POS0528 EARLY OPTIMISATION OF METHOTREXATE THERAPY PREVENTS DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS: A SINGLE-CENTRE, RETROSPECTIVE COHORT STUDY

Background

According to the current EULAR recommendations for the management of rheumatoid arthritis (RA), methotrexate (MTX) should be started as soon as RA is diagnosed and rapidly optimized to achieve remission. Nonetheless, it has been estimated that a difficult-to-treat (D2T) disease occurs in 3-10% of RA patients1. Herein, we hypothesized that D2T-RA can be prevented with an optimal MTX treatment in early stages.

Objectives

The main objective of this study was to demonstrate an association between successful optimization of MTX treatment within two years of RA diagnosis and development of a status of D2T-RA later in the disease course.

Methods

In 2016 we started a ‘Refractory RA’ clinic at the Rheumatology Unit, University of Padua, Italy. In this retrospective cohort study conducted in December 2021, we enrolled patients fulfilling both the ACR/EULAR 2010 criteria for RA and the EULAR definition of D2T-RA2 diagnosed after 2000. We compared D2T-RA patients with non-D2T-RA controls from the same clinic having similar sex distribution and year of diagnosis. The primary outcome was the status of DT2-RA. The exposure was ‘MTX optimization’ after two years from diagnosis, as assessed with a numeric score (the sum of the following binary variables concerning MTX therapy: started within 3, 12 or 24 months from diagnosis; adequate dose (≥15 mg weekly); treatment duration≥6 months; early intolerance (≤3 months); range 0 to 6, with higher scores reflecting better optimization). We used multiple logistic regression analysis to examine the association (odds ratio (OR)) between MTX optimization scores and the outcome, controlling for potential modifiers (age, sex, body mass index, age at onset, and anti-citrullinated peptides antibodies [ACPA]).

Results

There were 37 DT2 RA patients and 107 non-D2T RA controls for the analysis (mean (SD) disease duration 12.8 (4.1) vs. 12.6 (4.6), p=0.621). Per protocol, gender (females 77.3 vs. 82.0%, p=0.247) and year of diagnosis (median [25th, 75th percentile]: 2008 [2004, 2011] vs. 2008 [2003, 2012]) were comparable between groups. Optimization of MTX therapy was poor overall, yet MTX optimization scores were significantly higher in D2T-RA than in non-D2T-RA patients (1.06 (0.21) vs. 0.56 (0.14), p<0.001). In multiple logistic regression, MTX optimization was protective against DT2-RA. Indeed, the likelihood of D2T-RA was decreased by 34%-54% according to MTX optimization scores. Other disease characteristics significantly associated with D2T-RA were an older age at diagnosis and female sex (Table 1). In December 2021 (last follow-up), D2T-RA patients were receiving a significantly higher daily dose of prednisone (4.3 (1.4) vs. 0.5 (0.2), p<0.001), and had a numerically greater burden of comorbidities (median 3 [1, 4] vs. 2 [1, 3], p=0.252) and disease activity (DAS28-ESR: 3.41 (0.40) vs. 2.6 (0.19), p=0.053) than non-D2T-RA patients.

Table 1.

Early factors associated with difficult-to-treat rheumatoid arthritis (multivariable logistic regression)

BSEP-valueOdds ratio95% ICMTX optimization score-0.5990.092<0.0010.5490.459, 0.657Age, years0.0330.008<0.0011.0341.017, 1.051Sex (female vs males)0.7230.2870.0122.0611.174, 3.615BMI, kg/m2-0.0060.0180.7481.0060.970, 1.043ACPA (positive vs negative)0.4310.24500.0791.5390.952, 2.487

ACPA, anti-citrullinated peptide antibodies; B, unstandardised beta coefficient; BMI, body mass index; MTX, methotrexate; SE, standard error.

Conclusion

DT2-RA may be prevented by optimization of MTX therapy within two years of RA management.

References

[1]de Hair MJH, Jacobs JWG, Schoneveld JLM, van Laar JM. Difficult-to-treat rheumatoid arthritis: an area of unmet clinical need. Rheumatology (Oxford);57(7):1135-1144.

[2]Nagy G et al. EULAR definition of difficult-to-treat rheumatoid arthritis. Ann Rheum Dis 2021;80:31-35.

Disclosure of Interests

Alessandro Giollo Consultant of: Galapagos, Novartis, Eli-Lilly, Margherita Zen: None declared, Maddalena Larosa: None declared, Federico Arru: None declared, Konstantinos Botsios: None declared, Antonia Calligaro: None declared, Andrea Doria Consultant of: GSK, Pfizer, Eli Lilly, Roche, Janssen, AstraZeneca, Galapagos.

AB0483 THE ROLE OF PENTRAXIN-3 AS PREDICTOR OF PREGNANCY COMPLICATIONS IN PATIENTS WITH SLE AND/OR ANTI-PHOSPHOLIPID SYNDROME

Background

Pentraxin-3 (PTX3) seems to be implicated in placentation and foetus tolerance, being mostly secreted in response to inflammatory stimuli by dendritic cells, macrophages, and endothelial cells (1). Although several studies have recently focused on this molecule (2-4), no data on women with SLE/APS are available to date.

Objectives

To assess the role of serum PTX3 and anti-PTX3 Abs as predictors of pregnancy complications in SLE and/or APS.

Methods

This case control study included pregnancies in women with SLE (SLICC, 2012) and/or APS (Miyakis, 2006), recruited at University of Padova in the Out-patient Clinic shared by Obstetrics and Gynaecologists and Rheumatologists. The control group included pregnancies of patients with other rheumatic diseases rather than APS and/or SLE. All pregnancies were recruited from 2015 to 2021 (conception date< 1st Apr 2021).

At first-trimester consultation, demographics, clinical, and serological variables were recorded. First-trimester serum PTX3 levels (ng/ml) were detected by a commercially available sandwich ELISA (Alexis, UK); IgG anti-PTX3 Abs were detected by home-made validated ELISA and expressed as Optical Density values, measured at 405 nm by microplate spectrometer. Cut-off of positivity corresponded to 0.234 OD.

Maternal complications included SLE flares (increase of ≥1 point in SLEPDAI); preeclampsia/eclampsia, HELLP, pregnancy induced hypertension, maternal death, gestational diabetes mellitus (GDM). Foetal complications included: miscarriage<10 week of gestation (WG); intra-uterine foetal death (IUFD) (≥10 WG); preterm delivery (<37 WG); intra-uterine growth restriction (IUGR); neonatal death within 28 days from birth.

Results

79 pregnancies occurred in 79 patients (Table 1). Serum IgG anti-PTX3 Abs were found in 11 women (13.9%, 95% CI 7.2-23.5), and they did not differ between cases and controls (p=0.08, 4 SLE/APS women vs. 7 controls). Anti-PTX3 were associated with GDM (p=0.04, stratified for maternal age) but not with IUGR (p=0.09). No other statistical associations were found between anti-PTX3 Abs and other maternal/foetal complications. PTX3 serum levels did not statistically differ between cases and controls (p=0.63, 0.37 ± 0.26 ng/mL in cases vs. 0.33 ± 0.24 ng/mL in controls). Serum PTX3 levels were lower in patients with GDM (0.3 ± 0.2 ng/mL) compared to non-GDM patients (0.4 ± 0.2) but it did not differ between IUGR and non-IUGR, although the mean PTX3 ± SD was lower in the IUGR group (0.25 ± 0.2 in IUGR vs 0.35 ± 0.2 in non-IUGR).

Table 1.

Clinical and serological characteristics of our cohort (N=79)

Patients (N, %)Age at pregnancy, years (mean ± SD)35.1 ± 3.9Cases13 (16.5)SLE9 (11.4)APS7 (8.9)SLE with secondary APS3 (23.1)Control Group66 (83.5)Serological featuresLAC11 (13.9)IgG/IgM anti-cardiolipin20 (25.3)IgG/IgM antibeta2-Glycoprotein I25 (31.6)Triple positive aPL tests6 (7.6)Primiparous23 (29.5)IgG anti-PTX3 Abs11 (13.9)IgG anti-PTX3 level (cut-off 0.234 OD), (median, IQR)0.2 (0.1-0.2)PTX3 ng/mL (mean ± SD)0.3 ± 0.2Concomitant treatmentHeparin15 (19.0)Aspirin44 (55.7)Immunosuppressants3 (3.8)Hydroxychloroquine21 (26.6)Prednisone9 (11.4)Prednisone dosage (mg/day) (median, IQR)5 (2.5-7.5)

Legend to Table 1: SD: standard deviation; SLE: Systemic Lupus Erythematosus; APS: antiphospholipid syndrome; LAC: Lupus anticoagulant; aPL: antiphospholipid antibodies; PTX: Pentraxin-3; Abs: antibodies; OD: optical density; IQR: interquartile range.

