The data project: a shared approach between stakeholders of the healthcare system in definition of a therapeutic algorithm for inflammatory arthritis

Rheumatic musculoskeletal diseases or RMD [rheumatoid arthritis (RA) and spondyloarthritis (SpA)] are systemic inflammatory diseases for which there are no biomarkers capable of predicting treatments with a higher likelihood of response in naive patients. In addition, the expiration of the anti-TNF blocking drugs' patents has resulted in the availability of anti-TNF biosimilar drugs with the same efficacy and safety than originators but at significantly reduced prices. To guarantee a personalized therapeutic approach to RMD treatment, a board of rheumatologists and stakeholders from the Campania region, Italy, developed a clinically applicable arthritis therapeutic algorithm to guide rheumatologists (DATA project). The general methodology relied on a Delphi technique forecast to produce a set of statements that summarized the experts' consensus. Selected clinical scenarios were discussed in light of the available evidence, and there were two rounds of voting on the therapeutic approaches. Separate discussions were held regarding rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. The decision-making factors for each disease were clinical presentation, demographics, and comorbidities. In this paper, we describe a virtuous process between rheumatologists and healthcare system stakeholders that resulted in the development of a shared therapeutic algorithm for RMD patients naive to bDMARDs.

Effectiveness and safety profile of tofacitinib and baricitinib in rheumatoid arthritis patients: results from a 24-month real-life prospective study in Southern-Italy

The primary objectives of the study were to evaluate the efficacy and safety of tofacitinib and baricitinib up to 24 months of follow-up in patients with rheumatoid arthritis (RA) treated in Southern Italy. Patients' data, activity index, and clinimetric scores were collected at baseline (T0), six (T6), twelve (T12), and twenty-four (T24) months following treatment initiation. At six, twelve, and twenty-four months, adverse events and treatment cessation were also recorded. Sixty-eight patients (mean age: 62.2±10.9 years; mean RA duration: 15±9.6 years) were enrolled over a period of 12 weeks. At baseline, twenty-four patients (35.3%) were treated with tofacitinib, and forty-four patients (64.7%) were treated with baricitinib. The baseline mean disease activity was moderate as measured by DAS28- ESR (5.0±1.0), DAS 28 CRP (4.69±0.94), and SDAI (26.87±10.73) score. Before beginning JAKinhibs therapy, thirty-two patients (61.8%) were taking bDMARDs, while the remaining thirty-six (38.2%) were bDMARDs-naïve. The 24-month retention rate for JAKinhibs was 91.1%. Six months after beginning treatment with JAKinhibs, a statistically significant improvement was observed in all evaluated activity indices and clinimetric scores. Improvement was confirmed during the 12- and 24-month follow-up evaluations. The positive correlation between baseline-T6 SDAI delta and discontinuation of JAKinhibs (p=0.02) suggests that RA worsening in the first six months may be a predictor of therapy withdrawal. Patients with RA responded favorably to tofacitinib and baricitinib in this prospective, real-world study from a single center in Southern Italy. Efficacy was observed despite an underlying persistent and treatment-resistant disease.

Autoimmune polyendocrine syndrome type 1: an Italian survey on 158 patients

BACKGROUND

Autoimmune Polyglandular Syndrome type 1 (APS-1) is a rare recessive inherited disease, caused by AutoImmune Regulator (AIRE) gene mutations and characterized by three major manifestations: chronic mucocutaneous candidiasis (CMC), chronic hypoparathyroidism (CH) and Addison's disease (AD).

METHODS

Autoimmune conditions and associated autoantibodies (Abs) were analyzed in 158 Italian patients (103 females and 55 males; F/M 1.9/1) at the onset and during a follow-up of 23.7 ± 15.1 years. AIRE mutations were determined.

RESULTS

The prevalence of APS-1 was 2.6 cases/million (range 0.5-17 in different regions). At the onset 93% of patients presented with one or more components of the classical triad and 7% with other components. At the end of follow-up, 86.1% had CH, 77.2% AD, 74.7% CMC, 49.5% premature menopause, 29.7% autoimmune intestinal dysfunction, 27.8% autoimmune thyroid diseases, 25.9% autoimmune gastritis/pernicious anemia, 25.3% ectodermal dystrophy, 24% alopecia, 21.5% autoimmune hepatitis, 17% vitiligo, 13.3% cholelithiasis, 5.7% connective diseases, 4.4% asplenia, 2.5% celiac disease and 13.9% cancer. Overall, 991 diseases (6.3 diseases/patient) were found. Interferon-ω Abs (IFNωAbs) were positive in 91.1% of patients. Overall mortality was 14.6%. The AIRE mutation R139X was found in 21.3% of tested alleles, R257X in 11.8%, W78R in 11.4%, C322fsX372 in 8.8%, T16M in 6.2%, R203X in 4%, and A21V in 2.9%. Less frequent mutations were present in 12.9%, very rare in 9.6% while no mutations in 11% of the cases.

CONCLUSIONS

In Italy, APS-1 is a rare disorder presenting with the three major manifestations and associated with different AIRE gene mutations. IFNωAbs are markers of APS-1 and other organ-specific autoantibodies are markers of clinical, subclinical or potential autoimmune conditions.

POS1246 COVID-19 IN ITALIAN PATIENTS WITH RHEUMATIC AUTOIMMUNE SYSTEMIC DISEASES: RESULTS OF A NATIONWIDE SURVEY STUDY

Background:

SARS-CoV-2 infection poses a serious challenge for patients with rheumatic autoimmune systemic diseases (ASD), characterized by marked immune-system dysregulation and frequent visceral organ involvement.

Objectives:

To evaluate the impact of Covid-19 pandemic in a large series of Italian patients with ASD.

Methods:

Our multicenter telephone survey (8-week period, March-April 2020) included a large series of 2,994 patients (584 M, 2,410 F, mean age 58.9±13.4SD years) with ASD followed at 34 tertiary referral centers of 14 regions of northern, central, and southern Italian macro areas, characterized by different prevalence of SARS-CoV-2 infection. According to currently used criteria, Covid-19 was classified as definite Covid-19 (signs or symptoms of Covid-19 confirmed by positive oral/nasopharyngeal swabs at PCR testing) or highly suspected Covid-19 (signs or symptoms highly suggestive of Covid-19, but not confirmed by PCR testing due to limited availability of virological tests in that period). The results were analyzed performing the Odds Ratio by Java-Stat 2-way Contingency Table Analysis.

Results:

The main findings of the survey study revealed a significantly increased prevalence of Covid-19 in:

a.the whole series of ASD patients (definite Covid-19: 22/2994, 0.73%; p=0.0007;

definite Covid-19 plus highly suspected Covid-19: 74/2,994, 2.47%; p<0.0001) when compared to Italian general population of Covid-19 infected individuals (349/100000 = 0.34%; data from Italian Superior Institute of Health;

https://www.epicentro.iss.it/en/coronavirus/sars-cov-2-national-surveillance-system).

b.the subgroup of patients with connective tissue diseases or systemic vasculitis (n = 1,901) compared to the subgroup of inflammatory arthritis (n = 1,093), namely rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis (definite Covid-19: 19/1,901, 0.99%, vs 3/1,093, 0.27%; p=0.036; definite Covid-19 plus highly suspected Covid-19: 69/1,901, 3.6%, vs 5/1,093, 0.45%; p<0.0001)

c.the subgroup of patients with pre-existing interstitial lung involvement (n = 526) compared to those without (n = 2,468) (definite Covid-19: 10/526, 1.90%, vs 12/2,468, 0.48%; p=0.0015; definite Covid-19 plus highly suspected Covid-19: 33/526, 6.27%, vs 41/2,468, 1.66%; p<0.0001).

