POS0132 THE FIRST ALGORITHM TO INTEGRATE ULTRASONOGRAPHY IN THE DIAGNOSTIC PROCESS OF DIFFERENTIAL DIAGNOSIS OF INFLAMMATORY ARTHROPATHY IN CLINICAL PRACTICE: A STUDY FROM THE MSUS WORKING GROUP OF THE ITALIAN SOCIETY OF RHEUMATOLOGY

Background

Musculoskeletal ultrasonography (MSUS) is a useful tool for the diagnosis of several Rheumatic and Musculoskeletal Diseases (RMDs) but its role in the diagnostic pathways in clinical practice is still unclear as feasibility issues limit its application as a bed side technique.

Objectives

To optimize the use of US in clinical practice, the MSUS Study Group of the Italian Society for Rheumatology aimed to develop an algorithm combining US with clinical and laboratory findings to improve the differential diagnosis among patients presenting with joint swelling.

Methods

Based on a systematic literature review1 and experts’ opinion, MSUS Study Group Members attempt to identify a set of statements including the main US elementary lesions useful for US scanning in the suspicion of Rheumatoid arthritis (RA), Psoriatic arthritis (PsA), Rheumatic Polymyalgia (PMR), Gout, Calcium Pyrophosphate Deposition Disease (CPPD), Osteoarthritis (OA). Then, the MSUS Study Group defined through a survey and ranked in a 1000minds exercise the most important clinical/laboratory findings for the differential diagnosis of those diseases. Higher-ranked items were fitted in an algorithm driving the differential diagnosis of RMDs to a reduced spectrum of 2 to 4 possible diseases. Finally, the algorithm supported the performance of US according to the established scans for those specific diseases. To assess the algorithm’s performance, a pilot study was conducted on 59 patients, comparing the algorithm-based diagnosis with the final diagnosis based on rheumatologist’s experience and/or on classification criteria.

Results

Sets of elementary US lesions and a scanning protocol for each included pathology were created (Table 1), optimized towards high sensibility and specificity. Among the findings evaluated, the age (<50 / ≥50 years old), the number of the involved joints (monoarticular/polyarticular), the serology (Rheumatoid Factor [RF] and anti-citrullinated protein antibody [ACPA]); the acute-phase reactants (C-reactive protein [CRP]; erythrocyte sedimentation rate [ESR]) reached the higher ranking in the survey and were introduced in the algorithm, showed in Figure 1. In the pilot study, the algorithm-based diagnosis was consistent with the final diagnosis in 52 cases (accuracy 88.1%). Among the 7 cases in which the algorithm misclassified patients, four patients had a final diagnosis of OA (3 diagnosed by the algorithm as PMR/RA/PSA and one as PSA), one gout (algorithm diagnosis: OA/CPPD/PSA), one RA (algorithm diagnosis: Gout/CPPD/PSA) and one CPPD (algorithm diagnosis: PMR/RA/PSA).

Table 1.

Elementary ultrasound lesions and joints to be scanned for each included pathology

DiseaseSites to scanUS elementary lesionsRAII-IV MCPsSynovial Hypertrophy (SH), Power Doppler (PD), erosionsWristV MTPPsAII-III MCPsPeritendonitisPIPsEnthesitisSoft tissue oedemaFlexor tendons of the handsTenosynovitisSoft tissue oedemaAchille’s tendon enthesisPD, erosionsProximal patellar tendon enthesisCPPDKnees (menisci and Hyaline Cartilage)CPP depositsWrist (triangular fibrocartilage complex)Any involved sitesCPP deposits, SH, PDGoutKneesDouble contour, tophiI MTPInvolved sitesSHPDOAInvolved sitesOsteophytesCartilage changesPMRShouldersBursitisArthritisRotator cuff integrityFigure 1.

The final algorithm

Conclusion

The diagnostic algorithm produced in this pilot study correctly classified patients with the most prevalent RMDs in clinical practice. A longitudinal study on a large sample size is ongoing to evaluate the added value of US when implemented in this algorithm regarding diagnostic certainty, accuracy and early diagnosis.

References

[1]Sakellariou G, Scirè CA, Adinolfi A, Batticciotto A, Bortoluzzi A, Delle Sedie A, et al. Differential Diagnosis of Inflammatory Arthropathies by Musculoskeletal Ultrasonography: A Systematic Literature Review. Front Med. 7 maggio 2020;7:141.

Disclosure of Interests

None declared

OP0252 FACTORS ASSOCIATED WITH SEVERE COVID-19 OUTCOMES IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOPATHY: RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE PHYSICIAN-REPORTED REGISTRY

Background

There is a paucity of data in the literature about the outcome of patients with idiopathic inflammatory myopathy (IIM) who have been infected with SARS-CoV-2.

Objectives

To investigate factors associated with severe COVID-19 outcomes in patients with IIM.

Methods

Data on demographics, number of comorbidities, region, COVID-19 time period, physician-reported disease activity, anti-rheumatic medication exposure at the clinical onset of COVID-19, and COVID-19 outcomes of IIM patients were obtained from the voluntary COVID-19 Global Rheumatology Alliance physician-reported registry of adults with rheumatic disease (from 17 March 2020 to 27 August 2021). An ordinal COVID-19 severity scale was used as primary outcome of interest, with each outcome category being mutually exclusive from the other:a) no hospitalization, b) hospitalization (and no death), or c) death. Odds ratios (OR) were estimated using multivariable ordinal logistic regression. In ordinal logistic regression, the effect size of a categorical predictor can be interpreted as the odds of being one level higher on the ordinal COVID-19 severity scale than the reference category.

Results

Complete hospitalization and death outcome data was available in 348 IIM cases. Mean age was 53 years, and 223 (64.1%) were female. Overall, 167/348 (48.0%) people were not hospitalized, 136/348 (39.1%) were hospitalized (and did not die), and 45/348 (12.9%) died. Older age (OR=1.59 per decade of life, 95%CI 1.32-1.93), male sex (OR=1.63, 95%CI 1.004-2.64; versus female), high disease activity (OR=4.05, 95%CI 1.29-12.76; versus remission), presence of two or more comorbidities (OR=2.39, 95%CI 1.22-4.68; versus none), prednisolone-equivalent dose >7.5 mg/day (OR=2.37, 95%CI 1.27-4.44; versus no glucocorticoid intake), and exposure to rituximab (OR=2.60, 95%CI 1.23-5.47; versus csDMARDs only) were associated with worse COVID-19 outcomes (Table 1).

Table 1.

Multivariable logistic regression analysis of factors associated with the ordinal COVID-19 severity outcomes. AZA, azathioprine; CI, confidence interval; combo, combination; CSA, ciclosporin; CYC, cyclophosphamide; DMARD, disease-modifying anti-rheumatic drug; b/tsDMARD, biologic/targeted synthetic DMARD, csDMARD, conventional synthetic DMARD; HCQ, hydroxychloroquine; IVIg, intravenous immunoglobulin; LEF, leflunomide; MMF, mycophenolate mofetil; mono, monotherapy; MTX, methotrexate; OR, odds ratio; Ref, reference; RTX, rituximab; SSZ, sulfasalazine; TAC, tacrolimus.

VariableOR (95%CI)P-valueVariableOR (95%CI)P-valueAge (per decade)1.59 (1.32-1.93)<0.001ComorbiditiesMale sex1.63 (1.004-2.64)0.048NoneRefNAPrednisolone-equivalent doseOne1.46 (0.79-2.72)0.228NoneRefNATwo or more2.39 (1.22-4.68)0.011>0 to 7.5mg/day1.10 (0.57-2.11)0.779Physician-reported disease activity>7.5mg/day2.37 (1.27-4.44)0.007RemissionRefNAIVIg0.41 (0.15-1.16)0.093Low/moderate1.23 (0.67-2.28)0.504DMARDsHigh4.05 (1.29-12.76)0.018csDMARD only (mono or combi - HCQ, MTX, LEF, SSZ)RefNARegionNo DMARD1.84 (0.90-3.75)0.094EuropeRefNAb/tsDMARD mono or combi (except RTX)1.60 (0.49-5.26)0.435North America0.89 (0.49-1.61)0.694CSA/CYC/TAC mono or combi (except RTX or b/tsDMARDs)1.55 (0.52-4.58)0.429Other4.25 (2.21-8.16)<0.001AZA mono1.70 (0.69-4.19)0.249Time periodMMF mono1.22 (0.53-2.82)0.634Before 15 June 2020RefNAAZA/MMF combi (except RTX or b/tsDMARDs)0.71 (0.25-2.00)0.51716 June - 30 September 20200.58 (0.26-1.27)0.171RTX mono or combi2.60 (1.23-5.47)0.012After 1 October 20200.58 (0.35-0.95)0.032

Conclusion

These are the first global registry data on the impact of COVID-19 on IIM patients. Older age, male gender, higher comorbidity burden, higher disease activity, higher glucocorticoid intake and rituximab exposure were associated with worse outcomes. These findings will inform risk stratification and management decisions for IIM patients.

References

None

Disclosure of Interests

Su-Ann Yeoh: None declared, Milena Gianfrancesco: None declared, Saskia Lawson-Tovey: None declared, Kimme Hyrich Speakers bureau: AbbVie unrelated to this work, Grant/research support from: Pfizer, BMS, both unrelated to this work, Anja Strangfeld Speakers bureau: AbbVie, Celltrion, MSD, Janssen, Lilly, Roche, BMS, Pfizer, all unrelated to this work, Laure Gossec Consultant of: AbbVie, Amgen, BMS, Galapagos, Gilead, GSK, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis, UCB, all unrelated to this work, Grant/research support from: Amgen, Galapagos, Lilly, Pfizer, Sandoz, all unrelated to this work, Loreto Carmona: None declared, Elsa Mateus Consultant of: Boehringer Ingelheim Portugal, not related to this work, Martin Schaefer: None declared, Christophe Richez Speakers bureau: Abbvie, Amgen, Astra Zeneca, Biogen, BMS, Celltrion, Eli Lilly, Galapagos, GSK, MSD, Novartis, and Pfizer, all unrelated to this abstract, Consultant of: Abbvie, Amgen, Astra Zeneca, Biogen, BMS, Celltrion, Eli Lilly, Galapagos, GSK, MSD, Novartis, and Pfizer, all unrelated to this abstract, Eric Hachulla Speakers bureau: Johnson & Johnson, GlaxoSmithKline, Roche-Chugai, all unrelated to this work, Consultant of: Bayer, Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, all unrelated to this work, Grant/research support from: CSL Behring, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, all unrelated to this work, Marie Holmqvist: None declared, Carlo Alberto Scirè Grant/research support from: AbbVie, Lilly, both unrelated to this work, Rebecca Hasseli: None declared, Arundathi Jayatilleke: None declared, Tiffany Hsu: None declared, Kristin D’Silva: None declared, Victor Pimentel-Quiroz: None declared, Monica Vasquez del Mercado: None declared, Samuel Katsuyuki Shinjo: None declared, Edgard Reis Neto: None declared, Laurindo Rocha Jr: None declared, Ana Carolina de Oliveira e Silva Montandon Speakers bureau: GSK, not related to this work, Paula Jordan: None declared, Emily Sirotich: None declared, Jonathan Hausmann Speakers bureau: Novartis, Biogen, Pfizer, not related to this work, Consultant of: Novartis, Biogen, Pfizer, not related to this work, Jean Liew Grant/research support from: Pfizer research grant, completed in 2021, not related to this work, Lindsay Jacobsohn: None declared, Monique Gore-Massy Speakers bureau: Aurinia Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, not related to this work, Consultant of: Aurinia Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, not related to this work, Paul Sufka: None declared, Rebecca Grainger Speakers bureau: AbbVie, Janssen, Novartis, Pfizer and Cornerstones, all unrelated to this work, Consultant of: AbbVie, Novartis, both unrelated to this work, Suleman Bhana Shareholder of: Pfizer, Inc, Speakers bureau: AbbVie, Horizon, Novartis, and Pfizer, all unrelated to this work, Consultant of: AbbVie, Horizon, Novartis, and Pfizer, all unrelated to this work, Employee of: Pfizer, Inc, Zachary Wallace: None declared, Philip Robinson Speakers bureau: Abbvie, Janssen, Roche, GSK, Novartis, Lilly, UCB, all unrelated to this work, Paid instructor for: Lilly, unrelated to this work, Consultant of: GSK, Kukdong, Atom Biosciences, UCB, all unrelated to this work, Grant/research support from: Janssen, Pfizer, UCB and Novartis, all unrelated to this work, Jinoos Yazdany Consultant of: Aurinia, Astra Zeneca, Pfizer, all unrelated to this work, Grant/research support from: Astra Zeneca, Gilead, BMS Foundation, all unrelated to this work, Pedro Machado Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this work., Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this work.

AB0253 CARDIOVASCULAR OUTCOMES IN PREVENTION RANDOMIZED CONTROLLED TRIALS IN PATIENTS WITH INFLAMMATORY ARTHRITIS: A SYSTEMATIC REVIEW

Background

Cardiovascular disease (CVD) risk in patients with chronic inflammatory arthritis (IA), including rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS), is substantially increased compared to the general population. New evidence strengthens the notion that the excess risk of CVD morbidity and mortality in patients with IA is related to both traditional (e.g. hypertension, diabetes, smoking) and novel CVD risk factors, including chronic inflammation, leading to an accelerated atherosclerosis. How to minimize such increased CVD prevalence is still poorly understood, and whether more intensive traditional risk factor control or disease specific risk factor should be targeted is still matter of debate.

Objectives

The aim of this systematic review was to identify intervention targeting CVD or inflammatory arthritis associated with improvement of CV risk outcomes (estimated CV risk, CV events, endothelial function, arterial stiffness, subclinical atherosclerosis) in adult patients with diagnosis of inflammatory arthritis (RA, PsA and AS).

Methods

Two independent reviewers retrieved randomized controlled trials of interest from systematic searches of Medline, Embase and Cochrane database (20th April 2020). Data extraction was performed using standard template; the quality of each included trials was assessed with the Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) [1]. Systematic review was conducted following the Preferred Reporting Items for systematic reviews and Meta-analysis (PRISMA) statement.

Results

Out of total of 4823 articles, 27 met the inclusion criteria. Among these, most (n=22) involved RA patients, one trial was based on mixed IAs patients and the remaining (n=4) were performed on spondylarthritis population. Total number of patients was 8045. Overall risk of bias was high in most of per protocol analysis trials (90%) and in 26.7% of intention-to-treat analysis trials. Four trials evaluated major adverse cardiovascular events (MACE) incidence and one of these demonstrated a significant reduction in incidence of MACE in RA patients underwent a treat-to-target strategy of CV risk factor. The same study also demonstrated a significant reduction in progression of subclinical atherosclerosis (carotid Intima-media thickness, cIMT), while other trials (n= 8) exploring effect of rosuvastatin, enalapril, tocilizumab and TNF-inhibitors failed to reach a similar result. Endothelial dysfunction, predominantly measured as reduce flow mediated dilatation (FMD), was widely used as surrogate outcome of CVD and it appeared to be significantly improved by treatment with statins, ACE-inhibitors, anakinra and tocilizumab. Treatment with pioglitazone, anakinra or tocilizumab in three trials significantly ameliorated arterial stiffness, estimated with pulse wave velocity (PWV), Cardio-ankle vascular index (CAVI) or augmentation index (AI). Two studies explored how a reduction of estimated CV risk could be achieved after treatment with enalapril and tight-control strategy aiming to SDAI ≤ 3.3. Results of both trials didn’t demonstrate any variation in QRISK3-2018 and Framingham risk score, respectively.

