Irena Wigler

Spa therapy for gonarthrosis: a prospective study

The objective of this study was to evaluate the effect of spa therapy on clinical parameters of patients with gonarthrosis. Patients with gonarthrosis (n=33) underwent a 2-week spa therapy using three treatment regimes and a 20-week follow-up as follows: group I (n=11) had mineral water baths and hot native mineral mud packs, group II (n=12) had mineral water baths and rinsed mineral-free mud packs and group III (n=10) had tap water baths and mineral-free mud packs. The patients and the assessing rheumatologist were blinded to the difference in the treatment protocols. A significant improvement in the index of severity of the knee (ISK), as well as night pain scores, was achieved in group I. Improvement in physical findings and a reduction in pain ratings on a visual analogue scale (VAS) did not reach statistical significance. Analgesic consumption was significantly decreased in both groups I and III for up to 12 weeks. Global improvement assessed by patients and physician was observed in all three groups up to 16 weeks but persisted to the end of the follow-up period in group I only. Patients with gonarthrosis seemed to benefit from spa therapy under all three regimes. However, for two parameters (night pain and ISK) the combination of mineral water baths and mud packs (group I) appeared to be superior.

The Effect of Infliximab and Timing of Vaccination on the Humoral Response to Influenza Vaccination in Patients with Rheumatoid Arthritis and Ankylosing Spondylitis

OBJECTIVESnTo assess the effect of the timing of vaccination in relation to administration of infliximab on the efficacy and safety of influenza vaccine in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS).nnnMETHODSnThe study population comprised 38 patients treated with infliximab at a mean dosage of 3 mg/kg (20 RA patients; 18 AS patients; 23 RA controls (treated with disease modifying antirheumatic drugs other than anti-tumor necrosis factor-alpha; and 17 healthy controls). Split-virion inactivated vaccine containing 15 mug hemagglutinin/dose of each of A/New Caledionan/20/1999 (H1N1), A/Wisconsin/67/2005 (H3N2), and B/Malaysia/2506/2004 (M) was used. Patients treated with infliximab were divided into 2 groups: 22 were vaccinated on the day of administration of infliximab, while 16 received the vaccine 3 weeks after infliximab. Baseline and 4- to 6-week clinical assessment of disease activity included erythrocyte sedimentation rate and C-reactive protein for all patients, the 28-joint disease-activity score for RA patients, and Bath Ankylosing Spondylitis Disease Activity Index for AS patients. Hemagglutination inhibition (HI) antibodies were tested by a standard World Health Organization procedure. Response was defined as >or=4-fold rise in HI antibodies 4 to 6 weeks after vaccination, or seroconversion in patients with a nonprotective baseline level of antibodies (<1/40). Geometric mean titers (GMT) were calculated to assess the immunity of the whole group.nnnRESULTSnAt baseline, RA patients and controls had similar occurrence of protective levels of HI antibodies and GMT, while AS patients had lower levels reflecting lower rates of previous vaccination. Four weeks after vaccination, a significant and similar increase in GMT for each antigen was observed in all groups (P < 0.004) except in the RA-infliximab group, vaccinated 3 weeks after administration of infliximab, in whom the increase in GMT was not significant for H1N1 (P = 0.12) and H3 (P = 0.06). AS patients demonstrated an increase in GMT, independently of the time of vaccination. The percentage of responders was similar in all groups. The response was not affected by variables such as age, gender, methotrexate, or prednisone use. Parameters of disease activity remained unchanged. No adverse effects other than injection site pain were recorded.nnnCONCLUSIONSnInfluenza virus vaccine generated a good humoral response in RA and AS patients treated with infliximab.