Of interest, the prevalence of Covid-19 did not correlate with presence/absence of different comorbidities, mainly diabetes, cardio-vascular and/or renal disorders, as well as of ongoing treatments with biological DMARDs; while patients treated with conventional DMARDs showed a significantly lower prevalence of Covid-19 compared to those without. Covid-19 was more frequently observed in the patients’ populations from northern and central compared to southern Italian macro area with lower diffusion of pandemic. Clinical manifestations of Covid-19, observed in 74 patients, were generally mild or moderate; 4/9 individuals requiring hospital admission died for severe pneumonia.

Conclusion:

The prevalence of Covid-19 observed in ASD patients during the first wave of pandemic was significantly higher than that observed in Italian general population; moreover, the actual prevalence of Covid-19 might be underestimated due to the high number of mild variants as well as the possible clinical overlapping between these two conditions. Patients with ASD should be invariably regarded as ‘frail patients’ during the pandemic course, considering the risk of worse outcome in the acute phase of Covid-19, as well as the potential long-term effects of viral infection.

The statistically significant association of Covid-19 with connective tissue diseases/systemic vasculitis, as well as with pre-existing interstitial lung involvement, suggests the presence of distinct clinico-pathological ASD subsets, characterized by markedly different patients’ vulnerability to SARS-CoV-2 infection.

Disclosure of Interests:

None declared

POS1349 THE JOINT INVOLVEMENT IN ADULT ONSET STILL’S DISEASE IS CHARACTERISED BY A PECULIAR MAGNETIC RESONANCE IMAGING AND A SPECIFIC TRANSCRIPTOMIC PROFILE

Background:

Adult onset Still’s disease (AOSD) is a rare systemic autoinflammatory disease and joint involvement is one of its clinical manifestations [1]. Arthritis, either oligoarthritis or bilateral symmetrical rheumatoid arthritis-like polyarthritis, is another common clinical feature of AOSD, with a migrating pattern at the beginning and becoming stable over the time [1].

Objectives:

The aims of the study were to assess joint involvement in AOSD by using magnetic resonance imaging (MRI), to describe main patterns of involvement, and associated clinical characteristics, and to evaluate the global transcriptomic profile of synovial tissues in AOSD to elucidate possible pathogenic pathways involved with.

Methods:

AOSD patients, who underwent to magnetic resonance imaging (MRI) exam on joints, were assessed to describe patterns of joint involvement and associated clinical characteristics. Some synovial tissues were collected for RNA-sequencing purposes.

Results:

In this study, 31 patients with AOSD (mean age 42.3 ± 15.2 years, 54.8% male gender), who underwent to at least one MRI exam on joints, were assessed. The most common MRI finding was the presence of synovitis on 60.5%, mainly in peripheral affected joints. MRI revealed a mild to moderate proliferative synovitis, as thickening of the synovial membrane, with low to intermediate signal intensity on T1-weighted images and intermediate to high signal intensity on T2-fat saturated weighted and STIR images, suggesting the presence of a hyperplastic than of a hypertrophied synovial tissue. Bone oedema and bone erosions were reported on 34.9% and 25.6% MRI exams, respectively. In all patients but one, bone erosions were synchronous with bone oedema, overlapping completely the locations. Assessing clinical characteristics in patients with MRI-erosions, a higher prevalence of splenomegaly, a more frequent chronic disease course, lower levels of erythrocyte sedimentation rate and ferritin was observed.

Assessing the synovial tissues of some AOSD patients, a moderate perivascular mononuclear infiltrate in the sub-lining stroma of hip synovial tissues was observed, whereas the lining cells were relatively unremarkable. In addition, interleukin (IL)-1β, IL-6, TNF, and heavy ferritin subunit (FeH) were found on AOSD synovial tissues.

An RNA-sequencing analysis assessed the global transcriptomic profile of synovial tissues on AOSD patients and matched-controls. Assessing IL-1 pathway, we found an increased expression of il1a, il1b, il1rap, il1r1, il18r1, and Il18bp on AOSD tissues when compared with controls. In IL-6 pathway, we found an increased expression of il6 and il6st/gp130 on AOSD synovial tissues whereas an increased expression of il6r was shown on the controls. Among genes involved in TNF pathway, tnf, traf1, traf2, tnfaip3 and tnfrsf1a resulted to be more expressed in AOSD synovial tissues than in controls. Finally, fth1 and ftl were more expressed in AOSD patients than controls, when we explored the iron uptake and transport pathway.

Conclusion:

A peculiar MRI pattern of joint involvement in AOSD was reported; the most common finding was the presence of synovitis, characterised by intermediate to high signal intensity on T2-fat-saturated weighted and STIR images. Bone erosions and bone oedema were also observed. This MRI pattern was associated with a hyper-activation of IL-1, IL-6, and TNF pathways together with a hyper-expression of ferritin genes on AOSD synovial tissues.

References:

[1]Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still’s disease. J Autoimmun. 2018;93:24-36.

Disclosure of Interests:

None declared

Levator ani and puborectalis muscle rupture: diagnosis and repair for perineal instability

BACKGROUND

Puborectalis muscle rupture usually arises from peri-partum perineal trauma and may result in anterior, middle compartment prolapses, posterior compartment prolapse which includes rectocele and rectal prolapse, with or without associated anal sphincter damage. Patients with puborectalis muscle and levator ani rupture may present some form of incontinence or evacuation disorder, sexual dysfunction or pelvic organ descent. However, the literature on this subject is scarce. The aim of our study was to evaluate management and treatment of functional disorders associated with puborectalis and/or pubococcygei rupture at the level of the insertion in the pubis in a cohort of patients referred to a tertiary care coloproctology center.

METHODS

We conducted a prospective cohort study of patients with levator ani and puborectalis muscle avulsion in the Proctology and Pelvic Floor Unit, Division of Digestive Surgery of the University Hospitals of Geneva from January 2001 to November 2018. Clinical examination, anoscopy and ultrasound were performed on a routine basis. Rupture of the levator ani muscle was diagnosed by clinical examination and ultrasound. A Wexner incontinence score was completed before and 6 months after surgery. Levator ani muscle repair was performed using a transvaginal approach.

