The differential crosstalk of the skin-gut microbiome axis as a new emerging actor in systemic sclerosis

OBJECTIVES

We characterized the microbiota in SSc, focusing on the skin-oral-gut axis and the serum and faecal free fatty acid (FFA) profile.

METHODS

Twenty-five SSc patients with ACA or anti-Scl70 autoantibodies were enrolled. The microbiota of faecal, saliva and superficial epidermal samples was assessed through next-generation sequencing analysis. GC-MS was used to quantify faecal and serum FFAs. Gastrointestinal symptoms were investigated with the University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument (UCLA GIT-2.0) questionnaire.

RESULTS

The ACA+ and anti-Scl70+ groups displayed different cutaneous and faecal microbiota profiles. The classes of cutaneous Sphingobacteriia and Alphaproteobacteria, the faecal phylum Lentisphaerae, the levels of the classes Lentisphaeria and Opitutae, and the genus NA-Acidaminococcaceae were significantly higher in faecal samples from the ACA+ patients than in samples from the anti-Scl70+ patients. The cutaneous Sphingobacteria and the faecal Lentisphaerae were significantly correlated (rho = 0.42; P = 0.03). A significant increase in faecal propionic acid was observed in ACA+ patients. Moreover, all levels of faecal medium-chain FFAs and hexanoic acids were significantly higher in the ACA+ group than in the anti-Scl70+ group (P < 0.05 and P < 0.001, respectively). In the ACA+ group, the analysis of the serum FFA levels showed an increasing trend in valeric acid.

CONCLUSION

Different microbiota signatures and FFA profiles were found for the two groups of patients. Despite being in different body districts, the cutaneous Sphingobacteria and faecal Lentisphaerae appear interdependent.

The Muscle Shortening Maneuver: a noninvasive approach to the treatment of peroneal nerve injury. A case report

BACKGROUND

The treatment of peripheral nerve injuries is a debated topic. The Muscle Shortening Maneuver (MSM), a physiotherapy approach, is noninvasive and free of side effects; it consists of a muscle shortening and a solicitation in traction applied simultaneously.

OBJECTIVE

The focus of this report is to describe the effects of the MSM combined with walking retraining in a patient with incomplete injury of the peroneal nerve.

DESCRIPTION

The patient was a 17-year-old man, who underwent osteotomy surgery of the proximal two-thirds of the fibula, due to an Ewing sarcoma that caused a partial injury of the left peroneal nerve. Our assessment plan of the left ankle movement ability comprised range of movement, muscle strength, and surface electromyography (EMG); and a gait analysis was conducted by using an iPhone application. MSM and walking retraining were administered twice and once a week, respectively, for 4 weeks.

OUTCOMES

The active range of movement substantially improved in dorsiflexion (≥15°), whereas slightly decreased in plantar flexion (-5°). Aside from the tibialis anterior, an increase in muscle strength was detected. Surface EMG showed an increased activation, particularly in the peroneus longus. A decrease in gait speed and step length was recorded from the gait analysis, with a better bilateral symmetry.

CONCLUSIONS

Positive outcomes were reported without evidence of risk or adverse events for the participant.

The muscle shortening maneuver in individuals with stroke: a consideration-of-concept randomized pilot trial

BACKGROUND AND PURPOSE

The Muscle Shortening Maneuver (MSM) is derived from Feldman's λ model of motor control, and seems to induce a more balanced agonist- antagonist-muscular action. The hypothesized mechanism of action is a modulation of the Tonic Stretch Reflex Threshold (TSRT). We designed a pilot, randomized trial aimed to explore the mechanisms of action of the technique. An ancillary objective was to research the implementation of the MSM as a stroke rehabilitation intervention.

METHODS

A sample of 10 participants with chronic stroke was enrolled and randomly assigned to MSM (n, 5) or conventional physical therapy (CPT) (n, 5) treatments. The TSRTs were assessed by the Montreal Spasticity Measure device. A selection of clinical and instrumental outcome measures was taken to investigate function and activity levels. Data were collected at baseline, end-of-treatment, and one month after the end-of-treatment.

RESULTS

No adverse events were observed. In both between- and within-group post-treatment assessments, in the affected ankle the MSM group showed decreased TSRTs of the plantar flexor, increased strength of the dorsiflexor and active range of motion; also, the time needed to perform the Timed Up and Go test decreased. No changes were evident across assessments in the CPT group.

DISCUSSION AND CONCLUSIONS

The MSM seems able to modulate the TSRTs in individuals with stroke. Although with the limitations due to the pilot design, the variation in participants' responses appear to be promising. Many methodological issues have to be clarified and specified conceiving the progression toward a confirmatory trial.

Shoulder impingement syndrome in water polo players: muscle shortening manoeuvre controls pain intensity, recovers function and normalizes sonographic parameters

PURPOSE

To evaluate the effects of muscle shortening manoeuvre (MSM) by sonography (US) in professional water polo players with shoulder impingement syndrome (SIS).

METHODS

Twenty-four professional water polo players (mean age: 22.13 ± 3.34) with SIS were assigned to one of 2 different treatment interventions: Group (1) MSM: a series of fast accelerations in the upward direction was applied to the upper limb that's connected to a spring through a metal plate with a ring. The ring was linked to a pulley system that was submitted to forces acting in the opposite direction (added mass). Group (2) Simple traction: the series of fast accelerations were performed without the springs. Pain intensity, Yocum and Hawkins tests for SIS, Neer's impingement sign, range of motion, muscle strength and shoulder US were assessed. The examination was performed before, immediately after and 30 days after each treatment to study the US width of subacromial-subdeltoid bursa (SSB), thickness of supraspinatus (ST), long biceps tendons (LBT); hypoechoic halo of surrounding the long biceps (LBH) and subscapular tendons (STH); width of acromio-clavicular joint capsule (ACJ) and the distance between bone heads (ACD). Impingement sign (IS) was evaluated by dynamic examination.

RESULTS

Immediately after treatment with MSM, pain was much reduced (p = 0.002); Yocum and Hawkins tests were decreased (p = 0.008, p = 0.031); Neer's impingement sign was negative; range of motion and muscle strength were increased. US showed that the following parameters were significantly reduced: SSB (p = 0.001), LBT (p = 0.014), LBH (p = 0.014), SSH (p = 0.002), ACJ (p = 0.004), ACD (p = 0.001). IS was no more detected. After 30 days, the improvement of clinical and US findings was maintained. In the control group, after simple traction, no clinical amelioration of US parameters was found immediately after the procedure.

