M. Doveri

Incident Comorbidity Among Patients with Rheumatoid Arthritis Treated or Not with Low-dose Glucocorticoids: A Retrospective Study

Objective. To assess the prevalence of comorbidity in a cohort of patients with rheumatoid arthritis (RA), treated or not with low-dose glucocorticoids (GC) and who have been followed for at least 10 years. Methods. This was a retrospective study by review of medical records. Results. We identified 365 patients: 297 (81.3%) were GC users (4–6 mg methylprednisolone daily) and 68 (18.7%) were nonusers. We found that fragility fractures occurred in 18.2% of GC users and in 6.0% of GC nonusers (p < 0.02); arterial hypertension in 32.3% of GC users and in 10.4% of GC nonusers (p < 0.0005); acute myocardial infarction in 13.1% of GC users and in 1.5% of the nonusers (p < 0.01). Prevalence of diabetes mellitus, cataract, and infections was comparable. We divided GC users into groups of different duration of GC therapy: < 2, 2–5, and > 5 years; the mean duration of GC treatment was 1.3 ± 0.5, 3.6 ± 1.1, and 12.1 ± 5.1 years, respectively. GC treatment for > 5 years was associated with significantly higher prevalence of fragility fractures (26.6%; p < 0.001 vs the other groups), arterial hypertension (36.7%; p < 0.0002 vs nonusers and GC users < 2 years), myocardial infarction (16.1%; p < 0.01 vs nonusers), and infections (9.7%; p < 0.005 vs the other groups). GC treatment for 2–5 years was associated with a significantly higher prevalence of arterial hypertension (30.0%; p < 0.01) compared to nonusers. Conclusion. Patients with RA treated with low-dose GC compared to patients never treated with GC show a higher prevalence of fractures, arterial hypertension, myocardial infarction, and serious infections, especially after 5 years of GC treatment. The high prevalence of myocardial infarction and fractures in patients with RA suggests that a more accurate identification of risk factors and prevention measures should be adopted when longterm GC treatment is needed.

Clinical and echocardiographic correlations of exercise-induced pulmonary hypertension in systemic sclerosis: A multicenter study

BACKGROUND Patients with systemic sclerosis (SSc) are at risk for developing pulmonary hypertension, which is associated with a poor prognosis. Exercise Doppler echocardiography enables the identification of exercise-induced increase in pulmonary artery systolic pressure (PASP) and may provide a thorough noninvasive hemodynamic evaluation. AIM The aim of this study was to evaluate the clinical and echocardiographic determinants of exercise-induced increase in PASP in a large population of patients with SSc. METHODS We selected 164 patients with SSc (age 58 ± 13 years, 91% female) with normal resting PASP (<40 mm Hg) who underwent a comprehensive 2-dimensional and Doppler echocardiography and graded bicycle semisupine exercise Doppler echocardiography. Pulmonary artery systolic pressure, cardiac output, and pulmonary vascular resistance (PVR) were estimated noninvasively. Cutoff values of PASP ≥50 mm Hg and PVR ≥3.0 Wood Units at peak exercise were considered a significant exercise-induced increase in PASP and PVR, respectively. RESULTS Sixty-nine (42%) patients showed a significant exercise-induced increase in PASP. Among them, peak PVR ≥3 Wood Units was present only in 11% of patients, about 5% of the total population. Univariate analysis showed that age, presence of interstitial lung disease, and both right and left diastolic dysfunction are predictors of peak PASP ≥50 mm Hg, but none of these parameters predict elevated peak PVR. CONCLUSIONS Exercise-induced increase in PASP occurs in almost one-half of patients with SSc with normal resting PASP. Peak exercise PASP is affected by age, interstitial lung disease, and right and left ventricular diastolic dysfunction and, only in 5% of the patients, is associated with an increase in PVR during exercise, suggesting heterogeneity of the mechanisms underlying exercise-induced pulmonary hypertension in SSc.

Thyroid autoimmunity may represent a predisposition for the development of fibromyalgia

In our previous study, we observed that the presence of autoimmune thyroid disease worsens fibromyalgia (FM) symptoms. The aims of this study are to evaluate whether there is a predisposition for the development of FM in patients with Hashimoto’s thyroiditis (HT) with or without subclinical hypothyroidism (SCH) and in patients with SCH alone and what is the weight of antithyroid antibody positivity and SCH on FM comorbidity. Fifty-two patients, 39 affected by HT with or without SCH and 13 by SCH, were matched with 37 patients affected by FM and 25 healthy subjects. Blood samples were collected from all study subjects for the determination of serum TSH, free triiodothyronine, free thyroxine, antithyroperoxidase antibody (TPOAb), antithyroglobulin antibody (TgAb) and non-organ-specific autoantibodies. Clinical assessment of patients and controls included the “Fibromyalgia Impact Questionnaire” (FIQ), while pain severity was evaluated using a visual analogue scale (VAS). Patients and controls were also characterized by the presence of diffuse pain, fatigue, paresthesiae, muscle spasms, non-restful sleep, tension headache and presence of mood disorders. FM comorbidity resulted in twelve HT subjects (31%) and none in SCH patient. In particular, FM comorbidity in HT patients without SCH was 33.3% and in HT patients with SCH was 28.5%. Based on our data, we speculate that maybe there is more than a hypothesis regarding the cause–effect relation between thyroid autoimmunity and the presence of FM, thus suggesting a hypothetical role of thyroid autoimmunity in FM pathogenesis.

