Defining remission in childhood-onset lupus: PReS-endorsed consensus definitions by an international task force

OBJECTIVE

To derive childhood-onset SLE (cSLE) specific remission definitions for future treat-to-target (T2T) trials, observational studies, and clinical practice.

METHODS

The cSLE International T2T Task Force conducted Delphi surveys exploring paediatric perspectives on adult-onset SLE remission targets. A modified nominal group technique was used to discuss, refine, and agree on the cSLE remission target criteria.

RESULTS

The Task Force proposed two definitions of remission: 'cSLE clinical remission on steroids (cCR)' and 'cSLE clinical remission off steroids (cCR-0)'. The common criteria are: (1) Clinical-SLEDAI-2 K = 0; (2) PGA score < 0.5 (0-3 scale); (4) stable antimalarials, immunosuppressive, and biologic therapy (changes due to side-effects, adherence, weight, or when building up to target dose allowed). Criterion (3) in cCR is the prednisolone dose ≤0.1 mg/kg/day (maximum 5 mg/day), whereas in cCR-0 it is zero.

CONCLUSIONS

cSLE definitions of remission have been proposed, maintaining sufficient alignment with the adult-SLE definition to facilitate life-course research.

PReS-endorsed international childhood lupus T2T task force definition of childhood lupus low disease activity state (cLLDAS)

OBJECTIVE

To achieve a consensus-based definition of Low Disease Activity (LDA) for use in cSLE trials.

METHODS

The International cSLE T2T Task Force, comprising of paediatric rheumatologists/nephrologists, and adult rheumatologists undertook a series of Delphi surveys/consensus meetings to discuss, refine, and vote upon cSLE LDA criteria.

RESULTS

The Task Force agreed that LDA should be based upon the adult-SLE Lupus Low Disease Activity State definition (LLDAS), with modifications to make it applicable to cSLE (cLLDAS). They agreed upon five cLLDAS criteria: (1) SLE Disease Activity Index (SLEDAI)-2 K ≤4, with no activity in major organ systems; (2) no new features of lupus disease activity compared with the last assessment; (3) Physician Global Assessment score of ≤1 (0-3 scale); (4) prednisolone dose of ≤0.15 mg/kg/day, 7.5 mg/day/maximum; while on (5) stable antimalarials, immunosuppressives, and biologics.

CONCLUSIONS

A cSLE-appropriate definition of cLLDAS has been generated, maintaining alignment with the adult-SLE definition to promote life-course research.

POS0334 DRIVERS OF NON-ZERO PHYSICIAN GLOBAL SCORES DURING PERIODS OF INACTIVE DISEASE IN JUVENILE IDIOPATHIC ARTHRITIS

Background

The ACR provisional criteria for defining inactive disease (ID) in Juvenile Idiopathic Arthritis (JIA) requires that the physician’s global assessment of disease activity (PhGA) is marked as 0 on the visual analog scale (VAS). However, some investigators have noticed the tendency of some clinicians to mark the PhGA>0 even on resolution of active disease. Due to the fact that the PhGA and the count of active joints are the two main physician-centered measures included in ID criteria the analysis of their discordance may be of importance to address the issue.

Objectives

To investigate the frequency in which the physician provides a global assessment of disease activity (PhGA)>0 and an active joint account (AJC)=0 in children with juvenile idiopathic arthritis (JIA) and search for determinants of divergence between the two measures.

Methods

Data were extracted from a multinational cross-sectional dataset of 7265 patients who had JIA by ILAR criteria, were recruited between 2011 and 2016 and had both PhGA and AJC recorded by the caring paediatric rheumatologist at the study visit. Determinants of discordance between PhGA and AJC=0 were searched for by multivariable logistic regression and dominance analysis.

Results

The PhGA was scored >0 in 1211 (32,4%) of 3668 patients who had an AJC of 0. In 536 patients (14,6%) the PhGA was the single most frequent reason for not meeting the ID definition in patients with AIJ=O. Independent associations with discordant assessment were identified for tender or restricted joint count>0, history of enthesis, presence of active uveitis or systemic features, enthesitis-related or systemic arthritis, increased acute phase reactants, pain visual analog scale (VAS)>0, and impaired physical or psychosocial wellbeing. In dominance analysis, tender joint count accounted for 35,43% of PhGA variance, followed by VAS>0 (17,72%), restricted joint count >0 (16, 14%) and physical health score >0 (11,42%) (Figure 1).

Figure 1.

Dominance analysis of relative importance of predictive factors in explaining the variance in PhGA.

Conclusion

We found that many paediatric rheumatologists did not mark a score of 0 for patients who they found not to have active joints. The presence of pain in joints not meeting the definition of active joint used in JIA was the main determinant of this phenomenon.

References

[1]Wallace CA, Giannini EH, Huang B, Itert L, Ruperto N; American College of Rheumatology provisional criteria for defining clinical inactive disease in select categories of juvenile idiopathic arthritis. Arthritis Care Res (Hoboken). 2011 Jul;63(7):929-36.

[2]Shoop-Worrall SJW, Verstappen SMM, Baildam E, et al. How common is clinically inactive disease in a prospective cohort of patients with juvenile idiopathic arthritis? The importance of definition. Ann Rheum Dis. 2017 Aug;76(8):1381-1388

[3]Giancane G, Campone C, Gicchino MF, et al; Paediatric Rheumatology International Trials Organisation. Determinants of Discordance Between Criteria for Inactive Disease and Low Disease Activity in Juvenile Idiopathic Arthritis. Arthritis Care Res (Hoboken). 2021 Dec;73(12):1722-1729.

[4]Taylor J, Giannini EH, Lovell DJ, Huang B, Morgan EM. Lack of Concordance in Interrater Scoring of the Provider’s Global Assessment of Children With Juvenile Idiopathic Arthritis With Low Disease Activity. Arthritis Care Res (Hoboken). 2018 Jan;70(1):162-166.

Disclosure of Interests

Ana Isabel Rebollo Giménez: None declared, Alessandra Alongi: None declared, Gabriella Giancane: None declared, Roberta Naddei: None declared, Valentina Natoli: None declared, Nicolino Ruperto Speakers bureau: NR has received honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers and Squibb, Celgene, inMed, Cambridge Healthcare Research, Domain Therapeutic, EMD Serono, Glaxo Smith Kline, Idorsia, Janssen, Eli Lilly, Novartis, Pfizer, Sobi, UCB., Consultant of: NR has received honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers and Squibb, Celgene, inMed, Cambridge Healthcare Research, Domain Therapeutic, EMD Serono, Glaxo Smith Kline, Idorsia, Janssen, Eli Lilly, Novartis, Pfizer, Sobi, UCB., Alessandro Consolaro Consultant of: AC has received honoraria from Abbvie in the past 3 years., Angelo Ravelli Speakers bureau: AR has received honoraria for speaker bureaus from the following pharmaceutical companies in the past 3 years:Abbvie, Angelini, Pfizer, Novartis, Reckitt Benckiser, Sobi, Alexion, Roche

POS0339 POINTS TO CONSIDER AT THE EARLIEST STAGES OF THE DIAGNOSIS AND MANAGEMENT OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS/MACROPHAGE ACTIVATION SYNDROME (HLH/MAS)

Background

Hemophagocytic Lymphohistiocytosis (HLH) and Macrophage Activation Syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that occur in many contexts and are often called by many names. They nevertheless can progress rapidly, and early identification and management are critical for preventing organ failure and mortality.

Objectives

The purpose of this effort was to develop a series of ‘points to consider’ to assist clinicians at the earliest stages of evaluation and diagnosis, management, and monitoring of patients with HLH/MAS in order to improve patient outcomes.

Methods

A working group of adult and pediatric rheumatologists (14), hematologist/oncologists (4), immunologists (2), infectious disease specialists (2), intensivists (3), allied health care professionals (1), and patients/parents (2) formulated relevant research questions for a systematic literature review (SLR). We then used the SLR results, Delphi questionnaires, and consensus methodology to devise and refine overarching and specific ‘points to consider’ statements.

Results

The group arrived at six overarching statements and 24 specific points-to-consider relevant to early decision-making in diagnostics, initial management, and monitoring of HLH/MAS. Major themes included the a) need for prompt recognition, evaluation, and management of underlying triggers and conditions, b) multi-disciplinary/expert input, and c) early, tailored intervention with the goals of halting disease progression and preventing life- and organ-threatening immunopathology

Conclusion

These 2022 EULAR/ACR Points to Consider provide guidance on the initial evaluation, management, and monitoring of patients during the initial consideration of HLH/MAS.

Disclosure of Interests

Bita Shakoory: None declared, Ashley Geerlinks: None declared, Marta Wilejto: None declared, Kate Kernan: None declared, Erkan Demirkaya: None declared, Angelo Ravelli: None declared, Rashmi Sinha: None declared, Raphaela goldbach-mansky Grant/research support from: SOBI, Novartis, Regneneron, IFM, Lilly, Pfizer, Fabrizio De Benedetti Consultant of: abbvie, sobi, novimmune, novartis, roche, sanofi, Grant/research support from: sobi novimmune novartis roche sanofi, Rebecca Marsh: None declared, Scott Canna Consultant of: Simcha Therapeutics, Grant/research support from: Immvention therapeutics, AB2Bio Ltd, Novartis

POS0173 DATA-DRIVEN MRI DEFINITIONS FOR ACTIVE AND STRUCTURAL SACROILIAC JOINT LESIONS IN JUVENILE SPONDYLOARTHRITIS TYPICAL OF AXIAL DISEASE

Background

For classification in juvenile spondyloarthritis (JSpA), it is important to develop cut-offs for active and structural lesions typical of axial disease on MRI that are readily and consistently interpreted. Since the maturing sacroiliac joint (SIJ) looks different from the adult SIJ, the criteria developed for positive MRI in adults may not be applicable in JSpA.

Objectives

As part of a study developing classification criteria for axial disease in JSpA, we aimed to determine quantitative SIJ imaging lesion cut-offs for inflammatory and structural lesions typical of axial JSpA using majority imaging expert decision as the reference criterion.

