Niccolò Possemato

Is colour duplex sonography-guided temporal artery biopsy useful in the diagnosis of giant cell arteritis? A randomized study

OBJECTIVEnThe aim of this study was to assess the usefulness of colour duplex sonography (CDS)-guided temporal artery biopsy (TAB) for the diagnosis of GCA in patients with suspected GCA.nnnMETHODSnFrom September 2009 through December 2012, 112 consecutive patients with suspected GCA were randomized to undergo CDS-guided TAB or standard TAB. All patients underwent temporal artery physical examination and temporal artery CDS prior to TAB. CDS of the temporal artery was performed by the same ultrasonographer, who was unaware of the patients clinical data, and all TABs were evaluated by the same pathologist. Seven patients in whom biopsy failed to sample temporal artery tissue were excluded from the analysis.nnnRESULTSnFifty patients were randomized to undergo CDS-guided TAB and 55 patients to standard TAB. Except for a younger age in patients who underwent standard TAB (P = 0.026), no significant differences were observed between the two groups. There were no significant differences in the frequencies of positive TAB for classic transmural inflammation (28% vs 18.2%) or for periadventitial small vessel vasculitis and/or vasa vasorum vasculitis (6% vs 14.5%) between the two groups. No significant differences in the frequency of positive TAB in the two groups were observed when we excluded the patients treated with glucocorticoids and when we stratified the patients of the two groups for the presence or absence of the halo sign.nnnCONCLUSIONnOur study showed that CDS-guided TAB did not improve the sensitivity of TAB for diagnosing GCA.

Comparison between colour duplex sonography findings and different histological patterns of temporal artery

OBJECTIVEnTo assess the findings of temporal artery colour duplex sonography (CDS) in GCA characterized by a histological pattern of periadventitial small vessel vasculitis (SVV) and/or vasa vasorum vasculitis (VVV) and compare it with those observed in classic GCA with transmural vasculitis.nnnMETHODSnWe studied 30 patients with SVV and/or VVV, 63 patients with classic GCA and 67 biopsy-negative patients identified over a 9-year period. CDS of the temporal arteries was performed in all patients by one ultrasonographer. Temporal artery biopsy was used as the reference standard. Sensitivities, specificities and likelihood ratios (LRs) were calculated.nnnRESULTSnThe frequency of the halo sign on CDS was significantly lower in the patients with SVV and/or VVV compared with those with classic GCA (20% vs 82.5%, P = 0.0001). The halo sign had a sensitivity of only 20% (95% CI 8.4, 39.1%) and a specificity of 80.6% (95% CI 68.7, 88.9%) for the diagnosis of SVV and/or VVV. The negative LR was 0.992 (CI 0.824, 1.195), and the positive LR was 1.030 (CI 0.433, 2.451). The halo sign for the diagnosis of biopsy-proven classic GCA had a higher sensitivity of 82.5% (CI 70.5, 90.5%), the same specificity of 80.6% (CI 68.7, 88.9%) and a higher positive LR (4.253; CI 2.577, 7.021).nnnCONCLUSIONnThe halo sign is infrequently found in GCA characterized by a histological pattern of SVV and/or VVV. This limits the sensitivity of CDS in correctly identifying patients with GCA.

Contrast-enhanced ultrasound of the carotid artery in patients with large vessel vasculitis: Correlation with positron emission tomography findings.

To assess the findings of contrast‐enhanced ultrasound (CEUS) of carotid arteries in patients with large vessel vasculitis (LVV) and to compare them with those observed using 18F‐fluorodeoxyglucose–positron emission tomography (18FDG‐PET).

The Role of Tumor Necrosis Factor-α Blockers in Psoriatic Disease. Therapeutic Options in Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory disease affecting peripheral and axial joints, usually associated with psoriasis (PsO) and involving various systems and organs (eye inflammation, such as uveitis; and involvement of nail and enthesis), and it usually requires a multidisciplinary treatment approach. Tumor necrosis factor-α (TNF-α) is overexpressed in psoriatic synovium and skin plaques and its selective inhibition by anti-TNF-α agents has been demonstrated to reduce TNF-α levels in the articular environment, reversing the synovial hyperproliferative phenotype. Studies performed on anti-TNF-α agents in PsA demonstrated that they are able to reduce neutrophil and macrophage infiltration as well as vascular cell adhesion protein 1 expression with ensuing synovial thickness normalization. The efficacy of anti-TNF-α agents for all PsA manifestations (peripheral arthritis, axial involvement, enthesopathy, and skin disease) suggests that anti-TNF-α efficacy might be related to the ability to influence angiogenesis and osteoclastogenesis, reduce synovial inflammation, and slow radiological disease progression. This review describes the role of anti-TNF-α in each manifestation of PsA.

Frequency of monoclonal gammopathy in psoriatic patients receiving anti‐TNF therapy compared with patients taking conventional drugs: a cross‐sectional study

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Clinical images: PET-CT and contrast-enhanced ultrasound in Takayasu’s arteritis

35 Kelchtermans H, De Klerck B, Mitera T et al. Defective CD4+CD25+ regulatory T cell functioning in collageninduced arthritis: an important factor in pathogenesis, counter-regulated by endogenous IFN-gamma. Arthritis Res Ther 2005;7:R402 15. 36 Glant TT, Mikecz K, Arzoumanian A et al. Proteoglycan-induced arthritis in BALB/c mice. Clinical features and histopathology. Arthritis Rheum 1987;30:201 12.