Conclusion

Optimal CVD management in IA patients remains undefined and it should be implemented as stated in international guidelines. Randomized controlled trials exploring efficacy of prevention strategy are few and predominantly focused on surrogate outcome measures of cardiovascular risk.

References

[1]Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019;366:l4898. https://doi.org/10.1136/bmj.l4898.

Disclosure of Interests

Carlo Garaffoni: None declared, Antonio Marangoni: None declared, Marcello Govoni Speakers bureau: Abbvie, Pfizer, Galapagos, BMS, Eli-Lilly, Paid instructor for: Pfizer, Consultant of: Abbvie, BMS, Novartis, Astrazeneca, Pfizer, Carlo Alberto Scirè Grant/research support from: AbbVie, Lilly

OP0168 DEVELOPMENT OF AN ULTRASOUND SCORING SYSTEM FOR CPPD EXTENT: RESULTS FROM A DELPHI PROCESS AND WEB-RELIABILITY EXERCISE BY THE OMERACT US WORKING GROUP

Background

Ultrasound (US) has proven to be an excellent imaging technique for detecting calcium pyrophosphate (CPP) deposition disease (CPPD); it is also widely available and inexpensive and can be performed during the clinic visit making it the preferred imaging modality for many rheumatologists. However, no validated grading systems have yet been developed allowing for a quantification of the extent of crystal deposition in CPPD.

Objectives

The aim of this study was to develop a scoring system for the quantification of CPP deposition at a patient level according to the OMERACT framework.

Methods

As part of the OMERACT methodology, we performed a systematic literature review (SLR) and meta-analysis aimed to estimate the prevalence of CPP deposition in peripheral joints by imaging, in order to identify relevant joints for CPPD monitoring. A preliminary survey was also circulated among the members of the OMERACT US – CPPD working group to collect their own suggestions according to their personal experience. Subsequently, a Delphi survey was prepared and circulated between members of the group, including statements that reflected both the results of the SLR and of the preliminary survey. In total, 32 statements were generated regarding the type of scoring for single structures, the sites to be included, the final scoring at patient level, and the scanning technique. Participants were asked to reply on a 5-point Likert scale (1, strongly disagree to 5, strongly agree) and agreement was achieved when 4 and 5 grades reached 75% or more of concordance. In case of disagreement, new statements were proposed according to the members’ suggestions and circulated for voting in a subsequent round. After agreement of a scoring system, the validation process began. Two rounds of a web-based exercise on static images were conducted on 120 images representing equally all sites under investigation and all degrees of crystal deposition, to assess the intra- and inter-reader reliability of the new scoring system. Representative images of the scoring system were visible throughout the entire exercise in order to facilitate the scoring of the lesions.

Results

Three Delphi rounds were needed to reach agreement on all items. 32/41 members of the OMERACT US-CPPD working group replied in the first round, 26/32 in the second, and 25/26 in the third round. Twenty statements were approved in the first round, 3 in the second, and 3 in the third round. Only the knees (menisci and hyaline cartilage) and the triangular fibrocartilage of the wrist were included in the final score, using a four-grade system (0-3). It was decided that each anatomical structure should be scored separately and then also summed in order to define the joint score. The sum of the assessed joints was the total score at patient level. The final scoring system with the definitions and the relative technical notes is represented in Figure 1. 33/41 members participated to the reliability exercise. The inter-reader reliability of the scoring was substantial (kappa of 0.72), and the intra-reader reliability was almost perfect (kappa of 0.82).

Conclusion

This is the first study for developing a scoring system for the extent of CPP crystal deposition in patients with CPPD. The scoring system demonstrated to be reliable in static images. The next step of the validation process is to assess the reliability of the scoring system in a patient-based exercise. This study represents a fundamental step in the OMERACT process of validating US as an outcome measure instrument, and above proposed scoring system will hopefully provide a useful tool for clinical practice and research.

Disclosure of Interests

None declared

POS0276 TRADITION VS INNOVATION! CONVENTIONAL RADIOGRAPHY AND ULTRASOUND IN THE DIAGNOSIS OF CPPD: INSTRUCTIONS FOR USE

Background

Conventional radiography (CR) is widely used as the first-line investigation for calcium pyrophosphate deposition (CPPD) disease, given its widespread use and the low cost. Next to it a series of advanced imaging techniques have been evaluated for accuracy and reliability. Among them, ultrasound (US) has been thoroughly tested and demonstrated to be accurate and reliable for CPPD diagnosis. However, even if there are data on the diagnostic accuracy of US and CR alone, it is not clear if performing both diagnostic tests and in which sequential order provides an added value for the diagnosis of CPPD.

Objectives

The aim of this study was to assess which diagnostic test performs better for the diagnosis of CPPD and if a combination of the two exams provides an additional value.

Methods

This is an ancillary study of the criterion validity of US in CPPD study1. Consecutive patients with knee osteoarthritis requiring total joint replacement were enrolled in 8 centres. Participants underwent US and CR of the affected knee prior to surgery. US was performed by experienced sonographers following the same scanning protocol described in the main study, while CR were performed in weight bearing AP and lateral views and were read by 2 experienced radiologists that reached a consensus on the presence/absence of CPPD. The evaluation of CPPD at the level of menisci and hyaline cartilage (HC) was based on the OMERACT definitions for US and on the new definitions developed by the ACR/EULAR CPPD classification criteria working group for CR [paper under submission]. Patients were classified as having CPPD considering histological examination as reference standard. Diagnostic indexes were calculated for US and CR alone and combined. Poisson models with robust estimation were used to estimate the best sequence of these diagnostic methods for a more accurate diagnosis of CPPD.

Results

51 pts were enrolled (63% F, mean age 74y ± 8). Diagnostic indexes of US and CR alone and combined are indicated in Table 1. Compared to histology, US demonstrated to be a sensitive tool for identification of CPPD at the knee, with a good sensitivity in all sites and in the overall evaluation. Instead, CR was less sensitive, but it was a highly specific exam for CPPD identification. Combining US and CR led to a higher sensitivity compared with CR alone, but a lower specificity compared to both CR and US alone, and it offered no additional increase in diagnostic accuracy. The Figure 1 shows the results of the appropriate sequence of use of US and CR in patients with suspected CPPD: in case of a positive CR at any of the 3 sites (menisci and HC) no additional exam is necessary, and the same in case of a positive US in at least two sites; however in case of a negative CR, US could help in a statistically significant way to identify CPPD patients, and further in case of a positive US in a single site CR can offer additional information.

Table 1.

diagnostic indexes of US, CR and US + CR in the identification of CPPD. MM: medial meniscus, LM: lateral meniscus, HC: hyaline cartilage, SN: sensitivity, SP: specificity, PPV: positive predictive value, NPV: negative predictive value, ACC: accuracy.

USSNSPPPVNPVACCMM0.880.810.820.880.84LM0.880.730.760.860.80HC0.780.860.820.830.82Overall0.920.640.730.890.78CRMM0.32110.610.67LM0.400.960.910.630.69HC0.480.930.850.680.73Overall0.540.920.880.660.73US + CRMM0.880.810.820.880.84LM0.920.690.740.900.80HC0.870.820.800.890.84Overall0.920.560.670.880.75Figure 1.

evaluation of sequence of US and CR

Conclusion

US confirmed a high diagnostic accuracy in identifying patients affected by CPPD at knee level, while CR demonstrated a high specificity but a low sensitivity. Performing both diagnostic tests could make sense in case of a negative CR or in case of an inconclusive US (only one positive site). To our knowledge, this is the first study that investigates the role of the combination of the two exams in CPPD. Further studies in a large number of patients and in different joints would be helpful to address this point.

References

[1]Filippou G. et al, Ann Rheum Dis, 2020

Disclosure of Interests

None declared

POS0328 AUTOPHAGY MODULATION BY TOFACITINIB IMPROVES PSORIATIC ARTHRITIS FIBROBLAST-LIKE SYNOVIOCYTES FUNCTION

Background

Psoriatic arthritis (PsA) is a chronic inflammatory systemic disease, and peripheral joints involvement is responsible of significant morbidity for patients, leading to damage accrual. Different drugs are available for the systemic management of this condition, with different mechanisms of action. Nevertheless, the rules driving the correct therapeutical choice in each individual patient are not completely defined. Janus kinases (JAK) inhibitors are a class of drugs able to reduce synovial inflammation, and tofacitinib, a JAK1/3 inhibitor, is the most studied. Preliminary evidence suggest an effect of tofacitinib on fibroblast-like synoviocytes (FLS) from PsA patients, reducing pro-invasive and pro-inflammatory properties. The link between JAK inhibition and FLS function improvement at synovial level is not fully understood.

Objectives

To evaluate the effect of tofacitinib on spontaneous autophagic activity of PsA FLS, and to confirm its effect on anti-inflammatory and anti-invasive properties of PsA FLS and synovial explants.

Methods

This is an in vitro study. Patients with active PsA underwent ultrasound-guided synovial biopsy. Histological evaluation was performed according to Krenn’s synovitis score. FLS, PBMCs and synovial explants cultures were set up, and cells were treated in vitro with tofacitinib 1 µM or vehicle control for 24h. Protein levels in cellular homogenates were analysed by western blot for relevant autophagy markers. Autophagy was also studied by fluorescence microscopy using GFP-LC3. Chemokines/cytokines levels into culture supernatants were quantified by ELISA. Migration assays were used to investigate the effect of tofacitinib on invasive properties of FLS. Differences were determined adopting the non-parametric Wilcoxon signed rank test.

Results

16 patients with moderately active PsA were enrolled (Table 1). Mean (SD) Krenn’s synovitis score was 4.4. (1.9). Tofacitinib significantly increased LC3-II and ATG7 levels in PsA FLS compared to vehicle control, while p62 levels were not significantly affected, suggesting an increase in spontaneous autophagy activity, confirmed by LC3-autophagic vesicles count (Figure 1). No effect was highlighted in PBMCs and synovial explants cultures. Tofacitinib significantly reduced migration properties of PsA FLS, as well as MCP-1 and IL-6 release into FLS and synovial explants cultures supernatants.

Table 1.

Baseline demographic and clinical data of included patients (N=16).

VariablesFrequencyAge (years), mean (SD)59.8 (7.9)Female, N (%)5 (31.3%)Disease duration (years), mean (SD)9.7 (7.9)CRP (mg/dl), mean (SD)1.5 (2.0)Patient Global Activity (0-100), mean (SD)73.4 (16.9)Physician Global Activity (0-100), mean (SD)56.3 (18.1)DAPSA, mean (SD)25.6 (6.8)HAQ (0-3), mean (SD)0.9 (0.5)Previous csDMARDs treatment, N (%)13 (81.3%)Previous bDMARDs treatment, N (%)6 (37.5%)Grey scale synovitis - joint to be biopsied (0-3), mean (SD)1.9 (0.8)Joint effusion - joint to be biopsied (0-3), mean (SD)1.4 (0.7)Power Doppler - joint to be biopsied (0-3), mean (SD)0.5 (0.6)Krenn’s synovitis score (0-9), mean (SD)4.4 (1.9)

Abbreviations: SD, standard deviation; CRP, C reactive protein; DAPSA, Disease Activity Index for Psoriatic Arthrititis; HAQ, Health Assessment Questionnaire; csDMARD, conventional synthetic disease modifying antirheumatic drugs; bDMARD, biological disease modifying antirheumatic drugs.

Figure 1.

Tofacitinib significantly increased LC3-II and ATG7 levels in PsA FLS homogenates (A), and LC3-autophagic vesicles (B). Tofacitinib significantly reduced MCP-1 and IL-6 release into FLS cultures supernatants (C), and reduced PsA FLS migration properties at 24h (D).

Conclusion

The induction of autophagy by tofacitinib might permit a better functioning of PsA FLS, with a coherent reduction in pro-invasive and pro-inflammatory properties. This may contribute to the rationale for tofacitinib use in PsA management.

References

[1]Gao Ann Rheum Dis. 2016 Jan;75(1):311-5

[2]O’Brien Front Immunol. 2021 Jun 24;12:672461.

Disclosure of Interests

Ettore Silvagni Grant/research support from: E. Silvagni has received research support from AbbVie., Sonia Missiroli: None declared, Simone Patergnani: None declared, Caterina Boncompagni: None declared, Maria Sofia Ciliento: None declared, Giovanni Lanza: None declared, Mariasole Perrone: None declared, Alessandra Bortoluzzi: None declared, Marcello Govoni: None declared, Carlotta Giorgi: None declared, Carlo Alberto Scirè Grant/research support from: C.A. Scirè has received research support from AbbVie., Paolo Pinton: 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

Persistence of bDMARD therapy in Rheumatoid Arthritis after first-line TNF-inhibitor failure: the RECORD study of the Italian Society for Rheumatology

OBJECTIVE

The optimal choice of a second biological disease-modifying anti-rheumatic drug (bDMARD) after failure with first line tumour necrosis factor inhibitor (TNFi) represents a critical therapeutic challenge. This study aims to evaluate the persistence with treatment using second line bDMARDs with different mechanisms of action in rheumatoid arthritis (RA) patients with inadequate response to first line TNFi.

METHOD

A retrospective cohort study on administrative healthcare databases was conducted. We analysed the relationship between different bDMARDs and persistence with treatment in RA patients who started second line bDMARD therapy according to two different strategies: cycling (second TNFi) or switching [change in mechanism of action: abatacept (ABA), tocilizumab (TCZ), and rituximab (RTX)] with or without concomitant conventional synthetic (cs) DMARDs.

RESULTS

The cohort comprised 1434 patients. The mean age was 53.8 years and 1142 (79.6%) were women. Among second line bDMARDs, 969 patients (67.6%) started TNFi, 204 (14.2%) ABA, 145 (10.1%) RTX, and 116 (8.1%) TCZ. A bDMARD was prescribed as monotherapy in 359 patients (25.0%). The switching strategy showed a lower overall discontinuation rate [hazard ratio (HR) 0.72], while switching compared to cycling showed significantly better survival for ABA (HR 0.61) and RTX (HR 0.76), but no significant difference for TCZ (HR 0.82). A lower impact of better drug survival in the switching strategy occurred in patients with concurrent methotrexate.

CONCLUSIONS

Among RA patients failing a first TNFi, switching is associated with marginally better persistence, in particular for ABA and RTX, with only marginal differences in patients on concurrent csDMARDs.