Methods

Subjects were a retrospective cohort of children with SpA who met the provisional Pediatric Rheumatology International Trials Organization criteria for enthesitis/spondylitis-related juvenile idiopathic arthritis or had a rheumatologist JSpA diagnosis. All subjects had symptom onset prior to age 18 years and underwent MRI as part of a diagnostic evaluation for axial disease. To enable SIJ quadrant-based scoring, all MRIs included semi-coronal slices through the cartilaginous part of the joint on fluid sensitive sequences and on T1-weighted sequences for the assessment of inflammation and structural lesions, respectively. MRIs were reviewed by 6 musculoskeletal imaging experts who were blinded to clinical details. MRI evaluation of the SIJ was based on standardized lesion definitions that were decided by consensus of the central imaging team and represented a mix of definitions from ASAS and the Juvenile Arthritis MRI Score Outcome Measures in Rheumatology working group. Using a web-based interface, raters globally assessed the presence or absence of lesions typical of axial SpA and performed SIJ quadrant or joint based scoring. Lesion scores were generated by averaging the scores of all raters. Sensitivity and specificity of lesion cut-offs were calculated using rater majority (≥4/6 raters) on a global assessment of the presence/absence of active or structural lesions typical of axial SpA with high confidence (confidence of ±3 or stronger on confidence scale from -5, “Definitely No”, to +5, “Definitely Yes”) as the reference standard.

Results

Imaging from 243 subjects, 61% male, median age 14.9 years, had sequences available for detailed MRI scoring. Active inflammatory lesion typical of axial disease in JSpA was defined as bone marrow edema (BME) in at least 3 SIJ quadrants (sensitivity 98.6%, specificity 96.5%). For structural lesion typical of axial JSpA, the optimal cut-off was erosion in at least 3 quadrants or at least one of the following lesions in at least 2 SIJ quadrants: sclerosis, fat lesion, backfill, ankylosis (sensitivity 98.6%, specificity 95.5%).

Conclusion

We propose data-driven cut-offs for active inflammatory and structural lesions on MRI typical of axial disease in JSpA that have high specificity and sensitivity using central imaging global assessment as the reference standard.

Table 1.

Performance of cut-offs for inflammatory and structural lesions of axial disease

Cut-offs for number of SIJ quadrants (any location)Sensitivity (95% CI)Specificity (95% CI)Definite active lesionBME score ≥2100 (95.0-100)93.5 (88.7-96.7)BME score ≥398.6 (92.5-100)96.5 (92.5-98.7)BME, same location on ≥3 consecutive slices88.6 (78.7-94.9)98.8 (95.8-99.9)Definite structural lesionErosion ≥295.7 (88-99.1)96.8 (92.7-99)Erosion, same location on ≥2 consecutive slices94.3 (86-98.4)98.1 (94.5-99.6)Erosion ≥391.4 (82.3-96.8)98.7 (95.4-99.8)Sclerosis ≥262.9 (50.5-74.1)98.1 (94.5-99.6)Fat lesion ≥222.9 (13.7-34.4%)98.7 (95.4-99.8%)Backfill ≥220 (11.4-31.3)100 (97.7-100)Ankylosis ≥21.3 (0.2-4.7)100 (94.9-100)ANY of the following in ≥2 SIJ quadrants: erosion, sclerosis, fat lesion, backfill, ankylosis98.6 (92.3-100)93.6 (88.5-96.9)Erosion ≥3 quadrants OR ≥2 quadrants of at least one of the following lesions: sclerosis, fat, backfill, ankylosis98.6 (92.3-100.0)95.5 (91.0-98.2)

Disclosure of Interests

Pamela F. Weiss Consultant of: Pfizer

Novartis

Biogen

Lilly

(All <$5K in the past fiscal year), Timothy G. Brandon: None declared, Amita Aggarwal: None declared, Ruben Burgos-Vargas Speakers bureau: Not in the last three years.

Novartis, Consultant of: Not in the last four years.

BMS, Lilly, Novartis, Robert A. Colbert: None declared, Gerd Horneff Speakers bureau: Pfizer, Novartis, Janssen, Chugai, Abbvie, Grant/research support from: Pfizer, Novartis, MSD, Chugai, Roche, Abbvie, Rik Joos Speakers bureau: Galapagos, Pfizer, AbbVie, Novartis, Amgen, BMS, Lilly, Grant/research support from: Pfizer, AbbVie, Roche, Ronald Laxer Consultant of: Abbvie, Novartis, Sobi, Sanofi, Eli Lilly Canada, Eli Lilly, Kirsten Minden Speakers bureau: Pfizer, Novartis, Consultant of: Pfizer, Novartis, Angelo Ravelli Speakers bureau: Abbvie, Novartis, SOBI, Angelini, Reckitt-Benkiser, Roche, Pfizer, Alexion, Grant/research support from: Novartis, Pfizer, Nicolino Ruperto Speakers bureau: NR has received honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers and Squibb, Celgene, inMed, Cambridge Healthcare Research, Domain Therapeutic, EMD Serono, Glaxo Smith Kline, Idorsia, Janssen, Eli Lilly, Novartis, Pfizer, Sobi, UCB., Consultant of: NR has received honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers and Squibb, Celgene, inMed, Cambridge Healthcare Research, Domain Therapeutic, EMD Serono, Glaxo Smith Kline, Idorsia, Janssen, Eli Lilly, Novartis, Pfizer, Sobi, UCB., Grant/research support from: The IRCCS Istituto Giannina Gaslini (IGG), where NR works as full-time public employee has received contributions from the following industries in the last 3 years: Bristol Myers and Squibb, Eli-Lilly, F Hoffmann-La Roche, Novartis, Pfizer, Sobi. This funding has been reinvested for the research activities of the hospital in a fully independent manner, without any commitment with third parties., Judith Smith Consultant of: Consulting panel of pediatric rheumatologists identifying issues in juvenile spondyloarthritis for Novartis. Paid < $5000, Matthew L. Stoll Consultant of: Currently consulting for Novartis, Shirley ML Tse: None declared, Filip van den Bosch Speakers bureau: Abbvie, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB, Paid instructor for: Amgen, Eli Lilly, Consultant of: Abbvie, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB, Robert G Lambert Paid instructor for: Novartis, Consultant of: CARE Arthritis, Calyx, Image Analysis Group, Novartis, David M. Biko Employee of: Merck (1998-2000), Nancy A. Chauvin Employee of: Forest Pharmaceuticals - Research scientist (1996) and Novartis - Pharmaceutical sales representative (1997), Michael L. Francavilla: None declared, Jacob L Jaremko: None declared, Nele Herregods: None declared, Ozgur Kasapcopur Speakers bureau: Pfizer, Abbvie, Novartis and Roche, Mehmet YILDIZ: None declared, Alison M. Hendry: None declared, Walter P Maksymowych Speakers bureau: Abbvie, Eli-Lilly, Janssen, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB Pharma, Grant/research support from: Abbvie, Novartis, Pfizer

OP0215 WHAT DOES THE PATIENT WELL-BEING VAS TELL US WHEN THE PHYSICIAN GLOBAL ASSESSMENT SCORE IS ZERO? ANALYSIS OF A LARGE MULTINATIONAL DATASET

Background

Parent- and child-reported outcomes (PCROs) are measures that reflect the parent and child perception of rheumatic disease course and effectiveness of therapeutic interventions. Among PCROs for the assessment of patients with juvenile idiopathic arthritis (JIA), the most widely adopted is the parent/patient global evaluation or well-being visual analogue scale (WB-VAS). Several studies in JIA have highlighted the discrepancies in the assessment of the disease status between the physician and the parent/patient. This difference might be due to the WB-VAS measuring a broader construct than the physician global assessment (PGA).

Objectives

To evaluate, in a large multinational sample of JIA patients, the disease characteristics of subjects considered as inactive by the physician with an increased WB-VAS score.

Methods

Data from the multinational dataset of patients enrolled in the Epidemiology Treatment and Outcome of Childhood Arthritis (EPOCA) study were analyzed. We have included only subjects with a PGA score of 0. PCROs were collected through the juvenile arthritis multidimensional assessment report (JAMAR). We compared demographic features, socio-economic status, level of education, subtype of JIA diagnosis and the main PCROs (pain level, presence of morning stiffness, count of joints with swelling or pain, functional ability, disease activity level, ongoing therapy, presence of medications side effects and health related quality of life measured with the pediatric rheumatology quality of life (PRQL) scale) between subjects with WB-VAS ≤ 1 and > 1.

Results

A total of 3537 patients were sorted into two groups according to the WB_VAS score: 2862 subjects were included in a first group (WB_VAS ≤1); 675 in a second one (WB-VAS >1). Respectively, 17,6% and 18,1% of families belonged to the lower socio-economic status, 70,5% and 71% to the intermediate, 11,9% and 10,8% to the higher. The percentages of patients in the three levels of education was not different in the two groups:20,2% and 22% in the lower, 48,9% and 50,1% in the intermediate, 30,8% and 27,9% in the higher level of education. No significant difference was observed in the distribution of JIA categories in the two groups. Subjects in first group were younger at disease onset (5.6 vs 6.4 years). Comparison of main PCROs results is presented in the Table 1 below.

Table 1.PCROsWB_VAS ≤1WB_VAS >1pVAS_Pain (mean)0.3 (0.9)2.4 (2.4)<0.001Presence of morning stiffness (%)227 (8.0)285 (42.4)<0.001Patients under treatment (%)1919 (67.2)540 (80.2)<0.001Reporting side effects (%)421 (22.1)236 (43.9)<0.001Number of adverse events to the therapy (mean)0.2 (0.7)0.8 (1.5)<0.001Juvenile Arthritis Functionality Scale (JAFS)Total Score (mean)0.5 (1.6)3.0 (4.4)<0.001JIA Quality of Life (JQL) Total Score (mean)1.6 (2.3)6.4 (4.4)<0.001VAS-Disease Activity (mean)0.4 (1.3)2.3 (2.4)<0.001Count of active joints (mean)0.2 (0.7)1.4 (2.2)<0.001

Conclusion

We have analyzed the variables that might determine a difference between the physician’s assessment of inactive disease and the parent’s/patient’s perception of well-being. In particular, socio-economic status, level of education, and gender representation seem not to impact on the general perception of well-being, while pain seems to have the greatest influence on the parent/patient quality of life assessment. Finally, children with lower WB-VAS score were younger at disease onset.