CONCLUSION

These data show that MSM could be significantly and rapidly effective against pain and the loss of function due to shoulder impingement in water polo players.

Effects of laser therapy and Grimaldi’s muscle shortening maneuver on spasticity in central nervous system injuries

Background an Aims: For 2003 year until today we treated hundreds of patients with Central Nervous System Injuries (CNSI), using Non-Surgical Laser Therapy (NSLT) obtaining good results in terms of sensibility and movement. In order to increase muscle strength and to further explore new emerging synergies, we have also started using a physical therapy practice based on the most current knowledge about the motor control, called Grimaldi’s Muscle Shortening Maneuver (GMSM). Spasticity is often the most disabling symptom and the current therapies are still not able to heal it at all. The goal of our study is to suggest a new way of treatment of spasticity, supporting it with objective measurements of muscle thresholds. Materials and Methods: In 2016-2017, 36 patients with traumatic or degenerative CNSI were enrolled. Lasers used were 808 nm, 10600 nm, and 1064 nm, applied with a first cycle of 20 sessions, four a day. Patients were subjected to Grimaldi’s Muscle Shortening Maneuver (MSM) twice a day, ten sessions at all, working selectively on hypertonic muscles and their antagonists. Before treatment, tonic stretch reflex thresholds (TSRTs) in Gastrocnemius Lateralis (GL) were assessed through a surface electromyography (sEMG) device paired with an electrogoniometer. Antagonist muscle force (Tibialis Anterioris) was assessed by some electronic hand-held dynamometers. For the clinical measure, we used the Modified Ashworth Scale (MAS). All tests have been performed at the baseline (before starting treatments), after one week (at the end of the last treatment) and after a month. Results: Results were considered positive if the instrumental assessment procedure showed modifications in TSRT values and subjects improved their antagonist muscle strength. Results showed modifications in TSRT values at every follow up. The average comparison between the follow-ups was always statistically significant (p .000). The increase in Tibialis Anterioris muscle strength was statistically significant as well (p .000). MAS showed some differences between followups but not all of them are statistically significant (T0-T1 p .063, T1-T2 p .001, T0-T2 p .000). Encouraging results suggest a possible correlation between laser and MSM therapies and modifications of TSRT in spastic muscles. Conclusion: Associating laser treatment and Grimaldi’s Muscle Shortening Maneuver (MSM) seems to be effective on spasticity in patients affected by traumatic or degenerative CNSI. Obviously, this kind of study design showed a lot of limits however this clinical series could be an important hint for every researcher working in the complex field of spasticity, a symptom that is poorly defined and hardly treated.

POS0487 THE CROSSTALK OF THE SKIN-ORAL-GUT MICROBIOME AXIS IN LIMITED AND DIFFUSE CUTANEOUS SYSTEMIC SCLEROSIS

Background

Systemic sclerosis (SSc) is a complex and still unclear rare disease. Microbiota has recently emerged as an important environmental factor in SSc pathogenesis, either at gut, oral and skin level.

Objectives

To investigate the role of microbiota in SSc subsets, focusing on the skin-oral-gut microbiota axis and serum and fecal free fatty acids (FFA) profile.

Methods

Twenty-six consecutive SSc patients (22 females) (mean disease duration (SD): 13 ± 6.91 yrs), classified according to the ACR/EULAR2013 criteria, were enrolled. Demographic, clinical and laboratory data were recorded. Gastrointestinal symptoms were investigated with UCLA GIT-2.0-questionnaire. Fecal, unstimulated saliva and superficial epidermal samples were collected. Microbiota was assessed through 16S ribosomal RNA Next Generation gene-sequencing analysis. Gas Cromatography-Mass Spettroscopy was used to measure FFAs in serum and fecal samples.

Results

Thirteen patients had limited cutaneous SSc (lcSSc), 13 diffuse cutaneous (dcSSc). The two subsets displayed a different cutaneous and fecal microbiota profile. In detail, the class of cutaneous Sphingobacteria was significantly higher in lcSSc (p<0.05), while the phylum of Lentisphaerae, the family of Victivallaceae and the genus of Victivallis were significantly higher in fecal samples of lcSSc (all p<0.05). A significant increase of fecal propionic acid was observed in lcSSc patients (p<0.05). Moreover, all fecal medium-chain FAs and hexanoic acids were significantly higher in lcSSc (p<0.05 and p<0.001, respectively). The analysis of serum FFAs levels showed an increase of valeric and octanoic acids in lcSSc (both p<0.05). A negative correlation between UCLA-GIT-2.0 total score and fecal octanoic acid (rho=-0.61; p=0.03), and a positive correlation with serum propionic acid (rho=0.55; p=0.05) was found in lcSSc.

Conclusion

Our findings show a different microbiota signature in the skin and gut, and a different FFAs profile in lcSSc and dcSSc. Such a differential regulation of microbiota composition and bacterial metabolite production suggests different dynamics of skin-oral-gut microbiota axis in SSc subsets. This data could be useful to develop personalized therapies targeting gastrointestinal and skin involvement.

Disclosure of Interests

None declared.

AB0747 Oral microbiome in rheumatic diseases.What involvement?

Background

The concept of core-microbiome in health is useful for investigating the possible role of the oral microbiome in autoimmune disease, such as Rheumatoid Arthritis, Spondyloarthritis, Sjogren Syndrome or Systemic Sclerosis (SSc), whose pathogenesis has not been fully understood. Environmental factors and certain genetic backgrounds have been proposed. Among the various environmental factors, the microbiota stands out, the entire composition of microorganisms, mainly bacteria but also fungi and viruses, which populate the human body.

Objectives

The aim of the study was to verify whether there were quantitative differences between the microorganisms present in the oral cavity, in particular between the lactobacillus spp., of patients with SSc compared to those present in the oral cavity of healthy subjects taken as controls.

Methods

Twenty-nine SSc female patients (mean age 62.) classified according to the ACR/EULAR2013 criteria and twenty-three female healthy subjects (HS, mean age 57.6) were enrolled and underwent tongue and gum swab sampling. Quantitative PCR was conducted in triplicates using Lactobacillus specific primers rpoB1, rpoB1o and rpoB2 for RNA-polymerase β subunit gene.

Results

Our data showed Lactobacillusspp.rpoB sequences significantly lower in the tongue of SSc patients than in HS (p=0.0211).The statistical analysis in HS highlighted a significant lower amount of rpoB on the gums than on the tongue.