The Italian Society for Rheumatology recommendations for the management of axial spondyloarthritis

Over the last few years, the landscape of treatments for axial spondyloarthritis (SpA) has been rapidly evolving, urging international scientific societies to draft or update existing clinical practice guidelines (CPGs) on the management of axial SpA. The Italian Society for Rheumatology (SIR) committed to provide revised and adapted evidence- and expert-based recommendations for the management of patients with axial SpA in Italy. A systematic approach to the adaptation of existing CPGs - the ADAPTE methodology - was adopted to obtain updated recommendations suitable for the Italian context. A systematic literature search was performed in Medline and Embase databases to find international CPGs and consensus statements with recommendations for the management of axial SpA published in the previous five years. A working group composed of rheumatologists with proven experience in the management of axial SpA and methodologists identified the key research questions which guided study selection and data extraction. Guideline quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The Italian recommendations were developed by endorsing or adapting and rewording some existing recommendations. The draft of the recommendations was sent to a multidisciplinary group of external reviewers for comment and rating. Six original CPGs were selected and used to create this SIR CPG, which includes a final set of 14 recommendations covering the management of patients with axial SpA across the following domains: assessment, pharmacological and non-pharmacological treatment, and follow-up. The dissemination and implementation of these SIR recommendations are expected to support an evidencebased clinical approach to the management of patients with axial SpA in Italy.

Accuracy of synovial fluid analysis compared to histology for the identification of calcium pyrophosphate crystals: an ancillary study of the OMERACT US Working Group - CPPD subgroup

The aim of this study was to evaluate the accuracy of synovial fluid analysis in the identification of calcium pyrophosphate dihydrate crystals compared to microscopic analysis of joint tissues as the reference standard. This is an ancillary study of an international, multicentre cross-sectional study performed by the calcium pyrophosphate deposition disease (CPPD) subgroup of the OMERACT Ultrasound working group. Consecutive patients with knee osteoarthritis (OA) waiting for total knee replacement surgery were enrolled in the study from 2 participating centres in Mexico and Romania. During the surgical procedures, synovial fluid, menisci and hyaline cartilage were collected and analysed within 48 hours from surgery under transmitted light microscopy and compensated polarised light microscopy for the presence/absence of calcium pyrophosphate crystals. All slides were analysed by expert examiners on site, blinded to other findings. A dichotomic score (absence/ presence) was used for scoring both synovial fluid and tissues. Microscopic analysis of knee tissues was considered the gold standard. Sensitivity, specificity, accuracy, positive and negative predictive values of synovial fluid analysis in the identification of calcium pyrophosphate crystals were calculated. 15 patients (53% female, mean age 68 yo ± 8.4) with OA of grade 3 or 4 according to Kellgren-Lawrence scoring were enrolled. 12 patients (80%) were positive for calcium pyrophosphate crystals at the synovial fluid analysis and 14 (93%) at the tissue microscopic analysis. The overall diagnostic accuracy of synovial fluid analysis compared with histology for CPPD was 87%, with a sensitivity of 86% and a specificity of 100%, the positive predictive value was 100% and the negative predictive value was 33%. In conclusion synovial fluid analysis proved to be an accurate test for the identification of calcium pyrophosphate dihydrate crystals in patients with advanced OA.

The Italian Society for Rheumatology clinical practice guidelines for the diagnosis and management of fibromyalgia Best practices based on current scientific evidence

Fibromyalgia or fibromyalgia syndrome (FMS) is defined as a central sensitization syndrome characterized by the dysfunction of neurocircuits detecting, transmitting and processing nociceptive stimuli; the prevalent manifestation is musculoskeletal pain. In addition to pain, there are multiple accompanying symptoms, in common with other algo-dysfunctional syndromes, which are reflected in a broad spectrum of somatic, neurocognitive and neuro-vegetative manifestations. An evidence-based approach is essential in FMS management, in order to improve patient health and to reduce its social burden. Since in the last ten years new international guidelines for clinical practice (Clinical Practice Guidelines or CPGs) concerning FMS diagnosis and pharmacological/ non-pharmacological management have been published, the Italian Society of Rheumatology (SIR) has decided to adapt them to the Italian national setting. The framework of the Guidelines International Network Adaptation Working Group was adopted to identify, appraise (AGREE II), synthesize, and customize the most recent CPGs on FMS to the needs of the Italian healthcare context. A working group of rheumatologists from SIR epidemiology unit and FMS experts identified relevant clinical questions to guide the systematic review of the literature. The target audience of these CPGs included physicians and healthcare professionals who manage FMS. The adapted recommendations were finally assessed by an external multidisciplinary panel. From the systematic search in databases (Pubmed/Medline, Embase) and grey literature, 6 CPGs were selected and appraised by two independent raters. The combination of the scientific evidence underlying the original CPGs with expert opinion lead to the development of 17 recommendations. The quality of evidence for each recommendation was reported and their potential impact on clinical practice was assessed. These SIR recommendations are expected to be a valuable aid in the diagnosis and treatment of FMS, as they will contribute to disseminate the best practice on the basis of the current scientific evidence.

POS0230 INTESTINAL MICROBIOTA CHANGES TNF-INHIBITORS INDUCED IN IBD-RELATED SPONDYLOARTHRITIS

Background:

the close relationship between joints and gut inflammation has long been known and several data suggest that the dysbiosis could represents the link between Spondyloarthritis (SpA) and Inflammatory Bowel Diseases (IBD). To date, the manipulation of the intestinal microbiota is considered the key to the cure or control of the natural history of several pathologies sustained or favored by dysbiosis. The introduction of biologic drugs, in particular Tumor Necrosis Factor inhibitors (TNFi), revolutionized the management of both these diseases, thanks to the strong inhibition of inflammation and partially indirectly with mechanisms not yet fully clarified. While the impact of conventional drugs on gut microbiota is well known poor data are available about TNFi.

Objectives:

to investigate the impact of TNFi on gut microbiota.

Methods:

we included CD or UC patients fulfilling criteria for axial or peripheral SpA (ASAS 2009) on a typical Mediterranean diet, naïve to biologics needing TNFi. Clinical history, physical examination, instrumental examinations, biochemical examination including C-reactive protein (CRP), erhytrocyte sedimentation rate (ESR), HLA-B27 and fecal calprotectin at the baseline and after 6 months were performed. TNFi included infliximab and adalimumab. Fecal samples were collected by patients themselves by 24 hours before the start of the therapy. The processing was performed through metagenomic NGS (next generation sequencing) including the amplification of the V3 and V4 regions of the 16S (V3 and V4) and sequencing on the Illumina MiSeq platform. All patients received the treatment at least until week 24. Clinical disease indices included Visual Analogue Scale (VAS)-pain and Visual Analgue Scale(VAS)-disease activity for all patients, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for axial involvement, clinical disease activity index (CDAI) and Health Assessment Questionnaire-Disability Index (HAQ-DI) for peripheral involvement, Harvey-Bradshaw Index for CD (HBI), or partial Mayo (pMAYO) score for UC, were assessed at baseline and at the end of the study. The study was approved by the ethics committee (approval code 0056924).

Results:

we evaluated 20 patients affected by enteropatic arthritis, naïve for biologic drugs, treated with TNFi. After six months of therapy we observed a significant increase in Lachnospiracae family (Δ +10.3, p 0.04) and in Coprococcus genus (Δ +2.8, p 0.003). We also observed a decrease trend in Proteobacteria (Δ -8.0 p 0.095) and Gammaproteobacteria (Δ -9, p 0.093) and an increase trend in Clostridia (Δ +8.2 p 0.083). We didn’t find differences between TNFi responders (SpA improvement or IBD remission achieved) and not responders in terms of alpha and beta-diversity.

Conclusion:

the decrease of Proteobacteria and the increase of Lachnospiraceae and Coprococcus is consistent with the hypothesis that TNFi therapy, by decreasing inflammation, tends to restore the intestinal eubiosis. However further studies on larger cohort incuding the evaluation of gut virota and micobiota will be necessary to definitively clarify the effects of TNFi on the composition and function of the gut microbiota.

References:

[1]Bazin T et al. Sci Rep. 2018;8(1):5446.

[2]Aden K et al. Gastroenterology. 2019;157(5):1279-1292.e11.

Table 1.

Comparison between clinical variables between baseline and T6 (six months)

Clinical variablesT0T6P_valueFecal Calprotectin(μg/g)- median (IQR)207.5(125.5-446.2)81(50-197.2)0.004CRP(mg/L)- median(IQR)8.2(4.8-20.8)2.9(1-4)0.001ESR(mm/h)- median(IQR)21.5(10.8-34)11(7.8-21)0.003VAS_pain- median(IQR)50(38.8-60)35(10-42.5)0.001VAS_disease- median(IQR)50(38.8-50)37.5(25-42.5)0.006HAQ- mediana(IQR)0.6(0.1-0.8)0.2(0.1-0.6)0.004BASDAI_score- median(IQR)5.2(4.1-5.6)2.8(2.5-4.3)0.013CDAI_activity- median(IQR)13(10.5-16)7(5.2-11)0.004IBD activity n(%) - 011 (55%)20 (100%)0.174IBD activity n(%) - 16 (30%)0 (0%)IBD activity n(%) - 22 (10%)0 (0%)IBD activity n(%) - 31 (5%)0 (0%)

Disclosure of Interests:

None declared.

AB0629 ACCURACY OF SYNOVIAL FLUID ANALYSIS FOR THE IDENTIFICATION OF CALCIUM PYROPHOSPHATE CRYSTALS: AN ANCILLARY STUDY OF OMERACT CRITERION VALIDITY STUDY FOR ULTRASOUND IN CPPD

Background:

Synovial fluid analysis (SFA) via compensated polarized light microscopy is still considered the gold standard for the identification and diagnosis of Calcium Pyrophosphate Deposition disease (CPPD)-related arthropathies[1], but very few studies have been published about its diagnostic accuracy.

Objectives:

The aim of this study was to evaluate the accuracy of SFA in the identification of calcium pyrophosphate dihydrate (CPP) crystals compared to microscopic analysis of joint tissues as the reference standard.

Methods:

This is an ancillary study of an international, multicentre cross-sectional study performed by the CPPD subgroup of the OMERACT Ultrasound working group[2]. Consecutive patients with knee osteoarthritis (OA) waiting for total knee replacement surgery were enrolled in the study from 2 participating centres, Mexico and Romania. During surgical procedures synovial fluid (SF), menisci and hyaline cartilage were collected and analysed within 48 hours after surgery under transmitted light microscopy and compensated polarised light microscopy for the presence/absence of CPP crystals. All slides were analysed by expert examiners on site, blinded to other findings. A dichotomic score (absence/presence) was used for scoring both SF and tissues. Microscopic analysis of knee tissues was considered the gold standard. Sensitivity, specificity, accuracy, positive and negative predictive values (PPV and NPV) of SFA in the identification of CPP crystals were calculated.

Results:

15 patients (53% female, mean age 68yo ± 8.4) with OA of grade 3 or 4 according to Kellgren-Lawrence scoring were enrolled. 12 patients (80%) were positive for CPP crystals at SFA and 14 (93%) at tissues microscopic analysis. Among 12 SFA positive patients, all were positive for CPP crystals in either medial or lateral meniscus, and 11 were positive in both; 10 patients were positive at the hyaline cartilage, and all 10 were also positive for at least one meniscus. Regarding the 3 SFA negative patients, only one had no crystals in the examined tissues, while the other 2 patients had CPP crystals in both menisci and hyaline cartilage. The overall diagnostic accuracy of SFA compared to histology analysis for CPPD was 87%, with a sensitivity of 86% and a specificity of 100%, the PPV was 100% and the NPV was 33% (Table 1).

Table 1.

sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of synovial fluid analysis compared to the reference standard. CI: Confidential Interval. SF: synovial fluid, in parentheses: numerators and denominators for all percentages provided.

SensitivitySpecificityPPVNPVAccuracySF analysis86% (12/14)100% (1/1)100% (12/12)33% (1/3)87% (13/15)(0.65-0.99) CI 95%(0.0-0.25) CI 95%(0.65-0.99) CI 95%(0.0-0.25) CI 95%

Conclusion:

SFA demonstrated to be an accurate test for the identification of CPP crystals in patients with advanced OA. However, is not always feasible and carries some risks for the patient. Considering the availability of validated imaging techniques for the detection of CPPD, such as US, SFA could be used in those patients where imaging and clinical data are not definitely confirmatory of the disease.

References:

[1]W. Zhang et al., ‘European League Against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: terminology and diagnosis’, Ann Rheum Dis, vol. 70, no. 4, pp. 563–570, Apr. 2011, doi: 10.1136/ard.2010.139105.

[2]G. Filippou et al., ‘Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study’, Ann Rheum Dis, p. annrheumdis-2020-217998, Sep. 2020, doi: 10.1136/annrheumdis-2020-217998.

Disclosure of Interests:

None declared.

OP0055 ULTRASOUND HALO SIGN AS A POTENTIAL MONITORING TOOL FOR PATIENTS WITH GIANT CELL ARTERITIS: A PROSPECTIVE ANALYSIS

Background:

Ultrasound of the temporal ± axillary arteries showing a non-compressible halo sign is recommended for diagnosing patients with giant cell arteritis (GCA); however, its value for monitoring disease activity is still poorly understood.

Objectives:

To assess the sensitivity to change of ultrasound halo features and their association with disease activity and glucocorticoid (GC) treatment in patients with newly diagnosed GCA.

Methods:

Two centre prospective study of new patients with ultrasound confirmed-GCA who underwent serial ultrasound assessments of the temporal (TA) and axillary (AX) arteries at fixed time-points. The number of arterial segments with halo and the maximum halo intima-media thickness (IMT) per segment was recorded at each visit. Only time-points in which >80% of patients were assessed were considered for analysis. Sensitivity to change of the halo sign was calculated as standardised mean difference (SMD) for each time-point separately. Correlation between ultrasound findings and erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Birmingham Vasculitis Activity Score (BVAS), and GC treatment was performed using Spearman’s correlation coefficient. Logistic regression was used to determine the probability of being in remission for each unit increase (standardised) of the halo feature of interest. Remission was defined as the absence of relapse with a prednisolone dose <30 mg/day, and relapse as the recurrence of GCA-related symptoms or rise of CRP/ESR values not otherwise explained and requiring GC increase. Halo features at disease onset and first relapse were compared using Wilcoxon test.

Results:

A total of 49 patients (73.5% females) with a mean age of 78.2 ± 7.4 years at baseline were assessed at 354 visits. TA involvement was reported in 47 (95.9%) patients and AX involvement in 11 (22.4%); 220 arterial segments with halo were recorded (201 TA, 19 AX). Halo sensitivity to change was calculated for weeks 1, 3, 6, 12 and 24, and showed a significant SMD between all time-points and baseline for the TA halo features, but only after week 6 for the AX halo features (Table and Figure). The number of TA segments with halo, sum of TA halo IMT and maximum TA halo IMT showed a significant correlation with ESR (0.41; 0.44; 0.48), CRP (0.34; 0.39; 0.41), BVAS (0.29; 0.36; 0.35) and GC cumulative dose (-0.34; -0.37; -0.32). The likelihood of achieving disease remission was lower in patients with a higher number of TA segments with halo (OR 0.39, p<0.05) and increased values of sum and maximum TA halo IMT (OR 0.34, p<0.05). By contrast, AX halo features showed no correlation with disease activity, nor any association with attaining clinical remission. During the study period, 32 relapses were observed (mean time for first relapse of 31.8 weeks ± 18.5 days). Halo sign was present in 16/17 (94.1%) cases of first disease relapse, all showing an increased halo IMT (sum and maximum) in relation to the previous ultrasound assessment performed. When compared to disease onset, a lower mean number of segments with halo and mean sum of halo IMT was reported for patients presenting with their first clinical relapse (2.93 ± 1.59 vs. 4.85 ± 1.51, p=0.0012; 2.01 ± 1.13 vs. 4.49 ± 1.95 mm, p=0.0012).

