What to Expect When Systemic Treatment in Juvenile Idiopathic Arthritis Is Withdrawn?

OBJECTIVE

The goal of juvenile idiopathic arthritis (JIA) treatment is to maintain clinical remission. It is also important to reduce drug exposure, whenever possible, in order to avoid or decrease potential side effects. We aimed to analyze remission survival after systemic treatment withdrawal and to determine which factors can influence it.

METHODS

We conducted a multicenter, observational, longitudinal study. All patients included had a diagnosis of JIA. We analyzed remission survival using Kaplan-Meier curves according to the systemic treatment received (methotrexate [MTX] alone or in combination with biologic disease-modifying antirheumatic drugs [bDMARDs]) and JIA subgroups (oligoarticular and polyarticular course, juvenile spondyloarthritis, and systemic JIA). In addition, risk factors were examined using multivariate analysis.

RESULTS

We included 404 patients with JIA; 370 of them (92%) had received systemic treatment at some point and half of them (185 patients) had withdrawn on at least 1 occasion. There were 110 patients who flared (59%) with a median time of 2.3 years. There were no differences in remission survival between JIA subcategories. Twenty-nine percent of patients with JIA who received MTX and bDMARDs, in which MTX alone was withdrawn, flared; median time to flare of 6.3 years. However, if only the bDMARD was withdrawn, flares occurred 57% of the time; median time to flare of 1.1 years.

CONCLUSION

Flares are frequent when systemic treatment is withdrawn, and uveitis or joint injections could be related risk factors. In MTX and biologic-naïve patients, the frequency of flares occurred in more than half of patients, although they were less frequent when clinical remission lasted for > 1 year.

Salivary gland ultrasound in clinical practice: What is its real usefulness?

BACKGROUND

Salivary gland ultrasound (SGU) provides information about structural gland abnormalities that can be graded and used for primary Sjögren's syndrome (pSS) diagnosis. Its potential role as a prognostic marker for detecting patients at high risk of lymphoma and extra-glandular manifestations is still under evaluation. We aim to assess the usefulness of SGU for SS diagnosis in routine clinical practice and its relationship with extra-glandular involvement and lymphoma risk in pSS patients.

METHODS

We designed a retrospective observational single-center study. Data was collected using the electronic health records of patients referred to an ultrasound outpatient clinic for evaluation over a 4-year period. Data extraction included demographics, comorbidities, clinical data, laboratory tests, SGU results, salivary gland (SG) biopsy, and scintigraphy results. Comparisons were made between patients with and without pathological SGU. The external criterion for comparison was the fulfillment of the 2016 ACR/EULAR pSS criteria.

RESULTS

A total of 179 SGU assessments were included from this 4-year period. Twenty-four cases (13.4%) were pathological. The most frequently diagnosed conditions prior to SGU-detected pathologies were pSS (9.7%), rheumatoid arthritis (RA) (13.1%), and systemic lupus (4.6%). One hundred and two patients (57%) had no previous diagnosis (sicca syndrome work-up); of these, 47 patients (46.1%) were ANA positive and 25 (24.5%) anti-SSA positive. In this study, the sensitivity and specificity of SGU for SS diagnosis were 48% and 98% respectively, with a positive predictive value of 95%. There were statistically significant relationships between a pathological SGU and the presence of recurrent parotitis (p=.0083), positive anti-SSB antibodies (p=.0083), and a positive sialography (p=.0351).

CONCLUSIONS

SGU shows high global specificity but low sensitivity for pSS diagnosis in routine care. Pathological SGU findings are associated with positive autoantibodies (ANA and anti-SSB) and recurrent parotitis.

What drives the decision to optimise biological treatment in children and youngsters with juvenile idiopathic arthritis? A discrete-choice experiment

OBJECTIVE

To analyse factors involved in the decision to optimise biologics in juvenile idiopathic arthritis.

METHODS

A "discrete-choice" methodology was used. In a nominal group meeting, factors which may influence physicians' decisions to optimise biological dose were identified, together with decision nodes. 1000Minds® was used to create multiple fictitious clinical scenarios based on the factors identified, and to deploy surveys that were sent to a panel of experts. These experts decided for each item which of two clinical scenarios prompted them to optimise the dose of biologic. A conjoint analysis was carried out, and the partial-value functions and the weights of relative importance calculated.

RESULTS

In the nominal group, three decision nodes were identified: (1) time to decide; (2) to maintain/reduce or prolong interval; (3) what drug to reduce. The factors elicited were different for each node and included patient and drug attributes. The presence of macrophage activation syndrome (MAS), systemic involvement, or subclinical inflammation made the decision easier (highest weights). The presence of joints of difficult control and year of debut influenced the decision in some but not all, and in different directions. Immunogenicity, adherence, and concomitant treatments were also aspects taken into account.