RESULTS

Fifty-two female patients (median age 56 ± 11.69 SD years, range 38-86 years) were included in the study. Thirty-one patients (59.6%) had anal incontinence, 25 (48.1%) urinary incontinence, 28 (53.9%) dyschezia (obstructive defecation or excessive straining to defecate), 20 (38.5%) dyspareunia, 17 (32.7%) colpophony, and 13 (25.0%) impaired sensation during sexual intercourse. Deviation of the anus on the side opposite the lesion was observed in 50 patients (96.2%), confirmed with clinical examination and both endoanal and perineal ultrasound. Out of these 52 patients, levator ani rupture (including puborectalis rupture) were categorized into right sided, 43 (82.69%), left sided, 7 (13.46%) and bilateral, 2 (3.85%). Levator ani muscle repair was performed in all patients, associated with posterior repair and levatorplasty in 26 patients (50%) and with sphincteroplasty in 34 patients (63.4%). Four patients (7.7%) experienced postoperative complications: significant postoperative pain (n = 3; 5.77%), urinary retention (n = 2; 3.85%), hematoma (n = 1; 1.92%), and perineal abscess (n = 1; 1.92%). Forty-one patients (78.8%) had full restoration of normal puborectalis muscle function (Wexner score: 0/20) after surgery, and overall, all patients had an improvement in the Wexner score and in sexual function. Dyschezia was reported by 28 patients (53.9%) preoperatively, resolved in 18 (64.3%) and improved by 50% or more in 10 (35.71%).

CONCLUSIONS

Diagnosis of levator ani and puborectalis muscle rupture requires careful history taking, clinical examination, endoanal and perineal ultrasound. Surgical repair improved anal continence as well as sexual function in all patients. Transvaginal levator ani repair seems to be well tolerated with good short-term results.

In memory of Dr. Luis Espinoza

Not available.

SAT0435 SECUKINUMAB EFFICACY In PsA PATIENTS IS DEPENDENT ON PATIENTS’ BODY MASS INDEX

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis burdened by a series of metabolic comorbidities. Among them, obesity is very common in PsA, with a prevalence of 27%, as confirmed by a recent Spanish work (1). Obesity in PsA has been associated with higher disease activity and a worse effectiveness of biologic treatment in PsA. This has been certainly proven for anti-TNF-α as demonstrated by different studies reporting, in obese patients, a reduced treatment response and adherence. In particular, results coming from DAN-BIO and ICE-BIO registries, (2) point out that obesity is a risk factor for anti-TNF withdrawal due to poor response. Although a recent multi-centric, retrospective study in Spain has shown that obese subjects with psoriasis have a poor therapeutic response to secukinumab, (3) no data are currently available for secukinumab in PsA obese patients.

Objectives:

Our studies focused on the relationship between BMI and clinical response to secukinumab in PsA.

Methods:

We, retrospectively, analysed clinical data of 100 patients with PsA (57% female, median age 53 (49.2-55 years)) satisfying CASPAR criteria (4) for PsA, afferent to our clinic, who were treated with secukinumab. Patients were divided into 2 groups based on BMI (BMI<25 normal weight and BMI≥25 overweight/obese).

Results:

In the normal weight group 75% were female, median age was 50.5 (41-54.6), median BMI was 22 (20.2-23.3) and median DAPSA was 19.19 (15.6-24.2). The features of the overweight/obese patients were similar to the normal weight group (48% were female, median age 54 (50-59), median BMI 29 (27.4-30.1) and median DAPSA 21.2 (19-24.4)). Clinical response to therapy, evaluated as the achievement of low disease activity or remission according to DAPSA, was recorded 6 months after starting treatment. After 6 months of treatment, the variation of the DAPSA was inversely related to BMI: overweight/obese patients had in fact a better response to secukinumab compared to normal weight patients. By using a correlation coefficient (SPSS), to analyze the degree of association between BMI and DAPSA, we observed that BMI and DAPSA are inversely related in our PsA patients (p=0.05). Interestingly, analysis of serum levels of IL-17 in 20 obese patients compared to 20 non-obese patients, showed significantly higher serum levels of IL-17 in the former (Figure 1), indicating IL-17 as a key cytokine driving inflammation in PsA obese patients.

Conclusion:

These are the first data about clinical response to secukinumab in obese PsA patients. Our results support the relevance of IL-17 in driving systemic inflammation in obese PsA patients, also providing evidence that obese patients may have a better response to secukinumab compared to non-obese patients. Interestingly, this effect was not

References:

[1]Rubén Queiro, Lorenzo A, Tejón P et al. Obesity in psoriatic arthritis. Comparative prevalence and associated factors. Medicine 2019 Jul;98(28):e16400

[2]Pil Højgaard, Glintborg B, Kristensen LE et al. The influence of obesity on response to tumour necrosis factor-a inhibitors in psoriatic arthritis:results from the DANBIO and ICEBIO registries. Rheumatology (Oxford). 2016 Dec;55(12):2191-2199

[3]Jaime Notario, Deza G, Vilarrasa E et al. Treatment of patients with plaque psoriasis with secukinumab in a real-life setting: a 52-weeks, multicenter, retrospective study in Spain. Journ of Derm Treat 2019 Aug;30(5):424-429

[4]Taylor W, Gladman D, Helliwell P et al. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006 Aug;54(8):2665-73.

[5]Lluís Puig. Cardiometabolic Comorbidities in Psoriasis and Psoriatic Arthritis. Int J Mol Sci. 2017 Dec 25;19(1).

Disclosure of Interests:

Ilenia Pantano: None declared, DANIELA IACONO Speakers bureau: PFIZER, BRISTOL MAYERS SQUIBB, SANOFI, ENNIO GIULIO FAVALLI: None declared, GIUSEPPE SCALISE: None declared, Luisa Costa: None declared, Francesco Caso: None declared, Giuliana Guggino Grant/research support from: Pfizer, Celgene, Speakers bureau: Celgene, Sandoz, Pfizer, Raffaele Scarpa: None declared, francesco ciccia Grant/research support from: pfizer, novartis, roche, Consultant of: pfizer, novartis, lilly, abbvie, Speakers bureau: pfizer, novartis, lilly, abbvie

AB0640 LONG-TERM EFFECTIVENESS AND DRUG SURVIVAL OF GOLIMUMAB IN PATIENTS AFFECTED BY PSORIATIC ARTHRITIS WITH CUTANEOUS INVOLVEMENT

Background:

Psoriatic arthritis (PsA) is a chronic immune-mediated disease associated with psoriasis (PsO). Overexpression of inflammatory cytokines such as tumor necrosis factor (TNF)-α plays a key role in the pathogenic mechanisms. Golimumab (GLM) is a fully human monoclonal antibody IgG1k neutralizing TNF-α approved for PsA and PsO, but effectiveness evaluation in real life remains a crucial issue.

Objectives:

In a real-life setting, to determine the survival rate of GLM (drug survival) at 48 months in the global population, in different clinical settings, and the effectiveness of GLM in improving joint symptoms and cutaneous manifestations in patients affected by moderate to severe PsA with cutaneous involvement.