Table 1.

SMD of halo features between baseline and different time-points

Week 1Week 3Week 6Week 12Week 24N of arterial segmentsSum of all segments with halo (n=49)-0.51-0.78-1.13-1.69-1.52Sum of TA segments with halo (n=47)-0.49-0.78-1.18-1.87-1.69Sum of AX segments with halo (n=11)-0.35--0.62-0.73-0.91Halo thickness (mm)Sum of all halo IMT (n=49)-0.98-1.44-1.37-1.60-1.48Sum of TA halo IMT (n=47)-1.01-1.55-1.54-1.81-1.69Sum of AX halo IMT (n=11)-0.15-0.45-0.81-0.84-0.98Max. TA halo IMT (n=47)-1.07-1.32-1.47-1.91-2.19Max. AX halo IMT (n=11)-0.04-0.29-0.94-1.13-1.01

In bold p<0.05; n=n at baseline

Conclusion:

Ultrasound is a reliable imaging tool to assess disease activity and response to treatment in patients with GCA. Future clinical trials in GCA should evaluate direct treatment effect on halo features as an outcome measure of interest.

Acknowledgements:

The first two authors contributed equally to this work

Disclosure of Interests:

None declared

POS1132 DIAGNOSTIC ACCURACY OF CONVENTIONAL RADIOGRAPHY OF THE KNEE FOR CALCIUM PYROPHOSPHATE DEPOSITION DISEASE: AN ANCILLARY STUDY OF THE OMERACT ULTRASOUND – CPPD GROUP

Background:

Conventional Radiography (CR) has been widely used in the assessment of knee chondrocalcinosis (CC) and is still considered one of the most important diagnostic methods for the diagnosis. However, there are very few studies that examine the diagnostic accuracy of CR compared to histology of the knee tissues.

Objectives:

To assess the diagnostic accuracy of CR of the knee in Calcium Pyrophosphate Deposition Disease (CPPD) by using the recently created definitions for CPPD in CR of the ACR/EULAR taskforce for the new classification criteria for CPPD.

Methods:

This is an ancillary study of the Criterion Validity of Ultrasound in CPPD study [1]. Consecutive patients with osteoarthritis (OA) awaiting total knee replacement were enrolled in 4 centres from Romania, Italy, USA and Mexico. All patients underwent CR of the knees taken maximum 6 months before surgery, in posterior-anterior weight baring and lateral projections. DICOM files of the radiographs were anonymised and read independently by two musculoskeletal radiologists with experience in microcrystalline arthropathies. For each patient, a dichotomic score was used (absence/presence of CC) at the level of the menisci and tibiofemoral hyaline cartilage by each reader. The definitions of the ACR/EULAR taskforce for identification of CPPD in CR were used in this study [paper in preparation]. According to these definitions CPPD in CR appears as “linear or punctate opacities in the region of fibro- or hyaline articular cartilage/synovial membrane or joint capsule/within tendons or entheses that are distinct from denser, nummular radio-opaque deposits due to basic calcium phosphate deposition”. In case of disagreement a consensus decision was taken by both radiologists after discussion of the case. Menisci and the hyaline cartilage were analysed using compensated polarized light microscopy as described previously [1], patients were considered positive for CPPD if at least one of their tissue specimens revealed the presence of calcium pyrophosphate crystals. All examiners were blind to each other’s findings.

Results:

We enrolled 33 patients with OA (61% female, mean age 69yo). The accuracy values of CR in the various sites of the knee are indicated in Table 1. CR demonstrated to be a specific exam for identification of CPPD at the knee, but sensitivity remains low in all sites and in the overall evaluation. Identification of CPPD appears challenging and this could be due to the advanced grade of OA in our cohort of patients. Advanced degeneration, dislocation of the menisci and thinning of the hyaline cartilage in these patients is frequent and the eventual presence of calcific deposits in one of these structures could overlap with other anatomical structures making the exact localisation difficult. According to the results of the predictive values, the presence of typical deposition on CR allows a definite confirmation of the diagnosis, but a negative radiography does not exclude CPPD as testified by the low negative predictive value.

Table 1.

Sensitivity, specificity, PPV, NPV, accuracy and AUC of CR for identification of CPPD by using the new ACR/EULAR taskforce definitions.

Medial meniscusLateral meniscusHyaline cartilageOverallSensitivity22%33%31%42%Specificity100%100%85%90%Positive predictive value100%100%67%80%Negative predictive value56%60%55%61%Accuracy61%68%58%66%AUC0.60.70.60.7

Conclusion:

CR has been extensively used for the diagnosis of OA and CPPD and has been tested previously for diagnostic accuracy. The results of our study confirm that the presence of typical CPPD calcifications, as defined by the ACR/EULAR task force, are highly specific but have low sensitivity for disease identification when using CR. Absence of CPPD on CR does not exclude the diagnosis.

References:

[1]Filippou G, et al. Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study. Ann Rheum Dis 2020. doi:10.1136/annrheumdis-2020-217998

Disclosure of Interests:

None declared.

POS0476 CAN LOW-DOSE ASPIRIN DURING PREGNANCY PREVENT THE DEVELOPMENT OF ADVERSE PREGNANCY OUTCOMES IN WOMEN WITH ARTHRITIS? DATA FROM THE P-RHEUM.it STUDY

Background:

In rheumatic diseases, specifically in chronic inflammatory arthritis (IA), there are no data about the effectiveness of LDA in preventing pregnancy complications.

Objectives:

To assess the potential benefit of LDA administration during pregnancy to prevent adverse pregnancy outcomes (APO) in IA.

To compare pregnancy outcomes in IA pregnancies treated during pregnancy with LDA with those untreated.

Methods:

Italian P-RHEUM.it register is designed as a nationwide, web-based longitudinal observational cohort study collecting data on pregnancies in inflammatory rheumatic diseases. At baseline, socio-demographic parameters, obstetric history, comorbidities and clinical/laboratoristic characteristics are registered. During pregnancy, the course of maternal disease, medications, development of fetus and complications are collected for each trimester.

Results:

From May 2018 to May 2020, 349 patients were enrolled. Forty-five patients with IA had completed their pregnancy with known outcome (20 Rheumatoid Arthritis, 10 Psoriatic Arthritis, 6 Ankylosing spondylitis, 5 Juvenile Idiopathic Arthritis, 4 Undifferentiated Arthritis): 13 (28.89%) treated with LDA during pregnancy and 32 (71.11%) without LDA prophylaxis. LDA was used with a higher frequency in women with previous APO, anti-phospholipid positivity and on biological DMARDs even if it’s not statistically significant (Table 1). All the LDA-treated women had a live-birth rate of 100%, whereas among women not treated with LDA the live birth rate was of 84.4% with 27 live-birth pregnancies, 3 early miscarriages, 1 fetal loss and 1 stillbirth observed. There were no significant differences between the LDA and the not LDA groups regarding pregnancy/peripartum obstetric complications (p=0.14), although less adverse pregnancy/peripartum outcomes were registered in LDA patients’ group (Table 1).

Conclusion:

The preliminary data of this prospective cohort study show that LDA improve pregnancy outcome in IA even if women treated with LDA had more risk factors for APO. The extension of this cohort will allow us to further investigate these important results.

References:

[1]Roberge S, et al. AmJObstetGynecol.2017;216:110-120.e6.

[2]Andreoli L et al. Annals of the Rheumatic Diseases 2017;76: 476–85.

[3]Sammaritano L et al. Arthritis & Rheumatology 2020; 72: 529–56.

Table 1.

Comparison between inflammatory arthritis pregnancies treated with low-dose aspirin and those untreated.

LDA (n 19)Not LDA (n 39)pMaternal age at conception, median (IQR)33 (30.5 - 36.5)33 (28.2 - 35)BMI, median (IQR)25.4 (22.9 - 28.5)22.5 (20.4 - 24.5)Smoking, n (%)3 (15.8%)4/36 (11.1%)0.68Previous APO, n (%)7/11 (63.7%)7/13 (56.1%)0.34aPL+, n (%)3 (15.8%)1/36 (2.8%)0.1CRP+, n (%)5/15 (33.3%)11/27 (40.7%)0.75GC at baseline, n (%)9 (47.4%)15/34 (44.1%)0.82cDMARDs at baseline, n (%)1 (5.3%)3/34 (8.8%)1bDMARDs at baseline, n (%)6 (31.6%)11 (28.2%)0.79Live-birth pregnancy, n (%)18 (94.7%)32 (82.1%)0.25Pregnancy loss, n (%)1 (5.3%)7 (17,9%)0.25Hypertensive disorders, n (%)2/18 (11.1%)6/38 (15,8%)1HELLP syndrome, n (%)0 (0%)0 (0%)1PROM, n (%)0 (0%)3/38 (7.9%)0.54Preterm delivery, 34-37 GW, n (%)2 (10.5%)2 (5.2%)0.59Preterm delivery, <34 GW, n (%)1 (5.3%)1 (2.6%)1IUGR, n (%)0 (0%)3 (7.8%)0.54SGA, n (%)0 (0%)0 (0%)1Pregnancy/Peripartum complications, n (%)3 (15.8%)11 (28.9%)0.35

Legend: aPL, Antiphospholipid syndrome; bDMARDs, biological disease-modifying antirheumatic drugs; BMI, Body mass index; cDMARDs, Conventional disease-modifying antirheumatic drugs; CRP, C-reactive protein; GC, Glucocorticoids; GW, gestational week; HELLP, haemolysis, elevated liver enzymes, and low platelets; Hypertensive disorder defined as gestational hypertension, preeclampsia and eclampsia; IQR, Interquartile range; IUGR, intrauterine growth restriction; LDA, Low-dose Aspirin; Pregnancy loss defined as early fetal-loss, miscarriage and still-birth; PROM, Premature rupture of membranes; SGA, Small for gestational age.

Acknowledgements:

I would like to acknowledge the Epidemiology Unit of the Italian Society for Rheumatology and the Investigators of the Italian Registry.

Disclosure of Interests:

None declared

OP0223 DEVELOPMENT AND PRELIMINARY VALIDATION OF ULTRASONOGRAPHIC DISEASE ACTIVITY AND DAMAGE SCORES IN PSORIATIC ARTHRITIS PATIENTS: RESULTS FROM THE UPSTREAM (ULTRASOUND IN PSORIATIC ARTHRITIS TREATMENT) STUDY

Background:

The UPSTREAM (NCT03330769) is a 24-month multi-center prospective cohort study that primarily aims to evaluate the additional value of musculoskeletal ultrasound (msk-US) over clinical examination in predicting 6-month minimal disease activity in Psoriatic Arthritis (PsA). (1)

Objectives:

To develop and preliminarily validate an activity msk-US score and a damage msk-US score for PsA using the UPSTREAM database.

Methods:

Patients classified with PsA according to CASPAR criteria and starting a new course of therapy for clinically active peripheral joint disease were eligible. The information regarding objectives, study design, clinical and US assessment has already been published (1). The msk-US examination was performed in 42 joints, 36 tendons, 12 entheses and 2 bursae defined through a web-based exercise (2). The sonographic elementary lesions were allocated to disease activity [i.e. synovitis (sy), tenosynovitis (ts), peritendinitis (pt), bursitis (bs) all evaluated both in Grey Scale (GS) and Power Doppler (PD) and active enthesitis (en)] and to damage (i.e. joint erosion, bone proliferation, tendon tear, enthesophyte, calcification and irregular enthesis bone profile). Hands and feet X-ray were assessed using the modified Sharp-Van der Heijde (mSVH) score. A principal component (PC) analysis (PCA) was performed for each score and the number of PCs was defined by means of parallel analysis using baseline data. Each PC was normalized (n) taking into account the proportion between the observed value (e.g. sy-GS count) and the maximum expected value (e.g. 42 for sy-GS). Spearman’ correlation was used to investigate the construct and discrimination validity of the new scores.

Results:

Between February 2017 and May 2020, 312 PsA patients (155 men), with a mean (SD) age of 52.8 13.4, were enrolled from 19 centers; 22 expert sonographers were involved with substantial agreement for US lesions evaluated (k ≥0.7). The median [IQR] disease duration was 1.3 [0.1-6.1] years and the median [IQR] tender joint and swollen joint counts were 6 [3-13] and 2 [1-5], respectively. The weight derived from PCA for each sonographic lesions and the final equation for calculating the scores are reported in Figure 1 (1A activity and 1B damage). The final msk-US activity score [n(ts-GS + ts-PD)*2.87] + [n(bs-GS + bs-PD)*1.76] + [n(pt-GS + pt-PD)*1.43] + [n(active en)*1.00] + [n(sy-GS)*0.83] + [n(sy-PD)*0.45] has the best construct and discrimination validities according to a significant correlation with all clinical variables usually related to clinical activity (Table 1). The msk-US damage score correlated with mSVH score, HAQ and other clinical variables (Table 1).

Table 1.VariablesMsk-US activity scoreMsk-US damage scoreSpearman correlationP-valueSpearman correlationP-valueESR0.1960.0020.0750.235CRP0.209<0.0010.0680.254TJC0.338<0.0010.286<0.001SJC0.338<0.0010.0720.221Dactylitis count0.284<0.001-0.0610.306LEI0.1940.0010.214<0.001Physician GA0.150.0120.0160.793Patient GA activity0.1380.018-0.0730.221Patient GA pain0.1990.001-0.0270.648HAQ0.238<0.0010.1460.014BASDAI0.237<0.0010.1750.003PSAID-90.70.0040.1480.013DAPSA0.392<0.0010.228<0.001Sharp van Der Heijde score0.1150.20.2660.003Figure 1.

Conclusion:

These newly developed and preliminary validated msk-US activity and damage scores could be used in patients with PsA in the context of observational and controlled trials.

References:

[1]Canzoni M et al. BMJ Open. 2018;8:e021942.

[2]Zabotti A et al. Ann Rheum Dis 2018;77:1537–1538.