CONCLUSIONS

The decision to optimise the dose of biological therapy in children and youngster can be divided into several nodes, and the factors, both patient and therapy-related, leading to the decision can be detailed. These decisions taken by experts may be transported to practice, study designs, and guidelines.

Impact of cardiovascular risk on the diagnostic accuracy of the ultrasound Halo Score for giant cell arteritis

OBJECTIVE

To evaluate the impact of cardiovascular risk (CVR) on the diagnostic accuracy of the ultrasonographic (US) Halo Score in patients with suspected giant cell arteritis (GCA).

METHODS

Retrospective observational study of patients referred to our US fast track clinic with suspected GCA for a 2-year period. The intima-media thickness (IMT) of cranial and extra-cranial arteries and the Halo Score was determined to assess the extent of vascular inflammation. The European Society of Cardiology Guidelines on CV Disease Prevention were used to define different categories of CVR and patients were classified according to the Systemic Coronary Risk Evaluation (SCORE). The gold standard for GCA diagnosis was clinical confirmation after a 6-month follow-up.

RESULTS

Of the 157 patients included, 47 (29.9%) had GCA after a 6-month follow-up. Extra-cranial artery IMT was significantly higher in patients with high/very high CVR than in those with low/moderate CVR, but only among patients without GCA. Non-GCA patients with high/very high CVR had also a significantly higher Halo Score in contrast with low/moderate CVR [9.38 (5.93) vs 6.16 (5.22); p = 0.007]. The area under the ROC curve of the Halo Score to identify GCA was 0.835 (95% CI 0.756-0.914), slightly greater in patients with low/moderate CVR (0.965 [95% CI 0.911-1]) versus patients with high/very high CVR (0.798 [95% CI 0.702-0.895]). A statistically weak positive correlation was found between the Halo Score and the SCORE (r 0.245; c = 0.002).

CONCLUSIONS

Elevated CVR may influence the diagnostic accuracy of the US Halo Score for GCA. Thus, CVR should be taken into consideration in the US screening for GCA.

Ultrasound intima media thickness cut-off values for cranial and extracranial arteries in patients with suspected giant cell arteritis

Objective

To determine the optimal ultrasound (US) cut-off values for cranial and extracranial arteries intima media thickness (IMT) to discriminate between patients with and without giant cell arteritis (GCA).

Methods

Retrospective observational study including patients referred to an US fast-track clinic. All patients underwent bilateral US examination of the cranial and extracranial arteries including the IMT measurement. Clinical confirmation of GCA after 6 months was considered the gold standard for diagnosis. A receiver operating characteristic (ROC) analysis was performed to select the cut-off values on the basis of the best tradeoff values between sensitivity and specificity.

Results

A total of 157 patients were included, 47 (29.9%) with clinical confirmation of GCA after 6 months. 41 (87.2%) of patients with GCA had positive US findings (61.7% had cranial and 44.7% extracranial involvement). The best threshold IMT values were 0.44 mm for the common temporal artery; 0.34 mm for the frontal branch; 0.36 mm for the parietal branch; 1.1 mm for the carotid artery and 1 mm for the subclavian and axillary arteries. The areas under the ROC curves were greater for axillary arteries 0.996 (95% CI 0.991–1), for parietal branch 0.991 (95% CI 0.980–1), for subclavian 0.990 (95% CI 0.979–1), for frontal branch 0.989 (95% CI 0.976–1), for common temporal artery 0.984 (95% CI 0.959–1) and for common carotid arteries 0.977 (95% CI 0.961–0.993).

Conclusion

IMT cut-off values have been identified for each artery. These proposed IMT cut-off values may help to improve the diagnostic accuracy of US in clinical practice.

The Role of Ultrasound and FDG-PET/CT to Detect Extracranial Artery Involvement in Patients with Suspected Large Vessel Vasculitis

OBJECTIVE

To assess the accuracy of ultrasound (US) versus FDG-PET/CT to identify extracranial involvement in suspected large vessel vasculitis (LVV) patients.

METHODS

Retrospective observational study of patients referred to our US fast track clinic with suspected LVV. All patients underwent US exam within 24 hours per protocol. FDG-PET/CT was performed according to clinician criteria. The gold standard for LVV diagnosis was clinical confirmation after 6 months.