References

[1]Consolaro A, et al. Phenotypic variability and disparities in treatment and outcomes of childhood arthritis throughout the world: an observational cohort study.Lancet Child Adolesc Health. 2019 Apr;3(4):255-263.

Disclosure of Interests

None declared

Distinct tumor-infiltrating lymphocyte landscapes are associated with clinical outcomes in localized non-small-cell lung cancer

BACKGROUND

Despite the importance of tumor-infiltrating T lymphocytes (TILs) in cancer biology, the relationship between TIL phenotypes and their prognostic relevance for localized non-small-cell lung cancer (NSCLC) has not been well established.

PATIENTS AND METHODS

Fresh tumor and normal adjacent tissue was prospectively collected from 150 patients with localized NSCLC. Tissue was comprehensively characterized by high-dimensional flow cytometry of TILs integrated with immunogenomic data from multiplex immunofluorescence, T-cell receptor sequencing, exome sequencing, RNA sequencing, targeted proteomics, and clinicopathologic features.

RESULTS

While neither the magnitude of TIL infiltration nor specific TIL subsets were significantly prognostic alone, the integration of high-dimensional flow cytometry data identified two major immunotypes (IM1 and IM2) that were predictive of recurrence-free survival independent of clinical characteristics. IM2 was associated with poor prognosis and characterized by the presence of proliferating TILs expressing cluster of differentiation 103, programmed cell death protein 1, T-cell immunoglobulin and mucin-domain containing protein 3, and inducible T-cell costimulator. Conversely, IM1 was associated with good prognosis and differentiated by an abundance of CD8⁺ T cells expressing cytolytic enzymes, CD4⁺ T cells lacking the expression of inhibitory receptors, and increased levels of B-cell infiltrates and tertiary lymphoid structures. While increased B-cell infiltration was associated with good prognosis, the best prognosis was observed in patients with tumors exhibiting high levels of both B cells and T cells. These findings were validated in patient tumors from The Cancer Genome Atlas.

CONCLUSIONS

Our study suggests that although the number of infiltrating T cells is not associated with patient survival, the nature of the infiltrating T cells, resolved in distinct TIL immunotypes, is prognostically relevant in NSCLC and may inform therapeutic approaches to clinical care.

LB0004 EFFICACY AND SAFETY OF SECUKINUMAB IN ENTHESITIS-RELATED ARTHRITIS AND JUVENILE PSORIATIC ARTHRITIS: PRIMARY RESULTS FROM A RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, TREATMENT WITHDRAWAL, PHASE 3 STUDY (JUNIPERA)

Background:

Enthesitis-related arthritis (ERA) and juvenile psoriatic arthritis (JPsA) are two ILAR categories of juvenile idiopathic arthritis (JIA) and represent paediatric correlates of axial spondyloarthritis (axSpA) and adult psoriatic arthritis (PsA), respectively.1,2 Secukinumab (SEC) has demonstrated efficacy and safety in adult patients (pts) with PsA, ankylosing spondylitis and non-radiographic axSpA.3-5

Objectives:

Evaluate efficacy and safety of SEC using a flare prevention design in pts with active ERA and JPsA.

Methods:

This 2-yr study consisted of an open-label (OL) s.c. SEC (75/150 mg in pts <50/ ≥50 kg) at baseline (BL), and at Weeks (Wk) 1, 2, 3, 4, 8 and 12 in treatment-period (TP) 1. Responder pts who achieved at least JIA ACR 30 response at Wk 12 were randomised into the double-blinded TP2 to continue SEC or placebo (PBO) q4w until a disease flare, or up to Wk 100. Pts (aged 2 to <18 yrs) classified as ERA or JPsA according to ILAR criteria of ≥6 months duration with active disease were included. Primary endpoint was time to flare in TP2 and key secondary endpoints were JIA ACR 30/50/70/90/100, inactive disease, JADAS, enthesitis count and safety. Analysis of time to flare in TP2 included proportion of disease flare, Kaplan-Meier (KM) estimate of median time to flare in days, hazard ratio (95% CI) from Cox model, and P-value for the Stratified log-rank test. KM estimates of the probability to disease flare by treatment groups in TP2 were plotted against days. Observed data were used in all analyses. Post-hoc analyses using non-responder imputation (NRI) were performed for JIA ACR 30/50/70/90/100 responses.

Results:

86/97 (89%) pts were enrolled in the OL period TP1 (mean age, 13.1 yrs; female, 33.7%; ERA, n=52; JPsA, n=34). At BL, mean JADAS-27 score was 15.1 and enthesitis count was 2.6. At the end of TP1, 90.4% (75/83) of pts achieved JIA ACR 30 and 69.9% (58/83) achieved JIA ACR 70. There were 21 and 10 flares in TP2, respectively in PBO and SEC treated pts with a significantly longer time to flare and 72% risk of flare reduction in SEC treatment vs PBO (HR: 0.28; 95% CI: 0.13–0.63; P<0.001) (Figure 1). JIA ACR responses, disease activity and enthesitis count are reported in Table 1. NRI analyses showed that 87.2%, 83.7%, 67.4%, 38.4% and 24.4% of pts achieved JIA ACR 30/50/70/90/100, respectively. Rates of adverse events (AEs; 91.7% vs 92.1%) and serious AEs (14.6% vs 10.5%) in SEC and PBO groups were comparable in the entire TP. No new safety signals were observed.

Table 1.

Efficacy of secukinumab in Treatment Periods 1 and 2 (Key secondary endpoints)

Efficacy Outcomes, %TP1TP2¥SEC (N=83)^SEC (N=37)PBO (N=37)P-valueJIA ACR 3090.489.264.90.014JIA ACR 5086.778.462.20.152JIA ACR 7069.967.643.20.042JIA ACR 9039.851.440.50.431JIA ACR 10025.343.237.80.745Inactive disease#36.147.237.80.500JADAS-27, mean (SD)15.1 (7.2)14.6 (8.1)13.3 (5.8)NAEnthesitis count, mean change from BL (SD)−1.8 (2.3)−2.1 (2.0)−1.9 (1.2)NA

P-values: Cochran-Mantel-Haenszel test, adjusted for analysis factors: JIA category (ERA/ JPsA) and MTX use at BL

¥The N numbers are values at the end of TP2

^Efficacy outcomes (%) in TP1 calculated in patients with evaluable data at Wk 12 (N=83)

#Inactive disease: Definition adapted from JIA ACR criteria of Wallace et al., 2011. N=36 for SEC at the end of TP2

JADAS, Juvenile Arthritis Disease Activity Score; N, total number of patients in the treatment group; NA, data not available

Figure 1.

Time to flare in Treatment Period 2 (Primary Endpoint)

Conclusion:

In children and adolescents with ERA and JPsA, efficacy of SEC was demonstrated with a significantly longer time to flare vs PBO with sustained improvement of signs and symptoms up to Wk 104 and a favourable safety profile.

References:

[1]Colbert RA. Nat Rev Rheumatol. 2010;6:477–85.

[2]Martini A, et al. J Rheumatol. 2019;46:190–7.

[3]McInnes IB, et al. Lancet. 2015;386:1137–46.

[4]Baeten D, et al. N Engl J Med. 2015;373:2534–48.

[5]Deodhar A, et al. Arthritis Rheumatol. 2021;73:110–20.

Disclosure of Interests:

Nicolino Ruperto Consultant of: Ablynx, Astrazeneca-Medimmune, Bayer, Biogen, Boehringer, Bristol Myers and Squibb, Celgene, Eli-Lilly, EMD Serono, Glaxo Smith and Kline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sinergie, Sobi and UCB, Grant/research support from: BMS, Eli-Lilly, GlaxoSmithKline, F Hoffmann-La Roche, Janssen, Novartis, Pfizer, Sobi, Speakers bureau: Ablynx, Astrazeneca-Medimmune, Bayer, Biogen, Boehringer, Bristol Myers and Squibb, Celgene, Eli-Lilly, EMD Serono, Glaxo Smith and Kline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sinergie, Sobi and UCB, Ivan Foeldvari Consultant of: Novartis, Speakers bureau: Novartis, Ekaterina Alexeeva Grant/research support from: Novartis, Pfizer, Sanofi, MSD, AMGEN, Eli Lilly, Roche, Speakers bureau: Novartis, Pfizer, Sanofi, MSD, AMGEN, Eli Lilly, Roche, NURAY AKTAY AYAZ: None declared, Inmaculada Calvo Consultant of: Sobi, Novartis, Abbvie, GlaxoSmithKline, Pfizer, Amgen, Clementia, Speakers bureau: Sobi, Novartis, Abbvie, GlaxoSmithKline, Pfizer, Amgen, Clementia, Ozgur KASAPCOPUR: None declared, Vyacheslav Chasnyk: None declared, Markus Hufnagel Grant/research support from: Astellas, F. Hoffmann-La Roche, Novartis, Zbigniew Żuber: None declared, Grant Schulert Consultant of: Sobi, Novartis, Seza Ozen: None declared, Artem Popov: None declared, Athimalaipet Ramanan Speakers bureau: Roche, Sobi, Eli Lilly, UCB, Novartis, Christiaan Scott: None declared, Betül Sözeri: None declared, Elena Zholobova Grant/research support from: Pfizer, Novartis, Speakers bureau: Abbvie, Pfizer, Roche, Novartis, Xuan Zhu Employee of: Novartis, sarah whelan Employee of: Novartis, Shareholder of: Novartis, Luminita Pricop Employee of: Novartis, Shareholder of: Novartis, Angelo Ravelli Consultant of: Abbvie, Bristol-Myers Squibb, Pfizer, Hoffmann-LaRoche, Novartis, Centocor, Angelini Holding, Reckitt Benckiser, Speakers bureau: Abbvie, Bristol-Myers Squibb, Pfizer, Hoffmann-LaRoche, Novartis, Centocor, Angelini Holding, Reckitt Benckiser, Alberto Martini Consultant of: Eli Lilly, EMD Serono, Janssen, Novartis, Pfizer, Abbvie, Speakers bureau: Eli Lilly, EMD Serono, Janssen, Novartis, Pfizer, Abbvie, Daniel J Lovell Consultant of: AstraZeneca, Wyeth, Amgen, Abbott, Pfizer, Hoffmann-La Roche, Novartis, UBC, Takeda, Janssen, GlaxoSmithKline, Boehringer Ingelheim, Celgene, Bristol Myers Squibb, AbbVie, Forest Research, Speakers bureau: AstraZeneca, Wyeth, Amgen, Abbott, Pfizer, Hoffmann-La Roche, Novartis, UBC, Takeda, Janssen, GlaxoSmithKline, Boehringer Ingelheim, Celgene, Bristol Myers Squibb, AbbVie, Forest Research, Hermine Brunner Consultant of: Aurina, AbbVie, Astra Zeneca-Medimmune, Biogen, Boehringer, Bristol-Myers Squibb, Celgene, Eli Lilly, EMD Serono, GlaxoSmithKline, F. Hoffmann-La Roche, Merck, Novartis, R-Pharm, Sanofi, Pfizer, Grant/research support from: Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, F. Hoffmann-La Roche, Janssen, Novartis, and Pfizer, Speakers bureau: Pfizer, Roche and GlaxoSmithKline