Acknowledgements:

Alberto Batticciotto; Oscar Massimiliano Epis; Luisa Arcarese; Luca Navarini; Marta Caprioli; Mirco Magnani; Roberta Ramonda; Marco Amedeo Cimmino

Disclosure of Interests:

Alen Zabotti: None declared, Matteo Piga: None declared, Anna Zanetti: None declared, Marco Canzoni: None declared, nicola boffini: None declared, valentina picerno: None declared, Giovanni Zanframundo: None declared, Ettore Silvagni: None declared, Ivan Giovannini: None declared, BERND RAFFEINER: None declared, Palma Scolieri: None declared, Paola Mancini: None declared, Simone Parisi: None declared, Alessandra Bortoluzzi Grant/research support from: GSK, Garifallia Sakellariou Consultant of: Consultant for Abbvie and Novartis, Orazio De Lucia: None declared, Ilaria Tinazzi: None declared, Fabiana Figus: None declared, Luca Idolazzi Speakers bureau: Received grants as speaker for Eli Lilly, UCB, Celgene, MSD, Abbvie, Novartis, Paid instructor for: Paid instructor for UCB during Product specialist Meeting, Mariagrazia Lorenzin: None declared, Sara Zandonella Callegher: None declared, Alberto Cauli: None declared, Greta Carrara: None declared, Carlo Alberto Scirè: None declared, Annamaria Iagnocco: None declared

POS1141 ASSESSING RELEVANT JOINTS FOR MONITORING CPPD DISEASE: A SYSTEMATIC LITERATURE REVIEW OF IMAGING TECHNIQUES BY THE OMERACT ULTRASOUND – CPPD SUBGROUP

Background:

Imaging has been extensively used for the Calcium Pyrophosphate Deposition Disease (CPPD) diagnosis but the prevalence of joint calcifications at imaging in CPPD patients has not been thoroughly assessed.

Objectives:

This systematic literature review (SLR) is aimed to estimate the prevalence of calcium crystal deposition in peripheral joints by imaging in suspected or definite CPPD patients to establish relevant joints for CPPD monitoring

Methods:

After defining PICOs, Pubmed and Embase were searched from inception to October 2020 for identifying studies that evaluated the use of Conventional Radiography (CR), Ultrasound (US), Computed Tomography (CT) and Dual Energy Computed Tomography (DECT) in detecting calcifications at peripheral joints in patients with defined or probable CPPD. Search strategies based on MeSH terms and free text were applied. Six reviewers independently screened titles and abstracts, eligible article full texts were evaluated for inclusion and data extraction.

Results:

The SLR identified 1149 manuscripts. 524 papers entered in the full text evaluation and 181 articles were finally included. Considering excluded abstracts and full texts, 23 and 17 were excluded as duplicate, 156 and 9 for language, 171 and 48 for population, 171 and 20 for intervention, 57 and 117 for outcome, 47 and 70 for study type and 76 for full text unavailability. Among included, 41 papers considered patients with definite CPPD with a total population of 1239 patients, 908 cases and 331 controls and 140 papers referred to patients with suspected CPPD with a total population of 26785 patients, 2896 affected by CPPD and 23889 controls. The results about all joints are summarized in the Table 1. In patients with definite diagnosis, knee and wrist are the joints with the highest prevalence of calcifications at all imaging types, followed by hip and acromion-clavicular joint while in patients with suspected CPPD, the knee is the most prevalent followed by the wrist, hip and ankle (only sites with more than 50 patients assessed considered). The hand joints are characterized by CPPD lowest prevalence at imaging. Bilateral imaging findings varies depending on the technique used, the site and the patient’s type.

Table 1.

Definite CPPD Diagnosis

KNEEWRISTHANDELBOWSHOULDERACHIPANKLEFOOTTMXRImaging positive cases/all cases330/584 57%214/409 52%43/158 27%54/212 25%65/249 26%37/84 44%140/293 48%30/255 12%15/59 25%0Cases positivebilaterally99/146 68%30/79 38%0/104/12 33%2/2 100%9/17 53%7/10 70%7/10 70%00USImaging positive cases/all cases155/252 62%86/118 75%4/42 9%2/2 100%0/304/30 13%47/80 59%30/255 12%15/59 25%0Cases positivebilaterally83/96 86%33/47 70%1/ 4 25%003/ 4 75%29/47 62%7/10 70%00CTImaging positive cases/all cases41/50 82%22/28 78%00000000Cases positivebilaterally27/30 90%000000000DECTImaging positive cases/all cases8/10 80%9/10 90%1/1 100%0000000Cases positivebilaterally001/1 100%0000000Suspected CPPD diagnosisKNEEWRISTHANDELBOWSHOULDERACHIPANKLEFOOTTMXRImaging positive cases/all cases1989/2442 81%549/1024 54%98/602 16%29/72 40%75/185 41%27/31 87%322/887 36%56/116 48%24/42 57%0Cases positive bilaterally611/1068 57%209/334 63%64/85 75%22/23 96%41/46 89%0/294/196 48%44/53 83%18/19 95%0USImaging positive cases/all cases241/261 93%125/185 68%2/39 5%1/1 100%4/12 33%02/2 100%27/78 35%8/37 22%0Cases positivebilaterally4/9 44%74/93 80%00000000CTImaging positive cases/all cases019/23 83%002/2 100%02/2 100%001/1 100%Cases positivebilaterally0000000001/1 100%DECTImaging positive cases/all cases1/1 100%2/2 100%00000000Cases positivebilaterally1/1 100%000000000

Table 1 For each joint, are summarized the ratio between positive joints and overall evaluated joints and the ratio between the joints positive bilaterally and overall joints evaluated bilaterally.

AC Acromion Clavicular, TM temporo mandibular

Conclusion:

According to the results of this SLR, knees and wrists could be the sentinel joints for CPPD detection by imaging.

Disclosure of Interests:

None declared.

AB0822 BREASTFEEDING AMONG WOMEN WITH RHEUMATIC DISEASES: ANALYSIS OF DATA FROM THE P-RHEUM.IT STUDY

Background:

The World Health Organization recommends that infants should be exclusively breastfed until the age of 6 months. The aim of this study was to assess the ratio of breastfeeding patients with Rheumatic Diseases (RD) and to identify possible causes of its discontinuation.

Objectives:

The aim of this study was to assess the ratio of breastfeeding patients with Rheumatic Diseases (RD) and to identify possible causes of its discontinuation.

Methods:

This study was embedded in the P-RHEUM.it register, as a nationwide prospective cohort study collecting data of pregnancies in inflammatory RD. Pregnancies, enrolled until the 20th week of pregnancy, are followed from pregnancy until 6 months postpartum. At baseline, sociodemographic parameters, obstetric history, comorbidities are reported. During pregnancy, the course of maternal disease, development of foetus and complications are reported. After delivery, the pregnancy outcome, data on lactation and child development are collected.

Results:

From May 2018 to May 2020 data of 349 patients were available. Data on lactation were available in 44 pregnancies. Two months after delivery 37 were continuing breastfeeding (n=26) or mixed feeding (n=11), while 7 were using formula feeding. Among patients using formula feeding 2 had a diagnosis of rheumatoid arthritis (RA), 1 of juvenile idiopathic arthritis, 1 of undifferentiated arthritis (UA), 1 of anti-phospholipid syndrome (APS), 1 of vasculitis and 1 of systemic lupus erythematosus. The reasons of formula feeding were the following: 2 for agalactia, 2 for personal preferences, 3 for drug-related concerns (1 for physician’s decision in a patient with APS; 2 for maternal concerns about drugs in patients with RA and UA treated respectively with Adalimumab and Tocilizumab). At 6 months 30 continued breastfeeding (n=23) or mixed feeding (n=7) and 14 formula feeding. The reasons of formula feeding were available in 9 patients: 3 for agalactia, 2 for personal preferences, 2 for physician’s decision in a patient with APS and in a patient positive for anti-phospholipid antibodies; 2 for maternal concerns about drugs.

Conclusion:

Preliminary data of this prospective study demonstrate a high percentage of breastfeeding/mixed feeding after delivery and after 6 months among women with RD. Drug related concerns are the main reason of discontinuation of breastfeeding, although medication results compatible with lactation. Using our results, strategies supporting patients with RD whishing to breastfeed may be developed.

References:

[1]Carina Gotestam Sporken et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis 2016.

[2]Sammaritano et al. 2020 American College of Rheumatology Guideline for the management of reproductive health in rheumatic and muscoloskeletal diseases, Arthritis Rheumatol. 2020.

Acknowledgements:

Authors would like to thank SIR study center and all patients who accepted to partecipate to our study

Disclosure of Interests:

None declared

POS0055 SARS-COV-2 OUTBREAK IN AUTOIMMUNE DISEASES: THE EURO-COVIMID STUDY

Background:

Coronavirus disease 2019 (COVID-19), has raised several questions in patients with immune-mediated inflammatory diseases (IMID). Whether the seroprevalence and factors associated with symptomatic COVID-19 are similar in IMID patients and in the general population is still unknown.

Objectives:

To assess the serological and clinical prevalence of COVID-19 in European IMID patients, along with the factors associated with its risk and the impacts the pandemic had on the IMID management.

Methods:

Prospective multicentre cross-sectional study among patients with five IMID (i.e. systemic lupus erythematous, Sjögren’s syndrome, rheumatoid arthritis, axial spondylarthritis or giant cell arteritis) from six tertiary-referral centers from France, Germany, Italy, Portugal, Spain and United Kingdom. Demographics, comorbidities, IMID, treatments, flares and COVID-19 details were collected. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serological tests were systematically performed.

Results:

Between June 7 and December 8, 2020, 3028 patients were included (median age 58 years, 73.9% females). SARS-CoV-2 antibodies were detected in 166 (5.5%) patients. Symptomatic COVID-19 was seen in 122 patients (prevalence: 4.0%, 95% CI 3.4-4.8%); 23 (24.2%) of them were hospitalized and four (3.2%) died. In multivariate logistic regression analysis, symptomatic COVID-19 was more likely to be observed in patients with higher levels of C-reactive protein (OR: 1.18; 95% CI 1.05-1.33; p = 0.006), and increased with the number of IMID flares (OR: 1.27; 95% CI 1.02-1.58; p = 0.03). Conversely, it was less likely to occur in patients treated with biological therapy (OR: 0.51; 95% CI 0.32-0.82; p = 0.006). During the pandemic, at least one self-reported disease flare was seen in 654 (21.6%) patients. Also, 519 (20.6%) patients experienced changes in their treatment, with 125 of these (24.1%) being due to COVID-19.

Conclusion:

The SARS-CoV-2 prevalence in IMID patients over the study period seems to be similar to that of the general population1. The IMID inflammatory status seems to be independently associated with the development of COVID-19.

References:

[1]Pollán M, Pérez-Gómez B, Pastor-Barriuso R, Oteo J, Hernán MA, Pérez-Olmeda M, et al. Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study. Lancet Lond Engl. 2020 Aug 22;396(10250):535–44.

Disclosure of Interests:

None declared.

POS1183 OUTCOMES OF COVID-19 INFECTION AMONG CHILDREN AND YOUNG PEOPLE WITH PRE-EXISTING RHEUMATIC AND MUSCULOSKELETAL DISEASES

Background:

It remains unknown whether children and young people with rheumatic and musculoskeletal diseases (RMD) who acquire COVID-19 infection have a more severe COVID-19 course, due to either underlying disease or immunosuppressive treatments.

Objectives:

To describe outcomes among children and young people with underlying RMD who acquire COVID-19 infection.

Methods:

All children and young people <18 years of age with COVID-19 (presumptive or confirmed) reported to the EULAR COVID-19 Database, which collects details regarding RMD diagnosis and treatment, COVID infection and outcomes, between 27 March 2020 and 29 January 2021 (cutoff date for this analysis) were included. Patient characteristics and COVID-19 outcomes are presented.

Results:

A total of 151 children and young people (age range 2-17 years; Table 1) have been reported to the database from 12 countries; mostly Spain (N=30), France (N=29), Israel (N=29), and Czechia (N=25). Most patients had a diagnosis of juvenile idiopathic arthritis (JIA; N=92; 61%). Other diagnoses were autoinflammatory syndrome (including TRAPS, CAPS, FMF; 12%), and systemic lupus erythematosus (4%). There were 14 (9%) hospitalisations and 1 (0.7%) death reported due to COVID-19. The most commonly reported symptoms were fever (46%), cough (34%), anosmia (19%), and headache (19%). Only 19 (13%) patients reported glucocorticoid use. DMARD therapy was used by 104 (69%) patients; 67 (44%) were on csDMARDs (methotrexate [N=54], antimalarials [N=7]), 45 (30%) on anti-TNF, 9 (6%) on IL-6 inhibitors, and 7 (5%) on IL-1 inhibitors. Among the 145 patients with hospitalisation data, patients on any DMARD therapy (cs/b/tsDMARDs) had similar odds for hospitalisation compared with those not on therapy, adjusted for age (odds ratio 0.7; 95% CI 0.2, 2.4).

All PatientsN151GenderFemale94 (62%)Male56 (37%)Unknown1 (<1%)Age, yearsMedian (IQR)12 (8, 15)Range2 to 17Top Rheumatology DiagnosesJuvenile Idiopathic Arthritis (JIA)92 (61%)Polyarthritis50 (33%)Oligoarthritis31 (21%)Systemic11 (7%)Autoinflammatory syndrome (e.g.18 (12%)TRAPS, CAPS, FMF)6 (4%)Systemic Lupus ErythematosusComorbiditiesNone stated112 (74%)Obesity9 (6%)Ocular inflammationAsthma9 (6%)3 (2%)Required HospitalisationYes14 (9%)No131 (87%)Missing6 (4%)Top 5 Symptoms ReportedFever69 (46%)Cough51 (34%)Anosmia28 (19%)Headache28 (19%)Fatigue23 (15%)Deaths due to COVID-19Yes1 (<1%)Treatment at onset of COVID-19 infectionGlucocorticoids19 (13%)csDMARDs67 (44%)Methotrexate54 (36%)Antimalarials7 (5%)Mycophenolate5 (3%)bDMARDs64 (42%)Anti-TNF45 (30%)IL-69 (6%)IL-18 (5%)Any DMARD104 (69%)

Conclusion:

These initial data on outcomes of COVID-19 in paediatric RMDs are very reassuring, with less than 1 in 10 patients reporting hospitalisation. Due to the database design and inherent reporting bias, this is likely an overestimate, suggesting that overall outcomes among this population appear to be generally good, with mild infection. Increasing case reports to the database will allow further exploration of drug- and disease-specific outcomes.

Disclosure of Interests:

None declared.

OP0309 THE ROLE OF IMAGING TO GUIDE INTERVENTIONAL PROCEDURES IN RHEUMATIC AND MUSCULOSKELETAL DISEASES: A SYSTEMATIC LITERATURE REVIEW TO INFORM EULAR RECOMMENDATIONS

Background:

Imaging guidance gives the opportunity to visualize a needle or other instrument when performing interventions on musculoskeletal sites in patients with rheumatic and musculoskeletal diseases (RMDs). Studies assessing the role of imaging guided procedures have been performed, however, no consensus has been made yet about when and which imaging techniques to use for these interventions.

Objectives:

To inform a EULAR taskforce on the current literature on different imaging techniques, procedures and materials to guide interventions on musculoskeletal sites in RMD patients.

Methods:

Prospective and retrospective studies published in English and comparing either palpation or imaging guided interventions in patients with RMDs were included. MEDLINE, EMBASE, the Cochrane Library and Epistemonikos were searched through October 2021. Risk of bias (RoB) was assessed using the Cochrane RoB tool for randomized trials version 2 (ROB2), the RoB tool for Non-Randomized Studies of Interventions (ROBINS-I) and the appraisal tool for cross-sectional studies (AXIS).