Methods:

We collected retrospectively from 1 January 2014 to 31 December 2019 data from 105 patients affected by PsA, according to the Classification for Psoriatic Arthritis (CASPAR) criteria, who started treatment with GLM. Inclusion criteria were age > 18 years and had a diagnosis of PsA > 6 months, the presence of peripheral arthritis (at least one active joint) and active PsO. Relevant anamnestic, clinical, biochemical data and biological treatment line were collected at baseline (T0) and after 6 (T6), 12 (T12), 24 (T24) and 48 (T48) months of GLM treatment. Comparisons between baseline and 48 months continuous variables were performed using a paired t-test or a Wilcoxon signed-rank test for paired samples. The drug survival rates were analyzed using Kaplan-Meier estimates. Drug survival rates were read from the Kaplan-Meier survival curves. Differences in drug survival between groups were analyzed using a log-rank (Mantel-Cox) test, by stratifying for sex, BMI, smoking habit and line of treatment. A p-value <0.05 was considered as statistically significant.

Results:

Peripheral arthritis was present in 67 (63.8%) cases, axial disease in 37 (35.3%), enthesitis and PsO as prominent manifestations in 82 (78%) and 84 (80%) patients respectively. Erosive disease was present in 38 (36.2%) of patients at baseline. The most frequent comorbidities were MetS described in 20 (19%) patients and cardiovascular disease described in 33 (31.4%) patients, probably due to the high incidence of smokers (33 (31.4%) of patients) and to the elevate BMI score (27.1±6.0). At 48 months, the 42% (44 of 105) (figure 1A) of the patients have discontinued therapy; the most frequent reason was insufficient response/loss of efficacy (30 patients (28.6%) out of 105). Unexpectedly, no statistical significant difference emerged according to gender (p=0.652), BMI (p=0.655), smoking habit (p=0.466) and line of treatment (p=0.208) (figure 1B-E). Finally, the effectiveness of GLM in improving joint symptoms and cutaneous manifestations was confirmed once again, with a statistical significant improvement at 48 months in clinical (BASDAI p<0.0001; PASI p<0.01; DAPSA p<0.0001) and biochemical (CRP<0.05) data.

Conclusion:

This multicentric study revealed a high drug persistence of GLM in real-life patients, although the presence of comorbidities. Unlike what is known in literature, our study population presented no differences in terms of clinical response and efficacy between male and female, smokers and no-smokers, obese and health-weight patients, different line of treatment. On the other hand, efficacy and safety of GLM has been demonstrated once again also in real-life treatments.

References:

No references.

Disclosure of Interests:

giulia lavinia fonti: None declared, Maria Sole Chimenti: None declared, Arianna D’Antonio: None declared, miriam teoli: None declared, Francesco Caso: None declared, Luisa Costa: None declared, marco tasso: None declared, Augusta Ortolan: None declared, Mariagrazia Lorenzin: None declared, Paola Conigliaro: None declared, paola triggianese: None declared, Raffaele Scarpa: None declared, Roberto Perricone: None declared, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly

Red flags for appropriate referral to the gastroenterologist and the rheumatologist of patients with inflammatory bowel disease and spondyloarthritis

Collaboration between gastroenterologists and rheumatologists is recommended for the correct management of patients with associated spondyloarthritis (SpA) and inflammatory bowel disease (IBD). We aimed to establish the appropriateness of several red flags for a prompt specialist referral. A systematic review of the literature was performed using the GRADE method to describe the prevalence of co-existing IBD-SpA and the diagnostic accuracy of red flags proposed by a steering committee. Then, a consensus among expert gastroenterologists and rheumatologists (10 in the steering committee and 13 in the expert panel) was obtained using the RAND method to confirm the appropriateness of each red flag as 'major' (one sufficient for patient referral) or 'minor' (at least three needed for patient referral) criteria for specialist referral. The review of the literature confirmed the high prevalence of co-existing IBD-SpA. Positive and negative predictive values of red flags were not calculated, given the lack of available data. A consensus among gastroenterology and rheumatology specialists was used to confirm the appropriateness of each red flag. Major criteria to refer patients with SpA to the gastroenterologist included: rectal bleeding, chronic abdominal pain, perianal fistula or abscess, chronic diarrhoea and nocturnal symptoms. Major criteria to refer patients with IBD to the rheumatologist included: chronic low back pain, dactylitis, enthesitis and pain/swelling of peripheral joints. Several major and minor red flags have been identified for the diagnosis of co-existing IBD-SpA. The use of red flags in routine clinical practice may avoid diagnostic delay and reduce clinic overload.

Chromosome Changes in Renal Cell Carcinoma

Cytogenetic studies have provided a great deal of useful information about the biology and diagnosis of renal cell tumors. Particularly papillary and non-papillary tumors seem to be characterized by different cytogenetic patterns. We report the cytogenetic and histologic analysis of 16 renal tumors, 5 of which showed clonal chromosome changes. Most had chromosome abnormalities which have so far been described as specific of particular histopathologic subgroups.

Diagnosis of Chromophobe Renal Cell Carcinoma by Chromosomal Analysis

Chromophobe renal cell carcinoma may pose a differential diagnostic problem by routine histologic examination because it may be misdiagnosed as another type of renal cancer with a totally different clinical behavior. A low DNA content as well as hypodiploidy seem to be associated with this renal tumor subtype. We report a case in which the cytogenetic report was of great value for a correct histologic diagnosis.

Consensus on the management of patients with psoriatic arthritis in a dermatology setting

BACKGROUND

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with psoriasis (PsO). Early diagnosis and prompt therapeutic intervention are crucial for limiting PsA progression and prevention of disability. Dermatologists are in a privileged position to detect early PsA. The management of patients with PsA in the dermatology setting is widely variable.

OBJECTIVE

To provide practical recommendations for the management of patients with PsA in the dermatology setting including early diagnosis and treatment.

METHODS

A consensus document was written by an expert panel composed by dermatologists (n = 12) and rheumatologists (n = 6). Eleven highly relevant questions were selected and elaborated with answers/statements based on a narrative literature review. The resulting document was discussed in a face-to-face meeting adopting a nominal group technique to reach consensus (i.e. 100% agreement) using the Delphi method.

RESULTS

A consensus was achieved in defining the following: the clinical characteristics differentiating inflammatory and non-inflammatory signs and symptoms of joint disease; the most important differential diagnoses of PsA in clinical practice; the most useful screening questionnaires, serum laboratory tests and imaging techniques for the detection of early PsA; the criteria for dermatologist to refer patients with PsO to rheumatologist; the criteria for the diagnosis of PsA; the selection of the indices that the dermatologist could use for measuring the activity and severity of PsA in clinical practice; when systemic steroids and/or intra-articular steroid injections are indicated in the treatment of PsA. Finally, systemic treatments including synthetic and biologic disease-modifying antirheumatic drugs to be considered for the treatment of PsA have been reported.

CONCLUSIONS

The implementations of these practical recommendations could be very helpful for the management of patients with PsA in the dermatology setting including early diagnosis and treatment.