IgG4‐Related Sacroiliitis

The value of research into cartilage is, I believe, self-evident and additionally extends to other diseases such as inflammatory polyarthritides, to which the cancer analogy might be more apt. Rather, my commentary was driven by a concern that our convergent focus on hyaline cartilage limits the potential to develop effective interventions by ignoring all of the other processes (and possible therapeutic targets) that participate in OA. Dr. Hardingham’s reassurance in that regard is, therefore, most welcome.

Rheumatic Manifestations of Scurvy

This paper reviews the rheumatological manifestations of scurvy, based on articles published in English from 1965 until October 2014, with a particular focus on rheumatological manifestations. Scurvy is a rare, uncommon disease in developed countries. Due to its clinical heterogeneity, the disease can easily mimic rheumatologic conditions leading to a delay in diagnosis and treatment.

Therapeutic Options After Treatment Failure in Rheumatoid Arthritis or Spondyloarthritides

The prognosis for patients with rheumatoid arthritis or spondyloarthritides has improved dramatically due to earlier diagnosis, recognition of the need to treat early with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), alone or in combinations, the establishment of treatment targets, and the development of biological DMARDs (bDMARDs). Many patients are now able to achieve clinical remission or low disease activity with therapy, and reduce or eliminate systemic corticosteroid use. Guidelines recommend methotrexate as a first-line agent for the initial treatment of rheumatoid arthritis; however, a majority of patients will require a change of csDMARD or step up to combination therapy with the addition of another csDMARD or a bDMARD. However, treatment failure is common and switching to a different therapy may be required. The large number of available treatment options, combined with a lack of comparative data, makes the choice of a new therapy complex and often not evidence based. We summarize and discuss evidence to inform treatment decisions in patients who require a change in therapy, including baseline factors that may predict response to therapy.

FRI0051 Comparison Between Clinical and Ultrasonographical Examination in Early Rheumatoid Arthritis Patients

Objectives To stress the need of routine use of US imaging in treat to target strategies aiming to achieve remission in early rheumatoid arthritis. Methods 72 patients consecutive with early rheumatoid arthritis (ERA,50 pts) or undifferentiated arthritis (UA, 22 pts) diagnosed according to 2010 ACR/EULAR criteria were enrolled in a single center from november 2012 to June 2014. Demographic (age, gender, disease duration, body mass index - BMI-), clinical (total swollen and tender joints count, DAS28, CDAI, SDAI, Health Assessment Questionnaire, EULAR response), serological (eritrocyte sedimentation rate, C reactive protein, rheumatoid factor -RF-, antibodies anti-cyclic citrullinated peptide -CCP-) data was collected at baseline and at 6 months follow-up. Ultrasonographic (US) hand (MCP joints, PIP joints and DIP joints), wrists (intercarpic and radiocarpic joints) and feet (MTP joints, PIP and DIP joints as well as ankle joints) evaluation was performed according to OMERACT recommendations at baseline and 6 months. Results At baseline examination the mean disease duration was 15,5±7,8 weeks (min – max 4 - 24), 33/72 (45.91%) were RF positive and 32/72 (43.1%) were ACPA positive. Sixty-four patients were treated with DMARDs (62.5% MTX, 25% HCQ, 13% others) and 57 patients received corticosteroids. Ten out of 72 patients (13.9%) showed radiographic erosions at baseline evaluation. At 6 months clinical evaluation 23 pts were in remission according to DAS28 criteria, 14 pts were in low disease activity, 23 in moderate disease activity and 10 pts still in high disease activity. Comparing US evaluation in the different level of disease acitivity only joint synovial PD showed a statistical significant difference (table1). Table 1. Clinical and US features at 6 months evaluation EULAR DAS US Features Synovial hypertrophy Synovial Power-Doppler Joints erosions Tenosynovitis At least one US alteration no. of pts (%) no. of pts (%) no. of pts (%) no. of pts (%) (%) Remission, no. of pts (%) (A) 17/23 (73.9) 11/23 (47.8) 5/23 (21.7) 11/23 (47.8%) 19/23 (82.6) LDA, no. of pts (%) (B) 14/14 (100) 11/14 (78.6) 5/14 (35.7) 6/14 (42.9%) 14/14 (100) MDA, no. of pts (%) (C) 22/23 (95.7) 19/23 (82.6) 7/23 (30.4) 11/23 (47.8%) 22/23 (95.7) HDA, no. of pts (%) (D) 9/10 (90) 9/10 (90) 3/7 (30) 7/10 (70) 10/10 (100) P value ns 0.021 ns ns ns P value (A+B vs C+D) ns 0.013 ns ns ns Conclusions At 6- months US joint and tendon examination of a consecutive series of patients with early RA only the presence of synovial joint PD were significantly reduced in patients with disease remission as compared to patients with more active disease. Disclosure of Interest None declared