OP0161 PREDICTIVE VALUE OF MUSCULOSKELETAL ULTRASOUND IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS IN CLINICAL REMISSION

Background:

The accurate assessment of remission status in JIA patients is of utmost relevance to taper medications and prevent side effects from their long-term administration. In RA patients in clinical remission (CR), musculoskeletal ultrasound (MSUS) allows to detect persistent joint inflammation (subclinical synovitis), which predicts disease flare and structural damage progression. Although subclinical synovitis has been reported in a substantial proportion of JIA patients with inactive disease, its prognostic value is still being defined.

Objectives:

1) to investigate the prevalence of MSUS-detected subclinical synovitis in JIA patients in CR; 2) to establish which and how many joints should be scanned to reliably assess remission; 3) to evaluate the persistence of subclinical synovitis over the time; 4) to investigate whether subclinical synovitis entails a risk of disease flare and whether it should affect the therapeutic strategy.

Methods:

135 consecutive JIA patients who met the Wallace criteria for CR were included in this 3-years prospective study. All patients underwent MSUS assessment of 56 joints at study entry and at 6 months follow-up visit. Joints were scanned for synovial hyperplasia, joint effusion and Power Doppler (PD) signal by two independent ultrasonographers. Patients were followed clinically for 3 years. A flare of synovitis was defined as a recurrence of clinically active arthritis. The association between clinical and MSUS variables with flare, was evaluated by adjusted logistic regression models.

Results:

135 patients (78.5% F; median age 11.3 y; median disease duration 5.7 y; median CR duration 1.4 y) were included. Fifty-seven/135 (42.2%) patients had persistent oligoarthiritis; 41/135 (30.4%) extended oligoarthiritis; 32/135 (23.7%) polyarthiritis; 5/135 (3.7%) systemic arthritis. Seventy-eight/135 (57.7%) patients were in CR on medication. Subclinical synovitis was detected in 32/135 (23.7%) patients and in 53/7560 (0.7%) joints. Subclinical tenosynovitis was present in 20/135 (14.8%) patients. Subclinical synovitis was found more frequently in the ankle and wrist joints. 58.6% of patients showed persistent subclinical synovitis at 6 month follow up MSUS examination. During the 3-year follow up 45/135 (33.3%) patients experienced a disease flare (median survival time 2.2 y). PD positivity in tendons was the stronger independent risk factor of flare on multivariable regression analysis (HR: 4.8; P=0.04). Other predictors of flare were the JIA subtype (oligo-extended form: HR: 2.3; P=0.031) and the status of CR on medication (HR: 3.7; P=0.002).

Conclusion:

our results confirm that MSUS is more sensitive than clinical evaluation in the assessment of persistent synovial inflammation in JIA patients. Subclinical tenosynovitis was the best predictor of disease flare. To date, the role of tenosynovitis in the diagnosis and prognosis of JIA has been poorly investigated. Our results further support the role of MSUS, especially of the wrist and the ankle, in monitoring JIA patients in clinical remission and to predict disease flare.

References:

[1]De Lucia O, et al. Baseline ultrasound examination as possible predictor of relapse in patients affected by juvenile idiopathic arthritis (JIA). Ann Rheum Dis. 2018 Oct;77(10):1426-1431.

[2]Filippou G, et al. The predictive role of ultrasound-detected tenosynovitis and joint synovitis for flare in patients with rheumatoid arthritis in stable remission. Results of an Italian multicentre study of the Italian Society for Rheumatology Group for Ultrasound: the STARTER study. Ann Rheum Dis 2018;77:1283-9.

Disclosure of Interests:

None declared

POS0071 IS ANTI-NXP2 AUTOANTIBODY A RISK FACTOR FOR CALCINOSIS AND POOR OUTCOME IN JUVENILE DERMATOMYOSITIS PATIENTS?

Background:

It has been published that the presence of NXP2 autoantibodies presents a risk for calcinosis in patients with JDM.

Objectives:

To investigate the incidence of calcinosis and response to the treatment in NXP2 positive JDM patients with calcinosis.

Methods:

The study design is a retrospective, multinational, multicenter study. Data on gender, race, age at disease onset and age at disease diagnosis, age at inclusion in the study, clinical presentation, muscle function tests, laboratory results, imaging, data on treatment and outcome of disease were collected

Results:

we collected 26 patients (19 F, 7 M) with JDM and positive NXP2 antibodies. Fourteen patients were white, eight asian, three black and one Hispanic ethnicity. The mean age at disease presentation was 6.5 years (SD 3.7), the median diagnosis delay was 4 months (range 0.5- 27 months). Patients were divided in two groups (A and B) based on the presence of calcinosis.

Eleven patients (42%) developed calcinosis (group A) in the course of the disease, 10 females and 1 male. Four patients already had calcinosis at presentation, 1 developed after 4 months, and 6 developed calcinosis later in disease course (median 2 years, range 0,8- 7,8). Four patients developed lipodystrophy in group A (1 in group B). In group A, 3 patients developed skin ulcerations (1 in group B), 2 patients had polyarthritis (1 in group B), 2 patients had gut involvement (1 in group B) and 1 patient had lung involvement (2 in group B).

The mean age at disease presentation (5.2 / 7.5 y) and mean CK level (1548.6 / 1811.6 U/L) were lower in group A. The platelet count (306.5 / 258 109/L), and mean values of AST (111.4 / 103.8 U/L), ALT (72.2 / 50.8 U/L), LDH (1048.3 / 808 IU/L), and IgG (11.8 / 9.9 g/L) were higher in group A. However, the differences were not statistically significant. ANA antibodies were positive in 9/11 in group A and 12/15 in group B. One patient in group A was also positive for anti-MDA5 antibody. The data on muscle strength measurement (MMT/CMAS) were available only in a few patients.

Treatments used for patients with calcinosis includes, methotrexate and glucocorticosteroids (GCS) (all patients), hydroxychloroquine (9), IVIG (7), cyclosporine (4), bisphosphonate (4), MMF (5), rituximab (4), cyclophosphamide (1), abatacept (1) and TNF alpha blocker (1).

Disease outcome (by evaluation of the treating physician) was excellent in 4, good in 2, stable in 2 and poor in 3 patients. None of the patients from group B had a poor disease outcome. Patients with excellent disease outcomes from group A were treated with GCS and methotrexate (4), hydroxychloroquine (3), IVIG (1) and cyclosporine (1). Out of two patients who had good outcomes, one was additionally treated with MMF, bisphosphonates and rituximab and the second was treated with cyclophosphamide and rituximab. One patient with calcinosis at the presentation (age 4 years) was treated also with anti-TNF alpha therapy which not only stopped progression but partially dissolved the calcinosis. However, after 2 years of anti-TNF alpha therapy the calcinosis start to progress and the therapy was changed to MMF and rituximab, which stopped the progression of calcinosis.

Conclusion:

Our preliminary results showed that calcinosis occurred in 42% of NXP2 positive JDM patients. Children with calcinosis were treated with several combinations of drugs. In four cases, rituximab and in one case, for limited time of 2 years, anti-TNF alpha agent, were used successfully.

References:

[1]Chung MP, Richardson C, Kirakossian D, Orandi AB, Saketkoo LA, et al. Calcinosis biomarkers in adult and juvenile dermatomyositis. Autoimmun Rev 2020; 19(6):102533.

Disclosure of Interests:

Natasa Toplak: None declared, Pallavi Pimpale Chavan: None declared, Silvia Rosina: None declared, Tomas Dallos Consultant of: Abbvie, Novartis, Rotem Semo Oz: None declared, Cassyanne Aguiar: None declared, Raju Khubchandani: None declared, Angelo Ravelli: None declared, Anjali Patwardhan: None declared.

THU0498 PATIENT-REPORTED TREATMENT BURDEN AND ITS IMPACT ON QUALITY OF LIFE IN JUVENILE IDIOPATHIC ARTHRITIS: RESULTS FROM THE PHARMACHILD REGISTRY

Background:

Juvenile Idiopathic Arthritis (JIA) patients experience impaired health and wellbeing due to multiple causes of physical and psychosocial distress, including treatment burden. Despite emerging evidence of its relevance [1], the contribution of treatment adverse events to patient-reported outcomes (PROs) in JIA has been poorly explored.

Objectives:

To evaluate and rank the impact of patient-reported adverse events (AEs) on overall wellbeing, health-related quality of life (HRQoL), school problems and self-reported medication adherence using data from Pharmachild, a large international JIA pharmacovigilance registry.

