R. Scarpa

Determinants of bone mineral density in immobilization: A study on hemiplegic patients

Osteoporosis that develops during immobli-zation is a severe condition that confers increased risk of fractures with their burden of mortality and disability. The aim of this study was to investigate the determinants of immobilization osteoporosis. As a model of this condition we studied hemiplegic subjects, measuring bone mineral density in the paralyzed lower limb as compared with the non-paralyzed one. In spite of the limits related to the loss of nervous stimulation, this model offers the advantage of a proper control for the complex genetic and environmental cofactors involved. We examined 48 hemiplegic subjects (31 men, 17 women in menopause) admitted consecutively over a 9-month period. Mean length of immobilization was 10.9 months for men (range 1–48 months) and 7.8 months for women (range 1–40 months). The average time since menopause was 14.9 years (range 1.7–23.9 years). For each subject the following were performed: questionnaire, medical examination, anthropometric measurements, evaluation of the scores for spasticity and for lower limb motor capacity in order to account for the different degrees of disability among patients. Bone mineral density was measured using dual-energy X-ray absorptiometry (DXA) at both femoral necks. For each patient we defined a percentage difference in bone loss between the paralyzed and non-paralyzed limb. Regression coefficient were calculated by multiple logistic regression. There was significant bone loss in the paralyzed limb in both sexes, accounting for up to 6.3% in women. Multiple regression analysis showed that the degree of bone loss depends significantly and directly on the length of immobilization, even when controlling for age and sex in the regression model (R=0.193,p=0.034). However, when time since menopause was included in the regression model, with length of immobility as a covariate, it was the only significant determinant of bone loss (R=0.312,p=0.039). No additional factors were observed among men. No differences were shown with regard to anthropometric measurements or functional scores. Length of immobilization accounts only for a small fraction of bone loss, which does not exceed 5% of the total variance. Our data show that postmenopausal women should be considered at highest risk for osteoporosis in cases of immobility and that different factors, other than length of immobility, might come into play in determining bone loss in this condition.

Interplay between environmental factors, articular involvement, and HLA-B27 in patients with psoriatic arthritis.

Medical records of 138 patients with psoriatic arthritis and 138 with rheumatoid arthritis were reviewed for the occurrence of an environmental factor triggering arthritis. Twelve (9%) of the patients with psoriatic arthritis had had an acute disorder immediately preceding onset of arthritis (an operation in four cases, articular trauma in three, abortion in two, myocardial infarction, thrombophlebitis, and phosphoric ester intoxication in one case each). Peripheral arthritis occurred in all these patients. Among the rheumatoid patients, an acute event immediately preceding the onset of the disease was recorded in two cases (1%) only (chi 2 = 7.52; p = 0.006). No significant association was found in the arthritic patients between the incidence of acute events preceding arthritis onset and positivity of the HLA-B27 phenotype.

Psoriatic arthritis: treatment strategies using anti-inflammatory drugs and classical DMARDs.

Psoriatic Arthritis (PsA) is a chronic inflammatory disease typically characterized by arthritis and psoriasis variably associated with other extra-articular manifestations. PsA has been considered a milder and less disabling disease compared with rheumatoid arthritis (RA), even if some studies showed that PsA had joint erosions and damage. In addition, about 20-40% of PsA patients have axial skeleton involvement that may lead to functional limitation and deformity. The treatment of PsA ranged from initial treatment with non-steroidal anti-inflammatory drugs (NSAIDs) to one or more disease-modifying anti-rheumatic agents (DMARDs) for the suppression of inflammation in patients with recalcitrant peripheral joint disease. In clinical practice, the most widely used DMARDs are methotrexate (level of evidence B), sulfasalazine (level of evidence A), leflunomide (level of evidence A), and ciclosporin (level of evidence B). However, the efficacy of these agents in inhibiting joint erosions has not been assessed in controlled studies. Finally, the effectiveness of DMARDs in treating enthesitis and dactylitis is controversial. The present paper revised the evidence-based results on treatment with conventional therapy for PsA. The revision was based on all the subsets of the diseases, namely the various manifestations of the articular involvement (peripheral, axial, enthesitis, dactylitis) as well as the skin and nail involvement.