Evidence-based algorithm for diagnosis and assessment in psoriatic arthritis: results by Italian DElphi in psoriatic Arthritis (IDEA)

Psoriatic arthritis (PsA) is a chronic inflammatory disease involving skin, peripheral joints, entheses, and axial skeleton. The disease is frequently associated with extrarticular manifestations (EAMs) and comorbidities. In order to create a protocol for PsA diagnosis and global assessment of patients with an algorithm based on anamnestic, clinical, laboratory and imaging procedures, we established a DElphi study on a national scale, named Italian DElphi in psoriatic Arthritis (IDEA). After a literature search, a Delphi poll, involving 52 rheumatologists, was performed. On the basis of the literature search, 202 potential items were identified. The steering committee planned at least two Delphi rounds. In the first Delphi round, the experts judged each of the 202 items using a score ranging from 1 to 9 based on its increasing clinical relevance. The questions posed to experts were How relevant is this procedure/observation/sign/symptom for assessment of a psoriatic arthritis patient? Proposals of additional items, not included in the questionnaire, were also encouraged. The results of the poll were discussed by the Steering Committee, which evaluated the necessity for removing selected procedures or adding additional ones, according to criteria of clinical appropriateness and sustainability. A total of 43 recommended diagnosis and assessment procedures, recognized as items, were derived by combination of the Delphi survey and two National Expert Meetings, and grouped in different areas. Favourable opinion was reached in 100% of cases for several aspects covering the following areas: medical (familial and personal) history, physical evaluation, imaging tool, second level laboratory tests, disease activity measurement and extrarticular manifestations. After performing PsA diagnosis, identification of specific disease activity scores and clinimetric approaches were suggested for assessing the different clinical subsets. Further, results showed the need for investigation on the presence of several EAMs and risk factors. In the context of any area, a rank was assigned for each item by Expert Committee members, in order to create the logical sequence of the algorithm. The final list of recommended diagnosis and assessment procedures, by the Delphi survey and the two National Expert Meetings, was also reported as an algorithm. This study shows results obtained by the combination of a DElphi survey of a group of Italian rheumatologists and two National Expert Meetings, created with the aim of establishing a clinical procedure and algorithm for the diagnosis and the assessment of PsA patients. In order to find accurate and practical diagnostic and assessment items in clinical practice, we have focused our attention on evaluating the different PsA domains. Hence, we conceived the IDEA algorithm in order to address PsA diagnosis and assessment in the context of daily clinical practice. The IDEA algorithm might eventually lead to a multidimensional approach and could represent a useful and practical tool for addressing diagnosis and for assessing the disease appropriately. However, the elaborated algorithm needs to be further investigated in daily practice, for evidencing and proving its eventual efficacy in detecting and staging PsA and its heterogeneous spectrum appropriately.

Accelerated bone turnover identifies hemiplegic patients at higher risk of demineralization

Immobilization osteoporosis represents a severe complication in hemiplegic patients (HPs), causing fragility fractures, which may occur during rehabilitation reducing functional recovery and survival. The aim of the study was to investigate determinants of bone loss, independent from length of immobilization, which may be useful in early identification of HPs at higher risk of demineralization. Forty-eight HPs of both sexes underwent anthropometric measurements, evaluation of scores of spasticity and of lower limb motory capacity. Laboratory tests were performed. On serum: calcium; phosphorus; creatinine; ALP; iPTH; 25(OH) vitamin-D; sex hormones; Δ4-androstenedione; DHEA-S; insulin; IGF-1; FT3; FT4; TSH; c-AMP. On urine: c-AMP and calcium/creatinine ratio. Two bone turnover markers were measured: serum osteocalcin (BGP) and urinary deoxypyridinoline (DPD). Bone mineral density was determined at both femoral necks, defining a percentage difference in bone loss between paretic and non-paretic limb, thus controlling for the complex cofactors involved. Only bone turnover markers significantly and directly correlated with the entity of demineralization, controlling for age, sex and length of immobilization in the multivariate analysis (BGP coefficient estimate=0.008; SE=0.003; p=0.020; DPD coefficient estimate=0.005; SE=0.002; p=0.036). BGP and DPD are not dependent on anthropometric and endocrine-metabolic parameters, disability patterns and duration of immobilization, thus represent independent determinants of the degree of demineralization. A cutoff was defined for BGP and DPD above which subjects show significantly greater risk of demineralization. The immobilization event generates more severe bone loss when it occurs in subjects with higher bone turnover. BGP and DPD measurements may be of primary importance for early identification of HPs at risk, with relevant preventive implications.

Robot-assisted radical prostatectomy: recent advances

Robot assisted radical prostatectomy (RARP) represents the leading application of robotic surgery in the urologic field and it has become the main treatment option for localized prostate cancer (PCa) in the USA In the present review we summarized and critically analyzed the literature of the past five years about this widely used robotic procedure. RARP has continuously evolved in terms of technical modifications and procedural steps. Long-term data are now available, suggesting comparable oncological outcomes to those of open and laparoscopic radical prostatectomy. Good functional outcomes have also been demonstrated. Technological innovations and the introduction of more advanced robotic platforms featuring novel arm-integrated equipment, together with a mature clinical experience with the robotic approach, are likely to lead towards optimal outcomes. Despite the expanding clinical implementation of RARP in the management of prostate cancer, some issues related to this procedure remain matter of debate, such as costs, comparative outcomes versus other approaches, and its role in high risk disease.

PHYSIOPATHOLOGY OF OSTEOPOROSIS: FROM RISK FACTORS ANALYSIS TO TREATMENT

Osteoporosis represents a relevant health issue, being the first cause of bone fractures in the elderly with subsequent implications in terms of survival and social costs. The improved knowledge about the physiopathology of this disease has led to a new definition of Osteoporosis, which shifts the attention from the “"decrease in bone mass"” to several elements related to what has globally been defined as bone quality. In fact, it has been shown that clinical risk factors affecting bone homeostasis coincide with osteoporosis risk factors. The evaluation of such clinical risk factors is an important element in the assessment of the global fracture risk. The availability of instruments for the assessment of the global fracture risk also suggests a change in the clinical perspective and raises new questions as yet unanswered.

Tryptophan hydroxylase autoantibodies as markers of a distinct autoimmune gastrointestinal component of autoimmune polyendocrine syndrome type 1

BACKGROUND

Autoantibodies to tryptophan hydroxylase (TPHAbs) directed against serotonin-producing enterochromaffin cells (EC) have been reported in autoimmune-polyendocrine-syndrome type 1 (APS-1) patients with gastrointestinal dysfunction (GID). Serotonin plays a critical role in enteric function and its peripheral blood levels reflect serotonin release from the gastrointestinal tract.

AIMS

We test the hypothesis that TPHAbs mark a distinct autoimmune component of APS-1 characterized by an autoimmune attack toward EC, which results in clinical GID.

METHODS

TPHAbs were measured in 64 APS-1 patients. Endoscopy with gastric (antrum/body) and duodenal biopsy was carried in 16 TPHAbs+ patients (8 with and 8 without GID) and in 2 TPHAbs- patients (without GID). Immunohistochemistry of biopsy specimens was carried out using antibodies to serotonin, chromogranin-A, CD3, CD4, CD8, and CD20. Serotonin serum levels were measured in TPHAbs+ and TPHAbs- patients who had endoscopy.

