Italian Guidelines for the Management of Sporadic Primary Hyperparathyroidism

AIM

This guideline (GL) is aimed at providing a clinical practice reference for the management of sporadic primary hyperparathyroidism (PHPT) in adults. PHPT management in pregnancy was not considered.

METHODS

This GL has been developed following the methods described in the Manual of the Italian National Guideline System. For each question, the panel appointed by Associazione Medici Endocrinology (AME) and Società Italiana dell'Osteoporosi, del Metabolismo Minerale e delle Malattie dello Scheletro (SIOMMMS) identified potentially relevant outcomes, which were then rated for their impact on therapeutic choices. Only outcomes classified as "critical" and "important" were considered in the systematic review of evidence. Those classified as "critical" were considered for the clinical practice recommendations.

RESULTS

The present GL provides recommendations about the roles of pharmacological and surgical treatment for the clinical management of sporadic PHPT. Parathyroidectomy is recommended in comparison to surveillance or pharmacologic treatment in any adult (outside of pregnancy) or elderly subject diagnosed with sporadic PHPT who is symptomatic or meets any of the following criteria: • Serum calcium levels >1 mg/dL above the upper limit of normal range. • Urinary calcium levels >4 mg/kg/day. • Osteoporosis disclosed by DXA examination and/or any fragility fracture. • Renal function impairment (eGFR <60 mL/min). • Clinic or silent nephrolithiasis. • Age ≤50 years. Monitoring and treatment of any comorbidity or complication of PHPT at bone, kidney, or cardiovascular level are suggested for patients who do not meet the criteria for surgery or are not operated on for any reason. Sixteen indications for good clinical practice are provided in addition to the recommendations.

CONCLUSION

The present GL is directed to endocrinologists and surgeons - working in hospitals, territorial services or private practice - and to general practitioners and patients. The recommendations should also consider the patient's preferences and the available resources and expertise.

The ATTRACT study: screening for the early identification of axial psoriatic arthritis in a cohort of Italian psoriatic patients

OBJECTIVE

There is growing interest in the early identification of patients with axial psoriatic arthritis (axPsA). We aimed to evaluate whether a dermatology-based screening strategy could help to identify axPsA patients.

METHODS

The dermatologist-centered screening (DCS) questionnaire was administrated by Dermatologists to consecutive patients fulfilling the inclusion criteria (1. age ≥ 18 years and 2. clinical diagnosis of psoriasis made by a dermatologist) to identify patients eligible (affirmative answers 1-3c of the DCS) for rheumatological evaluation. Clinical, laboratory, genetic, and imaging data were collected from all referred patients.

RESULTS

Among the 365 patients screened, 265 fulfilled the inclusion criteria and 124/265 (46.8%) were eligible for rheumatological referral. Diagnosis of axPsA, with or without peripheral PsA (pPsA), was made in 36/124 (29.0%) patients; pPsA without axial involvement was found in 21/124 (16.9%) patients. Back pain at screening was recorded in 174 (66%) patients, with 158 (60%) reporting a back pain duration longer than 3 months, and 140 (53%) reporting back pain onset before the age of 45. Active inflammatory and/or structural post-inflammatory changes in the sacroiliac joints and/or spine were observed in all axPsA patients.Patients with PsA showed a numerically longer duration of back pain and higher CRP levels in comparison with patients with Pso without PsA.

CONCLUSION

The DCS tool proved to be a valuable screening strategy for detecting and characterizing patients with axPsA in a real-life cohort of psoriasis patients in a dermatological setting and helped to identify a substantial number of patients affected by undiagnosed pPsA.

The Psoriatic Arthritis 5-Thermometer Scales (PsA-5Ts): Measurement Properties of a New Multidimensional Composite Tool for the Quick Assessment of the Overall Health Status in Psoriatic Arthritis

BACKGROUND

Psoriatic arthritis (PsA) is a heterogeneous condition that is difficult to assess. The goal of this research was to evaluate the clinimetric properties of the Psoriatic Arthritis 5-Thermometer Scales (PsA-5Ts), a new patient-reported outcome (PRO) to measure the overall health status in PsA patients.

METHODS

The PsA-5Ts were compared to composite measures of disease activity (DAPSA, PASDAS, CPDAI) and PROs (PsAID-12 and SF-36). The convergent validity was assessed through the Spearman's correlation coefficient and the discriminant validity through the receiver operating characteristic (ROC) curve analysis, applying the Minimal Disease Activity (MDA) as an external criterion.

RESULTS

The cross-sectional assessment included 155 patients. Significant high correlations were observed when comparing PsA-5Ts to composite indices of disease activity and PROs (all at significance levels of p < 0.0001). The PsA-5Ts subscales were highly significantly different in terms of MDA status (all at p < 0.0001). The PsA-5Ts had good discriminant validity like that of the DAPSA, CPDAI, PASDAS, and PsAID-12, and better than that of the SF-36, with an area under the ROC curve of 0.944 (65% CI 0.895-0.974).

CONCLUSIONS

The PsA-5Ts are an easy-to-use PRO that can be integrated with disease activity indices in the assessment of PsA in daily clinical practice.

Quantification of sarcopenia in patients with rheumatoid arthritis by measuring the cross-sectional area of the thigh muscles with magnetic resonance imaging

PURPOSE

To determine the utility of cross-sectional area (CSA) measurements on magnetic resonance imaging (MRI), at the level of the thigh muscles, to estimate muscle mass in discriminating rheumatoid arthritis (RA) patients with sarcopenia from those without.

MATERIALS AND METHODS

Consecutive female RA patients were enrolled for this cross-sectional study. Patients were assessed for disease activity, radiological damage, handgrip strength, physical performance and for the presence of sarcopenia, identified in accordance with the EWGSOP2 criteria. A 1.5 T MRI machine was used to scan the thigh muscles. A dimensional region growth algorithm (Horos™) was used to segment the muscles CSAs (in cm²) on MR images located 25 cm above the knee joint (MRI-CSA-25). The MRI-CSA-25 was obtained by summing the CSAs of the individual muscles. MRI-CSA-25 was correlated (Pearson's r) with the other variables, and its optimal cut-off point (Youden index) for sarcopenia diagnosis was identified in relation to the EWGSOP2 criteria.

RESULTS

32 RA female patients were studied, 34.4% diagnosed as sarcopenic. The mean MRI-CSA-25 was 151.00 cm² for patient with sarcopenia, 275.57 cm² for patient without sarcopenia (p < 0.001). MRI-CSA-25 correlated significantly with measures of physical performance, and disease activity, but not with radiological damage or age. The MRI-CSA-25 optimal cut-off point in discriminating sarcopenic patients was identified at 182.00 cm² (AUC-ROC = 0.894).

CONCLUSION

MRI-CSA-25 can differentiate sarcopenic versus non-sarcopenic RA patients, representing an imaging biomarker of this condition.

Reliability assessment of ultrasound muscle echogenicity in patients with rheumatic diseases: Results of a multicenter international web-based study

Objectives

To investigate the inter/intra-reliability of ultrasound (US) muscle echogenicity in patients with rheumatic diseases.

Methods

Forty-two rheumatologists and 2 radiologists from 13 countries were asked to assess US muscle echogenicity of quadriceps muscle in 80 static images and 20 clips from 64 patients with different rheumatic diseases and 8 healthy subjects. Two visual scales were evaluated, a visual semi-quantitative scale (0-3) and a continuous quantitative measurement ("VAS echogenicity," 0-100). The same assessment was repeated to calculate intra-observer reliability. US muscle echogenicity was also calculated by an independent research assistant using a software for the analysis of scientific images (ImageJ). Inter and intra reliabilities were assessed by means of prevalence-adjusted bias-adjusted Kappa (PABAK), intraclass correlation coefficient (ICC) and correlations through Kendall's Tau and Pearson's Rho coefficients.

Results

The semi-quantitative scale showed a moderate inter-reliability [PABAK = 0.58 (0.57-0.59)] and a substantial intra-reliability [PABAK = 0.71 (0.68-0.73)]. The lowest inter and intra-reliability results were obtained for the intermediate grades (i.e., grade 1 and 2) of the semi-quantitative scale. "VAS echogenicity" showed a high reliability both in the inter-observer [ICC = 0.80 (0.75-0.85)] and intra-observer [ICC = 0.88 (0.88-0.89)] evaluations. A substantial association was found between the participants assessment of the semi-quantitative scale and "VAS echogenicity" [ICC = 0.52 (0.50-0.54)]. The correlation between these two visual scales and ImageJ analysis was high (tau = 0.76 and rho = 0.89, respectively).

Conclusion

The results of this large, multicenter study highlighted the overall good inter and intra-reliability of the US assessment of muscle echogenicity in patients with different rheumatic diseases.

Ultrasound and magnetic resonance imaging as diagnostic tools for sarcopenia in immune-mediated rheumatic diseases (IMRDs)

Sarcopenia is characterized by loss of muscle mass, altered muscle composition, fat and fibrous tissue infiltration, and abnormal innervation, especially in older individuals with immune-mediated rheumatic diseases (IMRDs). Several techniques for measuring muscle mass, strength, and performance have emerged in recent decades. The portable dynamometer and gait speed represent the most frequently used tools for the evaluation of muscle strength and physical efficiency, respectively. Aside from dual-energy, X-ray, absorptiometry, and bioelectrical impedance analysis, ultrasound (US) and magnetic resonance imaging (MRI) techniques appear to have a potential role in evaluating muscle mass and composition. US and MRI have been shown to accurately identify sarcopenic biomarkers such as inflammation (edema), fatty infiltration (myosteatosis), alterations in muscle fibers, and muscular atrophy in patients with IMRDs. US is a low-cost, easy-to-use, and safe imaging method for assessing muscle mass, quality, architecture, and biomechanical function. This review summarizes the evidence for using US and MRI to assess sarcopenia.