RESULTS

Of the 113 patients included (74.3% female, mean age 74 years), 37(32.7%) were diagnosed of LVV after 6 months. Sensitivity and specificity of US was 86.5% and 96.1%, respectively (85.7% and 87.1% for intracranial and 94.1% and 80.2% for extracanial arteries, respectively). Only 12(42.9%) of 28 patients undergoing a FDG-PET/CT per clinician criteria, showed positive findings. Sensitivity and specificity of FDG-PET/CT for LVV was 61.1% and 90%, respectively (55.6% and 63.2% for intracranial and 84.6% and 93.3% for extacranial arteries). Taking FDG-PET/CT as the reference, US showed extracranial inflammation in 10/12(83.3%) and detected 2(12.5%) additional cases of extracranial involvement with negative FDG-PET/CT. Conversely, FDG-PET/CT showed extracranial inflammation in 2 patients with negative US (1 isolated aortitis and 1 aortoiliac involvement). FDG-PET/CT showed cranial artery uptake in none of patients.

CONCLUSIONS

US and FDG-PET/CT are both valid tools to detect extracranial involvement. Presence of US extracranial artery inflammation is consistent with FDG-PET/CT examination, although a negative US scan does not rule out extracranial involvement. Our data support the use of US as first-line investigation in patients suspected of cranial, but also extracranial LVV.

Long-Term Retention Rate of Golimumab in Patients With Rheumatoid Arthritis, Psoriatic Arthritis, and Spondyloarthritis in a Real-Life Setting

METHODS

We conducted a single-center, medical records review study of all patients with RA, PsA, and SpA on GLM treatment attending a large rheumatology department from 2010 to 2017. Times from start to end of GLM treatment were collected, as well as sociodemographic, clinical, and safety variables. Golimumab retention rate was estimated by the Kaplan-Meier method, and comparison across diseases was analyzed with the Mantel-Haenszel statistic (log-rank test). Cox proportional hazards regression models were used to identify factors associated with GLM discontinuation.

RESULTS

In the study period, a total of 212 patients (61 RA, 48 PsA, 103 SpA) were prescribed GLM. Retention rates were 72% in the first year, 61% in the second, 56% in the third, and 38% at 5 years. Differences were statistically significant across diseases (median times to GLM discontinuation were 50.2, 46.0, and 38.7 months for RA, SpA, and PsA, respectively) and according to the number of previous biologic therapies (55.2 months in biologic-naive patients vs 14.0 months in patients with ≥2 previous biologics; p < 0.001). The use of concomitant conventional synthetic disease-modifying antirheumatic drugs was associated with a lower probability of discontinuation (hazards ratio [HR], 0.57; 95% confidence interval [CI], 0.33-0.97). Female sex (HR, 1.84; 95% CI, 1.07-3.17) and having used 2 biologics before GLM (HR, 2.99; 95% CI, 1.76-5.06) were associated with increased discontinuation rates. Twenty-three patients (10.9%) had at least 1 serious adverse event.

CONCLUSIONS

In a real-life setting, GLM shows appropriate long-term safety-effectiveness ratio.

Ultrasound in clinically suspect arthralgia: the role of power Doppler to predict rheumatoid arthritis development

Objective

To determine the usefulness of power Doppler (PD) ultrasound (US) to predict rheumatoid arthritis (RA) development in patients with clinically suspect arthralgia (CSA).

Methods

Retrospective analysis of a US unit cohort over a 1-year period. Patients with CSA and no previous diagnosis of inflammatory arthritis (IA) were included for analysis. All underwent bilateral US examination of the hands and/or feet according to the EULAR guidelines. Active US inflammation was defined as PD synovitis and/or tenosynovitis ≥1 at any location. RA diagnosis according to clinician criteria 6 months after the US examination was checked. Univariate and multivariate logistic regression models were employed to investigate possible predictive factors of RA development.

Results

A total of 110 CSA patients (80 females, mean age 53.6 years) were included for analysis. After 6 months of follow-up, 14 (12.7%) developed RA and 34 (30.9%) IA. US active inflammation was present in 38 (34.5%) patients (28.2% showed PD synovitis and 18.2% PD tenosynovitis). Multivariate analysis showed that ACPA (OR 1.0003; 95% CI 1.002–1.006) and ESR (OR 1.054; 95% CI 1.016–1.094) were significantly associated with the detection of US active inflammation at baseline. Only PD tenosynovitis was found to be an independent predictive factor of an evolution towards RA (OR 6.982; 95% CI 1.106–44.057) and IA (OR 5.360; 95% CI 1.012–28.390).

Conclusion

US is able to detect features of subclinical inflammation in CSA patients, especially in those with higher ESR and ACPA values. Only PD tenosynovitis at baseline US assessment was found to be an independent predictor of RA and IA development in CSA patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02685-7.

Radiosynovectomy in routine care: an old tool with modern applications

Objectives:

Radiosynovectomy can be an effective treatment for difficult-to-treat monoarthritis resistant to systemic and local standard therapy. The objective of our study was to determine predictors of good response to radiosynovectomy in routine care and give an overview of this underused technique.