RESULTS

Thirty-seven of 64 patients were TPHAbs+ (11/12 with GID and 26/52 without GID; P < .001). Gastric and duodenal biopsies in all 8 TPHAb+ patients with GID showed lymphocytic infiltration with increased CD3+CD8+ intraepithelial lymphocytes and absence of EC. Furthermore, mean serotonin serum levels were below the normal range in TPHAb+ patients with GID (P < .01). In 8 TPHAb+ patients without GID gastric and duodenal biopsies showed different grades of inflammatory infiltration and reduced number of EC. Mean serotonin serum levels were near the lower limit of the normal range. In all TPHAbs+ patients the biopsies showed a reduced number of chromogranin-A positive cells consistent with enteroendocrine cells depletion. TPHAbs- patients without GID showed normal gastrointestinal mucosa and serotonin serum levels.

CONCLUSIONS

TPHAbs appear to be markers of a distinct autoimmune component of APS-1. Progressive involvement of the gastrointestinal EC leads to the transition from preclinical to clinical disease, characterized by GID and reduced serotonin serum levels.

[Psoriatic arthritis: epidemiological and clinical aspects in a cohort of 1.306 Italian patients]

Because there is the impression that psoriatic arthritis is a composite disorder with mild forms close to more severe and aggressive ones, we conducted a multicenter study with the aim of characterizing disease expression in a large cohort of Italian patients. One-thousand-three-hundred-six patients fulfilled inclusion criteria and were analyzed in this study. Psoriasis antedated the onset of arthritis in the majority of the cases (67.7%). More rare was inverse or simultaneous onset which occurred in 17.3% and 15.0% of the cases, respectively. Peripheral articular involvement (mono-oligo or polyarthritis) was recorded in 88.7% of the cases while spondylitis occurred in 11.3%. Peripheral enthesopathies were found in 28.1% of the cases with a marked occurrence in patients with axial involvement (64.5% vs 35.5% in oligo or polyarthritis). Abnormal levels of ESR and CRP respectively occurred in 52.2% and in 52.6% of the cases, while rheumatoid factor was detected in 5.0% of the cases. On the basis of distribution of joint involvement, symmetry and presence of peripheral enthesopathies we recognized three clusters of arthritis. Patients included in Cluster 1 and Cluster 2 showed a severe form of polyarthritis in most of the cases (82.9%), with increased serum levels of inflammatory indices in more than 85% of the cases. Almost all the hospitalized patients (97.1%) were included in this two clusters. They markedly assumed steroids and methotrexate or another DMARD. About half of the patients (51.1%) included in Cluster 3 showed mono-oligo articular involvement. Serum inflammatory indices were increased in 20.8% of the cases while hospitalization occurred only in 2.9% of the cases and NSAIDs were the treatment of choice. The evidence in our country of a large prevalence of severe forms of arthritis needing specific and aggressive approach outlines the requirement of an intense educational action aimed at increasing the awareness of this condition.

Clinical presentation of psoriatic arthritis

Psoriatic arthritis is a spondyloarthropathy which occurs in patients with skin and/or nail psoriasis. Basing its characterization on morphological purposes, several types of arthritis have been described. Alternatively, we propose a simplified classification into three subsets, focusing on the levels of expression of cutaneous and articular elements which devise this syndrome. The first is established psoriatic arthritis which occurs in patients with evident or remittent skin and/or nail psoriasis. Its clinical spectrum consists of the five subsets classically described by Moll and Wright in 1973. The second is psoriatic arthritis "sine psoriasis" which occurs in subjects without psoriasis but with a family history of the disease in first or second-degree relatives. The third is early psoriatic arthritis which consists of an articular involvement of recent onset, occurring in subjects belonging to established or sine psoriasis subsets.

Comparison of the Recent-Onset Arthritis Disability questionnaire with the Health Assessment Questionnaire disability index in patients with rheumatoid arthritis

BACKGROUND

Physical disability in patients with rheumatoid arthritis (RA) is often assessed by questionnaires. We compared the Recent-Onset Arthritis Disability (ROAD) questionnaire with the Health Assessment Questionnaire (HAQ) disability index (DI) in a cohort of RA patients. The aim of this study was to obtain information on several aspects of construct validity of these measures.

METHODS

A cross-sectional multicentre study was carried out among patients with RA who were attending hospital outpatient clinics. The patient group included 196 patients partially or not responding to disease modifying anti-rheumatic drugs. For the evaluation of the psychometric properties of the ROAD in comparison with HAQ-DI this population has been compared to another cohort of 247 outpatients with RA who were participating in a long-term observational study. All patients completed the ROAD and HAQ-DI. Additional comparator composite indices of disease activity were analysed. The ROAD structural validity was first assessed using exploratory factor analysis. Concurrent validity was analysed by Spearman's correlations and cross-tabulations. Discriminant validity to distinguish patients with active and non-active disease was assessed with receiver operating characteristic (ROC) curve analysis. For agreement analysis Bland and Altman plots were calculated.

RESULTS

Factor analysis yielded a two-factor ROAD score that accounted for 68.74% of the explained variance in the questionnaire. The first factor, namely upper extremity function/activity daily living and work (ROAD-upper) accounted for 55.6% of the explained variance. The second factor, namely lower extremity function (ROAD-lower) accounted for 13.1% of the explained variance. Significant correlations were found between the scores of the ROAD and the other clinical variables with a high ability to measure pain and disease activity, supporting the concept of convergent construct validity. The discriminatory power of both questionnaires to assess inactive and active RA patients was good, without significant difference.

CONCLUSIONS

ROAD is a good alternative to the HAQ-DI for the assessment of physical disability in RA. Use of the ROAD makes it easier and less costly to collect data and reduces the burden on RA patients and should be applied in both clinical trials and routine clinical care settings.

[Methotrexate in the treatment of peripheral arthritis in ulcerative colitis]

OBJECTIVE

To evaluate efficacy of methotrexate treatment in peripheral arthritis of ulcerative colitis.

METHODS

We studied 18 patients (10/8 M/F; mean age: 38.90 yrs; range: 21-65 yrs), with peripheral arthritis (14 with polyarticular, 4 with oligoarticular subset) associate ulcerative colitis. Methotrexate 20 mg/week was administered in our patients, who were already receiving mesalazina for inflammatory bowel disease. At baseline, after 3 (T1), 6 (T2) and 12 months (T3) serological parameters (ESR and CRP), functional status (HAQ) and disease activity (VAS, GH, Ritchie articular index) were evaluated.

RESULTS

During the therapy a significant improvement was observed in disease activity, functional status and serological parameters since T1. ESR and CRP did not change at T2 and T3. Instead VAS, GH, Ritchie articular index and HAQ had a significant and gradual improvement from T1 to T3.

CONCLUSION

Methotrexate treatment was efficacious in the treatment of peripheral arthritis associate ulcerative colitis. This drug induced improvement in disease activity, functional status and serological parameters after 3 months of therapy.