Conclusion

To our knowledge, this is the first study which assessed the frequency of anti-PTX3 Abs in a cohort of SLE and/or APS pregnant women. These Abs occurred in the minority of patients (13.9%) and did not differ between SLE/APS women and controls. Due to our sample size, these findings need to be confirmed in larger cohorts.

References

[1]Cruciani L, et al. Journal of Perinatal Medicine, 2010:38.

[2]Akolekar R, et al. Prenat. Diagn. 2009;29:934–8.

[3]Bassi N, et al. Clinic Rev Allerg Immunol 2015;49:217–26.

[4]Gatto M, et al. Journal of Autoimmunity, 2016;74:208–16.

Disclosure of Interests

None declared

POS0741 REPORT FROM THE APS STUDY GROUP OF THE ITALIAN SOCIETY FOR RHEUMATOLOGY (SIR-APS) ON aPL NEGATIVIZATION

Background

The rate of antiphospholipid antibodies (aPL)negativization in antiphospholipid syndrome (APS) patients is uncertain, but it is estimated to be as high as 8%. aPL disappearance seems to be more frequent in patients positive for one single aPL test and appears to be related with the immunosuppressant/immunomodulatory treatment undertaken by the patient. Currently, a consensus definition of aPL negativization is lacking, as well as international recommendations on how to approach treatment in patients with a persistent aPL negative seroconversion.

Objectives

The aim of our work was to evaluate the clinical approach and the level of consensus among experts from the APS Study Group of the Italian Society for Rheumatology (SIR-APS) in different clinical scenario addressing aPL negativization and its definition.

Methods

Experts of SIR-APS were contacted using a survey methodology.

Results

A structured survey was circulated among 30 experts.Up to 90% of the interviewed experts agreed on defining aPL negativization as the presence of two negative determinations, one year apart (90%).Almost ful lconsensus exist among experts in some clinical settings, including: a) the role of aPL negativitation in the management of a thrombotic event determined by concomitant presence of cardiovascular risk factors, both modifiable and not modifiable (90%): b) approach to young patients with triple aPL positivity who experienced pulmonary arterial thrombotic event and tested negative for aPL detection after five year of vitamin K antagonist (VKA) treatment (90%); c)the use of “extra criteria” aPL antibodies testing before pondering VKA suspension (93%).

Conclusion

Consensus is needed to support the management of patients with APS in areas where controlled data are missing. A substantial agreement exists among expert in defying aPL negativization as the presence of two negative determinations, one year apart. On the contrary, VKA suspension should be embraced with extreme caution when it comes to APS patients, particularly if they experienced arterial thrombotic events and/or tested positive for triple aPL. Nevertheless, VKA cessation might be considered when risk factors are carefully monitored/treated and the presence for “extra criteria” aPL is ruled out.

References

[1]Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, Derksen RHWM, DE, Groot PG, Koike T, Meroni PL, Reber G, Shoenfeld Y, Tincani A, Vlachoyiannopoulos PG, Krilis SA. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006; 4: 295–306.

[2]Coloma Bazán E, Donate López C, Moreno Lozano P, Cervera R, Espinosa G.

Discontinuation of anticoagulation or antiaggregation treatment may be safe in patients with primary antiphospholipid syndrome when antiphospholipid antibodies became persistently negative. Immunol Res Immunol Res; 2013; 56: 358–61.

[3]Radin M, Schreiber K, Sciascia S, Roccatello D, Cecchi I, Aguirre Zamorano MÁ, Cuadrado MJ. Prevalence of Antiphospholipid Antibodies Negativisation in Patients with Antiphospholipid Syndrome: A Long-Term Follow-Up Multicentre Study. Thromb Haemost 2019; 119: 1920–6.

Acknowledgements

Italian Society of Rheumatology

Disclosure of Interests

None declared

OP0002 LOW COMPLEMENT LEVELS IN THE FIRST TRIMESTER PREDICT DISEASE FLARE IN SLE PREGNANCY: A NETWORK META-ANALYSIS ON 532 PATIENTS

Background

The complement system is a key-player in the pathogenesis of systemic lupus erythematosus (SLE); its decreases correlate with disease activity and precedes flare. Since synthesis of complement proteins increase during gestational course, it is debated whether complement levels exert a prognostic role in pregnant women with SLE.

Objectives

We performed a network meta-analysis to assess the prognostic role of complement in pregnant SLE women, to evaluate the possible role of complement fluctuations during pregnancies.

Methods

Data from available prospective studies (Jan 2002-Dec 2020) investigating pregnancies in at least 50 SLE patients, excluding miscarriages before 12 weeks, were pooled together. After a systematic literature search, corresponding authors of 19 retrieved studies meeting inclusion criteria were invited to contribute with additional data, including complement levels [6 months before pregnancy, at conception, 1st trimester (T1), 2nd trimester (T2), 3rd trimester (T3) and 3 months after delivery].

Results

A total of 532 SLE women from four eligible studies were included in the analysis [1-4]. Lupus Nephritis (LN) was diagnosed in 237 patients (44.5%) and Antiphospholipid Syndrome in 68 (12.8%). A total of 170 patients (32%) experienced a flare during pregnancy, defined as need of new Immunosuppressants or increase of prednisone > 9 mg/day.

Patients with LN had significantly lower mean levels of complement (C3 at conception; C3 at T1; C3 after 3 months of delivery; C4 at all timepoints except for C4 at T3). SLE patients who experienced flares during pregnancy had significantly lower mean levels of complement (all timepoints for both C3 and C4). Table 1 shows the mean C3 and C4 levels in different timepoints according to diagnosis and flare during pregnancy. The lowest levels of complement were observed in patients with a concomitant diagnosis of LN and presence of flare, particularly during the T1 (Figure 1). Nevertheless, both in LN and flare groups the lowest levels of C3 and C4 were documented at T1.

Table 1.

Complement levels at the different timepoints according to diagnosis or presence of flare (bold results are statistically significant)

Patients with LN(237)Patientswithout LN (295)Patients with Flare (170)Patients without Flare (362)Patients with LN and Flare (73)Patients with LN and without Flare (164)C3 6 months before pregnancy (mean ±SD)90.7±18.694.1±25.285.6±19.195.6±23.375 ±17.999.1±12.5C3 conception (mean ±SD)96.1±13.991.1±1395.3±19.591.8±9.197 ±21.695.6±7.1C3 1sttrimester (mean ±SD)84.6±32.298.4±14.178.3±22.8100.5±20.756.8 ±19.997.2±28.7C3 2ndtrimester (mean ±SD)108.5±21108.3±12.294.16±13.4115.7±12.387.5 ±10.9118.6±16.8C3 3rdtrimester (mean ±SD)105.5±15.7108.2±19.198.97±18.6111.4±1698.1 ±12.6109.1±15.8C3 3 months after delivery (mean ±SD)93.4±12103.1±15.492.4±15.7102.6±13.490.5 ±10.894.8±12.3C4 6 months before pregnancy (mean ±SD)15.7±5.514.1±2.811.8±3.916.5±3.310.5±3.418.4±4.2C4 conception (mean ±SD)15.4±4.113.9±2.813.3±3.215.7±3.411±1.317.8±3C4 1sttrimester (mean ±SD)15±7.816.3±2.812.5±5.917.5±4.29.3±7.617.9±6.2C4 2ndtrimester (mean ±SD)17.7±4.718.7±4.215.5±4.319.8±3.713.6±4.119.6±3.5C4 3rdtrimester (mean ±SD)17.8±4.417.5±5.115.7±5.818.6±415.8±4.818.8±3.9C4 3 months after delivery (mean ±SD)16.2±4.319.8±6.914.9±3.920±6.413.3±3.117.6±4Figure 1.

Complement Levels during time in patients with Lupus Nephritis and presence, or absence, of flare.

Conclusion

In this prospective large cohort of SLE patients low C3/C4 levels, particularly in T1, were associated with a higher frequency of flare. Lowering levels of complement, especially in T1, even within normal range might alert the treating clinicians in predicting disease course and consequently avoid flares, especially in LN.