Results:

Sixty-six studies, with moderate to high RoB, consisting of 49 randomized controlled trials, three prospective cohort studies and 14 retrospective studies were included.

Fifty-one studies compared one imaging technique against either another imaging technique, or palpation-guided interventions. Most of the studies were on peripheral joints (47/51), while data on joints of the axial skeleton were scare and heterogeneous (4/51). For peripheral joints, ultrasound (US) was the most studied imaging technique (49/51), followed by fluoroscopy (10/51). Results revealed a higher accuracy and safety (including procedural pain) of US or fluoroscopy compared to palpation- guided interventions. Data on other imaging techniques was scarce (computed tomography: n=3, arthroscopy: n=1) and the results heterogeneous. Results of studies comparing different imaging techniques (12/51) did not favor one imaging method over another.

Three studies comparing different materials used for imaging guided interventions were found (e.g. automatic vs manual syringes), showing little evidence for one material being superior to another one.

Fifteen studies were found comparing different imaging guided procedures (e.g. intraarticular vs periarticular injections). Overall, studies indicated an advantage of targeted vs. not targeted interventions (intraarticular vs periarticular or intraepineurial vs extraepineurial injections) concerning pain levels, while the comparison of different puncture sites to inject (e.g. ulnar vs midline carpal tunnel injection) was inconclusive.

Conclusion:

Imaging guidance, especially US, performs favorably for interventions at the peripheral joints compared to palpation-guided interventions, concerning accuracy and safety. Data for the axial skeleton are scarce. Imaging guided targeted interventions may lead to better outcomes than non-targeted interventions.

Disclosure of Interests:

None declared.

POS1406 DEVELOPMENT OF A DIAGNOSTIC ALGORITHM FOR THE DIFFERENTIAL DIAGNOSIS OF INTERSTITIAL LUNG DISEASE: PRELIMINARY DATA FROM A MULTICENTER RETROSPECTIVE CASE-CONTROL STUDY

Background:

Interstitial lung diseases (ILDs) represent a heterogeneous group of disorders with different treatment and prognosis. ILD may be the presenting or the dominant manifestation of a connective tissue disease (CTD). Multidisciplinary team (MDT) discussion is currently the diagnostic standard. However, there is no consensus on how MDT diagnosis is validated and on the core elements of discussion.

Objectives:

To explore the performance of a diagnostic algorithm for the differential diagnosis of ILD based on clinical, serological and radiological data, supporting clinician decision-making.

Methods:

In this retrospective study, analysis was performed on clinical, serological and radiological features at diagnosis and 1-year follow-up in 71 patients, including 41 with CTD-ILD and 30 with idiopathic interstitial pneumonias (IIPs). In order to identify robust hallmarks, we conducted the Receiver Operating Characteristic (ROC) curve analyses in logistic regression, to discriminate significantly different features between CTD-ILD and non-CTD-ILD groups.

Results:

Out of 71 patients 46% were women, with a mean age of 66±11 years. History of smoking (8.8% current and 39.8% former smokers), was more associated with IIPs. 54% of patients had dyspnea on exertion and 39% dry cough, both more frequently associated with IIPs (p = 0.016). Among radiological features, NSIP pattern was more frequent in CTD-ILD, while UIP was associated with IIP. Lung fibrosis extent was greater in IIP (p = 0.063), in which CT is generally performed in symptomatic patients at diagnosis and rarely for screening purpose. Baseline features with good performance (OR p-value ≤ 0.05) were eligible as potential candidate discriminators: age, sex, smoking habit, rheumatological signs and symptoms, autoantibodies, ILD patterns were selected, to build a multivariate model with high discrimination accuracy (AUC 0.971). The model has a sensitivity of 100% and specificity of 89.7%. The most relevant correlations between population features and CTD-ILD are presented in Table 1.

Table 1.

Correlation analysis of the most significant discriminative features.

FeaturesOdds ratioP valueArea under ROC curveSex (female)3.290.019*0.643Age0.910.001*0.736Smoke0.12<0.001*0.738Respiratory symptoms (dyspnea and/or dry cough)0.260.016*0.644Rheumatological symptoms (any)28.8<0.001*0.839 • Raynaud’s phenomenon15.040.0110.654 • Cutaneous manifestations8.160.0530.593Autoantibodies (ANA, ENA, RF, ACPA, myositis-specific antibodies or aPL) positivity33.68<0.001*0.792Lung function test • Forced vital capacity (%FVC)0.970.1750.638 • Diffusing capacity of carbon monoxide (%DLCO)0.960.0720.665High-resolution computed tomography (HRCT) imaging • Honeycombing0.340.0680.593 • Emphysema0.140.005*0.647 • Extent of lung involvement (%)0.970.0630.668HRCT pattern • NSIP vs UIP30.033*0.625

Abbreviations: ANA, antinuclear antibody; ENA, extractable nuclear antigen; RF, rheumatoid factor; ACPA, anti-citrullinated peptide antibody; aPL, antiphospholipid antibody; NSIP, nonspecific interstitial pneumonia; UIP, usual interstitial pneumonia.

Conclusion:

Our study shows that the most important variables in the differential diagnosis between CTD-ILD versus IIPs include, as expected, autoimmune features (rheumatological symptoms and serological data). Questionnaire tool containing these specific hallmarks may be relevant during MDT discussion, limiting the number of misdiagnosed CTD-ILDs and potentially avoiding further unnecessary investigations. However, only prospective cohort studies of early onset ILD are needed to fully validate the relative importance of clinical, serological, functional and radiological data.

References:

[1]Furini F. et al, The Role of the Multidisciplinary Evaluation of Interstitial Lung Diseases: Systematic Literature Review of the Current Evidence and Future Perspectives. Front Med (Lausanne). 2019; 6: 246.

Disclosure of Interests:

None declared

Role of comorbidities on therapeutic persistence of biological agents in rheumatoid arthritis: results from the RECord-linkage On Rheumatic Disease study on administrative healthcare databases

Objectives: This study aimed to evaluate the impact of different comorbidities on thereflecting its safety profile persistence of biological disease-modifying anti-rheumatic drugs (bDMARDs) in rheumatoid arthritis (RA), taking advantage of a retrospective analysis of administrative healthcare databases (AHDs).Method: A retrospective observational study was conducted on AHDs of the Lombardy region, Italy (2004-2013). Among RA patients treated with bDMARDs, drug survival was estimated using Cox proportional hazard models [hazard ratio (HR), 95% confidence interval (CI)], crude and adjusted for prespecified confounders (gender, age, disease duration, concomitant use of non-steroidal anti-inflammatory drugs, glucocorticoids, conventional DMARDs, specific bDMARDs), in first-line and subsequent lines of treatment. The role of comorbidities in administration of specific bDMARDs was analysed through multinomial logistic models.Results: The study included 4657 RA patients. In the first-line treatment strategy, the Charlson Comorbidity Index (CCI) (RA excluded) was significantly associated with an increased rate of bDMARD failure (CCI = 1: HR 1.28, 95% CI 1.13-1.46; CCI ≥ 2: HR 1.26, 95% CI 1.03-1.53). Among selected comorbidities, chronic obstructive pulmonary disease (HR 1.38, 95% CI 1.01-1.91), diabetes (HR 1.18, 95% CI 1.01-1.37), and previous-year bacterial infections (HR 1.18, 95% CI 1.07-1.30) were slightly associated with risk of bDMARD failure, while acute myocardial infarction (HR 1.30, 95% CI 0.97-1.75), mild liver disease (HR 1.21, 95% CI 0.91-1.60), and solid tumours (HR 1.19, 95% CI 0.93-1.53) were not. In the following treatment lines, neoplasms were associated with reduced risk of failure (HR 0.64, 95% CI 0.41-0.99). Multiple comorbidities were associated with first-line abatacept and rituximab administration.Conclusions: Comorbidities affect treatment decisions in RA and influence bDMARD failure, and should be considered when analysing the persistence of biological therapy.

Reply to the Letter to the Editor: The Italian Society of Rheumatology clinical practice guidelines for the management of polymyalgia rheumatica

Not available.

A seasonal pattern in the onset of polymyalgia rheumatica and giant cell arteritis? A systematic review and meta-analysis

OBJECTIVES

Studies on the seasonality of onset of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) have shown conflicting results. The aim of this systematic literature review and meta-analysis is to determine from aggregated data whether there is a seasonal distribution for these diseases.

METHODS

A literature search was performed using Pubmed Central and Embase scientific databases. The incidences per 6-month periods, season or month of onset, that were reported in the studies were summarised in tables considering the two diseases as separate conditions or together. The Incidence Rate Ratio (IRR) for the cold period versus the warm period was pooled across studies by random effects meta-analysis weighed by inverse variance. Funnel plots and Egger test were used to explore possible publication biases. A sensitivity analysis was performed to weigh articles with a disproportionate number of patients compared to the rest.

RESULTS

In the scientific literature 22 suitable papers were found: 6 on PMR with 803 patients, 11 on GCA with 2,807 patients, and 5 studies considering both diseases with 19,613 patients. There was considerable heterogeneity amongst studies regarding their quality, the classification criteria used, and the definition of onset of symptoms. No seasonal aggregation was found for GCA and PMR. The pooled IRR estimate of the meta-analysis (1.13[0.89,1.36]) showed a non-significant, higher frequency of diseases onset in the warm season.

CONCLUSIONS

Our meta-analysis did not confirm a seasonal onset for PMR and GCA.

OP0317 ACCURACY OF THE OMERACT DEFINITIONS FOR IDENTIFICATION OF CALCIUM PYROPHOSPHATE CRYSTALS WITH ULTRASOUND: FINAL RESULTS OF THE OMERACT US IN CPPD SUB-TASK FORCE STUDY

Background:

The OMERACT Ultrasound (US) in calcium pyrophosphate deposition disease (CPPD) sub-task force has been working on the use of US in CPPD since 2014 first creating definitions for CPPD identification and then assessing the reliability[1].

Objectives:

Objective of this study is to assess the diagnostic accuracy (truth) of US in CPPD.

Methods:

Consecutive patients waiting to undergo knee replacement surgery due to osteoarthritis were enrolled in 12 centres from 6 countries. Each patient underwent US examination of the knee, focusing on the menisci and the hyaline cartilage, the day prior to surgery, scoring each site for presence/absence of CPP as defined previously[1]. After surgery, the menisci and the condyles were retrieved and examined microscopically. Six samples were collected, both from the surface and from the internal part of menisci and cartilage trying to cover a large part of it. All slides were observed under transmitted light microscopy and by compensated polarised microscopy. A dichotomous score was given for the presence/absence of CPP. US and microscopic analysis were performed by different operators, blind to each other’s findings. Sensitivity and specificity of US were calculated using microscopic findings as the gold standard.

Results:

101 patients have been enrolled in the study. 33 patients have been excluded due to loss of anatomical pieces at surgery. The mean age of the remaining 68 pts was 71yo (±8), 44 women, 34 were affected by CPPD according to microscopy. Overall and per site diagnostic US accuracy results are presented in table 1

Diagnostic accuracySensitivitySpecificityPositive Predictive valueNegative Predictive valueGlobal0.750.910.590.690.87Medial meniscus0.820.870.770.770.87Lateral meniscus0.750.830.680.680.83Medial cartilage0.860.790.920.880.85Lateral cartilage0.820.710.880.770.84Medial side (combined cartilage and meniscus)0.820.880.760.790.87Lateral side (combined cartilage and meniscus)0.780.880.690.730.86

Conclusion:

Our results demonstrate that US is an accurate exam for identification of CPPD. The best combination of sensitivity and specificity is achieved by examining the medial aspect of the knee.

References:

[1]Filippou G, Scirè CA, Adinolfi A,et al.Identification of calcium pyrophosphate deposition disease (CPPD) by ultrasound: reliability of the OMERACT definitions in an extended set of joints—an international multiobserver study by the OMERACT Calcium Pyrophosphate Deposition Disease Ultrasound Subtask Force.Ann Rheum Dis2018;:annrheumdis-2017-212542. doi:10.1136/annrheumdis-2017-212542

Disclosure of Interests:

Georgios Filippou: None declared, Anna Scanu: None declared, Antonella Adinolfi: None declared, Carmela Toscano: None declared, Dario Gambera: None declared, Raquel Largo: None declared, Esperanza Naredo: None declared, Emilio Calvo: None declared, Gabriel Herrero-Beaumont: None declared, Pascal Zufferey: None declared, Christel Madelaine-Bonjour: None declared, Daryl MacCarter: None declared, Stanley Makman: None declared, Zachary Weber: None declared, Fabiana Figus: None declared, Ingrid Möller: None declared, Marwin Gutierrez: None declared, Carlos Pineda: None declared, Denise Clavijo Cornejo: None declared, Héctor García: None declared, Victor Ilizaliturri: None declared, Jaime Mendoza Torres: None declared, Raul Pichardo: None declared, Luis Carlos Rodriguez Delgado: None declared, Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work., Edoardo Cipolletta: None declared, Teodora Serban: None declared, Catalin Cirstoiu: None declared, Florentin Ananu Vreju: None declared, Dun Grecu: None declared, Gael Mouterde: None declared, Marcello Govoni: None declared, Leonardo Punzi: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen., Carlo Alberto Scirè: None declared, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi

OP0063 QUANTITATIVE COMPUTED TOMOGRAPHY PREDICTS 10-YEAR MORTALITY IN INTERSTITIAL LUNG DISEASE RELATED TO SYSTEMIC SCLEROSIS

Background:

Interstitial lung disease (ILD) is the main cause of death in Systemic Sclerosis (SSc). Chest CT is the gold standard in detecting ILD although it is not easy to understand its prognostic value. ILD qualitative assessment is almost worthless. Goh et al. semi quantitative score of ILD extent is related to mortality risk but it is burdened by relevant inter/intra-readers variability. An operator independent algorithm based on voxel-wise analysis proved to identify SSc patients with an increased risk of mortality according to prediction models.

Objectives:

To verify if quantitative analysis of chest CT (QCT) predict 10 years-mortality in SSc patients.

Methods:

SSc patients with availability of a chest CT were enrolled in 13 different centers. The CT voxel-wise analysis with a free software (www.horosproject.com) provided QCT indexes: kurtosis, skewness, mean lung attenuation and standard deviation. Patients characteristics, autoimmune profile and pulmonary function test were collected. The follow-up interval lasted from the date of chest CT to the one of the last visit or death. Each QCT index cutoff, established in a previous study (1), clustered patients in two groups. Kaplan-Meier analysis estimated and compared survival in the above mentioned groups. p < 0.05 was considered statistically significant.

Results:

Five hundred sixty three SSc patients were enrolled (35938 patient-months); 52.4% had ILD detectable at CT scan. For each QCT index cutoff the cohort was split in two subgroups without differences in terms of sex, age, disease duration, autoimmune profile. All QCT indexes’ cutoff selected subgroups with statistically different survival rate (e.g in Figure 1).

Figure 1

Conclusion:

QCT can arise as the new gold standard in identifying SSc patients with poor prognosis. The real possibility to stratify SSc subjects according mortality risk will have a pivotal role in ILD treatment decisional process with the incoming anti-fibrotic drugs.