The occurrence of lower limb enthesopathy in coeliac disease patients without clinical signs of articular involvement

OBJECTIVEnCoeliac disease (CD) is a systemic autoimmune condition induced by gluten consumption in genetically predisposed people, affecting ∼1% of the general population. In the literature, there are many studies that report the association between CD and different kinds of arthritis. The aim of this study was to investigate the presence of entheseal abnormalities by US in patients with CD without clinical signs of articular involvement as compared with healthy control subjects.nnnMETHODSnSixty patients with CD attending the gastroenterology outpatient clinic of the University Federico II of Naples and 60 healthy control subjects matched for age and sex were enrolled in this study. Coeliac patients and healthy controls underwent clinical and US examination.nnnRESULTSnAmong 60 CD patients, 24 (40%) presented at least one entheseal alteration as compared with 6 (10%) control subjects (P < 0.01). In CD patients, the entheseal site more frequently involved was patellar (distal and proximal), while in the healthy controls the enthesopathies were all localized at the Achilles tendon.nnnCONCLUSIONnIn conclusion, the results of this study underline the ability of US to detect signs of subclinical enthesopathy and indicate the presence of a higher prevalence of subclinical enthesopathies in asymptomatic CD patients.

Diffuse idiopathic skeletal hyperostosis (DISH): a retrospective analysis.

SummaryDiffuse idiopathic skeletal hyperostosis (DISH) is a skeletal disease characterized by ligamentous ossification of the anterolateral side of the spine. The radiographs of the spine of 69 patients (22 males, 47 females, mean age 64.97±8.83 years) affected by DISH according to Resnicks criteria were selected. A lower rate of lumbar spine involvement (71%) and a different distribution between sexes were demonstrated, as compared to the data from the literature. Data on relationships among extent of hyperostosis, occupation and metabolic disorders suggest that an important role might be played by the exposure to microtrauma, while, in subjects affected by a metabolic disorder, this condition would represent a prevalent pathogenetic factor. These data underline some peculiarities in the clinical picture of DISH in the population from Campania, that could depend on genetic factors.

Psoriatic disease: Clinical staging

In 2006, the introduction of the concept “psoriatic disease” (PsD) extended the traditional idea of a condition confined to skin and joints. Now we consider PsD a systemic condition, in which the increased activity of tumor necrosis factor acts as the most potent engine for a series of molecular interactions. These lead not only to the genesis of skin and joint symptoms, but also to other clinical aspects such as inflammatory bowel disease, eye involvement, and metabolic syndrome. The blocking of a precise molecular target has dramatically modified therapeutic strategies, making possible adequate control of all the clinical aspects of the condition. Therefore, an expanded clinical staging of patients could now be considered in order to ensure the best therapeutic approach and prognosis.

OP0163 Weight loss and induction of minimal disease activity in psoriatic arthritis patients starting TNF-α blockers treatment

Background PsA patients exhibit an increased prevalence of obesity. By leading to an abnormal expression of “adipokines” (TNF-α, IL-6, leptin, adiponectin), obesity determines a pro-inflammatory status. Thus, an interaction between obesity-related and immunity-related inflammatory status may be postulated in obese PsA subjects. Intervention studies showed that caloric restriction can reduce circulating inflammatory markers. Objectives In this prospective study we correlated changes in the body weight with the minimal disease activity (MDA) achievement in PsA patients starting a treatment with TNF-α blockers. Methods Among the 138 obese PsA subjects starting a TNF-α blockers treatment, 69 received a hypocaloric diet (HD, intervention group) and 69 a self-managed diet (SD, control group). Both at baseline and after 6 months of follow-up, all patients underwent a complete clinical rheumatologic and laboratory evaluation in order to evaluate changes in metabolic variables, and the MDA achievement. Results only 126 of the 138 PsA subjects completed the follow-up (63 HD and 63 matched SD subjects). Clinical and demographic characteristics were similar between HD and SD subjects. During the 6-months treatment with TNF-α blockers, 49 PsA subjects achieved the MDA. HD was associated with a significantly higher Δ%ESR and with a trend to increased Δ%CRP as compared with the SD. The prevalence of successful (≥10% of weight loss) dietary intervention (p=0.001) showed a higher prevalence in MDA as compared to n-MDA subjects. HD was a predictor of MDA achievement (HR:4.79, p=0.002) after 6 months of treatment with TNF-α blockers as compared with SD subjects. A Kaplan-Meyer model confirmed a significant difference as to the 6-month MDA achievement between those with dietary intervention success and those without (Log Rank 10.432, p=0.001). Conclusions This prospective study shows that the adherence to a hypocaloric, fiber-enriched diet is associated with an increased achievement of MDA in PsA subjects starting a TNF-α blockers treatment. References Di Minno MND, Iervolino S, Lupoli R, Russolillo A, Peluso R, Coppola A, Scarpa R, Di Minno G. Cardiovascular risk in rheumatic patients: the link between inflammation and atherosclerosis. Semin Thromb Hemost. 2012 (in press). Hermsdorff HH, Zulet MΆ, Abete I, Martínez JA. Discriminated benefits of a Mediterranean dietary pattern within a hypocaloric diet program on plasma RBP4 concentrations and other inflammatory markers in obese subjects. Endocrine. 2009;36:445-51. Iervolino S, Di Minno MN, Peluso R, Lofrano M, Russolillo A, Di Minno G, Scarpa R. Predictors of Early Minimal Disease Activity in Patients with Psoriatic Arthritis Treated with Tumor Necrosis Factor-α Blockers. J Rheumatol. 2012 Jan 15. [Epub ahead of print] Di Minno MN, Iervolino S, Peluso R, Scarpa R, Di Minno G on behalf of the CaRRDs study group. Carotid intima-media thickness in psoriatic arthritis: differences between tumor necrosis factor-α blockers and traditional disease-modifying antirheumatic drugs. Artherioscler Thromb Vasc Biol. 2011;31:705-12. Disclosure of Interest None Declared