Conclusion

Our preliminary data show that the number of Lactobacillus on the tongue in SSc patients is about half that of HS. These data make it more likely that Lactobacillus in SSc patients may play a protective role. Further investigations will also be needed in other autoimmune diseases.

References

[1]Zaura E, Keijser BJ, Huse SM, Crielaard W Defining the healthy “core microbiome” of oral microbial communities. BMC Microbiol. 2009 Dec 15;9:259. doi: 10.1186/1471-2180-9-259.

[2]Nikitakis NG, Papaioannou W, Sakkas LI, Kousvelari E.The autoimmunity-oral microbiome connection. Oral Diseases (2017) 23, 828-839.

Disclosure of Interests

None declared

THE ROLE OF CHEST CT IN DECIPHERING INTERSTITIAL LUNG INVOLVEMENT: SYSTEMIC SCLEROSIS VERSUS COVID-19

OBJECTIVE

To identify the main computed tomography (CT) features that may help distinguishing a progression of interstitial lung disease (ILD) secondary to Systemic sclerosis (SSc) from COVID-19 pneumonia.

METHODS

This multicentric study included 22 international readers divided in the radiologist group (RAD) and non-radiologist group (nRAD). A total of 99 patients, 52 with COVID-19 and 47 with SSc-ILD, were included in the study.

RESULTS

Fibrosis inside focal ground glass opacities (GGO) in the upper lobes; fibrosis in the lower lobe GGO; reticulations in lower lobes (especially if bilateral and symmetrical or associated with signs of fibrosis) were the CT features most frequently associated with SSc-ILD. The CT features most frequently associated with COVID- 19 pneumonia were: consolidation (CONS) in the lower lobes, CONS with peripheral (both central/peripheral or patchy distributions), anterior and posterior CONS and rounded-shaped GGOs in the lower lobes. After multivariate analysis, the presence of CONS in the lower lobes (p < 0.0001) and signs of fibrosis in GGO in the lower lobes (p < 0.0001) remained independently associated with COVID-19 pneumonia or SSc-ILD, respectively. A predictive score was created which resulted positively associated with the COVID-19 diagnosis (96.1% sensitivity and 83.3% specificity).

CONCLUSION

The CT differential diagnosis between COVID-19 pneumonia and SSc-ILD is possible through the combination the proposed score and the radiologic expertise. The presence of consolidation in the lower lobes may suggest a COVID-19 pneumonia while the presence of fibrosis inside GGO may indicate a SSc-ILD.

THE MUSCLE SHORTENING MANOEUVRE: APPLICABILITY AND PRELIMINARY EVALUATION IN CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY: A RETROSPECTIVE ANALYSIS

INTRODUCTION

Physiotherapy plays a key role in cerebral palsy rehabilitation, through addressing body function/structure deficits, minimizing activity limitations, and encouraging participation. The muscle shortening manoeuvre is an innovative therapeutic technique, characterized by the ability to induce changes in muscle strength in a short time.

OBJECTIVE

To describe the applicability and estimate the effect of the muscle shortening manoeuvre applied to improve motor weakness and joint excursion of the ankle in children with hemiplegic cerebral palsy.

METHODS

Nine children with hemiplegic cerebral palsy received 3 intervention sessions in one week. Muscle strength, passive and active range of motion were assessed before, during and after the training, and at 1-week follow-up.

RESULTS

The children experienced an immediate increase in muscle strength and joint excursion of the ankle; the improvements were still present at follow-up after 7 days.

CONCLUSION

The muscle shortening manoeuvre may be an effective intervention to induce an immediate increase in muscle strength and range of motion of the ankle in children affected by hemiplegia due to cerebral palsy, thus promoting better physical functioning.

Oral Lactobacillus Species in Systemic Sclerosis

In systemic sclerosis (SSc), the gastrointestinal tract (GIT) plays a central role in the patient's quality of life. The microbiome populates the GIT, where a relationship between the Lactobacillus and gastrointestinal motility has been suggested. In this study, the analysis of oral Lactobacillus species in SSc patients and healthy subjects using culture-independent molecular techniques, together with a review of the literature on microbiota and lactobacilli in SSc, has been carried out. Twenty-nine SSc female patients (mean age 62) and twenty-three female healthy subjects (HS, mean age 57.6) were enrolled and underwent tongue and gum swab sampling. Quantitative PCR was conducted in triplicate using Lactobacillus specific primers rpoB1, rpoB1o and rpoB2 for the RNA-polymerase β subunit gene. Our data show significantly (p = 0.0211) lower LactobacillusspprpoB sequences on the tongue of patients with SSc compared to HS. The mean value of the amount of Lactobacillus ssprpoB gene on the gumsofSSc patients was minor compared to HS. A significant difference between tongue and gums (p = 0.0421) was found in HS but not in SSc patients. In conclusion, our results show a lower presence of Lactobacillus in the oral cavity of SSc patients. This strengthens the hypothesis that Lactobacillus may have both a protective and therapeutic role in SSc patients.

Rehabilitation of the face and temporomandibular joint in systemic sclerosis

BACKGROUND

Systemic sclerosis (SSc) alterations of the face and of the mouth cause aesthetic modifications and disability, impairing self-esteem and quality of life (QoL). The aim of this study was to verify the effects of two rehabilitation protocols on facial mimic and mouth opening.

METHODS

A total of 47 SSc patients (40 females and 7 males, mean age ± SD 59.08 ± 10.31 years), were consecutively selected: 22 were randomly assigned to protocol 1 [home exercises for temporomandibular joint (TMJ), mimic, masticatory and cervical spine muscles] and 25 to protocol 2 (home exercises and combined physiotherapeutic procedures performed by a physiotherapist). Each treatment had a duration of 12 weeks with a follow up of 8 weeks. TMJ dysfunction, orofacial involvement, disability, QoL, and safety were assessed at enrollment (T0), at the end of the treatment (T1), and at follow up (T2).

RESULTS

Both Protocol 1 and Protocol 2 induced significant improvements of some clinical and clinimetric parameters, but better results were obtained with Protocol 2. In the comparison between the effects of Protocol 1 and Protocol 2 at T1 and T2, a significant difference was observed only for Mouth Handicap in SSc [MHISS; Total (p = 0.00178] and for MHISS Mouth opening (p = 0.0098) at T1. No significant difference of indices of short-form 36 was observed.

