staining), increased expression of anti-apoptotic molecules (Bcl2 p=0.006), and reduced apoptosis (Annexin-V/PI p=0.002, Caspase-3 p=0.057) compared to sicca (n=16). Induction of autophagy in pSS SGECs correlated with histologic disease severity. Treatment of pSS SGECs with baricitinib ex vivo suppressed autophagy, increased apoptosis, and reduced expression of adhesion molecules.

Conclusion

SGECs in the inflammatory milieu of pSS are characterized by induction of autophagy and pro-survival mechanisms, and by expression of adhesion molecules. These changes correlate with SG infiltration with immune cells and with histologic disease severity. Among clinically available therapies, the JAK/STAT inhibitor baricitinib effectively reduced autophagy, countered the state of maladaptive activation of SGECs, and restored epithelial cell homeostasis. Transcriptomics and metabolomics studies are ongoing to dissect the specific mechanisms responsible for these beneficial effects.

References

[1]Colafrancesco S, et al. Maladaptive autophagy in the pathogenesis of autoimmune epithelitis in Sjӧgren’s Syndrome. Arthritis Rheumatol 2021.

Disclosure of Interests

Serena Colafrancesco Speakers bureau: Novartis

Sobi, Grant/research support from: Eli Lilly, cristiana barbati: None declared, Roberta Priori: None declared, Federico Giardina: None declared, angelica gattamelata: None declared, raffaella izzo: None declared, Bruna Cerbelli: None declared, Carla Giordano: None declared, Susanna Scarpa: None declared, Massimo Fusconi: None declared, Francesca Romana Spinelli Speakers bureau: Eli Lilly

Pfizer

Abbvie, Giulio Cavalli: None declared, cristiano alessandri: None declared, Fabrizio Conti: None declared

POS1218 RELAPSES OF IDIOPATHIC INFLAMMATORY MYOPATHIES AFTER VACCINATION AGAINST COVID19: A REAL-LIFE ITALIAN STUDY

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination plays a crucial role as pivotal strategies to curb the coronavirus disease-19 (COVID-19) pandemic. Despite the mass-scale vaccination, literature data about the incidence of disease flares in IIM patients are still not reported as well as the immunological condition.

Objectives

The present study aimed to describe the clinical status of patients affected by IIM after vaccination against COVID19 in order to assess the number of relapses or immune-mediated reactions in a cohort of Italian patients with such disease.

Methods

We included all patients affected by IIM and followed by Myositis Clinic, Rheumatology and Respiratory Diseases Units, Siena University Hospital, Bari University Hospital, Policlinico Umberto I, Sapienza University, Rome, and Policlinico Paolo Giaccone, Palermo. Inclusion criteria were a recent (<3 months) clinical and serological assessment before the survey and a definite diagnosis of dermatomyositis, polymyositis and anti-synthetase syndrome. All patients underwent a telephone survey in order to establish their clinical status and potential relapses after vaccination.

Results

A total of 119 IIM patients (median, IQR 58 (47-66) years; 32 males) were consecutively enrolled. Fifty had a diagnosis of DM, 39 had PM and 30 had ASS. The median months of disease duration was 79.62±83.98. According to number of organs involvement, forty-two had only one, 45 had two organs involvement, 20 had three, 11 had four and one had five. The majority of them received two doses of COVID-19 vaccine, except four patients who refused the vaccination: 94 (78.9%) Cominarty, 16 (13.4%) Moderna, 5 (0.04%) AZ. Seven (0.06%) patients had flare after vaccination, the majority of them were mild except one major with three organs involved and one life-threatening with systemic involvement. In order to understand or predict the effect of demographic and clinical features on the flare development after vaccination, a logistic regression analysis was performed. The goodness-of-fit statistics showed a Chi2 associated with the Log ratio (L.R.) of 0.045. From the probability associated with the Chi-square tests, the Type II analysis showed the variable that most influences the development of flare was the number of organs involved (p=0.047).

Sixty-eight patients received the third dose of COVID-19 vaccination: 51 (75%) Cominarty and 17 (25%) Moderna. Only one (0.01%) patient (the same who had life-threatening flare with systemic involvement after two doses) had flare after third dose and eventually died.

Conclusion

Vaccines against SARS-CoV2 have provided, both in registratory studies and in preliminary real-life evidence, an overall good efficacy and safety. Nevertheless, only scanty data are available for rheumatic patients in general and the ones affected by IIM in particular. To the best of our knowledge, ours represent the largest cohort of IIM patients in which immunogenicity of anti-SARS-CoV2 vaccine was assessed. In line with real-life data from other diseases, we found a non-statistically significant risk of relapse in our patients, which occurred seldom, usually mild and in patients with a more severe and aggressive course of disease.

ParametersFlare after two doses (n=7)No-flare after two doses (n=108)P valueAge (years)55 (51-68)59 (47-67)NSGender (M/F)2/530/82NSDiagnosis (DM/PM/ASS)2/2/348/36/28NSAntibodiesJo1225PL7-3PL12-1Ku-2Mi217PM/Scl15Ro5217TIG1g-5MDA5-6SRP-1SAE-2cN1a--NPX-1SSA-12Ds-DNA-1ANA (only positivity)-3negative227Length of disease (months)50 (19-200)60 (24-108)NSNumber of organs involved:One0360.0004Two243Three319Four110Five10Type of vaccination:Cominarty688NSModerna115AZ05Disease activity (PhGA≥2/PhGA<2)3/427/81NSMDI3 (1-6.5)2 (1-4)NSCRP (mg/dL)0.1 (0.01-0.3)0.99 (0.3-2.9)0.0041ESR32 (14-39)15.5 (8-27.5)NSCPK111 (63-905)97.5 (63-158)NSTreatment at time of vaccination: GCs010NS Immunosuppressive319 Biologic12 Combination365 no-treatment-12

Disclosure of Interests

None declared

AB1487 VALIDATION AND CULTURAL ADAPTATION OF THE QUALISEX QUESTIONNAIRE IN WOMEN WITH SJÖGREN’S SYNDROME IN ITALY

Background

The quality of sexual life (QSL) is a complex and multimodal experience influenced by endogenous and external factors, including age, gender, and cultural environment. Rheumatic diseases, with their burden of pain, fatigue, organ damage, and disability, can severely impair sexual life and this is true also for Sjögren’s Syndrome, where simple tools to assess the QSL in everyday clinical practice are needed.