Evidence-based algorithm for diagnosis and assessment in psoriatic arthritis: results by Italian DElphi in psoriatic Arthritis (IDEA)

Psoriatic arthritis (PsA) is a chronic inflammatory disease involving skin, peripheral joints, entheses, and axial skeleton. The disease is frequently associated with extrarticular manifestations (EAMs) and comorbidities. In order to create a protocol for PsA diagnosis and global assessment of patients with an algorithm based on anamnestic, clinical, laboratory and imaging procedures, we established a DElphi study on a national scale, named Italian DElphi in psoriatic Arthritis (IDEA). After a literature search, a Delphi poll, involving 52 rheumatologists, was performed. On the basis of the literature search, 202 potential items were identified. The steering committee planned at least two Delphi rounds. In the first Delphi round, the experts judged each of the 202 items using a score ranging from 1 to 9 based on its increasing clinical relevance. The questions posed to experts were How relevant is this procedure/observation/sign/symptom for assessment of a psoriatic arthritis patient? Proposals of additional items, not included in the questionnaire, were also encouraged. The results of the poll were discussed by the Steering Committee, which evaluated the necessity for removing selected procedures or adding additional ones, according to criteria of clinical appropriateness and sustainability. A total of 43 recommended diagnosis and assessment procedures, recognized as items, were derived by combination of the Delphi survey and two National Expert Meetings, and grouped in different areas. Favourable opinion was reached in 100% of cases for several aspects covering the following areas: medical (familial and personal) history, physical evaluation, imaging tool, second level laboratory tests, disease activity measurement and extrarticular manifestations. After performing PsA diagnosis, identification of specific disease activity scores and clinimetric approaches were suggested for assessing the different clinical subsets. Further, results showed the need for investigation on the presence of several EAMs and risk factors. In the context of any area, a rank was assigned for each item by Expert Committee members, in order to create the logical sequence of the algorithm. The final list of recommended diagnosis and assessment procedures, by the Delphi survey and the two National Expert Meetings, was also reported as an algorithm. This study shows results obtained by the combination of a DElphi survey of a group of Italian rheumatologists and two National Expert Meetings, created with the aim of establishing a clinical procedure and algorithm for the diagnosis and the assessment of PsA patients. In order to find accurate and practical diagnostic and assessment items in clinical practice, we have focused our attention on evaluating the different PsA domains. Hence, we conceived the IDEA algorithm in order to address PsA diagnosis and assessment in the context of daily clinical practice. The IDEA algorithm might eventually lead to a multidimensional approach and could represent a useful and practical tool for addressing diagnosis and for assessing the disease appropriately. However, the elaborated algorithm needs to be further investigated in daily practice, for evidencing and proving its eventual efficacy in detecting and staging PsA and its heterogeneous spectrum appropriately.

OP0162 Obesity and the prediction of the minimal disease activity. A prospective study in psoriatic arthritis patients