POS0010 THE PSORIATIC ARTHRITIS 5-THERMOMETER SCALES (PsA-5Ts): A NEW INSTRUMENT FOR ASSESSING THE STATUS OF DISEASE ACTIVITY IN PSORIATIC ARTHRITIS

Background

There are a variety of composite disease activity monitoring methods and patient-centered metrics available for psoriatic arthritis (PsA). The Psoriatic Arthritis 5-Thermometer scales (PsA-5Ts) is a new tool, proposed, with the aim of improving its diagnostic accuracy.

Objectives

The goal of this research was to evaluate data on the measurement qualities of the PsA-5Ts, a composite measure of disease activity in PsA patients, in a real-world scenario (Figure 1).

Figure 1.

The Psoriatic Arthritis 5 Thermometer scales (PsA-5Ts) scoring and calculation rule

Methods

A total of 155 PsA patients were enrolled between May 2018 and December 2021. Adult-onset PsA CASPAR criteria were used to classify patients affected by PsA, while ASAS criteria were used to classify patients affected by axial-PsA (axPsA). All patients completed the PsA-5Ts, a simple instrument with five “thermometers” that incorporate pain, fatigue, physical function, skin disorders, and depression into a single assessment of disease activity. Additional continuous measures of disease activity (e.g., DAPSA, PASDAS, CPDAI) and patient-reported outcomes (PROs) measures of disease health status (e.g., PSAID and SF-36) were analyzed as comparisons. Spearman’s correlations and cross-tabulations were used to examine concurrent validity. Receiver operating characteristic (ROC) curve method was used to assess discriminant validity. As an external criterion, the Minimal Disease Activity (MDA) levels were used.

Results

The 96 female and 59 male patients ranged in age from 20 to 79 years old and had been living with PsA for an average of 8.35.2 years (6 months to 22 years). The PsA-5Ts’ area under the ROC curve (AUC-ROC) was 0.944. (95 percent CI 0.895 to 0.974) (Figure 2). The PsA-5Ts had same discriminant validity as the DAPSA, CPDAI, PASDAS, and PSAID, but it was better than the SF-36 (p=0.0011). PsA-5Ts subscales were highly significantly different between the MDA status (all at p<0.0001) when categorizing patients into those who rated their condition as reaching MDA (Kruskal-Wallis test). PsA-5Ts were also shown to have a remarkable (p<0.0001) correlation with known PsA activity measurement techniques.

Figure 2.

ROC curve analysis (AUC-ROC curves values, standard error and 95% confidence intervals) for the discriminatory power of disease activity, according to the different composite disease activity indices (DAPSA; CPDAI and PASDAS) and patient-reported outcomes (PROs) measures (PsA-5Ts, PSAID and SF-36). Receiver operating characteristic curves illustrating the relationship between sensitivity and complement of specificity (100-specificity) in PsA for activity measures using MDA as an external indicator. A line that runs diagonally across the figure from lower left to upper right will have an area of 0.5; this represents an instrument that does not discriminate.

Conclusion

For the evaluation of disease activity in PsA, PsA-5Ts is a useful alternative to continuous composite indices and other patient-centered assessments. The PsA-5Ts make data collection simpler, and they should be used in both clinical studies and everyday clinical treatment. In order to establish the tool’s clinical relevance, longitudinal construct validity, which concerns the measure’s capacity to identify a real change in health status as well as its accuracy in detecting changes of various magnitudes, must be addressed.

References

[1]Salaffi F, Di Carlo M, Carotti M, Farah S. The Patient-Reported Outcomes Thermometer-5-Item Scale (5T-PROs): Validation of a New Tool for the Quick Assessment of Overall Health Status in Painful Rheumatic Diseases. Pain Res Manag.

[2]Di Carlo M, Becciolini A, Lato V, Crotti C, Favalli EG, Salaffi F. The 12-item Psoriatic Arthritis Impact of Disease Questionnaire: Construct Validity, Reliability, and Interpretability in a Clinical Setting. J Rheumatol. 2017;44(3):279-285.

[3]Salaffi F, Sarzi-Puttini P, Atzeni F. How to measure chronic pain: new concepts. Best Pract Res Clin Rheumatol. 2015;29(1):164-186.

Disclosure of Interests

None declared

POS0241 JAK INHIBITORS IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS: EXPLORING EARLY RESPONSE ON CENTRAL SENSITIZATION AND CATASTROPHISM SYMPTOMS

Background

Catastrophizing has been demonstrated to be linked with central sensitization (CS), although few studies have investigated the potential of interactions between catastrophizing and CS in patients receiving JAK inhibitors.

Objectives

To explore the link between changes in Simplified Disease Activity Index (SDAI) and changes in pain catastrophizing, pain intensity, neuropathic pain component (NPC) and CS symptoms that occur with the introduction of a novel treatment targeting the JAK/STAT signalling pathway.

Methods

115 patients in an ongoing prospective observational analysis filled out questionnaires at the start and conclusion of the research, using the Pain Catastrophizing Scale (PCS) and Central Sensitization Inventory (CSI). The study included 22 patients on tofacitinib monotherapy (5 mg BD), 19 on tofacitinib and MTX, 19 on baricitinib monotherapy (4 mg OD), 14 on baricitinib and MTX, 17 on upadacitinib monotherapy (15 mg OD), 16 on upadacitinib and MTX, and 8 on filgotinib (200mg OD) and MTX. The disease activity index was evaluated by the simplified disease activity index (SDAI). The US scoring system validated in the US-CLARA was used. The Semantic Questionnaire for Rheumatology (SQR) and PainDETECT questionnaire (PDQ), were used to assess pain severity and NPC. Using multivariable linear regression models, we investigated the connection between changes in SDAI and in CSI, PCS, PDQ, SQR and US score.

Results

At baseline, the percentage of RA patients who exceeded the thresholds for the presence of NPC (PDQ > 19 points) of the CSI (> 40 points) and PCS (> 30 points) were 43.5%, 36.5%, and 62.6%, respectively. After 4 weeks of treatment, the patient-reported scores and the disease composite index decreased significantly, SRQ (p<0.0001), PDQ (p=0.0084), PCS (p=0.0066), CSI (p=0.0165) and SDAI (p<0.0001).The US score did not change significantly (5.25 to 5.03; p=0.248). SDAI achieved 10.6% remission and 15.2% low disease activity at week 4. Multivariate regression analysis indicated that changes in SDAI were exclusively connected to changes in catastrophizing (coefficient=0.500, P=0.0224).

Conclusion

After starting a Jak inhibitor, pain catastrophizing, but not articular inflammation on US, diminishes along with disease activity. These findings provide credence to the concept of catastrophizing as a dynamic construct that may be adjusted by therapy aimed at reducing inflammatory disease activity and pain levels in the RA patient.

References

[1]Hammer HB, et al. Pain catastrophizing, subjective outcomes, and inflammatory assessments including ultrasound: results from a longitudinal study of rheumatoid arthritis patients. Arthritis Care Res 2018;70:703–12

[2]Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2–S15

Table 1.

Multivariate regression analysis, using SDAI (Simplified Disease Activity Index) changes as dependent variable.

Independent variablesCoefficientStd. ErrorTP(Constant)-0.7239ACPA, titre-0.00024100.002528-0.09530.9242Age, yrs-0.090630.1028-0.8810.3803BMI-0.16000.2787-0.5740.5671Disease duration, yrs-0.10030.1611-0.6230.5347Educational level, yrs-0.10720.3703-0.2890.7728Diff. CSI0.31940.19841.6100.1105Diff. SRQ0.070180.37260.1880.8509Diff US score1.22480.70241.7440.0842Diff PCS0.50090.21602.3180.0224Diff PDQ0.18600.22710.8190.4146

Abbreviations: ACPA= Anti-Citrullinated Protein/peptide Antibody; BMI= Body Mass Index; CSI= Central Sensitization Inventory; SRQ= Semantic Questionnaire for Rheumatology; US= Ultrasonography; PCS= Pain Catastrophizing Scale; PDQ= PainDETECT Questionnaire.

Disclosure of Interests

None declared

POS0524 THE VALUE OF ULTRASOUND AND MAGNETIC RESONANCE IMAGING SCORING TECHNIQUES FOR DETECTING JOINT INFLAMMATION AND DAMAGE IN RHEUMATOID ARTHRITIS PATIENTS IN EXPLAINING FUNCTIONAL IMPAIRMENT AND HANDGRIP STRENGTH: A PILOT STUDY

Background

Composite disease activity ratings, which are used to assess the severity of rheumatoid arthritis (RA), may not effectively reflect the illness’s spatial impact on the hands. In RA, assessments of handgrip strength (HGs) and functional deficits are a kind of objective examination that focuses on the hands.

Objectives

The goal of this study was to see if there was a link between joint inflammation and damage in the wrists and hands, as measured by ultrasound (US) and magnetic resonance imaging (MRI), functional disability as measured by hand-specific self-report questionnaires, and composite disease activity indices.

Methods

Sixty-six female patients with RA were investigated (age 55.6 ± 12.2 years, range 20-80 years; disease duration 4.4 ± 3.0 years). The DAS28-CRP, the SDAI, the CDAI, and US and MRI scoring techniques such as the UltraSound-CLinical ARthritis Activity (US-CLARA) and modified Simplified Rheumatoid Arthritis Magnetic Resonance Imaging Score [SAMIS] were all used as baseline assessments (mod SAMIS) (Figure 1). Without contrast injection, the mod SAMIS score was rated for the presence/absence and semiquantitative assessments of synovitis, bone erosion (ERO), and bone marrow edema (BME). All patients had HGs and completed the shortened Disability of Arm, Shoulder, and Hand Questionnaire (QuickDASH), the Arthritis Impact Measurement Scales hand and finger function subscale, and the upper extremity function sub-score of the ROAD.