Methods:

Registry entries on 5340 prospective visits of 2251 patients enrolled till December 2018 were analyzed; all included patients were treated with at least one DMARDS or Biologic agent at the time of visit. In the Juvenile Arthritis Multidimensional Assessment Report (JAMAR), patients and parents compiled a checklist of treatments, side effects, self-reported adherence, administration difficulties and disease-related school problems occurred in the previous 4 weeks. Evaluated outcomes included patient acceptable symptom state (PASS), VAS-measured patient assessment of overall wellbeing (PGA) and HRQoL, assessed through the physical health (PhH) and psychosocial health (PsH) subscales. The relationships between AEs and PROs were tested through generalized linear models, accounting for disease activity and symptoms levels. Bayesian Networks were used to explore the causal effects of specific AEs on outcomes to disentangle the confounding role of disease status.

Results:

AEs were reported in 22.9% of visits. For similar levels of physician global assessment (MD global), patient-assessed disease activity, pain and function, patients reporting AEs had worse PGA, PsH, and lower probability of reaching PASS (fig. 1, all p-values <0.001). The impact of AEs on PGA was small but not trivial (effect size η20.031) and appears to be mediated by effects on PsH and school problems (p <0.001). Non-linear regression modelling revealed a significant moderating effect of MD global levels < 2.5 on the relationship between AEs and PGA (p 0.003), indicating that the impact of AEs is higher for lower disease activity states. AEs predicted self-reported medication adherence (p<0.001), even when adjusted for the number of administered treatments. In the Bayesian network model, mood swing and sleep problems emerged as the most influential items affecting PsH, (respectively, total effect 2.62 and 1.25, both p< 0.001). Fig. 2 shows the total standardized effect of specific AEs on mean PsH levels. Nausea had the highest impact on treatment adherence (total effect -0.0541, p <0.001), being the only AE directly linked to drug refusal.

Conclusion:

AEs have a measurable effect on the wellbeing and psychosocial health of JIA patients, particularly when disease activity is low, and significantly affect school activity and medication adherence. Mood swings and sleep problems show the strongest influence on HRQoL. Addressing AEs appears important to reduce disease impact, improve patients’ satisfaction and therapeutic compliance.

References: :

[1]Weitzman, Elissa R., et al. Journal of patient-reported outcomes 2.1 (2018): 1.

Acknowledgments:

for the Paediatric Rheumatology International Trials Organisation (PRINTO)

Disclosure of Interests: :

Alessandra Alongi: None declared, Alessandro Consolaro Grant/research support from: Pfizer Inc., AlfaSigma, Speakers bureau: AbbVie, Gordana Vijatov-Djuric: None declared, Giovanni Filocamo: None declared, Olga Vougiouka: None declared, Alma Nunzia Olivieri: None declared, Cristina Herrera Mora: None declared, Wolfgang Emminger: None declared, Angelo Ravelli: None declared, Nicolino Ruperto Grant/research support from: Bristol-Myers Squibb, Eli Lily, F Hoffmann-La Roche, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sobi (paid to institution), Consultant of: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda, Speakers bureau: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda

THU0298 SWITCH OR SWAP STRATEGY IN TAKAYASU ARTERITIS PATIENTS FAILING TNFA INHIBITORS?

Background:

biologic drugs (bDMARD), especially anti-TNFα (TNFi), are used in refractory TA patients. Up to 60% of patients are eventually switched to a different bDMARD because of inefficacy. No data are available on which strategy (switch or swap) is more efficient in this setting.

Objectives:

to evaluate whether switch or swap strategy can be more effective in TA patients failing TNFis.

Methods:

TA patients treated with bDMARDs after TNFi failure were identified from 3 referral centres. Patients were classified as “switch” if treated with a different TNFi (infliximab, IFX, etanercept, ETN, golimumab, GOL, adalimumab, ADA) or “swap” if treated with a non-TNFi bDMARD (tocilizumab, TCZ, ustekinumab, USK). Baseline features and disease outcome (number of patients with NIH score <2, steroid dose reduction (SDR), disease relapses and vascular interventions) at month 6 and month 12 after 2ndbDMARD introduction were analyzed. Non parametric tests were used.

Results:

24 TA patients were identified. TNFi (IFX= 13; ADA= 8; ETN= 1; GOL= 2) was withheld after a median of 19 (8.5; 38) months (in 9 patients <12 months) for inefficacy in 19 (79%) patients and side effects in 5 (21%) patients. 11 (46%) patients were switched and 13 (54%) patients were swapped (12 to TCZ, 1 to USK). Baseline features at 2ndbDMARD start are summarized in Table 1. 2ndbDMARD retention at month 6 was comparable between switch (8, 73%) and swap (10, 77%) patients, p=1. Reasons for discontinuation were: inefficacy in 5 patients, allergic reaction in 1 switch patient. 5 (45%) switch and 6 (46%) swap patients had a NIH<2 (p=1). Median SDR was similar: 3.75(0-19.69) in swap and 4.37(1.87-10) mg daily in switch, p=0.829. Also at month 12, 2ndbDMARD retention was comparable: 7 (64%) switch vs 7 (54%) swap, p=0.210. Discontinuation reason was inefficacy in all cases. 6 (54%) switch and 4 (30%) swap patients had a NIH<2 (p=0.222). Median SDR from baseline was 3.75(0.62-7.5) in switch and 1.25 (0-6.25) in swap,p=0.620. 12 patients experienced a relapse within the first year: 10 (77%) swap and 2 (18%) switch patients, p=0.074. 3 patients underwent vascular interventions within the first year: 2 (18%) switch and 1 (8%) swap patient, p=0.576.

Table 1.

Disease features of switch and swap TA patients at 2nd bDMARD start.

Switch (11 patients)Swap (13 patients)p valueAge (years)39 (31-54)37 (32-46)0.613Sex (female,%)821000.199Numano -I21 -IIa22 -IIb11 -III11 -IV02 -V56Disease duration (years)4 (2 -6)3 (2 – 8)0.743Previous csDMARD (%)911000.458TNFi duration (months)25 (9 – 27)16 (9 – 44)0.813Steroid dose (mg daily)15 (8.75 – 22.5)15 (10 – 25)0.726Current csDMARD, n(%)10 (91)9 (70)0.327 - Methotrexate66 - Azathioprine12 - Sirolimus10 - Salazopyrin01 - Cyclophosphamide10 - Mycofenolate10NIH ≥2 (%)73610.679CRP (mg/L)34 (14 – 73)24 (10 – 45)0.604ESR (mm/1h)43 (35 – 56)51 (35 – 68)0.729

Conclusion:

our retrospective study suggests that in first-line TNFi failure TA patients both switch and swap strategies are seemingly effective.

Disclosure of Interests:

Corrado Campochiaro Speakers bureau: Novartis, Pfizer, Roche, GSK, SOBI, Elena Galli: None declared, Emanuele Cocchiara: None declared, Alessandro Tomelleri: None declared, Silvia Sartorelli: None declared, Francesco Muratore: None declared, Maria Grazia Catanoso: None declared, Elena Baldissera Speakers bureau: Novartis, Pfizer, Roche, Alpha Sigma, Sanofi, Angelo Ravelli: None declared, Carlo Salvarani: None declared, Lorenzo Dagna Grant/research support from: Abbvie, BMS, Celgene, Janssen, MSD, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, SG, SOBI, Consultant of: Abbvie, Amgen, Biogen, BMS, Celltrion, Novartis, Pfizer, Roche, SG, and SOBI

SAT0489 CLINICAL COURSE AND THERAPY RESPONSE IN TAKAYASU ARTERITIS: COMPARISION BETWEEN CHILDHOOD AND ADULT ONSET

Background:

Takayasu arteritis (TA) is a granulomatous vasculitis of the large vessels of unknown origin, which mainly affects the aorta and its main branches.

TA is a disease of the young age with onset usually before 40 years and in more than 20% of patients the diagnosis is made before 19 years.

Very few clinical series have compared the clinical manifestations, treatment and outcomes between pediatric and adult patients.

Objectives:

Objective of our study was to compare childhood and adult onset TA evaluating clinical manifestations, treatment (including biotechnological agents) and outcomes.

Methods:

All consecutive patients with childhood-onset TA (onset <18 years) and adult-onset (onset ≥ 18 years) TA followed from 2002 to 2019 in two Italian centers (Genoa Gaslini Hospital and Santa Maria Nuova Hospital of Reggio Emilia) were retrospectively evaluated and compared.

All patients met TA classification criteria (ACR 1990 and EULAR/Printo/PrES 2010 for children).

Clinical, demographic, laboratory, radiological, therapeutic data were collected retrospectively at baseline, at 6-month follow-up and at the last follow-up.

Disease activity at each follow-up visit was evaluated according to NIH criteria.

Results:

58 patients were consecutively enrolled: 18 children (C) and 40 adults (A).

In both groups there was a higher prevalence of females (83.3% C vs 77.5% A; p NS).

The diagnostic delay was lower in the pediatric group (median of 5 months VS 10 months in A; p NS).

Fever and headache as presenting manifestations affected more frequently children with statistically significant differences (55,6% C vs 17,5% A, p 0,003; 27,8% C vs 5% A, p 0,025)

Adults had a higher frequency of claudication of the upper limbs and carotid/subclavian bruits (30% and 55% A vs 5,6% and 38,9% C respectively; p NS), while the discrepancy in blood pressure of the four limbs was higher in children (22,2% C vs 12,5% A; p NS).

Hypertension was not significantly different between the two groups at baseline and during the follow-up.

We found a significantly more frequent inflammatory involvement of the aorta (arch, thoracic, or abdominal) in children (72,2% C vs 30% A, p 0.003).

The subclavian arteries were most affected in the adults (65% A vs 38,9% C; p NS), although the difference was not statistically significant.