CONCLUSION

The present data suggest that TMJ involvement in SSc may be managed by rehabilitation treatments. The action of a physiotherapist prescribing and personalizing exercises may induce better therapeutic effects.

The Emerging Challenge of Pain in Systemic Sclerosis: Similarity to the Pain Experience Reported by Sjőgren's Syndrome Patients

In order to evaluate the importance of pain in systemic sclerosis (SSc), the characteristics of pain reported by patients with SSc were analyzed and compared with the characteristics of pain reported by patients with primary Sjőgren's syndrome (pSS). Pain was reported by 56 patients (80%) in a group of 70 patients with SSc and by 25 patients (78%) in a group of 32 patients with pSS. Pain severity was assessed by the Pain Rating Index (PRI) and the Present Pain Intensity (PPI) of the McGill Pain Questionnaire (MPQ) and by values obtained by a visual analog scale (VAS) indicating the intensity of pain felt in the moment of the examination and the intensity of pain felt in the week preceding the moment of the examination. No significant difference was detected in the comparison of mean values of pain indices between patients with SSc and patients with pSS and in the comparison among subgroups of patients with SSc. The data indicate that pain is a frequent and important cause of suffering in SSc as in other chronic diseases. The association of different methods may be especially useful to obtain a careful evaluation of pain in clinical research.

When should a rare inherited connective tissue disorder be suspected in bicuspid aortic valve by primary-care internists and cardiologists? Proposal of a score

Size threshold for aortic surgery in bicuspid aortic valve (BAV) is debated. Connective tissue disorders (CTDs) are claimed as a clinical turning point, suggesting early surgery in BAV patients with CTD. Thus, we aimed at developing a score to detect high risk of carrying CTDs in consecutive BAVs from primary care. Ninety-eight BAVs without ectopia lentis or personal/family history of aortic dissection were studied at the Marfan syndrome Tuscany Referral Center. Findings were compared with those detected in 84 Marfan patients matched for sex and age. We selected traits with high statistical difference between MFS and BAV easily obtainable by cardiologists and primary-care internists: mitral valve prolapse, myopia ≥ 3DO, pectus carenatum, pes planus, wrist and thumb signs, and difference between aortic size at root and ascending aorta ≥ 4 mm. Clustering of ≥ 3 of these manifestations were more frequent in Marfan patients than in BAVs (71.4% vs 6.1%, p < 0.0001) resulting into an Odds Ratio to be affected by MFS of 38.3 (95% confidence intervals 14.8-99.3, p < 0.0001). We propose a score assembling simple clinical and echocardiographic variables resulting in an appropriate referral pattern of BAVs from a primary-care setting to a tertiary center to evaluate the presence of a potential, major CTD.

Risk of Malignancy and Biologic Therapy in Rheumatic Inflammatory Diseases: A Single-center Experience

OBJECTIVES

Biologic disease modifying anti-rheumatic drugs (bDMARDs) have significantly improved the care of patients with rheumatic muscle-skeletal disorders (RMDs). Considering their immunosuppressive action, a theoretical increase of malignancy risk has been a major concern in the last few decades. The objective of this study is to analyze the incidence of malignancies in a cohort of patients affected by rheumatoid arthritis (RA), psoriathic arthritis (PsA), and ankylosing spondylitis (AS) treated with bDMARDs.

METHODS

The charts of bDMARD-treated RMD patients were reviewed, and data about bDMARD exposure and malignant cancers (excluding non-melanoma skin cancer) were collected.

RESULTS

921 patients were included (median age: 50.59 years, 66.67% females); 1374 bDMARD treatments were administered, 87.12% were tumor necrosis factor inhibitors. A total of 21 malignant neoplasms were detected in 21 patients (61.90% females, median age at cancer diagnosis: 64.99 years), 66.67% in RA patients, 19.05% in PsA, and 14.28% in AS. Among them, 10 patients (47.62%) were treated with etanercept, 6 patients (28.57%) with adalimumab, and 1 case each with tocilizumab, certolizumab, golimumab, infliximab, and abatacept. The most common malignancies that we found were lung cancers, ductal mammary carcinomas, melanomas, and lymphomas. The incidence rate (IR) of malignancies in our cohort was 3.47 per 1000 person-years (p-y); the higher IRs were in RA patients (5.13 per 1000 p-y), in males (4.21 per 1000 p-y), and in patients aged >70 years (10.14 per 1000 p-y).

CONCLUSIONS

The results of our study showed IR of malignancies in RMD patients treated with bDMARDs that is in agreement with literature data.

Low bone mass and hypovitaminosis D in haemophilia: A single-centre study in patients with severe and moderate haemophilia A and B

INTRODUCTION

Haemophilia (H) is frequently associated with a multifactorial reduction in bone mineral density (BDM), but little is known about possible differences between HA and HB according to their severity.

AIM

To evaluate the association between low bone mineral density (BMD), 25-hydroxyvitamin D [25(OH)D] concentrations and bone turnover markers in patients with HA and HB younger or older than 50 years.

METHODS

In 78 patients <50 years and 33 patients >50 years with severe (S) or moderate (M) HA and HB, BMD was measured by dual-energy X-ray absorptiometry at femoral neck (FN) and lumbar spine and then correlated to annual bleeding rate (ABR), World Federation of Haemophilia orthopaedic joint scale (WFH score), 25(OH)D concentrations, parathyroid hormone (PTH), amino-terminal telopeptide of type 1 collagen (NTx), urinary pyridinolines, osteocalcin and bone-specific alkaline phosphatase.

RESULTS

Overall, a high prevalence of hypovitaminosis D was diagnosed. In patients <50 years, low FN-BMD was significantly more frequent in HA than in HB, while PTH, pyridinolines, ABR and WFH score were associated with H type and severity. In patients >50 years, similarly low FN-BMD was observed in HA and HB, while ABR and WFH score were associated with H type and severity, being milder in HB.

CONCLUSIONS

Low bone mass is a frequent comorbidity in haemophilic patients of all ages, apart from those with MHB. Clinical and laboratory assessments confirm a higher bone impairment and faster bone resorption in HA compared with HB. Looking at H type and severity, MHB seems to have a normal bone metabolism and a less severe disease.