Objectives

To translate ad adapt into Italian the Qualisex, a new brief questionnaire originally created for Rheumatoid Arthritis patients, for women with primary Sjögren’s Syndrome (pSS) and evaluate the impact of the disease on their sexuality.

Methods

Consecutive sexually active pSS (according to ACR/EULAR 2016 criteria) patients aged >18 were asked to participate in this study approved by the local bioethics committee. With the permission of the developer, the French original version of the Qualisex questionnaire (consisting of 10 items, the higher the score, the greater the negative impact of the disease on the QSL) was translated and adapted into Italian according to current guidelines. In the absence of a gold standard assessment for sexuality in pSS, face and content validity was assessed cross-sectionally by correlations with other disease aspects such as anxiety and depression measured by Hospital Anxiety and Depression Scale (HADS), EULAR SS patient-reported index (ESSPRI), and quality of the relationship. As a measure of reliability, internal consistency was assessed through Cronbach’s Alpha coefficient. A Cronbach’s value >0.7 is generally regarded as satisfactory. The feasibility of the scale was indirectly assessed through missing data. To assess the factorial structure of the Italian version of the questionnaire an Exploratory Factor Analysis (EFA) was carried out. Moreover we also assessed the level of redundancy by means of intra-item correlation of the Qualisex questionnaire. ESSDAI (EULAR Sjögren’s Syndrome Disease Activity Index), and SSDDI (Sjogren’s Syndrome Disease Damage Index) were assessed as well. Analyses were carried out with IBM SPSS Statistics for Macintosh, version 22.0 (IBM Corp., Armonk, NY, USA).

Results

40 sexually active women with pSS and a median age of 53 (IQR 45.25-57.25) were enrolled. The EFA showed that the model with a single factor appeared to be highly significant (Chi235= 2943.10; p<0.05); the average inter-item correlation was found to be 0.392 (Min -0.479; Max 0.834) which is an acceptable value as for redundancy. There were no missing answers. Cronbach’s alpha coefficient resulted to be 0.86 which indicates an adequate internal consistency. The median Qualisex score was 4.65 (IQR 2.13–6.2). As far as correlations, age (Rho=0.39; p<0.05), menopause (Rho=0.41; p<0.05), relationship quality (Rho=0.55; p<0.05), anxiety (HADS-A; Rho=0.38; p<0.05), and depression (HADS-D; Rho=0.47; p<0.05) appeared to be positively correlated with Qualisex score. Also, a positive correlation with ESSPRI (Rho=0.43; p<0.05), and drug use (Rho=0.37; p<0.05) was demonstrated. On the contrary no significant correlation was found with education (Rho=-0.07; p=0.64), systemic disease activity (Rho=0.14; p=0.39), and damage (Rho=0.06; p=0,74).

Conclusion

The Italian version of the Qualisex questionnaire is a valid, reliable and useful tool to assess the quality of sexual life in pSS. QSL in pSS women has an inverse relationship with age, menopause, drug use, ESSPRI, mood disorders, and dissatisfaction with the partner, while, as previously reported, no correlation was found with disease activity, damage, and educational status. This further highlights the impact of subjective symptoms such as dryness, pain, fatigue, and the overall psychological well-being on patients’ life. Thus, it is critical for the physician to consider patients’ perspective.

Disclosure of Interests

None declared

Maladaptive autophagy in the pathogenesis of autoimmune epithelitis in Sjӧgren's Syndrome

OBJECTIVE

Salivary gland epithelial cells (SGECs) are key cellular drivers in the pathogenesis of primary Sjӧgren's Syndrome (pSS); however, the mechanisms sustaining SGECs activation in pSS remain undetermined. The aim of this study is to determine the role of autophagy in the survival and activation of SGECs in pSS.

METHODS

Primary SGECs isolated from minor salivary glands (SG) of patients with pSS or sicca syndrome were evaluated by flow-cytometry, immunoblotting, and immunofluorescence to assess autophagy (autophagic-flux, LC3IIB, p62, LC3B+/LAMP1+ staining), apoptosis (annexin V/PI, Caspase-3) and activation (ICAM, VCAM). Focus score and germinal centers presence was assessed in SG from the same patients to correlate with histological severity. Human salivary gland (HSG) cells were stimulated in vitro with PBMCs and serum from pSS patients in the presence or absence of autophagy inhibitors to determine changes in autophagy and epithelial cell activation.

RESULTS

SGECs from pSS patients (n=24) exhibited increased autophagy (autophagic-flux p=0.001; LC3IIB p=0.02; p62 p=0.064; LC3IIB/LAMP1+ staining), increased expression of anti-apoptotic molecules (Bcl2 p=0.006), and reduced apoptosis (Annexin-V/PI p=0.002, Caspase-3 p=0.057) compared to sicca (n=16). Autophagy correlated with histologic disease severity. In vitro experiments on HSG cells stimulated with serum and PBMCs from pSS patients confirmed activation of autophagy and expression of adhesion molecules, which was reverted upon pharmacologic inhibition of autophagy.

CONCLUSIONS

In pSS SGECs, inflammation induces autophagy and pro-survival mechanisms, which promote SGEC activation and mirror histological severity. These findings indicate that autophagy is a central contributor to the pathogenesis of pSS and a new therapeutic target.

POS1464-HPR ASSESSMENT OF EMOTIONAL WELL-BEING IN RHEUMATIC PATIENTS DURING COVID-19 LOCKDOWN THROUGH A WEB-BASED SURVEY APPROACH

Background:

The severe measures of lockdown imposed in Italy to limit the SARS coronavirus 2 disease (COVID-19) spread caused an increase of reported anxiety, depression and suicidal rate among general population. Patients affected by rheumatic disorders feature an increased risk of mood disorders for the chronic course of the disease itself and for the related disability.

Objectives:

Aim of this study was to investigate the impact of COVID-19 lockdown on emotional well-being of a large cohort of rheumatic patients through a telemedicine approach.

Methods:

Patients in follow-up in rheumatologic out-patient clinics of our hospital were invited to participate to an online survey. They were asked also to invite their best friend, matched for age and sex, to participate the survey, as control group. The online survey included demographic questions and validated, psychometric scales for stress vulnerability (Stress Vulnerability Scale-SVS), resilience (Resilience Scale-RS), depression (Zung’s depression questionnaire-Zung-D) and anxiety (Zung’s anxiety questionnaire-Zung-A) evaluation.