Italian evidence-based recommendations for the management of ankylosing spondylitis: the 3E Initiative in Rheumatology

OBJECTIVE

The 3E (Evidence, Expertise, Exchange) Initiative is a multinational effort of rheumatologists aimed at developing evidence-based recommendations addressing specific questions relevant to clinical practice. The objective of the Italian part of the 3E Initiative was to develop new recommendations designed to help Italian rheumatologists in everyday clinical practice management of patients suffering from ankylosing spondylitis (AS).

METHODS

An international scientific committee selected a set of questions concerning the diagnosis, monitoring, and treatment of AS using a Delphi procedure. Evidence-based answers to each question were sought by a systematic literature search in MedLine for papers published up to August 2006. A panel of 55 Italian rheumatologists with expertise in the field of AS used the evidence thus gathered to develop recommendations, filling gaps in evidence with their expert opinion.

RESULTS

After discussion and votes, the panel developed 12 statements/recommendations: 3 concerning diagnosis (low back pain approach, early diagnosis, and GPs referral recommendations); 3 concerning monitoring (disease activity, severity, and prognosis), and 6 concerning treatment (bisphosphonates role; treatment of enthesitis; inter-agent safety/efficacy, long-term safety/efficacy, efficacy on different disease manifestations, and the role on inflammatory bowel disease flare precipitation of NSAIDs/COX-II inhibitors).

CONCLUSION

Italian recommendations for the management of AS in everyday practice were developed. Their dissemination and implementation in daily clinical practice should help to improve practice uniformity and eventually optimize the management of AS patients.

The psoriatic arthritis cost evaluation study: a cost-of-illness study on tumour necrosis factor inhibitors in psoriatic arthritis patients with inadequate response to conventional therapy

OBJECTIVE

To evaluate costs, benefits and cost-effectiveness of anti-TNF agents in PsA patients with inadequate response to conventional treatment.

METHODS

A total of 107 patients, from nine Italian rheumatology centres, with different forms of PsA were given anti-TNF treatment, mainly etanercept (87%). Information on resource use, health-related quality of life, disease activity, function and laboratory values were collected at baseline and through out the 12 months of therapy. Cost (expressed in euro 2007) and utility (measured by EuroQol) before and after anti-TNF therapy initiation were compared in order to estimate the incremental cost per quality-adjusted life year (QALY) gained, and cost-effectiveness acceptability curve was calculated.

RESULTS

At the end of 12 months, there was a significant increase in direct cost due to an increase of drug cost caused by TNF inhibitors that was only partially offset by the decrease in indirect cost. In the last 6 months of therapy, the direct cost increased by euro5052, the cost for the National Health System (NHS) by euro5044 and the social cost by euro4638. However, a gain of 0.12 QALY resulted in a cost per QALY gained of euro40 876 for the NHS and of euro37 591 for the society. The acceptability curve showed that there would be a 97% likelihood that anti-TNF therapy would be considered cost-effective at willingness-to-pay threshold of euro60 000 per QALY gained.

CONCLUSION

Cost-effectiveness ratios are within the commonly accepted willingness-to-pay threshold. These results need to be confirmed in larger samples of patients.

Association of MICA alleles with psoriatic arthritis and its clinical forms. A multicenter Italian study

OBJECTIVE

Analysis of the association between psoriatic arthritis (PsA) clinical forms and MICA gene transmembrane polymorphisms.

METHODS

Patients were classified as having peripheral asymmetric oligoarthritis (AO), peripheral symmetric poly-arthritis (PA) and spondylitis (SP), or disease combinations (PA/SP, OA/SP). Two hundred and twenty-six patients with PsA were typed for MICA exon 5 microsatellite (TM) by heteroduplex analysis and compared with 225 normal controls.

RESULTS

MICA-TM microsatellite typing revealed that, among the different clinical forms of PsA, only the combined PA/SP subset shows a significant positive association with MICA-A9 and a lower frequency of MICA-A4, A5 genotype in PsA patients with a decrease, only in the PA/SP cohort, of all MICA-A5 combinations except MICA-A5, -A9.

CONCLUSION

These results suggest a role for genes within the HLA region in the pathogenesis of PsA, and reinforce the idea that the different forms of PsA may have heterogeneous genetic basis.

Pulse hypertension: a new component of the metabolic syndrome in elderly women?

The classification of arterial hypertension (HT) to define metabolic syndrome (MS) is unclear in that different cutoffs of blood pressure (BP) have been proposed. We evaluated the categorization of HT most qualified to define MS in relationship with coronary heart disease (CHD) mortality at a population level. A total of 3257 subjects aged > or =65 years were followed up for 12 years. MS was defined according to the criteria of the National Education Cholesterol Program using three different categories of HT: MS-1 (systolic blood pressure (SBP) > or =130 and diastolic blood pressure (DBP) > or =85 mm Hg), MS-2 (SBP > or =130 or DBP > or =85 mm Hg) and MS-3 (pulse pressure (PP) > or =75 mm Hg in men and > or =80 mm Hg in women). Gender-specific adjusted hazard ratio (HR) with 95% confidence intervals (CI) for CHD mortality was derived from Cox analysis in the three MS groups, both including and excluding antihypertensive treatment. In women with MS untreated for HT, the risk of CHD mortality was always significantly higher than in those without MS, independent of categorization; the HR of MS was 1.73 (CI 1.12-2.67) using MS-1, 1.75 (CI 1.10-2.83) using MS-2 and 2.39 (CI 3.71-1.31) using MS-3. In women with MS treated for HT, the HR of CHD mortality was significantly increased only in the MS-3 group (1.92, CI 1.1-2.88). MS did not predict CHD in men. In conclusion, MS can predict CHD mortality in elderly women with untreated HT but not in those with treated HT; in the latter, PP is the most predictive BP value.

[Magnetic resonance imaging of the peripheral joints in psoriatic arthritis]

OBJECTIVE

Magnetic resonance imaging (MRI) has been widely used for the evaluation of rheumatoid arthritis (RA), with only a minority of studies considering other types of arthritis. This review is concerned with an evaluation of the MRI appearance of peripheral joints in psoriatic arthritis (PsA).

METHODS

A Medline search was performed to identify all publications from the years 1985 to 2006 concerning MRI of the peripheral joints and PsA. Additional papers were retrieved by scanning the references to the Medline-listed articles. Articles written in English, French, German, and Italian were included.

RESULTS

Most papers studied the hand and wrist, and only few of them were concerned with the knee, foot, temporomandibular joint, and elbow. Patients with PsA showed often, but not always, a pattern of joint inflammation which extended beyond the capsule into the extraarticular tissue. Bone oedema and erosions were less frequent than in RA. In particular, bone oedema at the entheseal junction was seen, especially in the knee. The degree of synovitis, assessed by dynamic MRI, was similar in PsA and RA.

DISCUSSION

Data on MRI of the peripheral joints in PsA are scanty. Only few studies were specifically designed to evaluate the pattern of arthritis in PsA, with most information deriving from papers where different types of arthritis were considered together. An enthesis-related origin of PsA has been proposed in contrast to the primarily synovial inflammation of RA. This pathogenic interpretation is likely to be true, but does not explain all cases of PsA, and needs to be confirmed by further studies.