Figure 1.

The modified simplified SAMIS magnetic resonance score (mod SAMIS) scoring spreadsheet. The MRI was graded for the presence/absence of synovitis and semiquantitative ratings of bone marrow oedema and bone erosion, without contrast injection.

Results

The mod SAMIS total score and the US-CLARA had a strong correlation (rho=0.377, p=0.0018) for all patients. Among the SAMIS sub-scores, there was a significant relationship between mod SAMIS bone oedema (SAMIS-BME) and US-CLARA (rho=0.799, p<0.001) and mod SAMIS synovitis (SAMIS-synovitis) and US-CLARA (rho=0.539, p<0.001). There were also significant negative relationships between the HGs score and the mod SAMIS total score and US-CLARA (rho = -0.309, p=0.011 and rho = -0.775, p<0.0001, respectively). The HGs and disease activity composite indices, as well as hand-specific self-report questionnaires, were shown to have high relationships (p<0.0001) in individuals with RA. The hand and finger function sub-scales, as well as the mod SAMIS erosion (SAMIS-ERO) and HGs, exhibited no significant relationship. For each of the three components, interobserver agreement was good to excellent (intraclass correlation values = 0.713, 0.912, and 0.821, respectively) (synovitis, BME, and BME) (Figure 2).

Figure 2.

Scatterplot with linear regression lines displays the relationship between (A) mod SAMIS total score vs HGs, (B) US-CLARA vs HGs, and (C) US-CLARA vs mod SAMIS total score.

Conclusion

BME and synovitis have an impact on upper-extremity function. The US-CLARA and mod SAMIS total score are promising solutions for semi-quantitative evaluation of joint inflammation and damage in RA. These shortened scores might cut down on image processing time in US and MRI-controlled RA investigations, as well as make using these imaging modalities in RA treatment response evaluation studies simpler.

References

[1]Salaffi F, Carotti M, Farah S, Ceccarelli L, Di Carlo M. Handgrip Strength Features in Rheumatoid Arthritis Patients Assessed Using an Innovative Cylindrical-Shaped Device: Relationships With Demographic, Anthropometric and Clinical Variables. J Med Syst. 2021, 9;45(11):100.

[2]Salaffi F, Di Carlo M, Iannone F, Fedele AL, Epis OM, Pellerito R, Foti R, Passiu G, Punzi L, Furini F, Sarzi-Puttini P, Carletto A, Gremese E, Lapadula G, Ferraccioli G. The UltraSound-CLinical ARthritis Activity (US-CLARA) index: Properties of a new composite disease activity index for rheumatoid arthritis. Semin Arthritis Rheum. 2018;47(5):619-629.

Disclosure of Interests

None declared.

The value of ultrasound and magnetic resonance imaging scoring systems in explaining handgrip strength and functional impairment in rheumatoid arthritis patients: a pilot study

Purpose

The goal of this study is to investigate the relationship between joint inflammation and damage of the wrists and hands, measured by semiquantitative ultrasound and magnetic resonance imaging scoring systems, with functional disability and handgrip strength (HGs).

Materials and methods

Consecutive adult RA patients with active disease, as defined by a Disease Activity Score 28 joints C-reactive protein (DAS28-CRP) > 3.2, underwent a cross-sectional evaluation comprehensive of a clinimetric assessment, an HGs evaluation, an ultrasound assessment aimed at calculating the UltraSound-CLinical ARthritis Activity (US-CLARA), and a magnetic resonance imaging scored according to the modified Simplified Rheumatoid Arthritis Magnetic Resonance Imaging Score (mod SAMIS). The Spearman’s rho correlation coefficient was used to test the correlations.

Results

Sixty-six patients with RA were investigated (age 55.6 ± 12.2 years). The mod SAMIS total score and the US-CLARA had a weak but significant correlation (rho = 0.377, p = 0.0018). Among the mod SAMIS sub-scores, there was a significant relationship between mod SAMIS bone edema (SAMIS-BME) and US-CLARA (rho = 0.799, p < 0.001) and mod SAMIS synovitis (SAMIS synovitis) and US-CLARA (rho = 0.539, p < 0.001). There were also significant negative relationships between the HGs score and the mod SAMIS total score and US-CLARA (rho = − 0.309, p = 0.011 and rho = − 0.775, p < 0.0001, respectively).

Conclusions

BME and synovitis have an influence on the function of the upper extremities. The US-CLARA and the mod SAMIS total score are intriguing options for semiquantitative assessment of joint inflammation and damage in RA.

Predicting Severe/Critical Outcomes in Patients With SARS-CoV2 Pneumonia: Development of the prediCtion seveRe/crItical ouTcome in COVID-19 (CRITIC) Model

Objective: To create a prediction model of the risk of severe/critical disease in patients with Coronavirus disease (COVID-19). Methods: Clinical, laboratory, and lung computed tomography (CT) severity score were collected from patients admitted for COVID-19 pneumonia and considered as independent variables for the risk of severe/critical disease in a logistic regression analysis. The discriminative properties of the variables were analyzed through the area under the receiver operating characteristic curve analysis and included in a prediction model based on Fagan's nomogram to calculate the post-test probability of severe/critical disease. All analyses were conducted using Medcalc (version 19.0, MedCalc Software, Ostend, Belgium). Results: One hundred seventy-one patients with COVID-19 pneumonia, including 37 severe/critical cases (21.6%) and 134 mild/moderate cases were evaluated. Among all the analyzed variables, Charlson Comorbidity Index (CCI) was that with the highest relative importance (p = 0.0001), followed by CT severity score (p = 0.0002), and age (p = 0.0009). The optimal cut-off points for the predictive variables resulted: 3 for CCI [sensitivity 83.8%, specificity 69.6%, positive likelihood ratio (+LR) 2.76], 69.9 for age (sensitivity 94.6%, specificity 68.1, +LR 2.97), and 53 for CT severity score (sensitivity 64.9%, specificity 84.4%, +LR 4.17). Conclusion: The nomogram including CCI, age, and CT severity score, may be used to stratify patients with COVID-19 pneumonia.

Frailty prevalence according to the Survey of Health, Ageing and Retirement in Europe-Frailty Instrument (SHARE-FI) definition, and its variables associated, in patients with symptomatic knee osteoarthritis: findings from a cross-sectional study

Background

Frailty is a frequent condition in patients with knee osteoarthritis (KOA). However, there are different constructs on how to define it. Survey of Health, Ageing and Retirement in Europe-Frailty Instrument (SHARE-FI) is one of them.

Aim

To assess the prevalence of frailty, according to the SHARE-FI definition in patients with symptomatic KOA, and to establish its associated factors.

Methods

Symptomatic KOA patients were evaluated for pain symptoms, quality of life, comorbidities, ongoing drug therapy, and radiological damage. Patients were categorised according to the SHARE-FI definition into frail, pre-frail, and non-frail, and compared to a group of healthy controls associated by age and gender.

Results

170 symptomatic KOA patients (76.5% female, mean age 70.1 years) and 186 healthy controls were included. According to SHARE-FI criteria, 35 patients (20.6%) were categorised frail, 50 (29.4%) pre-frail, and 85 (50%) non-frail. The prevalence of frail or pre-frail subjects was statistically significantly higher in patients with symptomatic KOA. Stratifying the patients according to the frailty categories, frail subjects showed significantly higher mean values of pain. The results from logistic regression analysis revealed that polypharmacy (p = 0.003), pain (p = 0.016) and comorbidities (p = 0.035) were the variables independently associated with frailty in symptomatic KOA.

Discussion

Frailty or pre-frailty, defined by SHARE-FI, is common in symptomatic KOA. The main factors associated with frailty were polypharmacy, pain and comorbidity burden.

Conclusions

SHARE-FI can represent an useful tool to define frailty in symptomatic KOA.

Differentiation between infectious spondylodiscitis versus inflammatory or degenerative spinal changes: How can magnetic resonance imaging help the clinician?

Spondylodiscitis is a complex disease whose diagnosis and management are still challenging. The differentiation between infectious and non-infectious aetiology is mandatory to avoid delays in the treatment of life-threatening infectious conditions. Imaging methods, in particular magnetic resonance imaging (MRI), play a key role in differential diagnosis. MRI provides detailed anatomical information, especially regarding the epidural space and spinal cord, and may allow differential diagnosis by assessing the characteristics of certain infectious and inflammatory/degenerative lesions. In this article, we provide an overview of the radiological characteristics and differentiating features of non-infectious inflammatory spinal disorders and infectious spondylodiscitis, focussing on MRI results and presenting relevant clinical and pathological features that help early diagnosis.

New advances in CT imaging of pancreas diseases: a narrative review

Computed tomography (CT) plays a pivotal role as a diagnostic tool in many diagnostic and diffuse pancreatic diseases. One of the major limits of CT is related to the radiation exposure of young patients undergoing repeated examinations. Besides the standard CT protocol, the most recent technological advances, such as low-voltage acquisitions with high performance X-ray tubes and iterative reconstructions, allow for significant optimization of the protocol with dose reduction. The variety of CT tools are further expanded by the introduction of dual energy: the production of energy-selective images (i.e., virtual monochromatic images) improves the image contrast and lesion detection while the material-selective images (e.g., iodine maps or virtual unenhanced images) are valuable for lesion detection and dose reduction. The perfusion techniques provide diagnostic and prognostic information lesion and parenchymal vascularization and interstitium. Both dual energy and perfusion CT have the potential for pushing the limits of conventional CT from morphological evaluation to quantitative imaging applied to inflammatory and oncological diseases. Advances in post-processing of CT images, such as pancreatic volumetry, texture analysis and radiomics provide relevant information for pancreatic function but also for the diagnosis, management and prognosis of pancreatic neoplasms. Artificial intelligence is promising for optimization of the workflow in qualitative and quantitative analyses. Finally, basic concepts on the role of imaging on screening of pancreatic diseases will be provided.