The effects of Zintona EC (a ginger extract) on symptomatic gonarthritis

OBJECTIVEnEvaluation of the effect of a ginger extract (Zintona EC) on patients suffering from gonarthritis.nnnMATERIAL AND METHODSnTwenty-nine patients (6 men and 23 women) with symptomatic gonarthritis (ACR criteria), in the age range 42-85 years, were included after randomization in a double blind, placebo controlled, crossover study of 6 months duration. The treatment group was given a ginger extract (250 mg of Zingiberis Rhizoma per capsule, qid), while the placebo group received the same number of identical looking capsules per day. The crossover occurred after 3 months of therapy. Results were evaluated by a 100mm visual analog scale (VAS) of pain on movement and of handicap.nnnRESULTSnEight patients dropped out because of inefficacy, three from group 1 (ginger extract first) and five from group 2 (placebo first). One patient from group 1 and one from group 2 dropped out because of heartburn (while they were on ginger extract). Twenty patients completed the study period of 24 weeks and 19 that of 48 weeks follow-up. By the end of 24 weeks there was a highly statistically significant difference between the VAS of pain and handicap of the two groups (P<0.001). However, at crossover both groups showed a statistically significant decrease in VAS of pain on movement and of handicap, but the differences between the groups did not reach statistical significance.nnnCONCLUSIONSnZintona EC was as effective as placebo during the first 3 months of the study, but at the end of 6 months, 3 months after crossover, the ginger extract group showed a significant superiority over the placebo group.

The cellular immune response to influenza vaccination is preserved in rheumatoid arthritis patients treated with rituximab

OBJECTIVESnYearly vaccination against influenza is currently recommended to patients with rheumatoid Arthritis (RA). Antibody and cell-mediated responses are both involved in the defense against influenza. Humoral responses to influenza vaccine are impaired in RA patients treated with rituximab (RTX). The objectives of this study were to comparatively assess cell mediated and humoral responses to influenza vaccination in RA patients with or without RTX-induced CD20 B-cell depletion.nnnMETHODSnTrivalent influenza subunit vaccine was administered to 46 RA patients and to 16 healthy controls. The RA group included 29 patients treated by RTX and 17 on conventional disease-modifying anti-rheumatic drugs (DMARDs), mostly methotrexate. Peripheral blood mononuclear cells and sera were obtained immediately before and 4-6 weeks after vaccination. Cell-mediated response to influenza antigens was evaluated by flow cytometry for activated CD4 T-cells. Humoral response was evaluated by haemagglutination inhibition assay.nnnRESULTSnCellular response: Cell-mediated responses were comparable in RTX-treated vs. DMARDs-treated patients. The recall postvaccination CD4+ cellular response was similar in RA patients and healthy controls. A positive correlation was found between CD19+ cell count on the day of vaccination and cellular response in RTX-treated RA patients. Humoral response: The antibody response rate was significantly impaired in the RTX group: being 26.4%, 68.4% and 47.1% in RTX-treated, DMARDs-treated and controls, respectively.nnnCONCLUSIONnCellular immunity to influenza vaccination in RTX-treated patients was similar to DMARDs-treated patients and healthy controls, while humoral immunity was severely impaired. The preservation of cellular immunity may explain the relatively low rate of infection among B-cell depleted patients.

Computed tomographic demonstration of calcification of the ligamenta flava of the lumbosacral spine in ankylosing spondylitis.

An axial computed tomographic (CT) scan of the lumbosacral regions was performed in 65 patients. The patient population was divided into two groups. The first (control) group included 40 elderly patients without calcification of the ligamenta flava. The second group included 25 patients with ankylosing spondylitis. More than 90% of those in the second group showed calcified lumbosacral ligamenta flava. In two patients these calcifications produced spinal stenosis. The diagnostic and practical importance of these findings are discussed.

Prevalence of axial spondyloarthropathy among patients suffering from Fibromyalgia - an MRI study with application of the ASAS classification criteria.

To evaluate the prevalence of sacroiliitis, the radiographic hallmark of inflammatory spondyloarthropathy, among patients diagnosed with fibromyalgia syndrome (FMS), using the current Assessment of SpondyloArthritis International Society (ASAS) criteria and magnetic resonance imaging.