References

[1]Saavedra MÁ et al. Int J Rheum Dis 2020

[2]Moroni G et al. J Autoimmun 2016

[3]Rodrigues BC et al. Lupus 2019

[4]Borella E et al. Immunol Res 2014

Disclosure of Interests

None declared

OP0125 THE MANAGEMENT OF PREGNANCY IN AUTOIMMUNE RHEUMATIC DISEASES: ANALYSIS OF 758 PREGNANCIES FROM THE PROSPECTIVE NATIONWIDE P-RHEUM.IT STUDY (THE ITALIAN REGISTRY OF PREGNANCY IN THE RHEUMATIC DISEASES)

Background

Pregnancy is a topic of fundamental importance for women living with autoimmune rheumatic diseases (ARD). Efforts at national and international levels have been put in the collection and harmonization of data in order to implement an evidence-based management of pregnant patients.

Objectives

The P-RHEUM.it study was designed as a nationwide, web-based longitudinal observational cohort study to collect data about pregnancy in ARD in 26 centers in Italy. The study started in May 2018 and has been supported by the Italian Society for Rheumatology.

Methods

Pregnant patients with a definite rheumatic disease according international criteria were enrolled up to gestational week (GW) 20. The course of maternal disease activity, the use of medications, fetal and maternal complications, and the quality of life (EuroQoL questionnaire) were collected for each trimester, as well as pregnancy outcome, mode of delivery, neonatal complications, and maternal and children’s follow-up to 6 months after delivery, including the screening for post-partum depression by means of EPDS (Edinburgh Postnatal Depression Scale).

Results

As of December 2021, 758 pregnancies had been enrolled, 205 (27%) ongoing and 553 (73%) with outcome. Pregnancy loss occurred in 54 (9.8%) cases (40 spontaneous miscarriages; 6 voluntary terminations). Live births were 495 (89.5%), perinatal death occurred in 4 (0.7%) cases. Table 1 reports on the group of 495 live births, along with subgroups of Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE), the two most represented diseases. Regarding treatments, 166 (30%) pregnancies were exposed to corticosteroids, 239 (43%) to hydroxychloroquine, 59 (10.7%) to csDMARDs, 84 (15.2%) to TNF inhibitors, 1 (0.2%) to non-TNFi bDMARDs, 299 (54%) to low dose acetylsalicylic acid, and 126 (22.8%) to heparin.

Table 1.PREGNANCIES WITH LIVE BIRTHS, EXCLUDING PERINATAL DEATHSTotal pregnancies (n=495)RA pregnancies (n=69)SLE pregnancies (n=93)Age at conception (years)34 (31 - 37)34.5 (32 - 38)34 (31 - 36)Disease duration (years)6.1 (2.2 - 11.1)7.1 (4.3 - 11.6)9.3 (5.9 - 15.9)Caucasian431 (87.8%)53 (79.1%)75 (80.6%)Never smokers358 (73.8%)53 (80.3%)66 (71.7%)Body Mass Index >3045 (9.5%)7 (10.3%)5 (5.6%)Arterial Hypertension6 (1.2%)0 (0%)2 (2.2%)Time to pregnancy (months)3 (1 - 6)3 (1 - 6)3 (0 - 10)Physician-reported flares in the 12 months prior to conception107 (23%)22 (34.4%)13 (14.8%)Physician global assessment at enrolment (VAS 0-100)5 (0 - 17)5 (0 - 20)4 (0 - 10)Patient global health at enrolment (VAS 0-100)18 (7 - 30)10 (5 - 29)10 (5 - 25)EuroQoL at enrolment (-1.6 – 1)1 (0.8 - 1)1 (0.8 - 1)1 (0.8 - 1)Flares during pregnancy35 (7.1%)6 (8.7%)7 (7.5%)Hypertensive disturbances*8 (1.7%)1 (1.6%)6 (6.6%)Delivery at term (≥37 GW)410 (85.1%)53 (77.9%)74 (80.4%)Spontaneous vaginal delivery173 (35.9%)23 (33.8%)23 (25.3%)Congenital malformations11 (2.4%)2 (3.1%)1 (1.1%)Small for gestational age (SGA) neonate24 (4.9%)1 (1.4%)9 (9.9%)Breastfeeding in the first 4 weeks after delivery341 (79.7%)45 (77.6%)59 (76.6%)EPDS score at risk for post-partum depression22 (14.1%)0 (0%)3 (10.3%)

Continuous variables are expressed as median (interquartile range); *gestational hypertension/preeclampsia/HELLP syndrome/eclampsia.

Conclusion

Multiple factors may have contributed to the high rate of live births, including good disease control before and during pregnancy thanks to the use of anti-rheumatic drugs and low frequency of general risk factors. SLE pregnancy was affected by a higher frequency of complications (hypertensive disturbances, SGA babies) as compared to RA pregnancy. Nearly 80% of patients breastfed in the first month after delivery. For the first time, data about the screening questionnaire for post-partum depression were collected, showing at least 1 out 10 patients can be at risk.

References

[1]Meissner Y et al. Arthritis Res Ther;21(1):241; Ann Rheum Dis. 2021;80(1):49-56.

Acknowledgements

P-RHEUM.it study is supported by the Italian Society for Rheumatology (SIR). All the Investigators are acknowledged for their contribution.

Disclosure of Interests

None declared

OP0295 GR2 MULTICENTRIC PROSPECTIVE FRENCH STUDY’S RESULTS: DAMAGE BUT NOT REMISSION AT FIRST TRIMESTER PREDICTS ADVERSE PREGNANCY OUTCOME IN LUPUS PREGNANCIES

Background:

Active Systemic Lupus Erythematosus (SLE) during pregnancy is associated with poor obstetrical outcome but it is still not clear if remission, lupus low disease activity state (LLDAS) is the best target to achieve at conception. Besides, the effect of damage on pregnancy outcome has not been studied.

Objectives:

Our aim was to determine the 1st trimester risk factors for adverse pregnancy outcome (APO).

Methods:

Inclusion criteria were: 1) women≥18 years enrolled in the prospective GR2 study; 2) with SLE (SLICC criteria); 3) and an ongoing singleton pregnancy at 12 weeks (only 1 pregnancy per patient). We used the following definitions: DORIS1, DORIA2, clinical SLEDAI-2K=0, LLDAS3 (for SLE activity), SFI4 (for flares), and SLICC-damage index5 (for damage). APO included: foetal death, neonatal death, placental insufficiency with premature delivery<37 weeks, and small for gestational age (SGA:≤3rd percentile).

Results:

238 patients were included. 234 (98.3%) women were on hydroxychloroquine (HCQ) and 206 (86.5%) had a clinical SLEDAI-2K=0. Regarding pregnancy outcome, 230 (96.6%) patients had a live birth (mean term 37.7 weeks). Thirty-four (14.3%) patients developed at least 1 APO: placental insufficiency (n=22), foetal death (n=7), neonatal death (n=1), and SGA (n=5). Two different regression logistic models were assessed, one for DORIA and one for LLDAS. We found that only SLICC-Damage index and lupus anticoagulant (LAC) were associated with APO (p=0.02, OR 1.8, 95% CI: 1.1-2.9; p=0.001, OR 4.2, 95% CI: 1.8-9.7 respectively for DORIA model; p=0.03, OR 1.7, 95% CI:1.1-2.8; p=0.002, OR 3.7, 95% CI: 1.6-8.7 respectively for LLDAS model).

Conclusion:

We confirmed that LAC predicts APO. We found for the first time that chronic damage at 1st trimester also predicted APO. No effect of remission/LLDAS was observed in this cohort of patients on HCQ with a stable and well-controlled SLE.

References:

[1]van Vollenhoven R, et al. ARD 2017.

[2]Zen M, et al. ARD. 2015.

[3]Franklyn, K. et al. ARD 2016.

[4]Petri M, et al. NEJM 2005.

[5]Gladman DD, et al. Arthritis Rheum, 1997.