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.

Ultra-low-dose chest CT in adult patients with cystic fibrosis using a third-generation dual-source CT scanner

INTRODUCTION

Chest computed tomography (CT) examinations are performed routinely in some cystic fibrosis (CF) centers in order to evaluate lung disease progression in CF patients. Continuous CT technological advancement in theory could allows a lower radiation exposure of CF patients during chest CT examinations without an image quality reduction, and this could become increasingly important over time in order to reduce the cumulative radiation dose effects given the continuous increase of CF patients predicted median survival.

OBJECTIVE

The aim of this study was to compare objective and subjective image quality and radiation dose between low-dose chest CT examinations performed in adult CF patients using a third-generation DSCT scanner and a 64-slices single-source CT (SSCT) scanner.

MATERIALS AND METHODS

Between January 2016 and August 2019, 81 CF patients underwent low-dose chest CT examinations using both a 64-slices SSCT scanner (2016-2017) and a third-generation DSCT scanner (2018-2019). Objective image noise standard deviation (INSD), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), overall subjective image quality (OSIQ), subjective image noise (SIN), subjective evaluation of streaking artifacts (SA), movement artifacts (MA) and edge resolution (ER), dose-length product (DLP), volume computed tomography dose index (CTDIvol) and effective radiation dose (ERD) were compared between DSCT and SSCT examinations. DSCT examinations consisted in spiral inspiratory end expiratory acquisitions. SSCT examinations consisted in spiral inspiratory acquisitions and five axial expiratory ones.

RESULTS

DSCT protocol showed statistically significant lower spiral inspiratory phase mean DLP, CTDIvol and ERD than SSCT protocol, with a 25% DLP, CTDIvol and ERD reduction. DSCT protocol showed statistically significant higher overall (inspiratory and expiratory phases) mean DLP, CTDIvol and ERD than SSCT protocol, with a 40% DLP, CTDIvol and ERD increase. Objective image quality (INSD, SNR and CNR) and SIN differences were not statistically significant, but subjective evaluation of DSCT images showed statistically significant better OSIQ and ER, as well as statistically significant lower SA and MA with respect to SSCT images.

CONCLUSIONS

To our knowledge, this is the first study evaluating chest CT image quality and radiation dose in adult CF patients using a third-generation DSCT scanner, and it showed that technological advancements could be used in order to reduce radiation exposure of volumetric examinations. The spiral inspiratory dose reduction can be obtained with concomitant improvements in subjective image quality with comparable objective quality. This will probably allow a wider use of this imaging modality in order to assess bronchiectasis and will probably foster spiral expiratory acquisition for small airways disease evaluation.

The role of a chest computed tomography severity score in coronavirus disease 2019 pneumonia

The chest computed tomography (CT) characteristics of coronavirus disease 2019 (COVID-19) are important for diagnostic and prognostic purposes. The aim of this study was to investigate chest CT findings in COVID-19 patients in order to determine the optimal cut-off value of a CT severity score that can be considered a potential prognostic indicator of a severe/critical outcome.The CT findings were evaluated by means of a severity score that included the extent (0-4 grading scale) and nature (0-4 grading scale) of CT abnormalities. The images were evaluated at 3 levels bilaterally. A receiver operating characteristics (ROC) curve was used to identify the optimal score (Youden's index) predicting severe/critical COVID-19.The study involved 165 COVID-19 patients (131 men [79.4%] and 34 women [20.6%] with a mean age of 61.5 ± 12.5 years), of whom 30 (18.2%) had severe/critical disease and 135 (81.8%) mild/typical disease. The most frequent CT finding was bilateral predominantly subpleural and basilar airspace changes, with more extensive ground-glass opacities than consolidation. CT findings of consolidation, a crazy-paving pattern, linear opacities, air bronchogram, and extrapulmonary lesions correlated with severe/critical COVID-19. The mean CT severity score was 63.95 in the severe/critical group, and 35.62 in the mild/typical group (P < .001). ROC curve analysis showed that a CT severity score of 38 predicted the development of severe/critical symptoms.A CT severity score can help the risk stratification of COVID-19 patients.

Third-generation iterative reconstruction on a dual-source, high-pitch, low-dose chest CT protocol with tin filter for spectral shaping at 100 kV: a study on a small series of COVID-19 patients

Objectives

To investigate the role of third-generation iterative reconstruction (ADMIRE) in dual-source, high-pitch chest CT protocol with spectral shaping at 100 kVp in Coronavirus disease 2019 (COVID-19).

Methods

Confirmed COVID-19 inpatients undergoing to unenhanced chest CT were scanned with a dual-energy acquisition (DECT, 90/150Sn kV) and a dual-source, high-pitch acquisition with tin-filtered 100 kVp (LDCT). On the DECT with ADMIRE 3 (DECT3) were evaluated the pulmonary findings and their extension (25-point score). Two radiologists in consensus evaluated with 5-point scales the overall image quality, the anatomical structures, and the elementary findings on LDCT reconstructed with filtered backprojection (LDCT0), with ADMIRE 3 (LDCT3) and 5 (LDCT5), and on DECT3. The signal-to-noise ratio (SNR), the body mass index, the exposure times, and the radiation doses were recorded.

Results

Seventy-five patients (57 M/18F; median age: 63 y.o.) were included, with median pulmonary extension of 13/25 points. The imaging findings were detected in proportion comparable to the available literature. The ADMIRE significantly improved the SNR in LDCT (p < 0.00001) with almost no significant differences in overweight patients. The LDCT had median effective dose of 0.39 mSv and acquisition time of 0.71 s with significantly less motion artifacts than DECT (p < 0.00001). The DECT3 and LDCT3 provided the best image quality and depiction of pulmonary anatomy and imaging findings, with significant differences among all the series (p < 0.00001).

Conclusion

The LDCT with spectral shaping and ADMIRE3 provided acceptable image quality in the evaluation of patients with COVID-19, with significantly reduced radiation dose and motion artifacts.

Ultrasound measurement of muscle thickness at the anterior thigh level in rheumatology setting: a reliability study

Ultrasound (US) is a promising tool for assessing sarcopenia. We aimed to test in the rheumatology setting two US scanning protocols to measure muscle thickness (MT) at the anterior thigh level and to assess their feasibility and reliability. In the first phase of the study, three rheumatologists performed a US examination on 19 consecutive patients adopting two scanning protocols, namely the anterior superior iliac spine (ASIS) and the greater trochanter techniques. After consensus was obtained on the easiest scanning protocol to perform, two rheumatologists adopted only the ASIS technique in 40 consecutive patients. MT measurements were recorded as well as the time needed to complete each scanning protocol bilaterally. The median time needed to complete the US examination was under 5 minutes for each of the two techniques, with no significant difference between them (p = 0.64). In the first phase, we found an excellent inter-observer reliability of the proposed scanning protocols, with a higher but nonstatistically significant intraclass correlation coefficient (ICC) for the ASIS technique compared with the greater trochanter technique (ICC 0.97 vs. ICC 0.92, p = 0.05). The ASIS technique had a significantly higher intra-observer reliability (ICC 0.97 vs. ICC 0.92, p < 0.01). In the second phase, the ASIS technique confirmed on a larger sample its excellent inter-observer reliability, with an ICC of 0.96. The present study presents a novel tool for assessing sarcopenia and provides evidence in favor of feasibility and reliability of US measurement of MT at the anterior thigh level in rheumatology setting. Key Points • This study demonstrates that ultrasound (US) measurement of muscle thickness at the anterior thigh level is highly reliable, especially for the "anterior superior iliac spine (ASIS)" technique. • The short time needed to complete the US assessment highlights the feasibility of the proposed scanning protocols. • The simplicity and conciseness of the proposed techniques will allow other researchers and clinicians to use it for a fast assessment of sarcopenia.

Predictive validity of the 5-item Compliance Questionnaire for Rheumatology (CQR5) in detecting poor adherence of patients with rheumatoid arthritis to biological medication

Background

Adherence is a key factor for therapeutic success in patients with rheumatoid arthritis (RA). The aim of this study was to determine whether results from the 5-item Compliance Questionnaire for Rheumatology (CQR5) can predict future poor adherence to biological disease-modifying anti-rheumatic drugs (bDMARDs) in patients with RA, using medication possession ratio (MPR) as the gold standard comparator.

Methods

RA patients starting a bDMARD were prospectively followed for 12 months. At baseline, CQR5 was collected in relation to the prescribed bDMARD. Patients were dichotomised into good adherers and poor adherers, categories that were then used as the variable in a predictive function analysis of the CQR5 in order to determine the accuracy of the classification at the end of the study period in comparison with the MPR. The sensitivity, specificity, and likelihood ratio of detecting poor adherers were also determined because this is the clinically important purpose of the questionnaire. Satisfactory adherence was defined as > 80% compliance with the prescribed dose regimen.

Results

Of the 210 RA patients enrolled (147 women and 63 men; mean age 58.6 ± 12.8 years; mean disease duration 7.4 ± 2.5 years), at the end of the 12-month follow-up, 152 patients (72.4%) were good adherers and 58 (27.6%) were poor adherers according to MPR. Predictive analyses showed that the sensitivity and specificity of the CQR5 in detecting poor adherence were respectively 89.9% (95% CI 84.07–94.10%) and 80.8% (95% CI 67.46–90.37%). The accuracy of the CQR5 was 83.04% (95% CI 77.27–87.85%), the positive likelihood ratio (i.e. detecting ≤ 80% adherence) 4.67 (95% CI 2.58–8.18), and the area under curve 0.85 (95% CI 0.79–0.89).