Prevalence of Axial Spondyloarthritis Among Patients With Fibromyalgia: A Magnetic Resonance Imaging Study With Application of the Assessment of SpondyloArthritis International Society Classification Criteria

To evaluate the prevalence of sacroiliitis, the radiographic hallmark of inflammatory spondyloarthropathy, among patients diagnosed with fibromyalgia syndrome (FMS), using the current Assessment of SpondyloArthritis International Society (ASAS) criteria and magnetic resonance imaging.

FRI0679 Whole spine and SIJ MRI of psoriatic arthritis patients: descriptive study of the spine, and sacroiliac joints involvement in a cross sectional large cohort

Background Detection of axial disease has important implications. Data on the structural changes of the spine and SIJ in PsA is mainly based on plain XR and MRI of SIJ. The prevalence and distribution of spinal changes in PsA as detected by MRI is largely unknown. Objectives To evaluate acute and structural changes in spine and SIJ by whole spine MRI performed in a consecutive clinical cohort of PsA. Methods Adult PsA (CASPAR criteria) patients were enrolled in the study. All underwent clinical exam, CRP, HLA-B27 tests, and MRI of the entire spine and SIJ. Spinal sagittal T1-W, STIR and semi-coronal T1-W and T2-W with fat saturation sequences of the SIJ were performed. The spine was scored for the presence of syndesmophytes, bone marrow edema (BME)/fatty corners and enthesitis. SIJS were scored (Berlin score) for the presence of BME, fatty replacement, erosions, sclerosis, and ankylosis. Findings were further categorized into active sacroiliitis (ASAS1), structural sacroiliitis, and spinal findings compatible with SpA (≥3 BME or ≥4 fatty corners2). All MRIs were evaluated by an experienced musculoskeletal radiologist, blinded to clinical data. Data were analyzed by SPSS Version 20.0. Results Ninety six patients completed the study.(Table1) Active/structural/total sacroiliitis was detected in 26%/11.5%/37.5% of patients, respectively. Spinal SpA was demonstrated in 15.6%.(Table 2) Isolated spinal changes were detected in 2.1% of the cohort. Presence of inflammatory back pain (IBP) by ASAS correlated with the prevalence of active sacroiliitis (p 0.024) and SpA (axial/SIJ) (p 0.003). The extent of psoriasis severity (PASI) correlated with both SIJ and whole spine SpA changes. (p 0.02 for both) Gender differences or biologic therapy did not affect the prevalence of SIJ or spine involvement.Table 1. Demographic and clinical data Age (mean, yr) 50±13 Gender M:F 50:46 Psoriasis/PsA duration (mean, yr) 19±13.6/9±8 PASI 3.9±8.9 ASDAS-CRP 2.2±1 Back pain (%)/Inflammatory back pain by ASAS (%) 70%/30% HLA-B27 (%) 4.4% Current DMARD Tx (%)/Current biologic Tx (%) 45%/35%Table 2. Whole spine MRI findings N (%) patients Active Inflammatory Lesions u2003≥1 BME corner 22 (23%) u2003≥1 posterior elements enthesitis 4 (4%) Structural Lesions u2003≥1 corner erosion 10 (10.4%) u2003≥1 fatty corner 30 (31%) u2003≥1 syndesmophytes 30 (31%) Distribution of inflammatory lesions: u2003Cervical 2.1%, Thoracic 18.8%, Lumbar 14.6% Distribution of structural lesions: u2003Cervical 10.4%, Thoracic 32.3%, Lumbar 25% Conclusions In the present PsA cohort, active and structural sacroiliitis was more prevalent vs typical spinal SpA changes. In particular, there was a paucity of SpA changes in the cervical spine. The most prominent axial findings included fatty corners and syndesmophytes. IBP presence and extensive skin disease correlated with SpA axial and SIJ changes. References Lambert RG. Ann Rheum Dis. 2016,75. Hermann KG. Ann Rheum Dis 2012.71. Disclosure of Interest None declared