Table 1.Univariate analysis for APOMaternal featuresTotal (N=238)APO (N=34)Non-APO (N=204)P valueAge, mean (SD)31.6(4.5)30.7(4.8)31.7(4.4)0.22Secondary APS34(14.3)10(29.4)24(11.8)0.01Previous renal phenotype67(28.2)13(38.2)54(26.5)0.16At least 1 flare during pregnancy37(15.5)6(17.4)31(15.2)0.80Positive anti-DNA (N=222)104(46.8)21(67.7)83(43.5)0.01Hypocomplementemia (N=216)57(26.4)13(40.6)44(23.9)0.05LAC (N=232)41(17.7)15(44.1)26(13.1)<0.001Triple aPL (N=232)17(7.3)5(14.7)12(6.1)0.0824h-proteinuria>0.5g/day9(3.8)3(8.8)6(2.9)0.12Activity/DamageSLEDAI-2K, median (IQR) (N=212)2(0-3)2(2-4)2(0-2)0.01SLICC-DI, median (IQR) (N=236)0(0-0)0(0-0)0(0-0)0.007PGA, median (IQR)(N=235)0.1(0-0.2)0.1(0-0.41)0.1(0-0.2)0.06DORIA remission*154(64.7)17(50.0)137(67.2)0.05DORIS remission**147(61.8)17(50.0)130(63.4)0.13LLDAS (N=219)157(71.7)19(57.6)138(74.2)0.05Clinical SLEDAI-2K=0206(86.5)28(82.4)178(87.3)0.44TreatmentPrednisone (PDN)119(50.0)23(67.7)96(47.1)0.03PDN (mg/day) median (IQR)7(5-10)0(0-6)5(0-10)0.007Immunosuppressants57(24.0)13(38.2)44(21.6)0.04Hydroxychloroquine234(98.3)34(100.0)200(98.0)1.00Low dose aspirin165(69.3)29(85.3)136(66.7)0.03Low molecular weight heparin61(25.6)15(44.1)46(22.6)0.01

Legend: APS: antiphospholipid syndrome; aPL: antiphospholipid; PGA: Physician global assessment. *: DORIA definition of remission = clinical SLEDAI=0 and prednisone ≤5 mg/day; **: DORIS definition of remission = clinical SLEDAI=0, prednisone ≤5 mg/day, and PGA<0.5.

Disclosure of Interests:

None declared.

OP0297 THE SLE-DAS ENABLES ACCURATE AND USER-FRIENDLY DEFINITIONS OF REMISSION AND CATEGORIES OF LUPUS DISEASE ACTIVITY: DERIVATION AND VALIDATION STUDY IN 1190 SLE PATIENTS

Background:

Treatment of systemic lupus erythematosus (SLE) is tailored according to the intensity of SLE disease activity and aims to achieve remission. Current definitions of remission and disease activity categories are mostly based on the SLE Disease Activity Index (SLEDAI), which has important limitations. The SLE Disease Activity Score (SLE-DAS) is a validated continuous disease activity score with higher accuracy in measuring SLE activity and higher sensitivity-to-change as compared to SLEDAI1. SLE-DAS is user-friendly with its online calculator.

Objectives:

To derive and validate the SLE-DAS cut-off values for defining SLE disease activity categories and SLE clinical remission state.

Methods:

Derivation study was conducted at the Padova Lupus Clinic. Validation was performed prospectively in patients from the Cochin Lupus Clinic and by post-hoc analysis of BLISS-76 (NCT00410384) trial. Gold-standard for clinical remission state was fulfillment of Definition Of Remission In SLE (DORIS). In Padova and Cochin Clinics, at time of inclusion, a senior clinician classified each patient as presenting: (i) remission, (ii) mild, or (iii) moderate/severe disease activity. Derivation of the SLE-DAS cut-offs for disease activity categories was performed using ROC curve analysis against this expert clinical classification. Performance of these SLE-DAS categories of disease activity was assessed as compared with: (i) expert classification (in Cochin cohort); (ii) British Isles Lupus Assessment Group (BILAG) index (in BLISS-76). An index-based and a Boolean definition of remission were tested applying decision trees, using CHAID (chi-square automatic interaction detection) algorithm and their performance estimated.

Results:

We included 1190 SLE patients (221 in Padova, 150 in Cochin and 819 from BLISS-76 cohorts). In the derivation cohort, best SLE-DAS cut-off values for disease activity categories were: (i) remission, SLE-DAS≤2.08; (ii) mild activity, 2.08<SLE-DAS≤7.10; (iii) moderate/severe activity, SLE-DAS>7.10. Table 1 shows the performance of these SLE-DAS cut-offs. The SLE-DAS Boolean-based definition of remission (all SLE-DAS clinical items scores = 0 and prednisone ≤5mg/day) showed sensitivity and specificity of 100% in the derivation (Padova) and validation (Cochin) clinical cohorts. The SLE-DAS index-based definition of remission (SLE-DAS ≤2.08 and prednisone ≤5mg/day) presented sensitivity =100% and specificity =97.4% in the derivation and validation clinical cohorts. The SLE-DAS definitions of remission were fully substantiated by CHAID.

Table 1.

Performance of SLE-DAS cut-offs for remission and disease activity categories compared to physician’s classification and BILAG (n =1190).

Disease activity categorySensitivity (%)Specificity (%)Accuracy (%)DerivationPadova CohortRemission(SLE-DAS≤2.08)99.397.198.6Mild Disease Activity(2.08<SLE-DAS≤7.10)74.298.995.5Moderate and Severe Disease Activity(SLE-DAS>7.10)97.496.796.8ValidationCochin CohortRemission(SLE-DAS≤2.08)99.193.998.0Mild Disease Activity(2.08<SLE-DAS≤7.10)82.699.296.7Moderate and Severe Disease Activity(SLE-DAS>7.10)100.098.698.7ValidationBLISS-76Remission and Mild Disease Activity§vs. Moderate and Severe Disease Activity§§ (SLE-DAS≤7.10 vs. >7.10)91.484.190.8

§ Remission/Mild: No BILAG B or A scores

§§ Moderate/severe: ≥1 BILAG B or A scores

Conclusion:

The SLE-DAS is an accurate and easy to use tool for defining clinical remission state and SLE disease activity categories, validated with both the expert assessment and BILAG.

References:

[1]Jesus D, et al. Derivation and validation of the SLE Disease Activity Score (SLE-DAS): a new SLE continuous measure with high sensitivity for changes in disease activity. Ann Rheum Dis 2019;78:365-71.

Acknowledgements:

The authors would like to thank GlaxoSmithKline (Uxbridge, UK) for granting access to the data from the BLISS-76 trial through the Clinical Study Data Request consortium.

Disclosure of Interests:

None declared

Similar glycaemic control and risk of hypoglycaemia with patient- versus physician-managed titration of insulin glargine 300 U/mL across subgroups of patients with T2DM: a post hoc analysis of ITAS

AIMS

The Italian Titration Approach Study (ITAS) demonstrated comparable HbA_1c reductions and similarly low hypoglycaemia risk at 6 months in poorly controlled, insulin-naïve adults with T2DM who initiated self- or physician-titrated insulin glargine 300 U/mL (Gla-300) in the absence of sulphonylurea/glinide. The association of patient characteristics with glycaemic and hypoglycaemic outcomes was assessed.

METHODS

This post hoc analysis investigated whether baseline patient characteristics and previous antihyperglycaemic drugs were associated with HbA_1c change and hypoglycaemia risk in patient- versus physician-managed Gla-300 titration.

RESULTS

HbA_1c change, incidence of hypoglycaemia (any type) and nocturnal rates were comparable between patient- and physician-managed arms in all subgroups. Hypoglycaemia rates across subgroups (0.03 to 3.52 events per patient-year) were generally as low as observed in the full ITAS population. Small increases in rates of 00:00-pre-breakfast and anytime hypoglycaemia were observed in the ≤ 10-year diabetes duration subgroup in the patient- versus physician-managed arm (heterogeneity of effect; p < 0.05).

CONCLUSIONS

Comparably fair glycaemic control and similarly low hypoglycaemia risk were achieved in almost all patient subgroups with patient- versus physician-led Gla-300 titration. These results reinforce efficacy and safety of Gla-300 self-titration across a range of phenotypes of insulin-naïve people with T2DM.

CLINICAL TRIAL REGISTRATION

EudraCT 2015-001167-39.

SARS-CoV-2 infection in patients with autoimmune rheumatic diseases in northeast Italy: A cross-sectional study on 916 patients

Background

Whether patients with autoimmune rheumatic diseases (ARD) have a higher risk for SARS-CoV-2 infection (COVID-19) and how SARS-CoV-2 pandemic impacts on adherence to therapy has not been fully elucidated. We assessed the rate and clinical presentation of COVID-19, and adherence to therapy in a large cohort of patients with ARD followed-up in a tertiary University-Hospital in Northeast Italy.

Methods

Between April 9th and April 25th^, 2020, after SARS-CoV-2 infection peak, a telephone survey investigating the impact of COVID-19 on patients with systemic lupus erythematosus (SLE), systemic sclerosis (SSc), rheumatoid arthritis (RA), ANCA-associated vasculitis (AAV), and idiopathic inflammatory myopathies (IIM) was administered. Demographics, disease activity status, therapy, occupational exposure, and adherence to social distancing advise were also collected.