Conclusion

Higher baseline CQR5 scores significantly predict the treatment adherence of RA patients. This suggests that this instrument could be used for screening purposes in order to identify patients who are poorly adherent to bDMARDs.

Ultrasound measurement of muscle thickness at the proximal forearm in a rheumatologic setting

OBJECTIVES

To provide a detailed description of the ultrasound (US) scanning protocol to measure the muscle thickness in the forearm and to test its feasibility and interobserver reliability.

METHODS

Four rheumatologists trained in musculoskeletal US carried out the examinations in 45 subjects (30 consecutively enrolled patients and 15 healthy subjects). Each of the four rheumatologists took two measurements of each forearm (radial muscle thickness and ulnar muscle thickness) and the time needed to complete the bilateral US assessment was recorded.

RESULTS

The mean time required to acquire all measurements in each subject was less than four minutes. We found an excellent interobserver reliability of the proposed scanning protocol, with an intraclass correlation coefficient (ICC) among the four sonographers of 0.97 (CI 0.95-0.98) for the right ulnar muscle thickness, an ICC of 0.97 (CI 0.94-0.98) for the left ulnar muscle thickness, an ICC of 0.93 (CI 0.89-0.96) for the right radial muscle thickness and an ICC of 0.95 (CI 0.91-0.97) for the left radial muscle thickness.

CONCLUSIONS

The results of this study provide evidence in favour of interobserver reliability and feasibility of US measurement of the forearm muscle thickness.

Sural Nerve Size in Fibromyalgia Syndrome: Study on Variables Associated With Cross-Sectional Area

Increased cross-sectional area (CSA) of sural nerve, documented by ultrasound (US), has been revealed in small fibers neuropathy, condition present in about half of patients with fibromyalgia (FM). The aims of this study were to evaluate sural nerve CSA and to establish the variables associated with increased CSA in FM patients. A cross-sectional assessment was conducted in consecutive FM patients. Demographic data, clinimetric parameters [Fibromyalgia Impact Questionnaire (FIQR)], the neuropathic pain features [PainDetect Questionnaire (PDQ)], and the sural nerve CSA were recorded. CSA was determined by US, examining the sural nerve at the lateral region of the calf. CSA was compared with demographic and clinical variables. A multiple regression analysis was conducted applying CSA as dependent variable. One hundred and ten FM patients were enrolled. Sural nerve CSA showed a significant association with body mass index (BMI) (r = 0.422; p < 0.0001) and with PDQ (r = 0.361; p = 0.0001). The multiple regression analysis confirmed that BMI (p = 0.0001) and PDQ (p = 0.0028) were the two independent variables associated with CSA. The severity of the disease, measured with FIQR, showed no association. An increase in sural nerve CSA is closely related to BMI and to distinctive neuropathic symptoms. Overweight and obesity appear to be associated with a FM phenotype with documented peripheral nervous system involvement. Ultrasound examination of the sural nerve at calf level may reveal useful information in patients with FM, identifying a cluster of patients with peripheral nervous system alterations. This cluster of patients is generally overweight or obese, and complains of painful symptoms with neuropathic features.

Masses in right side of the heart: spectrum of imaging findings

Primary heart tumors are rare, benign tumors represent the majority of these. If a cardiac mass is found, the probability that it is a metastasis or a so-called “pseudo-mass” is extremely higher than a primary tumor. The detection of a heart mass during a transthoracic echocardiography (TE) is often unexpected. The TE assessment can be difficult, particularly if the mass is located at the level of the right chambers. Cardiac Computed Tomography (CCT) can be useful in anatomical evaluation and Cardiac Magnetic Resonance (CMR) for masses characterization as well. We provide an overview of right cardiac masses and their imaging futures. (www.actabiomedica.it)

The role of imaging in surgical planning for liver resection: what the radiologist need to know

The management of patients undergoing surgical resection for liver malignancies requires a multidisciplinary team, including a dedicated radiologist. In the preoperative workup, the radiologist has to provide precise, relevant information to the surgeon. This requires the radiologist to know the basics of surgical techniques as well as liver surgical anatomy in order to help to avoid unexpected surgical scenarios and complications. Moreover, virtual resections and volumetries on radiological images will be discussed, and basic concepts of postoperative liver failure, regeneration, and methods for hypertrophy induction will be provided. (www.actabiomedica.it)

Radiological diagnosis of Coronavirus Disease 2019 (COVID-19): a Practical Guide

Novel beta-coronavirus (2019-nCoV) is the cause of Coronavirus disease-19 (COVID-19), and on March 12th 2020, the World Health Organization defined COVID-19 as a controllable pandemic. Currently, the 2019 novel coronavirus (SARS-CoV-2) can be identified by virus isolation or viral nucleic acid detection; however, false negatives associated with the nucleic acid detection provide a clinical challenge. Imaging examination has become the indispensable means not only in the early detection and diagnosis but also in monitoring the clinical course, evaluating the disease severity, and may be presented as an important warning signal preceding the negative RT-PCR test results. Different radiological modalities can be used in different disease settings. Radiology Departments must be nimble in implementing operational changes to ensure continued radiology services and protect patients and staff health.

Diagnostic and interventional management of infective spine diseases

Spondylodiscitis (SD) is one of the main causes of back pain. Although the low mortality, high morbidity is related to spondilodiscitys, leading spine instability, chronic pain or neurological deficit. Diagnostic imaging plays a primary role in diagnosing spondylodiscitis. However different accuracy is highlighted by different diagnostic tool, depending also on timing of disease which represents a cardinal element for the phenotypic manifestation of the disease, beyond spatial resolution and tissue characterization proper of specific modality imaging. Conventional Radiology (CR), Computed Tomography (CT) and MRI (Magnetic Resonance Imaging) all have proven to be of primary importance in the approach to spondylodiscitis, although magnetic resonance imaging has demonstrated the greatest advantage in identifying the disease from its earliest stages, demonstrating high sensitivity and specificity (92% and 96%, respectively). This review focus on the role of different imaging modality in the approach to the spondylodiscitis, also addressing the role of interventional radiology that is pivotal not only for a diagnosis of certainty through biopsy, but also for a minimally-invasive treatment of paravertebral abscesses spondylodiscitis-related. (www.actabiomedica.it)

Clinical utility of Dual Energy Computed Tomography in gout: current concepts and applications

Gout is the most common inflammatory arthritis and is increasing in prevalence and incidence in many countries worldwide. Dual Energy Computed Tomography (DECT) has a high diagnostic accuracy in established gout, but its diagnostic sensitivity is low in subjects with recent-onset gout. A meta-analysis of 17 studies showed a pooled sensitivity and specificity of 0.85 and 0.88, respectively. DECT is a useful diagnostic tool for patients with contraindications for joint aspiration or for those who refuse joint aspiration. This article aims to give an up to date review and summary of existing literature on the role and accuracy of DECT in the imaging of gout. (www.actabiomedica.it)

Advanced diagnostic imaging and intervention in tendon diseases

Degenerative tendon pathology represents one of the most frequent and disabling musculoskeletal disorders. Diagnostic radiology plays a fundamental role in the clinical evaluation of tendon pathologies. Moreover, several minimally invasive treatments can be performed under imaging guidance to treat tendon disorders, maximizing the efficacy and reducing procedural complications. In this review article we describe the most relevant diagnostic features of conventional and advanced US and MRI imaging in tendon disorders, along with the main options for image-guided intervention. (www.actabiomedica.it)

Diagnostic and interventional radiology fundamentals of synovial pathology

The synovial membrane is a specialized mesenchymal tissue that lines the diarthrodial joints surfaces, bursae, and tendon sheaths of the body. This article aims to provide an overview of the fundamentals of synovial tissue, with particular regard to the imaging findings of the main pathologic processes that can affect the synovia and the role of image-guided interventions. (www.actabiomedica.it)

Chest CT features of coronavirus disease 2019 (COVID-19) pneumonia: key points for radiologists

COVID-19 is an emerging infection caused by a novel coronavirus that is moving so rapidly that on 30 January 2020 the World Health Organization declared the outbreak a Public Health Emergency of International Concern and on 11 March 2020 as a pandemic. An early diagnosis of COVID-19 is crucial for disease treatment and control of the disease spread. Real-time reverse-transcription polymerase chain reaction (RT-PCR) demonstrated a low sensibility; therefore chest computed tomography (CT) plays a pivotal role not only in the early detection and diagnosis, especially for false negative RT-PCR tests, but also in monitoring the clinical course and in evaluating the disease severity. This paper reports the CT findings with some hints on the temporal changes over the course of the disease: the CT hallmarks of COVID-19 are bilateral distribution of ground glass opacities with or without consolidation in the posterior and peripheral lung, but the predominant findings in later phases include consolidations, linear opacities, “crazy-paving” pattern, “reversed halo” sign and vascular enlargement. The CT findings of COVID-19 overlap with the CT findings of other diseases, in particular the viral pneumonia including influenza viruses, parainfluenza virus, adenovirus, respiratory syncytial virus, rhinovirus, human metapneumovirus, etc. There are differences as well as similarities in the CT features of COVID-19 compared with those of the severe acute respiratory syndrome. The aim of this article is to review the typical and atypical CT findings in COVID-19 patients in order to help radiologists and clinicians to become more familiar with the disease.

THU0477 SURAL NERVE SIZE IN FIBROMYALGIA SYNDROME

Background:

The pathophysiology of fibromyalgia syndrome (FM) still needs to be fully clarified. In addition to the central sensitization mechanisms, some evidence suggests an involvement of the peripheral nervous system, mainly intended as small fibers neuropathy. The sural nerve showed some alterations, in terms of increasead cross-sectional area (CSA), in the course of small fibers neuropathy.

Objectives:

To evaluate sural nerve CSA and factors associated with increased CSA in FM patients.