Effect of Dysmetabolisms and Comorbidities on the Efficacy and Safety of Biological Therapy in Chronic Inflammatory Joint Diseases

In the present study we evaluated how systemic arterial hypertension (SAH), dyslipidemia and diabetes mellitus influence the efficacy, safety and retention rate of biological disease-modifying anti-rheumatic drug (bDMARD) treatment in rheumatic musculoskeletal disorders (RMDs). The charts of RMD patients treated with the first-line bDMARD were reviewed, collecting data on safety, efficacy and comorbidities at prescription (baseline, BL), after 6 months (6M) and at last observation on bDMARD (last observation time, LoT). In 383 RMD patients, a higher rate of adverse events at 6M (p = 0.0402) and at LoT (p = 0.0462) was present in dyslipidemic patients. Patients who developed dyslipidemia or SAH during bDMARD treatment had similar results (dyslipidemia p = 0.0007; SAH p = 0.0319) with a longer bDMARD retention as well (dyslipidemia p < 0.0001; SAH p < 0.0001). SAH patients on angiotensin converting enzyme inhibitors (ACEis) or angiotensin-II receptor blockers (ARBs) continued bDMARDs for longer than non-exposed patients (p = 0.001), with higher frequency of drug interruption for long-standing remission rather than inefficacy or adverse reactions (p = 0.0258). Similarly, dyslipidemic patients on statins had a better bDMARD retention than not-exposed patients (p = 0.0420). In conclusion, SAH and dyslipidemia may be associated with higher frequency of adverse events but a better drug retention of first-line bDMARD in RMDs, suggesting an additional effect of ACEis/ARBs or statins on the inflammatory process and supporting their use in RMD bDMARD patients with SAH/dyslipidemia.

The Renal Resistive Index: A New Biomarker for the Follow-up of Vascular Modifications in Systemic Sclerosis

Objective.

The aim of the present retrospective observational study was to evaluate the change of Renal Resistive Index (RRI) over time (ΔRRI) and under treatment in patients with systemic sclerosis (SSc) as well as to correlate these changes with disease complications.

Methods.

Two hundred thirty patients [29 male, median age 57 (IQR 48–67) yrs] were enrolled. At baseline and follow-up (3.43, IQR 2.81–4.45 yrs), we collected the following data: disease variables, nailfold videocapillaroscopy (NVC) pattern, forced vital capacity (FVC), diffusing lung capacity for carbon monoxide (DLCO), systolic pulmonary arterial pressure (sPAP), presence of interstitial lung disease, RRI, evaluation of glomerular filtration rate, and new onset of pulmonary arterial hypertension (PAH).

Results.

RRI value is high in SSc patients with digital ulcers and anticentromere antibodies, active and late NVC patterns, and limited cutaneous SSc. A significant correlation was observed between ΔRRI and ΔsPAP (R = 0.17, P = 0.02), with statistically higher ΔRRI (0.08 ± 0.02 vs 0.03 ± 0.05, P = 0.04) in patients complicated by PAH onset. No other new-onset complication was associated with ΔRRI. The receiver-operating characteristic curve analysis confirmed the predictive role of ΔRRI in development of new PAH (area under the curve 0.84, 95% CI 0.75–0.93, P = 0.02). In patients with SSc never exposed to sildenafil, ΔRRI was higher (0.04 ± 0.05) compared to both patients exposed to sildenafil during the study period (0.01 ± 0.05, P = 0.03) or in those exposed at the time of baseline evaluation (0.00 ± 0.05, P = 0.01).

Conclusion.

RRI and its variation in time are a reliable marker of SSc-related vasculopathy, both in renal and extrarenal compartments.

Enthesopathy and involvement of synovio-entheseal complex in systemic sclerosis: an ultrasound pilot study

Objectives

SSc is a chronic autoimmune disease characterized by inflammation of the skin and multiple internal organs. Articular involvement is one of the main features of SSc, and typical hallmarks of SpA have been found in SSc patients. The aim of the present study was to estimate the prevalence of entheseal and synovio-entheseal complex (SEC) alterations in a cohort of SSc patients.

Methods

One hundred SSc patients and 25 healthy subjects were included in this cross-sectional study. The enthesis sites of lateral epicondylar common extensor tendons (CET) and the enthesis of the Glasgow Ultrasound Enthesis Scoring System were evaluated. SEC involvement was evaluated only at CET enthesis.

Results

In SSc, the Glasgow Ultrasound Enthesis Scoring System score was significantly higher (median 4.0, interquartile range 2.0–7.0) than in controls (median 1.0, interquartile range 0.0–3.0) (P < 0.0001). CET enthesis of SSc patients showed more frequent US B-mode alterations than that of controls (χ2 = 11.47, P = 0.0007 for size; χ2 = 13.79, P = 0.0002 for cortical irregularity, χ2 = 5.24, P = 0.022 for calcification/enthesophytes). Power Doppler US signal at CET enthesis was significantly more frequent in SSc patients than in healthy controls (χ2 = 9.11, P = 0.0025), as was the concomitant SEC involvement (χ2 = 8.52, P = 0.0035).

Conclusion

These data show that SSc patients frequently present US features of enthesopathy. Moreover, CET enthesopathy was correlated with SEC inflammation, suggesting that entheseal inflammation in SSc may share the same micro-anatomical targets as found in SpA.

Targeting anticoagulant protein S to improve hemostasis in hemophilia

Improved treatments are needed for hemophilia A and B, bleeding disorders affecting 400 000 people worldwide. We investigated whether targeting protein S could promote hemostasis in hemophilia by rebalancing coagulation. Protein S (PS) is an anticoagulant acting as cofactor for activated protein C and tissue factor pathway inhibitor (TFPI). This dual role makes PS a key regulator of thrombin generation. Here, we report that targeting PS rebalances coagulation in hemophilia. PS gene targeting in hemophilic mice protected them against bleeding, especially when intra-articular. Mechanistically, these mice displayed increased thrombin generation, resistance to activated protein C and TFPI, and improved fibrin network. Blocking PS in plasma of hemophilia patients normalized in vitro thrombin generation. Both PS and TFPIα were detected in hemophilic mice joints. PS and TFPI expression was stronger in the joints of hemophilia A patients than in those of hemophilia B patients when receiving on-demand therapy, for example, during a bleeding episode. In contrast, PS and TFPI expression was decreased in hemophilia A patients receiving prophylaxis with coagulation factor concentrates, comparable to osteoarthritis patients. These results establish PS inhibition as both controller of coagulation and potential therapeutic target in hemophilia. The murine PS silencing RNA approach that we successfully used in hemophilic mice might constitute a new therapeutic concept for hemophilic patients.