Results

916 patients (397 SLE, 182 AAV, 176 SSc, 111 RA, 50 IIM) completed the survey. 148 patients developed at least one symptom compatible with COVID-19 (cough 96, sore throat 64, fever 64, arthromyalgias 59, diarrhea 26, conjunctivitis 18, ageusia/hyposmia, 18). Among the 916 patients, 65 (7.1%) underwent SARS-CoV-2 nasopharyngeal swab (18 symptomatic and 47 asymptomatic), 2 (0.21%) tested positive, a proportion similar to that observed in the general population of the Veneto region. No deaths occurred. 31 patients (3.4%) withdrew ≥1 medication, mainly immunosuppressants or biologics. Adoption of social distancing was observed by 860 patients (93.9%), including 335 (36.6%) who adopted it before official lockdown.

Conclusions

COVID-19 incidence seems to be similar in our cohort compared to the general population. Adherence to therapy and to social distancing advise was high.

•

SARS-CoV-2 infection rate in ARDs seems to be similar to that of the general population.

•

Adoption of social distancing measures was prevalent among different ARD groups.

•

Earlier social distancing was more common in unremitted patients, treated with multiple drugs.

•

Therapy discontinuation due to COVID-related concerns was rare, but undertaken even by active patients.

•

Therapeutic regimens based on ≥3 drugs were associated with therapy discontinuation in our cohort.

SAT0163 IMMUNOSUPPRESSANT WITHDRAWAL AFTER REMISSION ACHIEVEMENT IN LUPUS NEPHRITIS: EFFECT ON FLARE OCCURRENCE

Background:

Whether and when immunosuppressive therapy may be safely withdrawn in patients with lupus nephritis (LN) is still poorly defined. Indeed, there is no clear agreement about the optimal duration of maintenance treatment.

Objectives:

We aimed at assessing the rate and predictors of flare after IS withdrawal in patients with LN in remission.

Methods:

Patients with systemic lupus erythematosus (SLE) (ACR criteria) and biopsy-proven LN diagnosed between 1990 and 2019, ever treated with IS and currently in follow-up were considered. IS discontinuation was defined as the complete withdrawal of any immunosuppressive drug in patients in remission. Remission was defined as normal serum creatinine, proteinuria <0.5 g/24h, inactive urine sediment, and no extra-renal SLE activity (clinical SLE Disease Activity Index [c-SLEDAI]-2K=0) on a stable immunosuppressive and/or antimalarial therapy and/or on prednisone ≤5 mg/day. Flares were defined according to SLEDAI Flare Index; renal flare was defined as an increase of proteinuria >0.5 g/24h requiring an increase in corticosteroid therapy or the reintroduction of IS. Predictors of a subsequent flare were analyzed by multivariate logistic regression analysis.

Results:

Out of 456 SLE patients regularly followed-up, 206 (45.1%) had LN and were considered in our study. Eighty-three patients (40.3%) discontinued IS after remission achievement (Table 1). After stopping therapy, patients were followed for a mean±SD of 99±77 months (range 12-378). Nineteen patients (22.8%) developed a flare after IS discontinuation, after a mean±SD follow-up of 78±68 months (range 7-312), and were re-treated; among them, 6 patients (7.2%) experienced a renal and 13 (15.6%) an extra-renal flare. Compared to patients who flared, patients in persistent IS-free remission had longer remission before IS withdrawal (51.2±31.5 vs. 29.3±16.5 months, p<0.001), and continued antimalarials after IS discontinuation (p=0.005). No differences in flare occurrence according to the type of IS discontinued were found. At multivariate analysis, therapy with antimalarials was the strongest protective factor against disease flare (OR 0.06, 95% CI 0.11-0.41, p=0.004) (Table 2). At last follow-up, mean±SD SLEDAI-2K was 3.1±2.8 and 1.5±1.6 in patients who experienced or not a flare after IS discontinuation, respectively (p=0.058), Indeed, 10/19 patients (52.5%) who developed a flare re-achieved remission.

Table 1.

Characteristics of 83 patients with LN in remission who discontinued immunosuppressive therapy, overall and according to flare occurrence

Total patients (83)Patients with flare (19)Patients without flare (64)P valueFemale, N(%)72 (88.7)16 (84.2)56 (87.5)nsAge at 2019, years43±1139±11.545±10.40.049SLE duration at 2019, years18±916.7±9.018.6±8.6nsSLE duration at IS discontinuation, years9.7±7.67.1±6.110.5±7.8nsTime to achieve remission, months27±3722.1±35.628.5±37.6nsRemission duration at IS discontinuation, months46±3029 ±16.551±31.5<0.001IS therapy duration, years6.7±4.35.2±3.87.1±4.20.061Anti dsDNA, N(%)65 (78.3)18 (95)47 (73)0.059HCQ after IS discontinuation, N(%)67 (80.7)12 (63.1)55 (85.9)0.005

IS, immunosuppressant; HCQ, hydroxychloroquine

Table 2.

Multivariate logistic regression: predictors of flare occurrence

Dependent variable: flare occurrenceOR95% CIp valueNumber of ISs, ever3.2641.030-10.3420.044HCQ therapy after IS discontinuation0.0960.014-0.6520.017Remission duration at IS discontinuation0.9540.912-0.9970.037Cyclophosphamide, ever0.0650.008-0.5480.012

IS, immunosuppressant; HCQ, hydroxychloroquine

Conclusion:

Based on our experience, withdrawal of IS is feasible in selected patients with LN, i.e. patients who achieved stable remission and received maintenance therapy with antimalarials. Patients who experience new flares can re-achieve remission with an appropriate treatment.

Disclosure of Interests: :

Margherita Zen Speakers bureau: BMS, Ely Lilly, Janssen, GSK, Mariele Gatto Speakers bureau: GSK, Francesco Benvenuti: None declared, Francesca Saccon: None declared, Maddalena Larosa: None declared, Luca Iaccarino Speakers bureau: GSK, Pfizer, Janssen, Novartis, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS

THU0275 SEVERE PREECLAMPSIA RELATED TO ANTIPHOSPHOLIPID SYNDROME: AN EUROPEAN STUDY OF 40 WOMEN

Background:

One of the 3 features of obstetrical antiphospholipid syndrome (APS) is severe preeclampsia (PE). Its time of occurrence, the associated risk of thromboses and systemic lupus erythematosus (SLE) have not been reported yet.

Objectives:

We analyzed severe PE in a series of women with APS.

Methods:

We retrospectively collected data of female patients from 5 French internal medicine and 1 Italian rheumatology units. Inclusion criteria were: a severe PE/eclampsia(1), that occurred before 34 weeks of gestation (WG) in patients who met the APS classification criteria(2).

Results:

40 patients were enrolled (Table 1). Because of known APS/positive aPL/previous obstetrical complications, 23(57.5%) patients were treated during the index PE: 4 with low dose aspirin (LDA), 4 with low molecular weight heparin (LMWH), and 15 with a combination of both. 7 patients were also treated with hydroxychloroquine, 8 with corticosteroids and 3 with immunosuppressants. 17(42.5%) patients received no treatment. 24(60%) live births were observed. During a follow-up period of 3 years, 26(65%) patients had at least 1 new pregnancy, with a total of 38 pregnancies which resulted in 33(86.8%) live births. 57.5% pregnancies who resulted in live births occurred without any maternal or fetal complications. All 26 patients who had at least 1 pregnancy after index PE were treated with LDA; LMWH was given at prophylactic and therapeutic dosage in 13(50%) patients, respectively. No patient experienced 3 consecutive miscarriages.

Table 1.

40 APS patients with severe PE

Overall features (n, %)Patients40 (100)Age at PE, (median, IQR)30.5 (27-33)PE term, WG (median, IQR)25.5 (23-29) Live births24 (60) Birth term, WG (median, IQR)25.5 (23.7-30.3) Associated SLE12 (30)Maternal complications (n, %)25 (62.5) HELLP18 (45) E6 (15) CAPS3 (7.5) Placental abruptions3 (7.5)Fetal complications (n, %)31 (77.5) IUGR18 (45) IUFD11 (2.5) Preterm delivery22 (55)Obstetrical history (n, %) Primiparous21 (52.5) Index PE before APS12 (30)Thrombosis (n, %) Thrombosis before PE index14 (35.0) Thrombosis after PE index2 (5.0)Abs at APS diagnosis (n, %) aPL triple positivity21 (52.5) IgG/IgM anti-cardiolipin34 (85.0) IgG/IgM anti-β2GPI25 (62.5) LAC33 (82.5)

Legend to Table 1:PE: preeclampsia; APS: antiphospholipid syndrome; IQR: interquartile range; WG: weeks of gestation; SLE: systemic lupus erythematosus; HELLP: Hemolysis, elevated liver enzymes, low platelet; E: eclampsia; CAPS: catastrophic APS; IUGR: intrauterine growth restriction; IUFD: intrauterine fetal death; CHB: congenital atrioventricular block; aPL: antiphospholipid antibodies; LAC: lupus anticoagulant.