Methods:

A cross sectional evaluation was conducted in consecutive FM patients according to the 2016 American College of Rheumatology criteria. Demographic, clinimetric parameters (in particular the revised Fibromyalgia Impact Questionnaire [FIQR] to assess the severity of the disease and the PainDetect Questionnaire [PDQ] to evaluate neuropathic pain features) and the sural nerve dimensions measured by ultrasound were recorded for each patient. The size of the sural nerve was described in terms of the mean cross-sectional area (CSA) measured bilaterally. CSA was measured at the leg level, 14 cm from the apex of the lateral malleolus, where the sural nerve is detectable as a structure adjacent to the small saphenous vein in the distal portion of the leg. The ultrasound examination was performed with a MyLab Class C (Esaote S.p.A., Genoa, Italy) equipped with a 6-18 MHz multifrequency broad band probe. CSA was compared with demographic and clinimetric parameters through one-way analysis of variance (ANOVA). A multiple regression was also conducted using CSA as dependent variable, with age, body mass index (BMI), disease duration, FIQR and PDQ as independent variables.

Results:

The study involved 110 FM patients (105 women and five men), with a mean age of 50.7 (±11.1) years and a mean disease duration of 5.8 (±5.2) years. Sural nerve CSA showed a statistically significant increase in patients with higher PDQ scores (p=0.0096) and, even more significantly, in overweight or obese subjects (p <0.001). The multiple regression analysis, using CSA as dependent variable, confirmed that the PDQ score (p=0.0049) and the body mass index (p<0.0001) are the only two independent variables associated with CSA size (Table 1).

Table 1.

Multiple regression analysis of the independent variables related to the mean cross-sectional area (dependent variable) of sural nerve.

Indipendent variablesCoefficientStandard errortprpartialrsemipartialConstant-0.2551BMI0.075920.018474.1110.00010.37390.3462Disease duration-0.024920.02092-1.1910.2364-0.11600.1003Age0.0024550.0098330.2500.80330.024480.02103FIQR0.00013760.0068620.02010.98400.0019660.001689PDQ0.052720.019972.6390.00960.25060.2223

Abbreviations: BMI=Body Mass Index; FIQR=revised Fibromyalgia Impact Questionnaire; PDQ=PainDetect Questionnaire

Conclusion:

Increased sural nerve CSA is associated with neuropathic like pain features and BMI. Overweight and obesity appear to be associated with an FM phenotype with greater peripheral involvement than normal-weight subjects. Sural nerve ultrasound, an easy to perform examination, could be a useful tool to identify this kind of patients.

References:

[1]Ebadi H, Siddiqui H, Ebadi S, Ngo M, Breiner A, Bril V. Peripheral Nerve Ultrasound in Small Fiber Polyneuropathy. Ultrasound Med Biol. 2015;41(11):2820-6. doi: 10.1016/j.ultrasmedbio.2015.06.011

[2]Giannoccaro MP, Donadio V, Incensi A, Avoni P, Liguori R. Small nerve fiber involvement in patients referred for fibromyalgia. Muscle Nerve. 2014;49(5):757-9. doi: 10.1002/mus.24156

Disclosure of Interests: :

None declared

THU0612-HPR DOES PAIN AND COMORBIDITY BURDEN PREDICT FRAILTY IN PATIENTS WITH KNEE-OSTEOARTHRITIS? FINDINGS FROM THE RESEARCH ON OSTEOARTHRITIS AGAINST FRAILTY (ROAF) STUDY

Background:

Pain and comorbidity burden has been suggested to act as a stressor during aging, potentially accelerating declines in health and functioning in patients with osteoarthritis of the knee (KNEE-OA) (1,2).

Objectives:

The aims of the present research were to assess(i) the prevalence of frailty and(ii) its potential associated factors in a cohort of adult patients with KNEE-OA.

Methods:

Patients fulfilling the clinical American College of Rheumatology knee-OA criteria were assessed according to the Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI), and classified as frail, pre-frail, or non-frail. The clinical evaluation included the following items: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain subscale (3) and Medical Outcomes Study Short Form-36 (SF-36). Evaluation of the comorbidities burden was performed with the modified Rheumatic Disease Comorbidity Index (mRDCI). Radiographic knee OA was defined according to Kellgren/Lawrence (KL) grades. Chi-square, analysis of variance (ANOVA), and multinomial logistic regression analyses were used to test the prognostic value of frailty for the outcomes of interest.

Table 1.

Multinomial logistic regression analyses:c oefficients, standard errors and Wald statistic.

VariableCoefficientStd. ErrorWaldPAge, yrs-0.178720.0653994.46820.0534Gender-0.0873040.733660.014160.9053BMI, Kg/m2-0.0963200.0811241.40970.2351Pain duration from diagnosis, yrs0.130650.0690513.58010.0585Educational level, yrs0.0669130.0803010.69440.4047Kellgren/Lawrence grades0.620740.506291.50320.2202mRDCI-0.602770.1899310.07140.0015SF36-MCS0.0281430.0200741.96550.1609SF36-PCS-0.000702600.0251180.00078240.9777WOMAC Pain subscale-0.291290.08161912.73730.0004Constant17.425185.732699.23930.0024Figure 1.

Distribution of the WOMAC-Pain scores according to the frailty categories by SHARE-FI, and p-values for comparison (ANOVA test)

Conclusion:

Frailty or pre-frailty are common in KNEE-OA. The main factors associated with frailty were pain and comorbidity burden. Implementation of the frailty assessment into the routine rheumatological practice could represent a major advance in KNEE-OA care. Further studies are needed to identify the physiological mechanisms underpinning these associations.

References:

[1]Veronese N, Maggi S, Trevisan C, Noale M, De Rui M, Bolzetta F, Zambon S, Musacchio E, Sartori L, Perissinotto E, Stubbs B, Crepaldi G, Manzato E, Sergi G. Pain Increases the Risk of Developing Frailty in Older Adults with Osteoarthritis. Pain Med. 2017;18(3):414-427.

[2]Salaffi F, Carotti M, Grassi W. Health-related quality of life in patients with hip or knee osteoarthritis: comparison of generic and disease-specific instruments. Clin Rheumatol. 2005 Feb;24(1):29-37.

[3]Salaffi F, Leardini G, Canesi B, Mannoni A, Fioravanti A, Caporali R, Lapadula G, Punzi L; GOnorthrosis and Quality Of Life Assessment (GOQOLA). Reliability and validity of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index in Italian patients with osteoarthritis of the knee. Osteoarthritis Cartilage. 2003;11(8):551-60.

Disclosure of Interests:

None declared

SAT0101 ABATACEPT IN RHEUMATOID ARTHRITIS ASSOCIATED-INTERSTITIAL LUNG DISEASE: SHORT TERM OUTCOME AND PROGNOSTIC FACTORS

Background:

The prevalence of interstitial lung disease (ILD) in rheumatoid arthritis (RA) varies in the medical literature from 1% to 67% and is a major cause of mortality. Previous works have identified increased age, smoking and anticytrullinated protein antibodies (ACPA) titre as risk factors for RA-ILD (RA-ILD). Conventional treatments for RA may lead to a new onset or worsening of RA-ILD, so treatment should be identified to prevent the onset or exacerbation of RA-ILD. Studies have shown that abatacept (ABA) may improve the outcome of RA-ILD.

Objectives:

The aim of our study is to evaluate ABA effectiveness and safety in patients with RA-ILD.

Methods:

We enrolled RA-ILD patients who started treatment with ABA. All patients underwent thoracic high-resolution computed tomography (HRCT) at the beginning of ABA treatment and after 18 months of therapy. HRCT abnormalities were evaluated using a a computer-aided method (CaM). At each visit clinical, laboratory and respiratory function characteristics were collected and the Clinical Disease Activity Index (CDAI) and the Health Assessment Questionnaire Disability Index (HAQ-DI) for disease activity and functional disability were measured. The cohort was divided into three groups based on the CaM-HRCT results: patients with a lung fibrosis progression of 15% or more were defined as “worsened”, those with a reduction of 15% or more were defined as “improved”, all other patients were defined as “stable”. The 15% threshold of change, derived from the CaM assessment, results from the determination of the standard deviation of the mean value change after 18 months of follow-up of the cohort. The multivariate regression model was used to assess the strength of the association between RA characteristics and HRCT response to ABA.

Results:

Forty-four patients (81% women) with a mean age of 59.1±8.0 years and a mean duration of the disease of 7.5±3.1 years were recruited. Twenty-three (52.3%) patients were positive for ACPA and 28 (63.6%) for rheumatoid factor. Five patients (11.4%) showed deterioration of ILD, 31 (70.6%) were in the “stable” group, and 7 patients (16.0%) experienced improvement over a mean follow-up period of 18 months. The factors related to ILD deterioration were use of methotrexate (MTX) (p=0.0078), and current smoking habit (p=0.0054), according to multivariate regression analysis (Table).

Conclusion:

Treatment with ABA is associated with an RA-ILD stability or improvement rate of 86.6% of patients, while the worsening rate is 11.4%. Concomitant treatment with MTX and current smoking habit are factors associated with RA-ILD worsening. MTX discontinuation and smoking cessation should be strongly promoted in patients with RA-ILD.

References:

[1]Salaffi F, Carotti M, Di Carlo M, Tardella M, Giovagnoni A. High-resolution computed tomography of the lung in patients with rheumatoid arthritis: Prevalence of interstitial lung disease involvement and determinants of abnormalities. Medicine (Baltimore). 2019 Sep;98(38):e17088.

[2]Mochizuki T, Ikari K, Yano K, Sato M, Okazaki K. Long-term deterioration of interstitial lung disease in patients with rheumatoid arthritis treated with abatacept. Mod Rheumatol. 2019;29(3):413-417.

Table.