Results:

The cohort was composed by 484 subjects (84,1% F, 15,9% M). The number of subjects and the frequency of various diagnosis are shown in Table 1. According to the psychometric scales, 55,5% and 43,3% of subject showed respectively an increased stress vulnerability and a reduced resiliency. Moreover, 64% and 40,5% of the enrolled subjects reported respectively anxiety and depressive symptoms worthy of psychiatric attention. There was a significant different distribution of scores for SVS (p<0,0001), Zung-A (p<0,0001) and Zung-D (p<0,0001) among the various diagnosis. In comparison with controls, higher scores of SVS were present in connective tissue diseases (CTD) (p=0,007), Sjogren’s Syndrome (SSJ) (p=0,0029) and fibromyalgia (FM) (p<0,0001) patients, higher scores of Zung-A were present in SSJ (p=0,006) and FM (p<0,0001) patients and higher scores of Zung-D were present in FM (p<0,0001) patients (Figure 1). Ordinal regression analysis showed that higher classes of anxiety were independently predicted by the Tension (β=0,32;CI=0,13-0,52;p=0,003) and Demoralization (β=0,22;CI=0,04-0,44;p=0,046) components of SVS and by the Zung-D score (β=0,09;CI=0,05-0,1;p<0,001), while higher classes of depression were independently predicted by SVS total (β=0,17;CI=0,03-0,30;p=0,012), by its subcomponent Demoralization (β=0,22;CI=0,01-0,43;p=0,038), by a lower absolute RS score (β=-0,083;CI=-0,1--0,06;p<0,001) and by the Zung-A score (β=0,11;CI=0,06-0,15;p<0,001). In both cases, a specific diagnosis was not associated to a higher risk of advanced anxiety and depression classes.

Conclusion:

Rheumatic patients developed a high frequency of anxiety and depressive symptoms following COVID-19 lockdown, of which a large part should be referred for specialist attention according to their severity. There was a large variability of the symptoms reported among the various diagnosis. CTD, SSJ and FM patients were the most susceptible to the development of anxiety, depression and stress vulnerability. The application of psycometric scales through a telemedicine approach represents a useful tool to identify patients with higher levels of anxiety and depression.

Table 1.DIAGNOSISFrequencyPercentControls459,3RA8216,9PSA214,3UA40,8SPA71,4CTD7014,5FM7916,3Myositis81,7Behcet’s112,3Vasculitis163,3APS61,2Other AID132,7SSJ12225,2Total484100

RA: Rheumatoid Arthritis, PSA: Psoriatic Arthritis; UA: Undifferentiated Arthritis; SPA: Spondyloarthritis; CTD: Connective tissues diseases (including Systemic Lupus Erythematosus, Scleroderma, Undifferentiated Connettivitis, Mixed Connettivitis); FM: Fibromyalgia; APS: Anti-phospholipid syndrome; Other AID: Other autoimmune/inflammatory disorders (including Adult-onset Still disease, IgG4 related disease); SSJ: Sjogren Syndrome

Figure 1.

Disclosure of Interests:

None declared

AB0317 ADHERENCE TO MEDITERRANEAN DIET AND NUTRITIONAL STATE IN ITALIAN WOMEN WITH ISOLATED SJÖGREN’S SYNDROME

Background:

The Mediterranean Diet (MD) has anti-inflammatory and immunomodulatory effects1,2 suggesting a protective role in rheumatic diseases. There is limited knowledge about the eating habits and the nutritional state in patients with isolated Sjögren Syndrome (SS) living within the Mediterranean area.

Objectives:

assessment of adherence to the MD and analysis of the nutritional state in women with SS and their correlations with the clinical, laboratory and histological data of the disease.

Methods:

patients classified as isolated SS according to AECG criteria 20023 who had undergone to minor salivary gland biopsy during the previous twelve months were consecutively enrolled during follow-up visits. The adherence to the MD was assessed by the Med Diet (MDiet)4 which includes eleven groups of foods; to each group is assigned a value ranging between 0 and 5 based on the frequency of monthly intake. The total score spans from 0 (poor adherence) to 55 (maximum adherence). The level of physical activity was measured by the 6-minutes walking test (6MWT) and by the International Physical Activity Questionnaire (IPAQ). Systemic disease activity was evaluated with the EULAR SS disease activity index (ESSDAI); EULAR SS patient-reported index (ESSPRI) was calculated as well. A subgroup of patients was asked to fill a daily food diary processed with FOOD CONS software which allows to study in detail their eating habits. Nutritional state, muscle strength and basal metabolic rate were assessed. Alcoholism or drug abuse, diabetes mellitus, specific dietary models, treatment with drugs and/or food supplements with anti-inflammatory and/or antioxidant activity were considered exclusion criteria. Multivariate linear regression was performed with R project for Statistical Computing.

Results:

N= 40 N= 26Age, median (range) 53 (25-80) 33 (25-71)BMI, median (range) 21 (19-29.3) 25.1 (19-33.7)MedDiet score, median (range) 33 (26-43) 33 (23-40)ESSDAI, median (range) 2 (0-16) 1 (0-16)ESSPRI, median (range) 6 (0-8.6) 5.3 (1.6-9)ESSPRI dryness, median (range) 6 (0-10) 6 (2-10)Focus score, median (range) 2.5 (0-9.6) 1.7 (0.8-6.24)ASM kg, median (range) - 16.8 (13.3-21.7)IPAQ meters, median (range) - 1386 (99-11865)6MWT meters, median (range) - 595 (536-680)

BMI, body mass index; ASM appendicular skeletal mass; IPAQ International Physical Activity Questionnaire; 6MWT, six minute walking test.

MDiet was administered to 40 female SS outpatients. Even if not reaching significativity, patients with a higher focus score in their MSG have a lower value of MDiet score (p = 0.058, r = -1.00). The MDiet score is not associated with ESSDAI (p = 0.85, r 0.02), but only with lower serum levels of C3 (p = 0.004, r = - 0.08).

In 26 patients, daily food questionnaire shows that their diet consists of 43% of carbohydrates while fats represent 40% of total energy intake, the remaining 17% daily energy comes from proteins. Fat consumption is higher compared to the levels of energy and nutrient intake for the Italian population5. Six patients had a reduction in muscle mass; sarcopenia is not associated to ESSDAI (p = 0.610).The MDiet score and the amount eaten of polyunsaturated fatty acids (PUFA) were reduced in patients with high value of subscale dryness of ESSPRI (p = 0.057, r -1.21; p =0.610, r -1.00).