Conclusion:

Among the APS criteria, “3 consecutive miscarriages criterion” was not found. The majority of patients also experienced thrombosis and SLE before the index PE.

References:

[1]Diagnosis and Management of preeclampsia and eclampsia. International Journal of Gynecology &Obestetrics 2002;77:67-75.

[2]Miyakis S, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006;4:295e 306.

Disclosure of Interests:

Maddalena Larosa: None declared, Nathalie Morel: None declared, Meriem BELHOCINE: None declared, Amelia Ruffatti: None declared, Nicolas Martin Silva: None declared, Romain Paul: None declared, Luc Mouthon: None declared, Michel DREYFUS: None declared, Jean-Charles PIETTE: None declared, Odile Souchaud-Debouverie: None declared, Catherine Deneux-Tharaux: None declared, Vassilis Tsatsaris: None declared, Emmanuelle Pannier: None declared, Gaêlle Guettrot Imbert: None declared, Véronique LE GUERN Grant/research support from: UCB for GR2 study (to our institution), Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS, Nathalie Costedoat-Chalumeau Grant/research support from: UCB to my institution

Italian Titration Approach Study (ITAS) with insulin glargine 300 U/mL in insulin-naïve type 2 diabetes: Design and population

BACKGROUND AND AIMS

Fostering patient's self-managing of basal insulin therapy could improve glucose control, by removing patient's and physician's barriers to basal insulin initiation, titration and glucose monitoring. The Italian Titration Approaches Study (ITAS) aims at demonstrating non-inferiority (<0.3% margin) in efficacy of glucose control (change in glycated hemoglobin [HbA1c] after 24 weeks) by the same titration algorithm of insulin glargine 300 U/mL (Gla-300), managed by the (nurse assisted) patient versus the physician, in insulin naïve patients with Type 2 Diabetes Mellitus (T2DM), uncontrolled with previous treatments.

METHODS AND RESULTS

ITAS is a phase IV, 24-week, national, multicenter, open label, randomized (1:1) parallel group study. 458 patients were enrolled, 359 randomized, and 339 completed the study, in 46 Italian centers. Baseline characteristics and previous medications of the ITT population (N = 355) are reported. Mean ± SD age, T2DM duration, HbA1c, FPG and BMI were 64.0 ± 9.8 years, 11.6 ± 7.6 years, 8.79 ± 0.65%, 170.9 ± 42.3 mg/dL, and 30.3 ± 5.6 kg/m², respectively. Vascular and metabolic disorders were most frequent (73.8% and 58.3%, respectively). More than 90% of patients were on metformin.

CONCLUSION

ITAS is the first study to compare two different managers (nurse-assisted patient vs physician) of the same titration algorithm of Gla-300 in insulin naïve patients with T2DM in unsatisfactory glucose control. This study might provide novel evidence on the efficacy/effectiveness of patient-managed titration algorithm of Gla-300 in a pragmatic setting and may reduce barriers to basal insulin initiation and its titration.

Diagnostic and prognostic role of renal histopathology in rheumatic diseases

The objective was to evaluate renal involvement in several rheumatic diseases (i.e. rheumatoid arthritis, systemic lupus erythematosus, Sjögren syndrome, systemic sclerosis, systemic vasculitides). The method chosen was to define histopathological profiles reported in renal biopsies performed on patients with renal involvement due to different rheumatic diseases. Renal involvement observed in patients with rheumatic disease can be the direct result of the disease per se and/or a complication of drugs used in the disease treatment. The clinical-pathological correlations derived from the study of renal tissues can be useful for differential diagnosis, prognosis assessment and therapeutic decisions. Renal biopsy should be considered as an important tool for the management of nephropathies in patients with systemic rheumatic diseases.

Endometriosis: Aetiopathogenetic Basis

Endometriosis, defined by the presence of endometrial tissue outside the uterine cavity, is a common condition affecting 10% of women in the reproductive age. Menstrual factors reported to increase risk include dysmenorrhea, early menarche, and shorter cycle lengths. The theory of retrograde menstruation with implantation of endometrial fragments, in conjunction with peritoneal factors to stimulate cell growth is the most widely accepted.

There is a growing body of evidence that immunological factors and angiogenesis play a key role in the pathogenesis of endometriosis. In women with endometriosis, there appears to be an alteration in the function of peritoneal macrophages, natural killer cells and lymphocytes, with production of growth factors and inflammatory mediators in the peritoneal fluid. Survival, adhesion, proliferation, invasion and vascularization of endometrial tissue in abdominal cavity may be the consequence of retrograde menstruation and referred to as implantation theory.

Bilateral Warthin tumor in psoriatic patients in therapy with multiple immunosuppressive therapy

Anti-TNFα drugs have strongly changed the way in which we deal with moderate and severe psoriasis. However, it is debatable whether biological drugs could increase the risk of developing cancer. The correlation between anti-TNFα drugs and lymphomas is well-known and is reported in all the technical details of biologic drugs. However, the association between anti-TNFα agents and solid tumors is still controversial. The authors report a case of bilateral salivary gland tumor in a psoriatic patient treated with several immunosuppressive therapies including anti-TNFα inhibitors.

[Endometriosis: aetiopathogenetic basis]

Endometriosis, defined by the presence of endometrial tissue outside the uterine cavity, is a common condition affecting 10% of women in the reproductive age. Menstrual factors reported to increase risk include dysmenorrhea, early menarche, and shorter cycle lengths. The theory of retrograde menstruation with implantation of endometrial fragments, in conjunction with peritoneal factors to stimulate cell growth is the most widely accepted. There is a growing body of evidence that immunological factors and angiogenesis play a key role in the pathogenesis of endometriosis. In women with endometriosis, there appears to be an alteration in the function of peritoneal macrophages, natural killer cells and lymphocytes, with production of growth factors and inflammatory mediators in the peritoneal fluid. Survival, adhesion, proliferation, invasion and vascularization of endometrial tissue in abdominal cavity may be the consequence of retrograde menstruation and referred to as implantation theory.

Calcifilassi e Necrosi Peniena: Case Report e Revisione Della Letteratura

Introduction

Calciphylaxis is a rare clinic condition characterised by skin necrosis due to medial and intimal calcification of small and medium arteries. It's observed in patients affected by end stage renal disease associated to secondary hyperparathiroidism. Penile involvement has been documented in very few cases. We present both a case of penile calciphylaxis and a review of literature, in order to increase comprehension of patophysiology diagnosis and therapy of this rare disease.

Materials and Methods

A retrospective review of literature was performed after treating a case of penile calciphylaxis. We describe patient characteristics, clinical presentation, laboratory and histopathologic findings, therapeutic strategy and outcomes of the case.

Results

A 65 year-old man, affected by diabetes, chronic ischemic cardiopathy and chronic renal failure in emodialithic treatment, was referred to our unit for the presence of increased consistency and significative pain of the distal portion of penis evolving in a complete glans necrosis. Blood levels of parathormone (PTH), calcium (Ca) and phosphorous (P) resulted pathologically elevated, promoting tissutal calcium deposition. The patient was treated with partial penectomy and the histologic findings confirm diagnosis of calciphylaxis, showing an ulcerative necrosis of glans with extensive calcium deposition and luminal narrowing of penile small arteries.

Conclusions

The increase of number of patients with chronic renal failure in emodialithic treatment could make penile calciphylaxis more p\revalent in the future. Early diagnosis, lowering of pathologic blood levels of Ca and P associated to surgical treatment of necrotic lesions of the patient could be fundamental for a better prognosis of this aggressive disease.

A Rare Case of Female Bladder Spontaneous Rupture

Bladder spontaneous rupture in the woman represents an extremely rare urologic emergency; its cause can be iatrogenic, neoplastic or diabetic.