Frequency of musculoskeletal conditions among patients referred to Italian tertiary rheumatological centers

OBJECTIVE

To describe the occurrence of different rheumatic diseases and to examine the characteristics of patients referred to six Italian rheumatological units. To compare these data with those from other countries.

METHODS

Six Italian rheumatological tertiary referral centers participated in the study. Diagnoses of in- and outpatients aged over 16 years were classified according to the International Classification of Diseases, ninth revision.

RESULTS

Three thousand, five hundred and thirty-seven patients with mean age 56 +/- 14.8 years, of which 2604 (73.6%) were women, were studied. Inflammatory joint and spine diseases were diagnosed in 40.4%, connective tissue diseases in 14.4%, degenerative joint and spine diseases in 21.4%, soft tissue rheumatisms in 18.5%, and metabolic bone diseases in 5.3%. There was a significant difference among centers in the frequency of most diagnoses: non-academic centers cared for more patients with arthritis and connective tissue diseases and for less patients with degenerative diseases, soft tissue rheumatisms and metabolic bone diseases. Connective tissue diseases were constantly seen more often in Italian centers, whereas soft tissue rheumatisms were seen more often abroad.

CONCLUSION

Our data emphasize the great variability of the diagnostic case-mix in different centers from the same country, an observation that raises some concerns of the results of descriptive multicenter studies. Studies on the breakdown of diagnoses made in rheumatological centers could be helpful to determine the burden of rheumatic diseases on the health system, and for the planning of health interventions by both the national rheumatological societies and health authorities.

HCV infection and chronic arthritis: Does viral replication matter?

BACKGROUND

HCV infection beside chronic hepatitis can induce immunological disorders with different clinical expressions such as chronic arthritis.

AIM

To study the prevalence of arthritis in HCV-Ab positive patients and verify possible correlation with viral replication, hepatic damage and autoimmunity imbalance.

STUDY DESIGN

Three hundred and eighty patients (196 M and 184 F) affected by HCV infection were examined and 38 (10%) were selected according to the presence of arthritis. Eight of them were excluded because arthritis raised before HCV infection. Each patient, once undergone liver biopsy, was evaluated for: clinical examination (articular evolution), Rx examination, serum expression of hepatic damage (mainly ALT), viral replication, and involvement of autoimmunity (ANA, RF, crioglobulins, AKA, CCP).

RESULTS

Data from patients [Lamprecht P, Gause A, Gross WL. Cryoglobulinemic vasculitis. Arthritis Rheum 1999; 42:2507-16.] with AKA and CCP positivity were not considered for statistical examination because the clear correlation between rheumatoid arthritis and these parameters. The remaining 20 patients showed hepatic damage 47%, viral replication in 74%, RF 42%, ANA 16%, crioglobulins 42% (RF positive). No correlation was evident between ANA serum concentrations and viral replication; furthermore a significant negative correlation between RF positivity and viral replication only in a subgroup of patients with serologic expression of hepatic damage was found.

CONCLUSIONS

These data support hypothesis that the onset of arthritis and presence of autoimmunity parameters ANA, RF are not related to the viral replication but others mechanism immunological induced by HCV might be considered.

Recommendations of the Italian Society for Rheumatology for the use of biologic (TNF-alpha blocking) agents in the treatment of psoriatic arthritis

AIM

To propose recommendations for the use of biologic (TNF-alpha blocking) agents in the treatment of psoriatic arthritis (PsA).

METHODS

We developed these recommendations by reviewing the evidence published in medical journals and in abstracts of the American College of Rheumatology (ACR) and of the European League against Rheumatism. A draft of the recommendations was circulated to a group of Italian Rheumatologists with a special interest in PsA and in therapy with biologic agents, and their suggestions were incorporated in the final version.

RESULTS

A consensus was achieved regarding the initiation and the monitoring of anti-TNF-alpha agents in PsA. More specifically, we propose that anti-TNF-alphaagents be considered in active PsA resistant to non-steroidal anti-inflammatory drugs, to at least two local steroid injections and at least 2 conventional disease-modifying anti-rheumatic agents (in cases of oligo/monoarthritis and/or enthesitis), and to at least two conventional disease-modifying anti-rheumatic agents (in patients with peripheral joints synovitis). Disease activity monitoring should be based on a variety of outcome measures including the ACR response criteria modified for use in PsA, the Bath ankylosing spondylitis disease activity index (BASDAI), and the Maastricht ankylosing spondylitis enthesis score (MASES). A favorable Expert opinion, based on evaluation of clinical symptoms and signs, of laboratory investigations (particularly acute phase reactants), and of imaging studies (whenever appropriate) should also be obtained.

CONCLUSION

These recommendations may be used for guidance in deciding which patients with PsA should receive biologic therapy. Regular updates of these recommendations will be implemented on the basis of the results of new clinical studies and of data from post-marketing surveillance.

Infliximab in the treatment of extra-intestinal manifestations of Crohn's disease

BACKGROUND

Crohn's disease (CD) is frequently associated with extra-intestinal manifestations (EIMs) and infliximab has been recently proposed for the treatment of CD with EIMs. Our aim was to evaluate the short-term efficacy of infliximab in this treatment.

PATIENTS AND METHODS

Thirty CD patients were treated with infliximab. Fifteen patients (50%) showed EIMs before starting therapy. Ten patients presented an arthritis (five sacroiliitis, five spondylitis), with six also reporting peripheral arthralgias. Four patients presented cutaneous EIMs while three patients had an ocular EIM.

RESULTS

At week 10, all patients reported an improvement in EIMs. Regarding arthritis, ASAS20 and ASAS40 improvement was observed in 80% and 60% of patients, respectively. In the four patients with cutaneous EIMs and in the three with ocular EIMs, complete healing was observed. Recurrence was observed in 10 out of 15 patients (66%) and a second course of treatment with infliximab was required. This proved to be effective in all cases except for one patient who stopped treatment because of a severe adverse reaction.

CONCLUSIONS

Infliximab is an effective drug in the short-term treatment of EIMs complicating CD. Although relapse of EIMs occurs frequently, retreatment ensures effective control of the symptoms.

The acromegalic arthropathy

Since the initial definition of acromegaly over 100 yr ago, extraordinary efforts have been made to control GH levels and the pituitary tumor. Criteria of cure have been evolving constantly and all previous statements should be revised according to modern criteria of disease control. Arthropathy is undoubtedly the most important cause of morbidity and functional disability of acromegaly, and bone alterations are highly characteristic of this syndrome. They involve theoretically all bones and, particularly, the appendicular and the axial skeleton. Radiographic changes at different joint sites are more common than symptoms related to their involvement. There is a progression in the acromegalic arthropathy, resembling that described for the acromegalic cardiomyopathy or for the acromegalic features at other organs, such as thyroid, breast and prostate. At early stage, cartilage hypertrophy predominates, and then degenerative changes start until osteoarthritis features occur. Arthropathy can be reversed by normalizing GH and IGF-I levels only at the initial stage. If the disease is left untreated for long time, the osteo-articular sequelae cannot be modified by any treatment of acromegaly.