Multivariate regression analysis of the variables related to the worsening of RA-ILD

Independent variablesCoefficientStd. ErrortPrpartial(Constant)1.6370Age-0.00120.0050-0.20.8131-0.042Sex0.0250.10.230.81610.042Disease duration0.0150.0170.890.37990.15ACPA positivity-0.0120.071-0.180.8566-0.032RF positivity0.00300.0790.0380.96940.0069Current smokers-0.340.11-2.990.0054-0.47MTX use-0.390.13-2.840.0078-0.45DLco0.00520.00610.840.40300.15FVC-0.00880.0088-1.0060.3224-0.17CAM-HRCT (% fibrosis)0.000820.00910.090.92850.016CDAI-0.00740.0038-1.960.0588-0.33HAQ-DI-0.0170.14-0.110.9059-0.021

Disclosure of Interests:

None declared

THU0518 ACCURACY OF DUAL-ENERGY COMPUTED TOMOGRAPHY FOR THE DETECTION OF BONE MARROW EDEMA IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

An important applications of the Dual energy computed tomography DECT in the field of musculoskeletal radiology is the detection of bone marrow edema (BME), using a post-processing software to remove calcium in trabecular bone by using a “virtual non-calcium (VNCa)” subtraction process DECT have been successfully employed in the evaluation of the extent of BME in patients with sacroiliitis (1)

Objectives:

The aims of this study were i)to evaluate the discriminating capacity of DECT versus MRI in the detection of BME of the sacroiliac joints in patients with axial-SpA and to define the optimal cutoff; ii) to define of inter-observer agreement between radiologists

Methods:

All patients underwent a pelvic DECT examination, within 30 days of the MRI imaging, (Somatom Force; Siemens Healthineers, Enlangen, Germany). Each exam was evaluated by two operators: an experienced radiologist and a radiologist in training. The dedicated software also allows the precise calculation of the attenuation values in the region of interest (ROI). On the reformatted color-coded dual-energy virtual non-calcium images bone marrow signal is depicted in green and corresponding to high signal intensity on T2-weighted fat suppression MR images (Fig. 1). With the consent of the two operators, three ROIs were manually positioned for each side of the sacroiliac joints in the subchondral region of the proximal, middle and distal thirds of each joint head, respectively. The interobserver agreement analysis was carried out in the semi-quantitative evaluation of the scores assigned in CT. The accuracy of DECT for the detection of BME compared to MRI was analyzed using the Receiver Operating Characteristics (ROC) curve method

Figure 1.

Patient with SpA A. Short tau inversion recovery MR image demonstrating extensive BME in both iliac and sacral subchondral bone, indicating active sacroiliitis. B. CT Semicoronal multiplanar reformatted grayscale image shows signs of structural change. C. Semicoronal multiplanar reformatted color-coded dual-energyVNCaimage reveals bone marrow signal involving both sacroliliac joints, corresponds toBMEon the MR image

Results:

56 axial-SpA patients have been evaluated, 30 males and 26 females, a mean age of 48.6 ± 12.3 years, a mean disease duration of 5.5 ± 2.9 years, a mean C-reactive protein level of 3.0 ± 2.5 mg/dl. The inter-rater agreement of readers showed a high statistical significance greater than 0.80, in particular the weighted kappa is 0.815, with a standard error of 0.04 and a 95% variability coefficient between 0.73 and 0.89. Sensitivity, specificity, and positive likelihood ratio in the identification of BME at DECT were 95.8%, 83.3% and 6.67, respectively. The differences in mean CT number (HU) among the four levels of edema category were significant (p<0.0001). The AUC was 0.905 in the differentiation of the presence of BME from no edema (Fig. 2). A cutoff value of –14.8 HU yielded overall sensitivity of 82.86% and specificity of 90.48%, with an LR+ of 8.70, in the detection of BME

Figure 2.

Graph shows ROC curves from CT numbers (in Hounsfield units) derived from DECT images in the detection of sacroiliitis with and without BME. AUC was 0.905

Conclusion:

We confirm the potential of DECT for the detection of BME of the sacroiliac joints in patients affected by SpA. This new method appears to be very useful, not only in the diagnostic phase, but also for the monitoring of patients.

References:

[1]Carotti M, Salaffi F, Beci G, Giovagnoni A. The application of dual-energy computed tomography in the diagnosis of musculoskeletal disorders: a review of current concepts and applications. Radiol Med. 2019;124(11):1175-1183.

Disclosure of Interests:

None declared

Computed tomography assessment of evolution of interstitial lung disease in systemic sclerosis: Comparison of two scoring systems

BACKGROUND

The aim of this study was to evaluate and compare the internal and external responsiveness of a computed-aided method (CaM) with a conventional visual reader-based score (CoVR) to measure interstitial lung disease (ILD) in patients with systemic sclerosis (SSc) on high resolution computed tomography (HRCT).

METHODS

Forty-five patients were evaluated in this retrospective cohort. HRCTs were collected at baseline and after 1 year. HRCT abnormalities were evaluated according to a CoVR (Warrick's method) and a quantitative CaM. Internal 1-year responsiveness was tested with a standardized mean response (SRM). Analyses of the receiver operating characteristic curves (ROCs) evaluated the sensitivity and specificity of the two methods to discriminate between clinically relevant progression and no relevant progression, using expert judgment as the gold standard (external responsiveness).

RESULTS

In one year, lung involvement was stable/improved in 17 of the 45 patients (37.8%) and worsened in 28 patients (62.2%). HRCT scores changed moderately over the follow-up period. Using SFM, CaM was significantly more responsive in detecting changes due to treatment than the CoVR method. Likewise, in the analysis of the ROC curve, CaM scores showed the highest performance (AUC ROC CaM vs. CoVR, 0.951 vs. 0.807; p = 0.0065).

CONCLUSION

Quantitative analysis of CaM was more responsive than the CoVR method to accurately evaluate and monitor SSc-ILD progression or response to therapy.

Sonographic assessment of calcium pyrophosphate deposition disease at wrist. A focus on the dorsal scapho-lunate ligament

OBJECTIVES

To investigate the diagnostic accuracy of ultrasound and conventional radiography in the evaluation of calcium pyrophosphate crystal deposits at wrist level.

METHODS

Consecutive patients with a "definite" diagnosis of calcium pyrophosphate deposition disease and disease-controls were prospectively included in this cross-sectional single-centre study. Scapho-lunate ligament, triangular fibrocartilage complex, and volar recess of the radio-lunate joint were explored using ultrasound, conventional radiography and computed tomography.

RESULTS

Sixty one patients and 39 disease controls were enrolled. Two-hundred wrists were evaluated using both conventional radiography and ultrasound and 26 using computed tomography. Ultrasound findings indicative of crystal deposits were found in at least one wrist in 95.1% of patients and in 15.4% of controls (P<0.001). Scapho-lunate ligament calcifications were reported in 83.6% of patients and in 5.1% of controls (P<0.001). On conventional radiography, calcifications were found in at least one wrist in 72.1% of patients and in 0% of controls (P<0.001). Using the Ryan-McCarty criteria as a gold standard, sensitivity, specificity and diagnostic accuracy were 0.72 (0.59-0.83), 1.0 (0.91-1.0) and 0.83 (0.74-0.90) for conventional radiography and 0.95 (0.86-0.99), 0.85 (0.69-0.94) and 0.91 (0.84-0.96) for ultrasound. The agreement between ultrasound and computed tomography was substantial when assessing triangular fibrocartilage complex (kappa=0.70; 0.43-0.97) and scapho-lunate ligament (kappa=0.69; 0.41-0.97), and moderate for radio-lunate joint (kappa=0.46; 0.12-0.80).

CONCLUSIONS

This study supports the diagnostic accuracy of ultrasound in evaluating wrist involvement in calcium pyrophosphate deposition disease. The inclusion of the scapho-lunate ligament in a disease-oriented scanning protocol could improve the diagnostic performance of ultrasound.

The Comprehensive Rheumatologic Assessment of Frailty (CRAF): development and validation of a multidimensional frailty screening tool in patients with rheumatoid arthritis

OBJECTIVES

Frailty is a topic that is gaining more and more interest in rheumatology. The aims of this study were to develop and preliminarily validate a frailty index dedicated to rheumatoid arthritis (RA) called the Comprehensive Rheumatologic Assessment of Frailty (CRAF).

METHODS

Ten major frailty domains of CRAF were identified: nutritional status, weakness, falls, comorbidity, polypharmacy, social activity, pain, fatigue, physical function, and depression. Convergent validity was evaluated correlating the scores of the CRAF with the Frailty Instrument for Primary Care of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI). Discriminant validity was assessed using receiver operating characteristic (ROC) curve analysis. Multivariate logistic regression model procedure was used to assess the relative contribution of the individual determinants on the CRAF.

RESULTS

Among the 219 RA patients, 79 (36.1%) were defined as non-frail (CRAF ≤0.12), 63 (28.8%) mild frail (0.12 <CRAF ≤0.24), 34 (15.5%) moderate frail (0.24 <CRAF ≤0.36), and 43 (19.6%) severe frail (CRAF >0.36). In testing for convergent validity, a significant correlation was found between CRAF and SHARE-FI (p <0.0001). The discriminatory power of CRAF was higher than those of the SHARE-FI (difference between areas under the ROC curves=0.0853± 0.0282. Variables associated with frailty at the multivariate analysis were advanced age and high disease activity (both at p<0.0001).

CONCLUSIONS

The CRAF demonstrated a robust validity and good discriminant accuracy. Implementation of the frailty assessment into the routine rheumatological practice could represent a major advance in RA care.

Adherence to subcutaneous anti-TNFα agents in patients with rheumatoid arthritis is largely influenced by pain and skin sensations at the injection site

AIM

The aims of this prospective study were to determine the dimension of adherence in rheumatoid arthritis (RA) patients receiving subcutaneously administered anti-tumor necrosis factor-α (anti-TNFα) agents and to evaluate the influence of injection site pain and skin perceptions following subcutaneous administration of anti-TNFα drugs on patients' adherence.