Methods:

Retrospective observational study of all the patients who underwent radiosynovectomy during a 6-year inclusion period. All the procedures were ultrasound guided and the radiopharmaceutical used was chosen according to joint size. The patient was considered to have an effective response to radiosynovectomy if the attending physician reported a positive outcome and there was no need to increase local and or systemic treatment due to arthritis in the affected joint during the next 12 months following the procedure.

Results:

We included 67 patients who underwent radiosynovectomy in the knee (73.1%), wrist (16.4%), and elbow (10.5%). Overall, 44 (65.7%) procedures were considered effective. In the multivariate analysis, infiltration of wrists (odds ratio = 0.192; confidence interval = 0.046–0.79) and pigmented villonodular synovitis (odds ratio = 0.13; confidence interval = 0.021–0.82) were independently associated with a noneffective response. No patients experienced complications associated with radiosynovectomy during follow-up.

Conclusion:

Infiltrations of wrists with joint damage seem less likely to have a response to radiosynovectomy. In pigmented villonodular synovitis, radiosynovectomy as an adjuvant therapy for relapse might not be effective when performed more than 6 months after surgery. Overall, radiosynovectomy is an effective and safe treatment for persistent monoarthritis.

Childhood Sjögren syndrome: features of an international cohort and application of the 2016 ACR/EULAR classification criteria

OBJECTIVE

Sjögren syndrome in children is a poorly understood autoimmune disease. We aimed to describe the clinical and diagnostic features of children diagnosed with Sjögren syndrome and explore how the 2016 ACR/EULAR classification criteria apply to this population.

METHODS

An international workgroup retrospectively collected cases of Sjögren syndrome diagnosed under 18 years of age from 23 centres across eight nations. We analysed patterns of symptoms, diagnostic workup, and applied the 2016 ACR/EULAR classification criteria.

RESULTS

We identified 300 children with Sjögren syndrome. The majority of patients n = 232 (77%) did not meet 2016 ACR/EULAR classification criteria, but n = 110 (37%) did not have sufficient testing done to even possibly achieve the score necessary to meet criteria. Even among those children with all criteria items tested, only 36% met criteria. The most common non-sicca symptoms were arthralgia [n = 161 (54%)] and parotitis [n = 140 (47%)] with parotitis inversely correlating with age.

CONCLUSION

Sjögren syndrome in children can present at any age. Recurrent or persistent parotitis and arthralgias are common symptoms that should prompt clinicians to consider the possibility of Sjögren syndrome. The majority of children diagnosed with Sjögren syndromes did not meet 2016 ACR/EULAR classification criteria. Comprehensive diagnostic testing from the 2016 ACR/EULAR criteria are not universally performed. This may lead to under-recognition and emphasizes a need for further research including creation of paediatric-specific classification criteria.

Persistence and adherence to biologic therapies in juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease that often requires biological therapy to control its activity. Medication persistence and adherence are important aspects on which we have scarce information. We performed a longitudinal, retrospective, and observational study based on data from the daily clinical management of JIA patients. We recorded clinical remission at 6 and 12 months. Persistence of biological therapy was evaluated using Kaplan-Meier curves, and adherence was assessed using the medication possession ratio (MPR). We included 68 patients who received biological therapy. Of these, 11 (16.2%) and 5 (7.4%) required a second and third drug, respectively. The persistence rate for biological therapy at 5 years was 64%, with no differences between the first and second lines. Adherence was high during the first year of treatment (MPR80: 96.3%) and also in the second and third years (MPR80: 85.2% and 91.8%, respectively). Persistence and adherence to biological therapy were remarkably high in our JIA cohort. Adherence to biological treatments could be related to a higher probability of fulfilling the Wallace remission criteria at 6 months, although this was not confirmed at 12 months.

Clinical impact of musculoskeletal ultrasound on rheumatoid arthritis in routine care

OBJECTIVE

To evaluate the impact of musculoskeletal ultrasound (MSUS) in the management of rheumatoid arthritis (RA) patients and to investigate factors affecting treatment strategy by the referring rheumatologist.

METHODS

Prospective study of RA patients evaluated at a MSUS clinic over a 6-month period. Data extraction included demographics, current treatment and MSUS findings. Pre- and post-MSUS follow-up of 3 months data were analyzed. Patients were classified into 2 groups based on the decision of the referring rheumatologist to change the treatment after the MSUS examination. Comparisons between groups were performed in a univariate analysis. We used logistic regression models to investigate factors associated with changes in clinical management.