A group of patients with Marfan's syndrome, who have finger and toe contractures, displays tendons' alterations upon an ultrasound examination: are these features common among classical Marfan patients?

The involvement of the musculoskeletal system with other mild pleiotropic manifestations represents a clinical criterion, called "systemic features," to d iagnose Marfan's syndrome. We aimed to investigate the features of the hands and feet redressable contractures present in a group of Marfan patients. In 13 patients with previously diagnosed Marfan's syndrome, an accurate clinical examination was performed. In particular the characterization of the musculoskeletal system by visual analogic scale to measure muscle pain (VAS) and muscle strength (MRC system) was carried out; the Beighton scale score was used to evaluate the articular hypermobility. Ultrasound examination (US) was performed to detect deep-superficial flexor tendons and extensor tendons of both hands, and the short and long flexor and extensor tendons of the fingers and toes in static and dynamic positions. The ImageJ program was adopted to measure a profile of tendon echo-intensity. A reduction of the thickness of all tendons was detected by US in our patients; the VAS and Beighton scale scores were in normal ranges. The profile of tendon echo-intensity showed different textural details in all Marfan patients. This study provides evidence for other contractures' localization, and for altered findings of the tendons in patients with Marfan syndrome and finger/toe contractures. These changes may be associated with structural modifications in connective tissue.

Clinical, instrumental, serological and histological findings suggest that hemophilia B may be less severe than hemophilia A

Recent evidence suggests that patients with severe hemophilia B may have a less severe disease compared to severe hemophilia A. To investigate clinical, radiological, laboratory and histological differences in the arthropathy of severe hemophilia A and hemophilia B, 70 patients with hemophilia A and 35 with hemophilia B with at least one joint bleeding were consecutively enrolled. Joint bleedings (<10, 10-50, >50), regimen of treatment (prophylaxis/on demand), World Federation of Hemophilia, Pettersson and ultrasound scores, serum soluble RANK ligand and osteoprotegerin were assessed in all patients. RANK, RANK ligand and osteoprotegerin expression was evaluated in synovial tissue from 18 hemophilia A and 4 hemophilia B patients. The percentage of patients with either 10-50 or more than 50 hemarthrosis was greater in hemophilia A than in hemophilia B (P<0.001 and P=0.03, respectively), while that with less than 10 hemarthrosis was higher in hemophilia B (P<0.0001). World Federation of Hemophilia (36.6 vs. 20.2; P<0.0001) and ultrasound (10.9 vs. 4.3; P<0.0001) score mean values were significantly higher in hemophilia A patients. Serum osteoprotegerin and soluble RANK ligand were decreased in hemophilia A versus hemophilia B (P<0.0001 and P=0.006, respectively). Osteoprotegerin expression was markedly reduced in synovial tissue from hemophilia A patients. In conclusion, the reduced number of hemarthrosis, the lower World Federation of Hemophilia and ultrasound scores, and higher osteoprotegerin expression in serum and synovial tissue in hemophilia B suggest that hemophilia B is a less severe disease than hemophilia A. Osteoprotegerin reduction seems to play a pivotal role in the progression of arthropathy in hemophilia A.

Sonographic visibility of the sinus tarsi with a 12 MHz transducer

OBJECTIVES

To assess the value of ultrasonography in studies of the ligaments within the sinus tarsi (ST) in healthy subjects.

MATERIALS AND METHODS

We examined 20 healthy volunteers using a 12-MHz transducer with THI and compound imaging. With the foot in inversion, the following structures were examined with coronal and transverse scans: (1) the root of the inferior extensor retinaculum (RIER); (2) the interosseous talocalcaneal ligament (ITCL); (3) the cervical ligament (CL); (4) the bifurcate ligament (BL); (5) the synovial recesses, which were examined for possible distention (distended synovial recesses, DSR). The sonographic features, orientation, and thickness of each ligament were assessed.

RESULTS

The easiest structure to identify (visualized in 20/20 subjects) was the RIER, which formed a semiarch. The two deeper layers were hypoechoic, the superficial layer hyperechoic. The ITCL was situated posteriorly and deep with an oblique course. It appeared hypoechoic with a mean thickness of 4.06 mm ± 0.7. It was visualized in 18/20 (90 %) subjects. The CL (isoechoic/hyperechoic) was located more anteriorly at an intermediate depth. The orientation was almost vertical. It was visualized in 17/20 (85 %) subjects, with a mean thickness of 2.28 mm ± 0.34. The BL appeared hypoechoic. It was visualized in 19/20 (95 %) subjects with transverse (anterior end of the ST) and longitudinal scans. The calcaneonavicular and calcaneocuboid components displayed mean (SD) thicknesses of 2.09 mm ± 0.37 and 2.7 mm ± 0.32, respectively. The ITCL and RIER were visualized in the same scan as a semiarch. DSR was observed in 4/20 (20 %) subjects.

CONCLUSIONS

The present study shows that, in patients with suspected ST pathology, the anatomic structures that make up this recess can be adequately examined with ultrasonography performed with ordinary 12-MHz transducers.

Muscle shortening manoeuvre reduces pain and functional impairment in shoulder impingement syndrome: clinical and ultrasonographic evidence

OBJECTIVES

To evaluate the short-term efficacy of muscle shortening manoeuvre (MSM), by inducing an increase in strength of the shoulder muscles, for the treatment of shoulder impingement syndrome (SIS).

METHODS

Sixty subjects (mean age: 58.6 years) with SIS were assigned to one of 3 different treatment interventions: 1) MSM: a series of fast accelerations in the upward direction was applied to the upper limb that was also submitted to forces acting in the opposite direction (added mass); 2) traditional physiotherapeutic technique: scapulothoracic gliding; 3) simple traction: the added mass was applied to the limb without the series of fast accelerations. Pain intensity, Neer's impingement sign, range of motion and muscle strength were assessed. Ultrasound (US) examination was performed before, immediately after and 30 days after each treatment to study the width of the subacromial-subdeltoid bursa, long biceps tendon sheath and acromioclavicular joint. Impingement was evaluated by dynamic examination.

RESULTS

After treatment with MSM, pain was significantly reduced (p<0.001), Neer's impingement sign was negative, range of motion and muscle strength were increased. US examination showed that the widths of the subacromial-subdeltoid bursa (p<0.001), long biceps tendon sheath (p<0.001) and acromioclavicular joint (p<0.001) were significantly reduced; impingement was no more detected. After 30 days, improvement in clinical and US findings was maintained. In the two control groups, no significant changes were observed after treatment.