METHOD

An inception cohort of patients starting subcutaneously administered anti-TNFα treatment was enrolled. Injection site pain perception was assessed through the Self-Injection Assessment Pain Questionnaire (SIAPQ), and adherence to treatment was ascertained by the Compliance Questionnaire for Rheumatology (CQR5). Associations between beliefs and non-adherence, and the influence of demographic (age, disease duration, educational level), clinical (body mass index, patient global assessment, physician global assessment, Numerical Rating Scale of pain, Health Assessment Questionnaire-Disability Index, Simplified Disease Activity Index, and comorbidities measured by the modified Rheumatic Disease Comorbidty Index), and radiographic (Simple Erosion Narrowing Score) variables were assessed using logistic regression models.

RESULTS

Adherence data over a 12-month interval were available for 193 patients. Of these, 21.7% reported non-adherence to anti-TNFα therapy. No difference (P = .383) was found for anti-TNFα drugs (adalimumab, etanercept, certolizumab pegol and golimumab). In the logistic model, age (P = .0029), higher disease activity (P = .020), low numbers of comorbidity conditions (P = .0004), injection site pain and skin perception (P = .0008), were significantly associated with increased likelihood of medication adherence.

CONCLUSION

Adherence is influenced by both demographic characteristics (age) and clinical factors (disease activity, comorbidity burden and injection site pain and skin perception) in RA patients.

Prevalence and distribution of cartilage damage at the metacarpal head level in rheumatoid arthritis and osteoarthritis: an ultrasound study

OBJECTIVES

To determine the prevalence and distribution of US-detected qualitative cartilage damage at metacarpal heads of patients with RA and hand OA.

METHODS

Fifty-two RA patients and 34 patients with hand OA were enrolled. US examination of the metacarpal head cartilage from the II to V finger of both hands was performed. A total of 414 MCP joints in RA and 266 MCP joints in OA patients were scanned with a linear probe up to 22 MHz. Qualitative assessments using a previously described scoring system for cartilage damage were performed. The prevalence and distribution of cartilage damage were analysed. Multivariate regression analysis was used to determine the predictive value of age, gender, BMI, disease duration and the presence of RF and anti-CCP antibodies for US-detected cartilage damage.

RESULTS

The metacarpal head cartilage was positive for cartilage damage in 35.7% (148/414) of MCP joints in RA and in 43.6% (116/266) of MCP joints in OA patients. In RA, the hyaline cartilage of the II and III metacarpal heads (bilaterally) was the most frequently affected. In OA, cartilage damage was more homogeneously distributed in all MCP joints. Multivariate regression analysis showed that age and disease duration, but not gender, BMI or autoantibody status, were independent predictors of US-detected cartilage damage in RA.

CONCLUSION

Cartilage damage was found in more than one-third of the MCP joints in both RA and OA patients, and in RA patients, the II and III MCP joints were the most damaged.

Development and validation of the SImple FIbromyalgia Screening questionnaire for improving the recognition of fibromyalgia in daily practice

OBJECTIVES

To develop and test in a preliminary way a new self-administered and user-friendly screening tool, called SImple FIbromyalgia Screening (SIFIS) questionnaire, to screen Italian speaking patients for the presence of fibromyalgia (FM).

METHODS

The development of the SIFIS questionnaire followed five steps: identification of a specific patient population, item pool development, item reduction, test of the provisional questionnaire, and validation study. The item generation was carried out by a review of the literature on the existing questionnaires. Thirty-three items were identified, and a survey was performed among 139 specialists. The frequency importance product allowed us to select the six most significant items. The validation study allowed the determination of sensitivities, specificities and likelihood ratios (LRs) aiming to calculate the post-test probability of the presence of FM, by applying the Bayesian Analysis Model method.

RESULTS

The preliminary testing was performed in 284 subjects with multi-site pain. In 230 (80.9%) of them, FM was diagnosed according to the modified 2010 American College of Rheumatology (ACR) criteria. For each of the six items, LRs varied between 3.37 and 5.00. The best positive LR was found in item 1, exploring persistent pain. The presence of four out of six items gave a post-test probability ≥80% (range: 81.8-87.1%).

CONCLUSIONS

The SIFIS questionnaire is a useful tool that can be used for potential screening.

Dual-energy CT: theoretical principles and clinical applications

The physical principles of dual-energy computed tomography (DECT) are as old as computed tomography (CT) itself. To understand the strengths and the limits of this technology, a brief overview of theoretical basis of DECT will be provided. Specific attention will be focused on the interaction of X-rays with matter, on the principles of attenuation of X-rays in CT toward the intrinsic limits of conventional CT, on the material decomposition algorithms (two- and three-basis-material decomposition algorithms) and on effective Rho-Z methods. The progresses in material decomposition algorithms, in computational power of computers and in CT hardware, lead to the development of different technological solutions for DECT in clinical practice. The clinical applications of DECT are briefly reviewed in relation to the specific algorithms.

High-resolution computed tomography of the lung in patients with rheumatoid arthritis: Prevalence of interstitial lung disease involvement and determinants of abnormalities

An international consensus for rheumatoid arthritis (RA) patients at risk of developing interstitial lung disease (ILD) is still lacking. The aims of study were to evaluate: the prevalence of ILD involvement in RA over high-resolution computed tomography (HRCT); the relationships between pulmonary function tests (PFTs), patient-centered measurements, and ILD; and the potential risk factors contributing to RA-ILD patients.Data regarding the clinical characteristics (age, sex, age at onset of RA), laboratory findings (rheumatoid factor [RF] and anti-citrullinated protein antibodies [ACPA]), respiratory functional assessment (forced vital capacity [FVC] and carbon monoxide diffusion capacity [DLCO]), patient-centred measures of dyspnea (PCMD), Health Assessment Questionnaire-Disability Index (HAQ-DI), and HRCT have collected retrospectively. HRCT abnormalities were evaluated using a conventional visual reader-based score (CoVR) and a computer-aided method (CaM). The relationships between the 2 HRCT scores-PFTs and PCMD-were calculated using Pearson correlation. The area under the receiving-operating characteristic (AUC-ROC) curve was calculated to determine the discriminatory performance of measurements between patients with and without ILD. The multivariate regression model was used to evaluate the association force between ILD and RA characteristics.In all, 151 patients (45 males and 106 females, mean age 53.4 ± 7.6 years) were included. ILD had been detected in 29 patients out of 151 (19.2%). Usual interstitial pneumonia was the most common HRCT. RA-ILD patients were older, and older at RA onset (both P < .01), with a higher HAQ-DI (P < .05) than patients without ILD. ACPA positivity and titer were higher in the RA-ILD group (P = .02). Extent and severity of ILD, and total CoVR and CaM score closely related to DLCO and PCMD (both P < .0001). A reduced DLCO was the most sensitive test for predicting the presence of ILD on HRCT (AUC-ROC 0.811 ± 0.037). Advanced age (P < .0001), age at RA onset (P = .025), ACPA titer (P = .004), and smoking (P = .008) were independent explanatory variables of HRCT damage in multivariate analysis.The RA-ILD is associated with age and older age of RA onset, smoking, and ACPA titer. DLCO seems to be the most sensitive parameter to predict ILD on HRCT, followed by PCMD.

Diagnostic value of major salivary gland ultrasonography in primary Sjögren's syndrome: the role of grey-scale and colour/power Doppler sonography

Primary Sjögren's syndrome (pSS) is an autoimmune connective tissue disease characterized primarily by chronic inflammatory involvement of the exocrine glands, particularly the salivary glands. The use of ultrasound in the study of salivary glands (SGUS) has expanded considerably in recent years. The ultrasound can document structural alterations that can be visualized as hyperechogenic and hypoechogenic areas, or as areas with non-homogeneous echogenicity. To date, several systems of SGUS scoring systems of abnormalities during pSS are available. From the studies published in recent decades, it has been possible to document the high sensitivity and specificity of the pathological findings that can be documented by SGUS. SGUS can also provide added value in identifying patients at risk for developing disease complications such as lymphoma. The Doppler technique can also supply information about glandular tissue vascularization, which is very useful for diagnostic and differential purposes. In this review we will present the state of the art of SGUS, with a prevailing focus on diagnostic use and possible future developments.

The Effect of Neuropathic Pain Symptoms on Remission in Patients with Early Rheumatoid Arthritis

BACKGROUND

The presence of neuropatic pain (NeP) is common in subjects with established Rheumatoid Arthritis (RA), and it can influence the disease remission. These aspects have not been investigated in patients with Early Rheumatoid Arthritis (ERA).

OBJECTIVE

To investigate the effect of NeP on the achievement of remission in patients with ERA.

METHOD

The study involved consecutive ERA patients with moderate or high disease activity. The painDETECT Questionnaire (PDQ), the 36-item Short Form Health Survey (SF-36), and the Euro- QoL-5 Dimensions (EQ-5D) were administered to all the patients, and their co-morbidity data were used to calculate their modified Rheumatic Disease Comorbidity Index (mRDCI). After six months' follow-up, the presence or otherwise of NeP in each individual patient was calculated, and whether or not the Boolean remission criteria were satisfied.

RESULTS

The study was completed by 115 patients (76% females) whose PDQ scores indicated that 13% had probable NeP. At the end of the follow-up period, 25 patients (21.7%) met the Boolean remission criteria. Logistic regression analysis showed that baseline PDQ scores (p=0.0023) and the mRDCI (p=0.0054) were the strongest predictors of not being in Boolean remission. Only one of the 15 patients with concomitant NeP achieved Boolean remission.

CONCLUSION

The presence of NeP may affect the achievement of remission in ERA patients. The PDQ can be a useful tool to measure central pain sensitisation in such patients.