Treatment regimen were different between the groups: glucocorticoid monotherapy was more frequently used in adults (45% A vs 27,8% C; p NS), glucocorticoids in combination with Cyclophosphamide or anti-TNF were more significantly used to induce remission at the beginning in the pediatric group (22% C vs 0 A, p 0,007 and 22% C vs 2,5% A, p 0,029).

At the last follow-up the disease was significantly more active in children according to NIH criteria (55.6% C vs 27.5% A, p 0,04).

Conclusion:

We reported some differences between children and adults. TA in children was characterized by a shorter diagnostic delay, a more frequent inflammatory involvement of the aorta and a more refractory disease. Patients with pediatric TA were treated more aggressively at the beginning.

Disclosure of Interests:

None declared

AB0972 DEVELOPMENT OF THE PARENT VERSION OF THE JUVENILE ARTHRITIS DISEASE ACTIVITY SCORE CUT-OFFS FOR MODERATE AND HIGH DISEASE ACTIVITY STATES IN JUVENILE IDIOPATHIC ARTHRITIS IN A LARGE MULTINATIONAL PATIENT SAMPLE

Background:

Measurement of disease activity level is of pivotal importance in the care of patients with juvenile idiopathic arthritis (JIA). According to the most recent requirements, both, parent’s and children’s perception should be taken into account while evaluating the disease course and assessing effectiveness of therapy. Therefore, a new disease activity evaluation tool, based only on parent assessment of the outcome, is under development and named Parent Juvenile Arthritis Disease Activity Score (parJADAS) [1].

Objectives:

The aim of this study is to develop the parJADAS cut-off values of moderate disease activity (MDA) and high disease activity (HDA) in JIA patients.

Methods:

The parJADAS (score range 0-40) is the sum of 4 values: 1) parent’s assessment of disease activity on a 21-numbered circle 0-10 VAS; 2) assessment of pain intensity on a 21-numbered circle 0-10 VAS; 3) proxy assessment of joint disease up to a maximum of 10 joints; 4) assessment of morning stiffness (MS) on a Likert scale, ranging from no MS (0 points) to > 2 hours of MS (10 points). The study dataset is composed of 2,412 patients with JIA, seen in 3389 visits with parJADAS available, enrolled in the the multinational registry PharmaChild, assessing the long-term safety of treatment of children with JIA. At each visit, subjects were subjectively rated as being in inactive disease, low disease activity, MDA, or HDA by the attending physician. For each patient, only one visit per disease state was retained.

To identify the cut-offs the following methods were implemented: 1) Mapping: the 25thpercentile value of the parJADAS in patients having MDA or HDA, respectively, was calculated; 2) Youden Index: Youden Index (J) identifies the maximum potential effectiveness of the biomarker through the receiver operating characteristic (ROC) curve analysis; 3) Max agreement: The analysis of agreement was based on kappa statistics, which assesses the agreement beyond chance between 2 dichotomous ratings. The first rating was obtained using all possible parJADAS values as hypothetical test criteria; to obtain the second rating, the categorical ratings of each attending physician were dichotomized and were coded as 0 or 1.

Results:

Preliminary cut-off values for parJADAS with sensitivity and specificity are presented in the table.

25th centileYouden IndexKappaMeanSensitivitySpecificityAUCMDA659773.482.00.853HDA14.81118.51571.287.60.892

Conclusion:

Tentative cut-off values for classifying the states of MDA and HAD using parJADAS were calculated. The obtained values will be tested in the validation analysis. Once validated the cut-offs are ideally suited to identify subjects at risk of disease flare when remotely monitored with the parJADAS.

References:

[1]Ridella F., et al. Ann Rheum Dis, volume 78, supplement 2, year 2019, page A1434.

Acknowledgments:

We wish to thank all researchers and patients participating in the PharmaChild registry

Disclosure of Interests:

Ilia Avrusin: None declared, Roberta Naddei: None declared, Francesca Ridella: None declared, Giedre Januskeviciute: None declared, Mikhail Kostik: None declared, Ben Whitehead: None declared, Romina Gallizzi: None declared, Elzbieta Smolewska: None declared, Serena Pastore: None declared, Philip Hashkes: None declared, Joost F. Swart: None declared, Nicolino Ruperto Grant/research support from: Bristol-Myers Squibb, Eli Lily, F Hoffmann-La Roche, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sobi (paid to institution), Consultant of: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda, Speakers bureau: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda, Angelo Ravelli: None declared, Alessandro Consolaro Grant/research support from: Pfizer Inc., AlfaSigma, Speakers bureau: AbbVie

AB0992 CONNECTING SLEEP QUALITY, PAIN AND MOOD DISTURBANCES IN JUVENILE FIBROMYALGIA

Background:

Subjective sleep problems, including difficulties falling asleep, waking up, un-restorative sleep and daytime sleepiness are highly prevalent in patients with juvenile fibromyalgia (JFM). Sleep disturbances has been considered a consequence of severe pain and depression, but also in healthy individuals sleep deprivation is also a risk factor for the development of chronic widespread pain, tenderness and fatigue, suggesting the important role of sleep in pain control and in the pathophysiology of fibromyalgia.

Objectives:

To estimate the incidence of polysomnographic alterations in JFM and to explore the relationship between sleep problems and the musculoskeletal pain, fatigue and mood and anxiety disorders.

Methods:

21 patients (M 3; F 18; mean age 16,1) with JFM were included. The objective sleep quality was measured by overnight polysomnography (PSG) (using the EMBLETTA MPR PG device). PSG data were compared to age and sex-matched controls. The subjective sleep disturbances were assessed by the Sleep Condition Indicator (SCI). Musculoskeletal symptoms were evaluated by using the widespread pain index (WPI). Pain intensity was evaluated on a 0-10 visual analogical scale (PVAS). Fatigue was assessed by using the Symptom Severity (SS) questionnaire. Mood and anxiety disorders were evaluated by using the Children Depression Index (CDI) and the Multidimensional Anxiety Scale for Children (MASC). Comparison of categorical data was performed by means of the Fisher’s Exact test. The relationship between sleep quality and clinical symptoms were assessed using Spearman’s rank order correlation coefficient (rs). All statistical test were 2-sided and p values less than 0.05 were considered statistically significant.

Results:

Nineteen out of 21 (90.5%) patients complained subjective sleep disturbances and un-restorative sleep. Seven out of 21 (33.3%) patients had mood and anxiety disorders. Eight out of 21 patients (38.1%) showed an electroencephalographic pattern of alpha wave intrusion in slow wave sleep (SWS). SCI was significantly correlated to CDI score rs -0,775 (p≤0,0001), MASC 0,61 (p=0,005), WPI -0,731 (p=0,001), SSI 0,492 (p=0,038), PVAS -0,590 (p=0,006).

Conclusion:

A substantial percentage of JFM patients experience sleep disturbances, which are, correlated with the severity of the muscolskeletal sympotms and mood and anxiety disorders. One third of JFM patients have alpha intrusion in the SWS. The important role of sleep in pain control suggests that the development of treatments to improve sleep quality may lead to more effective management of fibromyalgia in the future.

References:

[1]Ting TV et. al 2010 American College of Rheumatology Adult Fibromyalgia Criteria for Use in an Adolescent Female Population with Juvenile Fibromyalgia. J Pediatr. 2016 Feb;169:181-7.

[2]Choy EH. The role of sleep in pain and fibromyalgia. Nat Rev Rheumatol. 2015;11:513-20.

[3]Roizenblatt S et al. Alpha sleep characteristics in fibromyalgia. Arthritis Rheum. 2001;44, 222–230.

Disclosure of Interests:

None declared

THU0501 EARLY DIAGNOSIS OF THE AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME (ALPS) IN PATIENTS WITH UNDEFINED AUTOINFLAMMATORY OR AUTOIMMUNE DISORDERS: THE PRACTICAL ROLE OF A FLOW CYTOMETRY PANEL

Background:

ALPS is a rare disorder due to a defective apoptotic mechanism leading to abnormal lymphoproliferation and autoimmunity. The disease is difficult to identify in the early phase when it may be misdiagnosed. Elevated TCR alpha-beta CD4-CD8- lymphocytes (double negative T lymphocytes DNT) together with hyperIgG, high levels of IL10, Il18, vitamin B12 and soluble Fas ligand have been suggested as the main ALPS hallmarks (1). Therefore, a specific flow cytometry panel (DNT cells, ratio of CD25+CD3+ to HLA−DR+CD3+ cells, increased B220+ T-cells, and decreased CD27+ memory B cells) has been proposed to serve as a diagnostic screen for ALPS (2).

Objectives:

To evaluate the usefulness of a specific lymphocyte flow cytometry panel in the early identification of ALPS/ALPS-like disorders in a cohort of patients with undefined autoinflammatory or autoimmune disorders.

Methods:

The clinical data of patients referred to the pediatric Rheumatology Unit of the Istituto Giannina Gaslini Hospital for a suspicion of autoimmune or autoinflammatory condition from October 2015 to April 2018, were retrospectively analyzed. Data on clinical manifestations, laboratory workup, genetic analysis and treatment were collected. Flow cytometry was included among the screening panel: DNT, CD25+CD3+, HLA−DR+CD3+ cells, B220+ T-cells, and CD27+ memory B cells were included. A statistical analysis was performed: data were analyzed with an univariate logistic regression analysis, to identify the most significant variables associated with ALPS. These variables were then included in a multivariate analysis to select a set of clinical and laboratory parameters, each of them associated with a significant probability to be associated with ALPS independently from other variables.

Results:

475 patients were retrospectively analized. 211 patients not fulfilling the inclusion criteria were excluded. The patients were classified as follows: i) Autoimmune disease 26 pts (10 SLE; 3 MCTD; 6 jDM; 5 Behçet; 1 SjS; 1 Kawasaki) ii) Juvenile Idiopathic Arthritis 35 pts iii) Monogenic systemic autoinflammatory disease (MSAID) 27 pts (17 FMF; 3 MKD; 1 TRAPS; 4 DADA2; 2 SAVI) iv) PFAPA 100 pts v) Systemic Undefined Recurrent Fever 45 pts vi) Undetermined-SAID 15 pts vii) ALPS/ ALPS probable 16 pts. The flow cytometry panel showed, as expected, an elevation of DNT in all ALPS patients. Among the other parameters, CD3CD25+/CD3HLADR+, and B220+ T cells, were significatively altered in 75% of ALPS patients. Conversely, B CD27+ did not differentiate ALPS from the other subgroups. The multivariate analysis revealed 5 clinical/laboratory parameters that showed the higher independent association to ALPS in the cohort of patients. Splenomegaly, female gender, elevated DNT, arthralgia and elevated alfabeta+B220+ lymphocytes were positively and significantly associated to ALPS.