RESULTS

A total of 64 RA patients were included. Mean age was 61.9 years and 83.6% were female. Main referral indication was assessment of disease activity (89%). Overall, MSUS led to subsequent therapeutic actions by the referring rheumatologist in 41 (64.1%) patients, and to a change in the clinical impression of the complaint that generated the referral in 7 (11.5%) patients. The detection of power Doppler (PD), the 28 swollen joint count and the presence of radiographic erosions were significantly associated with a subsequent clinical action. In the multivariate analysis only PD remained significant (odds ratio = 3.29; 95% CI: 1.05-10.26).

CONCLUSION

Disease activity evaluation is the most common indication for MSUS examination, with the presence of PD the factor most frequently associated with changes in therapeutic management. This study highlights the impact of MSUS, especially the use of PD, to support treatment decisions in RA routine care.

Juvenile Sjögren's Syndrome: Clinical Characteristics With Focus on Salivary Gland Ultrasonography

OBJECTIVE

Juvenile Sjögren's syndrome (SS) is a rare, poorly defined, and possibly underdiagnosed condition affecting children and adolescents. The aim of this study was to characterize symptoms and clinical findings of juvenile SS and to explore the clinical application of major salivary gland ultrasonography (SGUS) in patients with juvenile SS.

METHODS

A cross-sectional multicenter study recruited patients with disease onset until age 18 years (n = 67). Disease characteristics were recorded, and unstimulated whole sialometry and SGUS examination of the parotid and submandibular salivary glands were performed.

RESULTS

The female:male ratio was 58:9. The mean age at first symptom was 10.2 years and 12.1 years at diagnosis. Ocular and oral symptoms were noted in 42 of 67 patients (63%) and 53 of 66 patients (80%), respectively. The American-European Consensus Group or American College of Rheumatology/European League Against Rheumatism classification criteria for primary SS were fulfilled by 42 of 67 patients (63%). Pathologic SGUS findings were observed in 41 of 67 patients (61%); 26 of 41 SGUS+ patients (63%) fulfilled primary SS criteria. Salivary gland enlargements/parotitis were noted in 37 of 58 patients and were nonsignificantly associated with SGUS+ status (P = 0.066). The mean levels of saliva were 5.6 ml/15 minutes in SGUS- patients compared to 3.3 ml/15 minutes in the SGUS+ patients (P = 0.049). A total of 36 of 41 SGUS+ patients (88%) were anti-Ro/La+ compared to 14 of 26 SGUS- patients (54%) (P = 0.001). In addition, 24 of 39 SGUS+ patients (62%) were positive for rheumatoid factor (RF), whereas only 5 of 25 SGUS- patients (20%) were RF+ (P = 0.001).

CONCLUSION

Juvenile SS is characterized by a large spectrum of clinical symptoms and findings. Several glandular and extraglandular parameters such as hyposalivation, swollen salivary glands, and autoantibodies are associated with pathologic SGUS findings.

Clinical impact of nailfold capillaroscopy in daily clinical practice

INTRODUCTION

Nailfold capillaroscopy (NC) is useful in the evaluation of Raynaud's phenomenon, associated with some connective tissue diseases and in the follow-up of patients with systemic sclerosis. Our study evaluates the impact of NC in the diagnosis, according to the reason for the request and profile of autoantibodies in daily clinical practice.

MATERIAL AND METHODS

All patients that undergone at least one NC between June 2012 and December 2017 were included. Clinical records were reviewed and analysed in a dichotomous way (yes/no), to see whether the NC contributed to a change of diagnosis in subsequent consultations. In addition, demographic, clinical and laboratory data were collected, and the relationship with NC patterns evaluated.

RESULTS

Of the 530 patients who had undergone at least one NC, 266 had Raynaud's phenomenon as primary indication for the technique. Of those, 20 patients (3.8%) had a diagnostic change in the post-NC consultation; 15 were diagnosed with systemic sclerosis, 4 with undifferentiated connective tissue disease and one with mixed connective tissue disease. All patients had, except for one patient diagnosed with undifferentiated connective tissue disease, positive antinuclear antibodies titres, 11 of them had disease specific antibodies (9 anti-centromere, one anti-Scl70 and other anti-RNPC). The positivity of antinuclear antibodies titres was associated with a higher probability of presenting a scleroderma pattern in the NC, and all patients with a specific rheumatological diagnosis had an abnormal NC.

CONCLUSION

NC is a useful technique, but with limited impact in the diagnosis of connective tissue diseases. Autoantibody positivity is associated with a greater likelihood of presenting pathological NC patterns.

Can ultrasound-detected subclinical synovitis be an indicator of flare recurrence in juvenile idiopathic arthritis remission patients on tapered TNFi?