Materials and Methods

A 56-year-old woman was referred to our unit because of the presence of acute abdominal pain, oligoanuria and vomiting for two days. At physical examination, the patient presented with confusional state, acute urinary retention and gross hematuria after urethral catheterization. Laboratory data demonstrated important metabolic abnormalities: hyperglycemia (946 mg/dL), acute renal failure (serum creatinine: 3.25 mg/dL), hyponatremia (120 mEq/L) and metabolic acidosis. At the CT of her abdomen and pelvis, a suspected bladder rupture (right lateral wall) was revealed, and confirmed after performing a retrograde cystography. Personal history was negative for trauma; glycemia was never controlled despite an important familiarity for type I diabetes. An episode of painless gross hematuria had occurred one month before, treated by the physician with antibiotics. Firstly the metabolic and electrolyte imbalance was corrected and then an emergency explorative laparotomy was performed. An important urinary leakage in the pelvis and a mild peritoneal effusion were documented. Furthermore, an important leak of papillary-like neoplastic material from the vesical breach was detected. The neoplasm seemed to involve the whole bladder. The surgical treatment consisted in bladder raphia, accurate washing of perivesical space, difficult salvage cystectomy (tenacious adhesions due to the urinary leakage) and bilateral ureterocutaneostomy. During the postoperative stay, the patient showed a difficult glycemia control with insulin therapy and wound dehiscence healed by second intention. The hospital discharge was on day 30, with the patient in good health and acceptable glycemia control.

Results

The pathological diagnosis was a G2 non-invasive urothelial carcinoma, also involving a vesical diverticulum; the neoplasm was associated with an erosive chronic cystitis with aspects of transparietal micro-abscessual flogosis (pT1 G2 N0 Mx). The patient will perform a CT scan 3 months after surgery before possibly starting chemotherapy.

Conclusions

Bladder spontaneous rupture in the woman is an extremely rare pathology; in the reviews we analyzed, it is dealt with as a clinical condition that more often occurs in patients submitted to pelvic surgery followed by adjuvant radiotherapy. Invasive bladder neoplasms, predominantly the sarcomatoid ones, are the second more frequent cause mentioned in the literature. Diabetic uropathy of the bladder associated with purulent bacterial cystitis in the elderly is the third cause, which is mentioned in two articles only. At last, only one study indicates the superficial urothelial bladder cancer (pT1- G2) as the responsible for this dramatic event. In our case, the suspected bladder diabetic uropathy, characterized by reduced perception of micturition stimulus, the increase in vesical capacity and detrusorial hypocontractility, were probably an important concomitant cause of this dramatic clinic condition, in association with the large superficial urothelial neoplasm. Moreover, diabetic neuropathy could explain the delay of patient presentation to the physician. Urinary leak, probably occurred 2 days before diagnosis, created an important metabolic imbalance and remarkable surgical difficulties. The timely treatment allowed for the resolution of a clinical condition associated with an elevated mortality due to septic shock.

Specific Immunotherapy for Allergic Rhinitis in Italy: The Doctors' Points of View

Specific immunotherapy (SIT) is the unique causal treatment for allergy, but its prescription is quite restricted. A perspective and cross-sectional survey based on telephone interviews was carried out in Italy to evaluate the profile of doctors prescribing SIT for allergic rhinitis. A total of 540 doctors were interviewed, 200 of whom are GPs, 60 allergists, 60 ENT specialists, 100 familial paediatricians, 60 hospital paediatricians and 60 pulmonologists. Significant differences concern diagnostic and therapeutic management of allergic rhinitis, mainly regarding SIT prescription. The allergist is the most important consultant who prescribes SIT, as opposed to the paediatrician. This study therefore provides the evidence that doctors' behaviour towards SIT depends on the type of graduate studies.

Specific immunotherapy for allergic rhinitis in Italy: the patients points of view

Specific immunotherapy (SIT) is the unique causal treatment for allergy, but its use is quite limited. A perspective, cross-sectional telephone interview survey was carried out in Italy to evaluate the characteristics of 500 patients with allergic rhinitis (250 of whom treated with SIT). Relevant differences were found concerning therapeutic management of allergic rhinitis, mainly regarding the use of drugs and co-morbidities. The allergist is the most important consultant who prescribes SIT. This study therefore provides evidence that the course of allergic rhinitis may depend on the therapy prescribed by and the level of allergy awareness of the physician.

Doctors' and patients' educational levels affect immunotherapy prescription

Cultural level appears to be a critical factor in the decision process of allergen-specific immunotherapy (SIT) both for doctors and patients. Thus, appropriate educational programs should be carried out to increase the number of allergic patients to be treated with SIT.

Balanitis Xerotica Obliterans: Presentation of a Case

Balanitis xerotica obliterans is a term applied to a chronic inflammatory disease of the glans penis and prepuce. The symptoms are usually a sudden FIMOSI, a reduction of the sensibility of the glans, a stenosis of the uretreal meatum and dysuria. The disease was thought in the past as a rare pathology, whereas recent reviews of the literature showed that its frequency is quite high. We present a case of a male patient who presented to the urological department of the Guastalla hospital for a sclerosing lesion of the glans. The lesion were biopsied, and the histological picture showed hyperkeratosis of the epithelium with atrophy of the malpighian layer, oedema of the upper dermis and inflammatory infiltrate of medium derma (lymphocytes and scattered histyocites). The early diagnosis and the following treatment of this pathology are very important for its resolution, although the surgery is not always needful (often it is sufficient the clinical diagnosis). The surgical excision shall be used always in case of differential diagnosis with a neoplastic and/or atypical or uncertain lesions (penis carcinoma).

Prevalence and patterns of antibiotic prescribing in Italian hospitals

Use of antimicrobial drugs is associated with the emergence of resistant bacteria, increasing hospital expenditures and requires an assessment of appropriateness. The aim of this study was to investigate prevalence and patterns of antibiotic prescribing and expenditures in Italian hospitals. A prevalence survey was performed in 15 Italian hospitals. Data on antimicrobial use and expenditures in the year 2000 and 1-day point prevalence information on antibiotic prescription, type and sources of infections and expenditures were obtained through a review of pharmacy records and charts of 2,165 inpatients. 45.5% of the patients surveyed were receiving at least one antibiotic: 148 for hospital-acquired infections (HAI), 262 for community-acquired infections (CAI). No active infection was recorded for 575 patients (58.4%). 57.3% of prescriptions for HAI and 65.9% for CAI were based on empiric and presumptive criteria, while 39% of HAI and 15.8% of CAI were oriented by microbiology and susceptibility testing results. Guidelines were followed in choosing the antimicrobial drugs for 22.8% of therapeutic and 46.8% of prophylactic courses. High rates of antibiotic usage were observed in Italian hospitals. Areas for improvement, both for the use of diagnostic resources and the prescribing habits, were identified. The 1-day prevalence survey of antimicrobial use may be a tool of feedback to prescribers for more appropriate drug selection.

Prevalence of nosocomial infections in 15 Italian hospitals: first point prevalance study for the INF-NOS project

BACKGROUND

The aim of our study was to assess the magnitude of nosocomial infections (NI) in 15 Italian hospitals.

PATIENTS AND METHODS

A multicenter point prevalence study of NI was carried out in October 2001 among eight medical, surgical and intensive care units in hospitals with more than 400 beds, after a pilot phase performed in April 2001.

RESULTS

Of the 2,165 surveyed patients, 163 had a total of 179 NIs. The global prevalence rate of patients with NI and of NI was respectively 7.5% (95% CI 6.4-8.6) and 8.3% (95% CI 7.1-9.4), ranging from 5.5% (95% CI 4.2-6.8) in medical wards to 34.2% (95% CI 25.7-42.7) in intensive care units (ICUs). The NI prevalence was higher in: hospitals that did not have an infection control committee (ICC) compared to hospitals with an ICC (10.3%, 95% CI 6.4-10.1 versus 7.2, 95% CI 6.0-8.3, p = 0.08); university hospitals compared with non-teaching hospitals (9.4%, 95% CI 4.5-14.2 versus 7.4%, 95% CI 6.3-8.5, p = 0.4) and; hospitals with 1,000 or more beds compared to lower volume hospitals (9.5%, 95% CI 7.3-11.7 versus 6.6%, 95% CI 5.3-7.8, p = 0.02). The most prevalent infections found were lower respiratory tract infections, urinary tract infections and surgical-site infections, representing 38.0%, 20.1% and 12.8%, respectively, of all NI. Among 1,674 patients without any infection, 575 (34.3%) of them had been undergoing antibiotic treatment at the time of the survey.