References:

[1]Ariani A et al. Rheumatology 2017

Disclosure of Interests:

Alarico Ariani: None declared, Elena Bravi: None declared, Maria De Santis: None declared, Vanessa Hax: None declared, Simone Parisi: None declared, Federica Lumetti: None declared, Francesco Girelli: None declared, Marta Saracco: None declared, Fabio De Gennaro: None declared, Alessandro Giollo: None declared, Masen Abdel Jaber: None declared, Francesco Bozzao: None declared, Mario Silva: None declared, Maria Chiara Ditto: None declared, Claudia Lomater: None declared, Flavio Mozzani: None declared, Daniele Santilli: None declared, eleonora Di Donato: None declared, Andrea Becciolini Speakers bureau: Sanofi-Genzyme, UCB and AbbVie, Francesco Pucciarini: None declared, Lorenzo Canziani: None declared, Flavio Cesare Bodini: None declared, eugenio arrigoni: None declared, M Bredemeier: None declared, Rafael Mendonça da Silva Chakr: None declared, Amelia Spinella: None declared, Luca Idolazzi: None declared, Roberto Bortolotti: None declared, Paola Tomietto: None declared, Elisa Baratella: None declared, Saverio Tollot: None declared, Dilia Giuggioli: None declared, Fabio Fischetti: None declared, Enrico Fusaro: None declared, Nicola Sverzellati: None declared, Carlo Alberto Scirè: None declared

AB1083 CURRENT PRACTICE AND OPINIONS ON IMAGING-GUIDED INTERVENTIONAL PROCEDURES IN RHEUMATIC AND MUSCULOSKELETAL DISEASES: INTERIM RESULTS OF A MULTINATIONAL MULTIDISCIPLINARY SURVEY TO INFORM EULAR POINTS TO CONSIDER

Background:

maging is widely used for diagnostic purposes in patients with rheumatic and musculoskeletal diseases (RMDs). In recent years, it is increasingly used also to guide interventional procedures. However, the extent of imaging application for this purpose as well as the different technical standards employed across Europe are not known.

Objectives:

To learn how much imaging is used for interventional procedures in RMDs. To explore the technical standards employed in different settings and how important they are rated by users.

Methods:

As part of the work of a multidisciplinary EULAR Task Force to develop recommendations for the use of imaging to guide interventional procedures in patients with RMDs, a survey was developed. The survey explored aspects of different interventional procedures (e.g. joint aspiration/injection) such as the use of imaging guide and the technical standards. Respondents provided also a 0-10 rating of how important they considered the same conditions/items with regard to each procedure. The survey was distributed to: rheumatologists across Europe, USA, Central America, South America, Asia and Pacific Area, HPs across Europe, European and American associations of other specialities (e.g. radiology, anaesthesiology). The survey was launched in December 2019. Interim results after 4 weeks are presented.

Results:

200 responses from 36 countries were collected. The respondents were mainly rheumatologists (90%) (Figure 1). 90% of respondents performed interventional procedures related to RMDs and of these, 76% use imaging guide. Ultrasonography (US) is the most commonly used technique (96%) followed by X-ray/fluoroscopy (13%). Among respondents using imaging guide, 60% received training on both imaging and imaging-guided procedures, 20% only on imaging and 16% no training. 49% of respondents perform the whole procedure using direct image guidance, 21% use imaging to find the appropriate anatomical landmark and then perform the procedure blindly. Air and contrast agent to control needle placement are rarely used (≤20%). Respondents provided also a rating (0-10) of how important they considered different technical conditions/items for each procedure and an estimate on a Likert scale of how often they used them for each of the procedures (Figure 1 shows an example). In most cases respondents use always/most of the times the conditions/items that they considered important. Discrepancies were mainly due to barriers at their own center.

Conclusion:

Imaging, mainly US, is widely used to guide interventional procedures. However, training is not homogeneous and the use of imaging guide as well as technical conditions are based on the operator’s opinion/experience. This survey will inform the EULAR points to consider for the use of imaging to guide interventional procedures in patients with RMDs.

Table 1.

Characteristics of respondents (n=200) N

N%Age≤ 30381931 –35562836 – 39502540 - 493316.5≥ 502311.5GenderFemale8944.5Male11155.5Specialty/PositionRheumatology18090Radiology115Physical medicine and rehabilitation31.5Pediatrics42Non-clinical researcher31.5Health professionals31.5Other31.5

Disclosure of Interests:

Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Philipp Bosch: None declared, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Carlo Alberto Scirè: None declared, Alessia Alunno: None declared, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Christian Dejaco: None declared

SAT0412 ACCURACY OF AN INSTRUMENT FOR SCREENING PSORIATIC ARTHRITIS AMONG PSORIATIC PATIENTS: RESULTS FROM THE MULTICENTRE ITALIAN STUDY HERACLES (SCREENING STRATEGIES FOR RHEUMATOLOGICAL REFERRAL OF PSORIATIC SUBJECTS AIMED TO DISCLOSE PSORIATIC ARTHRITIS)

Background:

Identifying psoriatic arthritis (PsA) among people with psoriasis is often challenging due to low specificity of symptoms at early PsA stage and/or delayed referral to the rheumatologist. Screening instruments -assisting the dermatologist to decide when rheumatological assessment is beneficial- have potential to reduce the diagnostic delay.

Objectives:

To evaluate the accuracy of a dermatologist-filled-out questionnaire designed for screening PsA among psoriatic patients under dermatology care.

Methods:

HERACLES is a multicentre, cross-sectional study running at 9 Italian dermatology and rheumatology tertiary centres. All participants were under dermatology care for skin psoriasis. Previous diagnosis of PsA precluded eligibility. Dermatologists at each site assessed consecutive psoriatic subjects, filled in the specifically-designed HERACLES questionnaire (HQ, Figure 1) and finally referred the participants to rheumatologists for clinical evaluation. All participants filled in the ToPAS, PASE, PEST and EARP questionnaires. Rheumatologists assessed the participants regardless of the questionnaires’ scores. The gold standard applied to assess the instruments’ accuracy was the diagnosis of PsA as established by the rheumatologists. ROC curve analysis evaluated the performance of the scores associated with the clinical criteria listed in the HQ, estimating the sensitivity and specificity of different cut-off levels. Further exploratory ROC curve analysis compared HQ performance to that of the other four questionnaires tested.

Figure 1.

Results:

Out of 759 subjects enrolled, 524 (69%) attended rheumatology assessment. Rheumatologists diagnosed PsA in 73/524 patients (13.9%, Figure 2). Mean age was 53 (SD 16) years and 46% were female. Mean psoriasis duration was 20 (SD 19) years. The area under the ROC curve of HQ was 0.775. The HQ score cut-off value of 2 yielded a sensitivity of 92% and a specificity of 47%; a cut-off value of 3 yielded a sensitivity of 66% and a specificity of 75%. The comparison between the ROC curve of the HQ and those of the other four questionnaires evaluated did not show any significant difference (p=0.523 versus TOPAS; p=0.201 versus PASE; p=0.345 versus PEST and p=0.240 versus EARP).

Figure 2.

Conclusion:

The HERACLES questionnaire, a tool designed for dermatologists, showed good sensitivity and specificity in identifying PsA cases among subjects with cutaneous psoriasis.

Acknowledgments:

The HERACLES project was supported by a research grant from FIRA and Pfizer Italia SRL

Disclosure of Interests:

Gabriele De Marco: None declared, Maria Manara Consultant of: Consultant and/or speaker for Eli-Lilly, MSD, Sanofi-Genzyme, Novartis, Alfa Wasserman and Cellgene, Speakers bureau: Consultant and/or speaker for Eli-Lilly, MSD, Sanofi-Genzyme, Novartis, Alfa Wasserman and Cellgene, Paolo Gisondi: None declared, Luca Idolazzi: None declared, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly, Stefano Piaserico: None declared, Alberto Cauli: None declared, Marco Amedeo Cimmino: None declared, Veronica Tomatis: None declared, Carlo Salvarani: None declared, Rosanna Scrivo: None declared, Anna Zanetti: None declared, Greta Carrara: None declared, Carlo Alberto Scirè: None declared, Angelo Cattaneo: None declared, Antonio Marchesoni Speakers bureau: Abbvie, Pfizer, UCB, Novartis, Celgene, Eli Lilly

The Italian Society for Rheumatology clinical practice guidelines for the diagnosis and management of knee, hip and hand osteoarthritis

Osteoarthritis (OA) is the most common musculoskeletal disease leading to functional decline and loss in quality of life. Knees, hands and hips are frequently affected joints with a relevant clinical and socio-economic burden. An evidence-based approach to OA management is essential in order to improve patients' health and to decrease social burdens. Since new international clinical practice guidelines (CPGs) focused on diagnosis or pharmacological/non-pharmacological treatment have become available in the last ten years, the Italian Society for Rheumatology (SIR) was prompted to revise and customize them for a multidisciplinary audience of specialists involved in the management of OA. The framework of the Guidelines International Network Adaptation Working Group was adopted to identify, appraise (AGREE II), synthesize, and customize the existing CPGs on OA to the needs of the Italian healthcare context. The task force, consisting of rheumatologists from the SIR epidemiology research unit and a committee with experience of OA, identified key health questions to guide a systematic review of published guidelines. The target audience included physicians and health professionals who manage OA. An external panel of stakeholders rated the guidelines. From a systematic search in databases (Pubmed/Medline, Embase) and grey literature, 11 CPGs were selected and appraised by two independent raters. Combining evidence and statements from these CPGs and clinical expertise, 16 guidelines were developed and graded according to the level of evidence. Agreement and potential impact on clinical practice were assessed. These revised guidelines are intended to provide guidance for diagnosis and treatment of OA and to disseminate best evidence-based strategies management of the disease.

The Italian Society of Rheumatology clinical practice guidelines for the diagnosis and management of gout

Gout is a chronic disease with an increased risk of premature death related to comorbidities. Treatment of gout has proved suboptimal and clinical practice guidelines (CPGs) are expected to have a key role in achieving improvement. Since new evidence has become available, the Italian Society for Rheumatology (SIR) has been prompted to update the 2013 recommendations on the diagnosis and management of gout. The framework of the Guidelines International Network Adaptation Working Group was adopted to identify, appraise (AGREE II), synthesize, and customize the existing gout CPGs to the needs of the Italian healthcare context. The task force consisting of rheumatologists from the SIR Epidemiology Unit and a committee with experience on gout identified key health questions to guide a systematic literature review. The target audience includes physicians and health professionals who manage gout in practice, and the target population includes adult patients suspected or diagnosed as having gout. These recommendations were finally rated by an external multi-disciplinary commission. From a systematic search in databases (Medline, Embase) and grey literature, 8 CPGs were selected and appraised by two independent raters. Combining evidence and statements from these CPGs and clinical expertise, 14 recommendations were developed and graded according to the level of evidence. The statements and potential impact on clinical practice were discussed and assessed. These revised recommendations are intended to provide guidance for the diagnosis and the treatment of gout and to disseminate the best evidence-based healthcare for this disease.

Providing updated guidelines for the management of rheumatic diseases in Italy with the ADAPTE methodology: a project by the Italian Society for Rheumatology

Not available.

Early Lupus Project: one-year follow-up of an Italian cohort of patients with systemic lupus erythematosus of recent onset

Objective

To describe the clinical and serological features of a prospectively followed cohort of early diagnosed systemic lupus erythematosus (SLE) patients during a one-year follow-up period.

Methods

SLE patients with disease duration less than 12 months were consecutively enrolled in a multicentre, prospective study. At study entry and then every 6 months, a large panel of data was recorded.

Results

Of 260 patients enrolled, 185 had at least 12 months of follow-up; of these, 84.3% were female, 92.4% were Caucasians. Mean diagnostic delay was about 20 months; higher values of European Consensus Lupus Activity Measurement (ECLAM) and of organs/systems involved were both associated with shorter diagnostic delay. Clinical and serological parameters improved after study entry. However, patients' quality of life deteriorated and cardiovascular risk factors significantly increased. About one-third of patients with active disease at study entry went into remission (ECLAM = 0). Negative predictors for remission were: oral ulcers, arthritis, low C4, anti-SSB (Ro) antibodies and therapy with mycophenolate. There was a widespread use of glucocorticoids both at baseline and during follow-up.

Conclusion

Clinical symptoms and serological parameters improve during the first period after diagnosis. However, patients’ quality of life deteriorates. The widespread use of glucocorticoids is probably the reason for the early significant increase of some cardiovascular risk factors.

Ultrasound in the diagnosis of calcium pyrophosphate dihydrate deposition disease. A systematic literature review and a meta-analysis

OBJECTIVE

Ultrasonography (US) demonstrated to be a promising tool for the diagnosis of calcium pyrophosphate dihydrate deposition disease (CPPD). The aim of this systematic literature review (SLR) was to collect the definitions for the US elementary lesions and to summarize the available data about US diagnostic accuracy in CPPD.

METHODS

We systematically reviewed all the studies that considered US as the index test for CPPD diagnosis without restrictions about the reference test or that provided definitions about US identification of CPPD. Sensitivity and specificity were calculated for each study and definitions were extrapolated. Subgroup analyses were planned by anatomical site included in the index text and different reference standards.

RESULTS

Thirty-seven studies were included in this review. All the studies were eligible for the collection of US findings and all definitions were summarized. US description of elementary lesions appeared heterogeneous among the studies. Regarding US accuracy, 13 articles entered in the meta-analysis. Considering each joint structure, the sensitivity ranged between 0.77 (0.63-0.87) and 0.34 (0.16-0.58) while the specificity varies between 1.00 (0.89-1.00) and 0.92 (0.16-1.00). Considering the reference standards used, the sensibility ranged between 0.34 (0.02-0.65) and 0.87 (0.76-0.99) while specificity ranged between 0.84 (0.52-1.00) and 1.00 (0.99-1.00).

CONCLUSION

US is potentially a useful tool for the diagnosis of CPPD but universally accepted definitions and further testing are necessary in order to assess the role of the technique in the diagnostic process.

Lifestyle and dietary habits of patients with gout followed in rheumatology settings

Diet and lifestyles modification are core aspects of the non-pharmacological management of gout, but a poor consistency with suggested guidelines is reported. This study aimed to investigate dietary and lifestyle habits of patients with gout followed in rheumatology settings. Data were retrieved from the baseline dataset of the KING study, a multicentre cohort study of patients with gout followed in rheumatology settings. Dietary habits were assessed with the Italian National Institute of Statistics (ISTAT) food-frequency questionnaire and compared with reported data about general population. The relative increase of exposure was estimated by standardized prevalence ratios adjusted for gender, age and geographical distribution. The study population included 446 patients, with a mean age of 63.9 years and a M/F ratio of 9:1. Compared to the Italian population, gouty patients showed a higher prevalence of obesity [1.82 (1.52-2.18)] and a higher consumption of wine [1.85 (1.48-2.32)] and beer [2.21 (1.68-2.90)], but a lower prevalence of smoking and a lower intake of liquor. They showed a lower intake of red meat [0.80 (0.71-0.91)], but a similar intake of other tested dietary factors. Gouty patients’ lifestyle is still partially different from the recommended.