OBJECTIVES

Subclinical synovitis is often detected by musculoskeletal ultrasound (MSUS) in juvenile idiopathic arthritis (JIA) patients in clinical remission. The main objective of this prospective, observational, longitudinal, multicentre study was to evaluate the predictive value of MSUS-detected subclinical synovitis in relation to flares at 12 months following TNFi tapering in a JIA population in stable clinical remission.

METHODS

We included 56 JIA patients in stable remission undergoing TNFi therapy tapered at baseline and in some cases at 6 months. We performed baseline and 6-month MSUS assessment on B-mode (BM) and power Doppler (PD) mode of 22 joints and 8 tendons.

RESULTS

Eighteen patients (32.1%) experienced a flare during the 12-month study period. BM synovitis was frequent (83.9%) but PD synovitis was scarcely found (8.9%). There were no significant differences in MSUS findings between patients who experienced a flare and those who remained in remission. Only 5 patients had positive for PD synovitis, in joints with BM synovitis grades 2 or 3, and none experienced a flare. Concomitant methotrexate (MTX) was more frequent in patients who were successfully tapered (71.1% vs. 27.8%; p=0.002) and patients older than 12 experienced a greater number of flares and earlier onset.

CONCLUSIONS

Subclinical synovitis, as detected by MSUS, proved not to be a predictor of flares. Those patients on a TNFi-tapered concomitant methotrexate regimen experienced the fewest flares although flare risk increased with age.

Nailfold Capillaroscopy Characteristics of Antisynthetase Syndrome and Possible Clinical Associations: Results of a Multicenter International Study

OBJECTIVE

To describe nailfold videocapillaroscopy (NVC) features of patients with antisynthetase syndrome (AS) and to investigate possible correlations with clinical and serological features of the disease.

METHODS

We retrospectively analyzed NVC images of 190 patients with AS [females/males 3.63, mean age 49.7 ± 12.8 yrs, median disease duration 53.7 mos (interquartile range 82), 133 anti-Jo1 and 57 non-anti-Jo1-positive patients]. For each patient, we examined number of capillaries, giant capillaries, microhemorrhages, avascular areas, ramified capillaries, and the presence of systemic sclerosis (SSc)-like pattern. Finally, we correlated NVC features with clinical and serological findings of patients with AS. Concomitantly, a historical cohort of 75 patients with antinuclear antibody-negative primary Raynaud phenomenon (RP) and longterm followup was used as a control group (female/male ratio 4.13/1, mean age 53.9 ± 17.6 yrs) for NVC measures.

RESULTS

NVC abnormalities were observed in 62.1% of AS patients compared with 29.3% of primary RP group (p < 0.001). An SSc-like pattern was detected in 67 patients (35.3%) and it was associated with anti-Jo1 antibodies (p = 0.002) and also with a longer disease duration (p = 0.004). Interestingly, there was no significant correlation between the presence of SSc-like pattern and RP, and only 47% of patients with SSc-like pattern had RP.

CONCLUSION

NVC abnormalities are commonly observed in AS, independently from the occurrence of RP. The presence of an SSc-like pattern could allow identification of a more defined AS subtype, and prospective studies could confirm the association with clinical and serological features of AS.

Salivary gland ultrasound is linked to the autoimmunity profile in patients with primary Sjögren's syndrome

Objective

Methods

Results

Conclusions

Prevalence and risk factors for osteoporosis and fractures in axial spondyloarthritis: A systematic review and meta-analysis

OBJECTIVES

To describe the prevalence of osteoporosis, the prevalence and incidence of fractures, and the frequency of risk factors for low bone mineral density (BMD) in axial spondyloarthritis (Ax-SpA).

METHODS

A systematic review and meta-analysis of observational studies was conducted. Medline, Embase, and Cochrane Library databases were searched with a sensitive strategy. Large cross-sectional and longitudinal studies published in the last 10 years (January 2006-2016) with representative samples of patients with Ax-SpA estimating the frequency of osteoporosis, risk factors or fractures were selected.

RESULTS

After screening 3597 titles and abstracts, 46 studies were reviewed in detail, of which 35 studies had a cross-sectional design, 5 were prospective and 6 retrospective; 21 studies compared Ax-SpA patients with a control group-either healthy individuals (18 studies) or subjects with other diseases (6 studies). The prevalence of osteoporosis varied from 11.7% to 34.4% and that of fractures from 11% to 24.6%. Alcohol intake (58-61%), use of corticosteroids (11.7-66.9%), and 25-OH vitamin D deficiency (26-76%) were unexpectedly high in Ax-SpA patients.