Conclusion:

This study highlights a lower degree of glandular lymphocytic infiltration (expressed as focus score) in minor salivary glands in patients following MD, so its anti-inflammatory role of seems to be confirmed. SS patients have an unbalanced diet because of a higher intake of fat foods, likely for their lubricating effect. Despite the absence of correlation with objective parameters, the increased dryness in patients with a reduced intake of PUFA arouses our interest in a future study including omega-3 supplementation.

References:

[1]Schwingshackl L et al., Nutr Metab Cardiovasc Dis 2014

[2]Mena MP et al., Am J Clin Nutr. 2009

[3]Vitali C et al, ARD 2002

[4]Panagiotakos D et al., J Med Food 2007

[5]LARN 2014

Disclosure of Interests:

None declared

Peripheral Nervous System Involvement in Sjögren's Syndrome: Analysis of a Cohort From the Italian Research Group on Sjögren's Syndrome

Purpose

The prevalence of peripheral nervous system (PNS) involvement in primary Sjögren's syndrome (pSS) has been reported to range from 2% to over 50%. Bias in study designs, including low number of patients and unclearly defined rheumatological and neurological diagnosis could explain such variability. Consequently, the exact depiction of PNS involvement in pSS is still lacking. This study aimed at analyzing the prevalence and the clinical and laboratory factors associated with PNS involvement in a very large cohort of well-characterized pSS patients with a clearly defined neurological diagnosis.

Methods

Clinical and serological data of 1,695 pSS patients with specific and accurate information on PNS involvement were analyzed. Comparisons between patients with and without PNS involvement and between patients with distinct subsets of PNS manifestations were performed.

Results

Prevalence of PNS involvement was 3.7%. The most frequent types observed were pure sensory neuropathies and axonal sensorimotor polyneuropathies (SMP). Patients with PNS involvement exhibited a more active disease profile and were more frequently treated with immunosuppressants. Intriguingly, clinical and serological negative prognostic factors, including purpura, extra-glandular manifestations, leukopenia, low complement and cryoglobulinemia, principally characterized patients with SMP, while subjects with pure sensory neuropathy displayed a milder phenotype.

Conclusion

Our results highlight that PNS involvement is rather rare, but prognostically relevant in pSS. Main adverse prognostic features characterize patients with SMP, while pure sensory neuropathies are usually associated with a mild clinical picture. These findings, useful for patient stratification, may suggest protean pathogenic pathways underlying different types of PNS manifestations in pSS.

Childhood-onset of primary Sjögren's syndrome: phenotypic characterization at diagnosis of 158 children

OBJECTIVES

To characterize the phenotypic presentation at diagnosis of childhood-onset primary Sjögren syndrome (SjS).

METHODS

The Big Data Sjögren Project Consortium is an international, multicentre registry using worldwide data-sharing cooperative merging of pre-existing clinical SjS databases from the five continents. For this study, we selected those patients in whom the disease was diagnosed below the age of 19 according to the fulfilment of the 2002/2016 classification criteria.

RESULTS

Among the 12 083 patients included in the Sjögren Big Data Registry, 158 (1.3%) patients had a childhood-onset diagnosis (136 girls, mean age of 14.2 years): 126 (80%) reported dry mouth, 111 (70%) dry eyes, 52 (33%) parotid enlargement, 118/122 (97%) positive minor salivary gland biopsy and 60/64 (94%) abnormal salivary ultrasound study, 140/155 (90%) positive antinuclear antibody, 138/156 (89%) anti-Ro/La antibodies and 86/142 (68%) positive rheumatoid factor. The systemic ESSDAI domains containing the highest frequencies of active patients included the glandular (47%), articular (26%) and lymphadenopathy (25%) domains. Patients with childhood-onset primary SjS showed the highest mean ESSDAI score and the highest frequencies of systemic disease in 5 (constitutional, lymphadenopathy, glandular, cutaneous and haematological) of the 12 ESSDAI domains, and the lowest frequencies in 4 (articular, pulmonary, peripheral nerve and central nervous system) in comparison with patients with adult-onset disease.

CONCLUSIONS

Childhood-onset primary SjS involves around 1% of patients with primary SjS, with a clinical phenotype dominated by sicca features, parotid enlargement and systemic disease. Age at diagnosis plays a key role on modulating the phenotypic expression of the disease.

Salivary Gland Ultrasonography in Sjögren's Syndrome: A European Multicenter Reliability Exercise for the HarmonicSS Project

Objectives: Salivary gland ultrasonography (SGUS) is increasingly applied for the management of primary Sjögren's syndrome (pSS). This study aims to: (i) compare the reliability between two SGUS scores; (ii) test the reliability among sonographers with different levels of experience.

Methods: In the reliability exercise, two four-grade semi-quantitative SGUS scoring systems, namely De Vita et al. and OMERACT, were tested. The sonographers involved in work-package 7 of the HarmonicSS project from nine countries in Europe were invited to participate. Different levels of sonographers were identified on the basis of their SGUS experience and of the knowledge of the tested scores. A dedicated atlas was used as support for SGUS scoring.

Results: Twenty sonographers participated in the two rounds of the reliability exercise. The intra-rater reliability for both scores was almost perfect, with a Light's kappa of 0.86 for the De Vita et al. score and 0.87 for the OMERACT score. The inter-rater reliability for the De Vita et al. and the OMERACT score was substantial with Light's Kappa of 0.75 and 0.77, respectively. Furthermore, no significant difference was noticed among sonographers with different levels of experience.

Conclusion: The two tested SGUS scores are reliable for the evaluation of major salivary glands in pSS, and even less-expert sonographers could be reliable if adequately instructed.

THU0220 AUTOPHAGY IN SJOGREN’S SYNDROME SALIVARY GLAND EPITHELIAL CELLS (SGECS) IS ASSOCIATED WITH THE SEVERITY OF INFLAMMATION AND EPITHELIAL CELLS ACTIVATION

Background:

Sjögren’s Syndrome (SS) is characterized by chronic inflammation supported by intrinsic activation of salivary gland epithelial cells (SGECs). Eventually, apoptosis of SGECs ensues, which leads to salivary gland dysfunction and exposition of autoantigens. Autophagy is a stress coping mechanisms of cells implicated in both survival and exposition of autoantigens, and is thereby plausibly implicated in the pathogenesis of SS. At present, the exact relationship between apoptosis and autophagy in SS SGECs is unclear, as is the link between these mechanisms and SGECs activation.