Conclusion:

The use of the specific flow cytometry panel, comprehensive of DNT, B220+, HLA-DR and CD25, in patients with undefined autoinflammatory or autoimmune disorders may identify a subgroup of patients with ALPS.

References:

[1]Joao B. Oliveira et al. Blood 2010; 116 (14): e35–e40.

[2]Lenardo MJ et al.Immunity. 2010;32(3):291–295.

Disclosure of Interests:

Caterina Matucci Cerinic: None declared, Leonardo Oliveira Mendonca: None declared, maurizio miano: None declared, paola terrnaova: None declared, federica casabona: None declared, Marta Bustaffa: None declared, Francesca Bovis: None declared, Roberta Caorsi: None declared, Stefano Volpi: None declared, Angelo Ravelli: None declared, Carlo Dufour: None declared, Marco Gattorno Consultant of: Sobi, Novartis, Speakers bureau: Sobi, Novartis

OP0293 USE OF WHOLE-BODY MAGNETIC RESONANCE TO IDENTIFY POTENTIAL DIAGNOSTIC CLUES IN CHILDREN WITH FEVER OF UNKNOWN ORIGIN (FUO)

Background:

Whole-body magnetic resonance imaging (WBMRI) is a fast and accurate method to detect diseases throughout the entire body without exposure to ionizing radiation. Possible emerging applications for this technique include rheumatologic field and evaluation of fever of unknown origin (FUO).

Objectives:

To evaluate the ability of WBMRI to identify significant potential diagnostic clue (PDC) in patients presenting a non specific inflammatory clinical picture.

Methods:

We retrospectively collected cases of pediatric patients followed in a single pediatric rheumatology center who underwent WBMRI between January 2010 and December 2015 for the following indications: i) FUO (temperature greater than 38.3°C for more than three weeks or failure to reach diagnosis after one week of investigations), iii) recurrent fever (febrile episodes separated by periods of normal temperature), iii) Inflammation of unknown origin, IUO (an illness of at least 3 weeks’ duration, with raised inflammatory markers and fever below 38.3°C).WBMRI studies were acquired with coronal and sagittal planes (slice thickness 5mm) with acquisition of several image sets with automatic direct image realignment after acquisition creating a whole-body scan.Sequences include short τ inversion recovery (STIR) and T1-weighted. All studies have been evaluated twice, the second time according to a predefined checklist, defined by an experienced radiologist, considering systematically single /multifocal bone lesion, bone marrow, joint effusion, soft tissues, adenopathies, parenchymal and vessels looking for PDC. We considered as a Potential Diagnostic Clue each alteration of the examined district that can potentially guide the diagnosis. Each alteration found is a PDC. We retrospectively evaluated patients’ clinical history and final diagnosis and we classified the PDCs identified during both first evaluation and re-evaluation as: Not useful (the identified PDC did not guide the diagnosis and is not coherent with the final diagnosis), consistent (the identified PDC is congruent with the patient’s final diagnosis) or diagnostic (the identification of the considered PDC strongly orient the final diagnosis).

Results:

We collected 104 patients who underwent WBMRI; 24 (23%) of them presenting FUO, 28 (27%) presenting recurrent fever and 52 (50%) presenting IUO. The mean age of onset symptoms was 6 years and nine months (range: 2 weeks old- 17 years and 6 months). The mean age of execution of WBMRI was 9 years (range: 5 months old- 19 years). After the whole diagnostic work-out a final diagnosis was achieved in 44 patients (42%).PDCs were identified at the first evaluation in 78/104 cases (75%). In 22 cases (21%) the identified PDCs were consistent with the diagnosis, whereas in 9 cases (8.5%) the identified PDCs were considered diagnostic. Globally we can consider that at first evaluation PDCs were somehow contributory to the diagnosis in 31 cases (30%; 6 JIA, 7 systemic infections, 5 monogenic inflammatory diseases, 4 ALPS, 2 Goldbloom’s Syndrome,2 Vasculitis,1 eosinophilic fasciitis, 1 hystiocytosis, 3 oncologic diagnosis).Blind re-evaluation of WBMRI allowed the identification of additional PDCs in 52 patients (12 of them previously negative). In 10 cases the PDC found after re- evaluation were consistent with the final diagnosis (2 JIA, one infectious disease, one neuroblastoma, 3 ALPS, 1 monogenic inflammatory disease, 1Takayasu arteritis, 1 Goldbloom’s syndrome).

Conclusion:

WBMRI can be a powerful diagnostic tool in patients with FUO. A predefined checklist increases sensitivity of WBMRI in the identification of PDC.

Disclosure of Interests:

Sara Signa: None declared, Roberta Caorsi: None declared, Giorgio Stagnaro: None declared, Francesca Minoia: None declared, Paolo Picco: None declared, Angelo Ravelli: None declared, Maria Beatrice Damasio: None declared, Marco Gattorno Consultant of: Sobi, Novartis, Speakers bureau: Sobi, Novartis

Prenatal MRI of neck masses with special focus on the evaluation of foetal airway

BACKGROUND

Prenatal magnetic resonance imaging is the best tool to visualize foetal airway.

OBJECTIVE

To evaluate the performance of MRI in the assessment of foetal airway status in the presence of a neck mass.

MATERIALS AND METHODS

Two paediatric radiologists with 12- and 2-year experience in foetal imaging retrospectively analysed 23 foetal MRI examinations, performed between 2001 and 2016, after a second-level ultrasound suspicious for presence of a neck mass. Postnatal imaging, postoperative report, histology, autopsy, and clinical outcomes were the reference standard to calculate sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of prenatal MRI in detecting airway patency. We used the Cohen к statistics to estimate the interobserver agreement. We also assessed MRI performance in the diagnosis of the mass nature.

RESULTS

We obtained data about postnatal airway status in 19 of 23 patients; prenatal MRI demonstrated a sensitivity of 9/9 [100%, 95% confidence interval (CI) 66-100%], specificity 8/10 (80%, 44-98%), accuracy 17/19 (89%, 67-99%), PPV 9/11 (82%, 48-98%), and NPV 8/8 (100%, 63-100%); the interobserver agreement was perfect. Prenatal MRI correctly identified 21 of 23 masses (к = 0.858); the interobserver agreement was almost perfect (к = 0.851).

CONCLUSION

Prenatal MRI demonstrated high accuracy in assessing foetal airway status and diagnosing mass nature, allowing proper delivery planning.

Use of the ultrasound-based total malignancy score in the management of thyroid nodules

Purpose

The purpose of this study was to validate the role of the total malignancy score (TMS) in identifying thyroid nodules suspicious for malignancy through the sum of their ultrasound features.

Methods

The local ethical committee approved this prospective observational study. We examined 231 nodules in 231 consecutive patients (164 females and 67 males; age range, 20 to 87 years; median age, 59 years; interquartile range, 48 to 70 years) who underwent ultrasound followed by fine-needle aspiration cytology (FNAC). The nodules were further classified using the TMS, which considers ultrasound features (number, echogenicity, structure, halo, margins, Doppler signal, calcifications, and growth), and the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), which considers cytological features. Patients with non-negative nodules (TBSRTC categories III to VI) underwent histological analysis, repeated FNAC, or 2 years of regular ultrasound follow-up. The associations between the final diagnosis, each of the ultrasound features, and the TMS were estimated using the chi-square test, the Mann-Whitney U test, and multivariate logistic regression. A receiver operating characteristic (ROC) curve was used to evaluate the diagnostic accuracy of the TMS.

Results

On ultrasound, 47% of the nodules (108 of 231) had a TMS <3, 18% (42 of 231) had a TMS of 3, and 35% (81 of 231) had a TMS >3. The FNAC results of 85% of the nodules (196 of 231) were benign, while 15% (35 of 231) had non-negative results. Hypoechogenicity, solid structure, the presence of microcalcifications, and the number of nodules were independent predictors of the final diagnosis, and the diagnostic accuracy of the TMS was good (area under the ROC curve, 0.82).

Conclusion

The TMS system is simple to use, reliable, easily reproducible, and closely reflects malignancy risk. Based on our results, FNAC could be limited to nodules with a TMS ≥3 without missing any cases of carcinoma.

Plasma endocannabinoid behaviour in total knee and hip arthroplasty

Endocannabinoids are a class of lipid mediators involved in a wide range of physiological pathways including pain perception, and immunological defences. In particular, the involvement of endocannabinoids in bone metabolism and bone resorption has recently been studied. Moreover, one study on total knee arthroplasty describes the probable role of endocannabinoids in pain perception after surgery. The aim of the present study was to evaluate variations of endocannabinoid concentrations in patients undergoing total hip or total knee arthroplasty before and after surgery. Sera from 23 patients were collected at three different times: before surgery and at two different times during rehabilitation, and endocannabinoids were quantified by HPLC-MS/MS analysis. Mean values of endocannabinoids in presurgical serum samples were: 6.11±0.5 ng/ml for N-palmitoylethanolamide, 1.39±0.08ng/ml for N-stearoylethanolamide, 4.84±0.04 ng/ml for N-oleoylethanolamide, 0.44±0.03ng/ml for N-arachidonoylethanolamide, 0.84±0.05ng/ml for N-linoleoylethanolamide, 0.17±0.01ng/ml for N-α-linolenoylethanolamide. Statistical analysis showed a significant decrease of all the endocannabinoids after surgery, while there were no remarkable differences between total hip and total knee arthroplasties or between genders. Moreover, the results show no significant correlation between endocannabinoid concentrations and C-reactive protein and Erythrocyte sedimentation rate. The present study shows for the first time a specific and univocal behaviour of six endocannabinoids and N-acylethanolamides in orthopaedic surgery, suggesting the endocannabinoid system as a possible pharmacological target for presurgical therapeutics.