CONCLUSION

The prevalence of osteoporosis and fractures in Ax-SpA varies between 11.7% and 34.4% and 11-24.6%, respectively. Alcohol intake, steroid use, and low levels of 25-OH-vitamin D should be taken into account in osteoporosis assessment in patients with Ax-SpA. Inconsistent results, lack of bone quality assessment, and high likelihood of bias of the published studies confirm the need for performing well-designed studies.

Recommendations for the Management of Comorbidity in Patients With Axial Spondyloarthritis in Clinical Practice

OBJECTIVES

To identify priorities among comorbidities in axial spondyloarthritis (AxSpA) and recommend how to follow them from an eminently practical perspective.

METHODS

A multidisciplinary group was selected (10 rheumatologists-six of them experts in AxSpA-, 2 general practitioners, an internist, a cardiologist, a gastroenterologist and a psychologist). In a first discussion meeting, the scope and users were established and a list of comorbidities was voted based on frequency and impact. The panelists had to defend the inclusion of each comorbidity/item in the document with consistent arguments. Four panelists and two methodologists developed systematic reviews on controversial topics. In a second meeting, the results of the reviews and the arguments concerning the items to be included were presented. After the meeting, the final document was drafted.

RESULTS

The final document includes two checklists, one for health professionals and another for patients; they incorporate cardiovascular risk, renal comorbidities, gastrointestinal risk, lifestyle, risk of infections and vaccinations, pulmonary involvement, concomitant medication, psycho-affective disorders, osteoporosis, and risk of fracture. In addition, the document reflects the arguments favoring the inclusion of each item and how to record the items for subsequent collection. The panel considered it also appropriate to likewise establish «practices to avoid» applicable to comorbidity in AxSpA.

CONCLUSIONS

Two checklists and a list of situations to avoid were generated to facilitate the management of comorbidities in AxSpA. In a future step, their utility and acceptance will be tested by a broad group of users that includes doctors, patients and nurses.

Multiobserver Reliability of Ultrasound Assessment of Salivary Glands in Patients with Established Primary Sjögren Syndrome

Objective.

To evaluate the multiobserver reliability of salivary gland ultrasonography (SGUS) for scoring greyscale (GS) parenchymal inhomogeneity and parenchymal color Doppler (CD) signal in patients with established primary Sjögren syndrome (pSS).

Methods.

The study comprised 2 multiobserver reliability assessments in patients with pSS in 2 European centers. The first reliability exercise was performed on 24 patients with pSS and 8 controls who were independently evaluated with GS and CD US by 5 observers at the Institute of Rheumatology, Belgrade, Serbia. The second reliability exercise was carried out on 10 patients with pSS who were independently assessed with GS and CD US by 8 observers at the Hospital G.U. Gregorio Marañón, Madrid, Spain. SGUS parenchymal inhomogeneity and parenchymal CD signal were semiquantitatively scored using a 4-grade scoring system. The multiobserver agreement was calculated by the overall agreement and Light’s κ statistics.

Results.

A total of 640 SGUS examinations were performed in the first reliability exercise and a total of 320 examinations in the second reliability exercise. Multiobserver reliability was good (κ = 0.71–0.79) to excellent (κ = 0.81–0.82) for GS parenchymal inhomogeneity in both exercises. There was a moderate (κ = 0.53–0.58) to good (κ = 0.70) multiobserver reliability for parenchymal CD signal in the first exercise. However, there was no agreement or only a fair agreement (κ = 0.03–0.29) for parenchymal CD signal in the second exercise.

Conclusion.

US may be a reliable technique in the multiobserver scoring of GS parenchymal inhomogeneity of major SG in patients with established pSS. CD scoring of SG needs further standardization to be used in multicenter studies.

Structural damage in rheumatoid arthritis: comparison between tendon damage evaluated by ultrasound and radiographic damage

OBJECTIVE

To compare structural damage assessed by conventional radiography and tendon damage assessed by musculoskeletal US (MSUS) at wrist and ankle in RA patients.

METHODS

We evaluated 72 consecutive patients [56 (77.8%) females] with RA. The MSUS evaluation consisted in a B-mode examination of bilateral extensor carpi ulnaris and tibialis posterior tendons. Tendon damage was defined and scored according to OMERACT. A total score for the tendon damage score (TDS) was calculated by summing the grades for each tendon. For the radiographic evaluations we used the van der Heijde score; a total radiographic score (RTS) was calculated by summing a bone erosion score (ERS) and a joint space narrowing score (JSNS).