Background Clinical studies show an increased prevalence of obesity in PsA patients. By leading to an abnormal expression of “adipokines” (TNF-α, IL-6, leptin, adiponectin), obesity determines a pro-inflammatory status. Thus, an interaction between obesity-related and immunity-related inflammatory status may be postulated in obese PsA subjects. Objectives We prospectively evaluated whether the presence of obesity impacts on the achievement of the Minimal Disease Activity (MDA) in subjects with PsA. Methods Among PsA subjects with an active disease starting a treatment with TNF-α blockers, 135 obese (Body Mass Index >30) and 135 matched normal-weighted patients (controls) were followed-up for 24 months. At baseline, at 12 and at 24 months follow-up, all subjects underwent a clinical, rheumatologic and laboratory assessment to evaluate the MDA achievement. Results Demographic and clinical data were similar between case and control subjects. Table 1. At 12 months follow-up, MDA was achieved by 98/270 PsA individuals (36.3%). The prevalence of obesity was higher in those not achieving the MDA than in those achieving it (64.0% vs 25.5%, p<0.001). After adjusting for all the other variables, obesity was associated with a higher risk of not achieving MDA (hazard ratio [HR]: 4.90, 95%CI:3.04-7.87, p<0.001). The HR of not achieving MDA was 3.98 (95%CI:1.96-8.06, p<0.001) and 5.40 (95%CI:3.09-9.43, p<0.001) in subjects with 1st degree (<30 BMI) and 2nd degree (30-35 BMI) obesity, respectively. Among the 98 subjects that had achieved MDA at the 12 months follow-up, the presence of obesity was associated with a poor probability of sustained MDA at 24-months follow-up (HR:2.04, 95%CI:1.015-3.61, p=0.014). Conclusions This prospective study shows that, after adjusting for all the other clinical and demographical variables, the obesity acts as a negative predictor of achieving and maintaining MDA. References Di Minno MND, Iervolino S, Lupoli R, Russolillo A, Peluso R, Coppola A, Scarpa R, Di Minno G. Cardiovascular risk in rheumatic patients: the link between inflammation and atherosclerosis. Semin Thromb Hemost. 2012 (in press). Iervolino S, Di Minno MN, Peluso R, Lofrano M, Russolillo A, Di Minno G, Scarpa R. Predictors of Early Minimal Disease Activity in Patients with Psoriatic Arthritis Treated with Tumor Necrosis Factor-α Blockers. J Rheumatol. 2012 Jan 15. [Epub ahead of print] Di Minno MN, Iervolino S, Peluso R, Scarpa R, Di Minno G on behalf of the CaRRDs study group. Carotid intima-media thickness in psoriatic arthritis: differences between tumor necrosis factor-α blockers and traditional disease-modifying antirheumatic drugs. Artherioscler Thromb Vasc Biol. 2011;31:705-12. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. World Health Organ Tech Rep Ser 2000; 894:i–xii:1–253 Di Minno MN, Tufano A, Guida A, Di Capua M, De Gregorio AM, Cerbone AM, Tarantino G, Di Minno G. Abnormally high prevalence of major components of the metabolic syndrome in subjects with early-onset idiopathic venous thromboembolism. Thromb Res. 2011 Mar;127(3):193-7 Disclosure of Interest None Declared

Physician’s Global Assessment in Psoriatic Arthritis: A Multicenter GRAPPA Study

Objective. Physician’s global assessment (PGA) of disease activity is a major determinant of therapeutic decision making. This study assesses the reliability of the PGA, measured by means of 0–100 mm visual analog scale (VAS), and the additional use of separate VAS scales for musculoskeletal (PhysMSK) and dermatologic (PhysSk) manifestations in patients with psoriatic arthritis (PsA). Methods. Sixteen centers from 8 countries enrolled 319 consecutive patients with PsA. PGA, PhysMSK, and PhysSk evaluation forms were administered at enrollment (W0) and after 1 week (W1). Detailed clinical data regarding musculoskeletal (MSK) manifestations, as well as dermatological assessment, were recorded. Results. Comparison of W0 and W1 scores showed no significant variation (intraclass correlation coefficients were PGA 0.87, PhysMSK 0.86, PhysSk 0.78), demonstrating the reliability of the instrument. PGA scores were dependent on PhysMSK and PhysSk (p < 0.0001) with a major effect of the MSK component (B = 0.69) compared to skin (B = 0.32). PhysMSK was correlated with the number of swollen joints, tender joints, and presence of dactylitis (p < 0.0001). PhysSk scores were correlated with the extent of skin psoriasis and by face, buttocks or intergluteal, and feet involvement (p < 0.0001). Finally, physician and patient assessments were compared showing frequent mismatch and a scattered dot plot: PGA versus patient’s global assessment (r = 0.36), PhysMSK versus patient MSK (r = 0.39), and PhysSk versus patient skin (r = 0.49). Conclusion. PGA assessed by means of VAS is a reliable tool to assess MSK and dermatological disease activity. PGA may diverge from patient self-evaluation. Because MSK and skin/nail disease activity may diverge, it is suggested that both PhysMSK and PhysSk are assessed.