Objectives:

To explore autophagy in SGECs from patients with SS and to evaluate its relationship with apoptosis and SGECs activation.

Methods:

Consecutive patients with suspected SS referring to our “Sjogren Clinic” were enrolled, and minor salivary gland (MSG) biopsies were collected for: (1) SGECs culture, (2) PCR analysis, (3) IFI analysis. In SGECs cultures, the expression of autophagy (LC3II), apoptosis (annexin V/PI) and adhesion molecules (ICAM) was investigated by flow cytometry (results expressed as mean % ± SD). The expression of the autophagy gene MAP1LC3II was evaluated by PCR (expressed as 2^deltaCT normalized to GADPH) on both MSG sections and MSG acinar and ductal epithelium samples obtained by laser capture microdissection. Tissue expression of LC3II was evaluated by IFI on SS MSG.

Results:

Primary SGECs cultures were established from 14 MSG obtained for diagnostic purposes (SS n=8, Sicca n=6). These cells exhibited an inverse correlation between apoptosis and autophagy (p=0.007, r=-0.784), with lower levels of apoptosis (19.7±6.5 vs 24.5±8.5, p=ns) and higher levels of autophagy (59.7±13.1 vs 54.19±19.4, p=ns) in SS compared to Sicca. In SS, MAP1LC3 was positively correlated with Focus Score (p=0.021 r=0.478); however, PCR studies did not reveal significant differences in MAP1LC3 expression between SS (n=26) and Sicca (n=15) (0.024±0.010 vs 0.022±0.008, p=ns). Ductal SGECs (n=4) isolated by laser microdissection of MSG revealed a higher expression of MAP1LC3 (0.005±0.0005 vs 0.003±0.0008; p=0.057) compared to normal acinar epithelium (n=5); a major expression of LC3II in ducts was confirmed by IFI (Image).

In SS, a higher expression of ICAM compared to sicca was observed (11.1±3.8 vs 6.9±6.9, p=0.006) and autophagy and apoptosis showed a trend of positive and negative correlation with this molecule, respectively (p=0.683 r=0.118 and p=0.106 r=-0.446).

Figure.

LC3-II staining in SS MSG [LC3-II+ (green) and Hoechst stain (blue); 60x magnification].

Conclusion:

In SS, autophagy is upregulated in SGECs and inversely correlated with apoptosis, thus supporting a role of this process in cells’ death prevention during inflammatory process. Indeed, the degree of msg inflammation is correlated more with the activation of autophagy than apoptosis. Interesting, in SS, SGECs autophagy is mainly observed at ductal level and is correlated with higher expression of adhesion molecules suggesting a link between this pathway and changes in SGECs immune phenotype.

Disclosure of Interests: :

Serena Colafrancesco: None declared, cristiana barbati: None declared, Valentina Iannizzotto: None declared, Linda Mastromanno: None declared, Saba Nayar: None declared, Elena Pipi: None declared, angelica gattamelata: None declared, francesco ciccia Grant/research support from: pfizer, novartis, roche, Consultant of: pfizer, novartis, lilly, abbvie, Speakers bureau: pfizer, novartis, lilly, abbvie, cristiano alessandri Grant/research support from: Pfizer, Francesca Barone: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi, Roberta Priori: None declared

THU0258 SJOGREN’S SYNDROME WITH AND WITHOUT AND AUTOIMMUNE THYROIDITIS: IS THERE ANY DIFFERENCE?

Background:

Sjögren’s syndrome (SS) is a systemic autoimmune disease mainly affecting exocrine glands and characterized by a progressive lymphocytic infiltration of salivary and lacrimal glands with consequent loss of function and development of sicca symptoms. Autoimmune thyroiditis (AT) is the most frequent autoimmune disease associated with SS and detectable in about 10 - 30% of cases1. Interestingly, patients with concomitant SS and AT seem to display a more attenuated phenotype compared to patients with solely SS. It is also noteworthy that up to 30% of patients with AT experience sicca symptoms without a clear diagnosis SS2. At the light of these evidences, it is unclear whether SS and AT represent two distinct nosological entities or different expressions of the same pathology.

Objectives:

Aim of this study is to evaluate the prevalence of AT in a large monocentric cohort of patients with SS and to define its clinical and laboratory characteristics compared to isolated SS.

Methods:

Consecutive patients with SS (AECG criteria) referring to our “Sjögren Clinic” (Sapienza University of Rome) were enrolled and divided in two groups: SS with AT (group 1) and SS without AT (group 2). Group 1 was further divided in two subgroups depending on the presence (1a) or absence (1b) of anti Ro/SSA antibodies. The following clinical and laboratory data were retrospectively collected for all patients: concomitant celiac disease, arthralgia, lung involvement, purpura, lymphoma, presence of ANA, anti-Ro/SSA, anti-La/SSB, rheumatoid factor, cryoglobulins, leukopenia and hypergammaglobulinaemia. These characteristics were compared between the following groups: group 1, group 2, group 1a and 1b. For statistic Chi Square and Fisher’s test analysis were performed.

Results:

Six-hundred and three SS patients were enrolled (group 1 n=135; group 2 n=381; group 1a n=96; group 1b n=39). The prevalence of AT was 135/603 (22.3%). When comparing SS patients with or without AT (group 1 vs group 2) the frequency of rheumatoid factor was significantly higher in group 2 compared to group 1 (p=0.006). No case of lymphoma was recorded in group 1 while 14 cases of lymphoma were ascertained in group 2 (p=0,08). Conversely, celiac disease was higher in group 1 compared to group 2 (p=0.01). No other differences between these groups were identified. Stratifying SS patients with AT according to the presence (group 1a) or not (group 1b) of anti Ro/SSA antibodies, ANA, rheumatoid factor and hypergammaglobulinemia were significantly more positive in group 1a compared to group 1b (p=0.0002, p=0.002, p=0.02, respectively); no clinical differences were identified.