CONCLUSIONS

Clinical and US findings demonstrate that MSM, by inducing an increase in muscle strength, is effective in the short-term treatment of SIS.

Angiogenesis is increased in advanced haemophilic joint disease and characterised by normal pericyte coverage

BACKGROUND

Repeated intra-articular bleedings in patients with haemophilia results in a crippling arthropathy for which no specific treatment is currently available. Recent studies have shown that neoangiogenesis is involved in the pathologic process. The aim of this study was to determine whether angiogenesis is dysregulated in haemophilic joint disease (HJD).

METHODS

Synovial tissue and synovial fluid were collected from patients with severe haemophilia undergoing knee or hip replacement and from a control group consisting of non-haemophilic patients undergoing diagnostic procedures. In a second set of patients, blood samples were collected in patients with mild, moderate and severe haemophilia A when free from current bleeding. Analysis of microvascular density, vascular endothelial growth factor (VEGF) expression and pericyte coverage was performed by immunofluorescence. Analyses of VEGF concentrations in plasma, platelet lysates and synovial fluid were performed by ELISA.

RESULTS

Microvascular density and VEGF expression were significantly increased in synovial tissue from haemophilic patients compared with controls (P = 0.005 and P = 0.02, respectively). There was no difference in pericyte coverage of synovial vessels or levels of VEGF in plasma, platelet lysates or synovial fluid.

CONCLUSIONS

Angiogenesis observed as synovial microvascular density, and VEGF expression is increased in HJD. As pericyte coverage was similar in synovial vessels from haemophilic and non-haemophilic patients, we assume that the vessels were mature, suggesting that the rate of new vessel formation is low in the chronic phase of haemophilic joint disease.

Clinical and radiological evaluation of sacroiliac joints compared with ultrasound examination in early spondyloarthritis

OBJECTIVE

To compare clinical and X-ray examinations with US findings of SI joints (SIJ) in early SpA patients.

METHODS

Twenty-three early SpA patients, diagnosed according to Assessment of SpondyloArthritis international Society criteria, were investigated clinically [sacral sulcus tenderness, BASMI, BASFI, BASDAI, pain and fatigue visual analogue scale (VAS), morning stiffness and sleep disturbance], with SIJ X-rays (New York score) and with My Lab70 US 7-10 MHz US (Esaote, Genoa, Italy), evaluating the width of the SIJ capsule and posterior sacroiliac (PSL) and sacrotuberosus (STL) ligament thickness and comparing the results with 23 healthy controls.

RESULTS

SIJ width [right 2.2 (0.6) and left 2.3 (0.7) in SpA vs 1.6 (0.1) and 1.7 (0.2) in healthy controls, respectively, expressed as mean (s.d.)] and STL thickness [right 3.9 (1.3) and left 3.4 (1.0) vs 1.8 (0.1) and 1.8 (0.1), respectively, expressed as mean (s.d.)] were higher in SpA patients than in controls (P < 0.001 and P < 0.05, respectively). PSL thickness was similar in patients and controls. Only STL thickness was higher when SIJ was tender at clinical examination (P < 0.01) and correlated with pain VAS (P < 0.001) and BASFI (P < 0.05). Furthermore, SIJ US results were unrelated to X-ray findings (similar when X-ray sacroiliitis was present and not).

CONCLUSION

Our exploratory study suggested that in early SpA patients US might be a promising method, complementary to other imaging techniques, to study articular and soft tissue periarticular involvement of SIJ, independent of clinical and X-ray examination.

Ultrasound detects joint damage and bleeding in haemophilic arthropathy: a proposal of a score

Haemarthrosis triggers haemophilic arthropathy (HA) because bleeding starts synovitis immediately, damages cartilage and leads to loss of function and disability. The aim of our study was to investigate the capacity of ultrasonography (US) in detecting bleeding and joint damage in HA. The joints of 62 patients (pts) with haemophilia A or haemophilia B were consecutively evaluated and scored (score ranging from 0 to 21) for effusion (E), bone remodelling (BR), cartilage damage (CD), synovial hypertrophy (SH), haemosiderin (H), osteophytes (O), haemarthrosis (Hae), erosion (Er) and fibrotic septa (FS) with US. X-rays [Pettersson Score (PXS)] were performed in 61 patients and clinical evaluation [World Federation Haemophiliac orthopaedic score (WFHO)] was performed in all patients. A total of 20 healthy subjects and 20 patients affected by Rheumatoid Arthritis (RA) were used as controls. Power Doppler US (PDUS) was performed in all patients on the knee, ankle and elbow joints. A total of 83 joints were studied (50 knees; 12 elbows and 21 ankles). US showed effusion in 57 joint, bone remodelling in 62, cartilage damage in 64, synovial hypertrophy in 45, haemosiderin in 39, osteophytes in 30, haemarthrosis in 24, erosion in 5 and fibrotic septa in 3. The X-rays score showed remodelling in 47 joints, narrowing joint space in 44, displacement/angulation in 39, osteoporosis in 42, subchondral irregularity in 44, subchondral cyst formation in 37, osteophytes in 36 and erosions in 25. The US score in healthy subjects was always ≤ 5 (range 0 to 4). In haemophiliacs, 34 of 83 joints showed US score ≤ 5, and 49 US score > 5. Joints with US score ≤ 5 had a low PXS (SRCC = 0.375, P < 0.01) and joints with US score > 5 showed a high PXS (SRCC = 0.440, P < 0.01). A significant correlation between US score and PXS for bone remodelling [Spearman's rho Correlation Coefficient (SRCC) = 0.429, P < 0.01] and for osteophytes (SRCC = 0.308, P < 0.05) was found. The correlation between the US score and number of bleedings in 83 joints was very significant (SRCC = 0.375, P < 0.01). A total of 24 bleeding joints were identified and verified with aspiration of haematic fluid. US may detect bone and cartilage alterations and synovitis. Indeed, PDUS identified bleeding also in asymptomatic joints and was able to show different entity of haemarthrosis. US may be a feasible and reliable tool to evaluate joint modifications in HA.