Economic considerations and patients' preferences affect treatment selection for patients with rheumatoid arthritis: a discrete choice experiment among European rheumatologists

OBJECTIVE

To compare the value that rheumatologists across Europe attach to patients' preferences and economic aspects when choosing treatments for patients with rheumatoid arthritis.

METHODS

In a discrete choice experiment, European rheumatologists chose between two hypothetical drug treatments for a patient with moderate disease activity. Treatments differed in five attributes: efficacy (improvement and achieved state on disease activity), safety (probability of serious adverse events), patient's preference (level of agreement), medication costs and cost-effectiveness (incremental cost-effectiveness ratio (ICER)). A Bayesian efficient design defined 14 choice sets, and a random parameter logit model was used to estimate relative preferences for rheumatologists across countries. Cluster analyses and latent class models were applied to understand preference patterns across countries and among individual rheumatologists.

RESULTS

Responses of 559 rheumatologists from 12 European countries were included in the analysis (49% females, mean age 48 years). In all countries, efficacy dominated treatment decisions followed by economic considerations and patients' preferences. Across countries, rheumatologists avoided selecting a treatment that patients disliked. Latent class models revealed four respondent profiles: one traded off all attributes except safety, and the remaining three classes disregarded ICER. Among individual rheumatologists, 57% disregarded ICER and these were more likely from Italy, Romania, Portugal or France, whereas 43% disregarded uncommon/rare side effects and were more likely from Belgium, Germany, Hungary, the Netherlands, Norway, Spain, Sweden or UK.

CONCLUSIONS

Overall, European rheumatologists are willing to trade between treatment efficacy, patients' treatment preferences and economic considerations. However, the degree of trade-off differs between countries and among individuals.

Italian Society of Rheumatology recommendations for the management of gout

OBJECTIVE

Gout is the most common arthritis in adults. Despite the availability of valid therapeutic options, the management of patients with gout is still suboptimal. The Italian Society of Rheumatology (SIR) aimed to update, adapt to national contest and disseminate the 2006 EULAR recommendations for the management of gout.

METHODS

The multidisciplinary group of experts included rheumatologists, general practitioners, internists, geriatricians, nephrologists, cardiologists and evidence-based medicine experts. To maintain consistency with EULAR recommendations, a similar methodology was utilized by the Italian group. The original propositions were translated in Italian and priority research queries were identified through a Delphi consensus approach. A systematic search was conducted for selected queries. Efficacy and safety data on drugs reported in RCTs were combined in a meta-analysis where feasible. The strength of recommendation was measured by utilising the EULAR ordinal and visual analogue scales.

RESULTS

The original 12 propositions were translated and adapted to Italian context. Further evidences were collected about the role of diet in the non-pharmacological treatment of gout and the efficacy of oral corticosteroids and low-dose colchicine in the management of acute attacks. Statements concerning uricosuric treatments were withdrawn and replaced with a proposition focused on a new urate lowering agent, febuxostat. A research agenda was developed to identify topics still not adequately investigated concerning the management of gout.

CONCLUSIONS

The SIR has developed updated recommendations for the management of gout adapted to the Italian healthcare system. Their implementation in clinical practice is expected to improve the management of patients with gout.

Ultrasound imaging for the rheumatologist XXXVII. Sonographic assessment of the hip in ankylosing spondylitis patients

OBJECTIVES

To investigate the prevalence of ultrasound (US) detectable inflammation in hips of patients with ankylosing spondylitis (AS) and the relationship between US and measures of disease activity and severity.

METHODS

Consecutive patients with AS attending the rheumatology units involved in this study were enrolled. Clinical and demographical data were recorded. US examination of bilateral hips was performed at the same time, evaluating anterior longitudinal scan to search for synovial hypertrophy (SH), joint effusion (JE) or power Doppler (PD) positive synovitis.

RESULTS

A total of 56 patients were included, median age (interquartile range, IQR) 49 (39, 59.5), median disease duration 98 (72, 204) months, 80.3% were treated with TNF-α inhibitors, median BASDAI 2.65 (1.96, 3.95), 30.3% had hip tenderness. US JE was found in 26.7% of patients, US SH in 16%, no patient had detectable PD. The concordance between clinical findings and US abnormalities was moderate, with a kappa of 0.44. Patients with detectable US abnormalities had higher median visual analogue scale (VAS) pain and C-reactive protein (CRP), while there was no significant association with other measures of disease activity and disability. In the subgroup of patients with no hip tenderness, US alterations were still significantly related to higher CRP levels, while in patients with hip tenderness and no US abnormalities CRP was not higher than in the asymptomatic patients.

CONCLUSIONS

US assessment of hip joint in AS patients can be considered of value, as suggested by the correlation with relevant clinical and laboratory measures. In asymptomatic patients, US examination might provide further information on subclinical involvement.

Ultrasound imaging for the rheumatologist XXXIII. Sonographic assessment of the foot in early arthritis patients

OBJECTIVES

To investigate the ability of ultrasonography (US) to detect synovitis in metatarsophalangeal joints (MTP) in patients with suspicion of early arthritis, and to discriminate between diagnoses.

METHODS

Patients referred to early arthritis clinics for differential diagnosis were enrolled, and clinical and laboratory measures were recorded. Ultrasonography of MTPs was performed searching for synovial hypertrophy (SH), joint effusion (JE) and power Doppler (PD), graded from 0 to 3 on a semi-quantitative scale. Patients were classified according to definite classification criteria, or as undifferentiated arthritis or non-inflammatory pathology. US findings were compared across different diagnoses and diagnostic accuracy was calculated taking clinical diagnosis as reference.

RESULTS

Out of 427 patients (71% rheumatoid arthritis (RA), 20% undifferentiated arthritis (UA), 15% spondyloarthritides (SpA), 13% non-inflammatory), 307 (71.9%) showed SH, 120 (25.5%) JE, 77 (18.0%) PD. RA patients had median JE, SH and PD scores significantly higher than non-inflammatory and other diseases. Patient with UA and SpA had higher scores of SH and JE compared to non-inflammatory, no significant differences were present among different diagnosis. In RA, SH and JE were more frequently detected in the second MTP, and PD in the fifth. Crystal-related arthritis showed a tendency towards a more frequent involvement of the first MTP. The diagnostic accuracy of single US measures was moderate, but the detection of a PD of 2 or more provided a high specificity for the diagnosis of RA.

CONCLUSIONS

US can be used as additional information in patients evaluated in an early arthritis setting. High scores of JE, SH and PD, together with the pattern of involvement are suggestive of RA.

Ultrasound imaging for the rheumatologist. XXXII. Sonographic assessment of the foot in patients with psoriatic arthritis

Psoriatic arthritis (PsA) is an arthropathy associated with psoriasis, which is part of the spondyloarthropathy family, and which may present with various forms, from mono-oligoarthritis to symmetric polyarthritis mimicking rheumatoid arthritis. In longstanding disease, the symmetric polyarthritis is the most common pattern of PsA, involving the small joints of hands, feet (the involvement of which seems to be very common, ranging from 50 to 100% of patients), wrists, ankles and knees. Other common features are represented by the inflammation of enthesis and tendons. Its exact prevalence, in Italy, should be about 30% in psoriatic subjects or 0.42% when considering the general population. The aims of our study were to investigate, by US examination, the prevalence and the features of foot involvement in PsA and to describe their correlations with clinical findings. Ultrasound (US) examinations were performed using a Logiq 9 (General Electric Medical Systems, Milwaukee, WI) equipped with a multifrequency linear probe, working at 14 MHz. One hundred and eighty feet were investigated in a total of 101 patients. Prior to US assessment, all patients underwent a clinical examination by an expert rheumatologist who recorded the presence/absence of pain, tenderness (detected by palpation and/or active or passive mobilisation of the feet) and swelling. US finding indicative of metatarsophalangeal joint inflammation were obtained in 77 (76.2%) patients, while only 34 (33.7%) patients were positive to the clinical examination. This study demonstrates that US detected a higher number of inflamed joints with respect to clinical assessment in PsA patients.

Ultrasound imaging for the rheumatologist XXX. Sonographic assessment of the painful knee

The knee joint is a frequent focus of attention for rheumatologists when assessing patients presenting to a clinic and may represent underlying intra-articular inflammatory pathology or involvement of the surrounding soft tissues. This study describes the correlation between clinical and ultrasound findings in patients presenting with a variety of rheumatic disorders and knee pain. US imaging provides for a sensitive and detailed identification of different intra- and peri-articular pathology responsible for knee pain.

Ultrasound imaging for the rheumatologist XXIX. Sonographic assessment of the knee in patients with osteoarthritis

OBJECTIVES

To investigate the prevalence and severity of sonographic-detected abnormalities in knee osteoarthritis (OA) and to correlate ultrasound (US) findings with clinical data.

METHODS

Outpatients with chronic, painful knee OA according to the ACR criteria were consecutively recruited and underwent clinical and US examinations. An expert rheumatologist recorded the presence of knee joint pain, swelling and tenderness, patient's global assessment of knee pain using visual analogue scale (VAS), and Lequesne Index of severity for knee OA. A second rheumatologist, blinded to the clinical data, performed the knee US examination using a Logiq9 machine equipped with a 12MHz linear probe and registering the presence of joint effusion, synovial proliferation, power Doppler (PD) signal, Baker's cyst, osteophytes and femoral cartilage abnormalities.

RESULTS

One hundred and sixty-four knees of 82 patients (53 women, 29 men) were studied; mean age was 63.2±8.1 SD years, mean disease duration was 4.3±5.6 SD years. All patients complained of at least one knee joint pain during physical activity. Mean patient's VAS for knee pain was 48.4±19.9 SD mm, mean Lequesne Index was 8.2±4.4 SD. Knee swelling was present in 39% of the patients and tenderness was found in 65.8%. US showed: joint effusion in 43.3% of the patients, synovial proliferation in 22.1%, PD signal in 2.9%, Baker's cysts in 6.6%, cartilage abnormalities in 79%, osteophytes in 100%. In all patients US findings were present at least at the level of one knee. Statistically significant correlations were demonstrated between a composite inflammatory score and both VAS (p=0.004) and Lequesne Index (p<0.0001).

CONCLUSIONS

This US study showed both inflammatory abnormalities and structural damage lesions in knee OA. Interestingly, statistically significant correlations were demonstrated between US inflammatory findings and the main clinical tests for OA, confirming that sonography has a relevant role in the global evaluation of patients with knee OA.

Ultrasound imaging for the rheumatologist. XXVIII. Impact of sonographic knee joint involvement in recent-onset inflammatory polyarthritis

OBJECTIVES

To assess the impact of the knee joint inflammation, detected by ultrasonography (US), on functional disability in patients with recent-onset inflammatory polyarthritis (IP).

METHODS

We included patients who had IP for less than 12 months and who had more than 5 swollen joints. All patients were assessed clinically at baseline. US was used to identify joint inflammation at multiple joint sites including: hands, wrists, elbows, shoulders, knees, ankles and feet. Joint group involvement was defined when at least one joint showed intra-articular signs of inflammation (synovial fluid abnormalities and/or synovial hypertrophy), according to the OMERACT definitions. Functional disability was measured using the health assessment questionnaire (HAQ) score. All patients with complete clinical and US data were included in the analysis.

RESULTS

Patients with US knee involvement showed more active and severe disease at baseline. The mean difference of HAQ between patients with and without US knee inflammation was 0.42 (95%CI 0.22, 0.62; p<0.001). This difference was still clinically and statistically significant even after controllino for disease extension and pattern of joint involvement. US shoulder involvement was also significantly and independently associated with higher mean HAQ scores.

CONCLUSIONS

US knee involvement is associated with higher disability in IP at first presentation. US is a good tool to help in the differentiation of patients with recent-onset IP with different disease severity.

Ultrasound imaging for the rheumatologist XXVI. Sonographic assessment of the knee in patients with psoriatic arthritis

Psoriatic arthritis (PsA) is an arthropathy associated to psoriasis, which is part of the spondyloarthropathy family, and which may present with various forms, from mono-oligoarthritis to symmetric polyarthritis mimicking rheumatoid arthritis. In longstanding disease, the symmetric polyarthritis is the most common pattern of PsA, involving small joint of hands, feet, wrists, ankles and, very frequently, knees. Other common features are represented by the inflammation of enthesis and tendons. Ultrasound (US) examinations were performed using a Logiq 9 (General Electric Medical Systems, Milwaukee, WI) equipped with a multifrequency linear probe, working at 10-14 MHz. One-hundred and sixty-six knee joints were investigated in a total of 83 patients. Prior to US assessment, all patients underwent a clinical examination by an expert rheumatologist who recorded the presence/absence of pain, tenderness (detected by palpation and/or active or passive mobilisation of the knee), and knee swelling. Sixty-two (74.7%) knee joints were found clinically involved, while at least one US finding indicative of joint inflammation was obtained in 70 (84.3%) knee joints. In the 59% of the patients we noticed synovial hypertrophy. Enthesitis was present in 39.7% of the subjects studied. This study demonstrated that US detected a higher number of inflamed knee joints and enthesis with respect to clinical assessment in PsA patients.

Ultrasound imaging for the rheumatologist. XXV. Sonographic assessment of the knee in patients with gout and calcium pyrophosphate deposition disease

The knee is a frequent target for gout and calcium pyrophosphate dihydrate (CPPD) disease with involvement of both articular and peri-articular structures. The aims of the present study were to investigate the relationship between clinical and ultrasound (US) findings and to describe the prevalence and distribution of crystal deposits in the knee in patients with gout and CPPD disease. Thirty patients with gout and 70 patients with CPPD disease were enrolled in the study. Prior to US assessment all patients underwent a clinical examination by an expert rheumatologist who recorded the presence/absence of pain, tenderness (evocated by palpation and/or active or passive mobilisation of the knee), and knee swelling. US examinations were performed using a Logiq 9 (General Electric Medical Systems, Milwaukee, WI) equipped with a multifrequency linear probe, working at 9 MHz. Two hundred knee joints were investigated in a total of 100 patients. Fifty-one (25.5%) knee joints were found clinically involved, while at least one US finding indicative of joint inflammation was obtained in 73 (36.5%) knee joints.The most frequent US finding indicative of knee joint inflammation was joint effusion, detected in 21 (35%) out of 60 knees and in 52 (37%) out of 140 knees, in gout and CPPD disease, respectively. Ten (17%) out of 60 knees and 21 (15%) out of 140 knees were found positive for synovial hypertrophy with or without intra-articular power Doppler, in gout and CPPD disease respectively. Sonographic evidence of crystal deposition within joint cartilage (hyaline and fibrocartilage) was more frequently seen than in the soft tissue in the knee.This study demonstrated that US detected a higher number of inflamed knee joints than clinical assessment in patients with crystal related arthropathies and that the distribution of crystal deposits at joint cartilage level permitted distinction between gout and CPPD disease. Further studies are required to investigate both sensitivity and specificity of US features indicative of crystal aggregates at both tendon and entheseal level.