Conclusion:

In this study, we confirm the presence of a less aggressive disease in patients with SS and AT compared to solely SS. The higher prevalence of rheumatoid factor and lymphoma occurrence in SS without AT, strictly suggest a more severe phenotype in this subset. Although is known that in SS patients with anti Ro/SSA+ antibodies and RF there is a more aggressive disease, in SS with AT the presence or absence of such autoantibodies do not seems to associate with any difference in clinical severity. Follow up studies are presently being carried out in order to provide conformation of a less sever phenotype and a better disease outcome in patients with associated SS and AT.

References:

[1]Jara, L.J., Navarro, C., Brito-Zerón, M.P. et al. Thyroid disease in Sjögren’s syndrome. Clin Rheumatol 26, 1601–1606 (2007)

[2]Vera D. Milic, Goran Radunovic, Ivan Boricic, Sanja Ognjanovic, Radmila Petrovic, Marija Radak-Perovic, Nada Vujasinovic-Stupar, Nemanja Damjanov, High prevalence of autoimmune thyroid disease in subjects with sicca symptoms without Sjögren’s syndrome, Rheumatology, Volume 52, Issue 4, April 2013, Pages 754–755.

Disclosure of Interests:

None declared

THU0266 RESILIENCE IN WOMEN WITH PRIMARY SJÖGREN’S SYNDROME

Background:

Resilience is the ability to react positively to stressful life events, a multidimensional feature that varies in relation to context, time, age, sex, culture and personal experience, appearing among the most important traits in patients suffering from rheumatic diseases1. Several studies focus on patients with RA and SLE and the role of resilience in the respective clinical manifestations, as well as in the development of anxiety and depression2,3. Conversely, the data available regarding patients with primary Sjögren’s Syndrome (pSS) are limited.

Objectives:

To assess, in women with pSS (classified according to the criteria of Vitali et al.4), the relationship between resilience and anxiety, depression, health, fatigue, physical activity and quality of life in relation to disease activity and duration and in consideration of demographic, job and cultural characteristics.

Methods:

74 female patients with pSS afferent to the dedicated clinic of the University Hospital Policlinico Umberto I of Rome were recruited. Resilience was assessed by administering the Italian validated version of the Resilience Scale (RS-14)5consisting of 14 items, each of which is assigned a score from 1 to 7, with a range from 14 to 98. Higher scores relate to greater resilience. ESSDAI (EULAR Sjögren’s syndrome disease activity index), ESSPRI (EULAR Sjogren’s Syndrome Patient Reported Index), SSDDI (Sjogren’s Syndrome Disease Damage Index) were assessed and EuroQol / GH EQ VAS (visual analogue scale), HADS (Hospital Anxiety and Depression Scale), SF-12 (Short-form 12 health survey), FAS (Fatigue Assesment Scale), IPAQ (International Physical Activity Questionnaire), FACIT-F (Functional Assessment of Chronic Illness Therapy – Fatigue) questionnaires were submitted. Educational qualifications and job were also considered. The statistical analysis was carried out by means of Spearman’s correlation.

Results:

No relationship was found between resilience, systemic disease activity, disease duration, patient-reported symptoms and damage. Furthermore, no apparent link was found between socio-demographic characteristics, employment and resilience. Conversely, an inverse relationship was found between resilience and mood disorders (p=0.0379), with greater resilience associated with a better perception of quality of life (p=0.0232) and general health (p=0.0002), mainly mental (p=0.0001) than physical (p=0.0035), as well as less fatigue (p=0.0079) and more phyisically active lifestyle (p=0.0012)

Conclusion:

For the first time, the role of resilience in women with pSS in relation to their disease and other individual parameters was assessed. The most resilient patients are less depressed and show better perception of their health. Greater resilience tends to correlate with less anxiety, physical and mental fatigue and a more active lyfestile, while there was no relation between resilience value, active disease and socio-demographic features.

References:

[1]Rojas M. et al., Resilience in women with autoimmune rheumatic diseases, Joint Bone Spine (2017).

[2]Sílvia Fernanda Cal et al., Resilience in systemic lupus erythematosus, Psychology, Health & Medicine (2013), 18:5, 558-563.

[3]NeiLi Xu et al., Associations of perceived social support and positive psychological resources with fatigue symptom in patients with rheumatoid arthritis.PLoS One. 2017; 12(3).

[4]Vitali C, et al. Classification criteria for Sjogren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis 2002; 61:554-558.

[5]Camilla Callegari et al., Reliability and validity of the Italian version of the 14-item Resilience Scale, Psychology Research and Behavior Management 2016:9 277–284.

Disclosure of Interests:

None declared

Multicolor flow cytometric analysis of TLR2 and TLR9 expression and function in NK cells from patients with ANCA-associated vasculitis

BACKGROUND

The primary objective of this study was to provide an assessment of NK cells in patients with ANCA-associated vasculitis (AAV).

METHODS

Patients were classified based on the presence or absence of ANCAs and compared with healthy controls (HCs). By multiparameter flow cytometry, we evaluated the number and proportion of NK cells (CD3-CD56+) and the CD56^dim , CD56^bright , CD56^dim CD57^bright subsets; TLR2 and TLR9 expression; intracellular IFN-γ production upon stimulation with TLR2 and TLR9 ligands; degranulation activity; serum cytokines; immunohistochemical staining of available biopsies.

RESULTS

No differences in the number and proportion of NK cells between patients and HC were observed, except for a lower proportion of CD56^dim subset in ANCA-negative patients than in HC (P = 0.02). With respect to HC, TLR2 expression levels were reduced in NK cells from ANCA-negative patients (P = 0.03), in the CD56^dim subset of ANCA-positive (P = 0.02) and ANCA-negative patients (P = 0.01), in the CD56^bright subset of ANCA-positive patients (P = 0.007), and in the CD56^dim CD57^bright subset of ANCA-positive (P = 0.04) and ANCA-negative patients (P = 0.03). No differences between patients and HC were found concerning IFN-γ production and degranulation activity. IL-22 levels were lower in ANCA-positive patients than in HC (P = 0.01). The immunohistochemical analysis showed sporadic CD56+ cells in one renal biopsy, and a diffuse and moderate infiltrate of IL-22+ cells in all renal biopsies and in skin tissue.

CONCLUSIONS

Our data suggest a role of infectious stimuli triggering NK cells in AAV pathogenesis. Poor detection of NK cells in affected tissues suggests a marginal involvement in local inflammatory responses. © 2017 International Clinical Cytometry Society.