THU0316 Frequency of Axial Spondyloarthropathy Among Patients Suffering from Fibromyalgia. A Magnetic Resonance Imaging Study Applying the Assessment of Spondylo-Arthritis International Society Classification Criteria

Background Fibromyalgia Syndrome (FMS), considered the result of increased processing of pain by the central nervous system, is a non-inflammatory condition characterized by chronic, widespread musculoskeletal pain and tenderness.Axial spondyloarthritis (SpA) is a group of inflammatory joint disease primarily involving the sacroiliac joints and axial spine. Although FMS and axial SpA differ vastly in their pathogenesis, a considerable clinical overlap may exist between these conditions. Chronic nocturnal back pain and disturbed sleep may accompany either condition. The Assessment of Spondylo-Arthritis international Society (ASAS) has published updated classification criteria for axial SpA with an imaging and clinical arms. We have previously described an increased prevalence of secondary FMS among female SpA patients. Objectives To evaluate the prevalence of axial SpA among FMS patients, utilizing the 2010 ASAS criteria (1). Methods Patients suffering from FMS (ACR 1990 classification criteria) were recruited consecutively from a specialized FMS clinic. Patients were interviewed regarding the presence of SpA features, as defined by the ASAS group (IBP, arthritis, enthesitis, uveitis, dactylitis, psoriasis, Crohns/colitis, good response to NSAIDS, family history of SpA) and underwent HLA-B27 testing and CRP measurement. MRI examinations of the sacroiliac joints were performed on a 1.5 T MRI unit using semicoronal T1 weighted, STIR and FSPGR pre- and post-contrast injection sequences. FMS severity was assessed by the FIQ and SF-36 questionnaires and physical examination of the tender points using a dolorimeter. SpA symptom severity was assessed by the BASDAI questionnaire Results 99 unselected patients were recruited and MRI results were available for 74. Table 1. Summary of MRI findings, HLA-B27 results and ASAS criteria positivity among FMS patients (N=74) Sacroiliitis (2) Erosions Sub-chondral sclerosis Fatty replacement Bone marrow edema* HLA-B27 positive ASAS SpA criteria positive 7 (9.5%) 13 (17.6%) 18 (24.3%) 5 (6.8%) 14 (19%) 3 (4%) 7 (9.5%) *Despite minor BME, some exams were not compatible with inflammatory sacroiliitis. Sacroiliitis, based on ASAS definition (2), was found among 7 patients, 7 of which fulfilled ASAS SpA classification criteria. 6 patients fulfilled the criteria based on sacroiliitis on imaging and SpA features, one additional patient fulfilled SpA criteria based on HLA-B27 positivity and additional SpA features. Conclusions Imaging findings suggestive of inflammatory SpA were not uncommon among patients presenting with a clinical diagnosis of FMS. Definite sacroiliitis and ASAS criteria SpA positivity were diagnosed among 9.5% of patients and additional changes typical of SpA were frequent. These findings suggest that FMS may mask an underlying SpA, a diagnosis with important therapeutic implications. Physicians involved in the management of FMS should remain vigilant to the possibility of underlying inflammatory disorders and actively search for such co-morbidities. References Sieper J et al. Ann Rheum Dis 2009;68:8(Suppl II):ii1–ii44 Rudwaleit M et al. Ann Rheum Dis 2009; 68(10):1520 Disclosure of Interest J. Ablin Speakers bureau: Pfizer Inc., I. Eshed: None declared, M. Berman: None declared, V. Aloush: None declared, I. Wigler: None declared, D. Caspi: None declared, M. Likhter: None declared, A. Sharabi: None declared, A. Rom-Broyde: None declared, S. Borok: None declared, D. Levartovsky: None declared, Y. Wolman: None declared, D. Paran: None declared, M. Anouk: None declared, O. Elkayam: None declared