Cell-free DNA in the plasma of patients with systemic sclerosis

The aim of the present study was to evaluate the concentration of cell-free DNA (cf-DNA) in the plasma of patients with systemic sclerosis (SSc) and to examine the correlation of cf-DNA with clinical variables of the disease. The study population consisted of 122 SSc patients and 16 healthy controls. Epidemiological and clinical data were collected by direct assessment. The β-globin gene was used to determine the total amount of DNA in the plasma by real-time quantitative PCR analysis. cf-DNA was found in all patients (mean concentration 1,420.7 copies/ml) and controls (mean concentration 1,462.5), with no significant difference. In SSc patients, no correlation was found between cf-DNA and the type of organ involvement, but patients with active disease presented significantly higher cf-DNA concentrations than those with inactive disease (p < 0.05). Our data suggest that cf-DNA could provide a useful biomarker for the assessment of disease activity in SSc patients.

Antipolymer antibody in Italian fibromyalgic patients

The objectives of the present study were to evaluate the presence of antipolymer antibody (APA) seropositivity in 285 Italian patients affected by primary fibromyalgia (FM) and to verify whether APA levels correlate with disease severity and with cytokine levels.APA levels were determined on serum samples by an indirect ELISA kit that detects IgG APA. Cytokines (IL-1, IL-6, IL-8, IL-10 and TNFα) were measured by ELISA in plasma. The impact of FM on the quality of life was estimated using the Fibromyalgia Impact Questionnaire, while pain severity was evaluated using a visual analogic scale. Patients were also characterized by the presence of tiredness, stiffness, nonrestorative sleep, anxiety, depression, tension headache, irritable bowel syndrome, temporomandibular dysfunction and Raynauds phenomena.Using a cut-off value of 30 U, APA-positive values were detected in 60 FM patients (21.05%) and in 15 healthy control individuals (15.00%) without significant differences among their levels or the percentage of seropositivity. FM patients with moderate and severe symptoms had slightly higher APA levels with respect to patients with mild symptoms. APA-seropositive patients exhibited significant correlations between APA levels and the Fibromyalgia Impact Questionnaire estimate (P = 0.042), tiredness (P = 0.003) and IL-1 levels (P = 0.0072).In conclusion, APA cannot be considered a marker of disease in Italian FM patients. The presence of APA, however, might permit the identification of a subset of FM patients with more severe symptoms and of patients who may respond differently to different therapeutic strategies.

Oral sildenafil in skin ulcers secondary to systemic sclerosis

Digital ulcers (DUs) are a major clinical problem in scleroderma patients, associated with reduced quality of life, pain, and disability, and resulting in loss of productivity and mutilation that c...

Comparison of real-time PCR and nested PCR for the detection of Y chromosome sequences in the peripheral blood mononuclear cells of patients with systemic sclerosis

Real-time PCR (RT-PCR) is a sensitive technique that has been recently applied to the determination and quantification of fetomaternal microchimerism.1–3 In a previous manuscript, we detected the presence of Y chromosome sequences in female patients with systemic lupus erythaematosus (SLE) using nested PCR.4 In the present study we evaluated the presence of Y chromosome sequences in the peripheral blood mononuclear cells (PBMCs) of female patients with systemic sclerosis (SSc) using nested and RT-PCR, correlating the results with the clinical and serological manifestations of the patients. Genomic DNA was isolated from …

SAT0034 Cardiac involvement in systemic sclerosis: The added value of magnetic resonance imaging

Background Cardiac involvement in systemic sclerosis (SSc) affects the prognosis of the disease. Myocardial fibrosisis the pathological hallmark of this complication and has been reported in 50–80% of cases in necropsy. Echocardiography is the routine imaging tool to easily detect cardiac involvement, but it is not accurate to detect myocardial fibrosis. Delayed gadolinium enhancement (DE) cardiovascular magnetic resonance (CMR) is the gold-standard for myocardial fibrosis assessment Objectives To evaluate the added value of DE-CMR to echocolorDoppler in SSc patients. Methods After a thorough clinical characterization, 53 SSc patients (age =52±14, 95% females, 34% diffuse form) underwent, on the same day, a comprehensive echocardiogram, including tissue Doppler imaging (TDI), and a DE-CMR. Results Echocardiography showed normal systolic function (ejection fraction =64±6%) and wall motion score index (=1) in 53/53 (100%) patients, whereas DE-CMR showed a pattern of non-ischaemic myocardial fibrosis in 12/53 (23%) patients. In 2/53 patients (4%), T2-weighted CMR showed myocardial oedema, that resolved after steroid therapy. Among clinical (age, duration of disease, limited or cutaneous form, Rodnan skin score, activity score), echocardiographic (indexed left atrium and left ventricular volumes, right atrium and ventricular dimensions, 2-D and TDI parameters of left and right ventricular function and pulmonary arterial systolic pressure) and CMR parameters, only TDI mitral annulus E/E’ was an independent predictor of the presence of myocardial fibrosis at multivariate analysis (hazard ratio 1.8; 95% confidence interval 1.1-3.1). Conclusions Subclinical cardiac involvement is relatively frequent in SSc. CMR can detect different patterns of reversible (by T2-weighted) and irreversible (by DE) cardiac involvement. Elevated E/E’ at echocardiography may raise the suspicion of myocardial fibrosis. Disclosure of Interest None Declared