Relationship between Damage Accrual, Disease Flares and Cumulative Drug Therapies in Juvenile-Onset Systemic Lupus Erythematosus

Our objective was to investigate the pattern of damage accumulation in patients with juvenile-onset systemic lupus erythematosus (JSLE) and the relationship between damage accrual, disease flares and cumulative drug therapies. All patients with SLE followed prospectively in three tertiary care centres were identified. Only patients who presented within 12 months of diagnosis and were followed for at least three years were included. Damage was measures based on chart review using the SLICC/ACR damage index (SDI), which was modified (M-SDI) by adding the item growth failure. Mild-moderate and severe disease flares were defined by the increase in SLEDAI-2K. The cumulative duration of drug therapies was calculated in each patient. Fifty-seven patients were included. The mean M-SDI score for the whole patient group increased over time, from 0.1 at one year to 0.8 at three years to 1.5 at five years. Ocular and renal damage and growth failure were observed most frequently. Compared to patients with stable damage, patients who accrued new damage had a significantly greater frequency of severe disease flare in the first three years of follow-up. No significant difference was observed in any cumulative drug therapy between patients who accrued damage and those who did not. Damage accrual was associated with severe disease flares, suggesting that judicious use of immunosuppressive agents to achieve prompt control of severe exacerbation of disease activity is important in minimizing damage in patients with JSLE.

Review: Macrophage activation syndrome in juvenile systemic lupus erythematosus: an under-recognized complication?

Macrophage activation syndrome (MAS) is a life-threatening complication of rheumatic diseases that is thought to be caused by the activation and uncontrolled proliferation of T lymphocytes and macrophages, leading to widespread haemophagocytosis and cytokine overproduction. It is seen most commonly in systemic juvenile idiopathic arthritis, but is increasingly recognized also in juvenile systemic lupus erythematosus (J-SLE). Recognition of MAS in patients with J-SLE is often challenging because it may mimic the clinical features of the underlying disease or be confused with an infectious complication. This review summarizes the characteristics of patients with J-SLEassociated MAS reported in the literature or seen by the authors and analyses the distinctive clinical, diagnostic and therapeutic issues that the occurrence of MAS may raise in patients with J-SLE. Lupus (2007) 16, 587—592.

Evidence-based diagnosis and treatment of macrophage activation syndrome in systemic juvenile idiopathic arthritis

BACKGROUND

Macrophage activation syndrome (MAS) is a severe and potentially lethal complication of several inflammatory diseases but seems particularly linked to systemic juvenile idiopathic arthritis (sJIA). Standardized diagnostic and treatment guidelines for MAS in sJIA are currently lacking. The aim of this systematic literature review was to evaluate currently available literature on diagnostic criteria for MAS in sJIA and provide an overview of possible biomarkers for diagnosis, disease activity and treatment response and recent advances in treatment.

METHODS

A systematic literature search was performed in MEDLINE, EMBASE and Cochrane. 495 papers were identified. Potentially relevant papers were selected by 3 authors after which full text screening was performed. All selected papers were evaluated by at least two independent experts for validity and level of evidence according to EULAR guidelines.

RESULTS

27 papers were included: 7 on diagnosis, 9 on biomarkers and 11 on treatment. Systematic review of the literature confirmed that there are no validated diagnostic criteria for MAS in sJIA. The preliminary Ravelli criteria, with the addition of ferritin, performed well in a large retrospective case-control study. Recently, an international consortium lead by PRINTO proposed a new set of diagnostic criteria able to distinguish MAS from active sJIA and/or infection with superior performance. Other promising diagnostic biomarkers potentially distinguish MAS complicating sJIA from primary and virus-associated hemophagocytic lymphohistiocytosis. The highest level of evidence for treatment comes from case-series. High dose corticosteroids with or without cyclosporine A were frequently reported as first-line therapy. From the newer treatment modalities, promising responses have been reported with anakinra.

CONCLUSION

MAS in sJIA seems to be diagnosed best by the recently proposed PRINTO criteria, although prospective validation is needed. Novel promising biomarkers for sJIA related MAS are in need of prospective validation as well, and are not widely available yet. Currently, treatment of MAS in sJIA relies more on experience than evidence based medicine. Taking into account the severity of MAS and the scarcity of evidence, early expert consultation is recommended as soon as MAS is suspected.

The EULAR Outcome Measures Library: development and an example from a systematic review for systemic lupus erythematous instruments

OBJECTIVES

Patient reported outcomes (PROs) are relevant in rheumatology. Variable accessibility and validity of commonly used PROs are obstacles to homogeneity in evidence synthesis. The objective of this project was to provide a comprehensive library of "validated PROs".

METHODS

A launch meeting with rheumatologists, PROs methodological experts, and patients, was held to define the library's aims and scope, and basic requirements. To feed the library we performed systematic reviews on selected diseases and domains. Relevant information on PROs was collected using standardised data collection forms based on the COSMIN checklist.

RESULTS

The EULAR Outcomes Measures Library (OML), whose aims are to provide and to advise on PROs on a user-friendly manner albeit based on scientific grounds, has been launched and made accessible to all. PROs currently included cover any domain and, are generic or specifically target to the following diseases: rheumatoid arthritis, osteoarthritis, spondyloarthritis, low back pain, systemic lupus erythematosus, gout, osteoporosis, juvenile idiopathic arthritis, and fibromyalgia. Up to 236 instruments (106 generic and 130 specific) have been identified, evaluated, and included. The systematic review for SLE, which yielded 10 specific instruments, is presented here as an example. The OML website includes, for each PRO, information on the construct being measured and the extent of validation, recommendations for use, and available versions; it also contains a glossary on common validation terms.

CONCLUSIONS

The OML is an in progress library led by rheumatologists, related professionals and patients, that will help to better understand and apply PROs in rheumatic and musculoskeletal diseases.

Vascular Map Combined with CT Colonography for Evaluating Candidates for Laparoscopic Colorectal Surgery

Contrast-enhanced computed tomography colonography (CE-CTC) is a useful guide for the laparoscopic surgeon to avoid incorrectly removing the colonic segment and the failure to diagnose of synchronous colonic and extra-colonic lesions. Lymph node dissection and vessel ligation under a laparoscopic approach can be time-consuming and can damage vessels and organs. Moreover, mesenteric vessels have extreme variations in terms of their courses and numbers. We describe the benefit of using an abdominal vascular map created by CE-CTC in laparoscopic colorectal surgery candidates. We describe patients with different diseases (colorectal cancer, diverticular disease, and inflammatory bowel disease) who underwent CE-CTC just prior to laparoscopic surgery.

Optimisation of disease assessments in juvenile idiopathic arthritis

A variety of clinical measures are available for assessment of disease status of children with juvenile idiopathic arthritis (JIA) in clinical trials, clinical care and long-term outcome surveys. The American College of Rheumatology (ACR) Pediatric 30 remains the preferred primary outcome measure for registrative trials, although in most therapeutic studies performed in the 2000s patients were also evaluated for more stringent levels of improvement, that is, applying the ACR Pediatric 50, 70, 90, and 100 response criteria. Because the recent therapeutic advances have made inactive disease an achievable goal in most patients, it has been suggested that endpoints for future clinical trials incorporate the evaluation of disease activity state, namely the assessment of inactive disease and low disease activity. The introduction of the Juvenile Arthritis Disease Activity Score (JADAS) and the establishment of its cut-offs for various disease activity states may foster the implementation of the treat-to-target strategy in both clinical trials and routine practice. In recent years, there has been an increased focus on the inclusion of patient and child perspectives in health outcome measures through the use of parent/child-reported outcomes. Integration of these measures in the clinical evaluation is considered important as they reflect the parent's and child's perception of the disease course and effectiveness of therapeutic interventions. Future studies will show whether the newer imaging modalities, namely magnetic resonance imaging and ultrasound, can replace conventional radiography for the assessment of structural joint damage and its progression.

Performance of the new SLICC classification criteria in childhood systemic lupus erythematosus: a multicentre study

OBJECTIVES

The Systemic Lupus International Collaborating Clinics (SLICC) group has recently proposed a new set of criteria for the classification of systemic lupus erythematosus (SLE). We aimed to compare the sensitivity and specificity of the new SLICC criteria with those of the American College of Rheumatology (ACR) criteria in our childhood-onset SLE patients.

METHODS

Three main paediatric lupus centres from Europe participated in this study. Of these centres, one was predominantly a paediatric nephrology centre (Great Ormond Street Hospital, London, UK), one was predominantly a paediatric rheumatology centre (Istituto Giannina Gaslini, Genoa, Italy), and one was a combined centre taking care of both group of patients (Hacettepe University, Ankara, Turkey). The features present at disease onset in patients with childhood-onset SLE, younger than 18 years of age, seen between January 2000 and December 2012 were retrospectively reviewed. For the evaluation of specificity, patients admitted to each centre between May and December 2012 for conditions other than SLE, in whom ANA was deemed necessary within the diagnostic work-up were included as controls. PASW 18.0 for Windows was used for statistical analyses.

RESULTS

Both sets of classification criteria were analysed in 154 childhood SLE patients with a mean age at disease onset of 12.7 years and in 123 controls with a mean age of 8.9 years. The sensitivity and specificity of the ACR criteria were 76.6% and 93.4%, respectively, whereas those of the SLICC criteria were 98.7% and 85.3%, respectively. Four patients out of 5 with haemolytic uraemic syndrome (HUS) and 4 patients out of 8 with juvenile dermatomyositis (JDM) met four of the SLICC criteria, whereas 22 lupus nephritis patients failed to meet four of the ACR criteria.

CONCLUSIONS

In our paediatric series, the SLICC criteria showed better sensitivity (p<0.001) and led to fewer misclassifications, but were less specific (p<0.001) than the ACR criteria.