CONCLUSION

The high rate of NI, particularly in ICUs, and the high number of improper procedures emphasize the need to develop clinically-oriented guidelines, tailor active infection control programs and implement an active ICU surveillance system.

[Gittes' pubovaginal suspension in the treatment of stress urinary incontinence (SUI)]

Since the 1993, a series of 22 women with stress urinary incontinence underwent bladder neck suspension, according to Gittes (pubovaginal suspension). No patients had preoperative detrusor instability or intrinsic sphincter dysfunction; 14 pts had a significant cystocele (II-III degree). We followed up 20 pts at 6 months: 9 pts (45%) were cured, 3 were significantly improved and 8 were not improved. Disappearance or marked improvement of moderate or severe cystocele wasn't confirmed in all pts. No serious complications were recognized. We believe that this procedure is quick and easy to perform with low morbidity and is useful where the indication is correct: patients with stress incontinence without significant anterior vaginal wall prolapse.

[The mini-invasive surgery of stress urinary incontinence (SUI): the use of the Vesica kit]

From February 1996 to March 1997, we have performed with the Vesica system the percutaneous bladder neck suspension in 13 pts (group 1) and the vaginal wall sling in 7 pts (group 2). After a mean follow-up of 12 months for group 1, 10 patients (76.9%) were "dry", 1 pt "improved" and 2 "failed"; in the group 2 (mean follow-up of 5 months) 6 pts/7 were "dry". Overall morbidity has been minimal. The percutaneous bladder neck suspension and the vaginal wall sling with Vesica system are minimally invasive surgical procedures for the urinary stress incontinence (hypermobility of bladder outlet and intrinsic sphincter deficiency).

[Correlation between the leak point pressure and the clinical grade of incontinence]

We evaluated one-hundred and forty-six women with stress urinary incontinence (SUI), mean age 61.5 years, with clinical examination, urodynamics and patient history, grading the subjective degree of SUI according to SEAPI QMM classification. SUI was grade 1 in 73 pts (mean LPP 107, 7 cmH2O, mean maximal urethral closure pressure 59, 13 cmH2O), grade 2 in 36 (mLPP 55, 4 cmH2O, mMUCP 50, 3 cmH2O), grade 3 in 37 (mLPP 32, 29 cmH2O, mMUCP 33, 76 cmH2O). There is statistically significant difference in mLPP (p = 0.001) and mMUCP (p = 0.02) among three groups. The grade of SUI increases as the likelihood that LPP will be < or = 90 cmH2O or < or = 60 cmH2O (72.2% of pts with grade 2 has a LPP < or = 60 cmH2O, 100% of pts with grade 3 has a LPP < or = 60 cmH2O). Women with severe leakage and/or predisposing factor (PF) to intrinsic sphincter deficiency are likely to have a low LPP: all patients with SUI grade 3 and PF have a LPP < or = 60 cmH2O, 77% of pts with SUI grade 3 or PF has a LPP < or = 60 cmH2O. Women with higher grades of leakage and PF are significantly more likely to have a very low LPP and intrinsic sphincter deficiency.

[Major complications of percutaneous nephrolithotripsy (PCNL). Analysis of our cases]

The major complications occurred in 140 cases of percutaneous nephrolithotomy, from March 1988 to December 1996 are studied. They were: 1 important hemorrhage with secondary nephrectomy, 1 intestinal fistula resolved with parenteral therapy, 1 hyponatriemic syndrome which required an intraperitoneal drainage and 1 global kidney functional exclusion after 3 months. Etiopathogenesis and suggestions for prevention are discussed as well as the necessity of adequate training.

[Valsalva leak point-pressure (LPP) and maximal urethral closure pressure (MUCP) in women with stress urinary incontinence (SUI)]

One-hundred and twenty-two women with USI have been evaluated with clinical examination and urodynamics and divided in two groups: only in 74 patients with urinary loss during the Valsalva manoeuvre, LPP was compared to MUCP by linear regression analysis and its ability (cut-off = 60 cmH2O) to predict a MUCP < or = 20 cmH2O was tested. Weak correlations were observed between MUCP and LPP (r = 0.56). Fifty-two patients presented a LPP < or = 60 cmH2O, in 6 of them MUCP was < or = 20 cmH2O; none with LPP > 60 cmH2O showed a MUCP < or = 20 cmH2O. Median MUCP and intravesical pressures at the instant of leakage of patients with LPP < or = 60 cmH2O were significantly different from those of patients with LPP > 60 cmH2O (p < 0.01). The specificity and positive predictive value of LPP < or = 60 cmH2O for the detection of a "low pressure urethra" were respectively 32% and 11.5%, while sensibility and negative predictive value were 100%. LPP can not be regarded as a specific test for urethral sphincteric deficits. For its sensibility, it can be an useful screening tool for patients at high risk of type III urinary incontinence.

Traumatic injury of the penis: surgical management

Three cases of penile injury secondary to mishap during sexual intercourse are described. The injury involved unilateral corpus cavernosum associated with urethral rupture in one case, penile fracture in the second patient and isolated urethral fracture in the third. Diagnosis and treatment of these uncommon lesions are discussed.

[Xanthogranulomatous pyelonephritis: conservative therapy in the para-nephritic stage. Apropos of a case]

Xantogranulomatous pyelonephritis is a rare disease, occuring most frequently in middle-aged woman. The patients usually present with recurrent fever, dysuria, renal colic or aspecific findings. We report a case of focal PXG (paranephric stage) treated with conservative surgery. Generally, treatment consists of nephrectomy for diffuse or advanced stage diseases, excision of the diseased renal segment for localized and low/high stage.

[Rouxel-Coadou method of ileal neobladder: clinico-functional considerations]

Twelve patients are submitted to orthotopic ileal neobladder, performed using staplers. The simplicity and speed of automatic stapling devices in the Rouxel-Coadou's surgical technique are reported. All patients underwent clinical and urodynamic evaluation at 3, 6, 12 months, after surgery (mean follow-up 6 months). They preferred complete daytime continence and 2 pts/4 night-time continence too. At one year, postvoid residual volume was absent, mean neobladder capacity was 450 ml and mean pressure at maximum capacity was 30-40 cm H2O. These preliminary results indicate that this technique guarantees a low-pressure reservoir with good capacity and compliance.

[Neoadjuvant chemotherapy in advanced-stage bladder carcinoma. A randomized prospective study comparing MVAC and MVEEC]

The Authors report the results with combination of cisplatin, methotrexate, vinblastine with adriamycin or epidoxorubicin (MVAC v MVEEC), in the neoadjuvant treatment of muscle-infiltrating bladder cancer (T2-4NO-1MO), before cystectomy. MVAC has been used in 29 patients and MVEEC in 25, who met eligibility criteria. Results from this prospective randomised trial show that MVAC and MVEEC can produce clinical and pathologic down-staging in 40-50% of cases: cCR+cPR are 15/28 (54%), pCR+pPR are 11/25 (44%). The survival duration of "pathologic" responders has been significantly longer than that of no responders (median no achieved at 200 weeks v 124 weeks for "pathologic" no responders). We conclude that neoadjuvant chemotherapy with MVAC or MVEEC select the more responsive patients, who have a longer survival.

Valutazioni Clinico-Urodinamiche Sulla Neovescica Ileale Ortotopica Riconfigurata Sec. Rouxel-Coadou: Nostra Esperienza

Twelve patients were submitted to orthotopic ileal neobladder, performed using staplers. All patients underwent clinical and urodynamic evaluations at 3, 6 and 12 months after surgery (mean follow-up 6 months). They reported complete daytime continence and 2 pts/4 night-time continence too. At one year, post-voiding volume was absent, mean neobladder capacity was 450 cc and mean pressure at maximum capacity was 30-40 cc. These preliminary results indicate that this technique guarantees low-pressure reservoir with good capacity and compliance.

Recidive neoplastiche vaginali di carcinoma vescicale dopo chirurgia demolitiva

We report four cases of vaginal recurrence after cystectomy for bladder cancer. Vaginal recurrences are relatively rare and patients who have undergone previous surgery and radiation to pelvic organs, or patients with tumour of the bladder neck and urethra appear to be at high risk. It is very important to know the predisposing factors in order to adopt appropriate surgical therapy.

Transrectal ultrasound in prostatic malacoplakia: Description of 2 cases

Clinically, it is difficult to distinguish prostatic malacoplakia from carcinoma. Two cases of prostatic malacoplakia are described, highlighting the ultrasound aspects of the lesion.