Myositis in primary Sjögren's syndrome: data from a multicentre cohort

OBJECTIVES

In primary Sjögren's syndrome (pSS), muscle pain and/or muscular weakness is relatively frequent while myositis has been reported in 3% of patients. The aim of this study was to describe the prevalence of myositis in a multicentre Italian pSS cohort and to address the clinical manifestations, histological findings and therapeutic strategies.

METHODS

Clinical, serological and therapeutic data from a pSS cohort of patients were retrospectively collected. According to Bohan and Peter's criteria, inflammatory myopathy (IM) was suspected in case of muscular weakness associated with increased creatine-phosphokinase (CPK) or abnormal electromyography (EMG). When performed, muscle biopsies were analysed.

RESULTS

In a cohort of 1320 patients, 17 (1.28%) presented muscular weakness [in some cases myalgias (7/17, 41.1%)], accompanied by increased CPK [13/17, (76.4%)] and/or abnormal EMG [13/14, (92.8%)]. Ten out of 17 (58.8%) fulfilled at least three diagnostic criteria for IM. Muscular biopsy was performed in 13/17 (76.4%) cases with histologically confirmed myositis in 6/13 (46.1%) (1"IBM-like"-5"PM-like"). In two "PM-like" cases, several fibres showed a decreased histochemical cytochrome C oxidase (COX) stain. Two biopsies tested "negative", four showed "non-specific" findings. All patients were treated with corticosteroids followed by different DMARDs.

CONCLUSIONS

Our retrospective analysis shows a prevalence of myositis in pSS lower than previously reported, mainly appearing as an overlapping syndrome. Histological findings confirm the possible presence of an IBM or of a myopathy more similar to PM with a decreased COX activity. Classical immunosuppressants are effective although in most difficult cases IVIg or RTX may be used with benefit.

The use of musculoskeletal ultrasound in a rheumatology outpatient clinic

INTRODUCTION

Musculoskeletal ultrasound (US) represents a valid, reliable and sensitive-to-change tool for the evaluation of patients suffering from rheumatic conditions. This method demonstrates a wide applicability and availability, finding place in the clinical practice in rheumatology outpatient clinic.

AIM

To perform an epidemiological evaluation related to the use of US in a university rheumatology outpatient clinic.

MATERIAL AND METHODS

During a 3-month period, data concerning consecutive patients attending to the US Unit of Department of Rheumatology, Sapienza University of Rome were registered. We collected the demographic data, the diagnosis, the reason for the US examination, the examined joints, as well as the requesting physicians' specialty.

RESULTS

In the period October-December 2013, 572 patients (M/F 137/435; mean age+/-SD 55.2+/-15.8 years) were registered. The US examination was more frequently requested for the following diseases: rheumatoid arthritis (29.5%), osteoarthritis (10.6%), spondyloarthritis (9.1%), and connective tissue diseases (8.9%). In 239 of cases (41.8%), the US evaluation was requested for other indications. The US evaluation was requested slightly more frequently for monitoring (55.7%) compared to diagnosis (44.3%). The requesting physician was a rheumatologist in the majority of the cases (80.6%). The most frequent requested were the hand joints (28.9%) and wrists (23.3%).

CONCLUSIONS

US examinations are most frequently used in the evaluation of patients with rheumatoid arthritis and mainly to monitor the disease. The exam is requested mostly by rheumatologists. The hand joints and wrists were the most frequently evaluated.

Ultrasound in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by synovial inflammation that can lead to structural damage of cartilage, bone and tendons. Assessing the inflammatory activity and the severity is essential in RA to help rheumatologists in adopting proper therapeutic strategies and in evaluating disease outcome and response to treatment. In the last years musculoskeletal (MS) ultrasonography (US) underwent tremendous technological development of equipment with increased sensitivity in detecting a wide set of joint and soft tissues abnormalities. In RA MSUS with the use of Doppler modalities is a useful imaging tool to depict inflammatory abnormalities (i.e. synovitis, tenosynovitis and bursitis) and structural changes (i.e. bone erosions, cartilage damage and tendon lesions). In addition, MSUS has been demonstrated to be able to monitor the response to different therapies in RA to guide local diagnostic and therapeutic procedures such as biopsy, fluid aspirations and injections. Future applications based on the development of new tools may improve the role of MSUS in RA.

Outcome of Pregnancy in Italian Patients with Primary Sjögren Syndrome

Objective.

To investigate pregnancy and fetal outcomes in patients with primary Sjögren syndrome (pSS).

Methods.

An obstetric history of 36 women with established diagnosis of pSS at pregnancy was obtained from a multicenter cohort of 1075 patients. In a subgroup case-control analysis, 12 deliveries in patients with pSS were compared with 96 control deliveries.

Results.

Thirty-six women (31 with anti-SSA/Ro and/or anti-SSB/La antibodies) with an established diagnosis of pSS had 45 pregnancies with the delivery of 40 newborns. Two miscarriages, 2 fetal deaths, and 1 induced abortion were recorded. Mean age at the first pregnancy was 33.9 years; mean number of pregnancies was 1.25; 18/40 (45%) cesarean births were delivered; mean pregnancy length was 38.5 weeks (range 32–43), with 6 preterm deliveries. The mean Apgar score at 5 min was 8.9, mean birthweight was 2920 g (range 826–4060 g). Congenital heart block (CHB) occurred in 2/40 (5%) newborns. The reported rate of breastfeeding for at least 1 month was 60.5%. In 4/40 pregnancies (10%) a flare of disease activity was observed within a year from delivery. In the case-control subgroup analysis, 12 deliveries were compared with 96 controls and no significant differences were found.

Conclusion.

Patients with pSS can have successful pregnancies, which might be followed by a mild relapse. CHB was the only cause of death for offspring of mothers with pSS.

Osteoarthritis of the foot: a review of the current state of knowledge

Foot osteoarthritis(OA)is very common disease that mainly affects older people deeply influencing their quality of life.The join most frequently involved in the articular degenerative process is the first metatarsophalangeal joint. Its severe impairment may lead to a specific clinical pattern known as hallux rigidus that often requires surgical treatment.Currently conventional radiograms of feet associated with an accurate clinical examination should be performed in order to diagnose foot OA.However, new imaging modalities as ultrasonography and magnetic resonance imaging are emerging as valuable tools to assess foot OA.Therapeutic options for foot OA consist of conservative strategies, including life-style modification and pharmacological treatment, options that are usually adopted in early-stage disease and in invasive surgical procedures reserved to late-stage conditions. At the present time there is a lack of evidence in international literature specifically dealing with foot OA, so further investigation on this topic is required to clarify its pathogenesis, the diagnostic pathway and the best clinical management.