Early detection of median nerve syndrome at the carpal tunnel with high-resolution 18 MHz ultrasonography in systemic sclerosis patients

OBJECTIVES

To investigate carpal tunnel syndrome (CTS) with ultrasound (US) in asymptomatic SSc patients and to seek out the relationship between CTS and SSc clinical variables

METHODS

In 64 SSc patients (55 women and 9 men, mean age 57±14 years) and in 30 healthy controls, area (MNA), transverse (MNT) and anteroposterior (MNAP) diameters of MN at carpal tunnel were studied with US (My Lab 25 XVG US Esaote 18 MHz). MN flattening ratio (MNFR) was calculated. Duration of disease, subset (limited, diffuse), phase of skin involvement (oedematous, atrophic, fibrotic), modified Rodnan skin score (mRSS) and friction tendon rub were also recorded.

RESULTS

MNA (p<0.001), MNT (p<0.005) and MNFR (p<0.005) were significantly higher in the SSc patients than in controls, while no difference in MNAP was found. There was no correlation between median nerve (MN) and SSc clinical features (only lower MNAP correlated inversely with longer disease duration; Spearman coefficient -0.2).

CONCLUSIONS

MN involvement is frequently present in all phases of asymptomatic SSc patients, independently to clinical variables.

Anti-cyclic Citrullinated Peptide Antibodies are Highly Associated with Severe Bone Lesions in Rheumatoid Arthritis Anti-CCP and Bone Damage in RA

In the present study we investigated the predictive value of anti-cyclic citrullinated peptide antibodies (anti-CCP) in early rheumatoid arthritis (RA) with respect to the bone damage. Fifty-four patients with early RA (onset <12 months), 35 classified as established RA (onset >12 months), 33 healthy donors and 76 non-RA autoimmune diseases, were enrolled. Anti-CCP and IgG, IgA, IgM rheumatoid factors (RFs) were determined at baseline. Disease activity score (DAS 28) was calculated at the entry. Bone involvement was evaluated by X-rays and sonography. The specificity of anti-CCP was 98.4%; significantly higher than those of the IgM- (86.0%), IgA- (86.0%) and IgG-RFs (66.2%), respectively. Anti-CCP were detected in 23/54 (42.6%) early RA patients and in 16/35 (45.7%) established RA patients. In the early RA group, 6/33 (18.2%) of the patients without bone lesions, 12/16 (75%) with juxta-articular osteoporosis (JO) and 5/5 with joint erosions (JE) resulted positive showing a significant difference between the groups without and with radiological damage. In the established RA group a significant difference being between the group without radiological damage and that with JE was found. Finally, in patients without radiological lesions, examined by ultrasound, anti-CCP antibodies were detected only in subjects with pathologic findings (31.25%). Data here reported confirm that the presence of anti-CCP are specific for diagnosis of RA, of recent onset also and they are potentially useful as prognostic index of bone involvement.

Angiotensin-converting enzyme I/D polymorphism and macrovascular disease in systemic sclerosis

OBJECTIVE

Systemic sclerosis (SSc) is characterized by microvascular and macrovascular alterations. The D allele of the ACE I/D polymorphism is known to be associated with an increased incidence of atherosclerosis and has been recently proposed as associated with increased risk of SSc. This study evaluates the relationship between intima-media thickness (IMT), ankle-brachial pressure measurements (ABPI) and ACE I/D polymorphism in SSc patients.

METHODS

According to the presence of ACE D allele (analysed by PCR), 53 SSc patients (47 females and 6 males; median age was 60.4 +/- 10.68 yrs; range 40-75 yrs) were divided in carriers of the D allele (DD + ID) (n = 46) and carriers of the I allele (II) (n = 7). In these patients, IMT and ABPI [calculated as the posterior tibial artery pressure (mmHg) divided by the brachial pressure] were obtained. Forty-three healthy controls (40 women and 13 men; median age 56.3 +/- 10.23; range 40-70 yrs) of the same ethnicity were recruited.

RESULTS

SSc patients had IMT significantly higher than controls (0.85 +/- 0.03 vs 0. 68 +/- 0.01; P < 0.03). No significant differences (P > 0.3) in ABPI values between patients (1.018 +/- 0.10) and controls (1.091 +/- 0.11) were found. SSc patients with ACE DD and ID genotype showed an IMT significantly greater (0.89 +/- 0.03) than those carrying the II genotype (0.61 +/- 0.01) (P < 0.04). ABPI was not different among ACE gene genotypes.

CONCLUSION

Our findings confirm an increased prevalence of macrovascular disease in SSc patients and show that IMT is greater in patients carrying the ACE DD and ID genotype in comparison with II homozygotes. This suggests that, in SSc, the presence of ACE D allele may predispose to an involvement of the macrovascular system.

Intravenous immunoglobulins improve the function and ameliorate joint involvement in systemic sclerosis: a pilot study

BACKGROUND

In systemic sclerosis (SSc), joint involvement may reduce the functional capacity of the hands. Intravenous immunoglobulins have previously been shown to benefit patients with SSc.

AIM

To verify the efficacy of intravenous immunoglobulins on joint involvement and function in SSc.

PATIENTS AND METHODS

7 women with SSc, 5 with limited and 2 with diffuse SSc, with a severe and refractory joint involvement were enrolled in the study. Methotrexate and cyclophosphamide pulse therapy did not ameliorate joint symptoms. Hence, intravenous immunoglobulins therapy was prescribed at a dosage of 2 g/kg body weight during 4 days/month for six consecutive courses. The presence of joint tenderness and swelling, and articular deformities (due to primary joint involvement and not due to skin and subcutaneous changes) were evaluated. Before and after 6 months of treatment, patients were subjected to (1) Ritchie Index (RI) evaluation of joint involvement; (2) Dreiser Algo-Functional Index (IAFD) evaluation of hand joint function; (3) pain visual analogue scale (VAS) to measure joint pain; (4) Health Assessment Questionnaire (HAQ) to evaluate the limitations in everyday living and physical disability; and (5) modified Rodnan Skin Score for skin involvement.

RESULTS

After 6 months of intravenous immunoglobulins therapy, joint pain and tenderness, measured with the VAS, decreased significantly (p<0.03), and hand function (IAFD) improved significantly (p<0.02), together with the quality of life (HAQ; p<0.03). All patients significantly improved, except for one. The skin score after 6 months of intravenous immunoglobulins therapy was significantly reduced (p<0.003).

CONCLUSION

This pilot study suggests that intravenous immunoglobulins may reduce joint pain and tenderness, with a significant recovery of joint function in patients with SSc with severe and refractory joint involvement. The cost of intravenous immunoglobulins might limit their use only to patients who failed disease-modifying antirheumatic drugs.