RESULTS

We evaluated 288 tendons. The mean (s.d.) of TDS was 2.3 (1.8). Fifty-four (75%) patients presented tendon damage of at least one tendon. From all evaluated tendons, 134 (46.5%) had no tendon damage, 146 (50.7%) had grade 1 and 8 (2.8%) had grade 2 tendon damage. The mean (s.d.) for RTS was 91.4 (97), for ERS was 47.3 (61.9) and for JSNS was 44.1 (37.2). We found a significant correlation between disease duration and both TDS and RTS (r = 0.413 and r = 0.560, respectively; P < 0.0001). We found a good significant correlation between TDS and all variables of radiographic structural damage (RTS, r = 0.65; ERS, r = 0.637; JSNS, r = 0.618; P < 0.001).

CONCLUSION

The MSUS assessment of only four tendons can be an additional feasible method to assess structural damage in RA patients.

Impact of musculoskeletal ultrasound on clinical practice in paediatric rheumatology

OBJECTIVES

Musculoskeletal ultrasound (MSUS) is an imaging technique increasingly used in paediatric rheumatology. The aim of our study was to evaluate the extent to which MSUS may influence the diagnosis and management decisions in daily clinical practice in paediatric rheumatology.

METHODS

All child patients attending our PR unit over a 3-month period were included. A consultant rheumatologist assessed juvenile patients and weighted the need for MSUS assessment under a Likert scale from 0 (not necessary) to 5 (very necessary) with scanning performed when the Likert score was greater than 0. The rheumatologist completed a questionnaire used to report previous and current diagnosis, therapeutic decisions and disease activity. An assistant rheumatologist who was blinded to the questionnaire carried out the MSUS scanning of selected joints. After MSUS examination, a second questionnaire was completed by the consultant rheumatologist reporting changes in diagnosis and systemic and local treatment, if applicable.

RESULTS

We included 111 patients [73 (65.8%) female]. Fifteen (13.5%) were new patients and 96 (86.5%) follow-up patients. Fifty-one (45.9%) patients were diagnosed with JIA. 65 (58.6%) patients qualified for MSUS. A total of 108 joints from 65 patients were clinically assessed with 93 (86.1%) joints deemed to require complementary MSUS assessment (mean assessed joints 1.4 per patient). Of the 65 patients undergoing MSUS, 38 (58.5%) patients there was a change in diagnosis, therapeutic decisions or both following the MSUS information.

CONCLUSIONS

MSUS may play a significant role in local diagnosis and therapeutic decisions among follow-up JIA patients and could help in the management of rheumatic diseases in children. Further longitudinal studies are needed to confirm the impact of MSUS in paediatric rheumatology.

Salivary gland ultrasound in children: a useful tool in the diagnosis of juvenile Sjögren's syndrome

Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease uncommon in children, clinically characterized by recurrent parotitis at the onset, which is a common disorder in childhood, most of them of infectious origin. Juvenile pSS diagnosis is based on clinical symptoms and presence of autoantibodies, after exclusion of infectious or lymphoproliferative diseases. However, salivary gland ultrasound (SGU) shows typical features of pSS that can add useful information for the diagnosis of this disorder. We describe three patients who presented with recurrent parotitis in which characteristic autoantibodies and typical SGU pattern allow us to make the diagnosis of juvenile pSS. We suggest that in children with recurrent parotitis SGU and autoantibodies should be routinely performed.

Does ultrasound-scored synovitis depend on the pharmacokinetics of subcutaneous anti-TNF agents in patients with rheumatoid arthritis?

OBJECTIVE

The aim of this study was to investigate the influence of the pharmacokinetics of s.c. anti-TNF agents on the grade of US-detected synovitis in RA patients.

METHODS

Fifty RA patients were prospectively recruited from the Biologic Therapy Unit of our hospital. Inclusion criteria were being in treatment with s.c. anti-TNF agents and having had neither changes in therapy nor local corticosteroid injections in the previous 3 months. Patients underwent clinical, laboratory [28-joint DAS (DAS28) and Simplified Disease Activity Index (SDAI)] and US assessment at two time points, i.e. at peak plasma drug concentration and at trough plasma drug concentration. US assessments were performed blindly to the anti-TNF agent, the administration time and the clinical and laboratory data. Twenty-eight joints were investigated for the presence and grade (0-3) of B-mode synovitis and synovial power Doppler signal. Global indices for B-mode synovitis (BSI) and Doppler synovitis (DSI) were calculated for 12 joints and for wrist-hand-ankle-foot joints. B-mode US remission was defined as a BSI <1 and Doppler US remission as a DSI <1.

RESULTS

There were no significant differences between the clinical, laboratory and B-mode and Doppler US parameters at peak time and trough time (P = 0.132-0.986). There were no significant differences between the proportion of patients with active disease and those in remission according to DAS28, SDAI, B-mode US and Doppler US at peak time and trough time assessments (P = 0.070-1).

CONCLUSION

Our results suggested that s.c. anti-TNF pharmacokinetics do not significantly influence US-scored synovitis in RA patients.