Fatigue and widespread pain in systemic lupus erythematosus and Sjögren's syndrome: symptoms of the inflammatory disease or associated fibromyalgia?

Fatigue and generalised pain are debilitating symptoms that negatively impact the quality of life in patients with systemic lupus erythematosus (SLE) and primary Sjögren's syndrome (pSS). Chronic widespread musculoskeletal pain and fatigue are the clinical hallmarks of fibromyalgia (FM), a clinical entity which can be associated to connective tissue disease. The aim of the present study was to assess the prevalence of FM syndrome, fatigue and widespread pain in SLE and pSS patients and to evaluate the contribution of inflammatory disease and FM on those constitutional symptoms. Fifty SLE and 50 pSS patients were enrolled in the study. Patients rated fatigue, pain, and disease activity using a 100-mm visual analogue scale and completed the Health Assessment Questionnaire and the Fibromyalgia Impact Questionnaire. Zung depression and anxiety scales were used to quantify mood disorders. Tender points were evaluated using an algometer. Disease activity score as evaluated for each SLE and pSS patient. Fibromyalgia has been diagnosed in a significantly higher percentage of SLE patients than pSS patients (32% vs. 18%, p=0.022) even if the percentage of patients reporting fatigue and pain was higher among pSS patients. No correlation with disease activity was observed in either group of patients. FM seems to contribute to constitutional symptoms more in SLE than in pSS, suggesting a different underlying cause of fatigue and widespread pain in these two different connective tissue diseases.

Unilateral painful, swollen and erythematosus knee. Case report

Musculoskeletal ultrasound (US) is gaining an increasing role in the assessment of a variegate set of joint and periarticular soft tissues abnormalities in rheumatology. In addition, US represents a useful technique in guiding local procedures such as aspiration of fluid collections and injections within the joints and periarticular musculoskeletal structures. We recently performed US in a patient with unilateral painful, swollen and erythematosus knee. Pre-patellar bursitis was demonstrated, without any signs of intra-articular abnormalities. US-guided aspiration of local effusion was performed; synovial fluid analysis demonstrated septic bursitis. Appropriate treatment determined the complete remission.

Ultrasound in the assessment of musculoskeletal involvement in systemic sclerosis

Systemic sclerosis (SSc) is a chronic connective disease in which the musculoskeletal involvement affects especially the hands and feet. Ultrasound (US) represents an important tool in the assessment of the joint and soft tissue involvement in this rheumatic disorder. Few authors have investigated the role of US in the evaluation of joints and peri-articular tissues in SSc patients. The current available literature regarding US applications in the assessment of musculoskeletal involvement in SSc has shown that US seems to be a useful tool in detecting the presence of inflammatory and structural abnormalities involving both joints and soft tissues. The aim of the present paper is to review the role of US in the assessment of musculoskeletal involvement in SSc.

The interobserver reliability of ultrasound in knee osteoarthritis

OBJECTIVE

To assess the interobserver reliability between sonographers with different levels of experience in detecting inflammatory and structural damage abnormalities in patients with knee OA.

METHODS

After achieving consensus on definitions and scanning protocols, three ultrasonographers with different levels of experience in musculoskeletal US examined the knees of nine patients with OA. US examinations were conducted with independent blinded evaluations of inflammatory (joint effusion, synovial hypertrophy, power Doppler signal, Baker's cysts) and structural (osteophytes, cortical bone irregularities, femoral hyaline cartilage abnormalities, protrusion of the medial meniscus) lesions. All abnormalities were scored by applying a dichotomous scale (0-1). In addition, at each knee joint site global scores for joint inflammation, cortical bone abnormalities and cartilage damage were calculated by summing the single-lesion scores. Reliability was assessed using kappa (κ) coefficients.

RESULTS

Seventeen knees were examined. Inflammatory abnormalities were observed with moderate to very good agreement (κ = 0.55-0.88) between the observers. From fair to very good agreement (κ = 0.31-0.82) was registered between sonographers for structural damage lesions. The overall κ was 0.716 for junior and 0.571 for beginner sonographers comparing their findings with those of senior sonographers.

CONCLUSION

This represents the first ultrasonographic study focusing on the analysis of interobserver reliability between sonographers with different levels of experience in demonstrating inflammatory and structural abnormalities in knee OA. Globally, even considering some variable results that were mainly obtained by the evaluation of single components of bone involvement, US offered a reliable assessment of a wide set of abnormalities in knee OA.

Adult-onset Still disease: a rare disorder with a potentially fatal outcome

Purpose

The aim of this study was to assess the clinical and laboratory features of a cohort of Italian patients with adult-onset Still disease (AOSD) with particular attention on possible life-threatening complications.

Methods

The clinical charts of 41 consecutive Italian patients with AOSD referred to our rheumatological department over the last 10 years were retrospectively examined. Data regarding clinical manifestations, laboratory features and complications were collected and compared with those reported in literature.

Results

The most frequent manifestations were: fever (90.2%), arthralgias (80.4%), skin rash (75.6%), sore throat (53.6%), arthritis (51.2%), lymphadenopathy (48.7%), hepatosplenomegaly (41.4%), myalgia (21.9%), fatigue (12%), diarrhoea and vomiting (9.7%), pleural effusion (9.7%), pericardial effusion (4.8%) and abdominal pain (2.4%). In two patients whose cases are described in detail; the course of the disease was complicated by disseminated intravascular coagulopathy, in one patient with a fatal outcome. ESR, CRP and leucocyte count mean values were 69.41 mm/h, 69.05 mg/l and 18,798.5 cell/mm³ (neutrophils 84.64%), respectively. Serum ferritin levels were increased in 48.7% of patients while transaminases were elevated in 42.6% of patients (71% considering only patients in an active phase of disease).

Conclusion

The results of this study are in line with those reported for other cohorts of patients. Even if the prognosis of AOSD is considered favourable, the present study indicates that the disease is a troubling condition needing prompt intervention. Occasionally, AOSD may rapidly worsen with life-threatening events.